Antibiotics: safe to delay in which ED patients?

  • Nauclér P & al.
  • Clin Microbiol Infect
  • 28 Feb 2020

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • For patients in the emergency department (ED) with mild to moderately severe infectious syndromes that are not sepsis and meningitis, very early antibiotic administration “is probably not required,” these authors suggest.
  • Awaiting results of, e.g., biomarkers and X-rays before deciding upon antibiotics might be reasonable.
  • Prospective trials are needed.

Why this matters

  • Unnecessary empirical antibiotic use contributes to side effects and bacterial resistance.

Key results

  • Sepsis and septic shock:
    • Observational data support early antibiotics for survival.
    • Patients with septic shock benefit most.
  • Bacterial meningitis:
    • Existing evidence links worse outcomes to delayed antibiotics.
    • Studies are small, observational, with considerable bias risk.
  • Lower respiratory tract infection: 
    • Retrospective studies link delay exceeding 4-8 hours to worse outcomes; prospective studies do not.
  • Urinary tract infection:
    • Mortality correlates more strongly with illness severity and comorbidities than with time to antibiotics.
  • Intra-abdominal infection:
    • No correlation between antibiotic timing and outcomes in acute cholangitis or cholecystitis.
    • Potential correlation in septic cirrhosis and bloodstream infections with abdominal source.

Study design

  • Systematic review of 39 reviews and 61 articles (including 4 randomized clinical trials) addressing clinical outcomes based on time to antibiotic treatment in patients with various infectious syndromes.
  • Funding: None disclosed.

Limitations

  • Many studies subject to bias.
  • No studies of skin and soft-tissue infections.