# Antibiotics



## cannonball88 (Sep 26, 2016)

After reading about some services with sepsis and septic shock protocols that include use of antibiotics, I'm wondering if anyone here has such a protocol. If so:

1. What antibiotics are in your protocol, and what guidelines do you have for their use?
2. What is the transport time to your closest appropriate facility to treat sepsis?
3. Has your service or local ED noticed a difference in patient outcomes?


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## NomadicMedic (Sep 26, 2016)

https://www.greenvillecounty.org/Em...s/training/EMS_Publishing/standing_orders.pdf

Section 8.17


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## cannonball88 (Sep 26, 2016)

Theoretically, and for the sake of argument, do you believe antibiotics being administered by EMS 20 minutes prior to ED arrival would make a difference in patient care vs. receiving them upon ED arrival 20 minutes later?


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## VentMonkey (Sep 26, 2016)

cannonball88 said:


> Theoretically, and for the sake of argument, do you believe antibiotics being administered by EMS 20 minutes prior to ED arrival would make a difference in patient care vs. receiving them upon ED arrival 20 minutes later?


20 minutes? Maybe not, but perhaps in more rural settings with extensive transport times, and/ or a community paramedic program.

A simple push dose antibiotic to the right patient population may do wonders. Sepsis is a killer. There's a thread on here already about this with the link @DEmedic posted above, and the Jems article as well.

Hopefully it helps answer some of your questions.


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## Summit (Sep 26, 2016)

cannonball88 said:


> Theoretically, and for the sake of argument, do you believe antibiotics being administered by EMS 20 minutes prior to ED arrival would make a difference in patient care vs. receiving them upon ED arrival 20 minutes later?


What does your review of the evidence tell you?


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## EpiEMS (Sep 26, 2016)

DEmedic said:


> https://www.greenvillecounty.org/Em...s/training/EMS_Publishing/standing_orders.pdf
> 
> Section 8.17


Out of curiosity, are you typically looking at long or long-ish transport times?


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## VentMonkey (Sep 26, 2016)

Summit said:


> What does your review of the evidence tell you?


Awww, not more homework!?? Jk.

Here's a fairly quick and good sepsis read from EMS World that parallels the Jems research

http://www.emsworld.com/article/10685110/sepsis-treatment


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## Summit (Sep 26, 2016)

http://lifeinthefastlane.com/ccc/antibiotic-timing/ summarized:


> Observational data has shown strong associations between early antibiotics and survival outcomes, however a recent (flawed) systematic review did not find a benefit for early antibiotics



And here is that metastudy which does not support SCC's 1-hour recognition 3-hour triage abx requirements and showed faster abx weren't associated with reduced mortality:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4597314/

I disagree with the criticism that the metastudy had a selection bias as the excluded studies for non-response don't seem to create that bias, and the objection over abx choice or confirmed bacteremia should be overcome by the pooled ORs which would offer sufficient power.

You can find plenty of other studies showing faster abx = less mortality, to the point where one could EASILY conjecture that 20 minutes would be important (I used to think so, less sure now). Then again, very little data for prehospital and you could extrapolate that prehospital setting is the least time sensitive and prehospital providers are probably the most diagnostically limited and least sensitive/specific diagnosticians of sepsis (remember the ED gets 3 hours from triage or 1 hour from recognition) considering how bad other clinicians are at it, even with fancy lab tests and electronic decision support, early warning, etc.

But the biggest challenge with sepsis is that no matter what we seem to do, we don't seem to be getting much better at treating it. We have good ideas, good hints, and then we do them all, and the results are unimpressive.


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## VentMonkey (Sep 26, 2016)

Summit said:


> http://lifeinthefastlane.com/ccc/antibiotic-timing/ summarized:
> 
> 
> And here is that metastudy which does not support SCC's 1-hour recognition 3-hour triage abx requirements and showed faster abx weren't associated with reduced mortality:
> ...


IMO, most prehospital providers (i.e., "street medics") seem severely lacking in the importance factor of how big of a killer this truly is. 

This disease process is harped on over and over again in critical care medicine, journals, abstracts, etc., but again, a larger issue we face is the severe lack of knowledge or perhaps even down play SIRS, sepsis, and the entire cascade it carries with many of these patients.

Sadly, until we evolve as a profession, and seriously consider re-writing the paramedic curriculum to make paramedicine a nationally mandated 4 year degree to include critical care topics such as this, I don't know that we'll be able to prove (confidently) any of these studies in the prehospital environment.

