A pilot study of prehospital antibiotics for severe sepsis

Abstract

Severe forms of sepsis are major contributors to morbidity and mortality worldwide, with mortality rates as high as 25%-60%. 1 Sepsis with hypotension and septic shock, which we define as sepsis with a systolic blood pressure ≤ 90 mm Hg that is refractory to an initial fluid bolus, 2 are important subsets of sepsis and are medical emergencies for which timeliness of care is crucial. The literature demonstrates that early administration of antibiotics provides a significant mortality benefit in both conditions. 1 Emergency medical services (EMS) personnel treat the majority of sepsis with hypotension and septic shock cases. 2 Consequently, oversight entities, including the Centers for Medicare & Medicaid Services, are recognizing that EMS providers are an important link in ensuring timely care for patients with sepsis. 3 A natural extension of current initiatives to reduce time to antibiotic administration in patients who exhibit sepsis with hypotension or septic shock is to consider implementing prehospital administration of antibiotics.Research regarding the feasibility of this practice and its effectiveness has primarily been performed in Europe. [4][5][6] Few American systems have begun examining similar prehospital antibiotic administration protocols. 7,8 These early studies have demonstrated evidence of improved patient outcomes including shorter intensive care unit (ICU) lengths of stay. 7,8 The primary aim of our investigation was to describe the safety and feasibility of a protocol for prehospital recognition of sepsis with hypotension and septic shock, drawing of blood cultures, and administration of intravenous (IV) antibiotics in an urban EMS service, thereby adding to the limited U.S. literature available on this subject and supporting the development of a large-scale randomized control trial (RCT). Primary feasibility measures included the frequency of allergic reactions, culture contamination, and paramedic adherence to the protocol in the prehospital environment. Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) were used to report the findings of this preliminary result. 9This pilot study was conducted at a large urban academic medical center under a state-granted special project waiver for the protocol implementation. This two-armed project consisted of a retrospective chart review for the historical cohort and a prospective observational study for the interventional arm.

Prehospital administration of antibiotics in addition to usual care versus usual care alone for patients with suspected sepsis – a systematic review

“…19,30 Four studies reported the secondary length of stay outcomes (hospital and ICU). 28,30,31,33 The individual study outcomes and results are detailed in Table 5.…”

“…Five studies reported on mortality, but only one was prospectively statistically powered to this outcome. 34 Three found no difference 19,30,31 whilst two reported statistically significant reductions favouring prehospital antibiotics. 28,33 Regarding 28-day mortality, the RCT by Alam et al 30 reported 8% mortality in both groups, though this time point was not the one to which the study's statistical power was calculated.…”

“…27 The remaining 28 texts underwent full-text screening for eligibility, with 24 texts excluded, leaving four for inclusion. [28][29][30][31] A final updated search was conducted on 21 January 2023, in which a further study 19 was identified and deemed eligible for inclusion. The flow of study identification and selection of the five final included articles is illustrated in Figure 1.…”

“…There was variation regarding the type of clinician providing care. Martel et al 28 and Cunningham et al 31 reported paramedics performing the identification of sepsis and providing care; Jouffroy et al 29 reported physician-centred care delivered in a mobile intensive care ambulance; Alam et al 30 nurses with emergency care training, and Jones et al 19 paramedics.…”

“…All included studies had similar inherent patient populations, that being adults with suspected sepsis in the prehospital setting, though criteria for identifying sepsis and determining eligibility for inclusion varied. Martel et al, 28 Jouffroy et al, 29 Jones et al 19 and Cunningham et al 31 included populations that were predominantly more unwell and more commonly in septic shock or 'severe sepsis', whereas Alam's RCT enrolled a population of whom only 4% were identified as being in septic shock. 30 Each study compared patient outcomes when an ambulance personnel regardless of clinician type administered intravenous broad-spectrum antibiotics in addition to the usual care of supplemental oxygen and fluid resuscitation.…”