Predictors of mortality in patients with bacteremia: the importance of functional status

Information Delay of Significant Bloodstream Isolates and Patient Mortality: A Retrospective Analysis of 6225 Adult Patients With Bloodstream Infections

BACKGROUND

Our aim in this study was to evaluate the clinical and prognostic impact of communicating microbiological information in real time for adult patients with bloodstream infections (BSIs).

METHODS

We retrospectively reviewed 6225 clinical episodes of bacteremia in a teaching hospital from January 2013 to December 2019. Bacteremia-associated mortality was compared when blood culture results were relayed to the infectious diseases specialist (IDS) in real time and periods when results were relayed the following morning. The impact of information availability using mortality at 30 days was used as the main outcome of the study.

RESULTS

The initial analysis (all microorganisms included) did not show an association of mortality and information delay to the IDS (odds ratio [OR], 1.18; 95% confidence interval [CI], .99-1.42). However, information delay of BSIs caused by fast-growing microorganisms such as Enterobacterales was associated with a significant increase in the odds of death at 30 days both in the univariate (OR, 1.76; 95% CI, 1.30-2.38) and multivariate analysis (OR, 2.22; 95% CI, 1.50-3.30). Similar results were found with mortality at 14 days and 7 days in the univariate (OR, 1.54; 95% CI, 1.08-2.20 and OR, 1.56; 95% CI, 1.03-2.37, respectively) and the multivariate analysis (OR, 2.05; 95% CI, 1.27-3.32 and OR, 1.92; 95% CI, 1.09-3.40, respectively).

CONCLUSIONS

Information delivered in real time has prognostic relevance and is likely to improve survival of patients with documented BSIs. Future studies should address the prognostic impact of adequate resource allocation (microbiologist/IDS with 24/7 coverage) in BSIs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Differential roles of comorbidity burden and functional status in elderly and non-elderly patients with infections in general wards

BACKGROUND

Differential roles of comorbidity burden, functional status and severity of illness in elderly and non-elderly patients admitted to general wards with infections in terms of short-term and long-term mortality remain poorly understood and worth further investigation.

METHODS

From 2011 to 2013, patients admitted to general wards with a main diagnosis of infections were included and their Barthel index, Charlson comorbidity index and Pitt bacteremia score were collected to evaluate their association with in-hospital and 1-year outcomes of the study cohort. Age stratification was applied for all outcome analysis.

RESULTS

A total of 2481 patients were identified, with main diagnoses of pneumonia (57%), urinary tract infection (28%) and intra-abdominal infection (18%). In-hospital mortality occurred in 291 (12%) of the population and was independently predicted by Barthel index ≤50 (odds ratio [OR] 5.67 and 2.73, respectively) and Charlson comorbidity index >2 (OR 1.49 and 2.87, respectively) in both elderly and non-elderly patients. Among 2190 hospital survivors, Barthel index ≤50 (hazard ratio [HR] 1.38) and Charlson comorbidity index >2 (HR 1.96) were associated with a higher hazard of 1-year mortality in elderly patients. However, only Charlson comorbidity index >2 (HR 2.87) was a significant characteristic of non-elderly patients to be correlated with higher 1-year mortality.

CONCLUSION

This study found that functional status on admission was predictive of in-hospital mortality of general patients with infections irrespective of age groups; however, it played a differential role in 1-year mortality in between elderly and non-elderly patients, emphasizing the importance of functional assessment among the elderly.

Ceftriaxone treatment of complicated urinary tract infections as a risk factor for enterococcal re-infection and prolonged hospitalization: A 6-year retrospective study

A frequent complication during hospital stay of patients with urinary tract infections (UTIs) is a re-infection of the urinary tract after the initial improvement. In this study, we investigated the impact of two empirical antibiotic therapies on the outcomes of complicated bacterial UTIs. We retrospectively evaluated 325 adult patients hospitalized during 6 years period with a diagnosis of complicated bacterial UTIs. The patients were classified into two groups according to the antibiotic therapy: ceftriaxone- and co-amoxiclav+gentamicin-treated group. Clinical data were collected from the patient records into a designed form. Output data included information on the treatment outcome, length of stay (LOS), development of complications, and cause of re-infections. The patients treated with ceftriaxone had significantly longer LOS (p = 0.012), as well as higher occurrence of complications (p = 0.023) and urinary tract re-infections (p < 0.001), compared to co-amoxiclav+gentamicin-treated group. No significant difference was observed in the treatment outcome between the two groups (p = 0.137). The most common complication in both investigated groups were re-infections of the urinary tract, and Enterococcus spp. was detected as the cause of re-infections only in patients from ceftriaxone-treated group (40/69 patients). Out of the 40 ceftriaxone-treated patients with enterococcal urinary tract re-infections, 35 patients had one or more chronic diseases and 29 patients had urinary catheter inserted. Ceftriaxone therapy should be considered carefully in patients with complicated UTIs due to the possibility of enterococcal re-infection and consequent prolonged hospital stay.

Constitutive Vagus Nerve Activation Modulates Immune Suppression in Sepsis Survivors

Patients surviving a septic episode exhibit persistent immune impairment and increased mortality due to enhanced vulnerability to infections. In the present study, using the cecal ligation and puncture (CLP) model of polymicrobial sepsis, we addressed the hypothesis that altered vagus nerve activity contributes to immune impairment in sepsis survivors. CLP-surviving mice exhibited less TNFα in serum following administration of LPS, a surrogate for an infectious challenge, than control-operated (control) mice. To evaluate the role of the vagus nerve in the diminished response to LPS, mice were subjected to bilateral subdiaphragmatic vagotomy at 2 weeks post-CLP. CLP-surviving vagotomized mice exhibited increased serum and tissue TNFα levels in response to LPS-challenge compared to CLP-surviving, non-vagotomized mice. Moreover, vagus nerve stimulation in control mice diminished the LPS-induced TNFα responses while having no effect in CLP mice, suggesting constitutive activation of vagus nerve signaling in CLP-survivors. The percentage of splenic CD4⁺ ChAT-EGFP⁺ T cells that relay vagus signals to macrophages was increased in CLP-survivors compared to control mice, and vagotomy in CLP-survivors resulted in a reduced percentage of ChAT-EGFP⁺ cells. Moreover, CD4 knockout CLP-surviving mice exhibited an enhanced LPS-induced TNFα response compared to wild-type mice, supporting a functional role for CD4⁺ ChAT⁺ T cells in mediating inhibition of LPS-induced TNFα responses in CLP-survivors. Blockade of the cholinergic anti-inflammatory pathway with methyllcaconitine, an α7 nicotinic acetylcholine receptor antagonist, restored LPS-induced TNFα responses in CLP-survivors. Our study demonstrates that the vagus nerve is constitutively active in CLP-survivors and contributes to the immune impairment.

Current etiology, clinical features and outcomes of bacteremia in older patients with solid tumors

PURPOSE

To assess the etiology, clinical features and outcomes of bacteremia in older patients with solid tumors.

METHODS

All episodes of bacteremia in hospitalized patients with solid tumors were prospectively collected. Patients aged ≥70 years were compared to patients aged <70 years. Risk factors for case-fatality rates in older patients were identified.

RESULTS

We compared 217 episodes of bacteremia involving older patients and 525 occurring in younger patients. Older patients had more frequently other comorbidities, but were less commonly neutropenic and carried less frequently central venous catheters. Bacteremia from an abdominal source was more common in patients ≥70, whereas an endogenous source and catheter-related infection were less frequently observed. Streptococcus bovis group (3.7% vs. 0.8%, p = .01) and Listeria monocytogenes (4.6% vs. 1.9%, p = .04) were more common in older patients, whereas coagulase-negative staphylococci were less frequently found (1.4% vs. 5.3% p = .01). Infection due to multi-drug resistant (MDR) strains was significantly higher in older patients (17.1% vs. 10.9%, p = .02), who in addition, presented higher overall mortality (35.4% vs 27.7%, p = .04). In older patients, lung tumor, neutropenia, and low grade fever were associated with early mortality, whereas comorbidities, corticosteroids, septic shock and inadequate empirical antibiotic therapy were associated with overall mortality.

CONCLUSIONS

We identified remarkable differences in the etiology and sources of bacteremia between older and younger cancer patients with bacteremia. Older patients had more frequent infection due to MDR organisms and presented a higher overall mortality. Corticosteroids and inadequate empirical antibiotic therapy are modifiable factors associated with mortality.

[Limitation of therapeutic effort in patients with bacteremia]

INTRODUCTION

The limitation of therapeutic effort (LTE) depends on medical, ethical and individual factors. We describe the characteristics of patients with bacteremia in which it was decided to limit the therapeutic effort.

METHOD

Prospective study of bacteremia in a community hospital in 2011. We collected information regarding patient variable (age, sex, Barthel index, comorbidities, Charlson Index and exogenous factors) as well as regarding the infectious episode (etiology, focus, place of adquisition, clinical expressivity, LTE and hospital mortality). The group in which LTE was performed was compared to the one that was not.

RESULTS

We collected 233 episodes of bacteremia in 227 patients. We performed LTE in 19 patients (8.2%). Patients with LTE were older (80.7 vs. 72.6 years, p=.014), had more comorbidity (Charlson index 4.6 vs. 2.1, p<.001 and most frequently were severe dependents (57.9% vs. 18.8%, p<.001). We found no association with sex, place of adquisition or clinical expressivity. The commonest clinical focus in patients with LTE was the urinary (42.1%) and there was a predominance of gram positive bacteria (63.2%). The empirical treatment was started early in 73.7% of cases. All patients except one died.

CONCLUSION

LTE is considered in an important number of patients with bacteremia. They usually are older, with more comorbidity and functional dependence, bad functional basal status and important comorbidity. Knowing their differential characteristics allow us to understand this decision.

Methicillin-sensitive Staphylococcus aureus bacteremia in aged patients: the importance of formal infectious specialist consultation

Background

Infectious specialist consultations (ISC) provide ever more evidence for improved outcome in Staphylococcus aureus bacteremia (SAB). Most ISC are formal (bedside). However, the impact of ISC on clinical management and prognosis lacks evaluation in aged patients with SAB.

Methods

Multicenter retrospective analysis of methicillin-sensitive (MS) SAB. Patients were stratified according to age ≥ 60 years (sub-analyses for ≥ 75 years and females) and formal (bedside) ISC given within 7 days of SAB diagnosis. The impact on management and outcome of formal ISC was explored. Statistics were performed with univariate analysis, Cox proportional hazards regression model analysis, including propensity-score adjustment, and graphic Kaplan–Meier interpretation.

Results

Altogether 617 patients were identified and 520 (84%) had formal ISC. Presence of formal ISC resulted in equivalent clinical management regardless of age over or under 60 years: localization and eradication of infection foci (80 vs. 82% and 34 vs. 36%) and use of anti-staphylococcal antibiotics (65 vs. 61%). Patients aged ≥ 60 years managed without formal ISC, compared to those with formal ISC, had less infection foci diagnosed (53 vs. 80%, p < 0.001). Lack of formal ISC in patients aged ≥ 60 years resulted in no infection eradication and absence of first-line anti-staphylococcal antibiotics. Formal ISC, compared to absence of formal ISC, lowered mortality at 90 days in patients aged ≥ 60 years (24 vs. 47%, p = 0.004). In Cox proportional regression, before and after propensity-score adjustment, formal ISC was a strong positive prognostic parameter in patients aged ≥ 60 years (HR 0.45; p = 0.004 and HR 0.44; p = 0.021), in patients aged ≥ 75 years (HR 0.18; p = 0.001 and HR 0.11; p = 0.003) and in female patients aged ≥ 75 years (HR 0.13; p = 0.005).

Conclusion

Formal ISC ensures proper active clinical management irrespective of age and improve prognosis in aged patients with MS-SAB.