Merit badge medicine makes for poor trial studies, and collectively that is what I feel many prehospital trial studies reflect, as most medics don't view this as either a career, or even worse, medicine.

So nothing new here in summation, but the patient suffers yet another debility that we very well could curtail given the right tools, but again, I digress...


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## gotbeerz001 (Sep 26, 2016)

Instead of pushing for paramedicine to change, maybe rural services simply need to hire CCT qualified medics. 


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## NomadicMedic (Sep 26, 2016)

gotshirtz001 said:


> Instead of pushing for paramedicine to change, maybe rural services simply need to hire CCT qualified medics.
> 
> 
> Sent from my iPhone using Tapatalk



Most rural services can barely staff the trucks. Not saying that's a valid excuse, but still factual.


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## Carlos Danger (Sep 26, 2016)

Summit said:


> http://lifeinthefastlane.com/ccc/antibiotic-timing/ summarized:
> 
> 
> And here is that metastudy which does not support SCC's 1-hour recognition 3-hour triage abx requirements and showed faster abx weren't associated with reduced mortality:
> ...



Honestly it's been a while since I reviewed the current guidelines and literature on early sepsis treatment. I see quite a bit of sepsis but it's usually already been diagnosed and cultures drawn and ABX given and now they just need a line or a drain or a laparotomy.

But IIRC, no study has shown that faster antibiotics improve outcomes, generally speaking. I think the only timeline that really matters according to the research that the surviving sepsis guidelines are based on, is that antibiotics be administered within one hour of the development of hypotension. So basically, if they are to the point that shock has developed, then yes, they need them quickly. But if they are not yet to that point, then 20 minutes or 60 minutes earlier probably doesn't matter.

I think beyond that, outcomes were unchanged as long as they were given within 8 hours of the recognition of the diagnostic criteria of sepsis. Again, this assumes normotension.

I don't think giving ABX in the field is a bad idea, but like so many other things, I'm just skeptical that it is going to help in most cases. It is certainly worth some trials. It'll be interesting to see what the research finds.


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## VentMonkey (Sep 26, 2016)

Remi said:


> Honestly it's been a while since I reviewed the current guidelines and literature on early sepsis treatment. I see quite a bit of sepsis but it's usually already been diagnosed and cultures drawn and ABX given and now they just need a line or a drain or a laparotomy.
> 
> But IIRC, no study has shown that faster antibiotics improve outcomes, generally speaking. I think the only timeline that really matters according to the research that the surviving sepsis guidelines are based on, is that antibiotics be administered within one hour of the development of hypotension. So basically, if they are to the point that shock has developed, then yes, they need them quickly. But if they are not yet to that point, then 20 minutes or 60 minutes earlier probably doesn't matter.
> 
> ...


That is medicine. One researchers quest to prove something's valid is followed by anothers to disprove it, so it seems to me.


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## Carlos Danger (Sep 26, 2016)

VentMonkey said:


> That is medicine. One researchers quest to prove something's valid is followed by anothers to disprove it, so it seems to me.



Well, depending on how you look at it, it's just confirming the initial findings, or it's just parsing the data closely to make sure it really means what it first appears to mean. You could easily sum the whole thing up by just saying "yep, the earlier that antibiotics are given, the better", but now you have to be in a hurry to give everyone who _may be_ septic ABX as soon as possible. There are downsides to that approach, too.


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## VentMonkey (Sep 26, 2016)

Remi said:


> Well, depending on how you look at it, it's just confirming the initial findings, or it's just parsing the data closely to make sure it really means what it first appears to mean. You could easily sum the whole thing up by just saying "yep, the earlier that antibiotics are given, the better", but now you have to be in a hurry to give everyone who _may be_ septic ABX as soon as possible. There are downsides to that approach, too.


Indeed, EBM is a double-edged sword. Hence, my push for at the very least extended curriculum at the national level so that _all _paramedics are better equipped with much needed critical thinking skills. Again, as a whole, so as not to single anyone.

And FWIW, I think @gotshirtz001 makes a good point. Having CCP's in QRV's isn't a half bad idea, but that is a different topic for a different thread.


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## Handsome Robb (Sep 26, 2016)

We're looking at starting to do a sepsis alert program and potentially abx but not for a little while. Our MD is very data driven. 

While I think it's interesting part of me wonders if this isn't the next "fad" of EMS kinda like therapeutic hypothermia. 


