Prehospital Antibiotics for Presumed Sepsis
Washington University Emergency Medicine Journal Club– March 16th, 2022
Vingnette:
You are moonlighting in a large community ED one afternoon when EMS brings you a 65-year-old male with a remote history of lymphoma, now in remission, with a chief complaint of fevers and cough. En route, EMS noted the patient to be febrile to 38.4 ℃ with a blood pressure of 108/68, heart rate 114, respiratory rate 18, and normal oxygen saturation on room air. After a bolus of 500 mL of LR the patient remained febrile, and his heart rate improved to 95. By EMS protocol, the paramedics then drew blood cultures from the initial IV site and administered 2 grams of ceftriaxone for presumed bacterial sepsis.
The patient arrives in stable condition, is ultimately diagnosed with metapneumovirus with a clear chest x-ray and is discharged home. While you understand the concerns about early therapy in presumed bacterial sepsis (having read multiple prior journal club write-ups on early goal directed therapy in sepsis) you wonder if this EMS protocol isn’t a bit overly aggressive, and likely to overdiagnose sepsis in patients with non-infectious SIRS and viral syndromes. In addition to increased cost, you also worry about breeding antibiotic resistance to one of our most frequently used parenteral antibiotics. As you presume this protocol is evidence-based, you email your Washington University EMS and critical care gurus to see if they know what the evidence really shows…
PICO Question
Population:
Intervention:
Comparison:
Outcome:
Search Strategy
Article 1: Varney J, Motawea KR, Kandil OA, Hashim HT, Murry K, Shah J, Shaheen A, Akwari J, Awad AK, Rivera A, Mostafa MR, Swed S, Awad DM. Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis. Heal Sci Rep . 2022;5. Answer Key.
Article 2: Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Léguillier T, Gueye-Ngalgou P, Vivien B. Impact of prehospital antibiotic therapy on septic shock mortality. Prehosp Emerg Care. 2021;25(3):317-24. Answer KEy.
Article 3: Alam N, Oskam E, Stassen PM, Exter PV, van de Ven PM, Haak HR, Holleman F, Zanten AV, Leeuwen-Nguyen HV, Bon V, Duineveld BAM, Panday RSN, Kramer MHH, Nanayakkara PWB, Alam N, Nanayakkara PWB, Oskam E, Stassen PM, Haak HR, Holleman F, Nannan Panday RS, Duineveld BAM, van Exter P, van de Ven PM, Bon V, Goselink J, De Kreek A, van Grunsven P, Biekart M, Deddens GJ, Weijschede F, Rijntjes N, Franschman G, Janssen J, Frenken J, Versluis J, Boomars R, de Vries G, den Boer E, van Gent A, Willeboer M, Buunk G, Timmers GJ, Snijders F, Posthuma N, Stoffelen S, Claassens S, Ammerlaan H, Sankatsing S, Frenken J, Alsma J, van Zanten A, Slobbe L, de Melo MM, Dees A, Carels G, Wabbijn M, van Leeuwen-Nguyen TTH, Assink J, van der Honing A, Luik P, Poortvliet W, Schouten WEM, Veenstra J, Holkenborg J, Cheung TC, van Bokhorst J, Kors B, Louis-Wattel GH, Roeleveld T, Toorians A, Jellema W, Govers A, Kaasjager HAH, Dekker D, Verhoeven MAM, Kramer MHH, Flietstra T, Roest L, Peters EJG, Hekker TAM, Ang W, van der Wekken W, Ghaem Maghami P, Kanen B, Wesselius H, Heesterman L, Zwietering AN, Stoffers J, on behalf of the, PHANTASi Trial Investigators and the ORCA (Onderzoeks Consortium Acute Geneeskunde) Research Consortium the Netherlands, PHANTASi Trial Investigators and the ORCA (Onderzoeks Consortium Acute Geneeskunde) Research Consortium the Netherlands. Prehospital antibiotics in the ambulance for sepsis: A multicentre, open label, randomised trial. Lancet Respir Med. 2018;6(1):40-50. Answer Key.
Article 4: Lane DJ, Wunsch H, Saskin R, Cheskes S, Lin S, Morrison LJ, Scales DC. Screening strategies to identify sepsis in the prehospital setting: A validation study. CMAJ. 2020;192(10):E230-9. Answer Key.
Bottom Line: