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PubMed2002

Reappraisal of community-acquired bacteremia: a proposal of a new classification for the spectrum of acquisition of bacteremia.

In recent years, dramatic changes in health care systems have shifted much of the care of sick individuals from hospitals to the community. Consequently, infections traditionally classified as community-acquired or hospital-acquired infections cannot now be readily classified into either category. We thus propose a new classification based on a wider spectrum of acquisition. A total of 1028 episodes of bloodstream infection (BSI) were divided into 5 categories: true community-acquired infections (370 episodes [36%]), infections in recently discharged patients (110 [11%]), infections associated with invasive procedures performed just before or at the time of admission (56 [5%]), infections in patients admitted from nursing homes (68 [7%]), and hospital-acquired infections (424 [41%]). Thus, 234 (39%) of the 604 bloodstream infections traditionally defined as community acquired were reclassified into 3 newly defined groups, each of which has distinct epidemiologic, clinical, and bacteriologic characteristics, as well as distinct antimicrobial susceptibility profiles. There is a conceptual and practical need for such a new classification.

Aged↗
PubMed2003

A prospective multicenter study of Staphylococcus aureus bacteremia: incidence of endocarditis, risk factors for mortality, and clinical impact of methicillin resistance.

Our objectives were to determine the incidence of endocarditis in patients whose Staphylococcus aureus bacteremia was community-acquired, related to hemodialysis, or hospital-acquired; to assess clinical factors that would reliably distinguished between S. aureus bacteremia and S. aureus endocarditis; to assess the emergence of methicillin-resistant S. aureus (MRSA) as a cause of endocarditis; and to examine risk factors for mortality in patients with S. aureus endocarditis. We conducted a prospective observational study in 6 university teaching hospitals; we evaluated 505 consecutive patients with Staphylococcus aureus bacteremia. Thirteen percent of patients with S. aureus bacteremia were found to have endocarditis, including 21% with community-acquired S. aureus bacteremia, 5% with hospital-acquired bacteremia, and 12% on hemodialysis. Infection was due to MRSA in 31%. Factors predictive of endocarditis included underlying valvular heart disease, history of prior endocarditis, intravenous drug use, community acquisition of bacteremia, and an unrecognized source. Twelve patients with bacteremia had a prosthetic valve; 17% developed endocarditis. Unexpectedly, nonwhite race proved to be an independent risk factor for endocarditis by both univariate and multivariate analyses. Persistent bacteremia (positive blood cultures at day 3 of appropriate therapy) was identified as an independent risk factor for both endocarditis and mortality, a unique observation not reported in other prospective studies of S. aureus bacteremia. Patients with endocarditis due to MRSA were significantly more likely to have complicating renal insufficiency and to experience persistent bacteremia than those with endocarditis due to MSSA. The 30-day mortality was 31% among patients with endocarditis compared to 21% in patients who had bacteremia without endocarditis (p = 0.055). Risk factors for death due to endocarditis included severity of illness at onset of bacteremia (as measured by Apache III and Pitt bacteremia score), MRSA infection, and presence of atrioventricular block on electrocardiogram. Patients with S. aureus bacteremia who have community acquisition of infection, underlying valvular heart disease, intravenous drug use, unknown portal of entry, history of prior endocarditis, and possibly, nonwhite race should undergo echocardiography to screen for the presence of endocarditis. We recommend that blood cultures be repeated 3 days following initiation of antistaphylococcal antibiotic therapy in all patients with S. aureus bacteremia. Positive blood cultures at 3 days may prove to be a useful marker in promoting more aggressive management, including more potent antibiotic therapy and surgical resection of the valve in endocarditis cases. MRSA as the infecting organism should be added to the list of risk factors for consideration of valvular resection in cases of endocarditis.

Bacteremia↗
PubMed2002

Klebsiella bacteremia in children in southern Israel (1988-1997).

