Risk factors and outcomes of afebrile bacteremia patients in an emergency department

Comparing the Prognostic Impacts of Delayed Administration of Appropriate Antimicrobials in Older Patients with Afebrile and Febrile Community-Onset Bacteremia

Although prompt administration of an appropriate antimicrobial therapy (AAT) is crucial for reducing mortality in the general population with community-onset bacteremia, the prognostic effects of delayed AAT in older individuals with febrile and afebrile bacteremia remain unclear. A stepwise and backward logistic regression analysis was used to identify independent predictors of 30-day mortality. In a 7-year multicenter cohort study involving 3424 older patients (≥65 years) with community-onset bacteremia, febrile bacteremia accounted for 27.1% (912 patients). A crucial association of afebrile bacteremia and 30-day mortality (adjusted hazard ratio [AHR], 1.69; p < 0.001) was revealed using Cox regression and Kaplan-Meier curves after adjusting for the independent predictors of mortality. Moreover, each hour of delayed AAT was associated with an average increase of 0.3% (adjusted odds ratio [AOR], 1.003; p < 0.001) and 0.2% (AOR, 1.002; p < 0.001) in the 30-day crude mortality rates among patients with afebrile and febrile bacteremia, respectively, after adjusting for the independent predictors of mortality. Similarly, further analysis based on Cox regression and Kaplan-Meier curves revealed that inappropriate empirical therapy (i.e., delayed AAT administration > 24 h) had a significant prognostic impact, with AHRs of 1.83 (p < 0.001) and 1.76 (p < 0.001) in afebrile and febrile patients, respectively, after adjusting for the independent predictors of mortality. In conclusion, among older individuals with community-onset bacteremia, the dissimilarity of the prognostic impacts of delayed AAT between afebrile and febrile presentation was evident.

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

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).

Current State of Knowledge on the Definition, Pathophysiology, Etiology, Outcomes, and Management of Fever in the Intensive Care Unit

Fever-an elevated body temperature-is a prominent feature of a wide range of disease conditions and is a common finding in intensive care, affecting up to 70% of patients in the intensive care unit (ICU). The causes of fever in the ICU are multifactorial, and it can be due to a number of infective and noninfective etiologies. The production of fever represents a complex physiological, adaptive host response that is beneficial for host defense and survival but can be maladaptive and harmful if left unabated. Despite any cause, fever is associated with a wide range of cellular, local, and systemic effects, including multiorgan dysfunction, systemic inflammation, poor neurological recovery, and an increased risk of mortality. This narrative review presents the current state-of-the-art knowledge on the definition, pathophysiology, etiology, and outcomes of fever in the ICU and highlights evidence-based findings regarding the management of fever in the intensive care setting.

Risk Factors for Bacteremia and Its Clinical Impact on Complicated Community-Acquired Urinary Tract Infection

Bacteremia has been associated with severity in some infections; however, its impact on the prognosis of urinary tract infections (UTIs) is still disputed. Our goal is to determine the risk factors for bacteremia and its clinical impact on hospitalized patients with complicated community-acquired urinary tract infections. We conducted a prospective observational study of patients admitted to the hospital with complicated community-acquired UTIs. Clinical variables and outcomes of patients with and without bacteremia were compared, and multivariate analysis was performed to identify risk factors for bacteremia and mortality. Of 279 patients with complicated community-acquired UTIs, 37.6% had positive blood cultures. Risk factors for bacteremia by multivariate analysis were temperature ≥ 38 °C (p = 0.006, OR 1.3 (95% CI 1.1-1.7)) and procalcitonin ≥ 0.5 ng/mL (p = 0.005, OR 8.5 (95% CI 2.2-39.4)). In-hospital and 30-day mortality were 9% and 13.6%, respectively. Quick SOFA (p = 0.030, OR 5.4 (95% CI 1.2-24.9)) and Barthel Index <40% (p = 0.020, OR 4.8 (95% CI 1.3-18.2)) were associated with 30-day mortality by multivariate analysis. However, bacteremia was not associated with 30-day mortality (p = 0.154, OR 2.7 (95% CI 0.7-10.3)). Our study found that febrile community-acquired UTIs and elevated procalcitonin were risk factors for bacteremia. The outcomes in patients with bacteremia were slightly worse, but without significant differences in mortality.

