Division of Infectious Diseases

Antimicrobial Stewardship & Sepsis – A Great Debate

Optimal management of sepsis has long-been a holy grail in medicine. One area that remains fraught with debate is how to effectively balance the need for emergent antimicrobial administration with principles of antimicrobial stewardship. A recent PointCounterpoint series on “Should Broad-Spectrum Antibiotics Be Routinely Administered to All Patients with Sepsis as Soon as Possible”published in CHEST highlights the debate. Disselkamp et al argue yes, early administration of broad-spectrum antibiotics increases the likelihood of adequate coverage AND is associated with decreased mortality. This does not negate the need for commitment to stewardship, but “If we do not use antibiotics for patients with life-threatenining organ dysfunction, who are we saving them for?”

Conversely,  Patel and Bergl argue that although delayed antibiotics due increase mortality in sepsis, the strong recommendation for empiric broad-antimicrobial therapy is inappropriate due to a paucity of high-quality evidence and risk of harm(such as adverse drug events, Clostridiodes difficile infection) with “indiscriminate broad-spectrum antibiotics.” They further argue that appropriate antibiotic therapy may not always be broad-spectrum, and the assumption that broad-spectrum is required is both flawed and potentially costly to patients and healthcare systems.

Further, perhaps this debate is not the most critical for our sepsis patients currently. Kashiouris et al demonstrated that delays in first antimicrobial execution (time from order to administration) are common and carry increased mortality, particularly for patients with many comorbidities. Regardless of what antibiotics are ordered, if not administered within the first hour, mortality continues to rise.

Do we have time to determine optimal antimicrobial therapy in sepsis when we frequently fail to administer it fast enough?

How do we determine the greater good? Immediate mortality or potential downstream morbidity and mortality from adverse events?

Our patients are relying on us for life-saving, timely antibiotics in sepsis and septic shock. Every minute matters – the time to diagnosis of sepsis, the time to ordering antibiotics, and the time to administration. Focusing on the drug choice, or time to ordering, is no longer enough. We must take a greater ownership over the entire process, including considering the speed of delivery, simultaneously, if we want to optimize care.

Originally posted on the IDSA News Journal Club

 

References:

Point: Yes; Disselkamp M, Yataco AO, Simpson SQ. Point: should broad-spectrum antibiotics be routinely administered to all patients with sepsis as soon as possible? Yes. Chest. 2019 Oct 1;156(4):645-7.

Point: No; Patel JJ, Bergl PA. Counterpoint: should broad-spectrum antibiotics be routinely administered to all patients with sepsis as soon as possible? No. Chest. 2019 Oct 1;156(4):647-9.

Kashiouris MG, Zemore Z, Kimball Z, Stefanou C, Fisher B, de Wit M, Pedram S, Sessler CN. Supply Chain Delays in Antimicrobial Administration After the Initial Clinician Order and Mortality in Patients With Sepsis. Critical care medicine. 2019 Oct 1;47(10):1388-95.


 

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