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Kim SE, Choi SM, Yu Y, Shin SU, Oh TH, Kang SJ, Park KH, Shin JH, Kim UJ, Jung SI. Replacement of the Dominant ST191 Clone by ST369 Among Carbapenem-Resistant Acinetobacter baumannii Bloodstream Isolates at a Tertiary Care Hospital in South Korea. Front Microbiol 2022; 13:949060. [PMID: 35910596 PMCID: PMC9335038 DOI: 10.3389/fmicb.2022.949060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
The clonal dissemination of carbapenem-resistant Acinetobacter baumannii (CRAB) bacteremia is a serious clinical problem worldwide. However, the factors related to the emergence and replacement of predominant CRAB clones in nosocomial settings are unclear. By multilocus sequence typing (MLST), we evaluated the genetic relatedness of CRAB bloodstream isolates at a tertiary care hospital over a 3.5-year period and investigated the clinical and microbiologic characteristics of the predominant sequence types (STs). One hundred and seventy-nine CRAB bloodstream isolates were collected from June 2016 to December 2019, and their MLSTs according to Oxford scheme and clinical data were obtained. The predominant STs were assessed for in vitro growth, competitive growth, and virulence in a mouse model of intraperitoneal infection. Two dominant clones—ST369 (n = 98) and ST191 (n = 48)—belonging to international clone 2 (IC2) were recovered from patients admitted to intensive care units (ICUs) or wards. ST191 predominated (61%, 27/43) from June 2016 to July 2017, whereas ST369 (72%, 98/136), which was first isolated from a patient admitted to the emergency room, replaced ST191 (15%, 21/136) after August 2017. In a multivariate analysis, leukopenia (OR = 3.62, 95% CI 1.04–12.6, p = 0.04) and ST191 or 369 (OR = 5.32, 95% CI 1.25–22.65, p = 0.02) were independent risk factors for 7-day mortality. Compared with non-ST369, ST369 was associated with a shorter time to bacteremia from ICU admission (7 vs. 11 days, p = 0.01), pneumonia as an origin of bacteremia (67 vs. 52%, p = 0.04), leukopenia (28 vs. 11%, p < 0.01), and a lower 7-day survival rate (41 vs. 70%, p < 0.01). In vitro, ST 369 isolates had significantly higher growth rates and enhanced competitive growth compared to ST191. Finally, ST369 had greater virulence and a higher mortality rate than other STs in a mouse infection model. We report almost-complete replacement of the predominant ST191 clone by ST369 within an 8-month period at our hospital. ST369 had a high incidence density rate of CRAB bacteremia, a short time to bacteremia after ICU admission, and a high early mortality rate, which may be in part explained by its faster competitive growth rate and higher virulence than ST191.
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Affiliation(s)
- Seong Eun Kim
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Su-Mi Choi
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Yohan Yu
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Sung Un Shin
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Tae Hoon Oh
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Seung-Ji Kang
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Jong Hee Shin
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Uh Jin Kim
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
- Uh Jin Kim,
| | - Sook In Jung
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
- *Correspondence: Sook In Jung,
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Hung YP, Chen PL, Ho CY, Hsieh CC, Lee CH, Lee CC, Ko WC. Prognostic Effects of Inappropriate Empirical Antimicrobial Therapy in Adults With Community-Onset Bacteremia: Age Matters. Front Med (Lausanne) 2022; 9:861032. [PMID: 35479958 PMCID: PMC9037591 DOI: 10.3389/fmed.2022.861032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Studies have reported the effects of delayed administration of appropriate antimicrobial therapy (AAT) on the short-term prognosis of patients with bloodstream infections; however, whether there is an age-related difference in these effects remains debated. Methods In this 4-year multicenter case-control study, patients with community-onset bacteremia were retrospectively categorized into the "middle-aged" (45-64 years), "old" (65-74 years), and "very old" (≥75 years) groups. Two methods were adopted to investigate the prognostic effects of delayed AAT in each age group. First, its effects were, respectively, investigated, after adjustment for the independent predictors of 30-day mortality. Second, patients in each age group were matched by the closest