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PubMed1999

Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality.

OBJECTIVE: To identify risk factors for vancomycin resistance and mortality in enterococcal bacteremia. DESIGN: Historical cohort study. SETTING: A large academic medical center with a high prevalence of vancomycin-resistant enterococci (VRE). PATIENTS: Two hundred sixty patients with enterococcal bacteremia, of whom 72 (28%) had VRE. RESULTS: Independent risk factors for infection with VRE were the mean number of antibiotic days (P<.001), renal insufficiency (P<.001), mean days of vancomycin use (P = .005), and neutropenia (P = .013). A trend toward a significant association between metronidazole use and VRE also was noted (P = .068). Mortality was attributable to the bacteremia in 96 patients (37%). Severity of illness (P<.001) and age (P = .020) were independent risk factors for mortality. Vancomycin resistance was not, however, an independent predictor of mortality. CONCLUSION: These results suggest that restrictions on antibiotic use, particularly in patients with renal insufficiency and neutropenia, may help to combat the rising incidence of VRE. Although patients with VRE bacteremia demonstrated higher mortality rates than patients with infection due to susceptible isolates, vancomycin resistance was not an independent predictor of mortality in these patients and likely serves more as a marker of underlying severity of illness.

Adolescent↗
PubMed2003

Outcomes of Hickman catheter salvage in febrile neutropenic cancer patients with Staphylococcus aureus bacteremia.

OBJECTIVE: To evaluate the outcome of attempted Hickman catheter salvage in neutropenic cancer patients with Staphylococcus aureus bacteremia who were not using antibiotic lock therapy. DESIGN: Retrospective cohort study. SETTING: A university-affiliated, tertiary-care hospital with 1,500 beds for adult patients. PATIENTS: All neutropenic cancer patients who had a Hickman catheter and S. aureus bacteremia (32 episodes in 29 patients) between January 1998 and March 2002. METHODS: Salvage attempts were defined as cases where the Hickman catheter was not removed until we obtained the results of follow-up blood cultures performed 48 to 72 hours after starting treatment with antistaphylococcal antibiotics. Salvage was considered to be successful if the Hickman catheter was still in place 3 months later without recurrent bacteremia or death. RESULTS: Catheter salvage was attempted in 24 (75%) of the 32 episodes. Of the salvage attempts, the success rate was 50% (12 of 24). Salvage attempts were successful in 14% (1 of 7) of the episodes with positive follow-up blood cultures, and in 65% (11 of 17) of those with negative follow-up blood cultures (P = .07). If the analysis is confined to cases with no external signs of catheter infection, salvage attempts were successful in 14% (1 of 7) of the episodes with positive follow-up blood cultures and in 80% (8 of 10) of those with negative follow-up blood cultures (P = .02). CONCLUSION: In neutropenic cancer patients with S. aureus bacteremia, attempted catheter salvage without antibiotic lock therapy was successful in 50% of the cases.

Administration, Oral↗
PubMed2006

Association of polymorphisms of IGF1R and genes in the transforming growth factor- beta /bone morphogenetic protein pathway with bacteremia in sickle cell anemia.

Infection and bacteremia are common in sickle cell disease. We hypothesized that, consistent with evidence for the genetic modulation of other disease complications, the risk of developing bacteremia might also be genetically modulated. Accordingly, we studied the association of single nucleotide polymorphisms (SNPs) in candidate genes with the risk of bacteremia in sickle cell anemia. We found significant associations with SNPs in IGF1R and genes of the TGF-beta /BMP pathway (BMP6, TGFBR3, BMPR1A, SMAD6 and SMAD3). We suggest that both IGF1R and the TGF-beta /BMP pathway could play important roles in immune function in sickle cell anemia and their polymorphisms may help identify a "bacteremia-prone" phenotype.

Adolescent↗
PubMed2006

Active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) decreases the incidence of MRSA bacteremia.