Risk profile, management, and outcomes of patients with venous thromboembolism attended in Spanish Emergency Departments: The ESPHERIA registry

The objective of this study was to determine the clinical profile of and diagnostic and therapeutic approach to patients with venous thromboembolism (VTE) in Spanish Emergency Departments (EDs). Risk factors, adherence to clinical practice guidelines, and outcomes were also evaluated.Patients with VTE diagnosed in 53 Spanish EDs were prospectively and consecutively included. Demographic data, comorbidities, risk factors for VTE, index event characteristics, hemorrhagic risk, and mortality were evaluated. Adherence to clinical practice guidelines was assessed based on clinical probability scales, requests for determination of D-dimer, use of anticoagulant treatment before confirmation of diagnosis, and assessment of bleeding and prognostic risk. Recurrence, bleeding, and death during admission and at 30, 90, and 180 days after diagnosis in the EDs were recorded.From 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (incidence 1.6 diagnoses per 1000 visits). The final analysis included 801 patients, of whom 49.8% had pulmonary embolism. The most frequent risk factors for VTE were age (≥70 years), obesity, and new immobility. Clinical probability, prognosis, and bleeding risk scales were recorded in only 7.6%, 7.5%, and 1% of cases, respectively. D-dimer was determined in 87.2% of patients with a high clinical probability of VTE, and treatment was initiated before confirmation in only 35.9% of these patients. In patients with pulmonary embolism, 31.3% had a low risk of VTE. Overall, 98.7% of patients with pulmonary embolism and 50.2% of patients with deep venous thrombosis were admitted. During follow-up, total bleeding was more frequent than recurrences: the rates of any bleeding event were 4.4%, 3.9%, 5.3%, and 3.5% at admission and at 30 and 90, and 180 days, respectively; the rates of VTE recurrence were 2.3%, 1.3%, 1.7%, and 0.6%, respectively. Mortality rates were 3.4%, 3.1%, 4.1%, and 2.6% during hospitalization and at 30, 90, and 180 days, respectively.VTE had a substantial impact on Spanish EDs. The clinical presentation and risk profile for the development of VTE in patients diagnosed in the EDs was similar to that recorded in previous studies. During follow-up, bleeding (overall) was more frequent than recurrences. Adherence to clinical practice guidelines could improve significantly.

Impact of total body weight on 30-day mortality in patients with gram-negative bacteremia

BACKGROUND

The impact of total body weight (TBW) on 30-day mortality associated with gram-negative bacteremia has not been previously evaluated.

METHODS

The cohort included 323 patients >/ = 18 years old with gram-negative bacteremia (1/1/2008-8/31/2011) who received >/ = 48 hours of antibiotics. We compared 30-day mortality of TBW <70 kg vs. >/ = 70 kg with a multivariable stepwise logistic regression adjusting for age >/ = 70 years, cancer diagnosis, and Pitt bacteremia score of >/ = 4.

RESULTS

The cohort was 57% TBW >/ = 70 kg and 43% TBW <70 kg. TBW >/ = 70 kg patients had lower 30-day mortality (11.0% vs. 16.3%), which was significant in the multivariable analysis (OR 0.45, 95% CI 0.21-0.97). Cancer and Pitt bacteremia score >/ = 4 were also independently associated with 30-day mortality. TBW was no longer significant when TBW <50 kg patients were excluded.

CONCLUSION

TBW >/ = 70 kg was associated with an improved 30-day mortality; however, the high mortality rates for patients with a TBW < 50 kg is responsible for this association.

Systemic inflammatory response syndrome is more associated with bacteremia in elderly patients with suspected sepsis in emergency departments

Early diagnosis of bacteremia for patients with suspected sepsis is 1 way to improve prognosis of sepsis. Systemic inflammatory response syndrome (SIRS) has long been utilized as a screening tool to detect bacteremia by front-line healthcare providers. The value of SIRS to predict bacteremia in elderly patients (≥65 years) with suspected sepsis has not yet been examined in emergency departments (EDs).We aimed to evaluate the performance of SIRS components in predicting bacteremia among elderly patients in EDs.We retrospectively evaluated patients with suspected sepsis and 2 sets of blood culture collected within 4 hours after admitting to ED in a tertiary teaching hospital between 2010 and 2012. Patients were categorized into 3-year age groups: young (18-64 years), young-old (65-74 years), and old patients (≥75 years). Vital signs and Glasgow Coma Scale with verbal response obtained at the triage, comorbidities, sites of infection, blood cultures, and laboratory results were retrieved via the electronic medical records.A total of 20,192 patients were included in our study. Among them, 9862 (48.9%) were the elderly patients (young-old and old patients), 2656 (13.2%) developed bacteremia. Among patients with bacteremia, we found the elderly patients had higher SIRS performance (adjusted odds ratio [aOR]: 2.40, 95% confidence interval [CI]: 1.90-3.03 in the young-old and aOR: 2.66, 95% CI: 2.19-3.23 in the old). Fever at the triage was most predictive of bacteremia, especially in the elderly patients (aOR: 2.19, 95% CI: 1.81-2.65 in the young-old and aOR: 2.27, 95% CI: 1.95-2.63 in the old), and tachypnea was not predictive of bacteremia among the elderly patients (all P > 0.2).The performance of SIRS to predict bacteremia was more suitable for elderly patients in EDs observed in this study. The elderly patients presented with more fever and less tachypnea when they had bacteremia.

Differential characteristics of bacteraemias according to age in a community hospital

OBJECTIVE

To describe the characteristics of bacteraemias, according to age, in a community hospital.

MATERIAL AND METHOD

A prospective study of bacteraemias was conducted in 2011. The patients were classified into 3 age groups: younger than 65 years, 65 to 79, and 80 or older. The study collected variables on the patients and episodes.

RESULTS

The study analysed 233 bacteraemias in 227 patients (23.8% in those younger than 65 years; 38.3% in the 65 to 79 age group; and 37.9% in the 80 years or older group). The most common underlying disease in all the groups was diabetes mellitus. In the most elderly patients, the Charlson index was highest, there was a lower proportion of exogenous factors, and almost 25% were severely dependent (Barthel index<20). Escherichia coli was the most common germ, and the main focus was urological. The patients aged 80 years or older had predominantly healthcare-associated infections, less severe symptoms (sepsis) (66.3%) and higher mortality (29.1%) compared with the younger patients.

CONCLUSIONS

The very elderly patients with bacteraemia presented fewer exogenous factors, greater comorbidity and a poorer functional situation. The most common focus was urological and the origin was healthcare related. Despite their less severe clinical presentation, these patients' mortality was greater, and their degree of dependence was a highly relevant independent risk factor.

Bloodstream infections in older patients

Bloodstream infections (BSIs) are both common and fatal in older patients. We describe data from studies evaluating older patients hospitalized with BSIs. Most older patients with BSIs present "typically" with either fever or leukocytosis. The most common source of BSI in older patients is the urinary tract, and accordingly, Gram-negative organisms predominate. A significant part of these BSIs may thus be preventable by removal of unnecessary urinary catheters. Increased long term mortality is reported following BSIs in older patients, however, data on other long-term outcomes, including functional capacity, cognitive decline and others are lacking. Management of BSIs may include less invasive procedures due to the fragility of older patients. This approach may delay the diagnosis and treatment in some cases. Older patients are probably under-represented in clinical trials assessing treatment of bacteremia. Physicians treating older patients should consider the relevance of these studies' outcomes.

