Análisis de la concordancia del tratamiento antibiótico de pacientes con sepsis grave en Urgencias

espanolObjetivos. El tratamiento antibiotico resulta de vital importancia en pacientes con sepsis grave/shock septico. Los objetivos fueron evaluar el grado de concordancia entre la prescripcion de antibioticos realizada en urgencias y prescripciones posteriores; relacionarlo con resultados en salud (mortalidad) y analizar los motivos de discordancia. Material y metodos. Estudio descriptivo retrospectivo del tratamiento antibiotico prescrito desde urgencias y el prescrito posteriormente en pacientes con criterios de sepsis grave/shock septico en el ano 2013. Se recogieron caracteristicas demograficas, foco infeccioso, antibiotico prescrito desde urgencias y los cambios posteriores, considerandose concordante cuando no habia cambio, si habia cambio pero el antibiotico inicial era correcto y suspensiones por fin de tratamiento. Se analizo mortalidad y evolucion del cuadro. Resultados. Se incluyeron 600 pacientes. El 60% sufrio cambio de tratamiento antibiotico respecto al iniciado en urgencias (87,6% justificados), con un grado de concordancia antibiotica global del 47,5%. La tasa de mortalidad al final del estudio fue 9,83%, no encontrandose relacion estadisticamente significativa con el grado de concordancia (OR=0,864 (0,503-1,484)/X2=0,28, p=0,597). Motivos de cambio de antibiotico: evolucion clinica (17,96%), cambio de espectro (35,03%), desescalada (41,32%), terapia secuencial (8,68%). El 11% requirio ingreso en Unidad de Cuidados Intensivos (UCI). Evoluciones clinicas: resolucion del cuadro (79,2%), reingreso antes de 30 dias (7,7%) y traslado a centros sociosanitarios (4,5%). La mediana de estancia hospitalaria fue 7 dias. Conclusiones. El grado de concordancia antibiotica resulto bastante alto y la tasa de mortalidad inferior a la descrita en la literatura, sin relacionarse con la discordancia. La presencia de concordancia se asocio a menos reingresos e ingresos en UCI. Los principales motivos de discordancia fueron seleccion del espectro inadecuado y el cambio tras cultivos microbiologicos. EnglishObjectives. Antibiotic treatment is vital in patients with severe sepsis/septic shock. The objectives were to assess the degree of concordance between antibiotic prescribed in emergencies and post requirements; to relate it to health outcomes (mortality) and to analyze the reasons for disagreement. Material and methods. Retrospective descriptive study of antibiotic treatment prescribed in emergencies and the subsequent treatment in patients with criteria of severe sepsis/septic shock in 2013. We collected patient demographic characteristics, infectious focus, antibiotic prescribed from emergencies and subsequent changes. It was considered concordant if there were no changes, if there were changes, but the initial antibiotic was right and suspensions for end of treatment. Mortality and evolution were analyzed. Results. Six hundred patients were included. A 60% experienced changes respect to the antibiotic treatment initiated in emergencies (87.6% justified), with a degree of overall antibiotic concordance of 47.5% The mortality rate at end-point was 9.83%, with no statistically significant relationship with the degree of concordance (OR=0.864 (0.503-1.484)/χ2=0.28; p=0.597). Reasons for change of antibiotic: clinical outcome (17.96%), change of spectrum (35.03%), de-escalation (41.32%), sequential therapy (8.68%). An 11% required ICU admission. Clinical outcomes: resolution of the disease (79.2%), readmission after 30 days (7.7%) and transfer to health centers (4.5%). The median hospital stay was 7 days. Conclusions. The degree of concordance antibiotic was quite high, and the mortality rate was lower than that described in the literature, without relating to the discordance. The presence of concordance was associated with fewer readmissions and ICU admissions. The main reasons for disagreement were inadequate spectrum selection and change after microbiological crops.