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However, there is no established reference standard for measuring antibiotic appropriateness (4), and we did not have appropriateness data available for the 24,093 patients in the study.Last, Inagawa et al (1) noted that we did not observe an association between recognition delay and mortality among patients with septic shock. We discussed the discrepancy between this and other literature and suggest that it may be due to a "ceiling effect" in our healthcare system with widespread attention to rapid recognition and treatment of septic shock. We agree that the timing of development of shock is an important factor to consider, although 75% of patients in our septic shock group received antibiotic orders within 3 hours, so the hypothesis that including patients who developed septic shock several hours after ED triage might have affected the result that is likely not applicable. Finally, we agree with Inagawa et al (1) that the subgroup analysis in our article should not be used to guide treatment of septic shock and patients with suspected septic shock should receive antibiotics as quickly as possible.