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Antimicrobials administration time in patients with suspected sepsis: is faster better? An analysis by propensity score.

ABSTRACT: Background:Early use of antimicrobials is a critical intervention in the treatment of patients with sepsis. The exact time of initiation is controversial and its early administration may be a difficult task in crowded emergency departments (ED). The aim of this study was to estimate, using a matched propensity score, the effect on hospital mortality of administration of antimicrobials within 1 or 3?hours, in patients admitted to the ED with sepsis. Methods:This was a secondary analysis of a multicenter prospective cohort. Patients included in the study were older than 18?years, hospitalized between 2014 and 2016 with suspected sepsis, and admitted to ED of three tertiary care university hospitals in Medellín, Colombia. A propensity score analysis for administration of antimicrobials, both within 1 and 3?h of admission by the ED, was fitted with 28 variables related with clinical attention and physiological changes. As a sensitivity analysis, a logistic regression model was fitted for antimicrobial use adjusted both by propensity score and confounding variables. Results:The study cohort was composed of 2454 patients with a median age of 62?years (IQR = 46-74). Among them, 32% (n = 781) received antibiotics within 3?h and 14% (n = 340) within the first hour. The main diagnoses were urinary tract infection (28%, n = 682) and pneumonia (27%, n = 671). Blood cultures were obtained in 87% (n = 2140) and yielded positive in 29% (n = 629), mainly with Escherichia coli (37%, n = 230), Staphylococcus aureus (21%, n = 132), and Klebsiella pneumoniae (10.2%, n = 64). The hospital mortality rate was 11.5% (n = 283). There were no significant differences in mortality, after adjustment, using antimicrobials either in the first hour (OR 1.03; 95% CI = 0.63; 1.70) or 3?h (OR 0.85; 95% CI = 0.61; 1.20). There were no changes with different models for sensitivity analysis. Conclusions:Despite the obvious constraints given for sample size and residual confounding, our results suggest that we need a more comprehensive approach to sepsis and its treatment, considering early detection, multiple interventions, and goals beyond the simple time-to-antimicrobials.

SUBMITTER: Ascuntar J

PROVIDER: S-EPMC7178597 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Antimicrobials administration time in patients with suspected sepsis: is faster better? An analysis by propensity score.

Ascuntar Johana J Mendoza Deibie D Jaimes Fabián F

Journal of intensive care 20200422

<h4>Background</h4>Early use of antimicrobials is a critical intervention in the treatment of patients with sepsis. The exact time of initiation is controversial and its early administration may be a difficult task in crowded emergency departments (ED). The aim of this study was to estimate, using a matched propensity score, the effect on hospital mortality of administration of antimicrobials within 1 or 3 hours, in patients admitted to the ED with sepsis.<h4>Methods</h4>This was a secondary ana ...[more]

PMID: 32337048

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Project description:PurposeSepsis with thrombocytopenia is highly prevalent in critically ill intensive care unit (ICU) patients and is associated with adverse outcomes. Platelet transfusion is the primary treatment of choice. However, evidence for the beneficial effects of platelet transfusion in patients with sepsis and thrombocytopenia is scarce and low in quality. This study aimed to evaluate the association between platelet transfusion and mortality among ICU patients with sepsis and thrombocytopenia.Patients and methodsUsing the Medical Information Mart for Intensive Care III database (v. 1.4), the outcomes of sepsis patients with platelet counts of ≤ 150,000/μL were compared between those who did and did not receive platelet transfusion. The primary outcomes were 28- and 90-day all-cause mortalities. The secondary outcomes were red blood cell (RBC) transfusion, ICU-free days, and hospital-free days. Propensity score matching was employed to assemble a cohort of patients with similar baseline characteristics.ResultsAmong 7,765 eligible patients, 677 received platelet transfusion and were matched with 677 patients who did not receive platelet transfusion according to propensity scores. Platelet transfusion, as compared with no platelet transfusion, was associated with an increased risk of 28-day all-cause mortality [36.9 vs. 30.4%, odds ratio (OR), 1.21; 95% confidence interval (CI), 1.01-1.46; p = 0.039], increased risk of 90-day all-cause mortality (50.8 vs. 44.6%, OR, 1.13; 95% CI, 1.00-1.31; p = 0.048), fewer mean (standard deviation) 28-day ICU-free days (15.88 ± 8.97 vs. 18.64 ± 8.33 days, p < 0.001), and fewer hospital-free days (10.29 ± 8.49 vs. 11.43 ± 8.85 days, p = 0.017). The rate of RBC transfusion was not significantly different between the platelet transfusion and non-transfusion groups (p = 0.149). The results were maintained across several subgroup and sensitivity analyses.ConclusionIn this study, platelet transfusion was associated with higher 28- and 90-day all-cause mortalities. These results suggest the potential hazards of platelet transfusion in ICU patients with sepsis and thrombocytopenia.

Project description:BackgroundAlbumin may be beneficial in patients with septic shock but availability is limited and cost is high. The objective of the present study was to investigate if the use of dextran-70 in addition to albumin and crystalloids influences organ failure or mortality in patients with severe sepsis or septic shock.MethodsPatients with severe sepsis or septic shock (n = 778) admitted to a university hospital intensive care unit (ICU) between 2007 and 2015 that received dextran-70 during resuscitation were propensity score matched to controls at a 1 to 1 ratio. Outcomes were highest acute kidney injury network (AKIN) score the first 10 days in the ICU, use of renal replacement therapy, days alive and free of organ support the first 28 days after admission to ICU, mortality and events of severe bleeding. Outcomes were assessed using paired hypothesis testing.ResultsPropensity score matching resulted in two groups of patients with 245 patients in each group. The dextran group received a median volume of 1483 ml (interquartile range, 1000-2000 ml) of dextran-70 during the ICU stay. Highest AKIN score did not differ between the control- and dextran groups (1 (0-3) versus 2 (0-3), p = 0.06). Incidence of renal replacement therapy in the control- and dextran groups was similar (19% versus 22%, p = 0.42, absolute risk reduction -2.9% [95% CI: -9.9 to 4.2]). Days alive and free of renal replacement, vasopressors and mechanical ventilation did not differ between the control- and dextran groups. The 180-day mortality was 50.2% in the control group and 41.6% in the dextran group (p = 0.046, absolute risk reduction 8.6% [-0.2 to 17.4]). Fraction of patients experiencing a severe bleeding in the first 10 days in the ICU did not differ between the control and dextran groups (14% versus 18%, p = 0.21).DiscussionThere is a paucity of high quality data regarding effects of dextran solutions on outcome in sepsis. In the present study, propensity score matching was used in attempt to reduce bias.ConclusionNo evidence to support a detrimental effect of dextran-70 on mortality or on organ failures in patients with severe sepsis or septic shock could be detected.

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Antimicrobials administration time in patients with suspected sepsis: is faster better? An analysis by propensity score.

Publications

Antimicrobials administration time in patients with suspected sepsis: is faster better? An analysis by propensity score.

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