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Casado A, Gimeno A, Aguilar-Guisado M, García M, Rodríguez JF, Rivas PA, Bueno C, Lepe JA, Cisneros JM, Molina J. Safety of early oral ambulatory treatment of adult patients with bloodstream infections discharged from the emergency department. Antimicrob Agents Chemother 2023; 67:e0078023. [PMID: 37889016 PMCID: PMC10648851 DOI: 10.1128/aac.00780-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/06/2023] [Indexed: 10/28/2023] Open
Abstract
This study evaluates the safety of early oral ambulatory treatment of adult patients diagnosed with bacteremia after their discharge from the emergency department. A cohort of 206 febrile ambulatory patients was assessed. Bacteremic low-risk patients were recommended an oral treatment and were compared with matched febrile non-bacteremic outpatients. Rates of 14-day mortality and unplanned re-consultations were similar and below 5% in both cohorts, highlighting the safety of oral therapy of low-risk bacteremia, even from its onset.
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Affiliation(s)
- Ana Casado
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
| | - Adelina Gimeno
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
| | - Manuela Aguilar-Guisado
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel García
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
| | | | | | - Claudio Bueno
- Emergency Department, Virgen del Rocío University Hospital, Seville, Spain
| | - Jose Antonio Lepe
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Cisneros
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - José Molina
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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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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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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Megged O, Assous MV. Non-typhoidal Salmonella bacteremia: comparison of adults and children in a single medical center. J Med Microbiol 2022; 71. [PMID: 35612897 DOI: 10.1099/jmm.0.001463] [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] [Indexed: 11/18/2022] Open
Abstract
Introduction. Non-typhoidal Salmonella (NTS) bacteremia can cause significant morbidity and mortality. There is high incidence of Salmonellosis in the Middle East, including Israel, but there is a paucity of data on the clinical and epidemiological features of children in comparison to adults.Hypothesis/Gap Statement. Previous studies describing the differences between paediatric and adult populations with Salmonella bacteremia are sparse.Aim. This study's aim was to describe the differences between adults and children with NTS bacteremia.Methodology. All records of patients with NTS bacteremia between 1 January 1998 and 31 July 2020 were reviewed. Data regarding clinical manifestations and laboratory results were extracted from the medical records; records of children (aged <18 years) were compared with those of adults.Results. Records for 137 cases of Salmonella bacteremia (69 adults and 68 children, aged 2 days to 98 years) were reviewed. Seventy nine (58 %) patients had concomitant gastrointestinal symptoms. Fifty-eight (84 %) adults and 13 (19 %) children had underlying conditions (P<0.001). Eighteen patients died, none of whom was a child. Over the study period, most of the children (n=46, 67 %) but only five adults were discharged from the emergency department on their first visit to the ED.Conclusions. The main characteristics of NTS bacteremia in children compared to adults, are higher rates of prior discharge from emergency department, higher rate of gastrointestinal symptoms and better prognosis.
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Affiliation(s)
- Orli Megged
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Pediatric Department and Infectious Diseases Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Marc V Assous
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Clinical Microbiology and Immunology Laboratory, Shaare Zedek Medical Center, Jerusalem, Israel
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Epidemiology and outcome of occult bacteremia in patients discharged from emergency departments or ambulatory units: one-year study. Eur J Clin Microbiol Infect Dis 2022; 41:649-655. [PMID: 35150380 DOI: 10.1007/s10096-022-04419-2] [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: 11/08/2021] [Accepted: 02/04/2022] [Indexed: 11/03/2022]
Abstract
Microbiological diagnosis of bloodstream infection (BSI) is made several hours after blood culture sampling. This delay could be critical in ambulatory clinics, emergency departments, and hospital day care units, as the patient may be discharged prior to blood culture positivity. Our aim was to evaluate the clinical outcome (including the number of readmissions) of patients diagnosed with BSI after discharge. We prospectively included all adult patients with positive blood culture for BSI that was confirmed after discharge from our center (Grenoble-Alpes University Hospital) in 2016. Patients were contacted about their blood culture results, and their clinical status was controlled via an external consultation or their family physician, with hospital readmission if necessary. Clinical outcome, accuracy of initial diagnosis, microbiological epidemiology, and antibiotic prescription were assessed. In 2016, 1433 episodes of positive blood culture were detected in our hospital, with 50 (3.5%) occurring after patient discharge. Clinically relevant bacteria were determined in 32/50 cases (64%), while other positive blood culture results were considered to be contaminants. Clinical reevaluation was performed in 45 patients (90%). The diagnosis was changed during the clinical reassessment of 24/49 patients (49%). Antibiotics were prescribed prior to discharge for 24/50 patients (48%), modified during follow-up for 15/45 (33%), and initiated for 13/45 (29%) at the reevaluation. Overall, 24/45 (53%) patients were readmitted to hospital units after reevaluation. The clinical follow-up of patients with positive blood culture after discharge led to diagnostic changes and hospital readmission in around half of patients.
