Predicting Neonatal Early Onset Sepsis: A 14-Year Cohort Study

BACKGROUND

In many infants, treatment is started for suspicion of early onset sepsis (EOS), of whom the majority do not have an infection. Early prediction of the absence of a culture-proven sepsis (CPS) would significantly reduce the time of antibiotic treatment and hospitalization. Our objective was to analyze 3 criteria in infants with CPS: positive blood culture (BC) at 24 hours after the onset of suspicion of EOS (OSEOS), C-reactive protein (CRP) ≥10 mg/L and clinical signs of infection, so we can consequently consider to stop antibiotic treatment in infants without these criteria.

METHODS

We included all infants with suspicion of EOS from 2007 until 2020. The proportion was calculated of (1) infants with CPS with, at 24 hours, a positive BC and/or CRP ≥10 mg/L and/or clinical signs of infection and (2) infants without CPS with CRP <10 mg/L between 12 and 24 hours after OSEOS.

RESULTS

The BC showed growth of a pathogenic microorganism in 50 of 4120 included infants (1.2%). Time to positivity was ≥24 hours in 8 (16%) infants, of whom 7 infants had a raised CRP and/or clinical symptoms of infection within 24 hours. In 1095 (74%) of infants without CPS in whom CRP was measured between 12 and 24 hours after OSEOS, CRP was <10 mg/L.

CONCLUSION

A combination of BC, CRP, and clinical signs of infection can diagnose 98% (49/50) of infants with CPS 24 hours after OSEOS. Based on normal CRP and the absence of a positive BC, the decision to stop antibiotics could have been brought forward to 24 hours in 74% of infants.

Analysis of risk factors, pathogenic bacteria of maternal sepsis in term pregnant women with positive blood culture during hospitalization

The objective of this study was to evaluate the risk factors, pathogenic bacteria and drug sensitivity of maternal sepsis, and provide evidence for clinical prevention and treatment.A retrospective investigation of pregnant women with full-term maternal sepsis was performed to analyze the risk factors, pathogenic bacteria, and drug sensitivity of maternal sepsis.Univariate analysis showed that temperature, serum procalcitonin (PCT) and C-reactive protein (CRP) at admission, white blood cell count (WBC), PCT, CRP and neutrophilic granulocyte percentage (N%) during fever, premature rupture of membranes (PROM), antibiotic use within 1 week, mode of production, onset and duration of fever, between groups were statistically significant (P < .05). Logistic regression analysis showed that cesarean section was an independent risk factor for sepsis (OR = 11.839, 95%CI: 3.121-44.906). Apparent increase was found in body temperature (OR = 3.664, 95%CI: 1.722-7.795), duration of fever (OR = 1.953, 95%CI: 1.242-3.071), and PCT (OR = 1.080, 95%CI: 1.002-1.163). Also, increasing neutrophil ratio (OR = 1.180, 95%CI: 1.073-1.297) indicated a high possibility of maternal sepsis. The organism Escherichia coli (E. coli) was the most common pathogenic bacteria in the positive blood culture group (90%), and the sensitivity to carbapenems (meropenem and imipenem/cilastatin) was 100%, that to piperacillin-tazobactam and amoxicillin sulbactam was over 90%, and that to ceftazidime was 95%.Cesarean section was an independent risk factor for maternal sepsis in term pregnant women with positive blood culture. Besides, the E. coli was the most common pathogenic bacteria in the positive blood culture group. Antibiotics should be used in time and reasonably when the temperature was significantly increased with elevated PCT and N% after a cesarean section.

Seasonality of bacteremia cases in an emergency department

OBJECTIVES

To assess seasonal variation in episodes of bacteremia.

MATERIAL AND METHODS

Retrospective cohort study of cases of significant bacteremia found in blood cultures ordered in a hospital emergency department. The incidence, etiology, diagnostic and prognostic yield were analyzed for each season of the year.

RESULTS

A total of 4384 blood cultures were ordered in 4.1% of the emergency patients attended. The diagnostic yield was 12.2% (incidence, 490 cases per 100 000 cases attended). Cultures were ordered more often in winter (in 4.6% of the patients vs in 3.8% in the other seasons on average, P<.001). The diagnostic yield was lower in winter than in the other seasons (10.2% vs 13%, P=.01), and the contamination rate was higher (4.9% vs 3.8%, P=.02). Escherichia coli was isolated in fewer cultures in winter than in other seasons (36.4% vs 46.9%, P=.03), and Streptococcus pneumoniae was isolated in more (14.5% vs 5.9%, P=.001).

CONCLUSION

The microbiological profile of blood cultures, their diagnostic yield, and rate of contamination differ greatly in winter.

FeBRILe3 Project: protocol for a prospective pragmatic, multisite observational study and safety evaluation assessing Fever, Blood cultures and Readiness for discharge in Infants Less than 3 months old

INTRODUCTION

The purpose of this observational study is to assess the safety and impact of the introduction of a clinical practice guideline (CPG) recommending early discharge of infants with fever without source who are at low risk of serious bacterial infection (SBI). We hypothesise that implementation of this guideline will be associated with a rate of unplanned readmission to hospital (within 7 days of discharge) which is similar (ie, non-inferior) to that observed under previous standard practice.