Anaerobic spondylodiscitis: a retrospective analysis

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.

Prognostic Effects of Delayed Administration of Antimicrobial Therapy in Older Persons Experiencing Bacteremia With or Without Initial Sepsis Presentations

OBJECTIVES

To investigate the prognostic effects of delayed administration of appropriate antimicrobial therapy (AAT) in older persons experiencing bacteremia with and without initial sepsis syndrome, respectively.

DESIGN

A 4-year multicenter cohort study.

SETTING AND PARTICIPANTS

Older people (≥65 years of age) with community-onset bacteremia in the emergency department (ED) of 3 participating hospitals.

METHODS

Clinical data were retrospectively collected and causative microorganisms were prospectively collected for susceptibilities to determine the period of delayed AAT for each bacteremia episode. Sepsis was defined based on the Sepsis-3 criteria. A multivariable regression model was used to investigate the prognostic effects of delayed AAT, after adjusting independent determinants of 30-day mortality.

RESULTS

Of the total 2357 patients, their median (interquartile range) age was 78 (72-84) years and septic patients accounted for 48.4% (1140 patients) of the overall patients. Compared with nonseptic patients, septic individuals exhibited the shorter period of delayed AAT (median, 2.0 vs 2.5 hours; P < .001), longer hospitalization (median, 11 vs 9 days; P < .001), and higher crude mortality rates at 15 (28.9% vs 2.1%; P < .001) and 30 days (34.6% vs 4.0%; P < .001). In multivariable regression analyses, each hour of delayed AAT resulted in average increases in the 30-day crude mortality rates of 0.38% [adjusted odds ratio (AOR) 1.0038; P < .001), 0.42% (AOR 1.0042; P < .001), and 0.31% (AOR 1.0031; P = .04) among overall, septic, and nonseptic patients, respectively.

CONCLUSIONS AND IMPLICATIONS

For older persons with community-onset bacteremia, irrespective of whether or not patients experiencing initial sepsis presentations, the prognostic impacts of delayed AAT have been evidenced. Notably, because of the longer period of delayed AAT in patients without fulfilling the Sepsis-3, adopting a stricter sepsis definition and/or early bacteremia predictor to avoid delayed AAT and unfavorable prognoses in patients with bacteremia is necessary.

Clinical comparison of febrile and afebrile patients with pyogenic liver abscess: A two-centre retrospective study

BACKGROUND

: Limited research has been conducted on afebrile pyogenic liver abscess (PLA). This poses a challenge in rapid diagnosis and early tailored care to physicians. In his study, we aimed to compare the clinical characteristics of afebrile and febrile patients with PLA.

METHODS

: We retrospectively analyzed the data of patients with PLA who were admitted to the emergency departments of two university hospitals between January 2014 and March 2020. Patients were classified into afebrile and febrile groups by using body temperature higher than 38°C as the reference standard. The demographic, clinical, and laboratory characteristics of both groups were compared. The primary outcome was all-cause in-hospital mortality and length of hospital stay. Multivariate analysis was performed to define factors associated with afebrile PLA.

RESULTS

: Of the 239 patients included in this study, 51 patients (21.3%) were afebrile and 188 patients (78.7%) were febrile. There were no differences between the abscess characteristics, laboratory manifestations, and disease severity of both groups; however, age and Charlson score differed between the groups (P = 0.009 and P = 0.011). The all-cause in-hospital mortality rate was much higher in the afebrile PLA group than in the febrile PLA group (9.8% vs. 2.1%, P = 0.011). Regarding the length of stay, no significant differences were noted in the febrile PLA group compared with the afebrile PLA group (18.5% vs 17.3%, P = 0.514). In multivariate analyses, only age greater than 65 years was significantly associated with afebrile PLA.

