title: Septic shock and adequacy of early empiric antibiotics in the emergency department.
abstract: BACKGROUND
  Antibiotic resistance is an increasing concern for Emergency Physicians.
  
  
  OBJECTIVE
  To examine whether empiric antibiotic therapy achieved appropriate antimicrobial coverage in emergency department (ED) septic shock patients and evaluate reasons for inadequate coverage.
  
  
  METHODS
  Retrospective review was performed of all adult septic shock patients presenting to the ED of a tertiary care center from December 2007 to September 2008. Inclusion criteria were: 1) Suspected or confirmed infection; 2) ≥ 2 Systemic Inflammatory Response Syndrome criteria; 3) Treatment with one antimicrobial agent; 4) Hypotension requiring vasopressors. Patients were dichotomized by presentation from a community or health care setting.
  
  
  RESULTS
  Eighty-five patients with septic shock were identified. The average age was 68 ± 15.8 years. Forty-seven (55.3%) patients presented from a health care setting. Pneumonia was the predominant clinically suspected infection (n = 38, 45%), followed by urinary tract (n = 16, 19%), intra-abdominal (n = 13, 15%), and other infections (n = 18, 21%). Thirty-nine patients (46%) had an organism identified by positive culture, of which initial empiric antibiotic therapy administered in the ED adequately covered the infectious organism in 35 (90%). The 4 patients who received inadequate therapy all had urinary tract infections (UTI) and were from a health care setting.
  
  
  CONCLUSIONS
  In this population of ED patients with septic shock, empiric antibiotic coverage was inadequate in a small group of uroseptic patients with recent health care exposure. Current guidelines for UTI treatment do not consider health care setting exposure. A larger, prospective study is needed to further define this risk category and determine optimal empiric antibiotic therapy for patients.
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Flaherty
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Weber
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Maureen
authors.initials: M
authors.lastname: Chase
authors.affiliation: Department of Emergency Medicine, Johns Hopkins Medicine, Baltimore, MD.
authors.forename: Andrea F
authors.initials: AF
authors.lastname: Dugas
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Amanda M
authors.initials: AM
authors.lastname: Graver
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Justin D
authors.initials: JD
authors.lastname: Salciccioli
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Michael N
authors.initials: MN
authors.lastname: Cocchi
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Division of Pulmonary/Critical and Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Donnino
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy / Q000382:microbiology; D003428:Cross Infection / Q000188:drug therapy / Q000382:microbiology; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006801:Humans; D059413:Intraabdominal Infections / Q000188:drug therapy* / Q000382:microbiology; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000382:microbiology; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012772:Shock, Septic / Q000188:drug therapy* / Q000382:microbiology; D062606:Tertiary Care Centers; D014552:Urinary Tract Infections / Q000188:drug therapy* / Q000382:microbiology
chemical_list: D000900:Anti-Bacterial Agents
keywords: antibiotics; critical care; nosocomial; sepsis; urinary tract infection