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Westgeest AC, Lambregts MMC, Ruffin F, Korn RE, Webster ME, Kair JL, Parsons JB, Maskarinec SA, Kaplan S, Dekkers OM, de Boer MGJ, Fowler VG, Thaden JT. Female Sex and Mortality in Patients with Staphylococcus aureus Bacteremia: A Systematic Review and Meta-analysis. JAMA Netw Open 2024; 7:e240473. [PMID: 38411961 PMCID: PMC10900971 DOI: 10.1001/jamanetworkopen.2024.0473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/08/2024] [Indexed: 02/28/2024] Open
Abstract
Importance Staphylococcus aureus is the leading cause of death due to bacterial bloodstream infection. Female sex has been identified as a risk factor for mortality in S aureus bacteremia (SAB) in some studies, but not in others. Objective To determine whether female sex is associated with increased mortality risk in SAB. Data Sources MEDLINE, Embase, and Web of Science were searched from inception to April 26, 2023. Study Selection Included studies met the following criteria: (1) randomized or observational studies evaluating adults with SAB, (2) included 200 or more patients, (3) reported mortality at or before 90 days following SAB, and (4) reported mortality stratified by sex. Studies on specific subpopulations (eg, dialysis, intensive care units, cancer patients) and studies that included patients with bacteremia by various microorganisms that did not report SAB-specific data were excluded. Data Extraction and Synthesis Data extraction and quality assessment were performed by 1 reviewer and verified by a second reviewer. Risk of bias and quality were assessed with the Newcastle-Ottawa Quality Assessment Scale. Mortality data were combined as odds ratios (ORs). Main Outcome and Measures Mortality at or before 90-day following SAB, stratified by sex. Results From 5339 studies retrieved, 89 were included (132 582 patients; 50 258 female [37.9%], 82 324 male [62.1%]). Unadjusted mortality data were available from 81 studies (109 828 patients) and showed increased mortality in female patients compared with male patients (pooled OR, 1.12; 95% CI, 1.06-1.18). Adjusted mortality data accounting for additional patient characteristics and treatment variables were available from 32 studies (95 469 patients) and revealed a similarly increased mortality risk in female relative to male patients (pooled adjusted OR, 1.18; 95% CI, 1.11-1.27). No evidence of publication bias was encountered. Conclusions and Relevance In this systematic review and meta-analysis, female patients with SAB had higher mortality risk than males in both unadjusted and adjusted analyses. Further research is needed to study the potential underlying mechanisms.
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Affiliation(s)
- Annette C. Westgeest
- Division of Infectious Diseases, Duke University, Durham, North Carolina
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Merel M. C. Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Felicia Ruffin
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Rachel E. Korn
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Maren E. Webster
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Jackson L. Kair
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Joshua B. Parsons
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | | | - Samantha Kaplan
- Medical Center Library and Archives, Duke University, Durham, North Carolina
| | - Olaf M. Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G. J. de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Vance G. Fowler
- Division of Infectious Diseases, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Joshua T. Thaden
- Division of Infectious Diseases, Duke University, Durham, North Carolina
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Westgeest AC, Ruffin F, Kair JL, Park LP, Korn RE, Webster ME, Visser LG, Schippers EF, de Boer MGJ, Lambregts MMC, Fowler VG. The association of female sex with management and mortality in patients with Staphylococcus aureus bacteraemia. Clin Microbiol Infect 2023; 29:1182-1187. [PMID: 37321394 PMCID: PMC11148791 DOI: 10.1016/j.cmi.2023.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The association of biological female sex with outcome in patients with Staphylococcus aureus bacteraemia remains unresolved. The aim of this study was to determine the independent association of female sex with management and mortality in patients with S. aureus bacteraemia. METHODS This is a post hoc analysis of prospectively collected data from the S. aureus Bacteraemia Group Prospective Cohort Study. Adult patients with monomicrobial S. aureus bacteraemia at Duke University Medical Center were enrolled from 1994 to 2020. Univariable and multivariable Cox regression analyses were performed to assess differences in management and mortality between females and males. RESULTS Among 3384 patients with S. aureus bacteraemia, 1431 (42%) were women. Women were, as compared with men, more often Black (581/1431 [41%] vs. 620/1953 [32%], p < 0.001), haemodialysis dependent (309/1424 [22%] vs. 334/1940 [17%], p 0.001) and more likely to be infected with methicillin-resistant S. aureus (MRSA) (697/1410 [49%] MRSA in women vs. 840/1925 [44%] MRSA in men, p 0.001). Women received shorter durations of antimicrobial treatment (median 24 [interquartile range 14-42] vs. 28 [interquartile range 14-45] days, p 0.005), and were less likely to undergo transesophageal echocardiography as compared with men (495/1430 [35%] vs. 802/1952 [41%], p < 0.001). Despite these differences, female sex was not associated with 90-day mortality in either univariable (388/1431 [27%] in women vs. 491/1953 [25%] in men, p 0.204) or multivariable analysis (adjusted hazard ratio for women 0.98 [95% CI, 0.85-1.13]). DISCUSSION Despite significant differences in patient characteristics, disease characteristics, and management, women and men with S. aureus bacteraemia have a similar mortality risk.
