title: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
abstract: OBJECTIVE
  To determine the prevalence and impact on mortality of delays in initiation of effective antimicrobial therapy from initial onset of recurrent/persistent hypotension of septic shock.
  
  
  METHODS
  A retrospective cohort study performed between July 1989 and June 2004.
  
  
  METHODS
  Fourteen intensive care units (four medical, four surgical, six mixed medical/surgical) and ten hospitals (four academic, six community) in Canada and the United States.
  
  
  METHODS
  Medical records of 2,731 adult patients with septic shock.
  
  
  METHODS
  None.
  
  
  RESULTS
  The main outcome measure was survival to hospital discharge. Among the 2,154 septic shock patients (78.9% total) who received effective antimicrobial therapy only after the onset of recurrent or persistent hypotension, a strong relationship between the delay in effective antimicrobial initiation and in-hospital mortality was noted (adjusted odds ratio 1.119 [per hour delay], 95% confidence interval 1.103-1.136, p<.0001). Administration of an antimicrobial effective for isolated or suspected pathogens within the first hour of documented hypotension was associated with a survival rate of 79.9%. Each hour of delay in antimicrobial administration over the ensuing 6 hrs was associated with an average decrease in survival of 7.6%. By the second hour after onset of persistent/recurrent hypotension, in-hospital mortality rate was significantly increased relative to receiving therapy within the first hour (odds ratio 1.67; 95% confidence interval, 1.12-2.48). In multivariate analysis (including Acute Physiology and Chronic Health Evaluation II score and therapeutic variables), time to initiation of effective antimicrobial therapy was the single strongest predictor of outcome. Median time to effective antimicrobial therapy was 6 hrs (25-75th percentile, 2.0-15.0 hrs).
  
  
  CONCLUSIONS
  Effective antimicrobial administration within the first hour of documented hypotension was associated with increased survival to hospital discharge in adult patients with septic shock. Despite a progressive increase in mortality rate with increasing delays, only 50% of septic shock patients received effective antimicrobial therapy within 6 hrs of documented hypotension.
authors.affiliation: Section of Critical Care Medicine, Health Sciences Centre/St. Boniface Hospital, University of Manitoba, Winnipeg, MB, Canada. akumar61@yahoo.com
authors.forename: Anand
authors.initials: A
authors.lastname: Kumar
authors.forename: Daniel
authors.initials: D
authors.lastname: Roberts
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Wood
authors.forename: Bruce
authors.initials: B
authors.lastname: Light
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Parrillo
authors.forename: Satendra
authors.initials: S
authors.lastname: Sharma
authors.forename: Robert
authors.initials: R
authors.lastname: Suppes
authors.forename: Daniel
authors.initials: D
authors.lastname: Feinstein
authors.forename: Sergio
authors.initials: S
authors.lastname: Zanotti
authors.forename: Leo
authors.initials: L
authors.lastname: Taiberg
authors.forename: David
authors.initials: D
authors.lastname: Gurka
authors.forename: Aseem
authors.initials: A
authors.lastname: Kumar
authors.forename: Mary
authors.initials: M
authors.lastname: Cheang
mesh_terms: D000328:Adult; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007022:Hypotension / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008350:Manitoba / Q000453:epidemiology; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge / Q000706:statistics & numerical data / Q000639:trends; D015995:Prevalence; D012189:Retrospective Studies; D012772:Shock, Septic / Q000150:complications / Q000188:drug therapy / Q000401:mortality*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology
chemical_list: D000890:Anti-Infective Agents