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## gotbeerz001 (Sep 26, 2016)

DEmedic said:


> Most rural services can barely staff the trucks. Not saying that's a valid excuse, but still factual.


I don't see how increasing the requirements/time/money to become licensed would change that; I see it making the problem worse (at least temporarily)... Not saying it's an invalid argument, but the current training levels work for a busy urban medic with 20 min (or less) transport times. We are actually having trouble filling our open medic spots; we have upwards of 30 open positions in the SF Bay area. 


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## VentMonkey (Sep 26, 2016)

gotshirtz001 said:


> I don't see how increasing the requirements/time/money to become licensed would change that; I see it making the problem worse (at least temporarily)... Not saying it's an invalid argument, but the current training levels work for a busy urban medic with 20 min (or less) transport times. We are actually having trouble filling our open medic spots; we have upwards of 30 open positions in the SF Bay area.
> 
> 
> Sent from my iPhone using Tapatalk


As do we, but perhaps in systems such as mine, and even more so in true rural systems where definitive care is literally hours away.

We cover anything from busy metropolitan areas, to extremely remote areas with varying transport times to the nearest hospital.


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## EpiEMS (Sep 27, 2016)

Handsome Robb said:


> While I think it's interesting part of me wonders if this isn't the next "fad" of EMS kinda like therapeutic hypothermia.



On one hand, I think you could be right - insofar as that the evidence is there, but only sort of.
On the other, I do think EMS can do a lot more for sepsis (just in terms of volume) than for post-ROSC:

Sepsis incidence is on the order of 300 per 100,000 (or, for 300 million people, 900,000 cases - conservatively, let's assume this rate is correct, I would have guessed it'd be many times higher...) while we're talking about a fairly similar rate for OOHCA, circa 326,000 cases in 2015. But the percentage of those who experience ROSC is much lower...


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## VentMonkey (Sep 27, 2016)

EpiEMS said:


> On one hand, I think you could be right - insofar as that the evidence is there, but only sort of.
> On the other, I do think EMS can do a lot more for sepsis (just in terms of volume) than for post-ROSC:
> 
> Sepsis incidence is on the order of 300 per 100,000 (or, for 300 million people, 900,000 cases - conservatively, let's assume this rate is correct, I would have guessed it'd be many times higher...) while we're talking about a fairly similar rate for OOHCA, circa 326,000 cases in 2015. But the percentage of those who experience ROSC is much lower...


I think I'm right there with you on this one, @EpiEMS.

Comparing stats from ROSC studies, trials, therapies or what have you to those of a disease process that can start off with proper prehospital treatment and EGDT prior to even walking through the ED, is very much similar to how AMI/ ACS and CVA patients have IMO proved our worth as field clinicians.

Making prehospital providers part of a "code sepsis", or bundle even if it's merely standard shock therapy treatment (high flow O2, and bilateral large bore access, and IVF), can cut down on admission time. 

If we can prove our competency with this as we have with other disease processes this cuts down on the workload of the ED staff, and once more proves our value as a crucial link in the chain of early detection, and prevention.

While I don't think anyone here has, or will dispute this, it's just that comparing the poor outcomes most ROSC patients will have vs. that of even a properly identified SIRS patient is like comparing apples and oranges.


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## EpiEMS (Sep 27, 2016)

VentMonkey said:


> I think I'm right there with you on this one, @EpiEMS.
> 
> Comparing stats from ROSC studies, trials, therapies or what have you to those of a disease process that can start off with proper prehospital treatment and EGDT prior to even walking through the ED, is very much similar to how AMI/ ACS and CVA patients have IMO proved our worth as field clinicians.
> 
> ...



Spot on, I think -- I bring up ROSC as I tend to think we focus a lot of our efforts on a smaller population, particularly one where we can't do all that much. I think triage is a main function of EMS, and that's where we prove our value - identify the disease process, start basic measures, and go from there. I like aligning EMS sepsis therapy to the same framework as ACS and CVA -- it makes good sense given the similarities in terms of progression from entry into the health care system (ED to ICU/CCU, say) through (hopefully) discharge.


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## Handsome Robb (Sep 27, 2016)

Sorry I should have been more clear. I absolutely think early recognition, notification and aggressive prehospital treatment are merited, I'm not sold on prehospital abx. 

That's more where the fad comment came in, the abx. 


