Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults

A multisite validation of a two hours antibiotic susceptibility flow cytometry assay directly from positive blood cultures

BACKGROUND

Rapid antimicrobial susceptibility testing (AST) is urgently needed to provide safer treatment to counteract antimicrobial resistance. This is critical in septic patients, because resistance increases empiric therapy uncertainty and the risk of a poor outcome. We validate a novel 2h flow cytometry AST assay directly from positive blood cultures (PBC) by using a room temperature stable FASTgramneg and FASTgrampos kits (FASTinov® Porto, Portugal) in three sites: FASTinov (site-1), Hospital Ramon y Cajal, Madrid, Spain (site-2) and Centro Hospitalar S. João, Porto, Portugal (site-3). A total of 670 PBC were included: 333 spiked (site-1) and 337 clinical PBC (151 site-2 and 186 site-3): 367 gram-negative and 303 gram-positive. Manufacturer instructions were followed for sample preparation, panel inoculation, incubation (1h/37ºC) and flow cytometry analysis using CytoFlex (Site-1 and -2) or DxFlex (site-3) both instruments from Beckman-Coulter, USA.

RESULTS

A proprietary software (bioFAST) was used to immediately generate a susceptibility report in less than 2 h. In parallel, samples were processed according to reference AST methods (disk diffusion and/or microdilution) and interpreted with EUCAST and CLSI criteria. Additionally, ten samples were spiked in all sites for inter-laboratory reproducibility. Sensitivity and specificity were >95% for all antimicrobials. Reproducibility was 96.8%/95.0% for FASTgramneg and 95.1%/95.1% for FASTgrampos regarding EUCAST/CLSI criteria, respectively.

CONCLUSION

FASTinov® kits consistently provide ultra-rapid AST in 2h with high accuracy and reproducibility on both Gram-negative and Gram-positive bacteria. This technology creates a new paradigm in bacterial infection management and holds the potential to significantly impact septic patient outcomes and antimicrobial stewardship.

Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient

There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.

Sustainability in Internal Medicine: A Year-Long Ward-Wide Observational Study

Population aging and multimorbidity challenge health system sustainability, but the role of assistance-related variables rather than individual pathophysiological factors in determining patient outcomes is unclear. To identify assistance-related determinants of sustainable hospital healthcare, all patients hospitalised in an Internal Medicine Unit (n = 1073) were enrolled in a prospective year-long observational study and split 2:1 into a training (n = 726) and a validation subset (n = 347). Demographics, comorbidities, provenance setting, estimates of complexity (cumulative illness rating scale, CIRS: total, comorbidity, CIRS-CI, and severity, CIRS-SI subscores) and intensity of care (nine equivalents of manpower score, NEMS) were analysed at individual and Unit levels along with variations in healthcare personnel as determinants of in-hospital mortality, length of stay and nosocomial infections. Advanced age, higher CIRS-SI, end-stage cancer, and the absence of immune-mediated diseases were correlated with higher mortality. Admission from nursing homes or intensive care units, dependency on activity of daily living, community- or hospital-acquired infections, oxygen support and the number of exits from the Unit along with patient/physician ratios were associated with prolonged hospitalisations. Upper gastrointestinal tract disorders, advanced age and higher CIRS-SI were associated with nosocomial infections. In addition to demographic variables and multimorbidity, physician number and assistance context affect hospitalisation outcomes and healthcare sustainability.

Blood-Stream Infections: Causative Agents, Antibiotic Resistance and Associated Factors in Older Patients

Background

The rate of multi-drug antibiotic resistance in nosocomial bloodstream infections in elderly patients is increasing. This study examined the data for bloodstream infections to gain a better understanding of bacterial antibiotic resistance.

Methods

This was a retrospective study of 817 patients with the first positive blood culture between January 1, 2016 and December 31, 2019.

Results

Moyen's age was 77.4 ± 9.8 years, male (52.4%) and SOFA 5.0 ± 4. ESBL(+) rate was 78/817 (9.5%). ESBL(+) rate for Escherichia coli and Klebsiella pneumoniae was 69/141 (48.9%) and 9/52 (17.3%), respectively. The most common isolates were Escherichia coli (17.3%), Stenotrophomonas maltophilia (13.7%), and Staphylococcus species (23.1%). The rate of septic shock and mortality accounted for 22.3% and 28.9%, respectively. Escherichia coli is highly sensitive to carbapenem, and resistant (>50%) with quinolone and aminoside. Klebsiella pneumoniae and Pseudomonas aeruginosa were highly sensitive to carbapenem. Acinetobacter baumannii was resistant to meropenem (75%). Stenotrophomonas maltophilia was sensitive to quinolone (13.8 %), and highly resistant to remaining antibiotics. Methicillin-resistant Staphylococcus aureus had a low resistance rate for vancomycin, teicoplanin, and linezolid. Multivariate analysis showed that the significant factors associated with mortality were age >75; SOFA >7; respiratory infection; intensive care unit treatment and presentation with septic shock.

Conclusion

The mortality rate was still high, especially for antibiotic-resistant agents.

Predisposing Factors of Nosocomial Infections in Hospitalized Patients in the United Kingdom: Systematic Review

BACKGROUND

Nosocomial infections are infections incubating or not present at the time of admission to a hospital and manifest 48 hours after hospital admission. The specific factors contributing to the risk of infection during hospitalization remain unclear, particularly for the hospitalized population of the United Kingdom.

OBJECTIVE

The aim of this systematic literature review was to explore the risk factors of nosocomial infections in hospitalized adult patients in the United Kingdom.

METHODS

A comprehensive keyword search was conducted through the PubMed, Medline, and EBSCO CINAHL Plus databases. The keywords included "risk factors" or "contributing factors" or "predisposing factors" or "cause" or "vulnerability factors" and "nosocomial infections" or "hospital-acquired infections" and "hospitalized patients" or "inpatients" or "patients" or "hospitalized." Additional articles were obtained through reference harvesting of selected articles. The search was limited to the United Kingdom with papers written in English, without limiting for age and gender to minimize bias. The above process retrieved 377 articles, which were further screened using inclusion and exclusion criteria following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The retained 9 studies were subjected to critical appraisal using the Critical Appraisal Skills Programme (cohort and case-control studies) and Appraisal Tool for Cross-Sectional Studies (cross-sectional studies) checklists. Finally, 6 eligible publications were identified and used to collect the study findings. A thematic analysis technique was used to analyze data extracted on risk factors of nosocomial infections in hospitalized patients in the United Kingdom.

RESULTS

The risk factors for nosocomial infections that emerged from the reviewed studies included older age, intrahospital transfers, cross-infection, longer hospital stay, readmissions, prior colonization with opportunistic organisms, comorbidities, and prior intake of antibiotics and urinary catheters. Nosocomial infections were associated with more extended hospital stays, presenting with increased morbidity and mortality. Measures for controlling nosocomial infections included the use of single-patient rooms, well-equipped wards, prior screening of staff and patients, adequate sick leave for staff, improved swallowing techniques and nutritional intake for patients, improved oral hygiene, avoiding unnecessary indwelling plastics, use of suprapubic catheters, aseptic techniques during patient care, and prophylactic use.

CONCLUSIONS

There is a need for further studies to aid in implementing nosocomial infection prevention and control.

Prevalence of Hospital-Onset Bacteremia Pre- and Post-Implementation of a Needleless Blood Sampling Device From Existing Peripheral Catheters

Repeated access of peripheral intravenous (IV) devices theoretically increases the risk of bacterial exposure. PIVO™ (VelanoVascular) is a needleless, single-use device that enables blood sampling from an existing peripheral IV. The goal of this retrospective observational exploratory study was to evaluate the influence of PIVO use on rates of hospital-onset bacteremia and fungemia (HOB) by comparing HOB rates in the year before and after PIVO introduction in hospitals implementing PIVO and over similar time periods in "control" hospitals with no PIVO. Two hospitals implementing PIVO (Hospital 1, a large community hospital; Hospital 2, a tertiary oncology center), and 71 control hospitals were included. During the 1-year period before and after PIVO introduction, HOB rates decreased in hospitals 1 and 2 by 31.9% and 41.8%, respectively. Control hospitals that did not use PIVO had a 12.4% decrease in HOB rates. Multivariable logistic regression analyses found that PIVO was associated with a lower risk (Hospital 1 odds ratio [OR]: 0.63; 95% CI, 0.42-0.94) or no change (Hospital 2 OR: 1.05; 95% CI, 0.72-1.52) in HOB rates. Control hospitals also showed no change in HOB rates between the 2 time periods. These data do not support concerns about increased risk of bacteremia with PIVO.

