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Hasegawa K, Doi A, Iwata K. Comparison of oral versus intravenous antimicrobial therapy for patients who were diagnosed with bloodstream infections due to Gram-negative bacilli after discharge from the emergency department: A retrospective analysis. J Infect Chemother 2024:S1341-321X(24)00245-9. [PMID: 39237003 DOI: 10.1016/j.jiac.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/28/2024] [Accepted: 09/02/2024] [Indexed: 09/07/2024]
Abstract
INTRODUCTION Infections caused by Gram-negative bacilli (GNB) in the emergency department (ED) are common, and the blood cultures taken at the visit can turn positive often after the discharge. However, the differences in the clinical outcomes depending on the subsequent decision-making, either to giving the patients intravenous or oral antibiotics remain unknown. METHODS A single-center retrospective observational study was conducted for the outcome of the patients whose blood cultures at the visit turned positive and detected GNB. The primary outcomes were 30- and 90-day all-cause mortality from the first positive blood cultures, comparing intravenous treatment (IVT) and oral treatment (OT). The propensity score analysis was used to adjust potential confounders. RESULTS A total of 283 patients with GNB bloodstream infections (BSIs) diagnosed after ED discharge. No death occurred in either group within 30 days, with the average treatment effect (ATE) of OT being <0.001 (p = 0.45) after inverse probability weighting (IPW). At 90 days, mortality was 2.5 % for the OT group and 0 % for the IVT group (ATE 0.051; 96%CI 0.013-0.098; p = 0.001). CONCLUSION All of patients treated with oral antibiotics were alive at 30 days, but had a higher 90-day mortality compared to those given intravenous agents. The results were consistent after adjusting the potential confounders by using IPW. Given the overall low mortality in both groups after 90 days, even though oral antibiotic therapy was associated with higher mortality statistically, one might consider this as an option especially when the patient's preference was compelling.
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Affiliation(s)
- Kohei Hasegawa
- Department of Infectious Diseases, Sakai City Medical Center, Osaka, 593-8304, Japan
| | - Asako Doi
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, Hyogo, 650-0047, Japan.
| | - Kentaro Iwata
- Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, Hyogo, 650-0017, Japan
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Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J. Challenges of antimicrobial stewardship among older adults. Eur J Intern Med 2024; 124:5-13. [PMID: 38360513 DOI: 10.1016/j.ejim.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Specialist, Head of Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance, Hospital de Braga, Portugal.
| | - Virginie Prendki
- Department of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland; Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Marie Chedid
- Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - Davide Bosetti
- Department of Infectious Disease, Geneva University Hospital, Switzerland; Infection Control Programme and WHO Collaborating Centre for Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jordi Rello
- Medicine Department, Universitat Internacional de Catalunya, Spain; Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebrón Institute Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
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Wang CP, Hsieh MS, Hu SY, Huang SC, Tsai CA, Shen CH. Risk Factors and Scoring Systems to Predict the Mortality Risk of Afebrile Adult Patients with Monomicrobial Gram-Negative Bacteremia: A 10-Year Observational Study in the Emergency Department. Diagnostics (Basel) 2024; 14:869. [PMID: 38732284 PMCID: PMC11083546 DOI: 10.3390/diagnostics14090869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/10/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The mortality rate of afebrile bacteremia has been reported to be as high as 45%. This investigation focused on the risk factors and predictive performance of scoring systems for the clinical outcomes of afebrile patients with monomicrobial gram-negative bacteria (GNB) in the emergency department (ED). METHODS We conducted a retrospective analysis of afebrile adult ED patients with monomicrobial GNB bacteremia from January 2012 to December 2021. We dissected the demographics, clinical pictures, and laboratory investigations. We applied five scoring systems and three revised systems to predict