propensity-score (PS), which was calculated by independent predictors of mortality; the survival curves and Pearson chi-square tests were adopted to disclose its effects in each PS-matching group. Results Each hour of delayed AAT resulted in an average increase in the 30-day crude mortality rate of 0.2% (P = 0.03), 0.4% (P < 0.001), and 0.7% (P < 0.001) in middle-aged (968 patients), old (683), and very old (1,265) patients, after, respectively, adjusting the independent predictors of mortality in each group. After appropriate PS-matching, no significant proportion differences in patient demographics, bacteremia characteristics, severity of bacteremia and comorbidities, and 15-day or 30-day crude mortality rates were observed between three matched groups (582 patients in each group). However, significant differences in survival curves between patients with delayed AAT > 24 or >48 h and those without delayed administration were demonstrated in each age group. Furthermore, the odds ratios of 30-day mortality for delayed AAT > 24 or >48 h were 1.73 (P = 0.04) or 1.82 (P = 0.04), 1.84 (P = 0.03) or 1.95 (P = 0.02), and 1.87 (P = 0.02) or 2.34 (P = 0.003) in the middle-aged, old, and very old groups, respectively. Notably, the greatest prognostic impact of delayed AAT > 24 or >48 h in the very old group and the smallest impact in the middle-aged group were exhibited. Conclusion For adults (aged ≥45 years) with community-onset bacteremia, the delayed AAT significantly impacts their short-term survival in varied age groups and the age-related differences in its prognostic impact might be evident.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, Taiwan.,Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Rac H, Gould A, Bookstaver P, Justo J, Kohn J, Al-Hasan M. Evaluation of early clinical failure criteria for gram-negative bloodstream infections. Clin Microbiol Infect 2020; 26:73-77. [DOI: 10.1016/j.cmi.2019.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/08/2019] [Accepted: 05/19/2019] [Indexed: 11/26/2022]
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Rothe K, Wantia N, Spinner CD, Schneider J, Lahmer T, Waschulzik B, Schmid RM, Busch DH, Katchanov J. Antimicrobial resistance of bacteraemia in the emergency department of a German university hospital (2013-2018): potential carbapenem-sparing empiric treatment options in light of the new EUCAST recommendations. BMC Infect Dis 2019; 19:1091. [PMID: 31888581 PMCID: PMC6937826 DOI: 10.1186/s12879-019-4721-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background This study investigated predominant microorganisms causing community-onset bacteraemia at the medical emergency department (ED) of a tertiary-care university hospital in Germany from 2013 to 2018 and their antimicrobial susceptibility patterns. Methods Antimicrobial resistance patterns in patients with positive blood cultures presenting to an internal medicine ED were retrospectively analysed. Results Blood cultures were obtained at 5191 of 66,879 ED encounters, with 1013 (19.5%) positive results, and true positive results at 740 encounters (diagnostic yield, 14.3%). The most frequently isolated relevant microorganisms were Enterobacterales (n = 439, 59.3%), Staphylococcus aureus (n = 92, 12.4%), Streptococcus pneumoniae (n = 34, 4.6%), Pseudomonas aeruginosa (n = 32, 4.3%), Streptococcus pyogenes (n = 16, 2.2%), Enterococcus faecalis (n = 18, 2.4%), and Enterococcus faecium (n = 12, 1.6%). Antimicrobial susceptibility testing revealed a high proportion of resistance against ampicillin-sulbactam in Enterobacterales (42.2%). The rate of methicillin-resistant Staphylococcus aureus was low (0.4%). Piperacillin-tazobactam therapy provided coverage for 83.2% of all relevant pathogens using conventional breakpoints. Application of the new European Committee on Antimicrobial Susceptibility Testing (EUCAST) recommendations increased the percentage of susceptible isolates to high-dose piperacillin-tazobactam to 92.8% (p < 0.001). Broad-spectrum carbapenems would only cover an additional 4.8%. The addition of vancomycin or linezolid extended coverage by just 1.7%. Conclusions Using an ureidopenicillin-beta-lactamase inhibitor combination at the high dose suggested by the new EUCAST recommendations provided nearly 93% coverage for relevant pathogens in patients with suspected bloodstream infection in our cohort. This might offer a safe option to reduce the empiric use of carbapenems. Our data support the absence of a general need for glycopeptides or oxazolidinones in empiric treatment.
