Finally, studies are now emerging that indicate how few of the recommendations have been implemented. Early administration of antimicrobial therapy was poorly adhered to, even in recent reports. In these, although the Surviving Sepsis Campaign proposals were implemented, the mean delay to first infusion of antibiotics remained in excess of 3 hours [62] , and as many as 68% of patients did not receive their first dose within this period [79] . Only a few EGDT validation studies have been conducted in EDs applying aggressive treatment outside the ICU. However, even in those EDs, mortality sometimes remained at 31% before and after the institution of procedures to improve coordination between ED and ICU [80] . In addition, effort should be maintained after the initiation of an EGDT strategy because performance dramatically decreased after initial implementation [81, 82] .