OBJECTIVES: To evaluate the influence of performance of active surveillance cultures for methicillin-resistant Staphylococcus aureus (MRSA) on the incidence of nosocomial MRSA bacteremia in an endemic hospital. DESIGN: Before-after trial. SETTING: A 700-bed hospital. PATIENTS: All patients admitted to the hospital who were at high risk for MRSA bacteremia. INTERVENTION: Performance of surveillance cultures for detection of MRSA were recommended for all patients at high risk, and contact isolation was implemented for patients with positive results of culture. Each MRSA-positive patient received one course of eradication treatment. We compared the total number of surveillance cultures, the percentage of surveillance cultures with positive results, and the number of MRSA bacteremia cases before the intervention (from January 2002 through February 2003) after the start of the intervention (from July 2003 through October 2004). RESULTS: The number of surveillance cultures performed increased from a mean of 272.57 cultures/month before the intervention to 865.83 cultures/month after the intervention. The percentage of surveillance cultures with positive results increased from 3.13% before to 5.22% after the intervention (P < .001). The mean number of MRSA bacteremia cases per month decreased from 3.6 cases before the intervention to 1.8 cases after the intervention (P < 0.001). CONCLUSIONS: Active surveillance culture is important for identifying hidden reservoirs of MRSA. Contact isolation can prevent new colonization and infection and lead to a significant reduction of morbidity and healthcare costs.

Bacteremia↗
PubMed1998

Clinical significance of bacteremia involving the "Streptococcus milleri" group: 51 cases and review.

Fifty-one cases of bacteremia due to the "Streptococcus milleri" group were analyzed. Among these were 40 patients with underlying diseases, and associated local infections were present in 27 patients. The most frequent sites of infection were the thoracic cavity and the digestive and hepatobiliary tracts. A probable portal of entry related to mucosal-barrier trauma was identified for an additional 16 patients. The origin of bacteremia was unknown for the remaining eight patients. Abscess formation was evident for only six patients, and there were no cases of endocarditis. Multiple positive blood cultures and polymicrobial bacteremia were associated significantly with the presence of local sites of infection. The most common causative species were Streptococcus anginosus and Streptococcus constellatus. Two patients died of bacteremia.

Abscess↗
PubMed1999

Acinetobacter bacteremia in Hong Kong: prospective study and review.

The epidemiological characteristics of 18 patients with acinetobacter bacteremia were analyzed. Patients (mean age, 55.5 years) developed bacteremia after an average of 14.1 days of hospitalization. Fifteen of 16 patients survived bacteremia caused by Acinetobacter baumannii. Cultures of blood from the remaining two patients yielded Acinetobacter lwoffii. Most patients (78%) resided in the general ward, while four patients (22%) were under intensive care. Genotyping by arbitrarily primed polymerase chain reaction analysis and the temporal sequence of isolation were more useful than phenotyping by antimicrobial susceptibility in the determination of the source of bacteremia, and the intravascular catheter was the leading infection source (39% of cases). The possibility of an association of glucose with the pathogenesis of acinetobacter infection was raised.

Acinetobacter↗
PubMed1999

Recurrent gram-negative bacteremia: incidence and clinical patterns.

Fifty-eight patients who had at least two episodes of gram-negative bacteremia were evaluated to define the epidemiology of recurrent bacteremia caused by these organisms. Thirty-two patients (55%) had single relapses, 16 (28%) had one reinfection, and 10 (17%) had more than one recurrence of bacteremia. Intravenous catheters were the most common probable source of bacteremia. Relapses occurred earlier after the initial episode than did reinfections (58 days vs. 292 days; P = .002). The duration of antibiotic therapy for the first episode was shorter for patients with relapses than for those with reinfections (13.9 days vs. 17.5 days; P = .046). Microorganisms causing recurrent bacteremic episodes were not unusually resistant to antimicrobial agents. Reinfections may be difficult to prevent because they are associated with the severity of the underlying illness, which may not improve. The frequency of relapses might be reduced by increasing the duration of antibiotic therapy and eliminating foci of infection.

Adolescent↗
PubMed1999

Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome.

