Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 May;51(5):841-848.
doi: 10.1007/s00134-025-07899-w. Epub 2025 Apr 29.

Decision analysis model of rapid versus deferred antibiotic initiation in patients with suspected sepsis in the emergency department

Terra M Hill  1 , Lauren T Kerivan  1 , Katherine A Vilain  2   3 , Sam Windham  4 , Nima Sarani  5 , Steven Q Simpson  4 , Christopher A Guidry  6
Affiliations

Decision analysis model of rapid versus deferred antibiotic initiation in patients with suspected sepsis in the emergency department

Terra M Hill et al. Intensive Care Med. 2025 May.

Abstract

Purpose: Sepsis remains a major health concern with high associated mortality. Adequate treatment involves the use of antibiotic therapy although the timing of antibiotics is controversial. A decision analysis model of antibiotic initiation was created to determine optimal management of patients with suspected sepsis.

Methods: Two decision trees were created using data from the published literature. A limited model used mortality as the primary outcome using the impact of antibiotic timing on rates of progression to shock and in-hospital mortality. The primary model included mortality and stewardship-related factors such as antibiotic avoidance and antibiotic-associated adverse events. Rapid initiation of antibiotics was defined as universal antibiotic administration within 3 h of presentation whereas deferred initiation included administration up to 6 h. Sensitivity analyses were performed to evaluate the effectiveness of each option.

Results: When considering only mortality, rapid initiation was the optimal strategy. When considering stewardship-related factors, rapid initiation of antibiotics maximized utility in only 40.6% of model iterations. One-way sensitivity analysis demonstrated rapid initiation of antibiotics was optimal when initiation times were above 1.33 h and the prevalence of infection was above 89.5%. Two-way sensitivity analysis demonstrated that as time to antibiotics increased, rate of true infection above which rapid antibiotics is optimal drops from just under 91% to approximately 88.5%.

Conclusion: We constructed decision analysis models to characterize optimal conditions for antibiotic initiation in suspected sepsis. Our model suggests that the prevalence of infection needs to be approximately 90% for rapid initiation of antibiotics to be the optimal strategy.

Keywords: Antibiotic timing; Decision analysis; Emergency department; Sepsis.

PubMed Disclaimer

Conflict of interest statement

Declarations. Conflicts of interest: The authors declared no relevant potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

    1. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, McIntyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Hylander Moller M, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M, (2021) Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 49: e1063-e1143
    1. 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, Nannan Panday RS, Kramer MHH, Nanayakkara PWB, Investigators PHT, the ORCtN, (2018) Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Lancet Respir Med 6:40–50 - DOI - PubMed
    1. Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, Lemeshow S, Osborn T, Terry KM, Levy MM (2017) Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med 376:2235–2244 - DOI - PubMed - PMC
    1. Bisarya R, Song X, Salle J, Liu M, Patel A, Simpson SQ (2022) Antibiotic Timing and Progression to Septic Shock Among Patients in the ED With Suspected Infection. Chest 161:112–120 - DOI - PubMed
    1. Pak TR, Young J, McKenna CS, Agan A, DelloStritto L, Filbin MR, Dutta S, Kadri SS, Septimus EJ, Rhee C, Klompas M, (2023) Risk of Misleading Conclusions in Observational Studies of Time-to-Antibiotics and Mortality in Suspected Sepsis. Clin Infect Dis

MeSH terms

Substances

LinkOut - more resources