the clinical outcomes. RESULTS There were 600 patients included (358 males and 242 females), with a mean age of 69.6 ± 15.4 years. The overall mortality rate was 50.17%, reaching 68.52% (74/108) in cirrhotic patients. Escherichia coli was the leading pathogen (42.83%). The non-survivors had higher scores of the original MEDS (p < 0.001), NEWS (p < 0.001), MEWS (p < 0.001), qSOFA (p < 0.001), and REMS (p = 0.030). In univariate logistic regression analyses, several risk factors had a higher odds ratio (OR) for mortality, including liver cirrhosis (OR 2.541, p < 0.001), malignancy (OR 2.259, p < 0.001), septic shock (OR 2.077, p = 0.002), and male gender (OR 0.535, p < 0.001). The MEDS demonstrated that the best predictive power with the maximum area under the curve (AUC) was measured at 0.773 at the cut-off point of 11. The AUCs of the original NEWS, MEWS, qSOFA, and REMS were 0.663, 0.584, 0.572, and 0.553, respectively. We revised the original MEDS, NEWS, and qSOFA by adding red cell distribution width, albumin, and lactate scores and found a better predictive power of the AUC of 0.797, 0.719, and 0.694 on the revised MEDS ≥11, revised qSOFA ≥ 3, and revised NEWS ≥ 6, respectively. CONCLUSIONS The original MEDS, revised MEDS, revised qSOFA, and revised NEWS were valuable tools for predicting the mortality risk in afebrile patients with monomicrobial GNB bacteremia. We suggested that clinicians should explore patients with the risk factors mentioned above for possible severe infection, even in the absence of fever and initiate hemodynamic support and early adequate antibiotic therapy in patients with higher scores of the original MEDS (≥11), revised MEDS (≥11), revised NEWS (≥6), and revised qSOFA (≥3).
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Affiliation(s)
- Chung-Pang Wang
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-P.W.); (C.-H.S.)
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan 330, Taiwan;
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-P.W.); (C.-H.S.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40201, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
| | - Shih-Che Huang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Lung Cancer Research Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Che-An Tsai
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Chia-Hui Shen
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-P.W.); (C.-H.S.)
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Bnaya A, Schwartz Y, Wolfovitz Barchad O, Atrash J, Bar-Meir M, Shavit L, Ben-Chetrit E. Clinical presentation and outcome of hemodialysis tunneled catheter-related bloodstream infection in older persons. Eur Geriatr Med 2024; 15:235-242. [PMID: 37713092 DOI: 10.1007/s41999-023-00861-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The use of a tunneled catheter as the primary vascular access among old hemodialysis patients is frequent. Catheter-related bloodstream infection (CRBSI) is a common complication, associated with increased mortality. Data regarding the clinical presentation and outcomes of CRBSI among old hemodialysis patients is limited. METHODS All chronic hemodialysis patients hospitalized between 2010 and 2022 with CRBSI were included. Patients were classified into two groups: old adults (≥ 75) and younger patients. Clinical, microbiological, and outcome data were collected and analyzed. RESULTS One hundred and fifty-four patients with CRBSI were identified. Fifty-seven were aged ≥ 75 years. Mean age in the older and younger groups was 81.2 ± 5 and 59.7 ± 12.7, respectively. Male gender was predominant (64%). Charlson comorbidity score and Pitt bacteremia score were comparable among both groups. Norton score < 14 was more common among old persons (n = 24, 67% versus n = 21, 31%, p < 0.001), as well as nursing-home residence. Gram-negative pathogens and Staphylococcus aureus were common in both groups. The frequency of inappropriate empirical antimicrobial treatment was higher among older persons. Overall, in-hospital and 90-day mortality was high (age ≥ 75, 36.8%, age < 75, 24.7%, p = 0.14). Age was not significantly associated with mortality after adjustment for low Norton score, residence, and inappropriate antimicrobial therapy as well as resistance patterns of bloodstream isolates [OR = 1.2 (95% CI 0.4-3.3), p = 0.76]. CONCLUSIONS Clinical characteristics and outcomes of CRBSI were comparable among old and young hemodialysis patients. However, the high mortality rate in this cohort suggests that the use of tunneled catheters as a permanent vascular access should be discouraged in both patient groups.
