Mortality predictive factors of people living with human immunodeficiency virus and bloodstream infection

INTRODUCTION

Portugal has one of the highest mortality rates for people living with HIV (PLWHIV) in Europe. After antiretroviral therapy introduction, HIV-associated mortality declined, included the one associated with bloodstream infection (BSI). However it is still high, and European data are scarce . Therefore, characterizing BSI and defining prognostic factors may improve our approach.

METHODS

This was a 10-year retrospective study of predictive factors for 30-day and 3-year mortality in PLWHIV with BSI in a tertiary infectious diseases ward.

RESULTS

Of 2134 PLWHIV admissions, 145 (6.8%) had a BSI, mostly respiratory and catheter-related bacteremia and globally community-acquired. Nosocomial infections occurred in 42 (36%) cases, mostly caused by Enterococcus spp, Staphylococcus aureus, and Candida spp. PLWHIV with a BSI had higher 30-day mortality (27%) compared to those without a BSI (14%). APACHE II score, corticotherapy, and current intravenous drug use (IDU) had a prognostic impact on 30-day mortality. Three-year survival was 54% in PLWHIV with a BSI; a CD4 <200 cells, vascular or chronic pulmonary disease, and lymphoma were prognostic factors.

CONCLUSIONS

Patients with a BSI were more likely to present advanced HIV disease, have more comorbidities, a longer length of stay, and higher 30-day mortality. IDU and severity of infection determined the short-term prognosis. Three-year mortality was primarily influenced by lower CD4 cell counts, hematological tumor, and cardiopulmonary comorbidities. Systemic corticotherapy may influence nosocomial BSI and short-term prognosis.

Bloodstream infections in patients living with HIV in the modern cART era

Retrospective multicentre study aiming at analysing the etiology, characteristics and outcome of bloodstream infections (BSI) in people living with HIV (PLWHIV) in an era of modern antiretroviral therapy. Between 2008 and 2015, 79 PLWHIV had at least 1 BSI, for a total of 119 pathogens isolated. Patients were mainly male (72.1%), previous intravenous drug users (55.7%), co-infected with HCV or HBV (58.2%) and in CDC stage C (60.8%). Gram-positive (G+) pathogens caused 44.5% of BSI, followed by Gram-negative (G−), 40.3%, fungi, 10.9%, and mycobacteria, 4.2%. Candida spp. and coagulase-negative staphylococci were the most frequent pathogens found in nosocomial BSI (17% each), while E.coli was prevalent in community-acquired BSI (25%). At the last available follow-up, (mean 3.2 ± 2.7 years) the overall crude mortality was 40.5%. Factors associated with mortality in the final multivariate analysis were older age, (p = 0.02; HR 3.8, 95%CI 1.2–11.7) CDC stage C (p = 0.02; HR 3.3, 95%CI 1.2–9.1), malignancies, (p = 0.004; HR 3.2, 95%CI 1.4–7.0) and end stage liver disease (p = 0.006; HR 3.4, 95%CI 1.4–8.0). In conclusion, the study found high mortality following BSI in PLWHIV. Older age, neoplastic comorbidities, end stage liver disease and advanced HIV stage were the main factors correlated to mortality.

Bloodstream infections in HIV-infected patients

In the combined antiretroviral therapy era, HIV-infected patients remain a vulnerable population for the onset of bloodstream infections (BSI). Worldwide, nontyphoid salmonellae, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus and coagulase negative staphylococci are the most important pathogens. Intravenous catheter associated infection, skin-soft tissue infection and endocarditis are associated with Gram-positive bacteremia. Among the Gram-negative, nontyphoidal Salmonella have been previously correlated to sepsis. Other causes of BSI in HIV-infected patients are mycobacteria and fungi. Mycobacteria constitute a major cause of BSI in limited resource countries. Fungal BSI are not frequent and among them Cryptococcus neoformans is the most common life-threatening infection. The degree of immunosuppression remains the key prognostic factor leading to the development of BSI.

