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• W2788697411 abstract "In the Lancet Respiratory Medicine, Nadia Alam and colleagues1Alam N Oskam E Stassen PM et al.Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.Lancet Respir Med. 2018; 6: 40-50Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar assessed prehospital administration of intravenous ceftriaxone 2000 mg in addition to usual care (fluid resuscitation and supplementary oxygen) in the ambulance for patients with suspected sepsis in the randomised controlled PHANTASi trial.1Alam N Oskam E Stassen PM et al.Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.Lancet Respir Med. 2018; 6: 40-50Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar Unfortunately, this early intervention did not lead to improved sepsis survival compared with patients receiving usual care alone. Fewer patients died in the study (8% across both arms) than was predicted (40%) based on epidemiological studies at the time of the trial design. As is commonly known, mortality from sepsis has substantially decreased in recent decades, and in fact, the low mortality rate of PHANTASi exceeds that from our previous cohort study2Quinten VM van Meurs M Wolffensperger AE Ter Maaten JC Ligtenberg JJM Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?.Eur J Emerg Med. 2017; (published May 8.)DOI: 10.1097/MEJ.0000000000000460Crossref PubMed Scopus (38) Google Scholar (4%) in our emergency department. In an accompanying Comment,3Vincent J-L Antibiotic administration in the ambulance?.Lancet Respir Med. 2018; 6: 5-6Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Jean-Louis Vincent argued that the low severity of illness of the patients included in PHANTASi made it difficult to show an effect of prehospital antibiotics on mortality. Although we agree with this argument, the patients included in this well designed trial matched the mix of sepsis severity and percentage of admissions to intensive care in our emergency department cohort. Therefore, we disagree with Vincent that only patients with signs of organ dysfunction—ie, with sepsis according to the Sepsis-3 definitions4Singer M Deutschman CS Seymour CW et al.The third international consensus definitions for sepsis and septic shock (Sepsis-3).JAMA. 2016; 315: 801Crossref PubMed Scopus (12053) Google Scholar—might benefit from early antibiotics. Furthermore, we disagree that the PHANTASi trial reinforces the fact that timing of antibiotics is not very important in patients with infection. In a separate study,5Glickman SW Cairns CB Otero RM et al.Disease progression in hemodynamically stable patients presenting to the emergency department with sepsis.Acad Emerg Med. 2010; 17: 383-390Crossref PubMed Scopus (108) Google Scholar investigators showed that 22% of patients presenting at an emergency department with suspected sepsis without signs of organ dysfunction developed organ dysfunction within 48 h of admission despite antibiotic and supportive treatment. Previously, we noted2Quinten VM van Meurs M Wolffensperger AE Ter Maaten JC Ligtenberg JJM Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?.Eur J Emerg Med. 2017; (published May 8.)DOI: 10.1097/MEJ.0000000000000460Crossref PubMed Scopus (38) Google Scholar that 4% of patients with uncomplicated sepsis needed to be admitted to an intensive-care unit, and such patients would probably benefit from early administration of antibiotics. Alam and colleagues1Alam N Oskam E Stassen PM et al.Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.Lancet Respir Med. 2018; 6: 40-50Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar showed that the number of patients readmitted to hospital after 28 days was significantly lower in the intervention group with prehospital antibiotics, but could not explain the reason for this difference.1Alam N Oskam E Stassen PM et al.Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.Lancet Respir Med. 2018; 6: 40-50Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar We speculate that early antibiotics might attenuate the development of organ failure during a patient's hospital stay, and suggest that the time has come to make a shift from mortality towards (early) signs of organ failure as a marker and endpoint for future emergency department-based sepsis research. There is more to life than death alone. We declare no competing interests. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trialIn patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity. Full-Text PDF Antibiotic administration in the ambulance?Starting with the reasonable postulate that antibiotics are effective, it seems logical that the earlier antibiotics are given to patients with infection, the better the outcome will be. This is likely to be particularly true for patients with the most severe forms of infection, which are associated with the worst outcomes. Full-Text PDF" @default.
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• W2788697411 title "Prehospital antibiotics for sepsis: beyond mortality?" @default.
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