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Kenig A, Salameh S, Gershinsky Y, Amit S, Israel S. Blood cultures of adult patients discharged from the emergency department-is the safety net reliable? Eur J Clin Microbiol Infect Dis 2020; 39:1261-1269. [PMID: 32052342 DOI: 10.1007/s10096-020-03838-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 02/03/2020] [Indexed: 10/23/2022]
Abstract
We investigated the clinical implications of the practice in our emergency department (ED) of discharging patients with pending blood cultures. We reviewed the medical records of adults discharged with positive blood cultures from the ED of a 330-bed university hospital during a five-year period. Clinical characteristics, laboratory data, and antibiotic treatment prescribed in the ED and at discharge were accessed. Antimicrobial susceptibility profiles were used to determine whether antibiotic treatment was adequate. The outcomes assessed for 90 days following discharge were return to the ED, hospitalization, modified diagnosis, and death. Of 220,681 visits to the ED, 1362 showed positive blood cultures; of these, 307 (22.5%) were from discharged patients. More than half the isolates (56.3%) were considered contaminants. Of 124 visits with true bacteremia, Enterobacteriaceae were the most common pathogens (67.0%). This is concordant with urinary tract infection (UTI) being the most common diagnosis (52.4%). With antibiotic treatment, 69.4% had been discharged with antibiotic treatment, which was adequate in two-thirds of them. Among the 77 who returned to the ED, 27.5% had persistent bacteremia. The diagnosis was changed in 44.2% of them, mostly with brucellosis or bone and joint infections, and 84.4% were subsequently hospitalized. Within three months, 5.6% of bacteremic patients died, all after hospitalization. Bacteremia in discharged patients occurred mainly in association with UTI. Outcomes were generally favorable, although only about half received appropriate antibiotic treatment. Diagnoses were changed in a relatively high proportion of patients following culture results.
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Affiliation(s)
- Ariel Kenig
- Internal Medicine Department, Hadassah Medical Center, Ein Kerem Hospital, Jerusalem, Israel
| | - Shaden Salameh
- Emergency Department, Hadassah Medical Center, Mount Scopus Hospital, Jerusalem, Israel
| | - Yonatan Gershinsky
- Emergency Department, Hadassah Medical Center, Mount Scopus Hospital, Jerusalem, Israel
| | - Sharon Amit
- Clinical Microbiology and Infectious Diseases Department, Hadassah Medical Center, Ein Kerem Hospital, Jerusalem, Israel
| | - Sarah Israel
- Internal Medicine Department, Hadassah Medical Center, Mount Scopus Hospital, Jerusalem, Israel.
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Laín Miranda E, Toyas Miazza C, Castillo García F, Povar Marco J, Villuendas Usón M, Rezusta López A. Bacteriemia en pacientes adultos dados de alta en el servicio de urgencias. Semergen 2019; 45:467-473. [DOI: 10.1016/j.semerg.2019.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 05/21/2019] [Accepted: 05/27/2019] [Indexed: 11/30/2022]
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8
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Seo DY, Jo S, Lee JB, Jin YH, Jeong T, Yoon J, Park B. Diagnostic performance of initial serum lactate for predicting bacteremia in female patients with acute pyelonephritis. Am J Emerg Med 2016; 34:1359-63. [PMID: 27133532 DOI: 10.1016/j.ajem.2016.03.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The purpose of the present study was to investigate the diagnostic value of lactate for predicting bacteremia in female patients with acute pyelonephritis (APN). METHODS We conducted a retrospective study of female patients with APN who visited the study hospital emergency department. The demographics, comorbidities, physiologies, and laboratory variables including white blood cell count and segmented neutrophil count, C-reactive protein, and initial serum lactate levels were collected and analyzed to identify associations with the presence of bacteremia. RESULTS During the study period, a total of 314 patients were enrolled. One hundred twenty-three patients (39.2%) had bacteremia. Escherichia coli was the most frequent pathogen. Logistic regression analysis demonstrated that the lactate level was independently associated with the presence of bacteremia (odds ratio, 1.39 [95% confidence interval, 1.08-1.78]). The C-statistic of the lactate level was 0.67 (95% CI, 0.60-0.73). At a cutoff value of 1.4mmol/L, the lactate level predicted bacteremia with a sensitivity (53.7%), specificity (72.3%), positive predictive value (55.5%), negative predictive value (70.8%), positive likelihood ratio (1.93), and negative likelihood ratio (0.64). CONCLUSION The initial serum lactate level showed poor discriminative performance for predicting bacteremia in female patients with APN.
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Affiliation(s)
- Dong Young Seo
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju-si, Republic of Korea
| | - Sion Jo
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju-si, Republic of Korea.