Impact of the COVID-19 Pandemic on the Epidemiology of Bloodstream Infections in Hospitalized Patients-Experience from a 4th Military Clinical Hospital in Poland

Bloodstream infections (BSIs) are associated with high mortality and inappropriate or delayed antimicrobial therapy. The purpose of this study was to investigate the impact of the COVID-19 pandemic on the epidemiology of BSIs in hospitalized patients. The research aimed to compare the incidence of BSIs and blood culture results in patients hospitalized before and during the COVID-19 pandemic.

METHODS

Retrospective and prospective data were collected from blood cultures obtained from 4289 patients hospitalized between June 2018 and July 2022. Two groups of patients were distinguished: those with BSIs admitted during the pre-COVID-19 period and those admitted during the COVID-19 surge. Demographic and clinical data, blood cytology, and biochemistry results were analyzed, and the usefulness of PCT was assessed in patients with COVID-19.

RESULTS

The study showed a significant increase in the incidence of BSIs during the pandemic compared to the pre-COVID-19 period. Positive blood cultures were obtained in 20% of patients hospitalized during the pandemic (vs. 16% in the pre-COVID-19 period). The incidence of BSIs increased from 1.13 to 2.05 cases per 1000 patient days during COVID-19, and blood culture contamination was more frequently observed. The mortality rate was higher for patients hospitalized during the COVID-19 pandemic. An increased frequency of MDRO isolation was observed in the COVID-19 period.

CONCLUSIONS

The incidence of BSIs increased and the mortality rate was higher in the COVID-19 period compared to the pre-COVID-19 period. The study showed limited usefulness of procalcitonin in patients with COVID-19, likely due to the administered immunosuppressive therapy.

Dysbiosis of a microbiota-immune metasystem in critical illness is associated with nosocomial infections

Critically ill patients in intensive care units experience profound alterations of their gut microbiota that have been linked to a high risk of hospital-acquired (nosocomial) infections and adverse outcomes through unclear mechanisms. Abundant mouse and limited human data suggest that the gut microbiota can contribute to maintenance of systemic immune homeostasis, and that intestinal dysbiosis may lead to defects in immune defense against infections. Here we use integrated systems-level analyses of fecal microbiota dynamics in rectal swabs and single-cell profiling of systemic immune and inflammatory responses in a prospective longitudinal cohort study of critically ill patients to show that the gut microbiota and systemic immunity function as an integrated metasystem, where intestinal dysbiosis is coupled to impaired host defense and increased frequency of nosocomial infections. Longitudinal microbiota analysis by 16s rRNA gene sequencing of rectal swabs and single-cell profiling of blood using mass cytometry revealed that microbiota and immune dynamics during acute critical illness were highly interconnected and dominated by Enterobacteriaceae enrichment, dysregulated myeloid cell responses and amplified systemic inflammation, with a lesser impact on adaptive mechanisms of host defense. Intestinal Enterobacteriaceae enrichment was coupled with impaired innate antimicrobial effector responses, including hypofunctional and immature neutrophils and was associated with an increased risk of infections by various bacterial and fungal pathogens. Collectively, our findings suggest that dysbiosis of an interconnected metasystem between the gut microbiota and systemic immune response may drive impaired host defense and susceptibility to nosocomial infections in critical illness.

Association of Polypharmacy and Anticholinergic Burden with Length of Stay in Hospital Amongst Older Adults Admitted with Hip Fractures: A Retrospective Observational Study

BACKGROUND

Age-associated multimorbidity and polypharmacy, predispose individuals to falls and consequent hip fractures. We examined the impact of polypharmacy (≥ 4 drugs daily), including anticholinergic agents, on hospital length of stay (LOS), mobility within 1-day of hip surgery and pressure ulcers in adults ≥ 60 years admitted with hip fractures.

METHODS

In this retrospective observational study, information on medications at admission was obtained to calculate the total number of drugs taken, including those imposing an anticholinergic burden (ACB). Associations between variables were examined by logistic regression; adjusted for age, sex, co-morbidities, pre-fracture functional limitations and alcohol consumption.

RESULTS

There were 787 women and 318 men of similar mean age (± SD): 83.1 years (± 8.6) and 82.5 years (± 9.0), respectively. Compared to patients with an ACB score = 0 and taking < 4 drugs daily, those with an ACB score ≥ 1 and taking ≥ 4 drugs daily had greater risk of prolonged LOS (≥ 2 weeks), OR 1.8 (1.2-2.7); failure to mobilise within 1-day of surgery, OR 1.9 (1.1-3.3); and pressure ulcers, OR 3.0 (95% CI 1.2-7.9). LOS was further prolonged by failure to mobilise within 1-day of surgery and/or pressure ulcers. Those with either an ACB score ≥ 1 or the use of ≥ 4 drugs daily had intermediate risks.

CONCLUSIONS

Anticholinergic agents and polypharmacy in patients with hip fractures are associated with longer LOS in hospital, further accentuated by failure to mobilise within 1-day after surgery and pressure ulcers. This study provides further evidence of the impact of polypharmacy, including those with an ACB, on adverse health outcomes and lends support to reduce potentially inappropriate prescribing.

Excess length of stay and readmission following hospital-acquired bacteraemia: a population-based cohort study applying a multi-state model approach

OBJECTIVES

Population-based estimates of excess length of stay after hospital-acquired bacteraemia (HAB) are few and prone to time-dependent bias. We investigated the excess length of stay and readmission after HAB.

METHODS

This population-based cohort study included the North Denmark Region adult population hospitalized for ≥48 hours, from 2006 to 2018. Using a multi-state model with 45 days of follow-up, we estimated adjusted hazard ratios (aHRs) for end of stay and discharge alive. The excess length of stay was defined as the difference in residual length of stay between infected and uninfected patients, estimated using a non-parametric approach with HAB as time-dependent exposure. Confounder effects were estimated using pseudo-value regression. Readmission after HAB was investigated using the Cox regression.

RESULTS

We identified 3457 episodes of HAB in 484 291 admissions in 205 962 unique patients. Following HAB, excess length of stay was 6.6 days (95% CI, 6.2-7.1 days) compared with patients at risk. HAB was associated with decreased probability of end of hospital stay (aHR, 0.60; 95% CI, 0.57-0.62) driven by the decreased hazard for discharge alive; the aHRs ranged from 0.30 (95% CI, 0.23-0.40) for bacteraemia stemming from 'heart and vascular' source to 0.72 (95% CI, 0.69-0.82) for the 'urinary tract'. Despite increased post-discharge mortality (aHR, 2.76; 95% CI, 2.38-3.21), HAB was associated with readmission (aHR, 1.42; 95% CI, 1.31-1.53).

CONCLUSION

HAB was associated with considerably excess length of hospital stay compared with hospitalized patients without bacteraemia. Among patients discharged alive, HAB was associated with increased readmission rates.

Identifying the core components of a nursing home hospital avoidance programme

BACKGROUND

Nursing home hospital avoidance programmes have contributed to a reduction in unnecessary emergency transfers but a description of the core components of the programmes has not been forthcoming. A well-operationalised health-care programme requires clarity around core components to evaluate and replicate the programme. Core components are the essential functions and principles that must be implemented to produce expected outcomes.

OBJECTIVES

To identify the core components of a nursing home hospital avoidance programme by assessing how the core components identified at one nursing home (Site One) translated to a second nursing home (Site Two).

METHODS

Data collected during the programme's implementation at Site Two were reviewed for evidence of how the core components named at Site One were implemented at Site Two and to determine if any additional core components were evident. The preliminary updated core components were then shared with seven evaluators familiar with the hospital avoidance programme for consensus.

RESULTS

The updated core components were agreed to include the following: Decision Support Tools, Advanced Clinical Skills Training, Specialist Clinical Support and Collaboration, Facility Policy and Procedures, Family and Care Recipient Education and Engagement, Culture of Staff Readiness, Supportive Executive and Facility Management.

CONCLUSION

This study launches a discussion on the need to identify hospital avoidance programme core components, while providing valuable insight into how Site One core programme components, such as resources, education and training, clinical and facility support, translated to Site Two, and why modifications and additions, such as incorporating the programme into facility policy, family education and executive support were necessary, and the ramifications of those changes. The next step is to take the eight core component categories and undertake a rigorous fidelity assessment as part of formal process evaluation where the components can be critiqued and measured across multiple nursing home sites. The core components can then be used as evidence-based building blocks for developing, implementing and evaluating nursing home hospital avoidance programmes.

