Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important. Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock. A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012-2013. The criterion early appropriate antibiotic treatment was defined as administration of the first dose of adequate antibiotics within 1h, and the second dose given with less than 25% delay after the recommended dose interval. A high-risk patient was defined as a septic patient with either shock within 24h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality. Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment. Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.

Objectives The aim of this study was to identify prehospital and early hospital risk factors associated with 30-day mortality in patients with blood culture-confirmed community-acquired bloodstream infection (CA-BSI) in Sweden.

Methods A retrospective case–control study of 1624 patients with CA-BSI (2015–2016), 195 non-survivors satisfying the inclusion criteria were matched 1:1 with 195 survivors for age, gender and microorganism. All forms of contact with a healthcare provider for symptoms of infection within 7 days prior CA-BSI episode were registered. Logistic regression was used to analyse risk factors for 30-day all-cause mortality.

Results Of the 390 patients, 61% (115 non-survivors and 121 survivors) sought prehospital contact. The median time from first prehospital contact till hospital admission was 13 hours (6–52) for non-survivors and 7 hours (3–24) for survivors (p<0.01). Several risk factors for 30-day all-cause mortality were identified: prehospital delay OR=1.26 (95% CI: 1.07 to 1.47), p<0.01; severity of illness (Sequential Organ Failure Assessment score) OR=1.60 (95% CI: 1.40 to 1.83), p<0.01; comorbidity score (updated Charlson Index) OR=1.13 (95% CI: 1.05 to 1.22), p<0.01 and inadequate empirical antimicrobial therapy OR=3.92 (95% CI: 1.64 to 9.33), p<0.01. In a multivariable model, prehospital delay >24 hours from first contact remained an important risk factor for 30-day all-cause mortality due to CA-BSI OR=6.17 (95% CI: 2.19 to 17.38), p<0.01.

Conclusion Prehospital delay and inappropriate empirical antibiotic therapy were found to be important risk factors for 30-day all-cause mortality associated with CA-BSI. Increased awareness and earlier detection of BSI in prehospital and early hospital care is critical for rapid initiation of adequate management and antibiotic treatment.All data relevant to the study are included in the article or uploaded as supplemental information.

Background Rapid, adequate treatment is crucial to reduce mortality in sepsis. Risk stratification scores used at emergency departments (ED) are limited in detecting all septic patients with increased mortality risk. We assessed whether the addition of prehospital lactate analysis to clinical risk stratification tools improves detection of patients with increased risk for rapid deterioration and death in sepsis. Methods A10-month observational study with consecutive, prospective prehospital inclusion of adult patients with suspected sepsis. Prehospital lactate was used as a continuous variable and in intervals. Analyses of patient subgroups with high and lower priorities according to Rapid Emergency Triage and Treatment System (RETTS) and National Early Warning Score 2 (NEWS2) were performed. Primary outcome was 30-day mortality, secondary outcomes were sepsis at the ED and in-hospital mortality. Results In all, 714 patients were included with a 30-day mortality of 10%. Among the 322 cases (45%) fulfilling Sepsis-3 criteria, the 30-day mortality was 14%. Prehospital lactate was higher among non-survivors (2.6 vs 2.0 mmol/L, p < 0.001). Mortality at different lactate intervals were: 6.7%, at 0-2 mmol/l; 10.0% at > 2-3 mmol/l; 19.2% at > 3-4 mmol/l; and 17.0% at levels > 4 mmol/l. The highest RETTS priority (red) group had higher lactate levels than the lower (non-red) priority group (2.5 vs 1.9 mmol/L, p < 0.001). In the non-red group, prehospital lactate was higher among non-survivors (2.4 vs 1.8 mmol/L, p = 0.002). In the multivariable regression analysis, prehospital lactate > 3 mmol/l was a predictor of 30-day mortality (OR 2.20, p = 0.009) This association was even stronger in the lower priority RETTS non-red group (OR 3.02, p = 0.009). Adding prehospital lactate > 3 mmol/l increased identification of non-survivors from 48 to 68% in the RETTS red group and from 77 to 85% for the NEWS2 >= 7 group. Conclusion The addition of a prehospital lactate level > 3 mmol/l improved early recognition of individuals with increased mortality risk in a cohort with suspected sepsis admitted to the ED. This was particularly evident in patients whose risk stratification scores did not indicate severe illness. We suggest that the addition of prehospital lactate analysis could improve recognition of subjects with suspected sepsis and increased mortality risk.