Background: In sepsis, every hour of delay in antibiotic administration after the onset of hypotension is associated with 4-7% increase in mortality, but little is known about the characteristics of patients with treatment delays. Our objective was to determine if septic adults presenting to the Emergency Department (ED) who receive antibiotics more than 60 minutes after hypotension differ in their demographics and initial clinical presentation compared to those receiving timely treatment.

Methods: We extracted data from the electronic health record (EHR) on all adults presenting to a single academic ED between 6/1/2012 and 12/31/16 with suspected infection (blood cultures drawn, intravenous antibiotics within 48 hours) and sepsis (change from baseline Sequential Organ Failure Assessment Score (SOFA) of at least 2 by 48 hours and at least 4 antibiotic days unless death or discharge to hospice sooner; or validated sepsis discharge code) who developed hypotension (SBP <90) within 72 hours of presentation. Timestamped EHR-derived measurement to systemic inflammatory response syndrome (SIRS) and SOFA score of at least 2 and SBP<90 were used to assess recognition of sepsis and hypotension. We categorized patients by time from hypotension until antibiotic administration: 1. Antibiotics before hypotension (n=2108, 60%) ; 2. Antibiotics 0-60 minutes after hypotension (n=483, 14%); 3. Antibiotics >60 minutes after hypotension (n=911, 26%). This abstract focuses on bivariate analyses comparing “timely” (0-60 minutes) versus “delayed” (>60 minutes) antibiotics after hypotension.

Results: Of 3,502 patients with sepsis who developed hypotension within the first 72 hours of presentation, 40% (1,394) received antibiotics after 1st hypotension. Among these, 65% (n=911) received antibiotics more than 60 minutes after 1st hypotension. The delayed group was younger and more likely to have heart failure, metastatic cancer, substance use disorders, and Medi-Cal coverage (Table). The delayed group was more likely to present with hypotension on triage (52% vs 44%), but was less likely categorized as “emergent” acuity in the ED and less likely to meet at least 2 SIRS (24% vs 52%) or qSOFA (27% vs 47%) criteria for sepsis screening on triage. Both time from ED admission to antibiotic administration and time from physician order of antibiotic administration were significantly longer in the delayed group (Table, p<0.001).

Conclusions: Among septic patients with hypotension, we found delayed antibiotics are common. Patients receiving delayed antibiotics may present in a “muted” fashion: they often present with isolated hypotension before meeting full sepsis diagnostic criteria (SIRS or qSOFA). Our findings suggest that timely sepsis recognition may require additional suspicion by providers and modified EHR sepsis alert systems for patients presenting with hypotension when other measures of sepsis diagnostic criteria are initially absent, especially in patients with complex medical comorbidities.

IMAGE 1: Comparison of Demographics, Triage Information, and ED Course between Timely and Delayed Antibiotic Cohorts