Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
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.
Kumar
Anand
A
Section of Critical Care Medicine, Health Sciences Centre/St. Boniface Hospital, University of Manitoba, Winnipeg, MB, Canada. akumar61@yahoo.com
Roberts
Daniel
D
Wood
Kenneth E
KE
Light
Bruce
B
Parrillo
Joseph E
JE
Sharma
Satendra
S
Suppes
Robert
R
Feinstein
Daniel
D
Zanotti
Sergio
S
Taiberg
Leo
L
Gurka
David
D
Kumar
Aseem
A
Cheang
Mary
M
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
D000890:Anti-Infective Agents