Journal
CRITICAL CARE MEDICINE
Volume 44, Issue 12, Pages 2145-2153Publisher
LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/CCM.0000000000001868
Keywords
antimicrobials; health services research; quality improvement; sepsis; shock
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Funding
- Eli-Lilly
- Astellas
- Pfizer
- Merck
- Manitoba Health Research Council
- Health Sciences Centre (Winnipeg) Foundation
- Deacon Foundation (Winnipeg)
- AKPA Pharma DMC
- Tory
- Uni-Labs
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Objectives: To identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock. 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. Interventions: None. Measurements and Main Results: Higher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p<0.0001); older age (+16 min per 10 yr; p<0.0001); presence of comorbidities (+35 min; p<0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p<0.0001), between 3 and 7 days (+121 min; p<0.0001), and longer than 7 days (+130 min; p<0.0001); and a diagnosis of pneumonia (+45 min; p<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<0.001) and higher temperature (-15 min per 1 degrees C; p<0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p<0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p<0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, 47 min; p<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.
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