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## EpiEMS (Sep 27, 2016)

Handsome Robb said:


> Sorry I should have been more clear. I absolutely think early recognition, notification and aggressive prehospital treatment are merited, I'm not sold on prehospital abx.
> 
> That's more where the fad comment came in, the abx.
> 
> ...



That's what my understanding of your comment was (relative paucity of evidence for prehospital antibiotics) -- I can't imagine any regular on this board being against good evidence-based assessment and treatment!


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## Flight-LP (Sep 27, 2016)

Handsome Robb said:


> Sorry I should have been more clear. I absolutely think early recognition, notification and aggressive prehospital treatment are merited, I'm not sold on prehospital abx.
> 
> That's more where the fad comment came in, the abx.
> 
> ...



^
I
I
I

This.........

There are too many variables present in treating SIRS, sepsis, and septic shock for the pre-hospital environment to adequately and efficiently begin antibiotic treatment.

Just a few off the top of my head...............

Pharmacokinetic issues with metabolism and excretion. Are the kidneys adequately functioning? Do we have any hepatic dysfunction? Not going to know until we get a Chemistry and LFTs drawn.

Hydrophilic vs. lipophilic? Fluid and volume administration is going to have a potentially profound effect.

Co-morbid issues? Need for 'pressors? Age? Pathogen? 

Then we have to look at the logistical issues............what should we carry?

Amp/Gent? Amp/Cefepime? Zosyn? Vancomycin? Rocephin? All have their place in the front line for different pathogens and populations. How would we address the cost?

I'm definitely an advocate for aggressive Abx tx for these folks and I utilize the hell out of them on my hospital Pedi / Neo team, but it just doesn't seem reasonable or prudent to use them in the pre-hospital environment.


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## Alan L Serve (Sep 27, 2016)

Flight-LP said:


> ^
> I
> I
> I
> ...


Just go with Imipenem/Cilastin IV and you'll hit just about everything. Throw in some Azithromycin to hit all the atypicals.


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## Flight-LP (Sep 27, 2016)

Alan L Serve said:


> Just go with Imipenem/Cilastin IV and you'll hit just about everything. Throw in some Azithromycin to hit all the atypicals.



Not quite that simple...................

Primaxin isn't used for sepsis (organism susceptibility)  or meningitis (doesn't cross the BBB) and its cost is generally prohibitive for most EMS services. It's also not the safest option for kids and pregnant females. Works great for CF infections though...................

Zithromax may cover some atypicals, but it is not indicated for sepsis and is inferior to most other antibiotics in most of its coverage categories.


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## Summit (Sep 28, 2016)

Vanc/Zosyn is the typical empiric combo en vogue for sepsis... a lot of the time... except when it isn't (for many reasons). And I still see plenty of ER/ICU staff that don't know what order to give them in if they can only do one at a time (hint, Zosyn first, but why? Because it isn't the obvious reason).


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## EpiEMS (Sep 28, 2016)

Summit said:


> Vanc/Zosyn is the typical empiric combo en vogue for sepsis... a lot of the time... except when it isn't (for many reasons). And I still see plenty of ER/ICU staff that don't know what order to give them in if they can only do one at a time (hint, Zosyn first, but why? Because it isn't the obvious reason).


Sounds like good reasons to refrain from general implementation of antibiotics for EMS -- too many complications for your general provider to deal with?


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## Carlos Danger (Sep 28, 2016)

Flight-LP said:


> Pharmacokinetic issues with metabolism and excretion. Are the kidneys adequately functioning? Do we have any hepatic dysfunction? Not going to know until we get a Chemistry and LFTs drawn.
> 
> Hydrophilic vs. lipophilic? Fluid and volume administration is going to have a potentially profound effect.
> 
> ...



I don't understand how or why any of these factors would preclude the use of prehospital antibiotics. I would do the same thing that the ED does, which is draw cultures, then give a broad-spectrum agent that is suitable for the likely source, and then switch to a more specific agent when the cultures come back.

I'm not sure what the most appropriate antibiotic is to use prehospital, if you had to choose only one. Zosyn? It wouldn't be that hard to carry a few different drugs though, either, and write protocols to guide which one to use based on history and presentation.

I am skeptical of the utility of prehospital ABX as well, for the reasons I stated earlier. But I think it definitely needs to be trialed, using different agents and protocols.


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## Tigger (Sep 29, 2016)

Remi said:


> Honestly it's been a while since I reviewed the current guidelines and literature on early sepsis treatment. I see quite a bit of sepsis but it's usually already been diagnosed and cultures drawn and ABX given and now they just need a line or a drain or a laparotomy.
> 
> But IIRC, no study has shown that faster antibiotics improve outcomes, generally speaking. I think the only timeline that really matters according to the research that the surviving sepsis guidelines are based on, is that antibiotics be administered within one hour of the development of hypotension. So basically, if they are to the point that shock has developed, then yes, they need them quickly. But if they are not yet to that point, then 20 minutes or 60 minutes earlier probably doesn't matter.
> 
> ...


This is a good summary of the research I have seen. Patients in "septic shock" need antibiotics quickly, though the original study that showed every hour that goes by without them results in an 8% increase in mortality has not been replicated to my knowledge.

That said, there are probably systems (mine included) that could benefit. I would rather take these patients to a hospital with an ICU that is 90 minutes away than our local bandaid box that is 45 minutes away that could start a broad spectrum antibiotic but do nothing else.


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## rescue1 (Sep 29, 2016)

I think we have a fairly long way to go before we can consider prehospital abx in sepsis a good idea, and certainly a long way before it's "standard of care", like the JEMS article suggested. I think the jump to getting medics to rapidly and aggressively fluid resuscitate septic patients is more pressing--I would say most systems (definitely all my old jobs) lack a sepsis recognition/treatment plan like a "code sepsis". I don't think we're ready for a jump from barely thinking about sepsis to suddenly using lactate meters and giving Zosyn. 

The article I looked at (from Greenville EMS) also indicates that their new sepsis guidelines included massive fluid infusions. I'm not sure if anyone here works there, but if providers were treating sepsis more aggressively than they were before it's difficult to say whether or not the increased survival rate came from rapid recognition and fluids vs early abx. Are there any studies that looked at antibiotic use alone? 

This is all even assuming that the time saved is even clinically significant, for which we have one study on Early Goal Directed Therapy, which is a technique that's come under pretty severe criticism within the past year or so. 

I guess basically I'm saying I'd like to see actual data on whether or not this helps before I get excited about it.


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## Alan L Serve (Sep 30, 2016)

I really don't know enough about antibiotics but I do know that I've seen patients get a lot better a lot quickly after a lot of the right antibiotics. It can't be too hard for us to do blood cultures, gram stains, and biochemical/metabolic tests in the ambulance. Right?

Someone pass me the Medical Tricorder.


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## Carlos Danger (Oct 1, 2016)

Alan L Serve said:


> I really don't know enough about antibiotics but I do know that I've seen patients get a lot better a lot quickly after a lot of the right antibiotics. It can't be too hard for us to do blood cultures, gram stains, and biochemical/metabolic tests in the ambulance. Right?
> 
> Someone pass me the Medical Tricorder.



I dont know what a medical tricorder is, but we were drawing labs in the ambulance in the 90's.

None of those tests need to be done before the first dose of ABX.


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## NomadicMedic (Oct 1, 2016)

With a little training, medics can easily draw cultures before starting any abx. I don't know why this is such a huge deal. If it's clinically indicated, let's get out of the EMS dark ages and embrace some EBM.


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## luke_31 (Oct 2, 2016)

Remi said:


> I dont know what a medical tricorder is, but we were drawing labs in the ambulance in the 90's.
> 
> None of those tests need to be done before the first dose of ABX.


The medical tricorder is a joke, it's a medical device from Star Trek that does the work of a CT, MRI, blood labs, X-Ray, and apparently the doctor's assessment too.


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## MapleLeaf4Evr (Oct 3, 2016)

I am a military medic up in the Justin Bieber filled expanse of Canada.  We have an abx protocol if any of the following conditions are met:

- globular eye injury;
- serious orofacial infection;
- penetrating abdominal injury; or
- Any other injury with obvious surface contamination and a transport time > 2 hrs.

400 mg Moxifloxacin is our oral antibiotic of choice.  Our IV alternatives are Cefoxitin or Clindamycin.


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## SpecialK (Oct 3, 2016)

In Australasia all services are carrying ceftriaxone and so is the Republic of Ireland.  Benzylpenicillin in the UK.  

We're not doing cultures anymore, can't get the 21 District Health Boards to do things one way re microbiological specimens so the ambulance service has foregone it until the DHBs can agree on something; which I don't see happening.


