Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study.

BACKGROUND: Timely administration of antibiotics is one of the most important interventions in reducing mortality in sepsis. However, administering antibiotics within a strict time threshold in all patients suspected with sepsis will require huge amount of effort and resources and may increase the risk of unintentional exposure to broad-spectrum antibiotics in patients without infection with its consequences. Thus, controversy still exists on whether clinicians should target different time-to-antibiotics thresholds for patients with sepsis versus septic shock. METHODS: This study analyzed prospectively collected data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Adjusted odds ratios (ORs) were compared for in-hospital mortality of patients who had received antibiotics within 1 h to that of those who did not. Spline regression models were used to assess the association of time-to-antibiotics as continuous variables and increasing risk of in-hospital mortality. The differences in the association between time-to-antibiotics and in-hospital mortality were assessed according to the presence of septic shock. RESULTS: Overall, 3035 patients were included in the analysis. Among them, 601 (19.8%) presented with septic shock, and 774 (25.5%) died. The adjusted OR for in-hospital mortality of patients whose time-to-antibiotics was within 1 h was 0.78 (95% confidence interval [CI] 0.61-0.99; p = 0.046). The adjusted OR for in-hospital mortality was 0.66 (95% CI 0.44-0.99; p = 0.049) and statistically significant in patients with septic shock, whereas it was 0.85 (95% CI 0.64-1.15; p = 0.300) in patients with sepsis but without shock. Among patients who received antibiotics within 3 h, those with septic shock showed 35% (p = 0.042) increased risk of mortality for every 1-h delay in antibiotics, but no such trend was observed in patients without shock. CONCLUSION: Timely administration of antibiotics improved outcomes in patients with septic shock; however, the association between early antibiotic administration and outcome was not as clear in patients with sepsis without shock.

Compliance of sepsis hour-1 bundle strategy for patients with septic shock in emergency department / 中华全科医师杂志

Objective:To investigate the implementation status of sepsis hour-1 bundle strategy for patients with septic shock in emergency department.Methods:A total of 116 septic shock patients admitted to the emergency department from January 2020 to December 2020 were included in this prospective study, and the implementation of sepsis bundles and the clinical outcomes of patients were recorded.Results:Among 116 patients, 20 cases (17.2%) had lactic acid monitored within 1 h, 20 cases (17.2%) had blood culture before antibiotics, 82 cases (70.1%) received broad-spectrum antibiotics, 16 cases (13.8%) received fluid resuscitation ≥30 ml/kg, and 57 cases (49.1%) received vasoactive drugs during resuscitation. Finally, the sepsis hour-1 bundle strategy was fully implemented only in 13 cases (11.2%). Compared with the group with incomplete implementation of sepsis hour-1 bundle strategy, the volume of fluid recovery in the group with full implementation was significantly increased [33.7 (30.0,37.5) vs. 8.9(7.3,10.8) ml/kg, Z=-4.78, P<0.001], mean artery blood pressure significantly increased [70.0 (70.0,76.7) vs. 67.7 (61.7,76.7)mmHg(1 mmHg=0.133 kPa) , Z=-2.00, P<0.001], and lactic acid significantly decreased [3.0 (2.0,3.2) vs. 4.4 (3.7,7.2) mmol/L, Z=-2.76, P=0.006]. However, there were no significant differences in ICU mortality, in-hospital mortality and 28-day mortality between the two groups ( P>0.05). Conclusions:Septic shock patients in emergency department have poor compliance with the implementation of sepsis hour-1 bundle strategy, and relevant management training should be strengthened.

Effect of septic shock rapid response group on compliance with hour-1 bundle therapy strategy / 中华急诊医学杂志

Objective:To investigate the effect of septic shock rapid response team (SSRRT) on the compliance and prognosis of hour-1 bundle therapy strategy in emergency department patients with septic shock.Methods:This study was conducted on emergency patients with septic shock who were admitted to Huai’an First Hospital Affiliated to Nanjing Medical University from January 2020 to December 2021. The inclusion criteria were emergency patients with septic shock who met the international guideline for surviving sepsis campaigns (Sepsis 3.0). Exclusion criteria: age<18 years, pregnant patients, patients transferred from another hospital who had received fluid resuscitation and/or vasoactive drugs, patients requiring emergency surgery, patients with emergency detention time<1 h, patients who refused to place central venous catheterization or had contraindications for catheterization, and patients who refused to give informed consent. SSRRT was established in January 2021. According to the establishment of SSRRT, patients were divided into the pre-SSRRT intervention group and the post-SSRRT intervention group. The general clinical data of the enrolled patients were collected, including vital signs, lactate, fluid resuscitation volume, maximum vasoactive drug pumping rate at the diagnosis of septic shock, implementation of hour-1 bundle therapy strategies, and ICU and 28-day mortality. Statistical software SPSS 25.0 was used. Pearson chi-squared test was used to compare categorical variables between groups, and Mann-Whitney U test was used to compare continuous variables between groups.Results:A total of 289 emergency patients met the inclusion criteria, 115 patients were excluded, and 174 patients were eventually included, including 83 patients in the pre-SSRRT group and 91 patients in the post-SSRRT group. Compared with the pre-SSRRT group, the proportion of lactate monitoring (54.2% vs. 100.0%, P<0.001), blood culture (27.7% vs. 93.4%, P<0.001), antibiotics (57.8% vs. 97.8%, P<0.001), fluid resuscitation volume ≥ 30 mL/kg (4.8% vs. 34.1%, P<0.001), and mean arterial pressure ≥ 65 mmHg (49.4% vs. 68.1%, P<0.001) were significantly increased. There was no significant difference in ICU mortality (50.6% vs. 37.4%, P=0.079) or 28-day mortality (53.0% vs. 38.5%, P=0.054) between the two groups. Conclusions:SSRRT can significantly improve the compliance of hour-1 bundle therapy strategy implementation in patients with emergency septic shock, and has a trend of decreasing mortality.

The Update of the concept of sepsis and The Surviving Sepsis Campaign Bundle, The new challenges to current clinical practice / 医学研究生学报

In these years, renewal of the concept of sepsis, application of qSOFA and proposal of hour-1 bundle for sepsis further suggested to diagnose and treatment of sepsis earlier and faster than before. It presents new challenges to current clinical practice and asks us to be more alert to forewarning symptoms of patients, optimize hospital management procedures, strengthen training exercises and multidisciplinary collaboration in order to achieve optimal treatment of sepsis.