Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA.
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
Crit Care Med. 2021 Nov 1;49(11):e1144-e1150. doi: 10.1097/CCM.0000000000005090.
Best practice guidelines and quality metrics recommend immediate antibiotic treatment for all patients with suspected sepsis. However, little is known about how many patients given IV antibiotics in the emergency department are ultimately confirmed to have bacterial infection.
DESIGN, SETTING, AND PATIENTS: We performed a retrospective study of adult patients who presented to four Massachusetts emergency departments between June 2015 and June 2018 with suspected serious bacterial infection, defined as blood cultures drawn and broad-spectrum IV antibiotics administered. Structured medical record reviews were performed on a random sample of 300 cases to determine the post hoc likelihood of bacterial infection, categorized as definite, likely, unlikely, or definitely none.
None.
Among the 300 patients with suspected serious bacterial infections, mean age was 68 years (sd 18), median hospital length of stay was 5 days (interquartile range, 3-8 d), 45 (15%) were admitted directly to ICU, and 14 (5%) died in hospital. Overall, 196 (65%) had definite (n = 115; 38%) or likely (n = 81; 27%) bacterial infection, whereas 104 (35%) were unlikely (n = 55; 18%) or definitely not infected (n = 49; 16%). Antibiotic treatment durations differed by likelihood of infection (median 15 days for definite, 9 for likely, 7 for unlikely, and 3 for definitely not infected). The most frequent post hoc diagnoses in patients with unlikely or definitely no bacterial infection included viral infections (28%), volume overload or cardiac disease (9%), drug effects (9%), and hypovolemia (7%). The likelihoods of infection were similar in the subset of 96 cases in whom emergency department providers explicitly documented possible or suspected sepsis and in the 45 patients admitted from the emergency department to the ICU.
One third of patients empirically treated with broad-spectrum antibiotics in the emergency department are ultimately diagnosed with noninfectious or viral conditions. These findings underscore the difficulty diagnosing serious infections in the emergency department and have important implications for guidelines and quality measures that compel immediate empiric antibiotics for all patients with possible sepsis.
最佳实践指南和质量指标建议对所有疑似脓毒症患者立即进行抗生素治疗。然而，对于在急诊科给予静脉抗生素的患者中，有多少最终被确诊为细菌感染，人们知之甚少。
设计、地点和患者：我们对 2015 年 6 月至 2018 年 6 月期间在马萨诸塞州四家急诊科就诊的疑似严重细菌感染的成年患者进行了回顾性研究，这些患者的定义为抽取血培养并给予广谱静脉抗生素。我们对 300 例随机病例进行了结构化病历回顾，以确定细菌感染的后验可能性，分为明确、可能、不太可能或肯定没有。
无。
在 300 例疑似严重细菌感染的患者中，平均年龄为 68 岁（标准差 18 岁），中位住院时间为 5 天（四分位间距，3-8 天），45 例（15%）直接收入 ICU，14 例（5%）住院期间死亡。总体而言，196 例（65%）有明确（n=115；38%）或可能（n=81；27%）的细菌感染，而 104 例（35%）不太可能（n=55；18%）或肯定没有感染（n=49；16%）。抗生素治疗时间因感染可能性而异（明确诊断的中位数为 15 天，可能为 9 天，不太可能为 7 天，肯定没有感染为 3 天）。在不太可能或肯定没有细菌感染的患者中，最常见的后验诊断包括病毒感染（28%）、容量超负荷或心脏疾病（9%）、药物作用（9%）和低血容量（7%）。在急诊科医生明确记录可能或疑似脓毒症的 96 例病例亚组和从急诊科转入 ICU 的 45 例患者中，感染的可能性相似。
在急诊科接受广谱抗生素经验性治疗的患者中，有三分之一最终被诊断为非传染性或病毒性疾病。这些发现强调了在急诊科诊断严重感染的困难，对那些强制对所有疑似脓毒症患者立即使用经验性抗生素的指南和质量措施具有重要意义。