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Affiliation(s)
- Kathrin Rothe
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany. .,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.
| | - Nina Wantia
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Christoph D Spinner
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Jochen Schneider
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Tobias Lahmer
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics, and Epidemiology, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Dirk H Busch
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Juri Katchanov
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
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Lee CC, Lee CH, Yang CY, Hsieh CC, Tang HJ, Ko WC. Beneficial effects of early empirical administration of appropriate antimicrobials on survival and defervescence in adults with community-onset bacteremia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:363. [PMID: 31747950 PMCID: PMC6864953 DOI: 10.1186/s13054-019-2632-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/01/2019] [Indexed: 11/20/2022]
Abstract
Background Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. The effects of early administration of appropriate antimicrobials on the prognosis and timing of defervescence of bacteremic patients remain under debate. Methods In a 6-year retrospective, multicenter cohort, adults with community-onset bacteremia at the emergency departments (EDs) were analyzed. The period from ED arrival to appropriate antimicrobial administration and that from appropriate antimicrobial administration to defervescence was regarded as the time-to-appropriate antibiotic (TtAa) and time-to-defervescence (TtD), respectively. The primary study outcome was 30-day mortality after ED arrival. The effects of TtAa on 30-day mortality and delayed defervescence were examined after adjustment for independent predictors of mortality, which were recognized by a multivariate regression analysis. Results Of the total 3194 patients, a TtAa-related trend in the 30-day crude (γ = 0.919, P = 0.01) and sepsis-related (γ = 0.909, P = 0.01) mortality rate was evidenced. Each hour of TtAa delay was associated with an average increase in the 30-day crude mortality rate of 0.3% (adjusted odds ratio [AOR], 1.003; P < 0.001) in the entire cohort and 0.4% (AOR, 1.004; P < 0.001) in critically ill patients, respectively, after adjustment of independent predictors of 30-day crude mortality. Of 2469 febrile patients, a TtAa-related trend in the TtD (γ = 0.965, P = 0.002) was exhibited. Each hour of TtAa delay was associated with an average 0.7% increase (AOR, 1.007; P < 0.001) in delayed defervescence (TtD of ≥ 7 days) after adjustment of independent determinants of delayed defervescence. Notably, the adverse impact of the inappropriateness of empirical antimicrobial therapy (TtAa > 24 h) on the TtD was noted, regardless of bacteremia severity, bacteremia sources, or causative microorganisms. Conclusions The delay in the TtAa was associated with an increasing risk of delayed defervescence and 30-day mortality for adults with community-onset bacteremia, especially for critically ill patients. Thus, for severe bacteremia episodes, early administration of appropriate empirical antimicrobials should be recommended.
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Affiliation(s)
- Ching-Chi Lee
- Department of Internal Medicine, Madou Sin-Lau Hospital, No. 20, Lingzilin, 72152, Madou Dist., Tainan City, Taiwan.,Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Chao-Yung Yang
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Hung-Jen Tang
- Division of Infectious Disease, Department of Medicine, Chi-Mei Medical Center, No. 901, Chung-Hwa Road, Yung-Kang City, 710, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan. .,Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
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6
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Yang CY, Lee CH, Hsieh CC, Hong MY, Chen MJ, Lee CC. Differential effects of inappropriate empirical antibiotic therapy in adults with community-onset gram-positive and gram-negative aerobe bacteremia. J Infect Chemother 2019; 26:222-229. [PMID: 31575500 DOI: 10.1016/j.jiac.2019.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/08/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
Bacteremia is associated with high morbidity and mortality, which contribute substantially to health care costs. A beneficial influence of appropriate empirical antimicrobial therapy (EAT) on patient outcome is evidenced; However, the evidence highlighting a comparison of clinical manifestations and of the effects of inappropriate EAT between Gram-positive and Gram-negative bacteremia is insufficient. In a retrospective 6-year cohort study, the total 2053 adults (Gram-positive, 566; Gram-negative 1487) presenting with community-onset monomicrobial aerobes bacteremia were recruited. Inappropriate EAT was defined as the first dose of an appropriate antimicrobial agent not being administered within the first 24 h after blood cultures were drawn. Although the bacteremia severity (a Pitt bacteremia score) at onset, comorbidity severity (the McCabe-Johnson classification), and 28-day mortality rate were similar in the two groups. Furthermore, after adjustment of independent predictors of 28-day mortality respectively recognized by the multivariate regression model in Gram-negative and Gram-positive groups, the Kaplan-Meier curve and Cox regression analysis revealed a significant difference (adjust odds ratio [AOR], 2.68; P < 0.001) between appropriate and inappropriate EAT in the Gram-negative group, but not in the Gram-positive group (AOR, 1.54; P = 0.06). Conclusively, patients with Gram-positive and Gram-negative bacteremia exhibited the similar presentation in bacteremia severity, but a greater impact of inappropriate EAT on survival of patients with Gram-negative aerobe bacteremia was evidenced.
