O0028: The Association Between Intent to Obtain Cerebrospinal Fluid Culture Prior to Antibiotics and Antibiotic Timeliness in Pediatric Sepsis

Background: Sepsis is the most common cause of childhood death in the world and delays in antibiotic administration have been associated with increased morbidity and mortality. Sepsis guidelines recommend obtaining source cultures, including cerebrospinal fluid (CSF), prior to antibiotics if it does not delay antibiotic administration in order to improve diagnostic accuracy. The objective of this study was to evaluate the association between intent to obtain CSF prior to antibiotics and antibiotic delay in pediatric patients with sepsis.

Methods: This was a retrospective cohort study using a sepsis registry of children ≥ 60 days and < 21 years who visited emergency departments (ED) and had CSF obtained within 72-hours of arrival for concern of bacterial meningitis in the setting of ED attending concern for sepsis between April 2012 to March 2018. Children with CSF obtained for non-infectious reasons and children with intrathecal or ventriculoperitoneal devices were excluded. The primary exposure was physician intent to administer antibiotics as soon as possible, prior to CSF collection (Antibiotic ASAP cohort) versus intent to obtain CSF prior to antibiotics (CSF First cohort). Outcomes were: 1) delayed antibiotics, defined as >180 minutes after sepsis recognition, and 2) diagnostic failure, defined as receiving ≥ 5 days of meningitic-dosed intravenous antibiotics for presumed meningitis in the absence of identifying a causative pathogen for bacterial meningitis. A causative pathogen was considered identified by positive CSF culture OR pathogen identified on the meningoencephalitis panel with ≥ 10 white blood cells (WBC) in CSF, OR positive blood cultures with ≥ 10 WBC in CSF. A subgroup analysis was performed in patients with organ dysfunction at time of ED evaluation.

Results: From 04/2012-03/2018, 218 patients met inclusion criteria. 88 (40%) were in the Antibiotics ASAP cohort, 128 (59%) were in the CSF First cohort, and 2 (1%) had unclear intent. Delayed antibiotic administration occurred in 37 (19%) patients and 7 (3%) had diagnostic failure. The relative risk of delayed antibiotic administration in the CSF First cohort was 2.68 (95% CI 1.34-5.38) compared to the Antibiotics ASAP cohort. The relative risk of diagnostic failure was 0.92 (95% CI0.21-4.00) in the CSF First cohort compared to the Antibiotics ASAP cohort (Table 1). Among patients with organ dysfunction, the relative risk of delayed antibiotics was 2.87 (95% CI 1.06-7.79) in the CSF First cohort compared to the Antibiotics ASAP cohort, while there was no difference in diagnostic failure (Table 2).

Conclusion: In this study, intent to obtain CSF prior to antibiotics was associated with antibiotic delay in patients with suspected sepsis and was not associated with failure to determine presence of bacterial meningitis. These findings align with the sepsis recommendations to obtain source cultures before antibiotics when it does not delay antibiotic administration in cases of suspected sepsis.