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Affiliation(s)
- Alon Bnaya
- Institute of Nephrology, Shaare Zedek Medical Center, Affiliated with the Hebrew University, Jerusalem, Israel
| | - Yuval Schwartz
- Infectious Diseases Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University, P.O Box 3235, 91031, Jerusalem, Israel
| | - Orit Wolfovitz Barchad
- Infectious Diseases Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University, P.O Box 3235, 91031, Jerusalem, Israel
| | - Jawad Atrash
- Institute of Nephrology, Shaare Zedek Medical Center, Affiliated with the Hebrew University, Jerusalem, Israel
| | - Maskit Bar-Meir
- Pediatric Infectious Diseases, Shaare Zedek Medical Center, Affiliated with the Hebrew University, Jerusalem, Israel
| | - Linda Shavit
- Institute of Nephrology, Shaare Zedek Medical Center, Affiliated with the Hebrew University, Jerusalem, Israel
| | - Eli Ben-Chetrit
- Infectious Diseases Unit, Shaare Zedek Medical Center, Affiliated with the Hebrew University, P.O Box 3235, 91031, Jerusalem, Israel.
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Roseau-Vincenti A, Forestier E, Lanoix JP, Ricard C, Carret MC, Caraux-Paz P, Paccalin M, Gavazzi G, Roubaud-Baudron C. Empirical antibiotic therapy modalities for Enterobacteriaceae bloodstream infections in older patients and their impact on mortality: a multicentre retrospective study. Infection 2024; 52:155-163. [PMID: 37608043 DOI: 10.1007/s15010-023-02073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/01/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE Enterobacteriaceae (EB) bloodstream infections (BSI) are frequent and serious in older patients. Physicians are faced with the dilemma of prescribing early appropriate empirical antibiotics to limit the risk of death, and sparing broad-spectrum antibiotic prescription. The aim of the study was to assess the rate of appropriate empirical antibiotics prescription to treat EB BSI in older patients and its impact on survival. METHODS This study conducted in 49 centres enrolled retrospectively up to the 10 last consecutive patients aged 75 years and over and treated for EB BSI. Factors related to in-hospital death were investigated using logistic regression. RESULTS Among the 487 enrolled patients (mean age 86 ± 5.9 years), 70% had at least one risk factor of being infected by third-generation cephalosporins (3GC)-resistant strain; however, only 13.8% of EB strains were resistant to 3GC. An empirical antimicrobial treatment was initiated for 418 patients (85.8%), and for 86% (n = 360/418) of them, it was considered appropriate. In-hospital mortality was 12.7% (n = 62) and was related to the severity of infection (OR 3.17, CI 95% 1.75-5.75), while a urinary portal of entry was protective (OR 0.34, CI 95% 0.19-0.60). Neither the absence of nor inappropriate empirical antibiotics prescription was associated with increased mortality. CONCLUSION While patients enrolled in this study were at risk of being infected by multidrug-resistant bacteria, yet mainly treated with 3GC, empirical antibiotics prescription was appropriate in most cases and did not influence mortality.
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Affiliation(s)
| | | | | | - Cécile Ricard
- Epidémiologiste/statisticienne indépendante, Annecy, France
| | | | - Pauline Caraux-Paz
- Maladies infectieuses CH Intercommunal Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | | | - Gaëtan Gavazzi
- Clinique universitaire de médecine gériatrique, CHU Grenoble-Alpes, Grenoble, France
| | - Claire Roubaud-Baudron
- CHU Bordeaux, Pôle de gérontologie clinique, 33000, Bordeaux, France.
- Univ. Bordeaux, BRIC Bordeaux Institute of Oncology INSERM UMR 1312, 33000, Bordeaux, France.