The Accelerate Pheno™ System-A New Tool in Microbiological Diagnostics of Bloodstream Infections: A Pilot Study from Poland

The aim of this study was to evaluate the usefulness of the Accelerate Pheno™ system (APS) (Accelerate Diagnostics, Denver, CO, USA) for rapid laboratory diagnosis of bloodstream infections. The study included 45 positive blood samples obtained from patients hospitalized in University Hospital No. 1 in Bydgoszcz, Poland. In 40 (88.9%) blood samples, the APS was capable of identification of at least one microorganism at the genus or species level and in 38 (84.4%) of them additionally assessed antimicrobial susceptibility. The time of identification and the time to result of antimicrobial susceptibility ranged from 1:32 to 1:42 and 5:02 to 5:36 h, respectively. Six positive blood samples revealed a poly-microbial culture. In these cases, only one out of two or three microorganisms was detected by the APS, and the system assessed antimicrobial susceptibility only for them. For 78.6% positive blood samples, agreement on identification compared to mass spectrometry was found. For all but one sample, a 96-100% compliance of the resistance category was achieved when comparing the antimicrobial susceptibility testing results to conventional methods. Using the APS, the total time to report was reduced from 13:34 to even 63:47 h compared to the standard microbiological laboratory workflow. The APS is a very useful system, especially for the rapid assessment of antimicrobial susceptibility of bacteria directly from positive blood samples, offering the greatest potential for microbiology laboratories operating around the clock.

Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient

There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.

Hospital-Onset Bloodstream Infections Caused by Eight Sentinel Bacteria: A Nationwide Study in Israel, 2018–2019

Nationwide studies on hospital-onset bloodstream infections (HO-BSIs) are scarce. To describe incidence, mortality and antimicrobial resistance (AMR) of HO-BSI caused by eight sentinel bacteria in Israel, we used laboratory-based BSI surveillance data from 1 January 2018 to 31 December 2019. All hospitals reported positive blood cultures growing Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium. We calculated HO-BSI incidence and 14-day, 30-day and 1-year mortality in adults. We performed multivariable logistic regression to identify predictors of 30-day mortality. The study included 6752 HO-BSI events: K. pneumoniae (1659, 22.1%), E. coli (1491, 19.8%), S. aureus (1315, 17.5%), P. aeruginosa (1175, 15.6%), E. faecalis (778, 10.4%), A. baumannii (654, 8.7%), E. faecium (405, 5.4%) and S. pneumoniae (43, 0.6%). Overall incidence was 2.84/1000 admissions (95% CI: 2.77–2.91) and 6.88/10,000 patient-days (95% CI: 6.72–7.05). AMR isolates accounted for 44.2% of events. Fourteen-day, thirty-day and one-year mortality were 30.6% (95% CI: 28.5%–32.8%), 40.2% (95% CI: 38.2%–42.1%) and 66.5% (95% CI: 64.7%–68.3%), respectively. Organisms with highest risk for 30-day mortality (compared with E. coli) were A. baumannii (OR 2.85; 95% CI: 2.3–3.55), E. faecium (OR 2.16; 95% CI: 1.66–2.79) and S. pneumoniae (OR 2.36; 95% CI: 1.21–4.59). Mortality was higher in AMR isolates (OR 1.57; 95% CI: 1.4–1.77). This study highlights the incidence, associated high mortality and important role of antibiotic resistance in HO-BSI.

Metabolic preference assay for rapid diagnosis of bloodstream infections

Bloodstream infections (BSIs) cause >500,000 infections and >80,000 deaths per year in North America. The length of time between the onset of symptoms and administration of appropriate antimicrobials is directly linked to mortality rates. It currently takes 2–5 days to identify BSI pathogens and measure their susceptibility to antimicrobials – a timeline that directly contributes to preventable deaths. To address this, we demonstrate a rapid metabolic preference assay (MPA) that uses the pattern of metabolic fluxes observed in ex-vivo microbial cultures to identify common pathogens and determine their antimicrobial susceptibility profiles. In a head-to-head race with a leading platform (VITEK 2, BioMérieux) used in diagnostic laboratories, MPA decreases testing timelines from 40 hours to under 20. If put into practice, this assay could reduce septic shock mortality and reduce the use of broad spectrum antibiotics.

It is currently slow to identify bloodstream infection pathogens. Here the authors report a rapid metabolic preference assay that uses the pattern of metabolic fluxes observed in ex-vivo microbial cultures to identify common pathogens and determine their antimicrobial susceptibility profiles.

Clinical and Financial Impact of Rapid Antimicrobial Susceptibility Testing in Blood Cultures

The rapid identification of pathogens that cause bloodstream infections plays a vital role in the modern clinical microbiology laboratory. Despite demonstrating a significant reduction in turnaround time and a significant effect on clinical decisions, most methods do not provide complete antimicrobial susceptibility testing (AST) information. We employed rapid identification (ID) and AST using the Accelerate PhenoTest on positive blood cultures containing Gram-negative bacilli. The length of stay (LOS) significantly decreased from an average of 12.1 days prior to implementation to 6.6 days post-implementation (p = 0.02), representing potential total savings of USD 666,208.00. All-cause mortality did not differ significantly, 27 (19%) versus 18 (12%), p = 0.11. We also observed an associated decrease in the use of broad-spectrum antimicrobials, including meropenem and quinolones. The implementation of a rapid ID and AST method, along with a well-established antimicrobial stewardship program, has the potential to decrease LOS, broad-spectrum antibiotic use, and costs to the healthcare system, with no observable impact on mortality.

ICU-acquired central line-associated bloodstream infection and its associated factors in Oman

BACKGROUND

Despite the extensive use of central lines for ICU patients in Oman, no studies have been conducted among adult ICU patients to assess the prevalence, and predictors of CLABSIs.

AIM

To estimate the prevalence of ICU-acquired CLABSIs, identify the most common causative microorganisms, and define possible related risk factors associated with ICU-acquired CLABSIs among adult ICU patients in Oman.

METHOD

A retrospective case-control design was used to screen electronic medical records of for all adult ICU patients admitted over 2 years (2018-2019) in 2 tertiary hospitals in Oman. The CDC definition of CLABSIs was used to allocate a cases group (n = 58), and a randomly selected controls group (n = 174).

RESULTS

The prevalence of ICU-acquired CLABSIs was 8.9 and 8.31 per 1,000 catheter days for the years 2018 and 2019 respectively. The most common isolated microorganisms were gram-positive bacteria (46.6%). The risk factors for ICU-acquired CLABSIs are: heart failure (Odds Ratio [OR] = 11.67, P < .001), female gender (OR = 0.352, P = .035), presence of other infections (OR = 3.4, P = .009), tracheostomy (OR = 5.34, P = .004), and Total Parenteral Nutrition (OR = 3.469, P = .020).

CONCLUSIONS

The prevalence of ICU-acquired CLABSIs in developing countries like Oman is higher than most of developed countries. The current study provides baseline data that can be used as a reference for future national studies and help in building strategies to prevent and control ICU-acquired CLABSIs.

The Impact of Nosocomial Bloodstream Infections on Mortality: A Retrospective Propensity-Matched Cohort Study

Background

The mortality toll of nosocomial infections drives infection control efforts. We aimed to assess the contemporary mortality associated with nosocomial bloodstream infections (BSIs).

Methods

Retrospective propensity-matched cohort study conducted in 1 hospital in Israel between January 2010-December 2020. Adults >18 years old with nosocomial BSI were matched to controls using nearest neighbor matching of the propensity score for nosocomial BSI. We assessed all-cause mortality at 30 days, 90 days, and survival up to 1 year starting on the BSI day or matched hospital-day among controls; and the functional and cognitive change between admission and discharge using the Norton score among patients discharged alive. Residual differences between matched groups were addressed through Cox regression for 1-year survival.

Results

A total of 1361 patients with nosocomial BSI were matched to 1361 patients without BSI. Matching achieved similar patient groups, with small differences remaining in the Charlson score and albumin and hemoglobin levels. At 90 days, mortality was higher among patients with BSI (odds ratio [OR], 3.36 [95% confidence interval {CI}, 2.77-4.07]). ORs were higher when the BSI was caused by multidrug-resistant bacteria (OR, 5.22 [95% CI, 3.3-8.26]) and with inappropriate empirical antibiotics in the first 24 hours (OR, 3.85 [95% CI, 2.99-4.94]). Following full adjustment, the hazard ratio for 1-year mortality with nosocomial BSI was 2.28 (95% CI, 1.98-2.62). The Norton score declined more frequently among patients with BSI (OR, 2.27 [95% CI, 1.81-2.86]).

