Antibiotics

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cannonball88

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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?
 
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?
 
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?
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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.
 
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?
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What does your review of the evidence tell you?
 
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
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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.
 
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:
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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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...
 
Instead of pushing for paramedicine to change, maybe rural services simply need to hire CCT qualified medics.


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gotshirtz001 said:
Instead of pushing for paramedicine to change, maybe rural services simply need to hire CCT qualified medics.


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

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.
 
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.

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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That is medicine. One researchers quest to prove something's valid is followed by anothers to disprove it, so it seems to me.
 
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.
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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.
 
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.
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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.
 
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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DEmedic said:
Most rural services can barely staff the trucks. Not saying that's a valid excuse, but still factual.
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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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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
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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.
 
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.
Click to expand...

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...
 
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...
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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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