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Sharma A, Elligsen M, Daneman N, Lam PW. Patient predictors of pathogenic versus commensal Gram-positive bacilli organisms isolated from blood cultures. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e245. [PMID: 38156236 PMCID: PMC10753492 DOI: 10.1017/ash.2023.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/30/2023]
Abstract
Objective Gram-positive bacilli represent a diverse species of bacteria that range from commensal flora to pathogens implicated in severe and life-threatening infection. Following the isolation of Gram-positive bacilli from blood cultures, the time to species identification may take upward of 24 hours, leaving clinicians to conjecture whether they may represent a contaminant (inadvertent inoculation of commensal flora) or pathogenic organism. In this study, we sought to identify patient variables that could help predict the isolation of contaminant versus pathogenic Gram-positive bacilli from blood cultures. Design Retrospective cohort study. Settings One quaternary academic medical center affiliated with the University of Toronto. Patients Adult inpatients were admitted to hospital over a 5-year period (May 2014 to December 2019). Methods A total of 260 unique Gram-positive bacilli blood culture results from adult inpatients were reviewed and analyzed in both a univariable and multivariable model. Results Malignancy (aOR 2.78, 95% CI 1.33-5.91, p = 0.007), point increments in the Quick Sepsis Related Organ Failure Assessment score for sepsis (aOR 2.25, 95% CI 1.50-3.47, p < 0.001), peptic ulcer disease (aOR 5.63, 95% CI 1.43-21.0, p = 0.01), and the receipt of immunosuppression prior to a blood culture draw (aOR 3.80, 95% CI 1.86-8.01, p < 0.001) were associated with an increased likelihood of speciating pathogenic Gram-positive bacilli from blood cultures such as Clostridium species and Listeria monocytogenes. Conclusion Such predictors can help supplement a clinician's assessment on determining when empirical therapy is indicated when faced with Gram-positive bacilli from blood cultures and may direct future stewardship interventions for responsible antimicrobial prescribing.
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Affiliation(s)
- Arjun Sharma
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nick Daneman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Philip W. Lam
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Speaker SL, Pfoh ER, Pappas MA, Schulte R, Hu B, Gautier TN, Rothberg MB. Relationship Between Oral Temperature and Bacteremia in Hospitalized Patients. J Gen Intern Med 2023; 38:2742-2748. [PMID: 36997793 PMCID: PMC10506973 DOI: 10.1007/s11606-023-08168-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Early recognition and treatment of bacteremia can be lifesaving. Fever is a well-known marker of bacteremia, but the predictive value of temperature has not been fully explored. OBJECTIVE To describe temperature as a predictor of bacteremia and other infections. DESIGN Retrospective review of electronic health record data. SETTING A single healthcare system comprising 13 hospitals in the United States. PATIENTS Adult medical patients admitted in 2017 or 2018 without malignancy or immunosuppression. MAIN MEASURES Maximum temperature, bacteremia, influenza and skin and soft tissue (SSTI) infections based on blood cultures and ICD-10 coding. KEY RESULTS Of 97,174 patients, 1,518 (1.6%) had bacteremia, 1,392 (1.4%) had influenza, and 3,280 (3.3%) had an SSTI. There was no identifiable temperature threshold that provided adequate sensitivity and specificity for bacteremia. Only 45% of patients with bacteremia had a maximum temperature ≥ 100.4˚F (38˚C). Temperature showed a U-shaped relationship with bacteremia with highest risk above 103˚F (39.4˚C). Positive likelihood ratios for influenza and SSTI also increased with temperature but showed a threshold effect at ≥ 101.0 ˚F (38.3˚C). The effect of temperature was similar but blunted for patients aged ≥ 65 years, who frequently lacked fever despite bacteremia. CONCLUSIONS The majority of bacteremic patients had maximum temperatures below 100.4 ˚F (38.0˚C) and positive likelihood ratios for bacteremia increased with high temperatures above the traditional definition of fever. Efforts to predict bacteremia should incorporate temperature as a continuous variable.