Conclusions

Nosocomial BSIs incur a highly significant mortality toll, particularly when caused by multidrug-resistant bacteria. Among hospital survivors, BSIs are associated with functional decline.

Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

BACKGROUND

Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality.

METHODS

A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05.

RESULTS

3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line-related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States' states with higher quantities of geriatric trauma patients experienced reduced preventable mortality.

CONCLUSION

Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States' states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.

Association of risk of malnutrition with adverse outcomes and early support on discharge in acute stroke patients without prestroke disability: A multicenter, registry-based cohort study

BACKGROUND

Malnutrition in hospitals remains highly prevalent. As part of quality improvement initiatives, the Royal College of Physicians recommends nutrition screening for all patients admitted with acute stroke. We aimed to examine the associations of patients at risk of malnutrition with poststroke outcomes.

METHODS

We analyzed prospectively collected data from four hyperacute stroke units (HASUs) (2014-2016). Nutrition status was screened in 2962 acute stroke patients without prestroke disability (1515 men, [mean ± SD] 73.5 years ± 13.1; 1447 women, 79.2 ± 13.0 years). The risk of malnutrition was tested against stroke outcomes and adjusted for age, sex, and comorbidities.

RESULTS

Risk of malnutrition was identified in 25.8% of patients). Compared with well-nourished patients, those at risk of malnutrition had, within 7 days of admission, increased risk of stay on the HASU of >14 days (odds ratio [OR]: 9.9 [7.3-11.5]), disability on discharge (OR: 8.1 [6.6-10.0]), worst level of consciousness in the first 7 days (score ≥ 1) (OR: 7.5 [6.1-9.3]), mortality (OR: 5.2 [4.0-6.6], pneumonia (OR: 5.1 [3.9-6.7]), and urinary tract infection (OR: 1.5 [1.1-2.0]). They also required palliative care (OR: 12.3 [8.5-17.8]), discharge to new care home (OR: 3.07 [2.18-4.3]), activities of daily living support (OR: 1.8 [1.5-2.3]), planned joint care (OR: 1.5 [1.2-1.8]), and weekly visits (OR: 1.4 [1.1-1.8]).

CONCLUSION

Patients at risk of malnutrition more commonly have multiple adverse outcomes after acute stroke and greater need for early support on discharge.

Risk factors for nosocomial bloodstream infections in COVID-19 affected patients: protocol for a case-control study

BACKGROUND

Nosocomial bloodstream infection (nBSI) is an important clinical concern among COVID-19 hospitalised patients. It can cause sepsis and septic shock leading to high morbidity, mortality, and the emergence of antibiotic resistance. The aim of this case-control study is to identify the risk factors associated with the nBSI development in COVID-19 hospitalised patients and its incidence.

METHODS AND ANALYSIS

A retrospective case-control study will be performed. Cases will include nBSI episodes of adult patients (≥18 years) admitted to Hospital Universitari Germans Trias i Pujol, Barcelona, Spain, from April to December 2020 with a diagnosis of SARS-CoV-2 pneumonia. Patients transferred from other hospitals will be excluded. Controls will include hospitalisation episodes of COVID-19 patients without nBSI. We will recruit a minimum of 74 nBSI episodes (cases) and 74 controls (according to sample size calculation). We will collect data on sociodemographics, clinical status at admission, hospital admission, in-hospital mortality, and exposure data (use of antivirals, glucocorticoids or immunomodulatory agents, length of hospitalisation, and use of medical devices such as intravenous catheters). A bivariate and a subsequent multivariate regression analysis will be performed to assess the independent effect of the associated risk factors after adjusting for confounders. The nBSI incidence rate will be estimated according to the number of nBSI episodes in admitted COVID-19 patients among the total person-month of follow-up.

ETHICS AND DISSEMINATION

The protocol of this study was approved by the Ethical Committee for Drug Investigation of the Hospital Universitari Germans Trias i Pujol. The results of this case-control study will be published in a peer reviewed journal.

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective

Aims

This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service.

Methods and results

We retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day‐case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard‐of‐care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service—78 (68.4%) on a day‐case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out‐patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow‐up, there were 20 (17.5%) 30 day re‐admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard‐of‐care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P < 0.001).

Conclusions

Outpatient ambulatory management of decompensated HF with IV diuretics given either on a day case unit or in a domiciliary setting is feasible, safe, and effective in selected patients with decompensated HF. This should be explored further as a model in delivering HF services in the outpatient setting during COVID‐19.

Retrospective Analysis of Demographic, Psychiatric, and Physical Characteristics That Impact Length of Stay on an Inpatient Geriatric Psychiatric Unit

Currently, the aging adult population is rising fast and presenting multiple challenges for the US healthcare system. Older adults present unique challenges in their care of medical and psychiatric conditions. This study retrospectively examined characteristics that are associated with length of stay on an inpatient geriatric psychiatric unit in an urban located psychiatric hospital. A sample of 74 individuals was examined. Factors that influenced length of stay included commitment status and discharge to a different level of care. Reducing the length of stay for geriatric patients can help reduce costs and improve health outcomes.

Effectiveness of an electronic hand hygiene monitoring system in increasing compliance and reducing healthcare-associated infections

During an interventional study in a nephrology department, we investigated the effect of an electronic hand hygiene monitoring system on the hand hygiene compliance of healthcare workers (N = 99) and hospital-acquired bloodstream infections. The hand hygiene compliance of the doctors and nurses improved significantly during the intervention phase when they received group and individual feedback based on actionable insights from the electronic hand hygiene monitoring system. The improvements in hand hygiene compliance were associated with a significant reduction in the number of hospital-acquired bloodstream infections.

Evaluation of the Accelerate Pheno System for Rapid Identification and Antimicrobial Susceptibility Testing of Positive Blood Culture Bottles Inoculated with Primary Sterile Specimens from Patients with Suspected Severe Infections

The Accelerate Pheno system is approved for rapid identification and phenotypic antimicrobial susceptibility testing (AST) of microorganisms grown from positive blood cultures inoculated with blood from septic patients. We evaluated the performance of the system for identification and AST from positive blood culture bottles inoculated with primary sterile nonblood specimens from patients with suspected severe infections. One hundred positive blood culture bottles with primary sterile specimens (63 cerebrospinal fluids, 16 ascites, 7 pleural fluids, 4 vitreous fluids, 5 joint aspirates, and 5 other aspirates) from 100 patients were included. Pathogen identification was in agreement with conventional methods for 72 of 100 cultures (72%) and for 81 of 112 (72%) pathogens when considering all pathogens and for 72 of 92 (78%) cultures and 81 of 104 (78%) pathogens when considering on-panel pathogens only. Eight of 31 isolates (26%) not identified by APS were pathogens not included in the APS panel. APS and conventional methods accordingly identified all pathogens from two of nine polymicrobial cultures (22%). APS generated antimicrobial resistance results for 57 pathogens of 57 cultures. The overall category agreement between APS and culture-based AST was 91.2%; and the rate for minor errors was 6.9%, for major was 1.7%, and for very major errors was 0.2%. APS may accelerate pathogen identification and phenotypic AST from positive blood culture bottles inoculated with primary sterile specimens from patients with serious infections, especially for hospitals without an on-site microbiology laboratory. However, the inclusion of nonblood specimens with a high likelihood of polymicrobial infections may result in an inferior performance.

Impact of a Rapid Blood Culture Diagnostic Panel on Time to Optimal Antimicrobial Therapy at a Veterans Affairs Medical Center

PURPOSE

Utilization of rapid diagnostic testing alongside intensive antimicrobial stewardship interventions improves patient outcomes. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel in an established Antimicrobial Stewardship Program (ASP) with limited personnel resources.

METHODS

A single center retrospective pre- and post-intervention cohort study was performed following the implementation of a BCID panel on patients admitted with at least 1 positive blood culture during the study period. The primary outcome was time to optimal therapy from blood culture collection. Secondary outcomes included days of therapy (DOT), length of stay, and 30-day mortality and readmission rates.