Clinical conundrums in management of sepsis in the elderly

In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.

Fever presentation and associated factors in patients with healthcare-associated bacteraemia

Bacteraemia is a systemic infection associated with strong febrile immune reactions. Fever definitions, fever intensity and other factors might affect the recognition, management and prognosis of patients with bacteraemia. A prospective observational design was used to study 412 consecutive Taiwanese patients with healthcare-associated bacteraemia. The study variables were fever intensity, factors related to fever intensity, the association of physical function to thermogenic capacity and the sensitivity of three definitions of fever for identifying patients with bacteraemia. Age, Charlson comorbidity index (CCI) score, chills and pathogen types were predictors of fever intensity. Barthel index score, CCI score and pathogen types were predictors of chills, an indicator of thermogenic capacity. The sensitivity of three fever definitions (basal body temperature plus 1°C, ≥ 38°C and ≥ 38.3°C) to identify patients with bacteraemia was 93.3%, 83.5% and 71.4%, respectively. Clinicians can target patients with factors associated with blunted febrile response to bacteraemia for closer monitoring.

Evaluation of humoral immune response to nosocomial pathogen and functional status in elderly patients with sepsis

The clinical significance of humoral immune response to nosocomial pathogens and functional status in elderly patients with sepsis is not clear. We evaluated the humoral immune to nosocomial pathogens and the effect of functional dependencies on clinical outcomes among elderly patients with sepsis. This study prospectively enrolled patients aged ≥65 years with sepsis from September 2011 to May 2012 at a 2000-bed university hospital. The data including CD4 and CD8 T-cell count, functional status by measuring basic activities of daily living (ADL) and instrumental activities of daily living (IADL) were collected for all patients. In addition, the collected blood samples were analyzed for serum antibody levels against nosocomial pathogens using an ELISA. During the study period, 72 patients (38 males) treated with sepsis were enrolled. The all-cause in-hospital mortality rate was 16.7% (12/72). The mean CD4/CD8 T-cell ratio was significantly lower in nonsurvivors than in survivors (1.08 ± 0.72 vs. 1.93 ± 1.42, P=0.003). Serum antibody titers to Acinetobacter baumannii, Klebsiella pneumonia, Stenotrophomonas maltophilia, and Enterococcus faecalis were statistically higher in nonsurvivors than in survivors. On multivariate analysis, the IADL score was independently predictive of mortality in elderly patients with sepsis (odds ratio 1.410, 95% confidence interval 1.007-1.975, P=0.046). These results suggest that IADL scores could be used as predictors to identify elderly patients with a poor prognosis of nosocomial infections.

Functional status does not predict complicated clinical course in older adults in the emergency department with infection

OBJECTIVES

To identify the relationship between functional status and complicated clinical course in older adults in the emergency department (ED) with suspected infection and to identify other independent predictors of complicated clinical course.

DESIGN

A prospective observational cohort study.

SETTING

An academic, tertiary care ED with 70,000 visits per year.

PARTICIPANTS

Aged 65 and older, blood cultures obtained in the ED, and final ED physician diagnosis of acute infection.

MEASUREMENTS

Functional status was obtained using the Older Americans Resources Scale (OARS). Complicated clinical course was defined as in-hospital mortality, need for intensive care unit (ICU)-level care, or worsening in sepsis criteria within 48 hours. Analysis was performed using multivariable logistic regression.

RESULTS

One hundred five participants were enrolled, 34 with the primary outcome. OARS was not predictive of complicated clinical course in univariate (P = .13) or multivariable (P = .90) models. An OARS score of 25 or less was also not significant (P = .22). Independent predictors were immunosuppression (odds ratio (OR) = 3.45, 95% confidence interval (CI) = 1.06-11.20), systolic blood pressure (OR = 0.98, 95% CI = 0.96-1.00), pulse (OR = 1.03, 95% CI = 1.00-1.06), metabolic acidosis (OR = 3.46, 95% CI = 1.08-11.09), severe sepsis or septic shock (OR = 10.24, 95% CI = 1.44-72.79), and suspected bloodstream infection (OR = 3.56, 95% CI = 1.13-11.16).

CONCLUSION

For older adults admitted to the ED with infection, functional status did not predict complicated clinical course, but several other variables were predictive, including immunosuppression, several variables associated with hypoperfusion, and suspected bloodstream infection. Emergency physicians could consider these variables as potential indicators of complicated clinical course when making disposition decisions for this population.

Predictors of in-hospital mortality in elderly patients with bacteraemia admitted to an Internal Medicine ward

BACKGROUND

Infectious diseases are a common cause of increased morbidity and mortality in elderly patients. Bacteraemia in the elderly is a difficult diagnosis and a therapeutic challenge due to age-related vicissitudes and to their comorbidities. The main purpose of the study was to assess independent risk factors for in-hospital mortality among the elderly with bacteraemia admitted to an Internal Medicine Ward.

METHODS

Overall, a cohort of 135 patients, 65 years of age and older, with bacteraemia were retrospectively studied. Data related to demographic information, comorbidities, clinical parameters on admission, source and type of infection, microorganism isolated in the blood culture, laboratory data and empirical antibiotic treatment was recorded from each patient. Multivariate logistic regression was performed to identify independent predictors of all-cause in-hospital mortality.

RESULTS

Of these 135 patients, 45.9% were women. The most common infections in this group of patients were urinary tract infections (46.7%). The main microorganisms isolated in the blood cultures were Escherichia coli (14.9%), Methicillin-resistant Staphylococcus aureus (MRSA) (12.0%), non-MRSA (11.4%), Klebsiella pneumoniae (9.1%) and Enterococcus faecalis (8.0%). The in-hospital mortality was 22.2%. Independent prognostic factors associated with in-hospital mortality were age ≥ 85 years, chronic renal disease, bacteraemia of unknown focus and cognitive impairment at admission (OR, 2.812 [95% CI, 1.039-7.611; p = 0.042]; OR, 6.179 [95% CI, 1.840-20.748; p = 0.003]; OR, 8.673 [95% CI, 1.557-48.311; p = 0.014] and OR, 3.621 [95% CI, 1.226-10.695; p = 0.020], respectively). By multivariate analysis appropriate antibiotic therapy was not associated with lower odds of mortality.

