Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist

Effect of a bundle intervention on adherence to quality-of-care indicators and on clinical outcomes in patients with Staphylococcus aureus bacteraemia hospitalized in non-referral community hospitals

BACKGROUND

Although a significant number of cases of Staphylococcus aureus bacteraemia (SAB) are managed at non-referral community hospitals, the impact of a bundle-of-care intervention in this setting has not yet been explored.

METHODS

We performed a quasi-experimental before-after study with the implementation of a bundle of care for the management of SAB at five non-referral community hospitals and a tertiary care university hospital. Structured recommendations for the five indicators selected to assess quality of care were provided to investigators before the implementation of the bundle and monthly thereafter. Primary endpoints were adherence to the bundle intervention and treatment failure, defined as death or relapse at 90 days of follow-up.

RESULTS

One hundred and seventy patients were included in the pre-intervention period and 103 in the intervention period. Patient characteristics were similar in both periods. Multivariate analysis controlling for potential confounders showed that performance of echocardiography was the only factor associated with improved adherence to the bundle in the intervention period (adjusted OR 2.13; 95% CI 1.13-4.02). Adherence to the bundle, performance of follow-up blood cultures, and adequate duration of antibiotic therapy for complicated SAB presented non-significant improvements. The intervention was not associated with a lower rate of 90 day treatment failure (OR 1.11; 95% CI 0.70-1.77).

CONCLUSIONS

A bundle-of-care intervention for the management of SAB at non-referral community hospitals increased adherence to quality indicators, but did not significantly reduce rates of 90 day mortality or relapse.

Impact of [18F] FDG PET/CT on outcomes in patients with Staphylococcus aureus bacteremia: A retrospective single-center experience

OBJECTIVE

Staphylococcus aureus bacteremia (SAB) is a leading cause of community and hospital-acquired bacteremia with significant morbidity and mortality. Effective management depends on accurate diagnosis, source control and assessment of metastatic infections. [18F] FDG PET/CT has been shown to reduce mortality in high-risk SAB patients. This study aims to evaluate the impact of [18F] FDG PET/CT on outcomes in patients with SAB.

METHODS

Single-center, retrospective, real-life setting study including all consecutive SAB cases from 2017 to 2019. Medical records were analyzed to collect information.

RESULTS

Out of the 315 included patients, 132 underwent [18F] FDG PET/CT. In those patients, a clear focus of infection was more frequently identified, leading to better adapted treatments and extended hospital stays. Overall mortality rates at 30 days, 90 days and one year were 25.1 %, 36.8 % and 44.8 % respectively. Mortality was significantly lower in the [18F] FDG PET/CT group (p < 0.0001) and persisted (p < 0.05) after adjusting for imbalances between groups regarding oncologic patients and deaths within 7 days. The difference in mortality remained significant irrespective of prolonged bacteremia but was not significant with regard to hospital-acquired SAB. Supplementary analysis using the Cox proportional hazards model confirmed that [18F] FDG PET/CT was significantly associated with reduced mortality (p < 0.05).

CONCLUSION

In this real-life cohort, patients with SAB having undergone [18F] FDG PET/CT experienced lower mortality rates, highlighting the additional value of [18F] FDG PET/CT in SAB management. Further research is needed to identify the subpopulations that would benefit most from the integration of [18F] FDG PET/CT in their work-up.

Adherence to and clinical utility of "quality indicators" for Staphylococcus aureus bacteremia: a retrospective, multicenter study

BACKGROUND

We aimed to improve the prognosis, treatment, and management of Staphylococcus aureus bacteremia (SAB) by evaluating the association between adherence to quality indicators (QIs) and clinical outcomes in patients with their clinical outcomes.

METHODS

We retrospectively collected clinical and microbiological data on hospitalized patients with SAB from 14 hospitals (three with >  600, two with 401-600, five with 201-400, and four with ≤ 200 beds) in Japan from January to December 2022. The SAB management quality was evaluated using the SAB-QI score (ranging from 0 to 13 points), which consists of 13 QIs (grouped into five categories) based on previous literature.

RESULTS

Of the 4,448 positive blood culture episodes, 289 patients with SAB (6.5%) were enrolled. The SAB-QI scores ranged from 3 to 13, with a median score of 9 points. The SAB-QI score was highest in middle-sized hospitals with 401-600 beds. Adherence to each of the four QI categories (blood culture, echocardiography, source control, and antibiotic treatment) was significantly higher in survived cases than in fatal cases. Kaplan-Meier curves with log-rank tests demonstrated that higher adherence to SAB-QIs indicated a better prognosis. Logistic regression analysis revealed that age, methicillin resistance, multiple comorbidities (≥ 2), and low SAB-QI score were significantly associated with 30-day mortality in patients with SAB.