Risk of healthcare associated infections in HIV positive patients

HIV positive patients are a high risk population due to the alteration in their immune status. Health-care associated infections (HAI) have not been well described in this population, with some risk factors reported inconsistently in the literature. The aim of this study was to describe the epidemiology as well as the underlying risk factors for HAI, specifically urinary tract infection (UTI), bloodstream infection (BSI) and respiratory tract infection (RTI). This was a retrospective cohort study conducted at an academic health system in New York City which included three hospitals over a two year period from 2006 to 2008. There were 3,877 HIV positive patient discharges in 1,911 patients. There were a total of 142 UTI, 106 BSI, and 100 RTI. The incidence rates were 4.35 for UTI, 3.16 for BSI and 2.98 for RTI. CD4 count and antiretroviral therapy were not associated with HAI. Significant predictors of UTI included urinary catheter, length of stay, female gender, steroids and trimethoprim-sulphamethoxazole (TMP-SMX); of BSI were steroids and TMP-SMX; and RTI were mechanical ventilation, steroids and TMP-SMX. Multivariable analysis indicated that TMP-SMX was significantly associated with an increased risk of infection for all three types of HAI [BSI odds ratio 2.55, 95% confidence interval (1.22-5.34); UTI odds ratio 3.1, 95% confidence interval (1.41-7.22); RTI odds ratio 5.15, 95% confidence interval (1.70-15.62)]. HIV positive patients are at significant risk for developing HAI, but the risk factors differ depending on the specific type of infection. The fact that TMP-SMX is a risk factor in these patients warrants further research as this may have significant health policy implications.

A retrospective study on the effects of colistin therapy in children with multidrug-resistant Gram-negative bacterial pathogens: impact of HIV status on outcome

BACKGROUND

Nosocomially acquired multidrug-resistant (MDR) Gram-negative bacteria are important contributors to paediatric intensive care unit (PICU) mortality and morbidity, with limited treatment options.

AIM

To investigate the outcomes of all children treated with colistin for infection with MDR Gram-negative bacteria while admitted to PICU.

METHODS

Retrospective observational study of 19 months. Primary endpoints were all-cause intensive care unit mortality and safety. Secondary endpoints evaluated clinical and microbiological outcomes. Cases were stratified according to HIV status.

RESULTS

Twenty-seven children received 30 colistin courses during the study period. Eight patients (29.6%) were HIV infected, six (22.2%) were HIV uninfected but exposed, and 11 (40.7%) were HIV uninfected and unexposed. Common MDR Gram-negative bacteria cultured were: Acinetobacter species (n=22, 81.5%), Pseudomonas aeruginosa (n=11, 40.7%) and Klebsiella pneumoniae (n=7, 25.9%). Mortality was 37%, with no significant difference between HIV strata. No adverse drug reactions were noted. A composite clinical improvement was noted in 16 courses (53.3%) of colistin. Only 30% of colistin courses used in HIV-infected children resulted in an improved clinical assessment as compared with 83.3% of courses in HIV-uninfected/unexposed children (p=0.04). In HIV-infected children, five of 10 (50%) courses of colistin showed bacteriological clearance compared to the HIV uninfected/unexposed group where all cases showed bacterial eradication (p=0.02).

CONCLUSIONS

HIV-infected children had poorer clinical and bacteriological responses to colistin treatment than HIV uninfected/unexposed. These results require confirmation with prospective studies to determine whether findings are due to poor microbial response, immunodeficiency or repeated reinfections.

Hospital epidemiology and infection control in acute-care settings

Health care-associated infections (HAIs) have become more common as medical care has grown more complex and patients have become more complicated. HAIs are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. The role for infection control programs has grown and continues to grow as rates of antimicrobial resistance rise and HAIs lead to increasing risks to patients and expanding health care costs. In this review, we summarize the history of the development of hospital epidemiology and infection control, common HAIs and the pathogens causing them, and the structure and role of a hospital epidemiology and infection control program.

Staphylococcal skin infections in children: rational drug therapy recommendations