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Affiliation(s)
- Sidra L Speaker
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
| | - Elizabeth R Pfoh
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew A Pappas
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Schulte
- Department for Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Hu
- Department for Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas N Gautier
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
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Chen CH, Lien CJ, Huang YS, Ho YJ, Lin SY, Fan CY, Chen JW, Pei-Chuan Huang E, Sung CW. A simplified scoring model for predicting bacteremia in the unscheduled emergency department revisits: The SADFUL score. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:793-801. [PMID: 37062621 DOI: 10.1016/j.jmii.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Bacteremia is a severe complication of infectious disease. Patients with a high bacteremia risk in the emergency department (ED) but misidentified would lead to the unscheduled revisits. This study aimed to develop a simplified scoring model to predict bacteremia in patients with unscheduled ED revisits. METHODS Adult patients with unscheduled ED revisits within 72 h with a final diagnosis of infectious disease were retrospectively included. The development cohort included patients visiting the ED from January 1, 2019 to December 31, 2021. Internal validation was performed in patients visiting the ED from January 1, 2022 to March 31, 2022. Variables including demographics, pre-comorbidities, triage levels, vital signs, chief complaints, and laboratory data in the index visit were analyzed. Bacteremia was the primary outcome determined by blood culture in either index visits or revisits. RESULTS The SADFUL score for predicting bacteremia comprised the following predictors: "S"egmented neutrophil percentage (+3 points), "A"ge > 55 years (+1 point), "D"iabetes mellitus (+1 point), "F"ever (+2 points), "U"pper respiratory tract symptoms (-2 points), and "L"eukopenia (2 points). The area under receiver operating characteristic curve with 95% confidence interval in the development (1802 patients, 190 [11%] with bacteremia) and the validation cohort (134 patients, 17 [13%] with bacteremia) were 0.78 (0.74-0.81) and 0.79 (0.71-0.88), respectively. CONCLUSIONS The SADFUL score is a simplified useful tool for predicting bacteremia in patients with unscheduled ED revisits. The scoring model could help ED physicians decrease misidentification of patients at a high risk for bacteremia and potential complications.
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Affiliation(s)
- Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chun-Ju Lien
- Department of Medical Education, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Yu-Sheng Huang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Yi-Ju Ho
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shao-Yung Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Yi Fan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Edward Pei-Chuan Huang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan.
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Intrinsic values of procalcitonin in bacterial bloodstream infections in people aged 75 years and over: a retrospective study. Diagn Microbiol Infect Dis 2023; 105:115887. [PMID: 36640698 DOI: 10.1016/j.diagmicrobio.2022.115887] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/08/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate PCT measurement in the diagnosis of bloodstream infection (BSI) in hospitalized patients aged 75+. METHOD Descriptive, retrospective, monocentric study conducted in France, in patients with at least one blood culture and PCT and CRP measurements within the 24 hours before or after blood culture. RESULTS The mean PCT and CRP values for the 118 (15.2%) positive blood cultures were 18.90 ng/ml [95%CI: 0.007-334.7] and 153.93 mg/l [1-557], respectively. With a threshold of 0.3 ng/ml, PCT measurement had a sensitivity of 84%, a specificity of 53%, a PPV of 24%, and an NPV of 95%, making it possible to rule out BSI in 350 (45.1%) patients (α-risk=5%). CONCLUSION PCT measurement may eliminate BSI diagnosis more quickly than does blood culture reducing the inadequate and detrimental use of antibiotic therapy. A prospective study is required to validate its usefulness and confirm the cut-off value in geriatric populations.
