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Editorial: Point and Counterpoint| Volume 156, ISSUE 4, P647-649, October 01, 2019

COUNTERPOINT: Should Broad-Spectrum Antibiotics Be Routinely Administered to All Patients With Sepsis as Soon as Possible? No

DOI:https://doi.org/10.1016/j.chest.2019.05.031
COUNTERPOINT: Should Broad-Spectrum Antibiotics Be Routinely Administered to All Patients With Sepsis as Soon as Possible? No
Previous ArticlePOINT: Should Broad-Spectrum Antibiotics Be Routinely Administered to All Patients With Sepsis as Soon as Possible? Yes
Next ArticleRebuttal From Drs Disselkamp, Coz Yataco, and Simpson
      Because sepsis represents a dysregulated immune response to infection, antibiotics are a cornerstone to its management. Clinicians face two key practical questions related to antibiotics in suspected sepsis: When should antibiotic(s) be started; and what antibiotics should be given? Several well-conducted observational studies have reported poorer outcomes with delayed antibiotic administration in sepsis.
      • Kumar A.
      • Roberts D.
      • Wood K.E.
      • et al.
      Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
      Crit Care Med. 2006; 34 : 1589-1596
      , 
      • Ferrer R.
      • Martin-Loeches I.
      • Phillips G.
      • et al.
      Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program.
      Crit Care Med. 2014; 42 : 1749-1755
      , 
      • Whiles B.B.
      • Deis A.S.
      • Simpson S.Q.
      Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients.
      Crit Care Med. 2017; 45 : 623-629
      In an early retrospective study of > 2,000 hospitalized patients, survival decreased by 7.6% for every hour delay in antibiotic administration from hypotension onset.
      • Kumar A.
      • Roberts D.
      • Wood K.E.
      • et al.
      Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
      Crit Care Med. 2006; 34 : 1589-1596
      Similarly, among ED patients with severe sepsis, time to first antimicrobial agent has been associated with increased risk of progression to septic shock.
      • Whiles B.B.
      • Deis A.S.
      • Simpson S.Q.
      Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients.
      Crit Care Med. 2017; 45 : 623-629
      Finally, using prospectively collected data for the Surviving Sepsis Campaign, investigators showed that the probability of death increased with each hour delay in 17,990 patients across 165 ICUs worldwide, irrespective of the number of organ failures.
      • Ferrer R.
      • Martin-Loeches I.
      • Phillips G.
      • et al.
      Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program.
      Crit Care Med. 2014; 42 : 1749-1755
      Definition of time zero has varied across studies; nonetheless, the Surviving Sepsis Campaign gave a strong recommendation based on moderate-quality data to administer IV antimicrobial agents as soon as possible after recognition and within 1 h for both sepsis and septic shock.
      • Rhodes A.
      • Evans L.E.
      • Alhazzani W.
      • et al.
      Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
      Intensive Care Med. 2017; 43 : 304-377

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        • Roberts D.
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        • et al.
        Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
        Crit Care Med. 2006; 34: 1589-1596
        View in Article
        • Ferrer R.
        • Martin-Loeches I.
        • Phillips G.
        • et al.
        Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program.
        Crit Care Med. 2014; 42: 1749-1755
        View in Article
        • Whiles B.B.
        • Deis A.S.
        • Simpson S.Q.
        Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients.
        Crit Care Med. 2017; 45: 623-629
        View in Article
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        • Evans L.E.
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      Article Info

      Footnotes

      FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

      Identification

      DOI: https://doi.org/10.1016/j.chest.2019.05.031

      Copyright

      © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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      Linked Article

      • POINT: Should Broad-Spectrum Antibiotics Be Routinely Administered to All Patients With Sepsis as Soon as Possible? Yes
        CHESTVol. 156Issue 4
        • In Brief
          Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.1 It affects millions of people worldwide annually, with a mortality ranging from 25% to 50%.2 Significant improvements in patient outcomes have resulted from early identification and appropriate management in the initial hours following development of sepsis. Evidence-based guidelines currently recommend empiric broad-spectrum antibiotics with one or more antimicrobial agents within 1 h for patients with sepsis or septic shock, a strong recommendation with moderate quality of evidence.
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