CONCLUSIONS

Our study highlights that greater adherence to the SAB-QIs correlates with improved patient outcomes. Management of patients with SAB should follow these recommended indicators to maintain the quality of care, especially for patients with poor prognosticators.

Staphylococcus aureus bacteremia in alcoholics

BACKGROUND

Alcoholism associates with increased Staphylococcus aureus bacteremia incidence and mortality. The objective was to compare disease progression, treatment and prognosis of Staphylococcus aureus bacteremia in alcoholics versus non-alcoholics.

METHODS

The study design was a multicenter retrospective analysis of methicillin-sensitive Staphylococcus aureus bacteremia with 90-day follow-up. Patients were stratified as alcoholics or non-alcoholics based on electronic health record data. Altogether 617 Staphylococcus aureus bacteremia patients were included of which 83 (13%) were alcoholics.

RESULTS

Alcoholics, versus non-alcoholics, were younger, typically male and more commonly had community-acquired Staphylococcus aureus bacteremia. No differences in McCabe´s classification of underlying conditions was observed. Higher illness severity at blood culture sampling, including severe sepsis (25% vs. 7%) and intensive care unit admission (39% vs. 17%), was seen in alcoholics versus non-alcoholics. Clinical management, including infectious disease specialist (IDS) consultations and radiology, were provided equally. Alcoholics, versus non-alcoholics, had more pneumonia (49% vs. 35%) and fewer cases of endocarditis (7% vs. 16%). Mortality in alcoholics versus non-alcoholics was significantly higher at 14, 28 and 90 days (14% vs. 7%, 24% vs. 11% and 31% vs. 17%), respectively. Considering all prognostic parameters, male sex (OR 0.19, p = 0.021) and formal IDS consultation (OR 0.19, p = 0.029) were independent predictors of reduced mortality, whereas ultimately or rapidly fatal comorbidity in McCabe´s classification (OR 12.34, p < 0.001) was an independent predictor of mortality in alcoholics.

CONCLUSIONS

Alcoholism deteriorates Staphylococcus aureus bacteremia prognosis, and our results suggests that this is predominantly through illness severity at bacteremia onset. Three quarters of Staphylococcus aureus bacteremia patients we studied had identified deep infection foci, and of them alcoholics had significantly less endocarditis but nearly half of them had pneumonia.

Safety and effectiveness of fifth generation cephalosporins for the treatment of methicillin-resistant staphylococcus aureus bloodstream infections: a narrative review exploring past, present, and future

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) is a major issue in healthcare, since it is often associated with endocarditis or deep site foci. Relevant morbidity and mortality associated with MRSA-BSIs forced the development of new antibiotic strategies; in particular, this review will focus the attention on fifth-generation cephalosporins (ceftaroline/ceftobiprole), that are the only ß-lactams active against MRSA.

AREAS COVERED

The review discusses the available randomized controlled trials and real-world observational studies conducted on safety and effectiveness of ceftaroline/ceftobiprole for the treatment of MRSA-BSIs. Finally, a proposal of MRSA-BSI treatment flowchart, based on fifth-generation cephalosporins, is described.

EXPERT OPINION

The use of anti-MRSA cephalosporins is an acceptable choice either in monotherapy or combination therapy for the treatment of MRSA-BSIs due to their relevant effectiveness and safety. Particularly, their use may be advisable in combination therapy in case of severe infections (including endocarditis or persistent bacteriemia) or in monotherapy in subjects at higher risk of drugs-induced toxicity with older regimens. On the contrary, caution should be taken in case of suspected/ascertained central nervous system infections due to inconsistent data regarding penetration of these drugs in cerebrospinal fluid and brain tissues.

A fatal case of persistent bacteremia and acute cholecystitis caused by Staphylococcus aureus: A case report

Biliary tract infections caused by Staphylococcus aureus are rare. Here, we describe a case of fatal acute cholecystitis and persistent bacteremia caused by S. aureus in a patient with newly diagnosed diabetes mellitus. Staphylococcus aureus can cause bacteremic biliary tract infections, which are associated with higher mortality rates compared to biliary Klebsiella pneumoniae bacteremia. Early aggressive treatment and consultations with infectious disease specialists are recommended when biliary S. aureus bacteremia is clinically suspected.

The impact of infectious diseases consultation for children with Staphylococcus aureus bacteremia

BACKGROUND

Despite clear benefit of improved outcomes in adults, the impact of infectious diseases (ID) consultation for Staphylococcus aureus bacteremia in children remains understudied.

METHODS

To assess the impact of pediatric ID consultation on management and outcomes, we conducted a cohort study of children with S. aureus bacteremia at St. Louis Children's Hospital from 2011 to 2018. We assessed adherence to six established quality-of-care indicators (QCIs). We applied propensity score methodology to examine the impact of ID consultation on risk of treatment failure, a composite of all-cause mortality or hospital readmission within 90 days.

