Impact of the diagnostic process on the accuracy of source identification and time to antibiotics in septic emergency department patients

Uittenbogaard, Annemieke J.M.; Deckere, Ernie R.J.T. de; Sandel, Maro H.; Vis, Alice; Houser, Christine M.; Groot, Bas de

doi:10.1097/mej.0b013e3283619231

Cited by 10 publications

(5 citation statements)

References 19 publications

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“…Differentiating SP from NSA can be challenging as many of these patients have similar presenting complaints, clinical examination abnormalities, and clinicopathological findings. Early diagnosis of SP might improve outcomes through expedited administration of antimicrobials and definitive surgical correction (75, 76). Definitively identifying NSA might prevent unnecessary antimicrobial drug administration and surgical exploration of dogs with NSA, reducing morbidity, client cost and patient risk.…”

Section: Discussionmentioning

confidence: 99%

Biomarker Guided Diagnosis of Septic Peritonitis in Dogs

Martiny

Goggs

2019

Front. Vet. Sci.

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Septic peritonitis (SP) is common in dogs and is associated with high mortality. Early recognition is essential to maximizing survival and may be aided by biomarker measurement. The present study aimed to evaluate the ability of biomarkers to discriminate septic peritonitis from non-septic ascites (NSA). Eighteen dogs with SP and 19 age-matched controls with NSA were enrolled. Contemporaneous blood and peritoneal effusion samples were obtained. Concentrations of cell-free DNA (cfDNA), cytokines, glucose, lactate, N-terminal pro-C-type natriuretic peptide (NT-proCNP), nucleosomes, and procalcitonin (PCT) were measured using commercial reagents and assays. Paired biomarker concentrations were compared with the Wilcoxon matched-pairs signed rank test, and biomarker concentrations between groups were compared with the Mann-Whitney U -test. P -values were adjusted for multiple comparisons using the Bonferroni correction. Receiver operating characteristic curves were generated to assess the ability of the above biomarkers to discriminate SP from NSA. Dogs with SP had significantly greater blood CCL2 concentrations than dogs with NSA ( P = 0.032). Dogs with SP had significantly greater effusion CCL2, IL-6, IL-10, and lactate concentrations than dogs with NSA ( P ≤ 0.0121). Blood-effusion concentration gradients of CCL2, glucose, IL-6, IL-10, and lactate were significantly different in dogs with SP compared to dogs with NSA ( P ≤ 0.0165). Effusion lactate concentration had the highest AUROC value (0.866, 95% CI 0.751–0.980, P = 0.0001), although other biomarkers performed similarly. An effusion lactate concentration of 4.2 mmol/L was 72.2% (95% CI 46.5–90.3%) sensitive and 84.2% (95% CI 60.4–96.6%) specific for the diagnosis of SP.

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Section: Discussionmentioning

confidence: 99%

Biomarker Guided Diagnosis of Septic Peritonitis in Dogs

Martiny

Goggs

2019

Front. Vet. Sci.

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“…Presently, no studies have prospectively investigated the association between time to antibiotics and relevant outcomes in earlier sepsis stages. Given the high incidence of ED patients with uncomplicated sepsis who have a substantial chance to progress to severe sepsis [ 12 ], and the financial burden associated with severe sepsis [ 15 , 16 ], it would be important to explore if a measure as simple as early administration of antibiotics decreases hospital LOS, and thereby contributes to a reduction in healthcare-related costs [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study

et al. 2015

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IntroductionIn early sepsis stages, optimal treatment could contribute to prevention of progression to severe sepsis. Therefore, we investigated if there was an association between time to antibiotics and relevant clinical outcomes in hospitalized emergency department (ED) patients with mild to severe sepsis stages.MethodsThis is a prospective multicenter study in three Dutch EDs. Patients were stratified into three categories of illness severity, as assessed by the predisposition, infection, response, and organ failure (PIRO) score: PIRO score 1 to 7, 8 to 14 and >14 points, reflected low, intermediate, and high illness severity, respectively. Consecutive hospitalized ED patients with a suspected infection who were treated with intravenous antibiotics were eligible to participate in the study. The primary outcome measure was the number of surviving days outside the hospital at day 28 which was used as an inverse measure of hospital length of stay (LOS). The secondary outcome measure was 28-day mortality, taking into account the time to mortality.Multivariable Cox regression analysis was used to estimate the association between time to antibiotics and the primary and secondary outcome measures corrected for confounders, including appropriateness of antibiotics and initial ED resuscitation, in three categories of illness severity.ResultsOf the 1,168 included patients, 112 died (10%), while 85% and 95% received antibiotics within three and six hours, respectively. No association between time to antibiotics and surviving days outside the hospital or mortality was found. Only in PIRO group 1 to 7 was delayed administration of antibiotics (>3 hours) associated with an increase in surviving days outside the hospital at day 28 (hazard ratio: 1.46, 95% confidence interval: 1.05 to 2.02 after correction for potential confounders).ConclusionsIn ED patients with mild to severe sepsis who received antibiotics within six hours after ED presentation, a reduction in time to antibiotics was not found to be associated with an improvement in relevant clinical outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0936-3) contains supplementary material, which is available to authorized users.

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“…‘Therapeutic Guidelines: Antibiotic’ (TG‐A) provides locally derived, expert guidance regarding antimicrobial selection largely based on presumed source of sepsis . Source identification in the ED may not be possible or incorrect in up to 30% of cases, so recommendations are also made for circumstances in which source remains uncertain . Broad‐spectrum agents are sanctioned for unwell patients such as those with febrile neutropaenia, serious hospital‐acquired infection, meningitis or shock.…”

Section: Antimicrobialsmentioning

confidence: 99%

“…4 Source identification in the ED may not be possible or incorrect in up to 30% of cases, so recommendations are also made for circumstances in which source remains uncertain. 5 Broad-spectrum agents are sanctioned for unwell patients such as those with febrile neutropaenia, serious hospitalacquired infection, meningitis or shock. Despite regular updates and research confirming the appropriateness of TG-A recommendations, 6 compliance with these guidelines is poor, with doctors tending to overprescribe broad-spectrum drugs.…”

Section: Antimicrobial Selectionmentioning

confidence: 99%

Review article: Sepsis in the emergency department – Part 3: Treatment

Williams

Keijzers

Macdonald

et al. 2018

Emerg Medicine Australasia

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Although comprehensive guidelines for treatment of sepsis exist, current research continues to refine and revise several aspects of management. Imperatives for rapid administration of broad-spectrum antibiotics for all patients with sepsis may not be supported by contemporary data. Many patients may be better served by a more judicious approach allowing consideration of investigation results and evidence-based guidelines. Conventional fluid therapy has been challenged with early evidence supporting balanced, restricted fluid and early vasopressor use. Albumin, vasopressin and hydrocortisone have each been shown to support blood pressure and reduce catecholamine requirements but without effect on mortality, and as such should be considered for ED patients with septic shock on a case-by-case basis. Measurement of quality care in sepsis should incorporate quality of blood cultures and guideline-appropriateness of antibiotics, as well as timeliness of therapy. Local audit is an essential and effective means to improve practice. Multicentre consolidation of data through agreed minimum sepsis data sets would provide baseline quality data, required for the design and evaluation of interventions.

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Impact of the diagnostic process on the accuracy of source identification and time to antibiotics in septic emergency department patients

Cited by 10 publications

References 19 publications

Biomarker Guided Diagnosis of Septic Peritonitis in Dogs

Biomarker Guided Diagnosis of Septic Peritonitis in Dogs

The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study

Review article: Sepsis in the emergency department – Part 3: Treatment

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