82 y/o F from SNF, AMS, “foul smelling urine.”
80/50, 103.1 PR, 120HR 98%.
An initial POCUS showed a collapsing IVC, you give 30 cc/kg LR, 650 Tylenol PR, vancomycin loading dose, and 3.375g Zosyn. BP is now 110/74, HR is 80 bpm, labs show an obvious UTI, and you call to admit the patient.
Or as I like to call this, the “sepsis-high five.”
This is a single center study of 828 patients looking at time delay between first and second antibiotic. They broke it down to 6, 8, 12, and 24 hour drugs, and considered a delay of 25% significant (90 minutes for a q6 hour drug, 180 minutes for a BID drug, etc). The primary outcome being in-hospital mortality.
So what’d they find? Well, unsurprisingly, they found that 72% of patients had a delay with 6hr dosing between their first dose and second dose compared to 47% for Q8hr antibiotics, and 25% for Q12hr antibiotics. (<5% for Q24hr drugs- but they had 6 hours to hang the dang drug!)… They acknowledge several issues: we often order a one time dose in the ED, but the upstairs care only knows Q6hr drugs at 12-6-12-6 dosing. I think this is most likely the case in this study, since the next dose for a 6, 8, and 12 hour drug were 9.55, 9.6, and 10.6hr respectively. They also acknowledge that it is possible that delayed second antibiotics are not inherently contributory to adverse patient outcomes, but simply a surrogate for patients who generally received less attention and care overall, particularly given 43% of delays occurred in ED boarding in their institute.
Paradoxically, those that received the q6hour antibiotic (cough, ZoSyn, cough), had high rates of adherence to the sepsis bundle (fluid loading, early pressors, early abx, etc) – but also high rates of >25% delays to second doses. True, it only took an hour and a half to have a delay for zosyn, but that is the point here: while yes, you provided solid care up front, are your system failures (preset administration times from your inpatient order sets) hurting your patients? Or is it a sign that those getting tighter adherence to everything (Q6hr drugs, early pressors, etc), and that those patients are getting better care with better adherence to second dose antibiotics as merely a proxy?
Regardless, there was a 1.6x increased odds of mortality for those with >25% delay, and a 2.4x high rate of mechanical ventilation, with an OR of 72 for a missed second dose of a q 6hr drug, 24 for a q 8hr drug, and 7 for a q 12hr drug.
Call it better care. Call it a reason to do a ZoSyn continuous infusion. Call it an inpatient problem. Regardless, it should not be ignored.
Me? I maintain that if the patient is still in my emergency department, its still my patient no matter how long they have been there. Hence, I’ve been known to periodically order a second dose of ZoSyn – especially for the critically ill and those being transferred. So, much like after a successful intubation post-arrest there is much work to do, there is much work to do post resuscitation for a septic patient.