CONCLUSIONS

: Afebrile patients with PLA tend to be older, have higher Charlson scores, and in-hospital mortality rate than those with febrile patients. PLA patients older than 65 years are more likely to present without fever (<38°C) at the time of the emergency visit.

Bloodstream infections in head and neck cancer patients after curative-intent radiotherapy: a population-based study from the Danish Head and Neck Cancer Group database

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) undergoing radiotherapy (RT) or chemoradiation (CRT) may become immunocompromised. In this population-based study, we aimed to investigate the risk factors, microbiological aetiologies, prognosis and impact on early non-cancer mortality of bloodstream infections (BSIs) after RT/CRT.

METHODS

Patients with HNSCC of the pharynx, larynx and oral cavity treated with curative-intent RT/CRT in Denmark between 2010 and 2017 and subsequent BSI episodes occurring within 18 months of RT/CRT initiation were identified in national registries.

RESULTS

We included 5674 patients and observed 238 BSIs. Increasing age, stage and performance status were significantly associated with an elevated BSI risk, while sex, smoking and high-grade mucositis were not. Human papillomavirus-positive oropharyngeal cancer patients had a decreased risk. Staphylococcus aureus accounted for 34% of episodes occurring during the first 3 months. The 30-day post-BSI mortality rate was 26% (95% confidence interval: 19-32) and BSIs were involved in 10% of early non-cancer deaths.

CONCLUSION

The risk of BSI development is associated with several patient- and disease-related factors and BSIs contribute considerably to early non-cancer mortality. Empiric antibiotic treatment regimens should prioritise coverage for S. aureus when treating suspected systemic infection in this population.

Atypical Presentation of Bacteremic Urinary Tract Infection in Older Patients: Frequency and Prognostic Impact

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.

Are corticosteroids or end-stage renal failure associated with an afebrile presentation of Gram-negative bacteraemia?

OBJECTIVES

Assertions regarding afebrile presentation of sepsis frequently lead to superfluous antibiotic treatment. This study aimed to identify the risk factors for afebrile presentation of bacteraemia, focusing on glucocorticoid (GC) treatment and end-stage renal disease (ESRD).

METHODS

This retrospective cohort study included all patients with bacteraemia caused by common Gram-negative bacteria in one hospital. The exposure variables were GC treatment, administered for at least 48 hours before bacteraemia onset, and ESRD, defined as patients undergoing dialysis. Risk factors were assessed for afebrile presentation, defined as temperature between 36.0-37.7°C for all measurements, 48 hours prior to blood culture collection. Analyses were subgrouped by community-onset and hospital-acquired Gram-negative bacteraemia (GNB). Propensity score (PS)-weighted multivariate analyses were conducted.

RESULTS

Of 4179 patients with GNB, 1090 (26.1%) presented without fever before blood culture collection. In community-onset GNB, GC treatment was significantly associated with afebrile presentation, PS-weighted OR 1.42 (95% CI 1.25-1.61), absolute risk increase 7% (95% CI 4.3-9.8%), while ESRD was not. For hospital-acquired GNB, ESRD was significantly associated with afebrile presentation (OR 1.53; 95% CI 1.25-1.86; absolute risk increase 8.5%; 95% CI 4.4-13.1%); GC was not. Other risk factors for afebrile presentation in both subgroups included increasing Charlson comorbidity score, bacteraemia with non-fermenters Pseudomonas aeruginosa or Stenotrophomonas maltophilia (compared with Enterobacteriaceae), and lower albumin levels. Aging was not associated with afebrile presentation of GNB.

CONCLUSION

Although significant associations between GC and ESRD and afebrile presentation of GNB were observed, they were different in community-onset and hospital-acquired GNBs, and absolute risk increases were small.

No Fever, No Worries? A Retrospective Audit of Bacteraemic Patients in the Emergency Department

BACKGROUND

Early identification and treatment of serious infections improves clinical outcomes. Previous studies have found that septic patients without fever are more likely to die than those with fever, due to delay in antibiotic administration.

AIM

To determine whether antibiotic treatment and mortality differed in afebrile adult patients presenting to the Emergency Department with bacteraemia, compared with those with a history of fever.

METHODS

Retrospective six-month audit of all adult patients with positive blood cultures taken in the Emergency Department (ED) of a single tertiary hospital. Outcomes included receipt of antibiotics within 4 and 24 h of ED arrival, in-hospital mortality and 30-day mortality.

RESULTS

227 patients with clinically significant bacteraemia were identified, of which 38 (16.7%) were afebrile in ED. There was no statistically significant difference in the proportion of afebrile or febrile patients receiving antibiotics within 4-h (44.7% vs 55.6%, p = 0.222) or 24-h (89.5% vs 95.2%, p = 0.163) of arrival at ED. Inpatient mortality was not statistically different in the afebrile and febrile groups 15.8% vs 6.9%, p = 0.070), but 30-day mortality was higher among afebrile patients (27.6% vs 10.1%, p = 0.010).

CONCLUSIONS

There was no significant difference in receipt of antibiotics within 4 h or 24 h ED arrival between the febrile and afebrile groups. However, afebrile patients experienced higher 30-day mortality. While most bacteraemic patients received antibiotics within 24 h, only half received antibiotics within 4 h, representing a key area for improvement. This article is protected by copyright. All rights reserved.

Afebrile Bacteremia in Adult Emergency Department Patients with Liver Cirrhosis: Clinical Characteristics and Outcomes

Cirrhotic patients with bacteremia are at an increased risk of organ failure and mortality. In addition, they can develop serious infection without fever because of their impaired immune response. Our study aimed to investigate the clinical characteristics and outcomes in afebrile bacteremic patients with liver cirrhosis. A single-center, retrospective cohort study was performed on adult patients who visited the emergency department from January 2015 to December 2018. All patients with bacteremia and diagnosis of liver cirrhosis were enrolled and classified as either afebrile or febrile. In total, 104 bacteremic patients with liver cirrhosis (afebrile: 55 patients and, febrile: 49) were included in the study. Compared with the febrile group, patients in the afebrile group showed a significantly higher rate of inappropriate antibiotics administration (43.6% vs. 20.4%, p = 0.01). They were also at an increased risk of 30-day mortality (40% vs. 18.4%, p = 0.02), intensive care unit transfer (38.2% vs. 18.4%, p = 0.03) and endotracheal intubation (27.3% vs. 10.2%, p = 0.03). The afebrile state was also an independent risk factor associated with 30-day mortality in cirrhotic patients with bacteremia. Clinicians should perform a prudent evaluation in cirrhotic patients and carefully monitor for possible signs of serious infection even in the absence of fever.

Do Bacteremic patients with end-stage renal disease have a fever when presenting to the emergency department? A paired, retrospective cohort study

Background

Fever is a common symptom when patients present to Emergency Departments. It is unclear if the febrile response of bacteremic hemodialysis-dependent patients differs from bacteremic patients not receiving hemodialysis. The objective of this study was to compare Emergency Departments triage temperatures of patients with and without hemodialysis-dependent end-stage rental disease who have Staphylococcus aureus bacteremia and determine the incidence of afebrile S. aureus bacteremia.

Methods

Paired, retrospective cohort study of 37 patients with and 37 patients without hemodialysis hospitalized with Methicillin-resistant or Methicillin-susceptible S. aureus bacteremia. Emergency Department triage temperatures were reviewed for all patients, as were potential confounding variables.

