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Emergency Protocol of Antibiotic Administration for Sepsis

Clinician's Brief (Capsule)

Infectious Disease

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April 2014

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Septic peritonitis in dogs is challenging with high morbidity and mortality rates. Human studies indicate early diagnosis and administration of appropriate antimicrobials can improve outcome in sepsis patients. This study investigated whether a canine abdominal sepsis protocol implemented in emergency room could improve outcomes. The protocol included a sepsis screening tool and suggested diagnostics, appropriate antimicrobials, resuscitation guidelines, and methods to improve transfer from emergency to the operating room when necessary.

Diagnosis was made if abdominal fluid contained intracellular bacteria on cytologic examination. Further grouping was based on source of infection and kidney health, each having its own recommended antimicrobial protocol: 1) community-acquired infection with no evidence of renal insufficiency (amikacin 15 mg/kg IV q24h, clindamycin 12 mg/kg IV q12h); 2) community-acquired infection with renal insufficiency (cefotaxime 22 mg/kg IV q8h, clindamycin 12 mg/kg IV q12h); or 3) hospital-acquired infections where Enterococcus spp was a concern (either antimicrobial options and ampicillin 22 mg/kg IV q8h). Forty dogs with septic peritonitis were included. Controls included records of 20 dogs that underwent surgery for septic peritonitis before implementation of the protocol. With the sepsis protocol, all patients received antimicrobials within 2 hours of diagnosis, which significantly improved time to antimicrobial administration; however, it did not significantly affect survival.

Global Commentary

Sepsis still presents unacceptably high morbidity and mortality rates in human and veterinary medicine. The Surviving Sepsis Campaign (SSC) guidelines have led to improvement of these rates in humans1; however, until now, application of SSC guidelines in veterinary species has been poorly reported. This study demonstrated that one of these guidelines—early antibiotic therapy (<1 hour)—can be successful in critical dogs via a specific protocol. This fact deserves to be enhanced, because many recognize the difficulty of implementing new guidelines, especially in large-caseload institutions or academia. Even with this constraint, the rate of antibiotic administration in the first 2 hours was increased to 100%—a percentage far higher than reported compliance to SSC guidelines in humans.1

This study also demonstrated some of the recognized reasons for delays in initiating antibiotics (eg, waiting for radiographs, culture results, abdominal ultrasound) can be overcome by educational efforts and implementation of single measures.

Although the protocol did not demonstrate significant improvement in survival with intraabdominal sepsis, this should be interpreted with caution before we rule out the protocol´s use. Survival to discharge was higher in the protocol group but not significantly. Perhaps these results can be improved by increasing the size of the study population or by choosing cases with different sources of sepsis. The study also obtained other interesting conclusions relevant to intraabdominal sepsis management. The protocol led to a more rational antibiotic strategy with several benefits, including a decrease in inappropriate empirical treatment. Before the introduction of the protocol, the same condition was treated with different antibiotic combinations, likely reflecting different clinician preference. This approach can lead to emergence of nosocomial multiresistant species and should be discouraged. Now, when the threat of emergent resistant pathogens is significant, these findings should be welcomed.

There were disadvantages associated with the protocol: some animals received antibiotics for conditions that were purely inflammatory, although this probably reflected the difficulty in distinguishing systemic inflammatory response of infectious and noninfectious origin in the first hours of presentation, not an inherent limitation of the protocol itself.

Finally, based on human data, where Enterococcus spp are considered a questionable pathogen, the authors opted to not use antienterococcal therapy. As a result, multidrug-resistant Enterococcus spp infections became apparent in affected dogs. This suggested the limitations inherent in adapting human guidelines to veterinary patients.

Although, the major benefits of the study’s approach for morbidity and mortality remain to be seen, the results are encouraging. Like any good study, it has the merit to launch several questions, and when we read a study and question ourselves (What if the authors did this? Should they do that for the next time?), we know we have read good science. And only with good science can we move forward in our battle to decrease the heavy burden of sepsis.—Nuno Félix, DVM, MS

Source

Positive impact of an emergency department protocol on time to antimicrobial administration in dogs with septic peritonitis. Abelson AL, Buckley GJ, Rozanski EA. JVECC 23:551-556, 2013.

This capsule is part of the Global Edition of Clinician's Brief

References

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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