RESULTS

277 patients were screened with 180 patients included, with 82 patients in the pre-BCID and 98 in the post-BCID arms. Median time to optimal therapy was 73.8 hours (IQR; 1.1-79.6) in the pre-BCID arm and 34.7 hours (IQR; 10.9-71.6) in the post-BCID arm (p ≤ 0.001). Median DOT for vancomycin was 4 and 3 days (p ≤ 0.001), and for piperacillin-tazobactam was 3.5 and 2 days (p ≤ 0.007), for the pre-BCID and post-BCID arms, respectively. Median length of hospitalization was decreased from 11 to 9 days (p = 0.031). No significant change in 30-day readmission rate was noted, with a trend toward lower mortality (12% vs 5%; p = 0.086).

CONCLUSION

Introduction of BCID into the daily workflow resulted in a significant reduction in time to optimal therapy for bloodstream infections and DOT for select broad-spectrum antibiotics, highlighting the potential benefits of rapid diagnostics even in settings with limited personnel resources.

Bloodstream infections in the elderly: what is the real goal?

Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.

The Effect of Two Bed Bath Practices in Cost and Vital Signs of Critically Ill Patients

By promoting personal hygiene and improving comfort, bed baths can decrease the risk of infection and help maintain skin integrity in critically ill patients. Current bed-bathing practices commonly involve the use of either soap and water (SAW) or disposable wipes (DWs). Previous research has shown both bed-bathing methods are equally effective in removing dirt, oil, and microorganisms. This experimental study compared the cost, staff satisfaction, and effects of two bed-bathing practices on critically ill patients' vital signs. We randomly assigned 138 participants into 2 groups: an experimental group that received bed baths using DWs and a control group that received bed baths using SAW. We compared the bath duration, cost, vital sign trends, and nursing staff satisfaction between the two groups. We used the chi-square test and t-test for the statistical analysis, and we expressed the quantitative data as mean and standard deviation. Our results showed the bed baths using DWs had a shorter duration and lower cost than those using SAW. There were no significant differences in the vital sign trends between the two groups. The nursing staff preferred to use DWs over SAW. This study can help clinical nursing staff decide which method to use when assisting patients with bed baths.

Prognostic value of central venous-to-arterial carbon dioxide difference in patients with bloodstream infection

Background: Bloodstream infection (BSI) are prone to circulation disorders, which portend poor outcome. The central venous-to-arterial carbon dioxide difference (Pcv-aCO₂) is a biomarker for circulation disorders, but the prognostic value of Pcv-aCO₂ in BSI patients remains unclear. This study was to investigate the association of Pcv-aCO₂ with adverse events in BSI patients. Methods: The patients with BSI between August 2014 and August 2017 were prospectively enrolled. Clinical characteristic and laboratory results were collected. We analyzed the association of the level of Pcv-aCO₂ with clinical variables and 28-day mortality. Results: A total of 152 patients were enrolled. The Pcv-aCO₂ was positively correlated with white blood cell count (r=0.241, p=0.003), procalcitonin (r=0.471, p<0.001), C-reactive protein (r=0.192, p=0.018), lactate (r=0.179, p=0.027), Sequential Organ Failure Assessment (r=0.318, p<0.001) and Acute Physiology And Chronic Health Evaluation II score (r=0.377, p<0.001), while that was negatively correlated with central venous oxygen saturation (r=-0.242, p<0.001) and platelet (r=-0.205, p=0.011). Kaplan-Meier curves demonstrated that patients with Pcv-aCO₂ >6mmHg had a worse prognosis than those without (log rank=32.10, p<0.001). Multivariate analysis showed Level of Pcv-aCO₂ was an independent risk factor for 28-day mortality (HR: 3.10, 95% CI: 1.43-6.74, p=0.004). The area under the receiver operating characteristic curve of Pcv-aCO₂ for prediction of 28-day mortality in patients with BSI was 0.794. Pcv-aCO₂>6 mmHg had 81.1% sensitivity and 78.8% specificity for predicting 28-day mortality. Conclusion: Pcv-aCO₂ may be a simple and valuable biomarker to assessment of 28-day mortality in patients with BSI.

Risk of catheter-related bloodstream infection associated with midline catheters compared with peripherally inserted central catheters: A meta-analysis

Background

Both midline catheters (MCs) and peripherally inserted central catheters (PICCs) can cause catheter‐related bloodstream infection (CRBSI), but the prevalence associated with each is not clear.

Objective

To compare the risk of CRBSI between MCs and PICCs with a meta‐analysis.

Methods

The Web of Science Core Collection, PubMed, Scopus, Embase, The Cochrane Library and ProQuest were searched. All studies comparing the risk of CRBSI between MCs and PICCs were included. Selected studies were assessed for methodological quality using the Downs and Black checklist. Two authors independently assessed the literature and extracted the data. A fixed effects model was used to generate estimates of CRBSI risk in patients with MCs versus PICCs. Publication bias was evaluated, and meta‐analyses were conducted with RevMan 5.3.

Results

A total of 167 studies were identified. Ten studies were collected, involving 33,322 patients. The prevalence of CRBSI with MCs and PICCs was 0.58% (40/6,900) and 0.48% (127/26,422), respectively. Meta‐analysis showed that the prevalence of CRBSI was not significantly different between MCs and PICCs (RR = 0.77, 95% CI: 0.50–1.17, p = .22). While the result showed that the prevalence of CRBSI with MCs was lower than that with PICCs (RR = 0.55, 95% CI: 0.33–0.92, p = .02) after poor‐quality studies were removed. The sensitivity analysis shows that the results from this meta‐analysis are fair in overall studies and non‐poor‐quality studies. All studies have no significant publication bias.

Conclusions

This study provides the first systematic assessment of the risk of CRBSI between MCs and PICCs and provides evidence for the selection of appropriate vascular access devices for intravenous infusion therapy in nursing. The prevalence of CRBSI was not significantly different between them.

Bacterial behavior in human blood reveals complement evaders with some persister-like features

Bacterial bloodstream infections (BSI) are a major health concern and can cause up to 40% mortality. Pseudomonas aeruginosa BSI is often of nosocomial origin and is associated with a particularly poor prognosis. The mechanism of bacterial persistence in blood is still largely unknown. Here, we analyzed the behavior of a cohort of clinical and laboratory Pseudomonas aeruginosa strains in human blood. In this specific environment, complement was the main defensive mechanism, acting either by direct bacterial lysis or by opsonophagocytosis, which required recognition by immune cells. We found highly variable survival rates for different strains in blood, whatever their origin, serotype, or the nature of their secreted toxins (ExoS, ExoU or ExlA) and despite their detection by immune cells. We identified and characterized a complement-tolerant subpopulation of bacterial cells that we named “evaders”. Evaders shared some features with bacterial persisters, which tolerate antibiotic treatment. Notably, in bi-phasic killing curves, the evaders represented 0.1–0.001% of the initial bacterial load and displayed transient tolerance. However, the evaders are not dormant and require active metabolism to persist in blood. We detected the evaders for five other major human pathogens: Acinetobacter baumannii, Burkholderia multivorans, enteroaggregative Escherichia coli, Klebsiella pneumoniae, and Yersinia enterocolitica. Thus, the evaders could allow the pathogen to persist within the bloodstream, and may be the cause of fatal bacteremia or dissemination, in particular in the absence of effective antibiotic treatments.

Blood infections by antibiotic resistant bacteria, notably Pseudomonas aeruginosa, are major concerns in hospital settings. The complex interplay between P. aeruginosa and the innate immune system in the context of human blood is still poorly understood. By studying the behavior of various P. aeruginosa strains in human whole blood and plasma, we showed that bacterial strains display different rate of tolerance to the complement system. Despite the complement microbicide activity, most bacteria withstand elimination through phenotypic heterogeneity creating a tiny (<0.1%) subpopulation of transiently tolerant evaders able to persist in plasma. This phenotypic heterogeneity thus prevents total elimination of the pathogen from the circulation, and represents a new strategy to disseminate within the organism.

Clinical process optimization of transfemoral transcatheter aortic valve implantation

Background: The avoidance of prolonged hospital stay is a major goal in the management of transcatheter aortic valve implantation (TAVI) - medically and economically. Materials & methods: We compared the time range of the preprocedural length of stay in 2014/2015 with 2016/2017, after the implementation of the TAVI coordinator in 2016. This included restructured pathways for screening and pre-interventional diagnosis, performed examinations during the inpatient stay and major outcome variables. Results: After 2016, we observed a significant reduction in preprocedural length of stay (admission to procedure) compared with 2014/2015 (11.3 ± 7.9 vs 7.5 ± 5.6 days, p = 0.001). There was no difference in other major outcome variables. Conclusion: The introduction of the TAVI coordinator caused a shortening of preprocedural length of stay.