Results

54% (95% CI, 38–70%) and 82% (95% CI 65–91%) of hemodialysis and non-hemodialysis patients did not have a detectable fever (<100.4 °F) at triage. Triage temperatures were 100.5 °F (95% CI 99.9–101.2 °F) and 99.0 °F (95% CI 98.4–99.6 °F) in the hemodialysis and non-hemodialysis cohorts, respectively (p < 0.001). Triage temperature in patients with and without diabetes mellitus was 99.2 °F (95% CI 98.4–99.9 °F) and 100.4 °F (95% CI 99.7–101.0 °F), respectively (p = 0.03). We were unable to detect a significant effect of diabetes mellitus and other potential confounding variables on differences in temperature between the hemodialysis and non-hemodialysis cohorts (all interactions p > 0.19).

Conclusions

Hemodialysis-dependent patients with S. aureus bacteremia had significantly higher temperatures than non- hemodialysis-dependent end stage renal disease patients but more than half of patients were without detectable fever at triage, possibly reflecting use of insensitive methods for measuring temperature. Absence of fever at presentation to the Emergency Department should not delay blood culture acquisition in patients who are at increased risk of S. aureus bacteremia.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Atypical Presentation of Bacteremia in Older Patients Is a Risk Factor for Death

BACKGROUND

The absence of fever in bacteremia in patients who are older is known to delay diagnosis. Our objective was to determine whether atypical presentation was associated to mortality as a result of bacteremia in this patient cohort as well as possible factors associated with this atypical presentation.

METHODS

We conducted an observational prospective study in 2 French university hospitals in 2016-2017 including patients ages ≥75 years with bacteremia. Atypical presentation was defined as the absence of a temperature ≥38.3°C or <36°C, chills, or hypotension. Mortality and dependence for activities of daily living (ADL) were recorded at 1 week (D7) and 3 months (D90).

RESULTS

Among the 151 patients (mean age 85.4±5.8 years) enrolled, atypical presentation prevalence was 21.2%. D7 and D90 mortality rates were 7.9% and 40.0%, respectively. Atypical presentation was independently associated with D7 (odds ratio (OR) 4.46, 95% confidence interval (CI) 1.04-19.24) and D90 mortality (OR 3.76, 95% CI 1.30-10.92) after controlling for other prognostic factors. Patients with diabetes and those infected with Staphylococcus aureus were more likely to have atypical signs of infection. ADL score decreased from 3.6±2.0 before bacteremia to 2.8±2.1 at D90 (P <0.001).

CONCLUSION

Patients who are older with bacteremia have poor vital and functional prognoses in the short and long terms. The absence of typical signs of infection is associated with mortality. Blood culture should be considered for patients who are older, especially with diabetes with acute unexplained clinical manifestations.

Rate and Predictors of Bacteremia in Afebrile Community-Acquired Pneumonia

BACKGROUND

Although blood cultures (BCs) are the "gold standard" for detecting bacteremia, the utility of BCs in patients with community-acquired pneumonia (CAP) is controversial. This study describes the proportion of patients with CAP and afebrile bacteremia and identifies the clinical characteristics predicting the necessity for BCs in patients who are afebrile.

METHODS

Bacteremia rates were determined in 4,349 patients with CAP enrolled in the multinational cohort study The Competence Network of Community-Acquired Pneumonia (CAPNETZ) and stratified by presence of fever at first patient contact. Independent predictors of bacteremia in patients who were afebrile were determined using logistic regression analysis.

RESULTS

Bacteremic pneumonia was present in 190 of 2,116 patients who were febrile (8.9%), 101 of 2,149 patients who were afebrile (4.7%), and one of 23 patients with hypothermia (4.3%). Bacteremia rates increased with the CURB-65 score from 3.5% in patients with CURB-65 score of 0 to 17.1% in patients with CURB-65 score of 4. Patients with afebrile bacteremia exhibited the highest 28-day mortality rate (9.9%). Positive pneumococcal urinary antigen test (adjusted OR [AOR], 4.6; 95% CI, 2.6-8.2), C-reactive protein level > 200 mg/L (AOR, 3.1; 95% CI, 1.9-5.2), and BUN level ≥ 30 mg/dL (AOR, 3.1; 95% CI, 1.9-5.3) were independent positive predictors, and antibiotic pretreatment (AOR, 0.3; 95% CI, 0.1-0.6) was an independent negative predictor of bacteremia in patients who were afebrile.