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Laborde C, Deidda M, Bador J, Putot S, Manckoundia P, Putot A. Apyrexia improves the prognostic value of quick SOFA in older patients with acute pneumonia or bacteremic urinary tract infection. Infection 2022; 51:759-764. [DOI: 10.1007/s15010-022-01953-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 11/01/2022] [Indexed: 11/30/2022]
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Henri B, Sirvain S, de Wazieres B, Bernard L, Gavazzi G, Forestier E, Fraisse T. [Survey on antibiotic prescription practices for palliative care terminally ill patients of 75 years old and more]. Rev Med Interne 2022; 43:589-595. [PMID: 36064626 DOI: 10.1016/j.revmed.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/25/2022] [Accepted: 08/24/2022] [Indexed: 11/20/2022]
Abstract
Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits. METHOD ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017. RESULTS 220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP. CONCLUSION Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.
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Affiliation(s)
- B Henri
- Post-urgences gériatriques, CHU Purpan, 31000 Toulouse, France
| | - S Sirvain
- Court séjour gériatrique, CH Alès-Cevennes, 811 avenue du Dr J goubert, 30100 Ales, France
| | - B de Wazieres
- Service de gériatrie, CHU Caremeau, 30000 Nimes, France
| | - L Bernard
- Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France
| | - G Gavazzi
- Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
| | - E Forestier
- Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France
| | - T Fraisse
- Court séjour gériatrique, CH Alès-Cevennes, 811 avenue du Dr J goubert, 30100 Ales, France.
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12
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Chen CT, Wu MH, Huang TY, Li YY, Huang TJ, Lee CY, Lin CH, Lee CY. Anaerobic spondylodiscitis: a retrospective analysis. BMC Musculoskelet Disord 2022; 23:788. [PMID: 35978349 PMCID: PMC9382781 DOI: 10.1186/s12891-022-05749-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
Background This retrospective study analyzed the clinical characteristics and outcomes of patients with anaerobic spondylodiscitis. Methods From a total of 382 patients with infectious spondylodiscitis, nine patients (2.4%; two male and seven female with an average age of 67 years) with anaerobic spondylodiscitis between March 2003 and March 2017 were analyzed. Results Most of the patients (77.8%) initially presented with afebrile back pain. Hematogenous spread occurred in seven patients and postoperative infection in two patients. Bacteroid fragilis was the most common pathogen isolated from three patients. Atypical radiographic characteristics, including a vertebral fracture with the preservation of disk height or coexisting spondylolytic spondylolisthesis, occurred in four patients with hematogenous anaerobic spondylodiscitis. The eradication rate of anaerobic infection was significantly higher in the patients with hematogenous infection than in those with postoperative infection (100% vs. 0%, p = 0.0476). Anaerobic spondylodiscitis accounted for 2.4% of cases of infectious spondylodiscitis and predominantly affected the female patients. Conclusions Diagnostic delay may occur because of atypical spinal radiographs if the patient reports only back pain but no fever. Anaerobic infection following elective spinal instrumentation has a higher recurrence rate.
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Affiliation(s)
- Chien-Ting Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Meng-Huang Wu
- Department of Orthopedics, Taipei Medical University Hospital, No.252, Wu-hsing St., Taipei, 11031, Taiwan.,Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan
| | - Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Yao Li
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsung-Jen Huang
- Department of Orthopedics, Taipei Medical University Hospital, No.252, Wu-hsing St., Taipei, 11031, Taiwan.,Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan
| | - Chien-Yin Lee
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Che-Han Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ching-Yu Lee
- Department of Orthopedics, Taipei Medical University Hospital, No.252, Wu-hsing St., Taipei, 11031, Taiwan. .,Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan. .,International Ph.D. Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan.
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13
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Hernandez-Ruiz V, Letenneur L, Fülöp T, Helmer C, Roubaud-Baudron C, Avila-Funes JA, Amieva H. Infectious diseases and cognition: do we have to worry? Neurol Sci 2022; 43:6215-6224. [PMID: 35867217 PMCID: PMC9305033 DOI: 10.1007/s10072-022-06280-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Virgilio Hernandez-Ruiz
- UMR 1219, Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, 33000, Bordeaux, France.
- Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Luc Letenneur
- UMR 1219, Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, 33000, Bordeaux, France
| | - Tamas Fülöp
- Research Center On Aging, Geriatric Division, Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Québec, Canada
| | - Catherine Helmer
- UMR 1219, Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, 33000, Bordeaux, France
| | - Claire Roubaud-Baudron
- CHU Bordeaux, Pôle de Gérontologie Clinique, 33000, Bordeaux, France
- Univ. Bordeaux, INSERM, UMR U1312 - BRIC, 33000, Bordeaux, France
| | - José-Alberto Avila-Funes
- UMR 1219, Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, 33000, Bordeaux, France
- Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hélène Amieva
- UMR 1219, Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, 33000, Bordeaux, France
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14
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Miwa T, Takamatsu A, Honda H. Epidemiology and Factors Associated With Discharging Patients After Blood Culture Collection in the Emergency Department: A Case-Control Study in Japan. Open Forum Infect Dis 2022; 9:ofac342. [PMID: 35899274 PMCID: PMC9315278 DOI: 10.1093/ofid/ofac342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Some patients receive the diagnosis of bloodstream infection (BSI) after discharge from the emergency room (ER). Because the safety of discharging patients after a blood culture collection is unknown, the present study aimed to investigate the prevalence, outcomes, and factors associated with BSI diagnosed after ER discharge. Methods This monocentric, case-control study compared patients who received a BSI diagnosis after ER discharge with those who were admitted for BSI. Factors associated with ER discharge after a blood culture collection were identified using multivariate logistic regression analysis. Results Between January 2014 and December 2020, 5.5% (142/2575) of patients with BSI visiting the ER were initially discharged. This occurred more commonly during the coronavirus disease 2019 (COVID-19) pandemic in 2020. On multivariate analysis, factors independently associated with the discharge of patients with BSI were the absence of hypotension (adjusted odds ratio [aOR], 15.71 [95% confidence interval {CI}, 3.45–71.63]), absence of altered mental status in the ER (aOR, 8.99 [95% CI, 3.49–23.14]), unknown origin at ER discharge (aOR, 4.60 [95% CI, 2.43–8.72]), and low C-reactive protein (aOR, 3.60 [95% CI, 2.19–5.93]). No difference in 28-day mortality was observed between the groups. Conclusions BSI is occasionally diagnosed after ER discharge. The prevalence of BSI diagnosed after ER discharge may have increased during the COVID-19 pandemic. Normal vital signs, unknown origin at ER discharge, and low C-reactive protein were important considerations leading to the discharge of these patients.
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Affiliation(s)
- Toshiki Miwa
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Akane Takamatsu
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hitoshi Honda
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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15
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Ho CY, Hung YP, Chen PL, Hsieh CC, Lee CH, Lee CC, Ko WC. Prognostic Effects of Delayed Administration of Appropriate Antimicrobials in Bacteraemic Adults Initially Presenting with Various Body Temperatures. Infect Drug Resist 2022; 15:3149-3160. [PMID: 35747335 PMCID: PMC9211744 DOI: 10.2147/idr.s357183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the different impact of delayed administration of appropriate antimicrobial therapy (AAT) on short-term mortality of bacteraemia patients initially presenting with various body temperatures (BTs). Materials and Methods A six-year, two-center cohort consisting of adults with community-onset bacteraemia in emergency departments (EDs) was retrospectively collected. Through the multivariable analyses, clinical impacts of delayed AAT, assessed by the time gap between the first dose of AAT and ED arrival, on 30-day mortality (primary outcomes) were respectively examined in the different groups of initial BTs (iBTs). Results Of the 3171 adults, despite the similarities of delayed AAT in six iBT categories, hourly AAT delay was associated with an average increase in 30-day mortality rates of 0.24% in the group of iBT <36.0℃, 0.40% in the 36.0℃-36.9℃ group, 0.48% in the 37.0℃-37.9℃ group, 0.59% in the 38.0℃-38.9℃ group, 0.58% in the 39.0℃-39.9℃ group, and 0.71% in the ≥40.0℃ group, after respective adjusting independent predictors of mortality. Furthermore, for 589 patients who inappropriately received empirical antimicrobial treatment (ie, delayed AAT ≥ 24 hours), with a cutoff of 34.0℃, each 1℃ increase in iBTs was independently associated with an average increase in 30-day mortality rates of 42%. Conclusion For adults with community-onset bacteraemia, the iBT-related differences in the prognostic impacts of delayed administration of appropriate antimicrobials might be evident.
