In this episode, I’ll discuss prehospital antibiotics for severe sepsis.
Back in episode 185, I discussed a study that looked at Delays From First Medical Contact to Antibiotic Administration for Sepsis. The authors found that the median time from first medical contact to antibiotic administration was 4.2 hours with a delay of 0.52 hours accounted for by prehospital care and a delay of 3.6 hours accounted for by the emergency department.
In this study, only the total and ED time delay in giving antibiotics was associated with increased mortality. However, the study authors raised an interesting point:
Should antibiotics be given in the prehospital setting for sepsis?
At first glance, it seems that giving prehospital antibiotics is not supported by this study. After all, the delay in the prehospital period was not statistically significant in terms of effects on mortality. But if the antibiotic were to be given in the ambulance, 100% of the emergency department delay is eliminated, and this delay was associated with increased mortality.
Recently, a pilot study of prehospital antibiotics for severe sepsis has been published in Academic Emergency Medicine. The primary aim of the study was to describe the safety and feasibility of a protocol for prehospital recognition of sepsis with hypotension and septic shock, drawing of blood cultures, and administration of intravenous antibiotics in an urban EMS service in the US.
There was a prospective cohort that got prehospital antibiotics and it was compared to a retrospective cohort.
Patients had blood cultures drawn and then received either piperacillin/tazobactam if there was no penicillin allergy or ceftriaxone if there was a penicillin allergy. There were 29 patients involved in this prospective pilot study which were then compared to a retrospective cohort.
The time from receipt of the 911 call to antibiotic administration was significantly lower for the prospective cohort than the historical cohort (a mean of ~36 versus ~220 minutes, p<0.005). However, the time spent on scene by first responders increased by 10 minutes as did the scene plus transport time.
The study was not powered to look at hard outcomes like mortality, but it did demonstrate the feasibility of this approach.
Antibiotics were only administered in this study if 2 sets of blood cultures could be drawn. There was only one blood culture contamination in the prospective cohort. Additional antibiotics during the ED and hospital course were administered in all but one of the encounters, suggesting the protocol was able to successfully identify patients with an infection.
Emergency Medicine pharmacists have the potential to interact with their local EMS provider leadership to discuss these results. If you are not in contact with EMS leadership, ask around among the ED physicians you work with. Chances are several of them are involved in regular meetings and can put you in contact with the group.
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