| | - Jae Baek Lee
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju-si, Republic of Korea
| | - Young Ho Jin
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju-si, Republic of Korea
| | - Taeoh Jeong
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju-si, Republic of Korea
| | - Jaechol Yoon
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University and Biomedical Research Institute of Chonbuk National University Hospital, Jeonju-si, Republic of Korea
| | - Boyoung Park
- National Cancer Control Institute, National Cancer Center, Goyang-si, Kyunggi-do, Republic of Korea
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Shallcross LJ, Freemantle N, Nisar S, Ray D. A cross-sectional study of blood cultures and antibiotic use in patients admitted from the Emergency Department: missed opportunities for antimicrobial stewardship. BMC Infect Dis 2016; 16:166. [PMID: 27091375 PMCID: PMC4835863 DOI: 10.1186/s12879-016-1515-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 04/14/2016] [Indexed: 11/25/2022] Open
Abstract
Background Early review of antimicrobial prescribing decisions within 48 h is recommended to reduce the overall use of unnecessary antibiotics, and in particular the use of broad-spectrum antibiotics. When parenteral antibiotics are used, blood culture results provide valuable information to help decide whether to continue, alter or stop antibiotics at 48 h. The objective of this study was to investigate the frequency of parenteral antibiotic use, broad spectrum antibiotic use and use of blood cultures when parenteral antibiotics are initiated in patients admitted via the Emergency Department. Methods We used electronic health records from patients admitted from the Emergency Department at University Hospital Birmingham in 2014. Results Six percent (4562/72939) of patients attending the Emergency department and one-fifth (4357/19034) of those patients admitted to hospital were prescribed a parenteral antimicrobial. More than half of parenteral antibiotics used were either co-amoxiclav or piperacillin-tazobactam. Blood cultures were obtained in less than one-third of patients who were treated with a parenteral antibiotic. Conclusions Parenteral antibiotics are frequently used in those admitted from the Emergency Department; they are usually broad spectrum and are usually initiated without first obtaining cultures. Blood cultures may have limited value to support prescribing review as part of antimicrobial stewardship initiatives.
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Affiliation(s)
- Laura J Shallcross
- UCL Centre for Infectious Disease Informatics, Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.
| | - Nick Freemantle
- Department of Primary Care and Population Health, Upper Third floor, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | - Shasta Nisar
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, B15 2TH, UK
| | - Daniel Ray
- UCL Centre for Infectious Disease Informatics, Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.,Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, B15 2TH, UK
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Demissei BG, Cleland JG, O'Connor CM, Metra M, Ponikowski P, Teerlink JR, Davison B, Givertz MM, Bloomfield DM, Dittrich H, van Veldhuisen DJ, Hillege HL, Voors AA, Cotter G. Procalcitonin-based indication of bacterial infection identifies high risk acute heart failure patients. Int J Cardiol 2015; 204:164-71. [PMID: 26666342 DOI: 10.1016/j.ijcard.2015.11.141] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/16/2015] [Accepted: 11/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bacterial infections in patients hospitalized with acute heart failure are related to worse prognosis, but they can be difficult to diagnose. In this study we evaluated the prevalence, clinical correlates and association with outcomes of significantly elevated procalcitonin levels in patients hospitalized for acute heart failure without clear signs of bacterial infection. METHODS 1781 patients from the PROTECT trial were included. Patients with a body temperature >38°C, sepsis or active infection requiring IV antibiotics were excluded. Significant elevation of procalcitonin was considered present when levels exceeded 0.20 ng/mL. In-hospital and post-discharge outcomes were compared between groups of patients with and without elevated procalcitonin levels. RESULTS Procalcitonin ≥ 0.20 ng/mL was seen in 6.0% of patients (N=104). This group of patients had lower serum albumin, lower hemoglobin, higher leukocyte count, higher C-reactive protein, higher blood urea nitrogen, higher heart rate and more pulmonary rales. Interestingly, no significant differences were observed between the two groups in terms of severity of heart failure evidenced by left ventricular ejection fraction (LVEF) or B-type natriuretic peptide (BNP) levels. Patients with significantly elevated procalcitonin levels were more often classified as treatment failure or unchanged status, and had an increased risk of 30-day all-cause mortality even after adjustment for established prognosticators; HR=2.3 (95% CI, 1.3-4.2), (P=0.005). CONCLUSION Patients with acute heart failure and significantly elevated procalcitonin levels, indicating probable undiagnosed/untreated bacterial infection, had poorer in-hospital and post-discharge outcomes, despite similar severity of heart failure.
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Affiliation(s)
- Biniyam G Demissei
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - John R Teerlink
- University of California at San Francisco, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | | | - Howard Dittrich
- Abboud Cardiovascular Research Center, University of Iowa Carver College of Medicine, IA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Chang EK, Kao KL, Tsai MS, Yang CJ, Huang YT, Liu CY, Liao CH. Occult Klebsiella pneumoniae bacteremia at emergency department: A single center experience. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 48:684-91. [PMID: 26510516 DOI: 10.1016/j.jmii.2015.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/23/2015] [Accepted: 08/31/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Patients with undetected bacteremia when discharged from a hospital are considered to have occult bacteremia. Klebsiella pneumoniae bacteremia (KPB) is endemic to Taiwan. Our purpose was to study the impact of occult KPB. METHODS We retrospectively reviewed the records of patients who were discharged from our emergency department (ED) and subsequently diagnosed with KPB (occult bacteremia), from January 2008 to March 2014. All patients are followed for at least 3 months after the index ED visit. The study group was compared to KPB patients who were directly hospitalized (DH) from ED in 2008. Thirty-day mortality was the primary endpoint. RESULTS A total of 913 patients were admitted to our ED with KPB, and 88 of these patients (9.6%) had occult KPB. Among them, 43 had second ED visit and 41 were admitted. The overall 30-day mortality was 2.3%. Relative to patients with occult KPB, DH patients had more respiratory tract infections (p < 0.001) but fewer other intra-abdominal infections (p = 0.015). Liver abscess was the major diagnosis for the second ED visit (37.2%). DH patients had significantly greater 30-day mortality than that of overall patients with KPB (19.2% vs.2.3%, p < 0.001). CONCLUSION Most patients with occult KPB had favorable outcomes, but about half of them required a second ED visit. Clinicians should aggressively follow patients with occult KPB and should seek to identify the focus of infection in this endemic area.
