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Correspondence |

Potential Confounders in the “Influence of Gender on the Outcome of Severe Sepsis” Study FREE TO VIEW

Nishith K. Singh, MD; Vikas K. Singh, MBBS; Randeep Guleria, MD, DM
Author and Funding Information

Affiliations: Southern Illinois University School of Medicine Springfield, IL,  All India Institute of Medical Sciences New Delhi, India

Correspondence to: Vikas K. Singh, MBBS, Room 4083A, Teaching Block, All India Institute of Medical Sciences, New Delhi, India PIN Code 110029; e-mail: meetvsingh@yahoo.com


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(3):671. doi:10.1378/chest.08-1001
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To the Editor:

In the prospective observational study on influence of gender in the outcome of severe sepsis in a recent issue of CHEST (December 2007), Adrie and colleagues1 failed to incorporate an adjustment for the timing of administration and appropriateness of the antibiotic to be used as potential confounders in their analysis. The early (ie, within 1 h of diagnosis) institution of broad-spectrum antibiotics has been endorsed as a strong recommendation for the management of severe sepsis with or without shock by the 2008 Surviving Sepsis Campaign guidelines.2 Ample evidence to support the recommendations exists.

In a 14-center, retrospective cohort study3 of 2,731 adult patients with septic shock, the time to the initiation of effective antimicrobial therapy was the single strongest predictor of in-hospital mortality. In the same study, it was found that each hour of delay in antimicrobial administration over the ensuing 6 h was associated with an average decrease in survival of 7.6%. Also, the failure to initiate appropriate therapy (ie, therapy with an agent having activity against the pathogen that is subsequently identified as the causative agent) within a given time period correlates with increased morbidity and mortality.4

We wonder whether the presumed differences in level of care in the form of proper and timely antibiotic use may have accounted for the discrepant outcomes between sexes due to lack of adjustment in the study. The authors1 have beautifully used the propensity score to match confounding factors, but there is no mention of whether they were matched for two important determinants of outcome, the timing of administration and appropriateness of antibiotic use.

Adrie C, Azoulay E, Francais A, et al. Influence of gender on the outcome of severe sepsis: a reappraisal. Chest. 2007;132:1786-1793. [PubMed] [CrossRef]
 
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327. [PubMed]
 
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-1596. [PubMed]
 
Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000;118:146-155. [PubMed]
 

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References

Adrie C, Azoulay E, Francais A, et al. Influence of gender on the outcome of severe sepsis: a reappraisal. Chest. 2007;132:1786-1793. [PubMed] [CrossRef]
 
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327. [PubMed]
 
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-1596. [PubMed]
 
Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000;118:146-155. [PubMed]
 
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