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PubMed2003

Risk factors for primary bacteremia and endovascular infection in patients without acquired immunodeficiency syndrome who have nontyphoid salmonellosis.

This study sought to find the risk factors for primary bacteremia, endovascular infection, and in-hospital death for patients without acquired immunodeficiency syndrome who have nontyphoid salmonellosis. From September 1995 through September 2001, 301 patients with nontyphoid salmonellosis were admitted to our hospital; of these patients, 121 had primary bacteremia, and 28 had endovascular infection. Of the 121 patients with primary bacteremia, 64 were aged >50 years, and 26 had endovascular infection. Overall, 90 patients (29.9%) had immunodeficiency. Predictors of primary bacteremia were age; presence of systemic lupus erythematosus; group B, group C, or group D Salmonella infection; and immunodeficiency. The positive predictor of endovascular infection in adult patients with primary bacteremia was group C Salmonella infection, and negative predictors were immunodeficiency and solid-organ cancer. The overall in-hospital mortality rate was 12%; for primary bacteremia, it was 24.8%; for endovascular infection, it was 14.3%. Predictors of in-hospital death were age, extraintestinal infection, and solid-organ malignancy.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Clinical features and outcomes of bacteremia caused by Enterococcus casseliflavus and Enterococcus gallinarum: analysis of 56 cases.

The clinical significance and virulence potential of Enterococcus casseliflavus/flavescens and Enterococcus gallinarum are still uncertain. We retrospectively analyzed 56 cases of significant bacteremia caused by E. casseliflavus or E. gallinarum. Of these cases, 25 (44.6%) were associated with polymicrobial bacteremia, and 43 (76.8%) were associated with entry via the biliary tract. Resistance to vancomycin was observed in 17 (30.4%) of these 56 patients, and this resistance was significantly associated with E. gallinarum bacteremia (adjusted odds ratio [AOR], 10.56; 95% confidence interval [CI], 2.41-46.27) and bacteremia without biliary tract origin (AOR, 6.74; 95% CI, 1.44-31.67). The crude mortality rate was 13%, and the bacteremia-related mortality rate was 1.9%. In conclusion, bacteremia due to E. casseliflavus and E. gallinarum is commonly associated with biliary tract disease and may be associated with a low risk of mortality.

Adult↗
PubMed2003

Effect of nosocomial vancomycin-resistant enterococcal bacteremia on mortality, length of stay, and costs.

OBJECTIVE: To determine the impact of vancomycin-resistant enterococcal bacteremia on patient outcomes and costs by assessing mortality, excess length of stay, and charges attributable to it. DESIGN: A population-based, matched, historical cohort study. SETTING: A 1,025-bed, university-based teaching facility and referral hospital. PATIENTS: Two hundred seventy-seven vancomycin-resistant enterococcal bacteremia case-patients and 277 matched control-patients identified between 1993 and 2000. RESULTS: The crude mortality rate was 50.2% and 19.9% for case-patients and control-patients, respectively, yielding a mortality rate of 30.3% attributable to vancomycin-resistant enterococcal bacteremia. The excess length of hospital stay attributable to vancomycin-resistant enterococcal bacteremia was 17 days, of which 12 days were spent in intensive care units. On average, dollars 77,558 in extra charges was attributable to each vancomycin-resistant enterococcal bacteremia. To adjust for severity of illness, 159 pairs of case-patients and control-patients, who had the same severity of illness (All Patient Refined-Diagnosis Related Group complexity level), were further analyzed. When patients were stratified by severity of illness, the crude mortality rate was 50.3% among case-patients compared with 27.7% among control-patients, accounting for an attributable mortality rate of 22.6%. Attributable excess length of stay and charges were 17 days and dollars 81,208, respectively. CONCLUSION: Vancomycin-resistant enterococcal bacteremia contributes significantly to excess mortality and economic loss, once severity of illness is considered. Efforts to prevent these infections will likely be cost-effective.

Adolescent↗
PubMed2005

Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis.

OBJECTIVE: To examine the clinical outcomes and costs associated with Staphylococcus aureus bacteremia among hemodialysis-dependent patients. DESIGN: Prospectively identified cohort study. SETTING: A tertiary-care university medical center in North Carolina. PATIENTS: Two hundred ten hemodialysis-dependent adults with end-stage renal disease hospitalized with S. aureus bacteremia. RESULTS: The majority of the patients (117; 55.7%) underwent dialysis via tunneled catheters, and 29.5% (62) underwent dialysis via synthetic arteriovenous fistulas. Vascular access was the suspected source of bacteremia in 185 patients (88.1%). Complications occurred in 31.0% (65), and the overall 12-week mortality rate was 19.0% (40). The mean cost of treating S. aureus bacteremia, including readmissions and outpatient costs, was $24,034 per episode. The mean initial hospitalization cost was significantly greater for patients with complicated versus uncomplicated S. aureus bacteremia ($32,462 vs $17,011; P = .002). CONCLUSION: Interventions to decrease the rate of S. aureus bacteremia are needed in this high-risk, hemodialysis-dependent population.

