Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock

Objectives: To identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock. Design: In a retrospective cohort of critically ill patients with septic shock. Setting: Twenty-four ICUs. Patients: A total of 6,720 patients with septic shock. Interventions: None. Measurements and Main Results: Higher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p<0.0001); older age (+16 min per 10 yr; p<0.0001); presence of comorbidities (+35 min; p<0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p<0.0001), between 3 and 7 days (+121 min; p<0.0001), and longer than 7 days (+130 min; p<0.0001); and a diagnosis of pneumonia (+45 min; p<0.01) were associated with longer times to antimicrobial therapy. Two variables were associated with shorter times to antimicrobial therapy: community-acquired infections (-53 min; p<0.001) and higher temperature (-15 min per 1 degrees C; p<0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p<0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p<0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, 47 min; p<0.001) had shorter times to antimicrobial therapy. Conclusions: We identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.