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Affiliation(s)
- Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, 70142, Taiwan
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, 700007, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 70043, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan
| | - Chih-Chia Hsieh
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Chung-Hsun Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
- Clinical Medicine Research Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan
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Abstract
Infections in elderly patients can prove diagnostically challenging. Age-related factors affecting the immune system in older individuals contribute to nonspecific presentations. Other age-related factors and chronic conditions have symptoms that may or may not point to an infectious diagnosis. Delay in administration of antimicrobials can lead to poor outcomes; however, unnecessary administration of antimicrobials can lead to increased morbidity and contribute to the emergence of multidrug-resistant organisms. Careful clinical assessment and consideration of patient history and risk factors is crucial. When necessary, antimicrobials should be chosen that are appropriate for the diagnosis and deescalated as soon as possible.
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Affiliation(s)
- Mary Morgan Scott
- Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8066, St. Louis, MO 63110, USA
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110, USA.
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17
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Atypical Presentation of Bacteremic Urinary Tract Infection in Older Patients: Frequency and Prognostic Impact. Diagnostics (Basel) 2021; 11:diagnostics11030523. [PMID: 33804271 PMCID: PMC8001488 DOI: 10.3390/diagnostics11030523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
In older patients, urinary tract infection (UTI) often has an atypical clinical presentation, making its diagnosis difficult. We aimed to describe the clinical presentation in older inpatients with UTI-related bacteremia and to determine the prognostic impact of atypical presentation. This cohort study included all consecutive patients older than 75 years hospitalized in a university hospital in 2019 with a UTI-related gram-negative bacillus (GNB) bacteremia, defined by blood and urine cultures positive for the same GNB, and followed up for 90 days. Patients with typical symptoms of UTI were compared to patients with atypical forms. Among 3865 inpatients over 75 with GNB-positive urine culture over the inclusion period, 105 patients (2.7%) with bacteremic UTI were included (mean age 85.3 ± 5.9, 61.9% female). Among them, UTI symptoms were reported in only 38 patients (36.2%) and 44 patients (41.9%) had no fever on initial management. Initial diagnosis of UTI was made in only 58% of patient. Mortality at 90 days was 23.6%. After adjustment for confounders, hyperthermia (HR = 0.37; IC95 (0.14–0.97)) and early UTI diagnosis (HR = 0.35; IC95 (0.13–0.94)) were associated with lower mortality, while UTI symptoms were not associated with prognosis. In conclusion, only one third of older patients with UTI developing bacteremia had UTI symptoms. However, early UTI diagnosis was associated with better survival.
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Hyernard C, Roubaud Baudron C. The Reply. Am J Med 2020; 133:e445. [PMID: 32741452 DOI: 10.1016/j.amjmed.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Caroline Hyernard
- CHU de Bordeaux, Pôle de Gérontologie Clinique, F-33000 Bordeaux, France
| | - Claire Roubaud Baudron
- CHU de Bordeaux, Pôle de Gérontologie Clinique, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM UMR 1034 BaRITOn, F-33000 Bordeaux, France.
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19
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Jolobe OM. Problems in Evaluating the Prevalence of Bacteremia in Population Subgroups. Am J Med 2020; 133:e444. [PMID: 32741451 DOI: 10.1016/j.amjmed.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 11/18/2022]
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