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Affiliation(s)
- Eileen Kevyn Chang
- Department of Infectious Diseases, Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kai-Liang Kao
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Mao-Song Tsai
- Department of Infectious Diseases, Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chia-Jui Yang
- Department of Infectious Diseases, Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; College of Medicine, Yang-Ming University, Taipei, Taiwan
| | - Yu-Tsung Huang
- Department of Infectious Diseases, Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chia-Ying Liu
- Department of Infectious Diseases, Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chun-Hsing Liao
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan; College of Medicine, Yang-Ming University, Taipei, Taiwan.
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12
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Occult bloodstream infections in adults: a “benign” entity. Am J Emerg Med 2014; 32:966-71. [DOI: 10.1016/j.ajem.2014.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 05/04/2014] [Accepted: 05/05/2014] [Indexed: 11/22/2022] Open
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del Arco-Jiménez A, Olalla-Sierra J, de la Torre-Lima J, Prada-Pardal JL, Rivas-Ruiz F, Fernández-Sánchez F. [Results of an early intervention program for patients with bacteremia discharged from the Emergency Department]. Med Clin (Barc) 2013; 142:107-10. [PMID: 24210983 DOI: 10.1016/j.medcli.2013.05.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 05/27/2013] [Accepted: 05/30/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Occult bacteremia represents 3% of blood cultures drawn in the Emergency Department. In most cases, the evolution is unknown. The aim of the study is to analyze the results obtained after implementation of an intervention program for these patients. PATIENTS AND METHODS We describe the results of an early intervention program for patients with bacteremia in the Emergency Department discharged at home, which was implemented in daily clinical activity in Costa del Sol Hospital in Marbella (Malaga). We analyze the epidemiological, microbiological, Charlson comorbidity index, Pitt bacteremia index and 30-day mortality. RESULTS During 15 months, 90 patients were located. The median age was 67 years. There was a predominance of males with 54 of cases (60%). The acquisition place was predominantly the community with 51 cases (56.6%), being the most frequent microorganism Escherichia coli with 31 cases (34.4%). The median Charlson index and the bacteremia Pitt index were 1. Thirty-eight of the cases required hospitalization (42.2%). Pitt bacteremia index>1 and exchange antibiotic treatment were the related variables with need for admission. One patient died (1.2%) and 6 patients could not be located (6.6%). CONCLUSIONS The implementation of programs of early identification and management of patients with bacteremia in Emergency Department discharged al home allows early recovery of patients who require hospital admission and antibiotic treatment optimization. In our series, mortality after early intervention was low (1.2%).
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Affiliation(s)
- Alfonso del Arco-Jiménez
- Grupo de Enfermedades Infecciosas, Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, España.
| | - Julián Olalla-Sierra
- Grupo de Enfermedades Infecciosas, Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, España
| | - Javier de la Torre-Lima
- Grupo de Enfermedades Infecciosas, Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, España
| | - José Luis Prada-Pardal
- Grupo de Enfermedades Infecciosas, Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, España
| | - Francisco Rivas-Ruiz
- Unidad de Apoyo a la Investigación, Hospital Costa del Sol, Marbella, Málaga, España
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Mòdol Deltell JM, Tudela Hita P. [Occult bacteremia or bacteremia in adult patients discharged from the Emergency Department]. Med Clin (Barc) 2013; 142:111-3. [PMID: 24183123 DOI: 10.1016/j.medcli.2013.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 09/12/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Josep M Mòdol Deltell
- Unidad de Corta Estancia-Urgencias, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, España.
