Schinkel Michiel, Nannan Panday Rishi S, Wiersinga W Joost, Nanayakkara Prabath W B
Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands.
Section Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands.
J Thorac Dis. 2020 Feb;12(Suppl 1):S66-S71. doi: 10.21037/jtd.2019.10.35.
For many years, sepsis guidelines have focused on early administration of antibiotics. While this practice may benefit some patients, for others it might have detrimental consequences. The increasingly shortened timeframes in which administration of antibiotics is recommended, have forced physicians to sacrifice diagnostic accuracy for speed, encouraging the overuse of antibiotics. The evidence supporting this practice is based on retrospective data, with all the limitations attached, while the only randomized trial on this subject does not show a mortality benefit from early administration of antibiotics in a population of patients with sepsis as often seen in the emergency department (ED). Physicians are challenged to treat patients suspected of having sepsis within a short period of time, while the real challenge should be to identify patients who would not be harmed by withholding treatment with antibiotics until the diagnosis of infection with a bacterial origin is confirmed and the appropriateness of a course of antibiotics can be evaluated more adequately. Therefore, in the general population of patients with sepsis, taking the time to gather additional data to confirm the diagnosis should be encouraged without a specific timeframe, although physicians should be encouraged to perform an adequate work-up as soon as possible. Patients with suspected sepsis and signs of shock should immediately be treated with antibiotics, as there is no margin for error.
多年来,脓毒症治疗指南一直侧重于早期使用抗生素。虽然这种做法可能使一些患者受益,但对另一些患者可能会产生不利后果。推荐使用抗生素的时间框架日益缩短,这迫使医生为了速度而牺牲诊断准确性,导致抗生素过度使用。支持这种做法的证据基于回顾性数据,存在所有相关局限性,而关于这一主题的唯一随机试验并未表明,在急诊科常见的脓毒症患者群体中,早期使用抗生素能带来死亡率益处。医生面临的挑战是在短时间内治疗疑似患有脓毒症的患者,而真正的挑战应该是识别那些在确诊细菌感染源并能更充分评估抗生素疗程的适当性之前,不使用抗生素治疗也不会受到伤害的患者。因此,在脓毒症患者的总体群体中,应鼓励在没有特定时间框架的情况下花时间收集更多数据以确诊,不过应鼓励医生尽快进行充分的检查。疑似脓毒症且有休克迹象的患者应立即使用抗生素治疗,因为没有犯错的余地。