Academic Medical Centers↗
PubMed2005

Catheter-related vancomycin-resistant Enterococcus faecium bacteremia: clinical and molecular epidemiology.

OBJECTIVE: To study the clinical and molecular epidemiology of vancomycin-resistant Enterococcus faecium organisms causing catheter-related bacteremia in patients with cancer. DESIGN: Retrospective case-control study. SETTING: University of Texas M. D. Anderson Cancer Center, a tertiary-care hospital in Houston, Texas. PATIENTS: Case-patients were patients with cancer who had catheter-related vancomycin-resistant E. faecium bacteremia and control-patients were patients with cancer and vancomycin-resistant E. faecium gastrointestinal colonization without infection. RESULTS: Ten case-patients with catheter-related vancomycin-resistant E. faecium bacteremia were compared with 30 control-patients with gastrointestinal colonization by vancomycin-resistant E. faecium. Patients with catheter-related vancomycin-resistant E. faecium bacteremia were more likely to have required mechanical ventilation (P < .01), received total parenteral nutrition (P < .01), and had polyurethane catheters (P < .01) inserted in the femoral vein (P = .01). With the use of pulsed-field gel electrophoresis, 4 of the 10 catheter-related vancomycin-resistant E. faecium bacteremia isolates were genetically indistinguishable, whereas only 2 of the 30 control vancomycin-resistant E. faecium isolates displayed this same DNA pattern (P = .03). CONCLUSION: This study suggests that catheter-related vancomycin-resistant E. faecium bacteremia occurs more frequently in patients who receive total parenteral nutrition, mechanical ventilation, and femoral catheters.

Adult↗
PubMed2005

Nosocomial bacteremia: clinical significance of a single blood culture positive for coagulase-negative staphylococci.

OBJECTIVES: To describe the epidemiology of nosocomial coagulase-negative staphylococci (CoNS) bacteremia and to evaluate the clinical significance of a single blood culture positive for CoNS. DESIGN: A 3-year retrospective cohort study based on data prospectively collected through hospital-wide surveillance. Bacteremia was defined according to CDC criteria, except that a single blood culture growing CoNS was not systematically considered as a contaminant. All clinically significant blood cultures positive for CoNS nosocomial bacteremia were considered for analysis. SETTING: A large university teaching hospital in Geneva, Switzerland. RESULTS: A total of 2,660 positive blood cultures were identified. Of these, 1,108 (41.7%) were nosocomial; CoNS were recovered from 411 nosocomial episodes (37.1%). Two hundred thirty-four episodes of CoNS bacteremia in the presence of signs of sepsis were considered clinically relevant and analyzed. Crude mortality and associated mortality were 24.4% and 12.8%, respectively. Associated mortality was similar among patients with one positive blood culture and those with two or more (16.2% vs 10.8%, respectively; P = .3). Mortality rates after bacteremia for patients with a single positive blood culture and for those with two or more were 15.3% and 7.0%, respectively, at day 14 (RR, 2.2; CI95, 0.87-5.46) and 20.8% and 11.3%, respectively, at day 28 (RR, 1.9; CI95, 0.9-3.8). On multivariate analysis, only age and a rapidly fatal disease were independently associated with death. CONCLUSION: CoNS bacteremia harbor a significant mortality and a single positive blood culture in the presence of signs of sepsis should be considered as clinically relevant.

Adult↗
PubMed1999

Molecular epidemiology of gram-negative bacteremia.

We did pulsed field gel electrophoresis (PFGE) and antibiotic susceptibility testing on 202 gram-negative isolates obtained from blood cultures between 1 January 1989 and 31 December 1993. Seventy-eight patients had at least two gram-negative isolates of the same species recovered from blood drawn one or more days apart and met the other study criteria. Twenty patients had only 1 bloodstream infection, 48 patients had 1 recurrence of bacteremia, and 10 patients had > 1 recurrence of bacteremia. Of 80 recurrences of bacteremia, 52 (65%) were relapses and 28 (35%) were reinfections. Seventy-eight percent of the episodes of bacteremia occurring < or = 300 days apart were relapses, and 100% occurring > 300 days apart were reinfections (P < .001). Organisms causing recurrent bacteremia were not more resistant than those causing initial episodes. In conclusion, most episodes of recurrent gram-negative bacteremia were relapses. Relapses and reinfections could not be distinguished only by the length of time between episodes or by antimicrobial susceptibility patterns.