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Affiliation(s)
- Annette C Westgeest
- Division of Infectious Diseases, Duke University, Durham, NC, USA; Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
| | - Felicia Ruffin
- Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Jackson L Kair
- Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Lawrence P Park
- Division of Infectious Diseases, Duke University, Durham, NC, USA; Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Rachel E Korn
- Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Maren E Webster
- Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Emile F Schippers
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Vance G Fowler
- Division of Infectious Diseases, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
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Bai AD, Lo CKL, Komorowski AS, Suresh M, Guo K, Garg A, Tandon P, Senecal J, Del Corpo O, Stefanova I, Fogarty C, Butler-Laporte G, McDonald EG, Cheng MP, Morris AM, Loeb M, Lee TC. What Is the Optimal Follow-up Length for Mortality in Staphylococcus aureus Bacteremia? Observations From a Systematic Review of Attributable Mortality. Open Forum Infect Dis 2022; 9:ofac096. [PMID: 35415199 PMCID: PMC8995072 DOI: 10.1093/ofid/ofac096] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/19/2022] [Indexed: 11/14/2022] Open
Abstract
Background Deaths following Staphylococcus aureus bacteremia (SAB) may be related or unrelated to the infection. In SAB therapeutics research, the length of follow-up should be optimized to capture most attributable deaths and minimize nonattributable deaths. We performed a secondary analysis of a systematic review to describe attributable mortality in SAB over time. Methods We systematically searched Medline, Embase, and Cochrane Database of Systematic Reviews from 1 January 1991 to 7 May 2021 for human observational studies of SAB. To be included in this secondary analysis, the study must have reported attributable mortality. Two reviewers extracted study data and assessed risk of bias independently. Pooling of study estimates was not performed due to heterogeneity in the definition of attributable deaths. Results Twenty-four observational cohort studies were included. The median proportion of all-cause deaths that were attributable to SAB was 77% (interquartile range [IQR], 72%–89%) at 1 month and 62% (IQR, 58%–75%) at 3 months. At 1 year, this proportion was 57% in 1 study. In 2 studies that described the rate of increase in mortality over time, 2-week follow-up captured 68 of 79 (86%) and 48 of 57 (84%) attributable deaths that occurred by 3 months. By comparison, 1-month follow-up captured 54 of 57 (95%) and 56 of 60 (93%) attributable deaths that occurred by 3 months in 2 studies. Conclusions The proportion of deaths that are attributable to SAB decreases as follow-up lengthens. Follow-up duration between 1 and 3 months seems optimal if evaluating processes of care that impact SAB mortality. Clinical Trials Registration PROSPERO CRD42021253891.
