Delay Antibiotics for Sepsis Patients? No Thanks, Say Some Docs

Some doctors reject a provocative proposal to delay antibiotics for sepsis patients without shock. But proponents argue antibiotics pose significant risks, too.

Drawing the line on antibiotics for sepsis patients is drawing scrutiny, pitting an antibiotic stewardship perspective against the established reliance on antibiotics.

A recent editorial in Journal of the American Medical Association calls for a more conservative approach for treating sepsis—delaying antibiotics treatment in some cases of sepsis without shock.

With its deadly mortality rate, an aggressive approach to treating sepsis patients with antibiotics is common practice.

Treating patients with possible sepsis or septic shock requires a nuanced approach, the editorial co-authors wrote.

"The need to treat patients rapidly and aggressively ought to reflect on the severity of illness and certainty of diagnosis rather than applied uniformly to all patients. If a patient clearly has a bacterial infection, prompt treatment is indicated. If there is diagnostic uncertainty, however, clinicians should calibrate their response to severity of illness and probability of infection," they wrote.

The proposed approach challenges the standard of care, which calls for rapid administration of antibiotics to all sepsis patients whether they are in shock or not.

Aggressive track
 

Administering antibiotics to all sepsis patients should remain the standard of care, James O'Brien, MD, director of quality and patient safety at OhioHealth in Columbus, told HealthLeaders this week.

"The data supports that the sicker a patient is—and septic shock is probably the best example—the more likely they are to benefit from antibiotics. But there is evidence of patients with sepsis without shock who also benefit," he said.

O'Brien said a family medical case exemplifies the advisability of administering antibiotics to sepsis patients without shock.

His mother had melanoma removed from her back, then she got confused at home. She went to the hospital with no signs of shock but was treated for sepsis.

"As a result of the care that the hospital provided—getting rapid antibiotics and opening the wound to drain—she recovered. But if we had waited for tests to come back, it's very possible she could have progressed to develop shock. Then you're dealing with somebody whose mortality jumps up significantly," O'Brien said.

"So, I have hard time from the patient's standpoint waiting until they have shock, then all of a sudden we'll jump onboard," he said.

Adverse impacts
 

Patients face significant risks from antibiotics, Michael Klompas, MD, the lead author of the JAMA editorial, told HealthLeaders this week.

"The risks of antibiotics extend beyond Clostridium difficile alone. They can cause organ damage, interact with other medications, and promote colonization and infection with drug resistant pathogens that then pose downstream treatment problems," said Klompas, an infectious disease physician at Brigham & Women's Hospital in Boston. 

The JAMA editorial lists several other adverse impacts from antibiotics: kidney injury, hepatitis, cytopenias, sever rash, mitochondrial toxicity, and alteration of the microbiome.

There are adverse effects associated with antibiotics, Klompas said.

"Studies estimate that a remarkable 20%-25% of hospitalized patients exposed to antibiotics develop some sort of adverse effect. This flies in the face of the commonly held perception amongst both doctors and the general public that antibiotics are "free"—they are very safe and there's little downside."

Treatment for sepsis
 

Treatment of sepsis requires the exercise of good medical judgment, O'Brien said.

"It's more art than science now. For me, it winds up at the intersection between patient risk, the severity of illness, and the likelihood of alternative diagnoses. I factor all of those to determine the relative risk of treatment for sepsis versus the relative risk for not treating for sepsis," he said.

Sepsis patients stretch across a continuum, O'Brien said.

"If I have a patient who is elderly, is currently being treated for leukemia, and was recently in the hospital, these are all risk factors for sepsis. If they come in with shock, and I don't have an alternative diagnosis or reason for them to be in shock, I'm going to need to have significant evidence that the patient does not have sepsis."

"Alternatively, I could have a healthy 22-year-old who has no medical problems, has not been in contact with healthcare, and comes in with unclear complaints. There's no signs of shock and the patient is talking. That's someone I am going to be more delayed with."

Physicians are needed most keenly to treat more complicated sepsis cases, O'Brien said.

"There are a whole bunch of patients who end up being in that spectrum—between the polar opposites. In between is where you need a physician to integrate the data and make a decision when there is uncertainty."