Estimating length of stay and inpatient charges attributable to hospital-acquired bloodstream infections

Background

Hospital-acquired bloodstream infection (BSI) is associated with high morbidity and mortality and increases patients’ length of stay (LOS) and hospital charges. Our goals were to calculate LOS and charges attributable to BSI and compare results among different models.

Methods

A retrospective observational cohort study was conducted in 2017 in a large general hospital, in Beijing. Using patient-level data, we compared the attributable LOS and charges of BSI with three models: 1) conventional non-matching, 2) propensity score matching controlling for the impact of potential confounding variables, and 3) risk set matching controlling for time-varying covariates and matching based on propensity score and infection time.

Results

The study included 118,600 patient admissions, 557 (0.47%) with BSI. Six hundred fourteen microorganisms were cultured from patients with BSI. Escherichia coli was the most common bacteria (106, 17.26%). Among multi-drug resistant bacteria, carbapenem-resistant Acinetobacter baumannii (CRAB) was the most common (42, 38.53%). In the conventional non-matching model, the excess LOS and charges associated with BSI were 25.06 days (P < 0.05) and US$22041.73 (P < 0.05), respectively. After matching, the mean LOS and charges attributable to BSI both decreased. When infection time was incorporated into the risk set matching model, the excess LOS and charges were 16.86 days (P < 0.05) and US$15909.21 (P < 0.05), respectively.

Conclusion

This is the first study to consider time-dependent bias in estimating excess LOS and charges attributable to BSI in a Chinese hospital setting. We found matching on infection time can reduce bias.

What factors affect length of hospital stay among trauma patients? A single-center study, Southwestern Iran

PURPOSE

Trauma is a major health concern. Length of hospital stay (LOS) has been targeted as an important metric to assess trauma care. This study aims to evaluate the risk factors that affect LOS among trauma patients in a trauma center in Southwestern Iran.

METHODS

This cross-sectional study was conducted on patients admitted to Rajaee Trauma Center, Shiraz, Iran between January 1, 2018 and December 30, 2018. The inclusion criteria were age above 15 years and having traffic accident injuries, including car, motorcycle and pedestrian injury mechanisms. The exclusion criteria were existing diseases including cardiovascular, cerebral, renal, and pulmonary diseases prior to this study, dead upon arrival or within 48 h after admission, and stay at the hospital for less than 6 h. The risk variables analyzed for prolonged LOS were age, gender, mechanism of traffic accident injury, infection during hospital stay, type of injury, injury severity score, surgery during hospitalization, and survival. Poisson regression was performed to evaluate the partial effects of each covariate on trauma hospitalization (≥3 days as longer stay).

RESULTS

This study was conducted on 14,054 patients with traffic accident injury and the mean age was (33.89 ± 15.78) years. Additionally, 74.35% of the patients were male, with male to female ratio of 2.90. The result of Poisson regression indicated that male patients, higher age, combination of thoracic injuries, onset of infected sites, and surgery patients were more susceptible to have a longer LOS. Considering the site of injury, patients with face injuries followed by those with thorax injuries had the highest means of LOS (3.74 days and 3.36 days, respectively). Simultaneous existence of surgical intervention and infection in a patient had the greatest impact on prolonged LOS.

CONCLUSION

This study identified that age, gender, mechanism of injury, infection, type of injury, survival, and ISS could lead to prolongation of LOS, but the affect can be reduced by eliminating modifiable risk factors.

Virulence Potential of a Multidrug-Resistant Escherichia coli Strain Belonging to the Emerging Clonal Group ST101-B1 Isolated from Bloodstream Infection

Escherichia coli EC121 is a multidrug-resistant (MDR) strain isolated from a bloodstream infection of an inpatient with persistent gastroenteritis and T-zone lymphoma that died due to septic shock. Despite causing an extraintestinal infection, previous studies showed that it did not have the usual characteristics of an extraintestinal pathogenic E. coli. Instead, it belonged to phylogenetic group B1 and harbored few known virulence genes. To evaluate the pathogenic potential of strain EC121, an extensive genome sequencing and in vitro characterization of various pathogenicity-associated properties were performed. The genomic analysis showed that strain EC121 harbors more than 50 complete virulence genetic clusters. It also displays the capacity to adhere to a variety of epithelial cell lineages and invade T24 bladder cells, as well as the ability to form biofilms on abiotic surfaces, and survive the bactericidal serum complement activity. Additionally, EC121 was shown to be virulent in the Galleria mellonella model. Furthermore, EC121 is an MDR strain harboring 14 antimicrobial resistance genes, including bla_CTX-M-2. Completing the scenario, it belongs to serotype O154:H25 and to sequence type 101-B1, which has been epidemiologically linked to extraintestinal infections as well as to antimicrobial resistance spread. This study with E. coli strain EC121 shows that clinical isolates considered opportunistic might be true pathogens that go underestimated.

Total cost of surgical site infection in the two years following primary knee replacement surgery

Objective:

The disease burden of surgical site infection (SSI) following total knee (TKA) replacement is considerable and is expected to grow with increased demand for the procedure. Diagnosing and treating SSI utilizes both inpatient and outpatient services, and the timing of diagnosis can affect health service requirements. The purpose of this study was to estimate the health system costs of infection and to compare them across time-to-diagnosis categories.

Methods:

Administrative data from 2005–2016 were used to identify cases diagnosed with SSI up to 1 year following primary TKA. Uninfected controls were selected matched on age, sex and comorbidities. Costs and utilization were measured over the 2-year period following surgery using hospital and out-of-hospital data. Costs and utilization were compared for those diagnosed within 30, 90, 180, and 365 days. A subsample of cases and controls without comorbidities were also compared.

Results:

We identified 238 SSI cases over the study period. On average, SSI cases cost 8 times more than noninfected controls over the 2-year follow-up period (CaD$41,938 [US$29,965] vs CaD$5,158 [US$3,685]) for a net difference of CaD$36,780 (US$26,279). The case-to-control ratio for costs was lowest for those diagnosed within 30 days compared to those diagnosed later. When only patients without comorbidities were included, costs were >7 times higher.

Conclusion:

Our results suggest that considerable costs result from SSI following TKA and that those costs vary depending on the time of diagnosis. A 2-year follow-up period provided a more complete estimate of cost and utilization.

Glycopeptide Hypersensitivity and Adverse Reactions

Glycopeptides, such as vancomycin and teicoplanin, are primarily used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, such as cellulitis, endocarditis, meningitis, pneumonia, and septicemia, and are some of the most commonly prescribed parenteral antimicrobials. Parenteral glycopeptides are first-line therapy for severe MRSA infections; however, oral vancomycin is used as a first-line treatment of Clostridioides difficile infections. Also, we currently have the longer-acting lipoglycopeptides, such as dalbavancin, oritavancin, and telavancin to our armamentarium for the treatment of MRSA infections. Lastly, vancomycin is often used as an alternative treatment for patients with β-lactam hypersensitivity. Common adverse effects associated with glycopeptide use include nephrotoxicity, ototoxicity, and Redman Syndrome (RMS). The RMS is often mistaken for a true allergy; however, it is a histamine-related infusion reaction rather than a true immunoglobulin E (IgE)-mediated allergic reaction. Although hypersensitivity to glycopeptides is rare, both immune-mediated and delayed reactions have been reported in the literature. We describe the various types of glycopeptide hypersensitivity reactions associated with glycopeptides and lipoglycopeptides, including IgE-mediated reactions, RMS, and linear immunoglobulin A bullous dermatosis, as well as describe cross-reactivity with other glycopeptides.

Healthcare-Associated Infections Due to Multidrug-Resistant Organisms: a Surveillance Study on Extra Hospital Stay and Direct Costs

BACKGROUND

The increasing antimicrobial resistance poses a challenge to surveillance systems and raises concerns about the impact of multidrug-resistant organisms on patient safety.

OBJECTIVE

The study aimed to estimate extra hospital stay and economic burden of infections due to alert organisms - mostly multidrug-resistant - in a teaching hospital.

METHODS

The present retrospective matched cohort study was conducted based on the analysis of hospital admissions at Sant'Andrea Teaching Hospital in Rome from April to December 2015. Extra hospital stay was the difference in the length of stay between each case and control. All the patients developing an infection due to an alert organism were considered cases, all others were eligible as controls. The costs of LOS were evaluated by multiplying the extra stay with the hospital daily cost.