BACKGROUND: Klebsiella spp. have emerged in recent years as a major cause of gram-negative bacteremia in infants and children. We therefore aimed to document the epidemiology, antibiotic susceptibility pattern and outcome of both community-acquired and nosocomial Klebsiella spp. bacteremias in children. PATIENTS AND METHODS: From 1988-1997, 177 episodes of Klebsiella bacteremia, representing 15% of all gram-negative bacteremias, occurred at the Soroka Medical Center in 166 children aged 0-14 years. RESULTS: The overall incidence of Klebsiella bacteremia in southern Israel during the study period was 0.13/1,000, with an increase from 0.1 to 0.2/1,000 children from 1988-1992 to 1993-1997 (p = 0.02). 113 and 64 episodes were recorded in Bedouin Arabs and Jewish children, respectively. The incidence of Klebsiella bacteremia was significantly higher in Bedouins compared to Jewish children (p < 0.001). The incidence of Klebsiella bacteremia increased significantly among Jewish children from 1993-1997 compared to 1988-1992. The incidence of Klebsiella bacteremia was 2/1,000 admissions, with an increase from 1.8 to 2.2/1,000 from 1993-1997 compared to 1988-1992. The incidence of Klebsiella bacteremia was significantly higher among hospitalized Bedouin children compared to Jewish children (3.1 vs 1.4/1,000 admissions, p < 0.001). There were 48 (27%), 24 (14%) and 98 (55%) Klebsiella bacteremia episodes at the pediatric departments, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU), respectively. 76% of Klebsiella bacteremia episodes were nosocomial; 66% occurred at NICU. 71% and 90% of Klebsiella bacteremia episodes occurring at NICU and PICU, respectively, were nosocomial. The overall incidence of nosocomial infections was 1.5/1,000 admissions, with an increase from 1.2 to 1.8/1,000 from 1993-1997 compared to 1988-1992 (p = 0.03). The resistance rates of Klebsiella spp. to piperacillin, ceftriaxone, ceftazidime and gentamicin were 34%, 17%, 17% and 14%, respectively. A significant increase in the resistance rates to ceftriaxone and ceftazidime was observed from 1993-1997 compared to 1988-92 (21.9% vs 7.8%, p = 0.05 and 21.9% vs 5%, p = 0.03). A significant increase in resistance to ceftriaxone was recorded at PICU and NICU (from 12% and 0%, respectively, from 1988-1992, to 61% and 16%, respectively, from 1993-1997, p = 0.02). Overall mortality rate of Klebsiella bacteremia was 13% (21/167 cases, 12 and eight at PICU and NICU, respectively). CONCLUSION: An increase in Klebsiella bacteremia was recorded in southern Israel during the 10 years of the study. A marked increase in the rate of nosocomial Klebsiella bacteremia occurred at all departments. Resistance to third-generation cephalosporins emerged frequently at PICU and NICU during the last period of the survey.

Age Distribution↗
PubMed2000

Molecular typing of coagulase-negative staphylococci from blood cultures does not correlate with clinical criteria for true bacteremia.

PURPOSE: Determining whether a blood culture that contains coagulase-negative staphylococci represents bacteremia or contamination is a clinical dilemma. We compared molecular-typing results of coagulase-negative staphylococcal blood culture isolates with clinical criteria for true bacteremia. SUBJECTS AND METHODS: Pulsed-field gel electrophoresis and arbitrary primed polymerase chain reaction (PCR) were used to determine whether patients with two or more blood cultures with coagulase-negative staphylococcal isolates had the same strain of organism in each culture (same strain bacteremia). We evaluated three different clinical criteria for bacteremia: whether the patient received more than 4 days of antibiotics, whether there was an explicit note in the medical chart in which the physician diagnosed a true bacteremia, and the Centers for Disease Control surveillance criteria for primary bloodstream infection. Agreement between same-strain bacteremia and each definition was examined, based on the assumption that most true infections should be the result of a single strain. RESULTS: The study sample consisted of 42 patients and 106 isolates. Nineteen of the 42 bacteremias (45%) were the same strain. Classification of bacteremias as same-strain correlated poorly with all three clinical assessments (range of percent agreement, 50% to 57%; range of kappa statistic, 0.01 to 0.15). There were both false-positive and false-negative errors. Patients with three or more positive blood cultures were more likely to have same-strain bacteremia than those with only two positive cultures [11 of 15 (73%) vs 8 of 27 (30%), P = 0.006]. Pulsed-field gel electrophoresis was more discriminating than arbitrary primed PCR (percent agreement, 83%; kappa, 0.67). CONCLUSION: Molecular typing correlated poorly with clinical criteria for true bacteremia, suggesting either that true bacteremias are frequently the result of multiple strains or that the commonly used clinical criteria are not accurate for distinguishing contamination from true bacteremia. Vancomycin treatment of clinically defined coagulase-negative staphylococcal bacteremia may frequently be unnecessary.

