A Winnipeg doctor has a plan to save as many as 5,000 Canadian lives for little cost: Providing antibiotics to patients with severe sepsis – a form of blood poisoning caused by infections – soon after they roll through hospital doors. Though it sounds simple enough, some hospitals, for both bureaucratic and philosophical reasons, are not willing to jump on board so quickly.
"In Canada, we're still doing it on a piecemeal basis," said Anand Kumar, an intensive-care physician at Winnipeg Health Sciences Centre who, along with his colleagues, has been leading the charge for early antibiotics.
Sepsis can occur when a bacterial, fungal or viral infection moves into the bloodstream and attacks vital organs. More than 9,300 hospital patients died of sepsis in Canada in 2008, according to the latest data from the Canadian Institute for Health Information. Put another way, 30 per cent of patients in hospital with sepsis died, compared with 18 per cent for strokes and 9.1 per cent for heart attacks.
Dr. Kumar's research, published in 2006, found that it generally took six hours to get antibiotics to sepsis patients; for every hour delay, the risk of dying went up by 7.5 per cent. By getting antibiotics to patients within an hour or two after their blood pressure dropped, six hospitals in Winnipeg have been able to reduce sepsis-related mortality to 25 per cent from 65 per cent over the past few years – translating to about 200 lives saved every year.
"We just didn't realize that the risk of death was so closely related to the simple parameter of how fast you give appropriate antibiotics," said Dr. Kumar. "And nobody seemed in a hurry to give them, because we're doing all these other things." He and his team began a program to speed up antibiotics – and if it's applied across Canada, Dr. Kumar said it would cut the death rate from sepsis by half.
While the program may seem intuitive, not everyone is sold on the idea.
Andrew Morris, director of Toronto's Mount Sinai Hospital and University Health Network's antimicrobial stewardship program, fears that patients could be misdiagnosed in the rush to get them antibiotics, or worse, overprescribing drugs could lead to superbug infections, such as C. difficile. Many times, Dr. Morris said, it takes a while to get antibiotics to patients because it's not immediately clear if they have an infection, or there are other complications physicians have to contend with first.
"If everyone hears that the right thing to do is give everyone early antibiotics … that may save a few lives, but it also may cost a few lives," Dr. Morris said. "No one measures how many of those patients who didn't need antibiotics ended up getting C. difficile and having problems like that down the road. So, there are consequences of that approach."
Peter Brindley, an intensive-care physician at the University of Alberta Hospital in Edmonton, understands the cautious approach but believes Dr. Kumar's work has played a positive role in improving door-to-drug times in his area. "Patients are getting a system jumping all over them. And the antibiotics are probably the biggest part of it," he said.
There are no national guidelines around sepsis. But Dr. Kumar said the program has had a major impact in Winnipeg. The cost to implement the program would be less than $20,000 at each major hospital per year, he said.
Dr. Kumar said hospital staff are used to a certain kind of thinking when a patient comes in with severe sepsis: Stabilize the patient, give them fluids, get them on a ventilator, and then, when there was a bit of time, give them antibiotics.
"Nobody really realized how important the antimicrobials are. I think the new paradigm of thinking is that antibiotics are an intrinsic part of resuscitation. That they're no less important, and maybe more important," Dr. Kumar said.
Caroline Alphonso