METHODS AND ANALYSIS

This observational study is a prospective pragmatic, multisite safety assessment and impact project. It will evaluate the safety of a CPG which allows febrile infants fulfilling low-risk criteria to be discharged early from hospital if their blood cultures demonstrate no growth at 24 hours (compared with previous minimum 48 hours admission). This guideline has been implemented at two Western Australian metropolitan hospitals. Infants aged <3 months (chronological or corrected for premature birth before 37 weeks gestation) presenting with fever without source will be included. The primary outcome is readmission to hospital due to clinical deterioration/caregiver concern within 7 days of discharge, identified through review of electronic admission details and study-specific caregiver surveys. Secondary outcomes include rates of SBI, hospital lengths of stay compared with previous practice, clinician guideline adherence and caregiver satisfaction with the discharge process. Analysis will be within a sequential Bayesian safety monitoring framework, which incorporates new information and updates the evidence for guideline safety relative to previous practice (historical control) at prespecified interim analyses. Demographic and clinical information will be summarised.

ETHICS AND DISSEMINATION

Ethics approval and waiver of consent for data collection has been granted by the Child and Adolescent Health Service Human Research Ethics Committee (RGS0000001415). Caregivers will have the option to opt out of survey follow-up. Results will be disseminated via peer-reviewed publication.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619001010189).

The Neonatal Early Onset Sepsis Calculator; in Clinical Practice

Aims To determine the impact of applying the Neonatal Early Onset Sepsis Calculator (NEOSC) to clinical practice. We evaluated this multivariable risk prediction model, used in the assessment of infants >35 weeks GA, at risk of neonatal sepsis. Methods A retrospective, cohort study comparing the rates of blood culture use in a large maternity hospital before and after the introduction of the NEOSC. Cases were ascertained from the records of the Department of Microbiology. The key variables were the number of blood cultures (all gestational ages, <72 hours old), infant antibiotic use and sepsis rates. Data for three years prior to NEOSC use (January 2015 - December 2017) were compared with 15 months (January 2018 - Q1 2019) after it was implemented. Results Pre- and post- NEOSC use, the total blood cultures taken annually were: 1,312 (2015), 1,149 (2016), 1,319 (2017) and 702 (2018), 192 (Q1 2019) respectively, a statistically significant reduction [p < 0.00001, 95% CI]. There was no significant difference in rates of either: culture-confirmed GBS-sepsis [p value 0.18, 95% CI] or other-pathogen sepsis [p value 0.32, 95%CI] in term infants between the two periods. There was a significant reduction in antibiotic use in the first 24 hours of life (average 11.3% pre-NEOSC and 5.9% after NEOSC was implemented) [p < 0.00001, 95% CI]. Conclusion The introduction of the NEOSC has reduced blood culture and antibiotic use. This has been achieved without any increase in infection rates.

Under-detection of blood culture-positive enteric fever cases: The impact of missing data and methods for adjusting incidence estimates

Background

In surveillance for typhoid fever, under-detection of cases occurs when patients with fever do not seek medical care, or seek medical care but do not receive a blood test. Missing data may result in incorrect estimates of disease incidence.

Methods

We used data from an ongoing randomised clinical trial of typhoid conjugate vaccine among children in Nepal to determine if eligible patients attending our fever clinics who did not have blood taken for culture had a lower risk of disease than those who had blood drawn. We assessed clinical and demographic predictors of having blood taken for culture, and predictors of culture-positive results. Missing blood culture data were imputed using multiple imputations.

Results

During the first year of surveillance, 2392 fever presentations were recorded and 1615 (68%) of these had blood cultures. Children were more likely to have blood taken for culture if they were older, had fever for longer, a current temperature ≥38 degrees, or if typhoid or a urinary tract infection were suspected. Based on imputation models, those with blood cultures were 1.87 times more likely to have blood culture-positive fever than those with missing data.

Conclusion

Clinical opinion on the cause of the fever may play a large part in the decision to offer blood culture, regardless of study protocol. Crude typhoid incidence estimates should be adjusted for the proportion of cases that go undetected due to missing blood cultures while adjusting for the lower likelihood of culture-positivity in the group with missing data.

Typhoid fever is a serious illness caused by a bacterial infection in the blood. Typhoid spreads through contaminated water sources, poor sanitation or poor hygiene, and occurs most often in low-resource environments, with children being most at risk. It is hard to determine how common typhoid infections are in low-resource setting as there are many pathogens that can cause diseases with similar characteristics, and not all patients present to health-care facilities. The culture test to detect the presence of bacteria in the blood is poorly sensitive, costly to perform, and not available in all facilities. Therefore, true disease cases often go undetected, resulting in an underestimation of the true burden of disease. We examined factors associated with blood culture collection in fever patients attending typhoid surveillance clinics in Kathmandu, Nepal. We aimed to determine whether those who did not have a blood culture were different in terms of clinical and demographic characteristics to those who did have blood taken for culture and, additionally, whether they were more or less likely to test blood culture positive for typhoid fever. We provide estimates of inflation factors that can be used to adjust the crude incidence rate to account for the under-detection of typhoid cases.