Bacteremia↗
PubMed2006

Emergence of vaccine-related pneumococcal serotypes as a cause of bacteremia.

BACKGROUND: The heptavalent pneumococcal conjugate vaccine (PCV7) has decreased the incidence of invasive pneumococcal disease among children in the United States. In the postlicensure period, the impact of non-PCV7 serotypes against pediatric pneumococcal bacteremia is unknown. METHODS: Episodes of bacteremia due to Streptococcus pneumoniae and other respiratory pathogens (ORP), namely Neisseria meningitidis, Haemophilus influenzae, and Moraxella catarrhalis, were identified in children <18 years old at the Children's Hospital of Philadelphia from January 1999 to May 2005. For pneumococci, serotype distribution and antibiotic resistance were compared. RESULTS: A total of 188 episodes of pneumococcal bacteremia and 55 episodes of ORP bacteremia were identified. By comparing data from 1999-2000 with data from 2001 to May 2005, we found that the incidence of pneumococcal bacteremia decreased by 57%. The incidence of bacteremia caused by ORPs was unchanged; 1.43 episodes (95% confidence interval [CI], 0.84-2.29 episodes) to 1.25 (95% CI, 0.88-1.71) per 10,000 emergency department visits. Vaccine serotypes caused 85% of episodes of bacteremia in 1999-2000, compared with 34% of episodes of bacteremia in 2001 to May 2005 (P<.01). The percentage of isolates nonsusceptible to penicillin increased from 25% to 39% (P<.05). The percentage of episodes of pneumococcal bacteremia caused by vaccine-related serotypes--those of the same serogroup but not of the same serotype as PCV7--increased from 6% of episodes in the prelicensure period to 35% of episodes in the postlicensure period (P<.01). Rates of serotype pneumococcal bacteremia caused by nonvaccine serotypes were not statistically different between the 2 periods. CONCLUSIONS: The overall incidence of pneumococcal bacteremia decreased by 57% after the introduction of PCV7. During the postlicensure period, there were significant decreases in the incidence of pneumococcal bacteremia caused by vaccine serotypes; however, rates of penicillin resistance and bacteremia due to vaccine-related serotypes increased.

Adolescent↗
PubMed2005

Costs and outcomes among hemodialysis-dependent patients with methicillin-resistant or methicillin-susceptible Staphylococcus aureus bacteremia.

OBJECTIVE: Comorbid conditions have complicated previous analyses of the consequences of methicillin resistance for costs and outcomes of Staphylococcus aureus bacteremia. We compared costs and outcomes of methicillin resistance in patients with S. aureus bacteremia and a single chronic condition. DESIGN, SETTING, AND PATIENTS: We conducted a prospective cohort study of hemodialysis-dependent patients with end-stage renal disease and S. aureus bacteremia hospitalized between July 1996 and August 2001. We used propensity scores to reduce bias when comparing patients with methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) S. aureus bacteremia. Outcome measures were resource use, direct medical costs, and clinical outcomes at 12 weeks after initial hospitalization. RESULTS: Fifty-four patients (37.8%) had MRSA and 89 patients (62.2%) had MSSA. Compared with patients with MSSA bacteremia, patients with MRSA bacteremia were more likely to have acquired the infection while hospitalized for another condition (27.8% vs 12.4%; P = .02). To attribute all inpatient costs to S. aureus bacteremia, we limited the analysis to 105 patients admitted for suspected S. aureus bacteremia from a community setting. Adjusted costs were higher for MRSA bacteremia for the initial hospitalization (21,251 dollars vs 13,978 dollars; P = .012) and after 12 weeks (25,518 dollars vs 17,354 dollars; P = .015). At 12 weeks, patients with MRSA bacteremia were more likely to die (adjusted odds ratio, 5.4; 95% confidence interval, 1.5 to 18.7) than were patients with MSSA bacteremia. CONCLUSIONS: Community-dwelling, hemodialysis-dependent patients hospitalized with MRSA bacteremia face a higher mortality risk, longer hospital stays, and higher inpatient costs than do patients with MSSA bacteremia.

APACHE↗