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. 2023 Aug 25;5(9):e0959.
doi: 10.1097/CCE.0000000000000959. eCollection 2023 Sep.

Delayed Treatment of Bloodstream Infection at Admission is Associated With Initial Low Early Warning Score and Increased Mortality

Christian P Fischer  1 , Emili Kastoft  2   3 , Bente Ruth Scharvik Olesen  4 , Bjarne Myrup  2
Affiliations

Delayed Treatment of Bloodstream Infection at Admission is Associated With Initial Low Early Warning Score and Increased Mortality

Christian P Fischer et al. Crit Care Explor. .

Abstract

Objectives: To identify factors associated with antibiotic treatment delay in patients admitted with bloodstream infections (BSIs).

Design: Retrospective cohort study.

Setting: North Zealand Hospital, Denmark.

Patients: Adult patients with positive blood cultures obtained within the first 48 hours of admission between January 1, 2015, and December 31, 2015 (n = 926).

Measurements and main results: First recorded Early Warning Score (EWS), patient characteristics, time to antibiotic treatment, and survival at day 60 after admission were obtained from electronic health records and medicine module. Presence of contaminants and the match between the antibiotic treatment and susceptibility of the cultured microorganism were included in the analysis. Data were stratified according to EWS quartiles. Overall, time from admission to prescription of antibiotic treatment was 3.7 (3.4-4.0) hours, whereas time from admission to antibiotic treatment was 5.7 (5.4-6.1) hours. A gap between prescription and administration of antibiotic treatment was present across all EWS quartiles. Importantly, 23.4% of patients admitted with BSI presented with an initial EWS 0-1. Within this group of patients, time to antibiotic treatment was markedly higher among nonsurvivors at day 60 compared with survivors. Furthermore, time to antibiotic treatment later than 6 hours was associated with increased mortality at day 60. Among patients with an initial EWS of 0-1, 51.3% of survivors received antibiotic treatment within 6 hours, whereas only 19.0% of nonsurvivors received antibiotic treatment within 6 hours.

Conclusions: Among patients with initial low EWS, delay in antibiotic treatment of BSIs was associated with increased mortality at day 60. Lag from prescription to administration may contribute to delayed antibiotic treatment. A more frequent reevaluation of patients with infections with a low initial EWS and reduction of time from prescription to administration may reduce the time to antibiotic treatment, thus potentially improving survival.

Keywords: bacteremia; blood culture; organ dysfunction scores; systemic inflammatory response syndrome; triage.

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Conflict of interest statement

The authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Microbiology of positive blood cultures. Prevalence (%) of detected microorganisms among all positive blood cultures obtained within the first 48 hr of admission. Bloodstream infection (red bars, solid lines), probable contamination (light gray bars, dashed lines). CoNS = coagulase-negative Staphylococcus, E. coli = Escherichia coli, S. aureus = Staphylococcus aureus, S. pyogenes = Streptococcus pyogenes, S. pneumoniae = Streptococcus pneumoniae.
Figure 2.
Figure 2.
Early Warning Score (EWS), time to antibiotic treatment, and survival status at day 60. A, Time to antibiotic treatment (mean and 95% CI) among survivors (red bars) and nonsurvivors (light gray bars) at day 60 postadmission, by EWS quartile (EWS ranges from lowest to highest quartile 0–1, 2–3, 4–5, and 6+, respectively). Solid lines, all patients with positive cultures. Dashed lines, patients with contaminants excluded. Asterisk, difference (p < 0.05) within the EWS quartile (adjusted for age, sex, Charlson comorbidity index, presence of contaminants, and appropriate antibiotic treatment). B, Time to physician (mean and 95% CI) among survivors (red bars) and nonsurvivors (light gray bars) at day 60 postadmission, by EWS quartile. Solid lines, all positive cultures. Dashed lines, patients with contaminants excluded. C, Time to prescription of antibiotic treatment (mean and 95% CI) among survivors (red bars) and nonsurvivors (light gray bars) at day 60 postadmission, by EWS quartile. Solid lines, all patients with positive cultures. Dashed lines, patients with contaminants excluded. Asterisk, difference (p < 0.05) within the EWS quartile (adjusted for age, sex, Charlson comorbidity index, and presence of contaminants). D, Odds ratio (OR, mean, and 95% CI) of being nonsurvivor at day 60 postadmission by maximal time to antibiotic treatment (adjusted for age, sex, Charlson comorbidity index, EWS quartile, presence of contaminants, and appropriate antibiotic treatment).
Figure 3.
Figure 3.
Effect of time to antibiotic treatment within 6 hr on survival 60 d postadmission. A, Percentage alive 60 d postadmission according to time to antibiotic treatment ≤ 6 hr (red bars) and time to antibiotic treatment > 6 hr (light gray bars), by EWS quartile. Solid lines, all positive cultures. Dashed lines, patients with contaminants excluded. Asterisk, difference (p < 0.05) within the Early Warning Score (EWS) quartile (adjusted for age, sex, Charlson comorbidity index, presence of contaminants, and appropriate antibiotic treatment). B, Percentage started on antibiotic treatment within 6 hr among survivors (red bars) and nonsurvivors (light gray bars) at day 60 postadmission, by EWS quartile. Solid lines, all positive cultures. Dashed lines, patients with contaminants excluded. Asterisk, difference (p < 0.05) within the EWS quartile (adjusted for age, sex, and Charlson comorbidity index).
Figure 4.
Figure 4.
Microbiology and Early Warning Score (EWS), time to antibiotic treatment, and survival 60 d postadmission. A, Distribution of EWS quartiles (the lower quartile, the lighter colored bar) by microorganism. Asterisk, difference (p < 0.05) when compared to patients with contaminants (adjusted for age, sex, and Charlson comorbidity index). B, Percentage survivors (red bars) and nonsurvivors (gray bars) at day 60 postadmission by microorganism. Darker part of each bar, time to antibiotic treatment ≤ 6 hr. Asterisk, difference from patients with contaminants comparing survival at day 60 (adjusted for age, sex, Charlson comorbidity index [CCI], and EWS quartile). Diamond, difference from patients with contaminants comparing time to antibiotic treatment ≤ 6 hr (adjusted for age, sex, CCI, and EWS quartile). CoNS = coagulase-negative Staphylococcus. E. coli = Escherichia coli, S. aureus = Staphylococcus aureus, S. pyogenes = Streptococcus pyogenes, S. pneumoniae = Streptococcus pneumoniae.
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