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## rescue1 (Oct 3, 2016)

MapleLeaf4Evr said:


> I am a military medic up in the Justin Bieber filled expanse of Canada.  We have an abx protocol if any of the following conditions are met:
> 
> - globular eye injury;
> - serious orofacial infection;
> ...



How rural is your service? 

Interestingly (or perhaps not that interestingly), I'd have no real argument with EMS giving abx for these conditions, all of which tend to be very easy to diagnose and all of which very obviously require antibiotics. You guys also have the advantage of more education for your medics.

I guess I would make the argument that urban services with short transport times would probably see no benefit from this though. But that's probably true of several medications/procedures that are fairly ubiquitous in EMS too.


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## MapleLeaf4Evr (Oct 4, 2016)

rescue1 said:


> How rural is your service?
> 
> Interestingly (or perhaps not that interestingly), I'd have no real argument with EMS giving abx for these conditions, all of which tend to be very easy to diagnose and all of which very obviously require antibiotics. You guys also have the advantage of more education for your medics.
> 
> I guess I would make the argument that urban services with short transport times would probably see no benefit from this though. But that's probably true of several medications/procedures that are fairly ubiquitous in EMS too.



These are protocols for our military medics but they apply to all areas of practice whether it is on a deployment overseas or during every day business here at home.

Based on this, it is hard to answer your question specifically, but our transport times might be anywhere from 10 minutes to 72 hrs depending on where we are working.


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## VinBin (Oct 9, 2016)

I think rather than focusing on antibiotics in sepsis with hemodynamic changes (which is really the only reason I see to rush to abx in pre-hospital medicine), focus on stabilizing patients first with good BLS/ALS and fluid management. Trying to do lab tests to evaluate renal/liver function before giving antibiotics, and also drawing blood cultures (*and to be careful to prevent contamination, *which is a huge issue in a relatively controlled ED environment and almost impossible in EMS) is going to be unlikely to bring about any meaningful clinical outcome improvements. This is the same reason studies find BLS services performing better than ALS in trauma, trying to do too much when the goal should be to transfer to the ED is often an ego game of medics trying to prove their skills/ability/etc.


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## SpecialK (Oct 9, 2016)

From what I understand, there is good evidence that delays to antibiotic therapy increased mortality from sepsis.  

By "sepsis with hemodynamic changes" I presume you were talking about septic shock.  Yes, these patients do need a good volume of fluid, but that's going to do nothing about treating the actual cause of the infection which has given them sepsis.  

There is some risk with the inappropriate administration of antibiotics, but in severe sepsis or septic shock, pragmatically the balance of risk is going to be on administering antibiotics no?

While the evidence is limited, for example there are no randomized trials, antibiotics are carried by many ambulance services in the world.  In New Zealand there have been a number of case reports of patients with septic shock who've received early prehospital Ceftriaxone making completely normal recoveries.

You don't want to hand it out to every man and his dog, but it is cheap, easy to administer, and in the absence of ability to test for a specific pathogen and tailor antimicrobial therapy, where's the risk in appropriately administering a broad spectrum antibiotic?


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## medicsb (Oct 9, 2016)

I'm not completely opposed to the idea of EMS-initiated ABx Tx, but I do not think it should be standing order.  Med command order all day every day until it can be demonstrated that paramedics can appropriately identify patients in need of early ABx.  And even still, it should be studied even if medical control is providing the orders.  Over-administration of ABx can be bad and certainly there are many illnesses, intoxications, injuries, etc. that can produce VS that meet SIRS (e.g. seizure, sympathomimetics, heat exposure, dehydration, etc) without the presence of infection.  Within a reasonable amount of time, I can usually determine a source - CXR for pulm, urine dip for UTI/pyelo, and a good head-to-toe for skin.  Exam or lack of findings in the other three may necessitate LP or CT of abd & pelvis, but at that point starting broad spectrum ABx should be started.

I'd focus more on early identification (SIRS + lactate + EtCO2), fluid boluses, and IV pressors PRN (really, though pressors are rarely needed in the prehospital phase).  If the political climate is right, I'd take labs drawn by EMS (could draw extra blue top tubes - the ones for coags - as they can have blood transferred to culture bottles).  As an EM doc, I would appreciate a sepsis alert of full VS (incl temp and EtCO2), suspected source, and initiation of of a 30ml/kg fluid bolus in the right patient (one without a h/o severe heart failure).  The ideal would be a partially exposed pt. (outer clothes removed) with good IV access and enough of a heads-up that I could summon the right number of RNs, gain a urine sample (by straight cath if need be), Xray tech for the CXR, and rapid head to toe skin exam.  If a 30ml/kg bolus was completed prehospital and pt. remained hypotensive (MAP <65), I would move quickly on central venous access, pressors, and ABx initiation.  