CONCLUSION

Bacteraemia in the elderly has a high mortality rate. There are no set of signs or clinical features that can predict bacteraemia in the elderly. However, older age (≥ 85 years), chronic renal disease, bacteraemia of unknown focus and severe cognitive impairment adversely affects the outcome of elderly patients with bacteraemia admitted to an Internal Medicine ward.

Bacteremia in the elderly

Bacteremia is an increasingly significant health problem among the elderly. Older adults may present with atypical manifestations of bacteremia. In addition, there are age-related differences in etiologic agents and corresponding resistance patterns. Important factors to consider when prescribing antibiotics for older adults with bacteremia include the severity and source of infection, antimicrobial susceptibility of the organism and renal function. The association between increasing age and poor outcomes in patients with bacteremia is well established. Despite the current paucity of data, the understanding of the natural history of bacteremia in the elderly should not be limited to mortality but should also focus on functional status, cognitive function and the eventual need for long-term care. Appropriate management of bacteremia in the elderly requires timely administration of broad-spectrum antibiotics in addition to managing key geriatric issues. Further studies are required to assess the impact of using broader outcomes other than mortality when addressing bacteremia in the elderly.

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients

BACKGROUND

We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients.

METHODS

In a single-center, historical cohort study (1992-2006), we compared middle-aged (45-64 years; n = 524), old(65-74 years; n = 326), and very old ICU patients (> 75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay.

RESULTS

Although the total number of ICU admissions (patients aged > or = 45 years) decreased by approximately 10%, the number of very old patients increased by 33% between the periods 1992-1996 and 2002-2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992-1996) to 13.5% (1997-2001) and 17.4% (2002-2006) (p <0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4 per thousand in middle-aged, 5.5 per thousand in old, and 4.6 per thousand in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0 -1.5) and significant for very old age (hazard ratio,1.8; 95% confidence interval, 1.4 -2.4).

CONCLUSION

Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

[Bacteremia in very elderly patients: risk factors, clinical characteristics and mortality]

INTRODUCTION

There is little information on bacteremia in very elderly patients. This study describes the characteristics of bacteremia in this population.

METHODS

This is a prospective study investigating bacteremia episodes in patients over 80 years old in comparison with episodes in patients aged 18-64 and 65-79 years.

RESULTS

A total of 146 bacteremia episodes were analyzed in patients over 80 years old. Comorbidity was documented in 66.4% and immunodeficiency in 6.8% of patients. Among the total, 82.2% had no underlying disease or a disease considered non-fatal. Eighty episodes were community-acquired. The main infectious foci included primary (25.3%) and urinary tract (20.5%) infection, and the most frequent isolates were Escherichia coli (28.2%), coagulase-negative Staphylococcus (14.7%) and S. aureus (13.6%). Sepsis or septic shock occurred in 55.5% of the cases, and 31 patients died due to a bacteremia-related cause. Immunodeficiency was less frequent in patients over 80 years old, but they had a higher proportion of community-acquired infections and gram-negative infections. Bacteremia-related mortality was highest in the oldest group of patients and was associated with a fatal or ultimately fatal underlying disease, S. aureus infection, and inappropriate empirical antibiotic treatment. A lower Pitt severity score was related to lower mortality risk.

CONCLUSIONS

Very elderly bacteremic patients showed a lower frequency of immunodeficiency, a higher percentage of community-acquired and gram-negative infections. Bacteremia-related mortality was greater in the most elderly group and was associated with fatal or ultimately fatal underlying disease, S. aureus infection and initiation of inappropriate empirical antibiotic treatment.

Frequency of Permanent Pacemaker or Implantable Cardioverter-Defibrillator Infection in Patients with Gram-Negative Bacteremia

BACKGROUND

Despite the frequent occurrence of bacteremia due to gram-negative organisms in patients with underlying permanent pacemakers (PPMs) or implantable cardioverter defibrillators (ICDs), the outcome and treatment of these patients has received scant attention. In patients with PPMs or ICDs who have Staphylococcus aureus bacteremia, 45% have PPM/ICD infection.

METHODS

We conducted a retrospective cohort study over a 7-year period to assess the clinical features and frequency of PPM/ICD infection in patients with gram-negative bacteremia, as well as the incidence of relapse in patients for whom the device was not removed.

RESULTS

Forty-nine patients were included in the study; 3 (6%) had either definite (2 patients) or possible (1 patient) PPM/ICD infection. Both patients with definite PPM/ICD infection had clear infection of the generator pocket. None of the other patients with alternate sources of bacteremia developed PPM/ICD infection. Thirty-four patients with retained PPM/ICD were observed for >12 weeks (median time, 759 days), and 2 (6%) developed relapsing bacteremia, although they each had alternative sources of relapse.

CONCLUSIONS

In sharp contrast to S. aureus infection, PPM/ICD infection in patients with gram-negative bacteremia was rare, and no patients appeared to have secondary PPM/ICD infection due to hematogenous seeding of the system. Despite infrequent system removal in these patients, relapsing bacteremia among patients who survived initial bacteremia was rarely seen. If secondary PPM/ICD infection occurs in patients with gram-negative bacteremia, it is either uncommon or it is cured with antimicrobial therapy despite device retention.

Prognostic indexes of septic syndrome in the emergency department

OBJECTIVE

Sepsis is a frequent and often lethal condition. Rapid identification and aggressive therapy in the emergency department (ED) are essential for outcome. Several indexes were found to be significantly related to short-term clinical outcome, but only bedside, rapidly available tests are thought to be useful in the ED. To define the prevalence and mortality of patients with severe sepsis presenting to the ED of a tertiary care hospital in Italy, we furthermore investigated the ability of bedside, non-invasive prognostic indexes to identify patients with adverse short-term clinical outcome.

METHODS

All patients admitted to the ED with a diagnosis of severe sepsis or septic shock were included. Retrospective data were collected by a dedicated software program using predefined searching criteria including clinical data, vital sign parameters, sepsis-related organ failure assessment (SOFA) score, and blood tests. The relationship between prognostic indexes and 24-h or 28-day mortality was evaluated by multivariate logistic regression analysis.

