title: The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis.
abstract: OBJECTIVE
  We sought to systematically review and meta-analyze the available data on the association between timing of antibiotic administration and mortality in severe sepsis and septic shock.
  
  
  METHODS
  A comprehensive search criteria was performed using a predefined protocol.
  
  
  METHODS
  
  
  
  METHODS
  adult patients with severe sepsis or septic shock, reported time to antibiotic administration in relation to emergency department triage and/or shock recognition, and mortality.
  
  
  METHODS
  immunosuppressed populations, review article, editorial, or nonhuman studies.
  
  
  METHODS
  Two reviewers screened abstracts with a third reviewer arbitrating. The effect of time to antibiotic administration on mortality was based on current guideline recommendations: 1) administration within 3 hours of emergency department triage and 2) administration within 1 hour of severe sepsis/septic shock recognition. Odds ratios were calculated using a random effect model. The primary outcome was mortality.
  
  
  RESULTS
  A total of 1,123 publications were identified and 11 were included in the analysis. Among the 11 included studies, 16,178 patients were evaluable for antibiotic administration from emergency department triage. Patients who received antibiotics more than 3 hours after emergency department triage (< 3 hr reference) had a pooled odds ratio for mortality of 1.16 (0.92-1.46; p = 0.21). A total of 11,017 patients were evaluable for antibiotic administration from severe sepsis/septic shock recognition. Patients who received antibiotics more than 1 hour after severe sepsis/shock recognition (< 1 hr reference) had a pooled odds ratio for mortality of 1.46 (0.89-2.40; p = 0.13). There was no increased mortality in the pooled odds ratios for each hourly delay from less than 1 to more than 5 hours in antibiotic administration from severe sepsis/shock recognition.
  
  
  CONCLUSIONS
  Using the available pooled data, we found no significant mortality benefit of administering antibiotics within 3 hours of emergency department triage or within 1 hour of shock recognition in severe sepsis and septic shock. These results suggest that currently recommended timing metrics as measures of quality of care are not supported by the available evidence.
authors.affiliation: All authors: Department of Emergency Medicine, University of Mississippi School of Medicine, Jackson, MS.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Sterling
authors.forename: W Ryan
authors.initials: WR
authors.lastname: Miller
authors.forename: Jason
authors.initials: J
authors.lastname: Pryor
authors.forename: Michael A
authors.initials: MA
authors.lastname: Puskarich
authors.forename: Alan E
authors.initials: AE
authors.lastname: Jones
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D004636:Emergency Service, Hospital; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D018805:Sepsis / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D012772:Shock, Septic / Q000188:drug therapy / Q000401:mortality; D014218:Triage
chemical_list: D000900:Anti-Bacterial Agents