I swear most medics and EMTs could do the early stuff better than nurses, who are too often hindered by their "need" to gain demographic information before actually initiating care (yes it is a pet peeve of mine when I'm trying to exam a patient and get a good H&P and the nurse keeps interrupting to ask crap like whether the pt. has gotten a flu vaccine or ask if they know their social security number - I know they're required to ask this stuff and pressured by nurse managers and other desk jockeys to get it early, but it DOES often hinder pt. care).  

Anyhow, to do this would mean for EMS to slow down a little and to shed the notion that everything should be done on the move.  I have no problem with EMS taking 10 minutes to perform a more thorough exam and gain key information if it helps expedite ED care.


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## Akulahawk (Oct 9, 2016)

medicsb said:


> I'm not completely opposed to the idea of EMS-initiated ABx Tx, but I do not think it should be standing order.  Med command order all day every day until it can be demonstrated that paramedics can appropriately identify patients in need of early ABx.  And even still, it should be studied even if medical control is providing the orders.  Over-administration of ABx can be bad and certainly there are many illnesses, intoxications, injuries, etc. that can produce VS that meet SIRS (e.g. seizure, sympathomimetics, heat exposure, dehydration, etc) without the presence of infection.  Within a reasonable amount of time, I can usually determine a source - CXR for pulm, urine dip for UTI/pyelo, and a good head-to-toe for skin.  Exam or lack of findings in the other three may necessitate LP or CT of abd & pelvis, but at that point starting broad spectrum ABx should be started.
> 
> I'd focus more on early identification (SIRS + lactate + EtCO2), fluid boluses, and IV pressors PRN (really, though pressors are rarely needed in the prehospital phase).  If the political climate is right, I'd take labs drawn by EMS (could draw extra blue top tubes - the ones for coags - as they can have blood transferred to culture bottles).  As an EM doc, I would appreciate a sepsis alert of full VS (incl temp and EtCO2), suspected source, and initiation of of a 30ml/kg fluid bolus in the right patient (one without a h/o severe heart failure).  The ideal would be a partially exposed pt. (outer clothes removed) with good IV access and enough of a heads-up that I could summon the right number of RNs, gain a urine sample (by straight cath if need be), Xray tech for the CXR, and rapid head to toe skin exam.  If a 30ml/kg bolus was completed prehospital and pt. remained hypotensive (MAP <65), I would move quickly on central venous access, pressors, and ABx initiation.
> 
> ...


Where I work, we have to do the triage and that's done at the bedside. I agree that there are portions of the Triage and "Patient Data Profile" that can wait. What _I_ want to know is why you're here, what you're allergic to, what medications you take, and the basics of who you are and your age. During the initial assessment/eval, we gather data that also fills out parts of the triage forms we must fill out. Once all the basic stuff is done and we've got the basics done, then we can (and should) go back and gather the rest of the demographics we need. We do spend too much time initially than we should. It takes me about 7 minutes to complete the Triage and PDP forms _if_ I can get all the data quickly. That translates sometimes into a 3-5 minute delay in actually initiating care if I'm the only nurse in the room. If I have more hands to assist me, then we can get things going much more quickly.


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## usalsfyre (Oct 11, 2016)

VinBin said:


> (*and to be careful to prevent contamination, *which is a huge issue in a relatively controlled ED environment and almost impossible in EMS)



Last time I checked, my ambulances/aircraft weren't really any dirtier than an ED room. I've worked in both. Preventing contamination is more of a training issue than anything.


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## VinBin (Oct 19, 2016)

usalsfyre said:


> Last time I checked, my ambulances/aircraft weren't really any dirtier than an ED room. I've worked in both. Preventing contamination is more of a training issue than anything.


It's not a question of "dirty vs clean." You can prevent contamination in a sewer if you prep the patient and use strict sterile technique. It's a matter of which environment can accommodate that for a majority of blood draws. I have seen many contaminated blood cultures from the ED, but consider doing the same in a moving ambulance, where the majority of the time the counters, drawers, seats, aren't really cleaned as well as they should be. It is a training issue but the situation/environment can make a big difference.


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