Reduced utility of early procalcitonin and blood culture determination in patients with febrile urinary tract infections in the emergency department

To investigate the prognostic role of procalcitonin (PCT) assessment and blood culture (BC) acquisition in the emergency department (ED) in patients with urinary tract infection (UTI) or urosepsis. We enrolled patients admitted for UTI to our ED over a 10-year period. Mortality and in hospital length of stay (LOS) were compared between patients with UTI or urosepsis who had sampling for PCT levels and BC taken in the ED (ePCT group-eBC group) and those who had not (no-ePCT group-no-eBC group). 1029 patients were analyzed, 52.7% of which were female. Median age was 77 [65-83]; 139 patients (13.5%) had complicated UTI. Median LOS was 10 [7-17] days. In the ePCT group, LOS was 10 [7-16] days, vs. 10 [7-17] (p = 0.428) in the no-ePCT group. In the eBC group, LOS was 10 [6-16] days vs. 10 [7-17] days (p = 0.369) in the no-eBC group. The overall mortality rate was 6.6%. The mortality rate was not affected by early PCT determination (6% in the ePCT group vs. 6.9% in the no-ePCT group, p = 0.584). Similarly, the mortality rate was not different in the eBC group as compared to the no-eBC group (5.4% vs. 6.9%, p = 0.415). Performance of ePCT or eBC testing made no significant difference in terms of improvement of mortality rates in septic patients (11.4% vs. 7.2%; p = 0.397 and 8.8% vs. 9.8%; p = 0.845, respectively). The prognostic relevance of early evaluation of PCT and BC in the ED of patients with febrile UTI appears limited. In complicated UTI patients, PCT and BC testing may be more appropriate in the context of improving antibiotic stewardship, or as an integral component of PCT-guided standardized protocols.

Clinical Significance of Isolates Known to Be Blood Culture Contaminants in Pediatric Patients

Background and objectives: The objective of this study was to investigate the clinical significance of isolates from blood stream infection known to be blood culture contaminants in pediatric patients. Materials and Methods: Microbiological reports and medical records of all blood culture tests issued from 2002 to 2012 (n = 76,331) were retrospectively reviewed. Evaluation for potential contaminants were done by reviewing medical records of patients with the following isolates: coagulase-negative Staphylococcus, viridans group Streptococcus, Bacillus, Corynebacterium, Micrococcus, Aerococcus, and Proprionibacterium species. Repeated cultures with same isolates were considered as a single case. Cases were evaluated for their status as a pathogen. Results: Coagulase-negative Staphylococcus had clinical significance in 23.8% of all cases. Its rate of being a true pathogen was particularly high in patients with malignancy (43.7%). Viridans group Streptococcus showed clinical significance in 46.2% of all cases. Its rate of being a true pathogen was similar regardless of the underlying morbidity of the patient. The rate of being a true pathogens for remaining isolates was 27.7% for Bacillus and 19.0% for Corynebacterium species. Conclusions: Coagulase-negative Staphylococcus and viridans group Streptococcus isolates showed high probability of being true pathogens in the pediatric population, especially in patients with underlying malignancy.

The impact of a rapid molecular identification test on positive blood cultures from critically ill with bacteremia: A pre-post intervention study

Objectives

Bloodstream infections in critically ill require a speeded-up microbiological diagnosis to improve clinical outcomes. In this pre-post intervention study, we evaluated how a molecular identification test directly performed on positive blood cultures of critically ill improves patient’s therapeutic management.

Methods

All adult patients staying at the intensive care unit (ICU) at the time of positive blood culture detection were study-eligible. In the 8-month pre-intervention period (P0), standard positive blood culture management was performed. In the 10-month intervention period (P1), a BioFire^® FilmArray^® blood culture identification (FA-BCID) test (bioMérieux) was additionally performed 24/7 at detection. The evaluated clinical outcome was time to optimal antimicrobial treatment of the bloodstream infection. FA-BCID microbiological test performances were also analysed.

Results

163 positive blood culture episodes were allocated to P0 and 166 to P1. After the withdrawal of episodes in accordance with defined exclusion criteria, outcome analysis was performed on 110 bloodstream infections both in P0 and P1. Time to optimal antimicrobial treatment in P0 was 14h41 compared to 4h39 in P1. FA-BCID test results led to a treatment adjustment in 35/110 (31.8%) P1 episodes including 26 where the adjustment was the optimal antimicrobial treatment. FA-BCID testing identified 96.2% of the on-panel microorganisms thereby covering 85.2% of our ICU-strain epidemiology. Time to identification with FA-BCID testing was calculated at 1h35. Resistance detection was in complete concordance with routine results. Considering 150 FA-BCID tests were initially performed in P1, 4,3 tests were required to have 1 test leading to an improved therapeutic outcome.