| | - Pere Tudela Hita
- Unidad de Corta Estancia-Urgencias, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, España
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Gonçalves-Pereira J, Povoa P, Lobo C, Carneiro A. Bloodstream infections as a marker of community-acquired sepsis severity. Results from the Portuguese community-acquired sepsis study (SACiUCI study). Clin Microbiol Infect 2013; 19:242-8. [DOI: 10.1111/j.1469-0691.2012.03776.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lee CC, Hong MY, Chan TY, Hsu HC, Ko WC. The impact of appropriateness of antimicrobial therapy in adults with occult bacteraemia. Emerg Med J 2012; 31:53-8. [DOI: 10.1136/emermed-2012-201941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tudela P, Prat C, Lacoma A, Mòdol JM. Biomarcadores y sospecha de infección en los servicios de urgencias. Med Clin (Barc) 2012; 139:33-7. [DOI: 10.1016/j.medcli.2011.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 09/13/2011] [Indexed: 10/15/2022]
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Fu CM, Tseng WP, Chiang WC, Lai MS, Chie WC, Chou HC, Hsueh PR, Huei-Ming Ma M, Fang CC, Chen SC, Chen WJ, Chen SY. Occult Staphylococcus aureus Bacteremia in Adult Emergency Department Patients: Rare but Important. Clin Infect Dis 2012; 54:1536-44. [DOI: 10.1093/cid/cis214] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Molecular Approaches to the Diagnosis of Sepsis. Mol Microbiol 2011. [DOI: 10.1128/9781555816834.ch49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kao CH, Kuo YC, Chen CC, Chang YT, Chen YS, Wann SR, Liu YC. Isolated pathogens and clinical outcomes of adult bacteremia in the emergency department: a retrospective study in a tertiary Referral Center. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:215-21. [PMID: 21524617 DOI: 10.1016/j.jmii.2011.01.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 05/06/2010] [Accepted: 07/27/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Approximately two-thirds of the patients with severe sepsis or septic shock are first encountered in the emergency departments (EDs) of western countries, in which bacteremia is present in about 50% of patients with severe sepsis. The situation of bacteremia presenting to the EDs in Taiwan is not well documented. The objective of this study was to examine the epidemiology and microbiology of bacteremia in adult patients who visited the ED of a medical center in southern Taiwan. METHODS A retrospective observational study of the epidemiology and microbiology of bacteremia was conducted in the ED of a medical center involving 6,137 adult patients and 13,903 blood cultures. RESULTS A total of 831 consecutive patients with 890 episodes of bacteremia were obtained from January 1 to December 31, 2004, indicating a positive culture rate of 13.5% (1,872/13,903). Among these episodes, 525 (59%) were defined as true community-acquired infections followed by 263 (29.5%) as health care-associated infections and 102 (11.5%) as nosocomial infections. Of the 972 isolates, 289 (29.7%) were gram-positive species and 683 (70.3%) were gram-negative species. Urinary tract infections (32.2%, 287/890) were most common in these patients, with Escherichia coli (30.8%, 299/972) being the most common pathogen. Bacteremia caused by Staphylococcus aureus was more common in nosocomial than true community-acquired infections (31.3% vs. 12%) and had significantly higher possibility of resistance to methicillin in infections not purely acquired from community (odds ratio = 24.92; 95% confidence interval, 9.88-62.87). The overall crude mortality rate was 21% and nearly half of the mortalities occurred within 3 days of visiting the ED. All patients discharged inadvertently were uneventful (n = 65, two lost at follow-up). CONCLUSIONS Categories of bacteremia acquisition was associated with different distribution of pathogens, antimicrobial resistance, and clinical outcome. Traditional classification might overestimate the problem of drug resistance in community-acquired infections. The concept of health care-associated infection should be introduced to avoid overemphasis of drug-resistant problem in true community-acquired infection.
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Affiliation(s)
- Chih-Hsiang Kao
- Department of Emergency Medicine, Kaohsiung Veteran General Hospital, Kaohsiung, Taiwan
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Tudela P, Lacoma A, Prat C, Mòdol JM, Giménez M, Barallat J, Tor J. Predicción de bacteriemia en los pacientes con sospecha de infección en urgencias. Med Clin (Barc) 2010; 135:685-90. [DOI: 10.1016/j.medcli.2010.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 04/01/2010] [Accepted: 04/06/2010] [Indexed: 10/19/2022]
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Lin JN, Lai CH, Chen YH, Chang LL, Lu PL, Tsai SS, Lin HL, Lin HH. Characteristics and outcomes of polymicrobial bloodstream infections in the emergency department: A matched case-control study. Acad Emerg Med 2010; 17:1072-9. [PMID: 21040108 DOI: 10.1111/j.1553-2712.2010.00871.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Polymicrobial bloodstream infection (BSI) is a critical condition and has been increasingly reported; however, the authors were unable to find an emergency department (ED) patient-based study in the literature. METHODS A retrospective matched case-control study with a ratio of 1:3 among patients with polymicrobial BSIs in an ED was conducted. The case group was patients aged > 16 years with polymicrobial BSIs. Patients matched for age and sex with monomicrobial BSIs were sampled as the control group. Demographic information, underlying conditions, microbiologic data, and outcomes were collected for further analysis. RESULTS From January 2005 to December 2007, a total of 112 episodes of polymicrobial BSIs among 109 patients were included. Two pathogens were isolated among 87 (77.7%) episodes and three were found among 25 (22.3%) episodes. A history of hospitalization within 90 days was an independent risk factor for polymicrobial BSIs (p = 0.003). Intraabdominal infection (p < 0.001) and respiratory tract infection (p = 0.017) were more likely to be associated with polymicrobial BSIs. Gram-negative and Gram-positive bacteria were documented in 95.5 and 46.4% episodes of polymicrobial BSIs, respectively. Inappropriate antimicrobial treatment was observed in 53.6% of polymicrobial BSIs, but only accounted for 23.8% of monomicrobial BSIs (p < 0.001). The overall 30-day mortality rate of the polymicrobial group was significantly higher than those with monomicrobial BSIs (30.3 and 11.6%, respectively; p < 0.001). CONCLUSIONS Patients with polymicrobial BSIs had a high mortality rate. Acknowledgment of the clinical and microbiologic characteristics and recognition of patients at risk for polymicrobial BSIs are critical in EDs.
