Can I Start Antibiotics Before ED Discharge Tomorrow?
Yes, you should start empiric antibiotic therapy now if there are signs of infection, rather than waiting until ED discharge tomorrow. The decision depends on the severity of illness and clinical presentation.
Immediate Risk Stratification
Calculate a NEWS2 score immediately to determine urgency of antibiotic administration 1, 2:
- High risk (NEWS2 ≥7): Administer IV antibiotics within 1 hour of recognition 1, 2
- Moderate risk (NEWS2 5-6): Administer antibiotics within 3 hours 1, 2
- Low risk (NEWS2 <5): Administer antibiotics within 6 hours 1, 2
These timeframes represent maximum delays, not targets to work toward 1.
When to Start Antibiotics Immediately
For patients with septic shock or severe sepsis, antibiotics must be started as soon as possible—ideally within the first hour 1, 2. Delaying antibiotic therapy in critically ill patients to await diagnostic results is associated with increased mortality 1.
Start empiric antibiotics now (before ED transfer) if the patient has 1:
- Signs of septic shock (hypotension, altered mental status, lactate >2 mmol/L)
- Diffuse peritonitis or severe intra-abdominal infection
- Necrotizing soft tissue infection
- Severe systemic illness with high NEWS2 score (≥7)
When Antibiotics Can Be Safely Delayed
For hemodynamically stable patients without acute organ failure, antibiotics can be delayed up to 24 hours if appropriate monitoring is provided 1. This approach is acceptable for:
- Mild to moderate infections without systemic signs 1, 3
- Well-localized infections amenable to source control 1
- Patients awaiting diagnostic workup when infection severity is uncertain 3, 4
Withholding antibiotics for 4-8 hours until diagnostic results are available is acceptable for most cases unless septic shock or bacterial meningitis are suspected 3.
Critical Actions Before Starting Antibiotics
Obtain blood cultures and appropriate specimens before antibiotic administration, but do not delay antibiotics beyond 45 minutes for this purpose in high-risk patients 2, 4. For severe infections:
- Collect blood cultures as soon as possible 2
- Obtain deep tissue specimens (not swabs) from infected wounds after debridement [1, @18@]
- Measure lactate level for assessing tissue hypoperfusion 2
Empiric Antibiotic Selection
Base empiric therapy on the clinical severity, suspected source of infection, risk factors for multidrug-resistant organisms, and local resistance patterns 1, 4:
- Mild to moderate infections: Target aerobic gram-positive cocci (Staphylococcus aureus, Streptococcus) [1, @21@]
- Severe infections: Start broad-spectrum therapy pending culture results [1, @21@]
- Consider MRSA coverage if there is prior MRSA history, high local prevalence, or clinically severe infection 1
Common Pitfalls to Avoid
Do not prescribe antibiotics for clinically uninfected wounds or fever alone without evidence of bacterial infection 1, 4, 5. Approximately 50% of ICU patients receiving antibiotics do not have confirmed infections 6.
Do not delay source control procedures while waiting for antibiotics to work 1. Infected foci must be drained and infected devices removed promptly 4.
Avoid unnecessarily broad-spectrum antibiotics when narrow-spectrum therapy is appropriate 4, 6. Plan for de-escalation once culture results are available 4, 6.
Practical Approach for Your Patient
Given the vague presentation ("moving a bit but not a lot"), perform immediate clinical assessment including NEWS2 score, vital signs, and examination for infection source 1, 2.
If NEWS2 ≥5 or clinical concern for infection exists, start empiric antibiotics now rather than waiting until tomorrow 1, 2. The specific timeframe depends on severity, but delaying 12-24 hours until ED discharge is inappropriate for moderate to severe infections 1, 2.
If the patient is clinically stable with NEWS2 <5 and only mild symptoms, antibiotics can potentially be deferred until proper evaluation in the ED 3, but close monitoring every 4-6 hours is essential 1, 2.