Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam, N., Oskam, E., Stassen, P. M., Exter, P. v., Ven, P. M. v. d., Haak, H. R., Holleman, F., Zanten, A. v., Leeuwen-Nguyen, H. v., Bon, V., Duineveld, B. A. M., Panday, R. S. N., Kramer, M. H. H., Nanayakkara, P. W. B., Alam, N., Nanayakkara, P. W. B., Oskam, E., Stassen, P. M., Haak, H. R., Holleman, F., Panday, R. S. N., Duineveld, B. a. M., Exter, P. v., Ven, P. M. v. d., Bon, V., Goselink, J., Kreek, A. D., Grunsven, P. v., Biekart, M., Deddens, G. J., Weijschede, F., Rijntjes, N., Franschman, G., Janssen, J., Frenken, J., Versluis, J., Boomars, R., Vries, G. d., Boer, E. d., Gent, A. v., Willeboer, M., Buunk, G., Timmers, G. J., Snijders, F., Posthuma, N., Stoffelen, S., Claassens, S., Ammerlaan, H., Sankatsing, S., Frenken, J., Alsma, J., Zanten, A. v., Slobbe, L., Melo, M. M. d., Dees, A., Carels, G., Wabbijn, M., Leeuwen-Nguyen, T. T. H. v., Assink, J., Honing, A. v. d., Luik, P., Poortvliet, W., Schouten, W. E. M., Veenstra, J., Holkenborg, J., Cheung, T. C., Bokhorst, J. v., Kors, B., Wattel, G. H. L., Roeleveld, T., Toorians, A., Jellema, W., Govers, A., Kaasjager, H. a. H., Dekker, D., Verhoeven, M. a. M., Kramer, M. H. H., Flietstra, T., Roest, L., Peters, E. J. G., Hekker, T. a. M., Ang, W., Wekken, W. v. d., Maghami, P. G., Kanen, B., Wesselius, H., Heesterman, L., Zwietering, A. N., & Stoffers, J. The Lancet Respiratory Medicine, 6(1):40–50, January, 2018.
Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial [link]Paper  doi  abstract   bibtex   
\textlessh2\textgreaterSummary\textless/h2\textgreater\textlessh3\textgreaterBackground\textless/h3\textgreater\textlessp\textgreaterEmergency 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.\textless/p\textgreater\textlessh3\textgreaterMethods\textless/h3\textgreater\textlessp\textgreaterAfter 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.\textless/p\textgreater\textlessh3\textgreaterFindings\textless/h3\textgreater\textlessp\textgreater2698 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.\textless/p\textgreater\textlessh3\textgreaterInterpretation\textless/h3\textgreater\textlessp\textgreaterIn 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.\textless/p\textgreater\textlessh3\textgreaterFunding\textless/h3\textgreater\textlessp\textgreaterThe NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).\textless/p\textgreater
@article{alam_prehospital_2018,
	title = {Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial},
	volume = {6},
	issn = {2213-2600, 2213-2619},
	shorttitle = {Prehospital antibiotics in the ambulance for sepsis},
	url = {https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(17)30469-1/abstract},
	doi = {10.1016/S2213-2600(17)30469-1},
	abstract = {{\textless}h2{\textgreater}Summary{\textless}/h2{\textgreater}{\textless}h3{\textgreater}Background{\textless}/h3{\textgreater}{\textless}p{\textgreater}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.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Methods{\textless}/h3{\textgreater}{\textless}p{\textgreater}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.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Findings{\textless}/h3{\textgreater}{\textless}p{\textgreater}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.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Interpretation{\textless}/h3{\textgreater}{\textless}p{\textgreater}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.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Funding{\textless}/h3{\textgreater}{\textless}p{\textgreater}The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).{\textless}/p{\textgreater}},
	language = {English},
	number = {1},
	urldate = {2020-01-08},
	journal = {The Lancet Respiratory Medicine},
	author = {Alam, Nadia and Oskam, Erick and Stassen, Patricia M. and Exter, Pieternel van and Ven, Peter M. van de and Haak, Harm R. and Holleman, Frits and Zanten, Arthur van and Leeuwen-Nguyen, Hien van and Bon, Victor and Duineveld, Bart A. M. and Panday, Rishi S. Nannan and Kramer, Mark H. H. and Nanayakkara, Prabath W. B. and Alam, N. and Nanayakkara, P. W. B. and Oskam, E. and Stassen, P. M. and Haak, H. R. and Holleman, F. and Panday, R. S. Nannan and Duineveld, B. a. M. and Exter, P. van and Ven, P. M. van de and Bon, V. and Goselink, J. and Kreek, A. De and Grunsven, P. van and Biekart, M. and Deddens, G. J. and Weijschede, F. and Rijntjes, N. and Franschman, G. and Janssen, J. and Frenken, J. and Versluis, J. and Boomars, R. and Vries, G. de and Boer, E. den and Gent, A. van and Willeboer, M. and Buunk, G. and Timmers, G. J. and Snijders, F. and Posthuma, N. and Stoffelen, S. and Claassens, S. and Ammerlaan, H. and Sankatsing, S. and Frenken, J. and Alsma, J. and Zanten, A. van and Slobbe, L. and Melo, M. M. de and Dees, A. and Carels, G. and Wabbijn, M. and Leeuwen-Nguyen, T. T. H. van and Assink, J. and Honing, A. van der and Luik, P. and Poortvliet, W. and Schouten, W. E. M. and Veenstra, J. and Holkenborg, J. and Cheung, T. C. and Bokhorst, J. van and Kors, B. and Wattel, G. H. Louis- and Roeleveld, T. and Toorians, A. and Jellema, W. and Govers, A. and Kaasjager, H. a. H. and Dekker, D. and Verhoeven, M. a. M. and Kramer, M. H. H. and Flietstra, T. and Roest, L. and Peters, E. J. G. and Hekker, T. a. M. and Ang, W. and Wekken, W. van der and Maghami, P. Ghaem and Kanen, B. and Wesselius, H. and Heesterman, L. and Zwietering, A. N. and Stoffers, J.},
	month = jan,
	year = {2018},
	pmid = {29196046},
	pages = {40--50},
}
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