To assess the optimal of timing of administering antibiotics to sepsis patients in the emergency department

Sepsis is a serious medical condition characterized by an inflammatory response to an infection that can affect the whole body. The patient may develop an inflammatory response to microbes in their blood, urine, lungs, skin, or other tissues. Sepsis is a serious condition with a very high death rate if left untreated. Most sepsis patients require antibiotics and admission to an intensive care unit (ICU). How soon broad spectrum antibiotics should be delivered is as yet unclear. Broad spectrum antimicrobial treatment is defined as a combination of antibiotics which act against a wide range of disease-causing bacteria, used to reduce mortality rates in patients with sepsis, severe sepsis or septic shock. We carried out a systematic review of the literature by searching key databases for high quality published and unpublished material on the timing of antibiotics in the emergency department prior to ICU admission. Our searches revealed no randomized controlled trials (RCTs) on the timing of broad spectrum antibiotic treatment in this population. We conclude that there is a need to carry out observational cohort studies, in the absence of RCTs, even if they lack the precision of RCTs. We also conclude that the earlier the antibiotics are administered the better. It is important to realize that the clock starts ticking when the patient arrives in the ED and stops once the antibiotic is started. The pre-intensive care unit period is the time spent in the ward or ED prior to being admitted to the ICU, where most patients with severe sepsis are admitted. The review was purposefully very specific as it is focused only on patients with severe sepsis and in finding only RCTs. The absence of these may imply, in itself, the complicated nature of the study question as it may be ethically wrong to randomize such patients to a seemingly inferior treatment arm.

Authors' conclusions: 

Based on this review we are unable to make a recommendation on the early or late use of broad spectrum antibiotics in adult patients with severe sepsis in the ED pre-ICU admission. There is a need to do large prospective double blinded randomized controlled trials on the efficacy of early (within one hour) versus late broad spectrum antibiotics in adult severe sepsis patients. Since it makes sense to start antibiotics as soon as possible in this group of seriously ill patients, administering such antibiotics earlier as opposed to later is based on anecdotal suboptimal evidence.

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Background: 

Severe sepsis and septic shock have recently emerged as particularly acute and lethal challenges amongst critically ill patients presenting to the emergency department (ED). There are no existing data on the current practices of management of patients with severe sepsis comparing early versus late administration of appropriate broad spectrum antibiotics as part of the early goal-directed therapy that is commenced in the first few hours of presentation.

Objectives: 

To assess the difference in outcomes with early compared to late administration of antibiotics in patients with severe sepsis in the pre-intensive care unit (ICU) admission period. We defined early as within one hour of presentation to the ED.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009); MEDLINE (1990 to February 2010); EMBASE (1990 to February 2010); and ISI web of Science (February 2010). We also searched for relevant ongoing trials in specific websites such as www.controlled-trials.com; www.clinicalstudyresults.org; and www.update-software.com. We searched the reference lists of articles. There were no constraints based on language or publication status.

Selection criteria: 

We planned to include randomized controlled trials of early versus late broad spectrum antibiotics in adult patients with severe sepsis in the ED, prior to admission to the intensive care unit.

Data collection and analysis: 

Two authors independently assessed articles for inclusion.

Main results: 

We found no studies that satisfied the inclusion criteria.

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