1. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial
- Author
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Nadia Alam, Erick Oskam, Patricia M Stassen, Pieternel van Exter, Peter M van de Ven, Harm R Haak, Frits Holleman, Arthur van Zanten, Hien van Leeuwen-Nguyen, Victor Bon, Bart A M Duineveld, Rishi S Nannan Panday, Mark H H Kramer, Prabath W B Nanayakkara, N. Alam, P.W.B. Nanayakkara, E. Oskam, P.M. Stassen, H.R. Haak, F. Holleman, R.S. Nannan Panday, B.A.M. Duineveld, P. van Exter, P.M. van de Ven, V. Bon, J. Goselink, A. De Kreek, P. van Grunsven, M. Biekart, G.J. Deddens, F. Weijschede, N. Rijntjes, G. Franschman, J. Janssen, J. Frenken, J. Versluis, R. Boomars, G. de Vries, E. den Boer, A. van Gent, M. Willeboer, G. Buunk, G.J. Timmers, F. Snijders, N. Posthuma, S. Stoffelen, S. Claassens, H. Ammerlaan, S. Sankatsing, J. Alsma, A. van Zanten, L. Slobbe, M.M. de Melo, A. Dees, G. Carels, M. Wabbijn, T.T.H. van Leeuwen-Nguyen, J. Assink, A. van der Honing, P. Luik, W. Poortvliet, W.E.M. Schouten, J. Veenstra, J. Holkenborg, T.C. Cheung, J. van Bokhorst, B. Kors, G.H. Louis- Wattel, T. Roeleveld, A. Toorians, W. Jellema, A. Govers, H.A.H. Kaasjager, D. Dekker, M.A.M. Verhoeven, M.H.H. Kramer, T. Flietstra, L. Roest, E.J.G. Peters, T.A.M. Hekker, W. Ang, W. van der Wekken, P. Ghaem Maghami, B. Kanen, H. Wesselius, L. Heesterman, A.N. Zwietering, J. Stoffers, Internal Medicine, Internal medicine, AII - Infectious diseases, APH - Methodology, Epidemiology and Data Science, APH - Quality of Care, APH - Digital Health, ACS - Diabetes & metabolism, ACS - Heart failure & arrhythmias, General Internal Medicine, AGEM - Endocrinology, metabolism and nutrition, MUMC+: MA Alg Interne Geneeskunde (9), Interne Geneeskunde, and RS: CAPHRI - R1 - Ageing and Long-Term Care
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Pulmonary and Respiratory Medicine ,Resuscitation ,medicine.medical_specialty ,IMPACT ,UNITED-STATES ,law.invention ,EARLY WARNING SCORE ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Acute care ,Emergency medical services ,EPIDEMIOLOGY ,Medicine ,030212 general & internal medicine ,GOAL-DIRECTED THERAPY ,Intention-to-treat analysis ,business.industry ,MORTALITY ,SEPTIC SHOCK ,030208 emergency & critical care medicine ,Emergency department ,CARE ,Early warning score ,TIME ,EMERGENCY MEDICAL-SERVICES ,Relative risk ,Emergency medicine ,business - Abstract
BACKGROUND: Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care.METHODS: After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428.FINDINGS: 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone.INTERPRETATION: In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity.FUNDING: The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).
- Published
- 2018
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