Pre-Referral Antibiotics and Mortality Among Adults With Sepsis in Southeast Asia: A Secondary Analysis of a Prospective Cohort Study.

OBJECTIVE

Early antibiotics are considered critical for bacterial sepsis treatment, although the benefit of this early timing may differ by the presence of shock. Little evidence exists from low- or middle-income settings. In patients referred from community hospitals to a tertiary center, we tested whether pre-referral antibiotic administration is associated with 28-day survival in sepsis, and whether this association differs by the presence of shock.

DESIGN

Secondary analysis of a prospective cohort study that enrolled patients from 2013 to 2017 with a primary diagnosis of infection made by an attending physician and at least three Surviving Sepsis Campaign criteria for sepsis.

SETTING

Tertiary care hospital in northeastern Thailand.

PATIENTS: A total of 2593 adults with sepsis defined by primary diagnosis of infection and modified Sequential Organ Failure Assessment score greater than or equal to 2 who were referred from community hospitals.

INTERVENTIONS: Antibiotics administered at the referring community hospital.

MEASUREMENTS AND MAIN

RESULTS

The median age was 59 years (interquartile range 44-72), 2233 (86.1%) were transferred the same day as initial presentation, and 1897 (73.2%) received antibiotics prior to referral. Blood cultures grew bacteria in 313 (12.1%). Twenty-eight-day mortality was 18.9%. In the propensity score-matched cohort ( n = 722 sepsis without shock, n = 244 septic shock), shock modified the association between pre-referral antibiotics and death (interaction p = 0.001). In patients with septic shock, pre-referral antibiotics were associated with lower hazard of death (hazard ratio [HR], 0.38; 95% CI, 0.19-0.75) but in patients without shock there was no association with hazard of death (HR, 1.36; 95% CI, 0.96-1.92).

CONCLUSIONS

In rural Thailand, antibiotic administration prior to referral was associated with lower hazard of death in patients with septic shock. Our findings extend to a resource-limited setting evidence supporting the benefit of early antibiotic administration in septic patients with shock.