Blog | Monday, January 29, 2018

The IDSA takes an admirable position in not endorsing the new sepsis guidelines

Wow! This article explains wonderfully the problem of guidelines. Confirmation bias will impact all guideline panel members. As you read the IDSA explanations, you can see that they have focused on the unintended consequences of markedly increasing sensitivity and therefore markedly decreasing specificity. The reference for the IDSA article (abstract only unless you have access).

The main points are found in the report, IDSA withholds support for international sepsis guidelines

“The IDSA's major concern with the guidelines is that they fail to recognize the “practical difficulties” in diagnosing sepsis. The authors reported that up to 40% of patients admitted to ICUs for sepsis do not have an infection, and therefore, do not have sepsis.”

“Hence, the benefits of treating patients who are infected need to be balanced against the harms of treating patients who at first appear as if they might have infections but in fact do not,” they wrote.

“The guidelines strongly recommend initiating IV antimicrobials within 1 hour of identifying suspected sepsis or septic shock. Although it is “understandable and appropriate” to immediately administer broad-spectrum antibiotics and fluids to patients with suspected septic shock, the authors noted that health care providers should take the time to gather additional data and decide whether antibiotics are necessary in patients presenting with less severe disease who may not have an infection.”

Their other major points include inadequate guidance on the use of procalcitonin, especially to limit antibiotic duration. The recommendation of 7-10 days of antibiotics does not take into consideration infections for which shorter durations give superior results. The guidelines also do not address de-escalation after identifying a pathogen and its sensitivities.

I believe that injudicious antibiotic use in the ICU represents the greatest danger for antibiotic resistance. The IDSA position brings an important nuanced assessment of the sepsis controversy. I hope all students and houseofficers will read this and understand the importance of this common sense paper. Bravo IDSA!!!

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former regional dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.