Antibiotics

[EpiEMS]

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.

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.

 

[Handsome Robb]

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]

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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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!

 

[Flight-LP]

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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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.

 

[Alan L Serve]

^
I
I
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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.

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

 

[Flight-LP]

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.

 

[Summit]

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).

 

[EpiEMS]

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?

 

[Carlos Danger]

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?

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.

 

[Tigger]

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.

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.

 

[rescue1]

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.

 

[Alan L Serve]

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.

 

[Carlos Danger]

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.

 

[NomadicMedic]

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.

 

[luke_31]

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.

 

[MapleLeaf4Evr]

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.

 

[SpecialK]

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.

 

[rescue1]

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.

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.

 

[MapleLeaf4Evr]

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.

 

[VinBin]

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.