Author: Dr. Tisma
Background/Study Question
How often do septic patients receive their second antibiotic dose later than they should? What are the risk factors for these delays? And do these delays affect patient outcomes? Leisman et. al. published a study in 2017 that examined these important inquiries. These questions are particularly interesting to me as a resident in the Rush ED, where boarding times can be long enough such that septic patients destined for the general medicine
floors are still in the ED when their second dose is due!
Design:
The researchers performed a retrospective study in which they collected data about patients admitted with sepsis from a “sepsis database” that had been created for a prior research project. They documented various patient characteristics (vitals, labs, comorbidities, etc.), the amount of time between antibiotic doses (compared to the recommended dosing frequency), and their outcomes (particularly with regards to mortality and need for mechanical ventilation).
Results:
The group found that ⅓ of patients received their second dose of antibiotics with major delays, with an average of > 75% of the recommended dose interval! The primary risk factors for delayed second doses were shorter recommended dosing intervals (for example, only 4% of the second dose of Q24H antibiotics were found to be delayed, whereas 72% of the second
dose of Q6H antibiotics were delayed), boarding (43% of delays occurred during boarding, and 65% of boarding patients received delayed second doses…ouch), and compliance with initial sepsis bundle order sets. They also found that, YES, patient outcomes are affected by these delayed second doses. Patients have a 1.6x increased OR of mortality and 2.4x increased OR
of mechanical ventilation.
Discussion:
It is perhaps arguable that the results of this study are only relevant to the
particular medical center where it took place. Boarding times, provider/nursing staff experience, and abilities to order scheduled antibiotics, for example, certainly differ from ED to ED. That said, this site has a particular strength in sepsis research. Wouldn’t that suggest they’d have better compliance with timely second dose antibiotics in comparison to most sites? And thus, wouldn’t that suggest they’d subsequently have better outcomes?
Takeaway:
Regardless, what this study found is simple…boarding and shorter recommending dosing frequency are risk factors for delayed second dose antibiotics, and delayed second dose antibiotics lead to higher mortality rates and ventilator requirements. We should take this seriously, especially at Rush, and ESPECIALLY when we are boarding.
Citation:
Leisman, D, et. al. Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk Factors, and Outcomes. Crit Care Med. 2017, 45 (6):956-965.