To determine the prevalence and impact on mortality of delays in initiation of effective antimicrobial
therapy from initial onset of recurrent/persistent hypotension of septic shock.
A retrospective cohort study performed between July 1989 and June 2004.
Fourteen intensive care units (four medical, four surgical, six mixed medical/surgical) and ten hospitals (four academic, six community) in Canada and the United States.
Medical records of 2,731 adult patients with septic shock.
Measurements and Main Results:
The main outcome
measure was survival to hospital discharge. Among the 2,154 septic shock patients (78.9% total) who received effective antimicrobial
therapy only after the onset of recurrent or persistent hypotension, a strong relationship between the delay
in effective antimicrobial
initiation and in-hospital mortality was noted (adjusted odds ratio 1.119 [per hour delay
], 95% confidence interval 1.103–1.136, p
< .0001). Administration of an antimicrobial
effective for isolated or suspected pathogens within the first hour of documented hypotension was associated with a survival rate of 79.9%. Each hour of delay
administration over the ensuing 6 hrs was associated with an average decrease in survival of 7.6%. By the second hour after onset of persistent/recurrent hypotension, in-hospital mortality rate was significantly increased relative to receiving therapy within the first hour (odds ratio 1.67; 95% confidence interval, 1.12–2.48). In multivariate analysis (including Acute Physiology and Chronic Health Evaluation II score and therapeutic variables), time to initiation of effective antimicrobial
therapy was the single strongest predictor of outcome
. Median time to effective antimicrobial
therapy was 6 hrs (25–75th percentile, 2.0–15.0 hrs).
administration within the first hour of documented hypotension was associated with increased survival to hospital discharge in adult patients with septic shock. Despite a progressive increase in mortality rate with increasing delays, only 50% of septic shock patients received effective antimicrobial
therapy within 6 hrs of documented hypotension.