Longer antibiotic delay intervals associated with hospital mortality in patients with suspected sepsis

While both time from ED triage to antibiotic order and time from antibiotic order to infusion were associated with increased hospital mortality, this was true only for longer delays, indicating that a one-hour antibiotic administration target may be too aggressive, study authors said.

Only longer delays in antibiotic administration after ED triage for suspected sepsis were associated with hospital mortality in a recent study.

Researchers retrospectively looked at patients treated in the ED for suspected sepsis from January 2014 to September 2017 at 12 hospitals in a large health care system in the Southeastern U.S. They defined suspected sepsis as digital signature of infection and organ dysfunction. For infection, they specified the antibiotics ordered and administered within 12 hours of ED triage and culture ordered within 48 hours of ED triage. They then applied SOFA criteria to capture organ dysfunction. The primary outcome was hospital mortality, including discharge to hospice. The primary exposures were recognition time (i.e., time in hours from ED triage to antibiotic order) and administration time (i.e., time in hours from antibiotic order to antibiotic infusion). Antibiotic order and administration times were obtained from the electronic health record. Results were published online on Feb. 15 by Critical Care Medicine.

The study cohort included 28,865 unique encounters representing 24,093 adult patients (mean age, 59.7 years; 53.1% women) presenting to the ED with suspected sepsis. The median time from ED triage to antibiotic administration (i.e., total delay) was 3.4 hours (interquartile range [IQR], 2.0 to 6.0 h), separated into a median recognition delay (i.e., time from ED triage to antibiotic order) of 2.7 hours (IQR, 1.5 to 4.7 h) and a median administration delay (i.e., time from antibiotic order to infusion) of 0.6 hour (IQR, 0.3 to 1.2 h).

After adjustment for other risk factors, both recognition delay and administration delay were associated with hospital mortality (P<0.01 for both). While pairwise comparisons showed nonsignificant effects for recognition delays up to six hours, there was an increased odds of hospital mortality with recognition delays greater than six hours compared with less than one hour (odds ratio, 1.21; 95% CI, 1.0 to 1.46). Likewise for administration delays, pairwise comparisons found increased odds of hospital mortality only for order-to-infusion times of 1.5 to 2 hours (odds ratio, 1.35; 95% CI, 1.07 to 1.71) and of 2 to 2.5 hours (odds ratio, 1.51; 95% CI, 1.14 to 2.00) compared with times less than 0.5 hour. For a subgroup of patients with suspected septic shock, administration delay was the only interval found to have a significant association with mortality.

Limitations of the study include the possibility of residual confounding and potentially limited generalizability to hospitals outside of the health system, the authors noted. “Delays in both recognition time and administration time contribute to the delay in antibiotic delivery for patients with suspected sepsis. … These results suggest that both metrics may be important to measure and improve but do not support a 1-hour antibiotic administration target for patients with suspected sepsis,” they concluded.