Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis

Garnacho-Montero J, Garcia-Garmendia JL, Berrero-Almodovar A, et al. Crit Care Med 2003;31:2742–2751.

Summary:

This study examined critically ill patients with sepsis who were admitted to the intensive care unit (ICU) of a tertiary hospital. The primary aim of this study was to determine whether giving adequate or inadequate empiric antibiotics had an impact on mortality in these patients. The study specifically excluded patients who developed their sepsis while already in the ICU. Four-hundred and six patients were included, with microbiological evidence of sepsis recorded in 67% of these. The investigators found that predictors of in-hospital mortality were:

• the sepsis-related organ failure (SOFA) score on admission to the ICU
• the increase in SOFA score over the first 3 days in the ICU
• respiratory failure within the first 24 hours in the ICU
• inadequate empiric antimicrobial therapy in patients with nonsurgical sepsis.

Adequate empiric antimicrobial therapy in surgical and urological sepsis was found to reduce mortality rates — the risk of death was reduced by two-thirds in surgical patients.

This study confirms that giving inadequate antimicrobial therapy increases the risk of death 8-fold in patients with sepsis. However, the choice of antimicrobial therapy only affected the 28- and 60-day mortality rate and did not have an impact on early (<3 days) death rate. Early death rate was associated with the development of respiratory, hepatic or renal failure and with the presence of pre-existing comorbidities.

Of the micro-organisms cultured, Escherichia coli was the commonest in both blood and the site of infection. Candida spp. were also common and were associated with inadequate treatment. Interestingly, this did not affect mortality. The other factor that was related to inadequate therapy was antibiotic treatment in the month before admission.

This article supports the following ‘real’ core principles:

• Adequate antibiotics given early reduce the risk of death.
• An antibiotic history is essential to guide the administration of more appropriate empiric therapy.

Learning points:

• Use broad-spectrum antibiotics early on.
• Consider the possibility of fungal infections.
• Take an antibiotic history and act on it.
• Some patients may be — or may become — so ill that death is inevitable.
• Pre-existing disease affects outcomes in patients with sepsis on admission to the ICU.