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Affiliation(s)
- Jiun-Nong Lin
- Department of Emergency Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taipei, Taiwan
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Alves DW, Bissell RA. Bacterial pathogens in ambulances: results of unannounced sample collection. PREHOSP EMERG CARE 2008; 12:218-24. [PMID: 18379921 DOI: 10.1080/10903120801906721] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
UNLABELLED The concern that the health care environment may harbor a substantial reservoir of infectious agents has been vigorously examined by microbiology and infectious disease experts. Although universal precautions and disposable equipment reduces risks to patients and providers, the ambulance remains vulnerable to bacterial contamination from biological secretions. Additionally, the nature of emergency medical services creates pressures on prehospital care providers. OBJECTIVE We hypothesized that a discrepancy exists between the expectation of disinfection of reusable equipment in emergency medical services (EMS) and the cleaning that actually occurs. METHODS We chose five areas within the ambulance for specimen collection for their reasoned propensity to yield a large spectrum of bacteria. Four first-due ambulances were selected for culturing. The crews did not have advance knowledge of the study or sample collection. Specific identifications with antibiotic susceptibility were completed, identifying three multidrug resistant organisms. RESULTS Specimens from all four ambulances grew moderate-to-large quantities of environmental and skin flora. Newer, automated microbiological techniques and concerns regarding multiple-drug-resistant organism prevalence as well as the potential for biological warfare make complete identification more important. CONCLUSIONS This study examined the bacterial pathogens found in EMS vehicles. Four of the seven species isolated were substantial nosocomial pathogens, and three of these four possess formidable antibiotic resistance patterns. All of the organisms detected are susceptible to the disinfectant agents currently in common use by EMS agencies.
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Affiliation(s)
- Donald W Alves
- Department of Emergency Medicine, Division of Special Operations, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21224, USA.
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Tudela P, Maria Mòdol J, Giménez M, Prat C, Vilaseca B, Tor J. Bacteriemia en pacientes no hospitalizados: tendencias evolutivas en los últimos 10 años. Med Clin (Barc) 2007; 129:770-2. [DOI: 10.1157/13113767] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
OBJECTIVE To assess C-reactive protein (CRP) as a marker of bacteraemia in ED patients. METHODS A retrospective review of a convenience sample of adult patients was conducted at an urban, tertiary care, academic ED. Patients were included in the present study if they had CRP and blood cultures taken during their ED assessment. Neutropenic patients were excluded. Sensitivity, specificity, predictive values and likelihood ratios for CRP in the detection of bacteraemia were calculated. RESULTS Over a 12 month period 1214 patients were included in the present study. Blood cultures were positive in 77 (6.3%, 95% confidence interval [CI] 5.0-7.6%), and contaminated in 33 (2.7%, 95% CI 1.8-3.6%). An elevated CRP was 94% sensitive (95% CI 86-98%) and 18% specific (95% CI 16-20%) for concurrent bacteraemia. The positive likelihood ratio for bacteraemia with an elevated CRP was 1.15 (95% CI 1.07-1.23), and the negative likelihood ratio was 0.33 (95% CI 0.23-0.49). CONCLUSION Although the present study has limitations, it appears to show that CRP has limited diagnostic utility for the detection of bacteraemia in ED patients.
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Affiliation(s)
- Nicholas G Adams
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.
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Bar-Meir M, Raveh D, Yinnon AM, Benenson S, Rudensky B, Schlesinger Y. Non-Typhi Salmonella gastroenteritis in children presenting to the emergency department: characteristics of patients with associated bacteraemia. Clin Microbiol Infect 2005; 11:651-5. [PMID: 16008618 DOI: 10.1111/j.1469-0691.2005.01200.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The records of children with Salmonella gastroenteritis only (n = 97), and those with associated bacteraemia (n = 64), seen in one medical centre during a 12-year period, were analysed retrospectively. Mean patient age was 2.24 +/- 2.8 years (range, 0.05-16 years), and 49% were male. Children with bacteraemia presented after a longer duration of symptoms (7.0 +/- 6.9 vs. 3.9 +/- 4.6 days, p 0.0002), and had higher erythrocyte sedimentation rates (45 +/- 22 vs. 33 +/- 22 mm/h, p < 0.02) and lactate dehydrogenase values (924 +/- 113 vs. 685 +/- 165 IU/L, p 0.001). There was a trend in bacteraemic children towards immunosuppression (6.3% vs. 1.0%, p 0.08) and a lower number of siblings (2.9 +/- 1.9 vs. 3.8 +/- 2.7, p 0.063). Non-bacteraemic children had a more severe clinical appearance, and a higher percentage had a moderate to bad general appearance (51.5 vs. 29.7%, p < 0.01), with dehydration (37.1 vs. 18.8%, p 0.02) and vomiting (58.8 vs. 39.0%, p 0.02). Laboratory dehydration indicators were also markedly worse in non-bacteraemic children, with urine specific gravity of 1020 +/- 9.4 vs. 1013 +/- 9.0 (p 0.0002), base excess of - 4.2 +/- 3.0 vs. - 2.5 +/- 3.4 mEq/L (p 0.01), and blood urea nitrogen of 10.1 +/- 7.0 vs. 7.4 +/- 4.5 mg% (p 0.002). Thus, the clinical presentation of bacteraemic children was more gradual, and associated gastroenteritis and dehydration was less pronounced. These findings may contribute in part to the inadvertent discharge of bacteraemic children from the emergency department.
