# Sepsis in the emergency department: a dual challenge of early management and antimicrobial stewardship

## TL;DR

This study shows that an antimicrobial stewardship program in emergency departments improves sepsis management and patient outcomes.

## Contribution

The study demonstrates that a stakeholder training and feedback-based AMS program significantly improves sepsis care in EDs.

## Key findings

- Sepsis recognition increased from 47.5% to 61% after the intervention.
- Adherence to antibiotic guidelines improved significantly (OR 4.54).
- 14-day mortality decreased with adherence to local antibiotic guidelines.

## Abstract

Sepsis is a life-threatening condition responsible for millions of deaths worldwide. Although mortality rates have declined, sepsis remains a major global health concern. Early recognition and prompt, appropriate treatment are essential for improving patient outcomes. However, implementing effective sepsis management protocols in Emergency Departments (EDs) is often hindered by staff shortages and high patient volumes. Strengthening sepsis care is also crucial for promoting responsible antibiotic use. This study aimed to evaluate the impact of an antimicrobial stewardship (AMS) program—based on stakeholder training, audit, and feedback—implemented in the ED on the management of sepsis.

A retrospective pre-post intervention analysis was conducted to assess changes in adherence to sepsis management guidelines and clinical outcomes following the introduction of the AMS program. The effect of the intervention on key process indicators was evaluated using Interrupted Time Series (ITS) analysis and logistic regression models adjusted for age and sex.

We analysed data from 577 septic patients in the pre-intervention period and 502 in the post-intervention period. Following implementation, sepsis recognition increased from 47.5% to 61% (p < 0.0001). Significant improvements were also observed in the collection of blood cultures (from 20.5% to 42.4%, p < 0.0001), antibiotic administration (25.7% to 46.8%, p < 0.0001), and crystalloid fluid administration (53% to 72%, p < 0.0001). Complete execution of the sepsis treatment bundle increased substantially post-intervention (OR 2.99, p < 0.0001). Adherence to institutional antibiotic guidelines also improved (OR 4.54, p < 0.0001). ITS analysis confirmed improvements in all components of the sepsis bundle and in sepsis recognition after the intervention. Adherence to local antibiotic guidelines alone (OR 0.59, 95% CI 0.33–1.04) and in combination with sepsis recognition (OR 0.51, 95% CI 0.28–1.01) was associated with a reduction in 14-day mortality.

The AMS program led to substantial improvements in nearly all key process indicators for sepsis management, supporting the objectives of the WHO Global Action Plan on Antimicrobial Resistance, particularly in countries with high prevalence of multidrug-resistant bacteria (WHO. Global Action Plan on Antimicrobial Resistance; World Health Organization: Geneva, Switzerland; 2015). Process indicators were confirmed to be associated with improved short-term survival.

Not applicable.

The online version contains supplementary material available at 10.1186/s12879-025-11947-7.