RESULTS

Of 306 patients with S. aureus bacteremia, 193 (63%) received ID consultation. ID consultation was associated with increased adherence to all QCIs, including proof-of-cure blood cultures, indicated laboratory studies, echocardiography, source control, targeted antibiotic therapy, and antibiotic duration. Obtaining proof-of-cure blood cultures and all indicated laboratory studies were associated with improved outcomes. In propensity score-weighted analyses, risk of treatment failure was similar among patients who did and did not receive ID consultation. However, the number of events was small and risk estimates were imprecise.

CONCLUSIONS

For children with S. aureus bacteremia, ID consultation improved adherence to QCIs, some of which were associated with improved clinical outcomes.

IMPACT

In children with Staphylococcus aureus bacteremia, consultation by an infectious diseases (ID) physician improved adherence to established quality-of-care indicators (QCIs). The current literature regarding ID consultation in pediatric S. aureus bacteremia is sparse. Three prior international studies demonstrated improved quality of care with ID consultation, though results were disparate regarding clinical outcomes. This article impacts the current literature by strengthening the evidence that ID consultation in children improves adherence to QCIs, and demonstrates that adherence to QCIs improves clinical outcomes.

Hospital-Wide Protocol Significantly Improved Appropriate Management of Patients with Staphylococcus aureus Bloodstream Infection

Background:Staphylococcus aureus bloodstream infection (SA-BSI) causes morbidity and mortality. We established a management protocol for patients with SA-BSI aimed at improving quality of care and patient outcomes. Methods: A retrospective pre−post intervention study was conducted at Maharaj Nakorn Chiang Mai Hospital from 1 October 2019 to 30 September 2020 in the pre-intervention period and from 1 November 2020 to 31 October 2021 in the post-intervention period. Results: Of the 169 patients enrolled, 88 were in the pre-intervention and 81 were in the post-intervention periods. There were similar demographic characteristics between the two periods. In the post-intervention period, evaluations for metastatic infections were performed more frequently, e.g., echocardiography (70.5% vs. 91.4%, p = 0.001). The appropriateness of antibiotic prescription was higher in the post-intervention period (42% vs. 81.5%, p < 0.001). The factors associated with the appropriateness of antibiotic prescription were ID consultation (OR 15.5; 95% CI = 5.9−40.8, p < 0.001), being in the post-intervention period (OR 9.4; 95% CI: 3.5−25.1, p < 0.001), and thorough investigations for metastatic infection foci (OR 7.2; 95% CI 2.1−25.2, p = 0.002). However, the 90-day mortality was not different (34.1% and 27.2% in the pre- and post-intervention periods, respectively). The factors associated with mortality from the multivariate analysis were the presence of alteration of consciousness (OR 11.24; 95% CI: 3.96−31.92, p < 0.001), having a malignancy (OR 6.64; 95% CI: 1.83−24.00, p = 0.004), hypoalbuminemia (OR 5.23; 95% CI: 1.71−16.02, p = 0.004), and having a respiratory tract infection (OR 5.07; 95% CI: 1.53−16.84, p = 0.008). Source control was the only factor that reduced the risk of death (OR 0.08; 95% CI: 0.01−0.53, p = 0.009). Conclusion: One-third of patients died. Hospital-wide protocol implementation significantly improved the quality of care. However, the mortality rate did not decrease.

How to apply structural equation modelling to infectious diseases concepts

BACKGROUND

Structural equation modelling (SEM) can address causation questions of great interest to infectious disease physicians and infection control practitioners that would elude techniques based on tests of association. Questions such as the size of intervention effects mediated on entities that cannot be easily measured, questions that cannot be studied in randomized controlled trials and question arising from 'big data'.

OBJECTIVES

To outline the computational and, moreover conceptual, differences between SEM methods versus the traditional tests of association.

SOURCES

Google scholar search for "structural equation modelling" and " Infection" CONTENT: Several examples of SEM applications to infectious diseases topics are used to illustrate. The SEM technique enables postulated causation models to be confronted with data. With this, the candidate models emerge as either 'importantly wrong', or potentially useful for enabling empiric predictions from the one identified as optimal.

IMPLICATIONS

Applications of SEM techniques and related modelling techniques to infectious diseases research will likely continue to emerge, especially so with the availability of 'big data'. ''Since all models are wrong the scientist must be alert to what is importantly wrong. It is inappropriate to be concerned about mice when there are tigers abroad.'' [George Box; 1].

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

BACKGROUND

Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported.

AIM

To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients.

METHODS

Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed.

FINDINGS

From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile.

CONCLUSION

This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.