CONCLUSIONS

A relevant proportion of patients with bacteremic CAP was afebrile. These patients had an increased mortality rate compared with patients with febrile bacteremia or nonbacteremic pneumonia. Therefore, the relevance of fever as an indicator for BC necessity merits reconsideration.

Nationwide Trend of Sepsis: A Comparison Among Octogenarians, Elderly, and Young Adults

OBJECTIVE

We aimed to compare the sepsis incidence, mortality rates, and primary sites of infection among adult, elderly, and octogenarian patients with sepsis.

DESIGN

Population-based cohort study.

SETTING

The entire health insurance claims data of Taiwan, which enrolled 99.8% of the 23 million Taiwanese population.

PATIENTS

Sepsis patients were identified by International Classification of Diseases, 9th Edition, Clinical Modification codes for both infection and organ dysfunction from January 1, 2002, to December 31, 2012. Patients were categorized into three age groups: 1) adults (18-64 yr); 2) elderly (65-84 yr); and 3) oldest old (≥ 85 yr). The 30-day all-cause mortality was verified by a linked national death certificate database.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

From 2002 to 2012, we identified 1,259,578 patients with sepsis, of which 417,328 (33.1%) were adults, 652,618 (51.8%) were elderly, and 189,632 (15.1%) were oldest old. We determined that the incidence of sepsis in the oldest old was 9,414 cases per 100,000 population on 2012, which was 31-fold greater than the adult incidence (303 cases per 100,000 population) and three-fold greater than the elderly incidence (2,908 cases per 100,000 population). Despite the increasing trend in incidence, the mortality decreased by 34% for adults, 24% for elderly, and 22% for oldest old. However, systemic fungal infection was disproportionately increased in oldest old patients (1.76% annual increase) and the elderly patients (1.00% annual increase).

CONCLUSION

The incidence of sepsis is disproportionately increased in elderly and oldest old patients. Despite the increasing trend in incidence, the mortality rate in geriatric patients with sepsis has decreased. However, the increased incidence of fungal infections in the geriatric population warrants further attention.

Performance enhancement of procalcitonin by high-sensitivity C-reactive protein at the optimal cutoff in predicting bacteremia in emergency department adult patients

Pathogenic bacteremia portends a high mortality risk in adult patients admitted to an Emergency Department (ED). This study aims to investigate the effect of adding high-sensitivity C-reactive protein (hs-CRP) to procalcitonin (PCT) and lactate in predicting bacteremia, Gram-negative (GNB) and Gram-positive bacteremia (GPB), using the optimal cutoff derived from the receiver operating characteristics analysis. We evaluated the diagnostic measures, including the positive-test likelihood (LR+), the negative-test likelihood (LR-), and the diagnostic odds ratio (DOR) using a single-center retrospective analysis design. This Standards for Reporting Diagnostic-compliant study comprised 886 consecutive adults who were admitted to the ED in 2010; to this cohort, a 22.2% prevalence of true bacteremia was subsequently confirmed. At the cutoff of 3.9 μg/L, PCT had a DOR of 5.3 (95% confidence interval [CI]: 3.76-7.61) and LR + of 2.8 (95% CI: 2.3-3.4) in predicting overall bacteremia. Elevated PCT and lactate (cutoff at 2 mmol/L), increased the DOR and LR + to 6.3 (95% CI: 4.27-9.29) and 4.0 (95% CI: 3.1-5.2). The DOR and LR + were further improved to 7.1 (95% CI: 4.2-11.95) and 5.6 (95% CI: 3.7-8.6), respectively, when hs-CRP at the cutoff of 1238 nmol/L was added to PCT plus lactate. High-sensitivity CRP at the cutoff of 1,255 nmol/L can enhance the discriminative power raising DOR and LR + values for GPB. The elevation of hs-CRP at the optimal cutoff might improve the diagnostic performance to predict unspecified bacteremia and GPB, but not GNB.