Our goal was to determine the impact of the initiation of inappropriate antimicrobial
therapy on survival to hospital discharge of patients with septic shock.
The appropriateness of initial antimicrobial therapy, the clinical infection site,
and relevant pathogens were retrospectively determined for 5,715 patients with septic
shock in three countries.
Therapy with appropriate antimicrobial agents was initiated in 80.1% of cases. Overall,
the survival rate was 43.7%. There were marked differences in the distribution of
comorbidities, clinical infections, and pathogens in patients who received appropriate
and inappropriate initial antimicrobial therapy (p < 0.0001 for each). The survival
rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively
(odds ratio [OR], 9.45; 95% CI, 7.74 to 11.54; p < 0.0001). Similar differences in
survival were seen in all major epidemiologic, clinical, and organism subgroups. The
decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal
infection to 17.6-fold with primary bacteremia. After adjustment for acute physiology
and chronic health evaluation II score, comorbidities, hospital site, and other potential
risk factors, the inappropriateness of initial antimicrobial therapy remained most
highly associated with risk of death (OR, 8.99; 95% CI, 6.60 to 12.23).
Inappropriate initial antimicrobial therapy for septic shock occurs in about 20% of
patients and is associated with a fivefold reduction in survival. Efforts to increase
the frequency of the appropriateness of initial antimicrobial therapy must be central
to efforts to reduce the mortality of patients with septic shock.