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Affiliation(s)
- Chao-Yung Yang
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Yuan Hong
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mei-Ju Chen
- Department of Senior Service, Southern Taiwan University of Science and Technology, Tainan, Taiwan.
| | - Ching-Chi Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, Taiwan; Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan.
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Yang CY, Lee CH, Hsieh CC, Ko WC, Lee CC. Etiology of community-onset monomicrobial bacteremic pneumonia and its clinical presentation and outcome: Klebsiella and Pseudomonas matters. J Infect Chemother 2017; 24:53-58. [PMID: 29017829 DOI: 10.1016/j.jiac.2017.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/10/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Abstract
To describe the difference of the clinical features, bacteremia severity, and outcome of patient with community-onset bacteremic pneumonia between Pseudomonas, Klebsiella, and other causative microorganisms, the total 278 adults with community-onset monomicrobial bacteremic pneumonia were studied in a retrospective cohort. Klebsiella (61 patients, 21.9%) and Pseudomonas (22, 7.9%) species was the leading and the fifth common pathogen, respectively. More patients having initial presentation with critical illness (a Pitt bacteremia score ≥ 4) and a fatal comorbidity (McCabe classification) as well as a higher short- (30-day) or long-term (90-day) mortality rate was evidenced in patients infected with Klebsiella or Pseudomonas species, compared to other causative microorganisms. Compared to patients in the Klebsiella group, more frequencies of recent chemotherapy and an initial presentation of febrile neutropenia, and less proportions of diabetes mellitus were disclosed among those in the Pseudomonas group. Of importance, a significantly differential survival curve between Klebsiella or Pseudomonas species and other species during 30-day or 90-day period after bacteremia onset but a similarity of Pseudomonas and Klebsiella species was evidenced, using the Cox-regression after adjusting the independent predictors of 30-day mortality. Conclusively, of pathogens causing community-onset bacteremic pneumonia, Klebsiella and Pseudomonas species should be recognized as the highly virulent pathogens and resulted in poor short- and long-term prognoses.
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Affiliation(s)
- Chao-Yung Yang
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Chung-Hsun Lee
- Department of Emergency 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, 70403, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Wen-Chien Ko
- Department of Medicine, College of Medicine, National Cheng Kung University, 70403, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan.
| | - Ching-Chi Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, Tainan 72152, Taiwan; Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan 71101, Taiwan.
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Kuo TH, Yang CY, Lee CH, Hsieh CC, Ko WC, Lee CC. Propensity score matched analysis comparing the clinical outcome of Klebsiella pneumoniae and Escherichia coli causing community-onset monomicrobial bacteremia. Medicine (Baltimore) 2017; 96:e7075. [PMID: 28658101 PMCID: PMC5500023 DOI: 10.1097/md.0000000000007075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Bacteremia is a life-threatening condition that is associated with substantial healthcare costs. Escherichia coli and Klebsiella pneumoniae are the leading causes of community-onset gram-negative bacteremia. However, a comprehensive comparison between these pathogens involved in bacteremia episodes has yet to be reported.In this retrospective cohort study, adults with community-onset monomicrobial bacteremia caused by E coli or K pneumoniae were recruited in the emergency department of a medical center during a 6-year period, and the clinical variables were collected retrospectively from medical records. The complicated abscess occurrence was determined through imaging studies, according to the opinion of an infectious disease consultant. According to the independent predictors of 28-day mortality identified through multivariate regression analyses, patients in the E coli group were propensity score matched (PSM) in a 1:1 ratio to those in the K pneumoniae group.A total of 274 and 823 adults with K pneumoniae and E coli bacteremia were included in the present study. The K pneumoniae group had more patients with fatal comorbidities (McCabe classification), critical illness (Pitt bacteremia score ≥ 4) at bacteremia onset, and initial syndrome (e.g., severe sepsis and septic shock) as well as a higher crude mortality rate than did the E coli group. After appropriate matching, no significant differences were observed in the critical illness at bacteremia onset, initial syndrome, major comorbidities, and comorbidity severity of the 2 groups (E coli, n = 242; K pneumoniae, n = 242). Furthermore, despite similar 14- and 28-day crude mortality rates between the 2 PSM groups, more frequent abscess occurrences and a longer length of hospitalization were observed in the K pneumoniae group than in the E coli group.Conclusively, numerous clinical features at initial presentations varied between the E coli and K pneumoniae groups. Despite conducting a PSM analysis to control the differences in the baseline characteristics, a longer length of hospitalization and more frequent abscess occurrences were observed in the K pneumoniae group than in the E coli group.