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Affiliation(s)
- Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Carson K L Lo
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam S Komorowski
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mallika Suresh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kevin Guo
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Akhil Garg
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Pranav Tandon
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julien Senecal
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Olivier Del Corpo
- Department of Medicine, Division of Experimental Medicine, Division of Infectious Diseases, McGill University, Montreal, Quebec, Canada
| | - Isabella Stefanova
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Clare Fogarty
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew P Cheng
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health, University Health Network, and the University of Toronto, Toronto, Ontario, Canada
| | - Mark Loeb
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
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Kim YS, Kim J, Cheon S, Sohn KM. Higher Risk for All-cause Mortality of Staphylococcus aureus Bacteremia in Patients with Non-Dialysis Dependent Chronic Kidney Disease. Infect Chemother 2020; 52:82-92. [PMID: 32114722 PMCID: PMC7113454 DOI: 10.3947/ic.2020.52.1.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 01/08/2023] Open
Abstract
Background Staphylococcus aureus bacteremia (SAB) is a common and serious infection with a high mortality. Patients with chronic kidney disease (CKD) are vulnerable to SAB, but there have been few studies performed on the clinical characteristics and outcomes of SAB in CKD patients stratified by dialysis. We aimed to estimate the all-cause mortality and identify its predictors in patients with CKD. Materials and Methods We conducted a retrospective study on the patients with SAB hospitalized in a tertiary care center in Korea between March 2014 and December 2018. Kaplan-Meier analysis was performed to compare all-cause mortality following SAB among patients with non-dialysis dependent CKD (ND-CKD), those receiving dialysis, and those without CKD (non-CKD). The predictors of mortality among CKD patients were analyzed by Cox proportional hazards regression. Results As a total, 278 SAB of 43 ND-CKD (31 males), 58 dialysis (39 males), and 177 non-CKD (112 males) patients were included. The 30-day mortality was 39.5% in ND-CKD, 27.6% in dialysis, and 7.9% in non-CKD patients. The hazard ratio of all-cause mortality following SAB in ND-CKD was 2.335 (95% confidence interval, 1.203 – 4.531; P = 0.003), compared to non-CKD patients. For methicillin-resistant S. aureus bacteremia (MRSAB), the hazard ratio of all-cause mortality in ND-CKD was 2.628 (95% CI, 1.074 – 6.435; P = 0.011), compared to dialysis patients. Appropriate antibiotics <48 h was independently related to improved survival following SAB among ND-CKD (adjusted HR, 0.304; 95% CI, 0,108 – 0.857; P = 0.024) and dialysis (adjusted HR, 0.323; 95% CI, 0,116 – 0.897; P = 0.030) patients. Conclusion ND-CKD patients demonstrated poor outcome following SAB and administration of appropriate antibiotics within 48 h could reduce the risk for mortality.
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Affiliation(s)
- Yeon Sook Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea.
| | - Jungok Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Shinhye Cheon
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyung Mok Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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A Prospective Cohort Study of Durations of Staphylococcus aureus Bacteremia According to Different Phenotypes and a New Concept of Persistent Bacteremia. Antimicrob Agents Chemother 2019; 64:AAC.01656-19. [PMID: 31636069 DOI: 10.1128/aac.01656-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/16/2019] [Indexed: 12/18/2022] Open
Abstract
The purpose of this study was to describe and compare the duration of Staphylococcus aureus bacteremia (SAB) according to methicillin resistance and the primary foci of infection. We also aimed to newly define persistent SAB considering these results. Nonduplicated episodes of SAB in patients aged ≥15 years from 14 hospitals in the Republic of Korea were analyzed between January 2009 and February 2018. The duration of SAB was defined as the number of days from the time of administration of an antibiotic to which the isolate was susceptible after the onset of SAB to the last day of a positive blood culture for S. aureus SAB durations were described and compared based on methicillin resistance and the primary foci of infection. Cases in the top quartile for the duration of bacteremia in the respective clinical context were classified as newly defined persistent SAB, and its association with in-hospital mortality was evaluated. A total of 1,917 cases were analyzed. The duration of SAB was longer in patients with methicillin-resistant SAB (MRSAB; n = 995) than in patients with methicillin-susceptible SAB (MSSAB; n = 922) (median duration, 1 day [interquartile range, 1 to 3 days] for MSSAB and 1 day [interquartile range, 0 to 5 days] for MRSAB; P < 0.001). The duration of bacteremia was longer in patients with endocarditis and bone and joint, endovascular, and surgical site infections and was shorter in patients with skin and soft tissue infections. Newly defined persistent SAB was independently associated with in-hospital mortality (adjusted odds ratio, 1.97; 95% confidence interval, 1.54 to 2.53; P < 0.001). The durations of SAB were dependent on methicillin resistance and the primary foci of infection, and considering these contexts, persistent SAB was significantly associated with in-hospital mortality.
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