Staphylococcus aureus remains one of the most common and troublesome of bacteria causing disease in humans, despite the development of effective antibacterials and improvement in hygiene. The organism is responsible for over 70% of all skin and soft tissue infections in children and accounts for up to one-fifth of all visits to pediatric clinics. Skin and soft tissue infections that are predominantly caused by S. aureus include bullous and non-bullous impetigo, folliculitis, furunculosis, carbunculosis, cellulitis, surgical and traumatic wound infections, mastitis, and neonatal omphalitis. Other skin and soft tissue infections may also be caused by S. aureus but are often polymicrobial in origin and require special consideration. These include burns, decubitus ulcers (particularly in the perianal region), puncture wounds of the foot, as well as human and mammalian bites. Treatment of staphylococcal skin infections varies from topical antiseptics to prolonged intravenous antibacterials, depending on severity of the lesions and the health of the child. The treatment of choice for oral antibacterials remains the penicillinase-resistant penicillins such as flucloxacillin. Cefalexin and erythromycin are suitable cost-effective alternatives with broader cover, although care must be taken with the use of macrolides because of development of resistance to multiple families of antibacterials, particularly the lincosamides. Other cephalosporins such as cefadroxil and cefprozil are also effective, can be given once daily and have a better tolerability profile -- while azithromycin has a further advantage of a 3-day course. However, all of these agents are more expensive. Although the antibacterials have been given for 10 days in most clinical trials, there is no evidence that this duration is more effective than a 7-day course. In children requiring intravenous therapy, ceftriaxone has a major advantage over other antibacterials such as sulbactam/ampicillin and cefuroxime in that it can be given once daily and may, therefore, be suitable for outpatient treatment of moderate-to-severe skin infections. Newer-generation cephalosporins and loracarbef are also effective and have a broader spectrum of activity, but do not offer any added benefit and are significantly more expensive. Skin and soft tissue infections due to methicillin-resistant S. aureus (MRSA) are still relatively uncommon in children. Well children with community-acquired MRSA infections can be treated with clindamycin or trimethoprim-sulfamethoxazole (cotrimoxazole), but must be observed closely for potentially severe adverse effects. In severe infections, vancomycin remains the treatment of choice, while intravenous teicoplanin and clindamycin are suitable alternatives. Linezolid and quinupristin/dalfopristin are currently showing great promise for the treatment of multi-resistant Gram-positive infections. While the choice of antibacterial is important, supportive management, including removal of any infected foreign bodies, surgical drainage of walled-off lesions, and regular wound cleaning, play a vital role in ensuring cure.

Nosocomial pulmonary infections in HIV-positive patients

PURPOSE OF REVIEW

Nosocomial infections (NI) constitute a significant public health problem and contribute to prolonged hospitalization, additional healthcare costs, and excess morbidity and mortality. Immunocompromised patients, including HIV-infected individuals, are at increased risk for NI, and 15-18.3% of them are represented by lower respiratory tract infections. Nosocomial pulmonary infections (NPI) appear to be more common in patients with acquired immunodeficiency syndrome (AIDS), as a result of the degree of immunosuppression, prior use of antibiotics, and exposure to invasive procedures.

RECENT FINDINGS

This article reviews the epidemiologic and clinical evidences and reports on the occurrence of NPI in HIV-infected inpatients.

SUMMARY

Although underestimated, NI occur commonly in HIV-infected patients, and among them nosocomial pneumonia, including tuberculosis and bacterial pneumonia, are associated with significant morbidity and mortality. The improvement of antiretroviral therapeutic options in developed countries has resulted in a decreased hospitalization rate of HIV-infected individuals. Healthcare delivery in the in- and outpatient setting represents a potential for infections, including lower respiratory tract ones, according to the degree of immunosuppression and the intensity of invasive procedures. To minimize the risk of acquisition of healthcare associated low respiratory tract infections, adherence of healthcare workers to common infection practices, specific respiratory precautions, and early identification of persons who have tuberculosis or are at high risk for active tuberculosis, should be strengthened.

Nosocomial infection among children with symptomatic human immunodeficiency virus infection

A prospective cohort study was conducted during a 15-month period to compare nosocomial infections (NIs) among pediatric patients without (n = 989 and with (n = 50) symptomatic human immunodeficiency virus (HIV) infection. Patients with symptomatic HIV infection presented higher overall NI incidence density rates (relative risk, 1.65; P= .0001), and may represent a population at high risk for the acquisition of NI.

Nasal MRSA colonization of AIDS Patients cared for in a Brazilian university hospital

Weekly culture surveillance was conducted over a 2-year period to determine the incidence of methicillin-resistant Staphylococcus aureus nasal colonization among acquired immunodeficiency syndrome patients cared for in a day-care unit and in an infectious diseases unit. Analysis of genomic DNA profiles showed a predominant pattern in both units.

Epidemiological differences between sepsis syndrome with bacteremia and culture-negative sepsis

OBJECTIVE

To explore the association of putative disease markers and potential risk factors with the nosocomial sepsis syndrome.

DESIGN

Prospective case-control study matched for gender, age, and length of preinfection hospital stay.

SETTING

1,200-bed tertiary-care center in Spain.

PATIENTS

Cases were selected using the sepsis syndrome criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference and were divided into three groups: sepsis with bacteremia (109 cases), sepsis with positive culture other than blood (122 cases), and sepsis with negative culture (115 cases without documented infection but with sepsis syndrome, clinically suspected infection, and empirical antibiotic treatment). Controls were randomly selected from the daily list of inpatients. Data were collected prospectively. Crude and multiple-risk-factor-adjusted odds ratios and their 95% confidence intervals were computed using conditional logistic regression analysis.