Anti-Bacterial Agents↗
PubMed1998

Vancomycin-resistant and vancomycin-susceptible enterococcal bacteremia: comparison of clinical features and outcomes.

Vancomycin-resistant Enterococcus (VRE) is a major nosocomial pathogen. We collected clinical and laboratory data on 93 hospitalized adults with VRE bacteremia and 101 adults with vancomycin-susceptible enterococcal (VSE) bacteremia. Risk factors for VRE bacteremia included central venous catheterization, hyperalimentation, and prolonged hospitalization prior to the initial blood culture. VRE-infected patients were less likely to have undergone recent surgery or have polymicrobial bacteremia, suggesting a pathogenesis distinct from traditional VSE bacteremia. Prior exposure to metronidazole was the only significant pharmacologic risk factor for VRE bacteremia. Animal studies suggest metronidazole potentiates enterococcal overgrowth in the gastrointestinal tract and translocation into the bloodstream. An increasing APACHE II score was the major risk factor for death in a multivariate analysis, with VRE status being of only borderline significance.

Adult↗
PubMedDate not supplied

Enterococcal bacteremia: to treat or not to treat, a reappraisal.

The treatment of enterococcal bacteremia not associated with endocarditis has been controversial. We retrospectively reviewed 81 episodes of enterococcal bacteremia and categorized them as to their clinical significance, using a strict case definition. Of the 81 episodes, 41 met our criteria for clinical significance. Mortality was 51% among the 41 patients with clinically significant bacteremia and 50% among the 40 patients with bacteremia of uncertain clinical significance. Despite these equivalent overall mortality figures, antibiotic therapy specific for Enterococcus species was associated with reduced in-hospital mortality among patients with clinically significant infections (relative risk [RR] = 0.46, 95% confidence interval [CI] = 0.27-0.77); mortality was also reduced in the first 7 days after the detection of bacteremia, when death was relatively likely to be directly due to the bacteremic episode (RR = 0.17, CI = 0.04-0.74). The association between appropriate antibiotic therapy and reduced mortality remained statistically significant when adjustments were made for a number of other factors related to mortality, including age, underlying conditions, prior use of antibiotics, nosocomial acquisition, polymicrobial etiology, prior surgery, and source of infection. Thus enterococcal isolates from the blood, even when of doubtful clinical significance, are poor prognostic markers associated with high mortality. However, when the clinical significance of bacteremia is defined by strict criteria, specific therapy against Enterococcus species is associated with improved outcome.

Adult↗
PubMed1992

Risk factors for mortality due to bacteremia and fungemia in childhood.

To define risk factors for mortality due to bacteremia and fungemia of childhood, 242 episodes (for which the mortality rate was 19%) were studied prospectively by univariate and multivariate analyses. The mortality rate was higher in neonates (23%) and in individuals 10-18 years old (26%) than in infants and young children (10%-16%). The mortality rate was 29% for children who had neutropenia, 29% for those who had received therapy with steroids, 26% for those who had received antibiotics, and 75% for those who were in septic shock. The fatality rates for polymicrobial bacteremia (40%), recurrent bacteremia (67%), and hospital-acquired bacteremia (28%) were higher than those for other types of bacteremia; the fatality rate was related to inappropriate empiric antibiotic treatment or to the specific organism isolated (mortality rates associated with the latter ranged from 0 to 60%). Seven variables that independently and significantly affected mortality were defined with use of multivariate logistic regression analysis: septic shock (odds ratio [OR], 26.4); polymicrobial (OR, 5.4), recurrent (OR, 4.5), or hospital-acquired (OR, 4.3) bacteremia; candidemia (OR, 3.6); inappropriate antibiotic treatment (OR, 2.4); and neutropenia (OR, 2.3). These variables should be considered for adequate management of bacteremic patients who are at high risk for death.

Adolescent↗
PubMed1993

Sustained bacteremia in 26 patients with a permanent endocardial pacemaker: assessment of wire removal.

We reviewed the data on 26 patients with permanent endocardial pacemakers who had 28 episodes of bacteremia to determine whether removal of the wire is required. Patients recovered completely from the first episode in seven of 20 cases of staphylococcal bacteremia and in six of six cases of nonstaphylococcal bacteremia (P = .015). Definitive cure was not achieved during the first episode in seven cases of staphylococcal bacteremia related to the pacing system when the wire was not withdrawn; however, cure was achieved in five of six cases when the whole pacemaker was removed (P < .01). The duration of treatment was longer for the patients from whom the wire was not removed during the first episode (P < .01). Whether cases of staphylococcal bacteremia were related to the pacing system or not, the rate of recovery of the responsible microorganism from the wires was similar for both groups of patients (six [82%] of seven and three [75%] of four, respectively). Nonstaphylococcal bacteremia was unrelated to the pacing system in five of six cases; these patients were all cured without removal of the wire.

Aged↗
PubMed1993

Comparison of patients with enterococcal bacteremia due to strains with and without high-level resistance to gentamicin.

Patients with enterococcal bacteremia due to strains with and without high-level gentamicin resistance (HLGR; MIC, > 2,000 mg/L) were compared. Between 1986 and 1991, there were 178 episodes of enterococcal bacteremia: 47 and 131 episodes, respectively, due to enterococcal strains with and without HLGR. Sixty-two, 57, and 59 episodes, respectively, were in patients with transient bacteremia (a single positive blood culture), bacteremia (two or more positive blood cultures), and polymicrobial bacteremia. Nosocomial bacteremia accounted for 61.7% and 51.1% of episodes due to strains with and without HLGR, respectively. All isolates were strains of Enterococcus faecalis except for 13 strains of Enterococcus faecium, 4 of Enterococcus avium, and 3 of Enterococcus durans. Although the mortality was slightly higher among patients infected with strains with HLGR than among those infected with strains without HLGR (38.3% vs. 30.5%, respectively), there was no statistical difference. The mortality rate was adversely affected by old age (P < .01) and rapidly and ultimately fatal underlying conditions (P < .001). The addition of gentamicin to the treatment regimens had no effect on mortality.

Adolescent↗
PubMed1995

Multifocal cellulitis and monoarticular arthritis as manifestations of Helicobacter cinaedi bacteremia.

Helicobacter cinaedi (formerly Campylobacter cinaedi) was first detected in the fecal flora of homosexual men. Since 1984, 11 case reports of H. cinaedi bacteremia have been published; most cases have presented as a nonspecific febrile illness in homosexual men infected with the human immunodeficiency virus (HIV). We identified seven additional cases of H. cinaedi bacteremia in two Denver hospitals within a 5-year period, which suggests that this illness is not as rare as was previously thought. Six of these cases of H. cinaedi bacteremia occurred in homosexual men who were infected with HIV. Four patients presented with the distinctive cutaneous manifestation of multifocal cellulitis, and two patients had monoarticular arthritis. Microbiological diagnosis of this infection was delayed by the slow growth of the bacterium in nonradiometric blood culture bottles. Although the patients' bacteremia was prolonged, their response to treatment was excellent. In contrast to campylobacter infections in HIV-infected patients, H. cinaedi bacteremia did not relapse after a course of effective therapy. H. cinaedi bacteremia should be suspected in HIV-infected individuals who present with an indolent febrile illness, particularly in the presence of multifocal cellulitis and/or arthritis.

AIDS-Related Opportunistic Infections↗
PubMed1995

Bacillus licheniformis bacteremia: five cases associated with indwelling central venous catheters.

Bacillus species are being more frequently recognized as pathogens in immunocompromised hosts or in patients with cancer and central venous catheters. Only nine cases of Bacillus licheniformis infection have been reported in the English-language literature since 1966. In a retrospective study we describe six patients and 17 episodes of B. licheniformis bacteremia over a 5-year span. All six patients had either a Hickman or a Broviac catheter in place for more than 3 months. Five of the six patients had multiple clinically significant episodes of bacteremia due to B. licheniformis. The six patients ranged in age from 4 years to 62 years. Two patients had leukemia or lymphoma and three patients had solid tumors, but only one patient was neutropenic. No deaths were related to B. licheniformis bacteremia. B. licheniformis should be considered as a potential pathogen in immunocompromised patients, especially when bacteremia is associated with the presence of long-term central venous catheters. Mortality due to B. licheniformis bacteremia is low, but recurrent bacteremia due to this organism causes significant morbidity and usually necessitates removal of the catheter.

Adolescent↗
PubMed1996

Differences in outcomes for patients with bacteremia due to vancomycin-resistant Enterococcus faecium or vancomycin-susceptible E. faecium.

To determine the differences in outcome in cases of enterococcal bacteremia due to vancomycin-resistant organisms, we compared consecutive patients on a liver transplant service who had clinically significant bacteremia due to vancomycin-resistant Enterococcus faecium (VREF) (n = 54) with a contemporaneous cohort of patients who had vancomycin-susceptible E. faecium (VSEF) bacteremia (n = 48). VREF bacteremia occurred significantly later in the hospitalization than did VSEF bacteremia (43 days vs. 24 days, respectively; P < .01); in addition, VREF was more frequently the sole blood pathogen isolated (91% of patients) than was VSEF (56% of patients) (P = .0002). Invasive interventions for intraabdominal and intrathoracic infection were required more often in the VREF cohort than in the VSEF cohort (34 of 45 patients vs. 20 of 41 patients, respectively; P = .01). Vancomycin resistance more frequently resulted in recurrent bacteremia (22 of 54 patients infected with VREF vs. 7 of 48 patients infected with VSEF; P = .006), persistent isolation of Enterococcus species at the primary site (27 of 33 patients infected with VREF vs. 7 of 18 patients infected with VSEF; P = .005), and endovascular infection (4 patients infected with VREF vs. none infected with VSEF). The decrement in patient survival, as measured from the last bacteremic episode, was greater in the VREF cohort (P = .02). Vancomycin resistance, shock, and liver failure were independent risk factors for Enterococcus-associated mortality. Higher rates of refractory infection, serious morbidity, and attributable death occurred in the VREF cohort and were partially mediated by the lack of effective antimicrobial therapy.

Adult↗
PubMed1996

Bacteremia due to Citrobacter species: significance of primary intraabdominal infection.

From 1982 to 1994, 45 patients (1.22 episodes per 10,000 discharged patients) were treated for citrobacter bacteremia at National Taiwan University Hospital (Taipei). All patients had at least one underlying disease. Citrobacter bacteremia most commonly occurred in patients with malignancies (48.9%) or hepatobiliary stones (22.2%). Intraabdominal tumors comprised the majority (59.1%) of malignancies. Bacteremia commonly originated from sites such as the abdominal cavity (51.1%), urinary tract (20%), and lung (11.1%). Polymicrobial bacteremia was diagnosed in 15 patients (33.3%); for nine (60%) of these patients, the source of the infection was intraabdominal. Prior treatment with a third-generation cephalosporin was significantly associated (P < .01) with the development of multidrug resistance among the isolates. The mortality associated with citrobacter bacteremia was 17.8%. Poor prognostic factors included pneumonia, altered mental status on presentation, hypothermia, oliguria, septic shock, deterioration in mental status, hyperbilirubinemia, azotemia, and thrombocytopenia. Combination therapy, as compared with other regimens, improved the outcome of citrobacter bacteremia.

Adolescent↗
PubMed1994

The impact of Mycobacterium avium complex bacteremia and its treatment on survival of AIDS patients--a prospective study.

It is currently recommended that patients with AIDS and Mycobacterium avium complex (MAC) bacteremia receive antimycobacterial treatment. However, no study has prospectively evaluated the impact of this infection and its treatment on survival. This study prospectively followed a cohort of 367 AIDS patients with < or = 50 CD4+ cells/microL and found that MAC bacteremia was independently associated with an increased risk of death (relative hazard [RH] = 1.8, 95% confidence interval [CI] = 1.3-2.4, P < .001). Patients with MAC bacteremia who were treated had a longer median survival than those who were not (263 vs. 139 days, P < .001); treatment was independently associated with a lower risk of death (RH = 0.45, 95% CI = 0.23-0.89, P < .001). However, 23% of patients with bacteremia died within 28 days of that diagnosis; few were treated. MAC bacteremia contributes to the death of patients with AIDS, and treatment increases survival. However, many patients will not survive long enough to receive treatment. These results underscore the importance of early diagnosis and chemoprophylaxis for MAC bacteremia.

AIDS-Related Opportunistic Infections↗
PubMed1996

Delta APACHE II for predicting course and outcome of nosocomial Staphylococcus aureus bacteremia and its relation to host defense.

To predict at an early phase the clinical course and outcome of nosocomial Staphylococcus aureus bacteremia, the APACHE II score at onset of bacteremia was calculated in 99 patients. A delta APACHE II score (i.e., the difference between this score and one calculated for the day before the bacteremia) was also determined. This delta APACHE II score was highly significantly correlated with clinical course (P<.001) and outcome (P<.001). The risk of a complicated clinical course and of dying from S. aureus bacteremia is determined at the very onset of bacteremia, and this risk can best be assessed by calculating the delta APACHE II score. Furthermore, a positive correlation was found between delta APACHE II scores and the level of serum opsonic activity (P=.003) toward S. aureus. Therefore, the complicated clinical course of S. aureus bacteremia is not due to a relative lack of specific opsonins.

APACHE↗