Conclusions

FA-BCID testing drastically reduced time to optimal antimicrobial treatment in critically ill with bloodstream infections.

Procalcitonin as a Predictive Marker for Bacteremia in Children With a Central Line and Fever

OBJECTIVES

Unnecessary use of antibiotics is an increasing problem. In this study, we sought to determine the diagnostic accuracy of procalcitonin in predicting bacteremia in children with a central line and fever, and we sought to determine optimal cutoff values to maximize sensitivity and specificity. This is the largest study to date in which procalcitonin is examined as a predictive marker of bacteremia in pediatric patients with a central line and fever.

METHODS

We conducted a retrospective cohort study of children aged 0 to 23 years with a central line and fever of 38°C who had procalcitonin and blood cultures drawn before initiation of antibiotics and had no other identified bacterial infection. Patients were also prospectively monitored via a custom-built electronic medical record dashboard for eligibility.

RESULTS

There were 523 patients and >2500 procalcitonin values reviewed for eligibility. Of these, 169 (47%) patients and 335 blood cultures with procalcitonin were included. There were 94 (28%) positive bacterial blood cultures and 241 (72%) negative bacterial blood cultures. In bacteremic cultures, the mean procalcitonin level was 9.96 ± 15.96 ng/mL, and the median procalcitonin level was 4.85 ng/mL (interquartile range 18.5). In nonbacteremic cultures, the mean procalcitonin level was 1.23 ± 10.37 ng/mL, and the median procalcitonin level was 0.3 ng/mL (interquartile range 0.7). A receiver operating characteristic analysis indicated a procalcitonin level of ≥0.6 ng/mL as the best cutoff point that produced a sensitivity of 85.6% and a specificity of 65.7% (area under the curve 0.85).

CONCLUSIONS

Procalcitonin is a sensitive biomarker in predicting bacteremia in children with a central line and fever.

Evaluation of blood culture epidemiology and efficiency in a large European teaching hospital

Background

Blood cultures remain the gold standard for detecting bacteremia despite their limitations. The current practice of blood culture collection is still inefficient with low yields. Limited focus has been given to the association between timing of specimen collection at different time points during admission and their yield.

Methods

We carried out a retrospective observational study by analyzing all 3,890 sets of cultures collected from the 1,962 admitted patients over the seven-month period of this study. We compared the blood culture yield between the early group (≤24 hours after admission) and the late group (> 24 hours of admission). We also investigated the effect of prehospital oral antibiotics and pre-analytical time on the first cultures in the emergency department. Epidemiology and efficiency of blood cultures were studied for each medical specialty.

Results

In total, 3,349(86.1%) blood cultures were negative and 541(13.9%) were positive for one or more microorganisms. After correcting for contamination, the overall yield was 290 (7.5%). The early group (n = 1,490) yielded significantly more true-positive cultures (10.1% versus 5.8%, P<0.001) than the late group (n = 2,400). The emergency department had a significantly higher yield than general wards, 11.2% versus 5.7% (p<0.001). Prehospital oral antibiotic use and pre-analytical time did not affect the yield of first cultures at the emergency department (p = 0.735 and 0.816 respectively). The number of tests needed to obtain one true-positive culture varied between departments, ranging from 7 to 45.

Conclusion

This study showed that blood cultures are inefficient in detecting bacteremia. Cultures collected during 24 hours after admission yielded more positive results than those collected later. Significant variations in blood culture epidemiology and efficiency per specialty suggest that guidelines should be reevaluated. Future studies should aim at improving blood culture yield, implementing educational programs to reduce contamination and cost-effective application of modern molecular diagnostic technologies.

The clinical impact of patients with bloodstream infection with different groups of Viridans group streptococci by using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)

The accuracy of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) for identifying viridans group streptococcus (VGS) was improving. However, the clinical impact of identifying VGS had not been well recognized. Our study had comprehensively studied the clinical manifestations and outcome of VGS blood stream infection by using MALDI-TOF MS for identification.This retrospective study enrolled 312 adult patients with a monomicrobial blood culture positive for VGS. Blood culture was examined through MALDI-TOF MS.The most common VGS species were the Streptococcus anginosus group (38.8%) and Streptococcus mitis group (22.8%). Most species showed resistance to erythromycin (35.6%), followed by clindamycin (25.3%) and penicillin (12.5%). Skin and soft tissue infection and biliary tract infection were significantly related to S. anginosus group bacteremia (P = .001 and P = .005, respectively). S. mitis group bacteremia was related to infective endocarditis and bacteremia with febrile neutropenia (P = .005 and P < .001, respectively). Infective endocarditis was also more likely associated with S. sanguinis group bacteremia (P = .009). S. anginosus group had less resistance rate to ampicillin, erythromycin, clindamycin, and ceftriaxone (P = .019, <.001, .001, and .046, respectively). A more staying in intensive care unit, underlying solid organ malignancy, and a shorter treatment duration were independent risk factors for 30-day mortality. This study comprehensively evaluated different VGS group and their clinical manifestations, infection sources, concomitant diseases, treatments, and outcomes. Categorizing VGS into different groups by MALDI-TOF MS could help clinical physicians well understand their clinical presentations.

