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RATIONALE Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared to those with community-acquired sepsis (CAS). Capacity strain, the extent to which demand for hospital resources exceeds availability thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. OBJECTIVE Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. METHODS This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from CAS by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by CDC Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. RESULTS 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (IQR 0.4 to 22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% CI: 2.4 to 4.8) to 6.8 hours (95% CI: 5.3 to 8.4) at census levels two standard deviations below and above the ward-specific mean, respectively. Each one-standard-deviation increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI: 0.32-1.29). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. CONCLUSIONS Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.