Antimicrobial therapy in septic patients in Emergency units: Right from the outset

Dear Editor,

We have read the manuscript published by González del Castillo et al.¹ with interest and would like to make a few comments. This was a retrospective study that evaluated the impact of appropriate antimicrobial therapy on hospital stay and mortality in patients attending the Emergency Unit due to an infection. It concluded that inappropriate antimicrobial therapy prolongs the hospital stay but does not increase mortality. The small number of severely ill patients (only 1.1% had septic shock) may perhaps explain why there is no correlation between inappropriate treatment and mortality. It is also striking that mortality was lower in patients prescribed an inappropriate treatment, although this difference was not significant due to the small sample size (4.8% vs 12.6%).

The impact on prognosis of the early administration of antimicrobial therapy to sepsis patients in Emergency Units has also been questioned by other authors.² However, there is a vast array of evidence supporting the need to initiate appropriate treatment early in sepsis patients.^3,4

Some years ago, we conducted a prospective study in patients admitted to the ICU with sepsis. The primary conclusion was that the administration of appropriate empirical antimicrobial therapy before admittance to the ICU was a protective factor for mortality.⁴ We have re-analysed our data to ascertain the impact of appropriate treatment in patients referred from the Emergency Unit. 421 patients were enrolled (median age 63 years). The most common foci were: abdomen (39.5%), lung (22.8%), skin and soft tissue (13.7%) and urinary system (12.8%). The multivariate analysis found appropriate treatment administered in the Emergency Unit to be a protective factor for hospital mortality: odds ratio (OR) of 0.26; 95% confidence interval: 0.15–0.45; p < 0.001.

Sepsis and septic shock account for a growing number of ICU admissions in Spain.⁵ Despite the fact that more and more elderly patients and patients with debilitating diseases are being admitted, a significant decrease in sepsis-related mortality has been seen in recent years.^5–7 The early care of patients with sepsis is key to reducing its high mortality. Emergency Units are known to be extremely busy, which makes identifying certain sepsis patients particularly challenging.^8,9

For this reason, we feel the results from González del Castillo et al. should be interpreted with caution. Having said that, we do of course agree with the authors regarding the need to improve knowledge on sepsis management and the quality of antibiotic prescribing throughout the healthcare system, particularly in Emergency Units.¹⁰ In doing so, we will help to increase appropriate antimicrobial therapy and reduce sepsis-related mortality.