RESULTS

Overall, 122 patients developed an infection due to alert organisms and were all matched with controls. The attributable extra stay was of 2,291 days (mean 18.8; median 19.0) with a significantly increased hospitalization in intensive care units (21.2 days), bloodstream infections (52.5 days), and infections due to Gram-negative bacteria (mean 29.2 days; median 32.6 days). Applying the single day hospital cost, the overall additional expenditure was 11,549 euro per patient. The average additional cost of antibiotic drugs for the treatment of infections was about 1,200 euro per patient.

CONCLUSION

The present study presents an accurate mapping of the clinical and economic impact of infections attributable to alert organisms demonstrating that infections due to multidrug-resistant organisms are associated with higher mortality, longer hospital stays, and increased costs. Article Highlights Box: The increasing antimicrobial resistance poses a challenge for surveillance systems and raises concerns about the impact of multidrug-resistant organisms on patient safety. • Healthcare-associated infections (HAIs) have historically been recognized as a significant public health problem requiring close surveillance. • Despite several and reliable findings have been achieved on clinical issues, our knowledge on the economic impact of healthcare-associated infections due to multidrug-resistant organisms needs to be widened. • Estimating the cost of infections due to multidrug-resistant organisms in terms of extra hospital stay and economic burden is complex, and the financial impact varies across different health systems. • Evaluations of social and economic implications of hospital infections play an increasingly important role in the implementation of surveillance systems. • The costs of infection prevention and control programs and dedicated personnel are relatively low and self-sustainable when efficient.

Central-Line-Associated Bloodstream Infections (CLABSIs) Incidence and the Role of Obesity: A Prospective, Observational Study in Greece

INTRODUCTION

Although central venous catheters (CVCs) provide reliable vascular access, there are several risks linked with their use, with the rates of central-line-associated bloodstream infections (CLABSIs) being the most important ones. CLABSIs have a big impact on mortality rates and health care costs. The aim of this study was to investigate the incidence of obesity in the development of central venous catheter infections.

MATERIAL AND METHOD

This is a prospective, observational study. The data were collected in the ICUs of three major hospitals in Greece, over a period of 18 months. Totally, 744 patients were included in the study.

RESULTS

The study included 744 ICU patients aged 63.6 ± 16.6 years. The Apache II score and MODS score of patients were 23.3 ± 6.9 and 7.5 ± 3.8, respectively. Totally, 5.426 catheter-days were included in the study. Among the 722 CVCs, 178 (24.7%) were CLABSIs. The incidence rate of CVC-associated CLABSI was 22.48 infections per 1000 catheter-days. CLABSI was significantly predicted by the BMI (p = 0.001), by the diabetes mellitus as comorbidity (p = 0.013), by the doctors' experience (p = 0.001), by the type of CVC (p = 0.001) and CVC site (p = 0.001), by the number of efforts for CVC insertion (p = 0.009), by the catheterization's duration (p = 0.001) and by the MODS score (p = 0.001).

CONCLUSIONS

Better staff training focused on care bundles preventing infections, better medical training focused on less efforts for CVC insertion, and the use of Ultrasounds during the CVC insertion may be the main factors that can lead to lower CLABSI rates in obese patients. Further research relating CLABSI rates in ICU patients and obesity is needed.

Attention to age: similar dosing regimens lead to different vancomycin levels among older and younger patients

BACKGROUND

little is known on the clinical implications of vancomycin trough levels among older patients.

OBJECTIVE

to evaluate the association between vancomycin levels and outcomes among older versus younger patients.

DESIGN

retrospective study.

SUBJECTS

patients aged 18-64 and ≥65 years treated with vancomycin for documented methicillin resistant Staphylococcus aureus (MRSA) infections.

METHODS

we compared the effectiveness and toxicity of vancomycin according to trough levels in older versus younger patients. Subgroup analysis of patients with glomerular filtration rate (GFR) > 60 ml/min/1.73 m2 was performed.

RESULTS

we included 181 patients aged ≥65 years and 104 younger patients. Mean age in the older group was 76.9 ± 8 years versus 50.9 ± 12.4 in the younger group. Vancomycin trough levels and 24-hours area under the curve to minimal inhibitory concentrations (AUC/MIC) were significantly higher in older patients who were also significantly more likely to achieve trough levels of ≥15 mg/l within 4 days, (98/181 (54.1%) vs. 38/104 (36.5%) in younger patients, P = 0.004). Results were similar among patients with GFR > 60. Thirty-day mortality was significantly higher in older (74/181, 40.9% vs. 13/104, 12.5%, respectively, P < 0.001). There was no association between vancomycin trough levels and mortality among older patients. No significant differences were demonstrated in clinical or microbiological success or nephrotoxicity.

CONCLUSIONS

applying uniform dosing recommendations across age groups among adults with MRSA infections results in higher vancomycin levels and AUC/MIC in older versus younger patients. Yet, mortality rates remain higher among older adults. Prospective studies are needed to define the optimal approach for using this drug in older patients.

Rapid molecular tests for detection of antimicrobial resistance determinants in Gram-negative organisms from positive blood cultures: a systematic review and meta-analysis

BACKGROUND

Timely detection of antimicrobial (cephalosporin/carbapenem) resistance (AMR) determinants is crucial to the clinical management of bloodstream infections caused by Gram-negative bacteria (GNB).

OBJECTIVES

To review and meta-analyse the evidence for using commercially available molecular tests for the direct detection of AMR determinants in GNB-positive blood cultures (PBCs).

DATA SOURCES

PubMed, Scopus and ISI Web of Knowledge.

STUDY ELIGIBILITY CRITERIA

Clinical studies evaluating the performance of two major commercial systems, namely the Verigene® and FilmArray® systems, for rapid testing of GNB-PBCs, in comparison with the phenotypic or genotypic methods performed on GNB-PBC isolates.

METHODS

Literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and, for meta-analysis of sensitivity and specificity of both systems, bivariate random-effects model.

RESULTS

Twenty studies were identified (3310 isolates) from 2006 to 2019. Nine studies were conducted in East Asia. In 15 studies using phenotypic comparators (1930 isolates), 1014 (52.5%) isolates were Escherichia coli, and 287 (14.9%) of all the isolates displayed AMR phenotypes. In five studies using genotypic comparators (1380 isolates), 585 (42.4%) were E. coli, and 100 (7.2%) of all the isolates displayed AMR genotypes. Pooled sensitivity and specificity estimates for detection of AMR determinants by the Verigene (i.e. CTX-M, IMP, KPC, NDM, OXA and VIM) and/or FilmArray (i.e. KPC) systems were 85.3% (95% CI 79.9%-89.4%) and 99.1% (95% CI 98.2%-99.5%), respectively, across the 15 studies, and 95.5% (95% CI 89.2%-98.2%) and 99.7% (95% CI 99.1%-99.9%), respectively, across the five studies.

CONCLUSIONS

Our findings show that the Verigene and FilmArray systems may be a valid adjunct to the conventional microbiology (phenotypic or genotypic) methods used to identify AMR in GNBs. The FilmArray system detects only one AMR genotype, namely KPC, limiting its use. Both Verigene and FilmArray systems can miss important cephalosporin/carbapenem resistance phenotypes in a minority of cases. However, the sensitivity and specificity of both systems render them valuable clinical tools in timely identification of resistant isolates. Further studies will establish the prominence of such rapid diagnostics as standard of care in individuals with bloodstream infections.

Concepts in Practice: Geriatric Emergency Departments

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Inpatient healthcare-associated bloodstream infections in older people

This retrospective study describes inpatient healthcare-associated bloodstream infections (HABSI) in older adults and explores whether urinary catheters (presence/insertion/removal) were related to HABSI events. One hundred and sixty-seven HABSI events were identified, predominantly (124, 74%) with Gram-negative bacteria. HABSI was attributed to a urinary source in 110 patients (66%), with over half (63, 57%) of these associated with urinary catheters. Catheter-associated HABSI may be avoidable and potential preventative strategies are discussed.

A systematic review of central-line-associated bloodstream infection (CLABSI) diagnostic reliability and error

OBJECTIVE

To establish the reliability of the application of National Health and Safety Network (NHSN) central-line-associated bloodstream infection (CLABSI) criteria within established reporting systems internationally.

DESIGN

Diagnostic-test accuracy systematic review.