RESULTS

Ninety patients were enrolled from June 2004 to June 2005 (0.2% of all incoming patients to ED and 0.7% of all critical patients). Mean age was 77 +/- 15 years, 54.4% were women. During follow-up (28 days) 46 patients died (51.1%), 21 patients (23.3%) within 24 h. At multivariate analyses, age >80 (odds ratio [OR] 4.10; 95% confidence intervals [CI] 1.39-11.90, p = 0.01), serum lactate >5 mmol/l (OR 3.40; 95% CI 1.21-9.60, p = 0.02) and acute renal failure (OR 18.90; 95% CI 1.80-200, p = 0.02) were independent predictors of 28-day mortality.

CONCLUSIONS

Among critical patients admitted to an Italian ED, those with severe sepsis/septic shock represent about 1%, with a very high mortality rate. Bedside non-invasive prognostic indexes are able to identify with high accuracy patients with adverse short-term clinical outcome.

Nosocomial bacteremia in very old patients: predictors of mortality

BACKGROUND AND AIMS

Nosocomial Bacteremia (NB) is associated with high mortality in elderly patients. To determine specific prognostic factors for 7- and 30-day mortality in elderly patients with NB, we analysed the characteristics of 62 NB patients, retrospectively.

METHODS

This retrospective study concerns 62 cases of NB diagnosed within a 3-year period in a geriatric department. Bacteremia is described according to CDC definitions. Epidemiological characteristics, co-morbidities, clinical (activities of daily living (ADL) before NB) and biological findings (neutrophil count, lymphocyte count, albuminemia before NB) were collected for each patient. A systemic clinical reaction was defined by the presence of one of the following parameters: chills, hypothermia <36 degrees C or hyperthermia >38.5 degrees C, or shock. Types of micro-organism and source of NB were also collected. All variables were analysed for mortality at day 7 (7-day mortality) and at day 30 (30-day mortality).

RESULTS

The 7-day mortality rate was 21% and the 30-day rate was 45%. In multivariate analysis, 7-day mortality was only associated with the absence of systemic clinical reaction [OR 9.7 (3.7-25.7)]. Again, in multivariate analysis, 30-day mortality was associated with an ADL score <2 [OR 8.3 (4.3-16.4)] and cocci gram positive NB [OR= 3.6 (1.9-6.9)].

CONCLUSIONS

The absence of any systemic clinical reaction as a single independent predictor for 7-day mortality suggests either a poorer immune response to nosocomial bacteremia or a delay in diagnosis. Functional status was the strongest predictor for 30-day mortality. In this population, further prospective studies need to include these factors to evaluate predictors of mortality for serious infectious diseases.

Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection

OBJECTIVE

To describe the profile of elderly patients with bacteremic urinary tract infections (UTI) and correlate clinical and laboratory findings with the outcome in order to identify independent predictors of mortality.

METHODS

This retrospective study took place in a large community-based, geriatric hospital and included 191 patients aged 75-105 years with urine and blood cultures simultaneously positive for bacterial organisms. Records were analysed for demographic information, clinical and laboratory data over a 29 month period. Mortality was assessed and was correlated with these findings.

RESULTS

Most of the patients (80.1%) had community-acquired infection. Gram-negative organisms accounted for 87.6% of bacterial isolates, with Escherichia coli accounting for 46.1% of cases. Non-Escherichia coli Gram-negative organisms were highly resistant to two common urinary tract antibiotics (gentamicin and ceftriaxone). Patients with chronic urinary catheter had Gram-negative bacteria significantly less sensitive to ciprofloxacin, gentamycin, ampicillin and ceftriaxon than patients without catheter (p<0.05). In-hospital mortality was 33%. Multiple logistic regression analysis revealed that mortality was significantly related to the number of underlying diagnoses (p<0.0203), cognitive status (p<0.0003), length of hospitalization (p<0.0397), low level of serum albumin (p<0.0021), high neutrophil count (p<0.0001) and high level of lactate dehydrogenase (p<0.0351). Fatality was not associated with advanced age in the very old.

CONCLUSION

Bacteremic UTI in the elderly has a high mortality rate. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteremic UTI and prompt, appropriate treatment are critical in reducing the mortality.

Risk factors for mortality resulting from bloodstream infections in a pediatric intensive care unit

BACKGROUND

Bloodstream infections (BSIs) are prevalent in the critical care setting and have high attributable morbidity and mortality. The purpose of this study was to identify factors that significantly contribute to immediate as well as eventual mortality in patients with bloodstream infections at a pediatric intensive care unit (PICU).

METHODS

Retrospective review of 2097 clinical records from admissions to our PICU in a 2-year period. Two separate case-control models were used. In the first model, eventual mortality (EM CASES) reflected those patients with eventual mortality, and EM CONTROLS were those who survived. In the second, infection-related mortality (IRM) cases were those with infection-related mortality, defined as death within 7 days of BSI, and IRM CONTROLS were survivors past 7 days. Logistic regression was used to adjust for differences for 3 categories: patient characteristics, microbiology and treatment variables.

RESULTS

We identified 74 separate episodes of bacteremia. Having an underlying malignancy or immunodeficiency was the only independently significant predictor of eventual mortality for BSI isolated within the PICU. Patients with infection-related mortality more likely had Gram-negative bacteremia and/or fungemia, were older and had inadequate initial empiric antibiotic treatment at the time BSI was diagnosed.

CONCLUSIONS

Targeted and aggressive early interventions should guide the empiric treatment of BSIs, whereas prolonged broad spectrum treatment should be minimized to avoid the emergence of resistant pathogen organisms.

A New Paradigm for Clinical Investigation of Infectious Syndromes in Older Adults: Assessment of Functional Status as a Risk Factor and Outcome Measure

Adults aged >or=65 years comprise the fastest-growing segment of the United States population, and older adults experience greater morbidity and mortality due to infection than do young adults. Although age is well established as a risk factor for infection, most clinical investigations of infectious diseases in older adults focus on microbiology and on crude end points of clinical success, such as cure rates or death; however, they often fail to assess functional status, which is a critical variable in geriatric care. Functional status can be evaluated either as a risk factor for infectious disease or as an outcome of interest after specific interventions using well-validated instruments. This article outlines the currently available data that suggest an association between infection, immunity, and impaired functional status in elderly individuals, summarizes the instruments commonly used to determine specific aspects of functional status, and provides recommendations for a new paradigm in which clinical trials that involve older adults include assessment of functional status.

Étude descriptive des bactériémies dans un hôpital gériatrique universitaire

OBJECTIVES

To describe clinical features, microbiologic characteristics and outcome of bacteremia in the elderly patients hospitalized in a geriatric hospital.