In a retrospective study, 80 episodes of nontyphoid salmonella (NTS) bacteremia in children were compared with 55 episodes in adults over a 10-year period. The study disclosed major differences in the predisposition, clinical presentation, and outcome as well as the microbiology of NTS bacteremia in relation to age. Adults were more likely than children to have predisposing diseases (95% vs. 15%, respectively; P < .0001) and to receive prior medications (95% vs. 23%, respectively; P < .0001), particularly immunosuppressive agents (58% vs. 5%, respectively; P < .0001). In most adults (67%), NTS infection presented as a primary bacteremia and was associated with a high incidence of extraintestinal organ involvement (34%) and a high mortality rate (33%). In children, NTS bacteremia was usually secondary to gastroenteritis (75%) and caused no fatalities. Although group D Salmonella (78%) and the serovar Salmonella enteritidis were the predominant isolates from adults, the emergence of infections due to group C Salmonella (46%) and the serovar Salmonella virchow in children was noted.

Adolescent↗
PubMed1998

Campylobacter jejuni bacteremia in human immunodeficiency virus (HIV)-infected and non-HIV-infected patients: comparison of clinical features and review.

Clinical and bacteriologic features and clinical outcomes of culture-confirmed campylobacter bacteremia in 21 patients (including nine human immunodeficiency virus [HIV]-infected subjects and 12 non-HIV-infected subjects) were retrospectively evaluated and compared. This study highlights differences between HIV-infected and non-HIV-infected individuals. Campylobacter jejuni bacteremia in HIV-infected patients was found to often be a severe, debilitating febrile illness requiring multiple and prolonged courses of antibiotic therapy. Extraintestinal features, particularly pulmonary involvement, were often observed. Cellulitis occurred in one patient. By contrast, in non-HIV-infected patients, the illness was generally an acute onset of fever associated with self-limiting enteritis, with fever resolving rapidly with antibiotic treatment. Travel history (42% of cases) appeared to be a common risk factor in the latter group. Two of these patients had cutaneous manifestations, thus suggesting that some strains may be more invasive. This study suggests that campylobacter bacteremia is an important cause of morbidity and mortality in HIV-infected individuals; the overall mortality rate among HIV-infected patients with bacteremia in this study was 33%. This is not the case for immunocompetent patients, in whom death rarely occurs.

Adult↗
PubMed1998

Clinical significance and outcome of anaerobic bacteremia.

We retrospectively studied the incidence of anaerobic bacteremia during 6 years (1991-1996) at Turku University Central Hospital (Turku, Finland). The clinical significance of a positive anaerobic blood culture, the effect of a positive culture on the choice of antimicrobial therapy, and the outcome for patients were evaluated. Cultures of blood from 81 patients yielded anaerobic bacteria (4% of all bacteremias). Anaerobic bacteremia was clinically significant in 57 patients (0.18 cases per 1,000 admissions). Only half (28) of these patients received appropriate and effective antimicrobial treatment before the results of blood cultures were reported; for 18 patients (32%), initially ineffective treatment was changed on the basis of the bacteriologic results, and for 11 patients (19%), the treatment was not changed. The mortality in these patient groups was 18%, 17%, and 55%, respectively. Empirical therapy may provide coverage for anaerobes in only half of the patients with anaerobic bacteremia, and failure to pay attention to the results of anaerobic blood cultures may have serious consequences for patients.

Bacteremia↗
PubMed1999

Penicillin resistance and other predictors of mortality in pneumococcal bacteremia in a population with high human immunodeficiency virus seroprevalence.

Rates of invasive disease caused by penicillin-resistant pneumococci are rising. Previous reports have found no association between resistant pneumococci and increased mortality. To evaluate the impact of penicillin resistance and other variables on mortality, we retrospectively studied all cases of pneumococcal bacteremia identified by our microbiology laboratory from 1 January 1992 through 31 December 1996. There were 462 cases of pneumococcal bacteremia in 432 patients. The mean age was 35 years; 55% of the cases occurred in male patients, 58% were in black patients, and 40% were in Hispanic patients. One-half of the cases occurred in patients with documented human immunodeficiency virus (HIV) infection. Penicillin resistance was first noted in 1994 and increased yearly, accounting for 17% of 1996 isolates. Of all resistant isolates, 65% were resistant to penicillin at a high level. The overall mortality was 17%. On multivariate analysis, high-level penicillin resistance, older age, severe disease, multilobar infiltrates and/or effusion(s) on chest roentgenogram, and Hispanic ethnicity were independent predictors of mortality in pneumococcal bacteremia. In HIV-infected patients, a CD4 cell count below the median just missed statistical significance. This is the first report demonstrating penicillin resistance as an independent predictor of mortality among patients with pneumococcal bacteremia.

