Antibiotic Timing and Progression to Septic Shock Among Patients in the ED With Suspected Infection
Antibiotic Timing and Progression to Septic Shock Among Patients in the ED With Suspected Infection
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DOI：
10.1016/j.chest.2021.06.029
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发表时间：
2022-01-06
期刊：
影响因子：
9.6
通讯作者：
Simpson, Steven Q.
中科院分区：
文献类型：
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作者：
Bisarya, Roshan;Song, Xing;Simpson, Steven Q.
背景：最近医学界的意见对脓毒症但没有感染性休克的患者早期使用抗菌药物提出了质疑。研究问题：疑似感染患者从急诊室就诊到使用抗生素的时间与进展为感染性休克有关吗？研究设计和方法：这是一项 2007 年 3 月至 2020 年 3 月的回顾性队列研究。所有疑似感染且在分诊 24 小时内首次使用抗菌药物的成人均纳入其中。就诊时出现休克的患者被排除在外。我们进行了单变量和多变量逻辑回归分析，预测进展为感染性休克。结果：该研究纳入了 74114 例患者。五千五百十名患者（7.4%）进展为感染性休克。在进展为感染性休克的患者中，88% 在分诊后的前 5 小时内接受了抗菌药物治疗。在多变量逻辑模型中，首次使用抗菌药物的时间（以小时为单位）显示，进展为感染性休克的 OR 为 1.03（95% CI，1.02-1.04；P < .001），院内死亡率的 OR 为 1.02（95% CI，0.99-1.04；P = .121）。根据疾病的严重程度进行调整后，在初次给予抗菌药物之前每延迟一小时，分诊后每 1 小时至 24 小时，感染性休克进展率就会增加 4.0%。快速序贯器官衰竭评估 (qSOFA) 结果呈阳性的患者比全身炎症反应综合征 (SIRS) 评分呈阳性的患者更早接受抗生素治疗（0.82 小时 vs 1.2 小时；P < .05）。然而，与分诊时 SIRS 评分阳性的患者（26 小时）相比，分诊时 qSOFA 结果呈阳性的患者（11.2 小时）到感染性休克的中位时间显着更短（P < .05）。解释。疑似感染患者首次抗菌药物给药的延迟与进展为感染性休克的可能性迅速增加有关。此外，qSOFA 评分在预测感染性休克方面比 SIRS 评分具有更高的特异性，但与更差的结果相关，即使患者早期接受抗生素治疗也是如此。
BACKGROUND: Recent medical society opinions have questioned the use of early antimicrobials in patients with sepsis, but without septic shock.RESEARCH QUESTION: Is time from ED presentation to administration of antibiotics associated with progression to septic shock among patients with suspected infection?STUDY DESIGN AND METHODS: This was a retrospective cohort study from March 2007 through March 2020. All adults with suspected infection and first antimicrobial administered within 24 h of triage were included. Patients with shock on presentation were excluded. We performed univariate and multivariate logistic regression analyses predicting progression to septic shock.RESULT: Seventy-four thousand one hundred fourteen patient encounters were included in the study. Five thousand five hundred ten patients (7.4%) progressed to septic shock. Of the patients who progressed to septic shock, 88% had received antimicrobials within the first 5 h from triage. In the multivariate logistic model, time (in hours) to first antimicrobial administration showed an OR of 1.03 (95% CI, 1.02-1.04; P < .001) for progression to septic shock and 1.02 (95% CI, 0.99-1.04; P = .121) for in-hospital mortality. When adjusted for severity of illness, each hour delayed until initial antimicrobial administration was associated with a 4.0% increase in progression to septic shock for every 1 h up to 24 h from triage. Patients with positive quick Sequential Organ Failure Assessment (qSOFA) results were given antibiotics at an earlier time point than patients with positive systemic inflammatory response syndrome (SIRS) score (0.82 h vs 1.2 h; P < .05). However, median time to septic shock was significantly shorter (P < .05) for patients with positive qSOFA results at triage (11.2 h) compared with patients with positive SIRS score at triage (26 h).INTERPRETATION. Delays in first antimicrobial administration in patients with suspected infection are associated with rapid increases in likelihood of progression to septic shock. Additionally, qSOFA score has higher specificity than SIRS score for predicting septic shock, but is associated with a worse outcome, even when patients receive early antibiotics.