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Affiliation(s)
- Tsung-Hang Kuo
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Institute of Clinical Medicine, National Cheng Kung University
| | - Chao-Yung Yang
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Chung-Hsun Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Department of Medicine, College of Medicine, National Cheng Kung University
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Wen-Chien Ko
- Department of Medicine, College of Medicine, National Cheng Kung University
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital
- Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan
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9
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Lee CC, Lee CH, Hong MY, Tang HJ, Ko WC. Timing of appropriate empirical antimicrobial administration and outcome of adults with community-onset bacteremia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:119. [PMID: 28545484 PMCID: PMC5445436 DOI: 10.1186/s13054-017-1696-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 05/02/2017] [Indexed: 12/29/2022]
Abstract
Background Early administration of appropriate antimicrobials has been correlated with a better prognosis in patients with bacteremia, but the optimum timing of early antibiotic administration as one of the resuscitation strategies for severe bacterial infections remains unclear. Methods In a retrospective cohort study, adults with community-onset bacteremia at the emergency department (ED) were analyzed. Effects of different cutoffs of time to appropriate antibiotic (TtAa) administration after arrival at the ED on 28-day mortality were examined, after adjustment for independent predictors of mortality identified by multivariate regression analysis. Results Among 2349 patients, the mean (interquartile range) TtAa was 2.0 (<1 to 12) hours. All selected cutoffs of TtAa, ranging from 1 to 96 hours, were significantly associated with 28-day mortality (adjusted odds ratio (AOR), 0.54–0.65, all P < 0.001), after adjustment of the following prognostic factors: fatal comorbidities (McCabe classification), critical illness (Pitt bacteremia score (PBS) ≥4) on arrival at the ED, polymicrobial bacteremia, extended-spectrum beta-lactamase-producer bacteremia, underlying malignancies or liver cirrhosis, and bacteremia caused by pneumonia or urinary tract infections. The adverse impact of TtAa on 28-day mortality was most evident at the cutoff of 48 hours, as the lowest AOR was identified (0.54, P < 0.001). In subgroup analyses, the most evident TtAa cutoff (i.e., the lowest AOR) remained at 48 hours in mildly ill (PBS = 0; AOR 0.47; P = 0.04) and moderately ill (PBS = 1–3; AOR 0.55; P = 0.02) patients, but shifted to 1 hour in critically ill patients (PBS ≥4; AOR 0.56; P < 0.001). Conclusions The time from triage to administration of appropriate antimicrobials is one of the primary determinants of mortality. The optimum timing of appropriate antimicrobial administration is the first 48 hours after non-critically ill patients arrive at the ED. As bacteremia severity increases, effective antimicrobial therapy should be empirically prescribed within 1 hour after critically ill patients arrive at the ED.
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Affiliation(s)
- Ching-Chi Lee
- Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, No. 20, Lingzilin, 72152, Madou Dist, Tainan City, Taiwan.,Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Ming-Yuan Hong
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi-Mei Medical Center, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan. .,Division of Infectious Disease, Department of Medicine, Chi-Mei Medical Center, No. 901, Chung-Hwa Road, Yung-Kang City, 710, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. .,Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan. .,Division of Infectious Disease, Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
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