[display_podcast]

Date: February 14th, 2018

Reference: Alam N et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Nov 2017.

Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.

Case: EMS is dispatched to a retirement home. They have a 73-year-old man who complains of weakness and a cough for the last 48 hours. You arrive and find the man lying in bed looking ill. He has a history of hypertension, benign prostatic hypertrophy and osteoarthritis. His medications include ramapril, hydrochlorothiazide and tamsulosin. On examination, he has a temperature of 38.7C, heart rate of 105 beats per minute, respiratory rate of 26, oxygen saturation of 88%. and a blood pressure of 88/50 mmHg. You load him on the stretcher, start an intravenous of normal saline and provide some supplemental oxygen via face mask. Clearly something infectious is going on and you wonder if starting antibiotics on route to the hospital would help?

Background: We have covered sepsis many times on the SGEM over the years (SGEM# 69, 90, 92, 113, and 168). It is a serious condition associated with high morbidity and mortality.

Jennifer Doyle

Other serious time-dependent conditions such as myocardial infarction and trauma have been improved significantly with emergency medical services (EMS). It has been reported that over half of patients with sepsis arrive to the emergency department via ambulance [1]. However, it is not clear if patients with suspected sepsis can have improved survival rates if antibiotics are provided in the pre-hospital setting.

There are studies showing that early recognition and prehospital administration of antibiotics are associated with increased survival rates [2-4]. Delay in antibiotics has been associated with an average decrease in survival of 7.6% per hour (Kumar et al).

We need to be skeptical of these retrospective studies, especially when prospective, observational studies have failed to show any association between early antibiotics and a reduction in mortality [5-7].

Now we have better evidence with the publication of the first prospective, randomized study investigating the effects of early antibiotic administration in patients with suspected sepsis.

Clinical Question: Can patients with varying degrees of sepsis benefit from early recognition and prehospital administration of IV antibiotics in the ambulance?

Reference:  Alam N et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Nov 2017.

Population: Adult patients (18 years and older) with a diagnosis of suspected infection, temperature >38C or <36C and at least one other SIRS (systemic inflammatory response syndrome) criteria (HR>90bpm, RR>20bpm, or both)

Exclusions: Allergy to ceftriaxone, other beta-lactams, know pregnancy or suspected prosthetic joint infection.

Intervention: Ceftriaxone 2g IVControl: Usual care (fluid resuscitation and supplementary oxygen)Outcome:

Primary: All-cause mortality at 28 daysSecondary: “Number of misdiagnoses of patients enrolled in the study by EMS, mortality during hospital stay and within 90 days, length of hospital stay, ICU admission, length of stay in ICU, TTA to the emergency department for usual care group, and TTA before hospital arrival for intervention group microbiological data, adverse events, and quality of life 1 month after discharge as measured with the SF-36 questionnaire”

Authors’ Conclusions: “In 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.”

Quality Checklist for Randomized Clinical Trials: