Patient Heterogeneity and the J-Curve Relationship Between Time-to-Antibiotics and the Outcomes of Patients Admitted With Bacterial Infection.
Patient Heterogeneity and the J-Curve Relationship Between Time-to-Antibiotics and the Outcomes of Patients Admitted With Bacterial Infection.
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患者异质性以及抗生素使用时间与细菌感染患者转归之间的 J 曲线关系。
DOI：
10.1097/ccm.0000000000005429
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发表时间：
2022
影响因子：
8.8
通讯作者：
Simon,Gyorgy
中科院分区：
文献类型：
--
作者：
Usher,MichaelG;Tourani,Roshan;Webber,Ben;Tignanelli,ChristopherJ;Ma,Sisi;Pruinelli,Lisiane;Rhodes,Michael;Sahni,Nishant;Olson,AndrewPJ;Melton,GenevieveB;Simon,Gyorgy
败血症仍然是美国医院利用率和死亡率的主要和可预防的原因。尽管更新了指南，脓毒症的最佳定义以及捆绑治疗的最佳时机仍然不确定。确定受益于早期治疗的感染患者是有针对性的干预措施的必要步骤。在这项研究中，我们旨在说明严重细菌感染患者使用抗生素时间的临床预测因素，并模拟延迟对不同脓毒症定义的风险调整结果的影响。设计：一项多中心回顾性观察性研究。设置：一个包括学术三级护理中心的七家医院网络。患者：18315例严重细菌性疾病伴或不伴脓毒症（急性器官功能障碍（AOD）或全身炎症反应综合征阳性）的患者。测量和主要结果：主要暴露时间是抗生素。我们确定了患者抗生素使用时间的预测因素，包括人口统计学、慢性病诊断、生命体征和实验室检查结果，并确定了延迟对住院死亡或住院时间超过10天的复合因素的影响。脓毒症患者和非脓毒症患者的抗生素使用时间分布相似。对于所有患者，观察到抗生素使用时间与结局之间的J曲线关系，主要由无AOD患者的住院时间驱动。无论是否存在脓毒症，患者特征均提供了良好至极好的抗生素使用时间预测。在脓毒症定义中，在就诊后2.5小时以上的所有时间点，缩短抗生素治疗时间与改善结局相关。结论：无论脓毒症标准如何，抗生素治疗时间都是患者因素的函数。同样，我们发现早期使用抗生素与所有严重细菌性疾病患者的预后改善相关。我们的研究结果表明，识别感染是一个限速和可操作的步骤，可以改善脓毒症和非脓毒症患者的结局。
OBJECTIVES:Sepsis remains a leading and preventable cause of hospital utilization and mortality in the United States. Despite updated guidelines, the optimal definition of sepsis as well as optimal timing of bundled treatment remain uncertain. Identifying patients with infection who benefit from early treatment is a necessary step for tailored interventions. In this study, we aimed to illustrate clinical predictors of time-to-antibiotics among patients with severe bacterial infection and model the effect of delay on risk-adjusted outcomes across different sepsis definitions.DESIGN:A multicenter retrospective observational study.SETTING:A seven-hospital network including academic tertiary care center.PATIENTS:Eighteen thousand three hundred fifteen patients admitted with severe bacterial illness with or without sepsis by either acute organ dysfunction (AOD) or systemic inflammatory response syndrome positivity.MEASUREMENTS AND MAIN RESULTS:The primary exposure was time to antibiotics. We identified patient predictors of time-to-antibiotics including demographics, chronic diagnoses, vitals, and laboratory results and determined the impact of delay on a composite of inhospital death or length of stay over 10 days. Distribution of time-to-antibiotics was similar across patients with and without sepsis. For all patients, a J-curve relationship between time-to-antibiotics and outcomes was observed, primarily driven by length of stay among patients without AOD. Patient characteristics provided good to excellent prediction of time-to-antibiotics irrespective of the presence of sepsis. Reduced time-to-antibiotics was associated with improved outcomes for all time points beyond 2.5 hours from presentation across sepsis definitions.CONCLUSIONS:Antibiotic timing is a function of patient factors regardless of sepsis criteria. Similarly, we show that early administration of antibiotics is associated with improved outcomes in all patients with severe bacterial illness. Our findings suggest identifying infection is a rate-limiting and actionable step that can improve outcomes in septic and nonseptic patients.