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Affiliation(s)
- M Bar-Meir
- Department of Pediatrics, Shaare-Zedek Medical Center, Jerusalem, Israel
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Laupland KB, Church DL, Gregson DB. Blood cultures in ambulatory outpatients. BMC Infect Dis 2005; 5:35. [PMID: 15904503 PMCID: PMC1156895 DOI: 10.1186/1471-2334-5-35] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 05/17/2005] [Indexed: 11/30/2022] Open
Abstract
Background Blood cultures are a gold standard specific test for diagnosing many infections. However, the low yield may limit their usefulness, particularly in low-risk populations. This study was conducted to assess the utility of blood cultures drawn from ambulatory outpatients. Methods Blood cultures drawn at community-based collection sites in the Calgary Health Region (population 1 million) in 2001 and 2002 were included in this study. These patients were analyzed by linkages to acute care health care databases for utilization of acute care facilities within 2 weeks of blood culture draw. Results 3102 sets of cultures were drawn from 1732 ambulatory outpatients (annual rate = 89.4 per 100,000 population). Significant isolates were identified from 73 (2.4%) sets of cultures from 51 patients, including Escherichia coli in 18 (35%) and seven (14%) each of Staphylococcus aureus and Streptococcus pneumoniae. Compared to patients with negative cultures, those with positive cultures were older (mean 49.6 vs. 40.1 years, p < 0.01), and more likely to subsequently receive care at a regional emergency department, outpatient antibiotic clinic, or hospital (35/51 vs. 296/1681, p < 0.0001). Of the 331 (19%) patients who received acute care treatment, those with positive cultures presented sooner after community culture draw (median 2 vs. 3 days, p < 0.01) and had longer median treatment duration (6 vs. 2 days, p < 0.01). Conclusion Blood cultures drawn in outpatient settings are uncommonly positive, but may define patients for increased intensity of therapy. Strategies to reduce utilization without excluding patients with positive cultures need to be developed for this patient population.
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Affiliation(s)
- Kevin B Laupland
- Departments of Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
- Critical Care Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
- Pathology and Laboratory Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
| | - Deirdre L Church
- Departments of Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
- Pathology and Laboratory Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
| | - Daniel B Gregson
- Departments of Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
- Pathology and Laboratory Medicine, Centre for Anti-microbial Resistance and Infectious Diseases Research Group, University of Calgary, Calgary Health Region, and Calgary Laboratory Services, Calgary, Alberta, Canada
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Cisneros-Herreros JM, Sánchez-González M, Prados-Blanco MT, Llanos-Rodríguez C, Vigil-Martín E, Soto-Espinosa de los Monteros B, Pachón-Díaza J. Hemocultivos en el servicio de urgencias. Enferm Infecc Microbiol Clin 2005; 23:135-9. [PMID: 15757584 DOI: 10.1157/13072162] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Culture of emergency room blood samples is common practice, but open to controversy. As compared to other emergency tests, blood collection requires twice as much time and needs a refined technique to avoid contamination, and the study has no immediate diagnostic utility. METHODS This prospective study includes consecutive adult patients with positive emergency room blood cultures. We analyzed the diagnostic sensitivity and contamination rate of the cultures and the etiology, clinical features and prognosis of the bacteremias encountered. RESULTS During the study period, 5.2 blood cultures were indicated per 1000 patients attended in the emergency room. The diagnostic yield (positive blood cultures/total cultures) was 20% and the contamination rate (contaminated blood cultures/total cultures) was 1%. The incidence of bacteriemia was 0.99 episodes per 1000 patients attended in the emergency room and 10.3 episode per 1000 hospitalized patients. Gram-negative bacteria predominated (57%). Sepsis was the most frequent clinical manifestation (50%), followed by severe sepsis (40%) and septic shock (10%). Mortality was 22%. Diabetes mellitus and severe sepsis/septic shock were independent factors associated with mortality. CONCLUSIONS Diagnostic performance and quality of emergency room blood cultures was high. The predominant etiology was gram-negative bacteria. Patients had a severe clinical presentation. Diabetes mellitus and severe sepsis and/or septic shock were independent prognostic factors of mortality.