PATIENTS AND METHODS

All episodes of bacteremia diagnosed from January 1(st) to December 31(st) 1998 were analysed, excluding false-positive cases due to skin contamination. The hospital comprises 1084 geriatric beds distributed as 111 in acute care (ACF), 333 in rehabilitation and intermediate-care (RICF), and 516 in long-term-care facilities (LTCF).

RESULTS

Sixty-six episodes of bacteremia were observed in 65 patients. Among them 59 (89%) were nosocomial bacteremia distributed as 20 in ACF, 29 in RICF and 10 in LTCF (rates of 0.6, 0.35, and 0.05 episodes per 1000 patient-days, respectively.). Escherichia coli and Staphylococcus aureus were the main bacterial species involved in 31% and 28% of the cases, respectively. E. coli strains were 50% resistant to amoxicillin and 41% resistant to co-amoxiclav, and 68% of S. aureus strains were resistant to methicillin. Portals of entry were urinary tract (44%), respiratory tract (14%), digestive tract (11%), and soft tissue (8%). The same bacterial strain as in bacteremia was isolated from a peripheric site in 30 cases (47%), most of them being urines. For 15% cases, portal of entry cannot be determined. Mortality associated to nosocomial bacteremia was 25%, and death was significantly associated to MRSA, urinary or intravascular devices, chronic wounds and inappropriate antibiotic prescription.

CONCLUSION

In geriatric hospitals, bacteremia are mainly nosocomial cases. Prevention should focus on indwelling devices and antibiotic resistance.

Acceptability of Severe Pain Among Hospitalized Adults

BACKGROUND

It is unclear why some hospitalized adults experiencing severe pain report that this degree of pain is acceptable to them.

METHODS

A 25% random sample of cognitively intact patients admitted to nine medical/surgical units in a New York City hospital were enrolled. Patients were interviewed daily, Monday to Friday from April 1, 2001 through February 14, 2003, to collect information on the presence of pain, pain intensity, analgesic use, and acceptance of pain. Patients were asked to rate their current level of pain using a four-point scale.

RESULTS

Three hundred ninety-two of 1254 patients ( 31%) experiencing severe pain reported that their pain was acceptable to them. Variables significantly associated with an episode of acceptable severe pain in multivariate analyses included resolution of the painful episode (odds ratio = 4.7; 95% confidence interval [CI], 3.54-6.17), recent surgery (odds ratio = 1.5; 95% CI, 1.11-1.99), African American compared to white (odds ratio = 0.7; 95% CI, 0.48-0.955), age (odds ratio = 0.985; 95% CI, 0.977-0.993), and patients taking analgesics (odds ratio = 0.7; 95% CI, 0.46-0.964 for nonsteroidal anti-inflammatory drugs [NSAIDs]/acetaminophen and odds ratio = 0.6; 95% CI, 0.46-0.85 for opioids). Overall, 86 of 252 (34%) reported the pain was acceptable because it had resolved, 47 (19%) believed the pain would eventually go away, and 47 (19%) reported they were able to tolerate the pain.

CONCLUSIONS

A substantial percentage of patients reporting severe pain report this experience as acceptable. Given recent research linking high intensity pain to adverse outcomes, future studies directed at improving the management of pain need to target both pain intensity and patients' beliefs about the acceptability of severe pain.

White cell count and intensive care unit outcome

A high white cell count on admission to the intensive care unit (ICU) is generally perceived to be associated with severe illness and poor outcome, but the implications of a low white cell count are less well recognised. We retrospectively analysed data on 4,165 patients. The white cell count on admission was split into four categories, leucopenic (< 4.0 x 10(9).l(-1)), normal (4.001-10.0 x 10(9).l(-1)), leucemoid (10.001-25.0 x 10(9).l(-1)) and an exaggerated leucemoid response (> 25.001 x 10(9).l(-1)). The mortality of patients with leucopenia on admission to the intensive care unit was higher than those with normal or moderately raised white cell count (37.5% vs. 18.9% and 23.9%, respectively). A leucopenic response, as well as an exaggerated leucemoid response, is associated with an increased mortality.

Ageing and infection

Average life expectancy throughout developed countries has rapidly increased during the latter half of the 20th century and geriatric infectious diseases have become an increasingly important issue. Infections in the elderly are not only more frequent and more severe, but they also have distinct features with respect to clinical presentation, laboratory results, microbial epidemiology, treatment, and infection control. Reasons for increased susceptibility include epidemiological elements, immunosenescence, and malnutrition, as well as a large number of age-associated physiological and anatomical alterations. Moreover, ageing may be the cause of infection but infection can also be the cause of ageing. Mechanisms may include enhanced inflammation, pathogen-dependent tissue destruction, or accelerated cellular ageing through increased turnover. In most instances, treatment of infection leads to a satisfactory outcome in the elderly. However, in palliative care situations and in patients with terminal dementia, the decision whether or not to treat an infectious disease is becoming a difficult ethical issue.

Bloodstream infection: differences between young-old, old, and old-old patients

OBJECTIVES

To compare the epidemiological and microbiological characteristics of bloodstream infection (BSI) between the young old (65-75), old (76-85), and old old (>85).

DESIGN

Retrospective study.

SETTING

Forty-six hospitals in southeast France.

PARTICIPANTS

One thousand seven hundred forty patients aged 65 and older with BSI, seen between January 1 and December 31, 1998.

MEASUREMENTS

Epidemiological and microbiological data and outcome.

RESULTS

Community-acquired BSIs (CABSIs) were significantly more frequent in the old old, but microbiological data were similar to those in the young-old group. Conversely, microbiological data were significantly different for nosocomial BSIs (NSBIs). Escherichia coli was the main pathogen in the old old and Staphylococcus aureus in the young old. Mortality was independently associated with the presence of methicillin-resistant S. aureus in NSBI and CABSI.

CONCLUSIONS

The differences in NBSI are important in serious infectious diseases and often require empirical antibiotic therapy. Age is also a risk factor but only for CABSI and suggests that the old-old patients represent a frail population in the community. Further prospective studies are needed to confirm these findings and analyze predisposing factors.