RESULTS

Presence of coma in the 48 hours before sepsis, intensive care unit (ICU) stay, and decreased serum albumin levels at admission were common epidemiological markers identified for the three groups of cases. Having a central venous catheter was the main healthcare-related risk factor for bacteremia. ICU stay and nasogastric tube were the main risk factors for sepsis with positive culture other than blood. Coma within 48 hours before sepsis and the need of intensive care were the only two markers identified for culture-negative sepsis.

CONCLUSION

Culture-negative sepsis does not behave like culture-positive sepsis, and this may imply that implementation of preventive measures to decrease the risk of bacteremia may not decrease the risk of sepsis syndrome.

Analysis of risk factors for nosocomial sepsis in surgical patients

BACKGROUND

This study aimed to identify patients at high risk for developing sepsis following surgery according to criteria determined by the American College of Chest Physicians and the Society of Critical Care Medicine Consensus Conference on sepsis.

METHODS

A prospective case-control study was performed in surgical patients in a tertiary care centre over 1 year. Patients were identified by a daily prospective surveillance. Controls were selected randomly from the daily list of surgical inpatients. Data were collected prospectively. Crude and adjusted odds ratios (ORs) and their 95 per cent confidence intervals were computed using logistic regression analysis.

RESULTS

During follow-up, 99 cases and 99 controls were identified. The main risk factors for sepsis found in the multivariate analysis were coma within 48 h before sepsis (OR 13.5, 95 per cent confidence interval 3.6-50.8), low serum albumin level at admission (OR 15.8, 5.4-46.4), two or more intrinsic co-morbidities (OR 11.8, 2.8-49.4) and parenteral nutrition (OR 5.1, 1.5-17.1). Emergency surgery (OR 3.0, 1.4-6.4), abdominal surgery (OR 2.6, 1.0-6.8) and number of surgical interventions (OR 2.5, 1. 1-6.1) were the variables related to surgery that significantly increased the risk of sepsis. Both the study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance indices showed a statistically significant trend with sepsis.

CONCLUSION

Patient-related factors appear to represent the greatest risk for developing postoperative nosocomial sepsis, rather than factors associated with the surgery.

Epidemiological analysis of bacterial strains involved in hospital infection in a university hospital from Brazil

Hospital infections cause an increase in morbidity and mortality of hospitalized patients with significant rise in hospital costs. The aim of this work was an epidemiological analysis of hospital infection cases occurred in a public University Hospital in Rio de Janeiro. Hence, 238 strains were isolated from 14 different clinical materials of 166 patients hospitalized in the period between August 1995 and July 1997. The average age of the patients was 33.4 years, 72.9% used antimicrobials before having a positive culture. The most common risk conditions were surgery (19.3%), positive HIV or AIDS (18.1%) and lung disease (16.9%). 24 different bacterial species were identified, S. aureus (21%) and P. aeruginosa (18.5%) were predominant. Among 50 S. aureus isolated strains 36% were classified as MRSA (Methicillin Resistant S. aureus). The Gram negative bacteria presented high resistance to aminoglycosides and cephalosporins. A diarrhea outbreak, detected in high-risk neonatology ward, was caused by Salmonella serovar Infantis strain, with high antimicrobial resistance and a plasmid of high molecular weight (98Mda) containing virulence genes and positive for R factor.

Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy

BACKGROUND

Intravenous therapy in the outpatient and home settings is commonplace for many diseases and nutritional disorders. Few data are available on the rate of and risk factors for bloodstream infection among patients receiving such therapy.

OBJECTIVE

To determine rates of and risk factors for bloodstream infection among patients receiving home infusion therapy.

DESIGN

Prospective, observational cohort study.

SETTING

Cleveland, Ohio, and Toronto, Ontario, Canada.

PATIENTS

Patients receiving home infusion therapy through a central or midline catheter.

MEASUREMENTS

Primary laboratory-confirmed bloodstream infection.