Blood Culture Turnaround Time in U.S. Acute Care Hospitals and Implications for Laboratory Process Optimization

The rapid identification of blood culture isolates and antimicrobial susceptibility test (AST) results play critical roles for the optimal treatment of patients with bloodstream infections. Whereas others have looked at the time to detection in automated culture systems, we examined the overall time from specimen collection to actionable test results. We examined four points of time, namely, blood specimen collection, Gram stain, organism identification (ID), and AST reports, from electronic data from 13 U.S. hospitals for the 11 most common, clinically significant organisms in septic patients. We compared the differences in turnaround times and the times from when specimens were collected and the results were reported in the 24-h spectrum. From January 2015 to June 2016, 165,593 blood specimens were collected, of which, 9.5% gave positive cultures. No matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry was used during the study period. Across the 10 common bacterial isolates (n = 6,412), the overall median (interquartile range) turnaround times were 0.80 (0.64 to 1.08), 1.81 (1.34 to 2.46), and 2.71 (2.46 to 2.99) days for Gram stain, organism ID, and AST, respectively. For all positive cultures, approximately 25% of the specimens were collected between 6:00 a.m. and 11:59 a.m. In contrast, more of the laboratory reporting times were concentrated between 6:00 a.m. and 11:59 a.m. for Gram stain (43%), organism ID (78%), and AST (82%), respectively (P < 0.001). The overall average turnaround times from specimen collection for Gram stain, organism ID, and AST were approximately 1, 2, and 3 days, respectively. The laboratory results were reported predominantly in the morning hours. Laboratory automation and work flow optimization may play important roles in reducing the microbiology result turnaround time.

Adequate or Inadequate? The Volume of Blood Submitted for Blood Culture at a Tertiary Children's Hospital

The volume of blood sampled for culture critically influences the results. This study aimed to determine (1) the volume of blood submitted for culture, (2) the proportion of blood cultures with adequate volume, (3) whether measured improvement from a previous educational intervention had been sustained, and (4) the impact of blood volume on culture result. The volume of blood submitted for cultures was determined over a 13-month period by weighing bottles before and after collection and before and after an educational intervention. The volume of blood submitted in 5127 culture bottles were measured. Fewer than 50% of all cultures were deemed adequate. A significant pathogen was isolated in 4.7% of blood cultures, and low-volume cultures were more likely to yield contaminant isolates (47/2422 [1.9%] vs 22/2705 [0.8%], P = .0005). Subsequently, the higher rate of contaminant isolates from low-volume cultures may affect selection and rationalization of antibiotic therapy.

[Assessment of an educational intervention regarding blood cultures as process indicators in an emergency department in Argentina]

OBJECTIVE

The aim of this study was to describe 2 process indicators related to taking blood cultures (BC) in an Adult Emergency Department of a tertiary university hospital in Buenos Aires,and to describe the changes after a series of educational activities for health professionals was implemented during May 2016 as regards the appropriate indication of BC and the proper collection technique.

MATERIALS AND METHODS

A retrospective cohort study was designed to assess its effectiveness, which consecutively included all patients admitted during 2015-2016. The BC request rate was used as a process indicator, and the percentage of contaminated BCs and the true positives rate were used as quality indicators. Both were measured monthly and prospectively during the period of study.

RESULTS

The annual adjusted rate of BC requests was 4.9% (95% CI 4.8-5) in 2015 and 2.9% (95% CI 2.8-2.9) in 2016. The rate of false positive (contaminated) BCs was 4.5% in 2015 and 4.3% after the educational intervention. The true positive BCs were 8.3% in 2015 and 12% post-intervention.

CONCLUSIONS

These findings prove how important and effective the educational interventions are.

Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children's Hospitals

OBJECTIVES

The incidence of staphylococcal scalded skin syndrome (SSSS) is rising, but current practice variation in diagnostic test use is not well described. Our aim was to describe the variation in diagnostic test use in children hospitalized with SSSS and to determine associations with patient outcomes.

METHODS

We performed a retrospective (2011-2016) cohort study of children aged 0 to 18 years from 35 children's hospitals in the Pediatric Health Information System database. Tests included blood culture, complete blood count, erythrocyte sedimentation rate, C-reactive protein level, serum chemistries, and group A streptococcal testing. K-means clustering was used to stratify hospitals into groups of high (cluster 1) and low (cluster 2) test use. Associations between clusters and patient outcomes (length of stay, cost, readmissions, and emergency department revisits) were assessed with generalized linear mixed-effects modeling.

