title: Impact of the diagnostic process on the accuracy of source identification and time to antibiotics in septic emergency department patients.
abstract: OBJECTIVE
  Timely administration of effective antibiotics is important in sepsis management. Source-targeted antibiotics are believed to be most effective, but source identification could cause time delays.
  
  
  OBJECTIVE
  First, to describe the accuracy/time delays of a diagnostic work-up and the association with time to antibiotics in septic emergency department (ED) patients. Second, to assess the fraction in which source-targeted antibiotics could have been administered solely on the basis of patient history and physical examination.
  
  
  METHODS
  Secondary analysis of the prospective observational study on septic ED patients was carried out. The time to test result availability was associated with time to antibiotics. The accuracy of the suspected source of infection in the ED was assessed. For patients with pneumosepsis, urosepsis, and abdominal sepsis, combinations of signs and symptoms were assessed to achieve a maximal positive predictive value for the sepsis source, identifying a subset of patients in whom source-targeted antibiotics could be administered without waiting for diagnostic test results.
  
  
  RESULTS
  The time to antibiotics increased by 18 (95% confidence interval: 12-24) min/h delay in test result availability (n=323). In 38-79% of patients, antibiotics were administered after additional tests, whereas the ED diagnosis was correct in 68-85% of patients. The maximal positive predictive value of signs and symptoms was 0.87 for patients with pneumosepsis and urosepsis and 0.75 for those with abdominal sepsis. Use of signs and symptoms would have led to correct ED diagnosis in 33% of patients.
  
  
  CONCLUSIONS
  Diagnostic tests are associated with delayed administration of antibiotics to septic ED patients while increasing the diagnostic accuracy to only 68-85%. In one-third of septic ED patients, the choice of antibiotics could have been accurately determined solely on the basis of patient history and physical examination.
authors: aLeiden University Medical Centre, Leiden bMedical Centre Haaglanden cHAGA Hospital, The Hague dErasmus Medical Center, Rotterdam, The Netherlands.
authors: Annemieke J M
authors: AJ
authors: Uittenbogaard
authors: Ernie R J T
authors: ER
authors: de Deckere
authors: Maro H
authors: MH
authors: Sandel
authors: Alice
authors: A
authors: Vis
authors: Christine M
authors: CM
authors: Houser
authors: Bas
authors: B
authors: de Groot
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D015331:Cohort Studies; D016001:Confidence Intervals; D003955:Diagnostic Tests, Routine; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D005260:Female; D006090:Gram-Negative Bacteria / Q000302:isolation & purification; D006094:Gram-Positive Bacteria / Q000302:isolation & purification; D017052:Hospital Mortality; D006785:Hospitals, University; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015999:Multivariate Analysis; D020380:Needs Assessment; D009426:Netherlands; D011446:Prospective Studies; D018570:Risk Assessment; D018805:Sepsis / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D012772:Shock, Septic / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D015996:Survival Rate; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents