127 Delayed Second Dose Antibiotics in Severe Sepsis and Septic Shock

Early antibiotic therapy is a mainstay in the management of patients with severe sepsis and septic shock. Recent studies have highlighted an increase in mortality in septic patients with delays in receiving their second dose of antibiotics. The purpose of this study is to: 1) Determine the frequency and factors associated with delays in second antibiotics administration in patients presenting to the emergency department (ED) with severe sepsis/septic shock (SS/SS) and 2) to evaluate if these delays influence a variety of clinical outcomes. This was a retrospective cohort study of ED treated adults (age > 18 years, n=1,075) presenting with SS/SS. Patients receiving intravenous (IV) Vancomycin, Beta-Lactams, Daptomycin, Carbapenems, and Fluoroquinolones within 12 hours of ED arrival were included. Patients who expired prior to the second dose of antibiotics being given were excluded. Appropriate second dose was defined as receiving an antibiotic of the same class at the appropriate time point (timely); delayed second dose of antibiotic was defined as dose time >25% of the recommended interval (delayed). Primary outcome was in-hospital mortality. Secondary outcomes included: intubation, vasopressor use, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Multivariate logistic regression analysis or Cox regression was performed with variables selected a priori as outlined below (Table 1). In total, 740 patients achieved timely antibiotics and 335 had a delayed second dose of antibiotics. The average ED length of stay was ∼8.9 hours in the timely group and ∼10.2 hours in the delayed group. In-hospital mortality in the timely group was 15.5% (17.6% in the shock cohort) and 13.7% in the delayed group (16.9% in the shock cohort). There was increased odds of delayed second dose of antibiotics for patients boarding in the ED (OR 2.54- 95% 1.81-3.55), patients who received antibiotics with need for re-dosing at 6-8 hours or 12-24 hours intervals (OR 2.99- 95% CI 1.95-4.57 and OR 2.46- 95% CI 1.72-3.51 respectively), patients who received 30by3 (OR 1.42- 95% CI 1.06-1.90), and in patients with ESRD (OR 2.57- 95% CI 1.50-4.39) (Table 1). Delays in the second dose of antibiotics was not associated with increased in-hospital mortality (OR 0.87- 95% CI 0.58-1.29) or other secondary outcomes. Factors of delayed second dose of antibiotics can be identified, and include boarding in the emergency department, selection of antibiotics which require more frequent dosing, and history of ESRD. However, patients with delays in second dose of antibiotic administration demonstrated no increased risk of in-hospital mortality or other outcomes. These findings are retrospective and require additional validation.Table 1Multivariate Regression Analysis for Predictors of Delayed Second DoseVariableDelayed Second DoseOR95% CIED boarding at 2nd Dose Time2.541.81-3.556-8 hour dose interval2.991.95-4.5712-24 hour dose interval2.461.72-3.5124-48 hour dose interval1.090.66-1.8130by31.421.06-1.90Antibiotics by 3 hours0.970.63-1.51ICU admission1.070.79-1.46ESRD2.571.50-4.39Age1.000.99-1.00MEDS1.020.99-1.05Lactic Acid0.980.92-1.04AKI0.840.60-1.18 Open table in a new tab