RESULTS

We included 1259 hospitalized children with SSSS; 84% were ≤4 years old. Substantial interhospital variation was seen in diagnostic testing. Blood culture was the most commonly obtained test (range 62%-100%), with the most variation seen in inflammatory markers (14%-100%). Between hospital clusters 1 and 2, respectively, there was no significant difference in adjusted length of stay (2.6 vs 2.5 days; P = .235), cost ($4752 vs $4453; P = .591), same-cause 7-day readmission rate (0.8% vs 0.4%; P = .349), or emergency department revisit rates (0.1% vs 0.6%; P = .148).

CONCLUSIONS

For children hospitalized with SSSS, lower use of diagnostic tests was not associated with changes in outcomes. Hospitals with high diagnostic test use may be able to reduce testing without adversely affecting patient outcomes.

Bloodstream Infections Caused by Contaminants: Epidemiology and Risk Factors: A 10-Year Surveillance

BACKGROUND

Skin colonization of microorganisms in blood cultures (BCs) are generally considered clinically non-significant and can be the source of a true infection, particularly in immunosuppressed patients.

OBJECTIVES

To study the epidemiology and risk factors for bacteremia caused by contaminants.

METHODS

This retrospective, descriptive study is based on adult BCs collected (2004-2013) and categorized as positive (True bacteremia [TrueB] or contamination) or negative. Clinical, demographic, and laboratory characteristics of BCs positive for the six most common potential contaminant pathogens (PCPs) that can cause TrueB and contamination (Coagulase-negative Staphylococcus [CoNS], Streptococcus viridans, Propionibacterium acnes, Corynebacterium spp., Bacillus spp., Clostridium spp.) were assessed. Ninety-two TrueB were identified vs. 196 contaminations (1:2 ratio).

RESULTS

From 74,014 BCs, PCPs were found in 3735 samples, of which 3643 (97.5%) were contaminations and 92 (2.5%) were TrueB. The overall rate of BC contamination decreased during the study period from 6.7% to 3.8%. CoNS was the most common PCP. Bacillus spp. were only contaminants. Clostridium spp. and Streptococcus viridans were more often TrueB. In a multivariate model, predictors of TrueB included high creatinine levels, Streptococcus viridans in BC, and multiple positive BCs. A single culture of CoNS was strongly predictive of contamination.

CONCLUSIONS

Ten years of data on BCs, focusing on six PCPs, demonstrates a significant, yet insufficient reduction in the rate of contamination. High creatinine level, isolation of Streptococcus viridans, and multiple positive BCs were predictors of TrueB, while growth of CoNS was strongly predictive of contamination. This model could assist in diagnostic and therapeutic decision making.

Should First-line Empiric Treatment Strategies for Neonates Cover Coagulase-negative Staphylococcal Infections in Kenya?

BACKGROUND

Neonatal mortality remains high in sub-Saharan Africa, and a third of deaths are estimated to result from infection. While coagulase-negative staphylococci (CoNS) are leading neonatal pathogens in resource-rich settings, their role, and the need for early anti-Staphylococcal treatment in empiric antibiotic guidelines, is unknown in sub-Saharan Africa.

METHODS

We examined systematic clinical and microbiologic surveillance data from all neonatal admissions to Kilifi County Hospital (1998-2013) to determine associated case fatality and/or prolonged duration of admission associated with CoNS in neonates treated according to standard World Health Organization guidelines.

RESULTS

CoNS was isolated from blood culture in 995 of 9552 (10%) neonates. Case fatality among neonates with CoNS isolated from blood did not differ from other neonatal admissions (P = 0.2), and duration of admission was not prolonged [odds ratio (OR) = 0.9 (0.7-1.0), P = 0.040]. Neonates with CoNS were more likely to have convulsions [OR = 1.4 (1.0-1.8), P = 0.031] but less likely to have impaired consciousness or severe indrawing [OR = 0.8 (0.7-0.9), P = 0.025; OR = 0.9 (0.7-1.0), P = 0.065].

CONCLUSIONS

CoNS isolation in blood cultures at admission was not associated with adverse clinical outcomes in neonates treated according to standard World Health Organization guidelines for hospital care in this setting. There is no evidence that first-line antimicrobial treatment guidelines should be altered to increase cover for CoNS infections in neonates in this setting.

