Design: In a retrospective cohort of critically ill patients with septic shock.
Setting: Twenty-four ICUs.
Patients: A total of 6,720 patients with septic shock.
Measurements and Main Results: Higher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p less than 0.0001); older age (+16 min per 10 yr; p less than 0.0001); presence of comorbidities (+35 min; p less than 0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p less than 0.0001), between 3 and 7 days (+121 min; p less than 0.0001), and longer than 7 days (+130 min; p less than 0.0001); and a diagnosis of pneumonia (+45 min; p less than 0.01) were associated with longer times to antimicrobial therapy. Two variables were associated with shorter times to antimicrobial therapy: community-acquired infections (–53 min; p less than 0.001) and higher temperature (–15 min per 1°C; p less than 0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p less than 0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p less than 0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, –47 min; p less than 0.001) had shorter times to antimicrobial therapy.
Conclusions: We identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.
This is important because in septic shock mortality increases with passage of time until antibiotic administration. These results suggest that increased patient complexity drives delay. Deceptive and indolent presentations appear to be associated with delay as evidenced by the finding of shorter times for higher temperatures. For already hospitalized patients, the longer they had been in the hospital the longer the delay. Might complacency regarding patients near the end of their stay drive this? Particularly intriguing is the fact that academic medical centers had longer delays (+52 minutes). I have to wonder if this relates to more restrictive antibiotic policies and layers of approval embedded at such institutions.