• Andre C K B Amaral, Robert A Fowler, Ruxandra Pinto, Gordon D Rubenfeld, Paul Ellis, Brian Bookatz, John C Marshall, Greg Martinka, Sean Keenan, Denny Laporta, Daniel Roberts, Anand Kumar, and Cooperative Antimicrobial Therapy of Septic Shock Database Research Group.
• 1Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.2Department of Emergency Medicine, University Health Network, University of Toronto, Toronto, ON, Canada.3Critical Care Medicine, Prairie Mountain Health, Brandon, MB, Canada.4Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.5Critical Care Medicine, Richmond General Hospital, Richmond, BC, Canada.6Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada.7Critical Care Medicine, Jewish General Hospital, Montreal, QC, Canada.8Critical Care Medicine and Department of Medicine, Winnipeg Regional Health Authority, Winnipeg, MB, Canada.
• Crit. Care Med. 2016 Dec 1; 44 (12): 2145-2153.

ObjectivesTo identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock.DesignIn a retrospective cohort of critically ill patients with septic shock.SettingTwenty-four ICUs.PatientsA total of 6,720 patients with septic shock.InterventionsNone.Measurements And Main ResultsHigher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p < 0.0001); older age (+16 min per 10 yr; p < 0.0001); presence of comorbidities (+35 min; p < 0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p < 0.0001), between 3 and 7 days (+121 min; p < 0.0001), and longer than 7 days (+130 min; p < 0.0001); and a diagnosis of pneumonia (+45 min; p < 0.01) were associated with longer times to antimicrobial therapy. Two variables were associated with shorter times to antimicrobial therapy: community-acquired infections (-53 min; p < 0.001) and higher temperature (-15 min per 1°C; p < 0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p< 0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p < 0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, -47 min; p< 0.001) had shorter times to antimicrobial therapy.ConclusionsWe identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.

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