Original Contribution| Volume 41, ISSUE 6, P573-580, December 2011

Effective Antibiotic Treatment Prescribed by Emergency Physicians in Patients Admitted to the Intensive Care Unit with Severe Sepsis or Septic Shock: Where is the Gap?

  • Roberta Capp
    Reprint Address: Roberta Capp, md, Harvard Affiliated Emergency Medicine Residency, Brigham & Women’s Hospital, 75 Francis Street, Neville House, Boston, MA 02115
    Harvard Affiliated Emergency Medicine Residency Program, Brigham & Women’s Hospital and Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
    Search for articles by this author
  • Yuchiao Chang
    Harvard Medical School, Boston, Massachusetts

    Department of Emergency Services, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author
  • David F.M. Brown
    Harvard Medical School, Boston, Massachusetts

    Department of Emergency Services, Massachusetts General Hospital, Boston, Massachusetts
    Search for articles by this author



      Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.


      The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage.


      This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results.


      Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms.


      Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Angus D.C.
        • Wax R.S.
        Epidemiology of sepsis: an update.
        Crit Care Med. 2001; 29: S109-S116
        • Parrillo J.E.
        • Parker M.M.
        • Natanson C.
        • et al.
        Septic shock in humans. Advances in the understanding of pathogenesis, cardiovascular dysfunction, and therapy.
        Ann Intern Med. 1990; 113: 227-242
        • Martin G.S.
        • Mannino D.M.
        • Eaton S.
        • Moss M.
        Epidemiology of sepsis in the United States from 1979 through 2000.
        N Engl J Med. 2003; 348: 1546-1554
        • Dellinger R.P.
        • Carlet J.M.
        • Masur H.
        • et al.
        Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.
        Crit Care Med. 2004; 32 (Review. Erratum in: Crit Care Med 2004;32(6):1448. Dosage error in article text. Crit Care Med. 2004;32(10):2169–70): 858-873
        • Sharma S.
        • Kumar A.
        Antimicrobial management of sepsis and septic shock.
        Clin Chest Med. 2008; 29: 677-687
        • Bochud P.Y.
        • Bonten M.
        • Marchetti O.
        • et al.
        Antimicrobial therapy for patients with severe sepsis and septic shock: an evidence-based review.
        Crit Care Med. 2004; 32: S495-S512
        • Kumar A.
        • Roberts D.
        • Wood K.E.
        • et al.
        Duration of hypotension before initiation of appropriate antimicrobial therapy is the critical determinant of survival in human septic shock.
        Crit Care Med. 2006; 34: 1589-1596
        • Leibovici L.
        • Shraga I.
        • Drucker M.
        • et al.
        The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection.
        J Intern Med. 1998; 244: 379-386
        • Ibrahim E.H.
        • Sherman G.
        • Ward S.
        • Fraser V.J.
        • Kollef M.H.
        The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting.
        Chest. 2000; 118: 146-155
        • Laterre P.F.
        • Garber G.
        • Levy H.
        • et al.
        Severe community-acquired pneumonia as a cause of severe sepsis: data from PROWESS study.
        Crit Care Med. 2005; 33: 952-961
        • Bryant R.E.
        • Hood A.F.
        • Hood C.E.
        • Koenig M.G.
        Factors affecting mortality of gram-negative rod bacteremia.
        Arch Intern Med. 1971; 127: 120-128
        • Kollef M.
        • Sherman G.
        • Ward S.
        • Fraser V.
        Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.
        Chest. 1999; 115: 462-474
        • Garnacho-Montero J.
        • Ortiz-Leyba C.
        • Herrera-Melero I.
        • et al.
        Mortality and morbidity attributable to inadequate empirical antimicrobial therapy in patients admitted to the ICUP with sepsis: a matched cohort study.
        J Antimicrob Chemother. 2008; 61: 436-441
        • Weiss S.J.
        • Derlet R.
        • Arndahl J.
        • et al.
        Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS).
        Acad Emerg Med. 2004; 11: 38-50
        • Trzeciak S.
        • Rivers E.P.
        Emergency department overcrowding in the United States: an emerging threat to the patient safety and public health.
        Emerg Med J. 2003; 20: 402-405
        • Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis
        The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine.
        Chest. 1992; 101: 1644-1655
        • American Thoracic Society; Infectious Diseases Society of America
        Guidelines for the management of adults with hospital-acquired, ventilator-associated, and health-care associated pneumonia.
        Am J Respir Crit Care Med. 2005; 171: 388-416
        • Kumar A.
        • Ellis P.
        • Arabi Y.
        • et al.
        Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock.
        Chest. 2009; 136: 1237-1248
        • Gaieski D.
        • Pines J.
        • Band R.
        Impact of time to antibiotics on survival in patients with severe sepsis and septic shock in whom early goal directed therapy was initiated in the emergency department.
        Crit Care Med. 2010; 38: 1-9
        • Nguyen B.
        • Rivers E.
        • Abrahamian F.
        • et al.
        Severe sepsis and septic shock: review of the literature and emergency department management guidelines.
        Ann Emerg Med. 2006; 48: 28-54
        • Rahal J.J.
        The role of carbapenems in initial therapy for serious Gram-negative infections.
        Crit Care. 2008; 12: S5
        • Lee S.Y.
        • Kotapati S.
        • Kuti J.L.
        • et al.
        Impact of extended spectrum beta-lactamase producing Escherichia coli and Klebsiella species on clinical outcomes and hospital costs: a matched cohort study.
        Infect Control Hosp Epidemiol. 2006; 27: 1226-1232
        • Alvarez-Lerma F.
        Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group.
        Intensive Care Med. 1996; 22: 387-394
        • Du B.
        • Long Y.
        • Liu H.
        • et al.
        Extended-spectrum beta-lactamase producing E. coli and Klebsiella pneumoniae bloodstream infections: risk factors and clinical outcome.
        Intensive Care Med. 2002; 28: 1718-1723
        • Ramphal R.
        • Ambrose P.G.
        Extended-spectrum B-lactamases and clinical outcomes: current data.
        Clin Infect Dis. 2006; 42: S164-S172
        • Friedman N.D.
        • Kaye K.S.
        • Stout J.E.
        • et al.
        Health care associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections.
        Ann Intern Med. 2002; 137: 791-797
        • Tacconelli E.
        • Venkataraman L.
        • De Girolami P.C.
        • Dagata E.M.
        Methicillin-resistant Staphylococcus aureus bacteraemia diagnosed at hospital admission: distinguishing between community-acquired versus healthcare-associated strains.
        J Antimicrob Chemother. 2004; 53: 474-479
        • Naimi T.S.
        • LeDell K.H.
        • Como-Sabetti K.
        • et al.
        Comparison of community and health care associated methicillin resistant Staphylococcus aureus infection.
        JAMA. 2003; 290: 2976-2984
        • Kollef M.H.
        • Shorr A.
        • Tabak Y.P.
        • et al.
        Epidemiology and outcomes of health care associated pneumonia.
        Chest. 2005; 128: 3854-3862
        • Mandell L.A.
        • Wunderink R.G.
        • Anzueto A.
        • et al.
        Infectious Diseases Society of America/American Thoracic Society Consensus guidelines on the management of community-acquired pneumonia in adults.
        Clin Infect Dis. 2007; 44: S27-S72
      1. The Joint Commission. Performance measurement: pneumonia. Available at: Accessed November 2009.