Septic Shock and Adequacy of Early Empiric Antibiotics in the Emergency Department

Abstract

Background Antibiotic resistance is an increasing concern for Emergency Physicians. Objectives To examine whether empiric antibiotic therapy achieved appropriate antimicrobial coverage in Emergency Department (ED) septic shock patients and evaluate reasons for inadequate coverage. Methods Retrospective review was performed of all adult septic shock patients presenting to the ED of a tertiary care center from December 2007 to September 2008. Inclusion criteria were: 1) Suspected or confirmed infection; 2) ≥ 2 SIRS criteria; 3) Treatment with one antimicrobial agent; 4) Hypotension requiring vasopressors. Patients were dichotomized by presentation from a community or health-care setting. Results Eighty-five patients with septic shock were identified. The average age was 68 ± 15.8 years. Forty seven (55.3%) patients presented from a health-care setting. Pneumonia was the predominant clinically suspected infection (38, 45%), followed by urinary tract infection (16, 19%), intra-abdominal (13, 15%) and other (18, 21%). Thirty-nine patients (46%) had an organism identified by positive culture, of which initial empiric antibiotic therapy administered in the ED adequately covered the infectious organism in 35 (90%). The four patients who received inadequate therapy all had urinary tract infections (UTI) and were from a health care setting. Conclusion In this population of ED patients with septic shock, empiric antibiotic coverage was inadequate in a small group of uroseptic patients with recent health care exposure. Current guidelines for UTI treatment do not consider health care setting exposure. A larger, prospective study is needed to further define this risk category and determine optimal empiric antibiotic therapy for patients.

Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter global prevalence of infections in urology (GPIU) study 2003–2013

“…Rapid and appropriate management of sepsis, including the administration of an initially adequate intravenous antibacterial, is essential for optimal outcomes [ 1 ]. However, compared to other causes of sepsis, inadequate coverage was identified as an outstanding problem in urosepsis [ 5 ]. Therefore, evidence about the pathogen spectrum and antibacterial resistance especially in urosepsis needs to be well collected.…”

Uncomplicated and Complicated Urinary Tract Infections in Adults: The Infectious Diseases’s Specialist Perspective

“…[121][122][123] The administration of an initially adequate intravenous antibiotic is essential for optimal outcome but inadequate coverage in urosepsis may be a problem due to the lack of solid microbiological data. 124 In a German study regarding sepsis, the bacterial spectrum of urosepsis consisted of E. coli in 61% of cases, followed by other enterobacteria in 16%, S. aureus in 8% and enterococci in 6% of cases. 125 A recent point prevalence study conducted in 70 countries from 2003 to 2013 shows that the overall prevalence of E. coli as a cause of urosepsis was 43% followed by Enterococcus spp (11%) and Klebsiella spp.…”

Individualized antibiotic strategies

“…antimicrobial therapy. The selection of antimicrobials frequently relies on a detailed patient's history, as in the case of a patient with recent healthcare exposure [15], recent travels to areas with high prevalence of MDR bacteria [16], previous antibiotic therapy [17], or a high incidence of difficult-to-treat pathogens in the given ward or ICU [18]. As such, if for community-acquired infections or for those patients without any of these confounders the selection of an empirical antibiotic therapy is most often appropriate, choosing appropriate empiric antimicrobials in those patients at risk of MDR may be challenging.…”