The effects of culture independent diagnostic testing on the diagnosis and reporting of enteric bacterial pathogens in Queensland, 2010 to 2014

Changes in diagnostic laboratory testing procedures can impact on the number of cases notified and the public health surveillance of enteric pathogens. Culture independent diagnostic testing using a multiplex polymerase chain reaction (PCR) test was introduced for the rapid detection of bacterial enteric pathogens in pathology laboratories in Queensland, Australia, from late 2013 onwards. We conducted a retrospective descriptive study using laboratory data to assess the impact of the introduction of PCR testing on four common enteric pathogens, Salmonella, Campylobacter, Shigella and Yersinia, in Queensland between 2010 and 2014. The number of stool specimens tested and the proportion positive for each of the four pathogens increased in 2014 after the introduction of culture independent diagnostic testing. Among the specimens tested by both PCR and culture, 12% of Salmonella positive stools, 36% of Campylobacter positive stools, 74% of Shigella / enteroinvasive Escherichia coli positive stools and 65% of Yersinia positive stools were PCR positive only. Including those where culture was not performed, 19% of Salmonella positive stools, 44% of Campylobacter positive stools, 83% of Shigella positive stools and 79% of Yersinia positive stools had no cultured isolate available for further characterisation. The detection and tracking of foodborne and non-foodborne gastrointestinal outbreaks will become more difficult as culture independent diagnostic testing becomes more widespread. Until new techniques for characterisation of pathogens directly from clinical specimens have been developed, we recommend laboratories continue to culture specimens concurrently or reflexively with culture independent diagnostic tests.

Australian Meningococcal Surveillance Programme, 1 April to 30 June 2017

The reference laboratories of the Australian Meningococcal Surveillance Programme (AMSP) report data on the number of cases of invasive meningococcal disease (IMD) confirmed by laboratory testing using culture and by non-culture based techniques. Data contained in quar-terly reports are restricted to a description of the number of cases of IMD by jurisdiction and serogroup, where known. A full analysis of laboratory confirmed cases of IMD in each calen-dar year is contained in the AMSP annual reports.

[Before-after study of the effect of implementing a sepsis code for emergency departments in the community of Aragon]

OBJECTIVES

To study the effect of an emergency department sepsis code on the degree of compliance with measures recommended by the Surviving Sepsis Campaign and short-term mortality in the Spanish Autonomous Community of Aragon.

MATERIAL AND METHODS

Quasi-experimental study of 2 case cohorts, one including of cases before implementation of the sepsis code and one included cases managed afterwards. We extracted retrospectively data from hospital records for infectious processes and organ failures between December 2012 and January 2013 for the pre-code group and between December 2014 and January 2015 for the post-code group. Staff training sessions on the campaign recommendations were provided and the code, which specified clinical pathways, was activated electronically on inputting clinical variables at the moment of triage. Outcome measures were the percentage of compliance with the campaign's recommendations in the first 3 hours after a patient's arrival at the emergency department in-hospital mortality, and 30-day mortality.

RESULTS

A total of 222 cases were included in each group. Compliance with the following campaign recommendations improved after implementation of the sepsis code: antibiotic therapy in the first hour (P=.100), extractions for blood cultures (P 001), lactic acid measurement (P 001), and recommended fluid loading (P 001). In-hospital mortality was 31.1% in the pre-code cohort and 20.7% post-code; 30-day mortality rates were 30.1% and 19.8%, respectively (P=.016, all comparisons).

CONCLUSION

Use of a sepsis code led to short-term improvement in how often the measures recommended by a sepsis survival campaign were put into practice.

Diagnosis of paediatric sepsis by automated blood culture system and conventional blood culture

OBJECTIVE

To evaluate the time required for isolation of aerobic bacterial pathogen from paediatric septicaemia suspects by using BACTEC 9240 blood culture system, and to compare the results with conventional blood culture technique.

METHODS

This comparative cross-sectional study was conducted at the Jinnah Hospital, Lahore, Pakistan, from July to December 2013, and comprised blood samples of suspected septicaemia children. The blood samples were inoculated into automated BACTEC 9240 Peds Plus/F resin-based media. At the same time, conventional blood culture bottle was also inoculated for comparison. The time of culture positivity and bacterial spectrum isolated from these samples was evaluated. SPSS 20 was used for data analysis.

RESULTS

Of the 100 blood culture samples, 36(36%) were true pathogens on BACTEC 9240, while 24(24%) were positive through the conventional method. The mean age of the participants was 0.65±20 days. Staphylococcus aureus was detected in 12(12%) samples by BACTEC 9240 and in 7(7%) cases by conventional system. BACTEC 9240 significantly reduced time of positivity from 48 hours to 21 hours compared to conventional system. The number of samples detected within 36 and 48 hours was 7(19.4%) by BACTEC 9240 and 17(70.8%) by conventional system (p<0.05).

CONCLUSIONS

Diagnosis of paediatric septicaemia through BACTEC 9240 was quicker with high yield and great sensitivity compared to the conventional technique.

Blood cultures in the evaluation of uncomplicated cellulitis

PURPOSE

The frequency of bacteremia and the array of microorganisms involved in cellulitis vary greatly among studies. Although current guidelines do not recommend routine blood culture in uncomplicated cellulitis, their implementation in clinical practice remains challenging. We therefore aimed to assess the frequency, determinants and microbiology of bacteremia in hospitalized patients with uncomplicated cellulitis.

METHODS

We retrospectively reviewed the medical records of all adult patients admitted at a primary-care hospital with a diagnosis of community-acquired uncomplicated cellulitis during a 4-year period. We looked at the factors associated with blood cultures sampling and at the incidence, determinants and microbiology of bacteremia in this population.

RESULTS

Among the 476 patients hospitalized with a diagnosis of cellulitis, 250 (52.5%) had blood cultures. Fever, high C-reactive protein and lymphatic insufficiency were significantly associated with the sampling of blood cultures. Twelve (4.8%) patients had bacteremia. Alcoholism and duration of hospitalization were associated with bacteremia in multivariate analysis. Among the 12 patients with bacteremia, 9 had Streptococcus sp. and 3 had Staphylococcus aureus infection.

CONCLUSION

In our study population with uncomplicated cellulitis, representative of unselected population admitted at primary-care hospitals, bacteremia was uncommon and not associated with discriminant patient characteristics, except for alcohol abuse. Episodes of bacteremia were exclusively due to gram-positive cocci susceptible to co-amoxicilin, a common first-line empirical therapy. In accordance with existing guidelines, we do not recommend to collect blood for cultures in uncomplicated cellulitis. Clinicians' awareness of guidelines and of the poor yield of blood cultures could reduce useless investigation.

Predictive factors of true bacteremia and the clinical utility of blood cultures as a prognostic tool in patients with community-onset pneumonia

Although blood cultures (BCs) are an important component of diagnostic practice for antibiotic management in patients with pneumonia, several studies have questioned whether they should be performed. The objective of this study was to evaluate the predictive factors of bacteremia and the role of BCs in patients with community-onset pneumonia (community-acquired pneumonia and healthcare-associated pneumonia).This study was retrospectively conducted in patients with community-onset pneumonia who were hospitalized at Jeju National University Hospital between January 2012 and December 2014. A true bacteremia (TB) group and a contaminants or negative bacteremia (CNB) group were classified according to the bacterial growth on the BC media and were investigated for the clinical relevance of the BCs.We enrolled 785 patients; the TB group and the CNB group contained 36 patients (4.5%) and 749 (95.4%) patients, respectively. Only 10 patients (1.2%) required a change in antibiotic therapy based on the BC results (3 patients with an escalation, 7 with a de-escalation). There was no significant difference between the community-acquired pneumonia and the healthcare-associated pneumonia groups with regard to the rate of antibiotic change due to the BC results (1.1% vs 1.4%; P = 0.751). Chronic liver disease (odds ratio [OR] 2.973, 95% confidence interval [CI] 1.099-8.037), a confusion, urea, respiratory rate, blood pressure, age ≥65 (CURB-65) score of 4 to 5 points (OR 3.484, 95% CI 1.304-9.307), and Pneumonia Severity Index (PSI) class V (OR 2.405, 95% CI 1.007-5.743) were independently associated with TB. In patients with PSI class V and a CURB-65 score of 4 to 5 points, the TB group tended to show a higher inhospital mortality rate than the CNB group (50.0% vs 29.4%; P = 0.060, 60.0% vs 42.5%; P = 0.480). The areas under the curve for PSI score and CURB-65 score for predicting TB revealed an increased tendency compared with that of C-reactive protein (0.72, 95% CI 0.630-0.809; and 0.72, 95% CI 0.622-0.819 vs 0.629, 95% CI 0.522-0.735, respectively).It seemed reasonable to selectively conduct BC in patients hospitalized with severe community-onset pneumonia based upon its low overall positive rate, its effects on antimicrobial modification, and the associations of TB with the severity indices of pneumonia.

Bacteraemia predictive factors among general medical inpatients: a retrospective cross-sectional survey in a Japanese university hospital

OBJECTIVES

The precise criteria for obtaining blood cultures have not been established; they depend on the physician's judgement. We examined clinical parameters to determine predictive factors of bacteraemia and the need for blood cultures among general medical inpatients.

DESIGN

A retrospective cross-sectional survey.

SETTING

A Japanese university hospital.

PARTICIPANTS

All general inpatients who had blood cultures taken from 1 January 2011 to 31 December 2012.

MAIN MEASURES

Clinical information at or just before blood culture sampling was extracted from medical charts. Factors potentially predictive of bacteraemia were analysed using Fisher's exact test, followed by multivariable logistic regression model analysis.

MAIN RESULTS

A total of 200 patients (male: female=119:81, 64.3±19.1 years old) comprised this study; 57 (28.5%) had positive blood culture results. Multivariable logistic regression analysis revealed that age >60 years (OR=2.75, 95% CI 1.23 to 6.48, p=0.015), female sex (OR=2.21, 95% CI 1.07 to 4.67, p=0.038), pulse rate >90 bpm (OR=5.18, 95% CI 2.25 to 12.48, p<0.001) and neutrophil percentage >80% (OR=3.61, 95% CI 1.71 to 8.00, p=0.001) were independent risk factors for positive blood culture results. The area under the receiver operating characteristic curve analysis of this model was 0.796.

CONCLUSIONS

Our results emphasise the importance of taking blood cultures if the pulse rate is >90 bpm, in elderly patients and in women, and for ordering a differential white cell count.