EARLY ANTIBIOTICS CAN BOTH PREVENT AND MITIGATE SEPTIC SHOCK IN ED PATIENTS WITH SUSPECTED INFECTION

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Certain medical societies have publicly questioned the use of early antibiotics in patients with sepsis without septic shock. However, we recently demonstrated that among emergency department patients with suspected infection, antibiotic delay was associated with development of shock, and that for those patients who developed shock in spite of early antibiotics, mortality was unexpectedly low. The purpose of our study was to determine if early antimicrobial administration in patients with suspected infection but not septic shock affects risk of mortality if septic shock does develop. METHODS: This was a single center retrospective cohort study from March 2007 to March 2020. All adults presenting to the emergency department with suspected infection and first antimicrobial administered < 24 hours from triage were included. Septic shock at presentation was defined by receiving vasopressors within 3 hours of triage. We performed univariate and multivariate logistic regressions predicting progression to septic shock and mortality. We also compared mortality in patients who presented with shock compared with patients who developed shock after treatment was initiated. RESULTS: 74,655 patients were included in the study. Of these, 541 (0.7%) patients were characterized as having septic shock on presentation. 5,510 (7.4%) patients did not have septic shock on presentation but progressed to septic shock after treatment initiation. For patients in the latter group, in-hospital mortality was 10.7%. For patients with septic shock on presentation, in-hospital mortality was 23% (p<0.001). Median time to antibiotics for the septic shock on presentation group was 0.35 hours, and 97% of these patients received their antimicrobials within 5 hours of triage. In a multivariate logistic regression model including only patients without septic shock on presentation, time to first antimicrobial had OR of 1.03 [95% CI: 1.02-1.04; p<0.001] for progression to septic shock and 1.02 [95% CI: 0.98-1.04; p = 0.090] for in-hospital mortality. In a multivariate logistic model including only patients with septic shock on presentation, time to first antimicrobial had an OR of 1.25 [95% CI: 1.05-1.48; p = 0.010] for in-hospital mortality. CONCLUSIONS: Delays in first antimicrobial administration in patients with suspected infection or septic shock are associated with increased likelihood of disease progression and in-hospital mortality. However, early administration of antibiotics in non-shock patients with suspected infection is associated with decreased mortality rate by half, even if shock does subsequently develop. CLINICAL IMPLICATIONS: Antibiotics administered before the onset of shock may mitigate the mortality associated with septic shock. DISCLOSURES: No relevant relationships by Roshan Bisarya, source=Web Response No relevant relationships by Mei Liu, source=Web Response No relevant relationships by Anurag Patel, source=Web Response No relevant relationships by John Salle, source=Web Response No relevant relationships by Steven Simpson, source=Web Response No relevant relationships by Xing Song, source=Web Response