A predictive model for mortality of bloodstream infections. Bedside analysis with the Weibull function

This paper describes the construction and validation of a prognostic model for predicting post-bloodstream infection survival up to Day 21. A Weibull multiple regression model was adopted in a prospective cohort study of all patients diagnosed with true bacteremia or fungemia in a teaching hospital between 1991 and 1994 (training set, 1,577 patients). The final model included six variables easily detected in any institution: source of infection, underlying neoplasm, septic shock, community-acquired, age over 65, and polymicrobial bacteremia. Using this model, it is possible to obtain a graphic representation of survival probability for any combination of these risk factors. The model was tested on a second set of patients diagnosed in the same hospital between 1996 and 1997 (validation set, 952 patients), confirming its reliability in predicting survival. In conclusion, the Weibull function, together with variables easily identified at bedside, enables a precise prediction of the short-term, post-bloodstream infection mortality of a given patient.

[Analysis of prognostic factors for mortality in bacteremia and fungemia at a university hospital. Experience of 10 years]

OBJECTIVE

The objective of this study was to determine the prognostic factors in relationship to evolution to death of bacteremia-fungemia (BF) episodes occurred in 1986 and to compare them with the results obtained ten years later in 1996.

PATIENTS AND METHODS

Prospective study of all BF episodes observed at Hospital Universitario La Princesa, Madrid, during the 1985-1986 and 1996-1997 periods. The same definitions were used for the two study periods. The univariate analysis of results was performed with the chi square test and variables with statistical significance with p < 0.10 in the multivariate analysis with the logistic regression model.

RESULTS

A total of 984 episodes were analyzed. There was an increased incidence per 1,000 admissions from 23.58 to 28.44. A change in the relationship of nosocomial acquisition (55.5%-42.6%) to community-acquired episodes (44.1%-57.4%) and an increase in gram-positive organisms (39%-48.6%) compared with gram-negative organisms (53.4%-41.8%) was observed. The organisms recovered most frequently in both periods were Escherichia coli and coagulase-negative Staphylococcus. An overall decrease of mortality rate from 26.2% down to 15.9% (OR: 4.52) was noted. Independent factors with poor prognosis in the first period included age over 60 years (OR: 4.52), underlying disease (OR: 2.79; more than one OR: 6.53), respiratory source (OR: 3.86), DIC (OR: 4.79), hypotension (OR: 3.19); as for the second period, the corresponding independent factors included age > 60 years (OR: 6.48), nosocomial acquisition (OR: 2.62), DIC (OR: 18.7), hypotension (OR: 3.07), and inadequate surgical treatment (OR: 7.61).

CONCLUSIONS

In the last ten years the incidence of BF episodes has increased. In contrast, mortality rate has decreased. Factors with poor prognosis, including age > 60, DIC, and hypotension, still persist.

Extremes of White Blood Cell Count do not Independently Predict Outcome among Surgical Patients with Infection

Historically patients with severely depressed or elevated white blood cell (WBC) counts during infection were felt to have worse outcomes. To test this assumption we prospectively analyzed all infections on the surgical services at the University of Virginia hospital between December 1, 1996 and April 1, 1999. Among 1737 infectious episodes 59 presented with leukopenia (WBC count ≤ 3,000 cells/μL) whereas 66 presented with leukemoid responses (WBC count ≥ 30,000 cells/μL). Compared with other infected patients leukopenic patients had higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (18 ± 0.9 vs 12 ± 0.2, P < 0.0001) and mortality (23.7% vs 11.4%, P = 0.004). Patients with leukemoid responses also had higher APACHE II scores (21 ± 1.0 vs 12 ± 0.2, P < 0.0001) and mortality (30.3% vs 11.4%, P < 0.0001). Compared with a control group randomly matched (2:1) by age and APACHE II score, however, there was no significant difference in mortality associated with leukopenia or a leukemoid response. Furthermore logistic regression did not reveal leukopenia or leukemoid responses to be independent predictors of mortality (odds ratio for death with leukopenia = 1.57, 95% confidence interval = 0.63–3.91, P = 0.33; odds ratio for death with leukemoid response = 1.19, 95% confidence interval = 0.70–2.02, P = 0.53). Although very low or very high WBC counts may represent markers of severe illness in infected surgical patients they do not appear to be significant contributors to a worsened outcome.

The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting

STUDY OBJECTIVE

To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission.

DESIGN

Prospective cohort study.

SETTING

A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital.

PATIENTS

Between July 1997 and July 1999, 492 patients were prospectively evaluated.

INTERVENTION

Prospective patient surveillance and data collection.

RESULTS

One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2. 18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment.

CONCLUSIONS

The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.

Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial

BACKGROUND

Vaccination of health-care workers has been claimed to prevent nosocomial influenza infection of elderly patients in long-term care. Data are, however, limited on this strategy. We aimed to find out whether vaccination of health-care workers lowers mortality and the frequency of virologically proven influenza in such patients.

METHODS

In a parallel-group study, health-care workers in 20 long-term elderly-care hospitals (range 44-105 patients) were randomly offered or not offered influenza vaccine (cluster randomisation, stratified for policy for vaccination of patients and hospital size). All deaths among patients were recorded over 6 months in the winter of 1996-97. We selected a random sample of 50% of patients for virological surveillance for influenza, with combined nasal and throat swabs taken every 2 weeks during the epidemic period. Swabs were tested by tissue culture and PCR for influenza viruses A and B.

FINDINGS

Influenza vaccine uptake in health-care workers was 50.9% in hospitals in which they were routinely offered vaccine, compared with 4.9% in those in which they were not. The uncorrected rate of mortality in patients was 102 (13.6%) of 749 in vaccine hospitals compared with 154 (22.4%) of 688 in no-vaccine hospitals (odds ratio 0.58 [95% CI 0.40-0.84], p=0.014). The two groups did not differ for proportions of patients positive for influenza infection (5.4% and 6.7%, respectively); at necropsy, PCR was positive in none of 17 patients from vaccine hospitals and six (20%) of 30 from no-vaccine hospitals (p=0.055).

INTERPRETATION

Vaccination of health-care workers was associated with a substantial decrease in mortality among patients. However, virological surveillance showed no associated decrease in non-fatal influenza infection in patients.

Assessment of the aging man

Knowledge of the aging process and the care of older patients has been increasing at a rapid pace. It is important to recognize and separate disease from the physiologic aging process. It is important to do appropriate comprehensive assessments in aging men, so that problems may be identified early and interventions instituted at the right time to delay physical decline, maintain independent living, and ultimately improve the quality of life of this part of the population.