RESULTS

Among 827 patients (988 catheters), the most common diagnoses were infections other than HIV (67%), cancer (24%), nutritional and digestive disease (17%), heart disease (14%), receipt of bone marrow or solid organ transplants (11%), and HIV infection (7%). Sixty-nine bloodstream infections occurred during 69,532 catheter-days (0.99 infections per 1000 days). In a Cox regression model with time-dependent covariates, independent risk factors for bloodstream infection were recent receipt of a bone marrow transplant (hazard ratio, 5.8 [95% CI, 3.0 to 11.3]), receipt of total parenteral nutrition (hazard ratio, 4.1 [CI, 2.3 to 7.2]), receipt of therapy outside the home (for example, in an outpatient clinic or physician's office) (hazard ratio, 3.6 [CI, 2.2 to 5.9]), use of a multilumen catheter (hazard ratio, 2.8 [CI, 1.7 to 4.7]), and previous bloodstream infection (hazard ratio, 2.5 [CI, 1.5 to 4.2]). Rates of bloodstream infection per 1000 catheter-days varied from 0.16 for patients with none of these 5 risk factors to 6.77 for patients with 3 or more risk factors. Centrally inserted venous catheters were associated with a higher risk than implanted ports were, but the difference was not statistically significant.

CONCLUSION

Bloodstream infections seem to be infrequent among outpatients receiving infusions through central and midline catheters. However, the rate of infection increases with bone marrow transplantation, parenteral nutrition, infusion therapy in a hospital clinic or physician's office, and use of multilumen catheters. Compared with implanted ports or peripherally inserted catheters, centrally inserted venous catheters may confer greater risk for bloodstream infection.

Long-term central venous catheter infection in HIV-infected and cancer patients: a multicenter cohort study

OBJECTIVES

To evaluate and compare the risk of long-term central venous catheter (CVC) infection in human immunodeficiency virus (HIV)-infected and cancer patients.

DESIGN

Prospective multicenter cohort study based on active surveillance of long-term CVC manipulations and patient outcome over a 6-month period.

SETTING

Services of infectious diseases and oncology of 12 university hospitals in Paris, France.

PARTICIPANTS

In 1995, all HIV and cancer patients with solid malignancy were included at the time of long-term CVC implantation.

RESULTS

Overall, 31.6% of long-term CVC infections were identified in 32% of 201 HIV and 5% of 255 cancer patients. Most were associated with bacteremia, most commonly coagulase-negative staphylococci. The long-term CVC time-related infection risk was greater in HIV than in cancer patients (3.78 vs 0.39 infections per 1,000 long-term CVC days; P<.001). The independent risk factors of long-term CVC infection were as follows: in HIV patients, frequency of long-term CVC handling and neutropenia; in cancer patients, poor Karnofsky performance status; in both HIV and cancer patients, recent history of bacterial infection. The risk of long-term CVC infection was similar for tunneled catheters and venous access ports in each population.

CONCLUSIONS

Prevention of long-term CVC infection should focus first on better sterile precautions while handling long-term CVC, especially in HIV patients who have frequent and daily use of the long-term CVC.

Risk factors for colonization or infection due to methicillin-resistant Staphylococcus aureus in HIV-positive patients: a retrospective case-control study

OBJECTIVE

To determine the risk factors for colonization or infection with methicillin-resistant Staphylococcus aureus in human immunodeficiency virus (HIV)-infected patients.

DESIGN

Retrospective matched-pair case-control study.

SETTING

Continuity clinic and inpatient HIV service of a university medical center.

POPULATION

Patients with HIV infection from the general population of eastern and coastal Texas and from the Texas Department of Criminal Justice.

DATA COLLECTION

Patient charts and the AIDS Care and Clinical Research Program Database were reviewed for the following: age, race, number of admissions, total hospital days, presence of a central venous catheter, serum albumin, total white blood cell count and absolute neutrophil count, invasive or surgical procedures, any cultures positive for S. aureus, and a history of opportunistic illnesses, diabetes, or dermatologic diagnoses. Data also were collected on the administration of antibiotics, antiretroviral therapy, steroids, cancer chemotherapy, and subcutaneous medications.

RESULTS

In the univariate analysis, the presence of a central venous catheter, an underlying dermatologic disease, lower serum albumin, prior steroid therapy, and prior antibiotic therapy, particularly antistaphylococcal therapy or multiple courses of antibiotics, were associated with increased risk for colonization or infection with methicillin-resistant S. aureus. Multivariate analysis yielded a model that included presence of a central venous catheter, underlying dermatologic disease, broad-spectrum antibiotic exposure, and number of hospital days as independent risk factors for colonization or infection with methicillin-resistant S. aureus.

CONCLUSIONS

In our HIV-infected patient population, prior hospitalization, exposure to broad-spectrum antibiotics, presence of a central venous catheter, and dermatologic disease were risk factors for acquisition of methicillin-resistant S. aureus.