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Raveh D, Gratch L, Yinnon AM, Sonnenblick M. Demographic and clinical characteristics of patients admitted to medical departments. J Eval Clin Pract 2005; 11:33-44. [PMID: 15660535 DOI: 10.1111/j.1365-2753.2004.00492.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The significant changes, which have affected departments of medicine over the last two decades, have been much editorialized. Surprisingly few data have been published that document these changes. We describe the demographic and clinical characteristics of patients admitted to one hospital's departments of internal medicine. METHODS During a 3 months prospective study, 1039 patients (46% of all 2277 new admissions to the departments of medicine, consisting of +/- 175 beds) were randomized for inclusion. Information was extracted from the medical records regarding demography; functional capacity; clinical data and outcome. RESULTS The mean age of the patients was 72 +/- 16 years (mean +/- SD); 51% were male, 56% were married, and 83% lived at home. Although 293 patients (28%) were defined as dependent, the majority lived at home (170, 58%). Cognition was normal in only 74%. The four most common disease categories leading to admission were infections (383 patients, 37%), cardiovascular disorders (372, 36%), respiratory conditions (284, 27%) and genito-urinary problems (90, 9%). Overall, 98 persons died (9%). Independent risk factors for death were: mechanical ventilation; a 'do not resuscitate' order; a high APACHE-II score; a low serum albumin level; higher age; and not being married (P < 0.01). CONCLUSIONS Geriatric patients occupy a central position in our medical wards. These data are relevant for allocation of special resources for departments with high proportions of geriatric patients; for the design of employment conditions that ascertains continuing job satisfaction; as well as for the planning of teaching opportunities for residents and students.
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Affiliation(s)
- D Raveh
- Infectious Disease Unit, Department of Medicine, Shaare Zedek Medical Center, Jerusalem, affiliated with the Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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Ramos JM, Masiá M, Elía M, Gutiérrez F, Royo G, Bonilla F, Padilla S, Martín-Hidalgo A. Epidemiological and clinical characteristics of occult bacteremia in an adult emergency department in Spain: influence of blood culture results on changes in initial diagnosis and empiric antibiotic treatment. Eur J Clin Microbiol Infect Dis 2004; 23:881-7. [PMID: 15599649 DOI: 10.1007/s10096-004-1235-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A prospective study was carried out to analyze the usefulness of blood culture results for adult patients who were discharged from the emergency department with bacteremia. Over a 29-month period, 110 patients with significant bacteremia who were seen in the emergency department and discharged home were studied. The mean age of the patients was 61.8 years. The most frequent initial major diagnosis was urinary tract infection (UTI) (n=63; 57.3%). Gram-negative organisms were isolated in 79 (71.8%) cases. A change in diagnosis (44.5% cases) was more common when the initial diagnosis was something other than UTI or when empiric antimicrobial therapy was ineffective or was not given (P<0.001). The significant predictors of modification of the initial empiric antibiotic therapy were ineffective empiric antimicrobial therapy and transfer of the patient from the emergency department to an infectious diseases outpatient clinic (P=0.01). Blood culture results may be useful for achieving the correct diagnosis in adult patients with bacteremia and for guiding treatment in the subsequent management of outpatients.
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Affiliation(s)
- J M Ramos
- Department of Internal Medicine, Hospital General Universitario de Elche, Alicante, Spain.
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Predictive Value of Leukocytosis and Neutrophilia for Bloodstream Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2004. [DOI: 10.1097/01.idc.0000104893.16995.0a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Raveh D, Schlesinger Y, Rudensky B, Benenson S, Gottehrer N, Yinnon A. Reply. Clin Infect Dis 2002. [DOI: 10.1086/342567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Mòdol J, Tudela P, Sabrià M, Veny A. Patients with bacteremia who were discharged from the emergency department. Clin Infect Dis 2002; 35:899-900; author reply 900-1. [PMID: 12228834 DOI: 10.1086/342566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Lonks JR, Garau J, Gomez L, Xercavins M, Ochoa de Echagüen A, Gareen IF, Reiss PT, Medeiros AA. Failure of macrolide antibiotic treatment in patients with bacteremia due to erythromycin-resistant Streptococcus pneumoniae. Clin Infect Dis 2002; 35:556-64. [PMID: 12173129 DOI: 10.1086/341978] [Citation(s) in RCA: 259] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2002] [Revised: 03/29/2002] [Indexed: 11/03/2022] Open
Abstract
The rate of macrolide resistance among Streptococcus pneumoniae is increasing, but some investigators have questioned its clinical relevance. We conducted a matched case-control study of patients with bacteremic pneumococcal infection at 4 hospitals to determine whether development of breakthrough bacteremia during macrolide treatment was related to macrolide susceptibility of the pneumococcal isolate. Case patients (n=86) were patients who had pneumococcal bacteremia and an isolate that was either resistant or intermediately resistant to erythromycin. Controls (n=141) were patients matched for age, sex, location, and year that bacteremia developed who had an erythromycin-susceptible pneumococcus isolated. Excluding patients with meningitis, 18 (24%) of 76 case patients and none of 136 matched controls were taking a macrolide when blood was obtained for culture (P=.00000012). Moreover, 5 (24%) of 21 case patients with the low-level-resistant M phenotype and none of 40 controls were taking a macrolide (P=.00157). These data show that development of breakthrough bacteremia during macrolide or azalide therapy is more likely to occur among patients infected with an erythromycin-resistant pneumococcus, and they also indicate that in vitro macrolide resistance resulting from both the efflux and methylase mechanisms is clinically relevant.
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Affiliation(s)
- John R Lonks
- Miriam and Rhode Island Hospitals and Brown Medical School, Providence, RI 02906, USA.
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