**7. Early detection**

The surviving sepsis guidelines now recommend IV antibiotics to be started within 1 h of sepsis recognition and should include combination therapy (at least two classes of antibiotics to cover a known or suspected pathogen) for patients with septic shock. Combination therapy should not routinely be used for patients without shock. Many studies have demonstrated improved survival in early appropriate administration of antibiotics at the first presence of septic shock [50]. Kumar et al. concluded for each hour of delay of appropriate antimicrobials resulted in a mean increase in mortality by 7.6%, with a range 3.6–9.9% [51]. Ferrer et al. published the results of a large population, which concluded that a delay in first antibiotic administration was associated with increased in-hospital mortality in patients with severe sepsis and septic shock [45]. It was also noted that there was a linear risk increase in mortality for every hour delay in antibiotic administration. Another study by Vazquez-Guillamet concluded that improved targeting in multidrug-resistant bacteria would have the greatest impact on reducing overall mortality. In their study, they calculated the number of patients needed to treat and found for every four patients treated with appropriate antimicrobial therapy in severe sepsis and septic shock, it prevents one patient death [52]. The appropriateness of early empiric antibiotics is driven by local hospital-resistance patterns. At times, selection of the most appropriate empiric antimicrobial regimen may be difficult for the clinician based, appropriate history, comorbidities, risk factors for resistant pathogens, and the complexity of patient transitions of care. Clinicians for decades have depended on phenotypic testing that detects the activity of enzymes (i.e., hydrolysis of antibiotics such as beta-lactams *in vitro*) to provide definitive guidance on antimicrobial therapy. These tests provide the clinician pathogen identity with sensitivity, which may have a turn-around time of up to 72 h. As mentioned above, timing of appropriate antimicrobial therapy is key for patient survival in the critically ill, especially with septic shock. New technological advancements in both phenotypic and genotypic testing (molecular tests that detect the resistance mechanisms of a specific gene) commonly known as "rapid diagnostics" will be able to provide detailed information within several hours versus current standards (48–72 h) [53–56].