METHODS

We conducted a search of Medline, SCOPUS, the Cochrane Library, CINAHL (EbscoHost), and PubMed (NCBI). Cohort studies were eligible for inclusion if they compared publicly reported CLABSI rates and were conducted by independent and expertly trained reviewers using NHSN/Centers for Disease Control (or equivalent) criteria. Two independent reviewers screened, extracted data, and assessed risk of bias using the QUADAS 2 tool. Sensitivity, specificity, negative and positive predictive values were analyzed.

RESULTS

A systematic search identified 1,259 publications; 9 studies were eligible for inclusion (n = 7,160 central lines). Publicly reported CLABSI rates were more likely to be underestimated (7 studies) than overestimated (2 studies). Specificity ranged from 0.70 (95% confidence interval [CI], 0.58-0.81) to 0.99 (95% CI, 0.99-1.00) and sensitivity ranged from 0.42 (95% CI, 0.15-0.72) to 0.88 (95% CI, 0.77-0.95). Four studies, which included a consecutive series of patients (whole cohort), reported CLABSI incidence between 9.8% and 20.9%, and absolute CLABSI rates were underestimated by 3.3%-4.4%. The risk of bias was low to moderate in most included studies.

CONCLUSIONS

Our findings suggest consistent underestimation of true CLABSI incidence within publicly reported rates, weakening the validity and reliability of surveillance measures. Auditing, education, and adequate resource allocation is necessary to ensure that surveillance data are accurate and suitable for benchmarking and quality improvement measures over time.

REGISTRATION

Prospectively registered with International prospective register of systematic reviews (PROSPERO ID CRD42015021989; June 7, 2015). https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID%3dCRD42015021989.

Predictive model of length of stay in hospital among older patients

BACKGROUND

Most National Health Service (NHS) hospital bed occupants are older patients because of their frequent admissions and prolonged length of stay (LOS). We evaluated demographic and clinical factors as predictors of LOS in a single NHS Trust and derived an equation to estimate LOS.

METHODS

Stepwise logistic and linear regressions were used to predict prolonged LOS (upper-quintile LOS > 17 days) and LOS respectively, from demographic factors and acute and pre-existing conditions.

RESULTS

Of 374 (men:women = 127:247) admitted patients (20% to orthogeriatric, 69% to general medical and 11% to surgical wards), median age of 85 years (IQR = 78-90), 77 had acute first hip fracture; 297 had previous hip fracture (median time since previous fracture = 2.4 years) and 21 (7.1%) had recurrent hip fracture, with median time since first fracture = 2.4 years. Median LOS was 6.5 days (IQR = 1.8-14.8), and 38 (10.2%) died after 4.8 days (IQR = 1.6-14.3). Prolonged LOS was associated with discharge to places other than usual residence: OR = 3.1 (95% CI 1.7-5.7), acute stroke: OR = 10.1 (3.7-26.7), acute first hip fractures: OR = 6.8 (3.1-14.8), recurrent hip fractures: OR = 9.5 (3.2-28.7), urinary tract infection/pneumonia: OR = 4.0 (2.1-8.0), other acute fractures: OR = 9.8 (3.0-32.3) and malignancy: OR = 15.0 (3.1-71.8). Predictive equation showed estimated LOS was 11.6 days for discharge to places other than usual residence, 15 days for pre-existing or acute stroke, 9-14 days for acute and recurrent hip fractures, infections, other acute fractures and malignancy; these factors together explained 32% of variability in LOS.

CONCLUSIONS

A useful estimate of outcome and LOS can be made by constructing a predictive equation from information on hospital admission, to provide evidence-based guidance for resource requirements and discharge planning.

Risk-Set Matching to Assess the Impact of Hospital-Acquired Bloodstream Infections

Hospital-acquired bloodstream infections have a definite impact on patient encounters and cause increased length of stay, costs, and mortality. However, methods for estimating these effects are potentially biased, especially if the time of infection is not incorporated into the estimation strategy. We focused on matching patient encounters in which a hospital-acquired infection occurred to comparable encounters in which an infection did not occur. This matching strategy is susceptible to a selection bias because inpatients that stay longer in the hospital are more likely to acquire an infection and thus also are more likely to have longer and more costly stays. Instead, we have proposed risk-set matching, which matches infected encounters to similar encounters still at risk for infection at the corresponding time of infection. Matching on the one-dimensional propensity score can create comparable pairs for a large number of characteristics; an analogous propensity score is described for risk-set matching. We have presented dramatically different estimates using these 2 approaches with data from a pediatric cohort from the Premier Healthcare Database, United States, 2009-2016. The results suggest that estimates that did not incorporate time of infection exaggerated the impact of hospital-acquired infections with regard to attributed length of stay and costs.

An in-depth analysis of nosocomial bloodstream infections due to Gram-negative bacilli: clinical features, microbiological characteristics and predictors of mortality in a 1 year, prospective study in a large tertiary care Italian hospital

BACKGROUND

Bloodstream infections (BSI) due to Gram negative bacilli (GNB) represent a major concern among nosocomial infections, since they are noticeably associated with a high mortality rates, increase of healthcare costs and prolongation of hospital stay.

METHODS

Over a 12-month period (2014-2015) all the adult patients admitted to a university-based Italian hospital were monitored for development of BSIs due to GNB. Multiple logistics regression models were performed to assess the impact of patients' risk factors on the in-hospital and 14-day mortality.

RESULTS

During the study period 208 patients were diagnosed with at least a BSI due to a Gram negative species for an incidence rate of 12.8 cases/1,000 admissions (95%CI: 11.2-14.7). Multivariate analyses showed that multiple organ dysfunctions along with immune deficit and inadequate therapy in the first 48hrs were associated with a higher risk of death.

CONCLUSIONS

A thorough evaluation of both immune status and organ dysfunction at the onset of septic events, along with adequate antimicrobial therapy appear to be the most reliable factors in predicting the outcome in these infections. SOFA score can be efficaciously substituted to the single organ dysfunctions analysis in predicting mortality after these events.

Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis

Background

Health care associated infections (HAI) among adults admitted to the intensive care unit (ICU) have been shown to increase length of stay, the cost of care, and in some cases increased the risk of hospital death (Kaye et al., J Am Geriatr Soc 62:306-11, 2014; Roberts et al., Med Care 48:1026-35, 2010; Warren et al., Crit Care Med 34:2084-9, 2006; Zimlichman et al., JAMA Intern Med 173:2039-46, 2013). Daily bathing with chlorhexidine gluconate (CHG) has been shown to decrease the risk of infection in the ICU (Loveday et al., J Hosp Infect 86:S1-S70, 2014). However, due to varying quality of published studies, and varying estimates of effectiveness, CHG bathing is not universally practiced. As a result, current opinion of the merit of CHG bathing to reduce hospital acquired infections in the ICU, is divergent, suggesting a state of ‘clinical equipoise’.

This trial sequential meta-analysis aims to explore the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections, and address the question: do we need more trials?

Methods

A systematic literature search was undertaken to identify trials assessing the effectiveness of chlorhexidine bathing to reduce risk of infection, among adult intensive care patients. With particular focus on: (1) Blood stream infections (BSI); (2) Central Line Associated Blood Stream Infections (CLABSI); (3) Multi-Resistant Drug Organism (MRDO); (4) Ventilator Associated Pneumonia; and, Catheter Associated Urinary Tract Infections (CAUTI). Only randomised-control or cluster randomised cross-over trials, were include in our analysis. A Trial Sequential Analysis (TSA) was used to describe the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections.

Results

Five trials were included in our final analysis - two trials were individual patient randomised-controlled, and the remaining cluster-randomised-crossover trials. Daily bathing with CHG was estimated to reduce BSI in the ICU by approximately 29% (Der-Simonian and Laird, Random-Effects.

(DL-RE) Incidence Rate Ratio (IRR) = 0.71, 95% confidence interval (CI) 0.51, 0.98); reduce CLABSI in the ICU by approximately 40% (DL-RE IRR = 0.60, 95% CI 0.34, 1.04); reduce MDRO in the ICU by approximately 18% (DL-RE IRR = 0.82, 95% CI 0.69, 0.98); no effect in reducing VAP in the ICU (DL-RE IRR = 1.33, 95% CI 0.81, 2.18); and, no effect in reducing CAUTI in the ICU (DL-RE IRR = 0.77, 95% CI 0.52, 1.15). Upper (superiority) monitoring boundaries from TSA were not crossed for all five specific infections in the ICU.

Conclusion

Routine bathing with CHG does not occur in the ICU setting, and TSA suggests that more trials are needed to address the current state of ‘clinical equipoise’. Ideally these studies would be conducted among a diverse group of ICU patients, and to the highest standard to ensure generalisability of results.