AIDS-Related Opportunistic Infections↗
PubMed1999

Bacteremia caused by staphylococci with inducible vancomycin heteroresistance.

The clinical significance of bacteremia due to vancomycin-heteroresistant staphylococci and a rapid laboratory screening method were examined; 203 strains of staphylococci isolated from patients with clinically significant bacteremia were screened by the disk-agar method with use of vancomycin-salt agar to demonstrate satellitism around an aztreonam disk as well as by conventional population screening. Eighteen isolates (three Staphylococcus aureus and 15 coagulase-negative staphylococci) were shown to be heteroresistant to vancomycin. A case-control clinical study showed that the interval between admission and bacteremia, admission to the intensive care unit, prior use of vancomycin and/or beta-lactams, and isolation of methicillin-resistant staphylococci were significantly more common among patients with bacteremia due to staphylococci with heteroresistance to vancomycin; these patients had an overall mortality of 44.4%. The use of vancomycin and admission to the intensive care unit were independently significant risk factors on multivariate analysis. Vancomycin heteroresistance is inducible by salt and beta-lactams. Indiscriminate sequential use of beta-lactams and glycopeptides may facilitate the emergence of glycopeptide resistance.

Adolescent↗
PubMed1994

Relatedness of coagulase-negative staphylococci causing bacteremia in low-birthweight infants.

OBJECTIVE: To investigate coagulase-negative staphylococcus (CONS) causing bacteremia in a neonatal intensive care unit (NICU). DESIGN: A 14-month retrospective review of 47 infants in the NICU with CONS bacteremia was undertaken to determine CONS glycocalyx production, plasmid pattern, total DNA restriction fragment polymorphism, and clinical risk factors. RESULTS: The isolates included 32 Staphylococcus epidermidis, six Staphylococcus haemolyticus, four Staphylococcus warneri, four Staphylococcus saprophyticus, and one Staphylococcus hominis. Sixty-five percent of S epidermidis produced glycocalyx; other species did not. Oxacillin resistance (52%) and the antibiograms of the CONS were consistent with other units in the hospital. Five similar CONS plasmid patterns were found among 16 isolates; 31 isolates had unique patterns. Extractions of total DNA from these isolates were digested using HindIII, HaeIII, and BstEII. Those with similar restriction fragment length patterns could not linked as nosocomially transmitted among infants with bacteremia. CONCLUSION: Our observations suggest that multiple strains of CONS infect infants in the NICU who have similar risk factors. Although current infection control practices limit transmission of a pathogen, they do not prevent CONS bacteremias.

Bacteremia↗
PubMed1998

Central venous catheters as a source of hemodialysis-related bacteremia.

OBJECTIVE: To describe investigations into an increase in hemodialysis-related bacteremia that occurred in our hospital in the first 6 months of 1996. SETTING: Hemodialysis unit in a tertiary-care medical center. METHODS: Prospective surveillance for hemodialysis bacteremia has been performed for several years. Cases that occurred in 1995 were compared to cases in the first 6 months of 1996. Unit data on dialysis runs and method of dialysis access were used to calculate rates. Nested polymerase chain reaction (PCR) was used to type 18 Staphylococcus aureus isolates from 1996. A case-control study comparing 80 randomly selected hemodialysis patients from 1995 and 1996 was performed to examine infection risk factors. RESULTS: The hemodialysis bacteremia rate was 1.2 per 1,000 runs in 1995 and 2.8 per 1,000 in the first 6 months of 1996 (P=.0009). The 25 cases in 1995 and 32 in the first half of 1996 were similar in age, gender, means of vascular access, and microbial etiology. Central venous catheter (CVC) access accounted for >90% of cases in both time periods. S aureus was the most common microbial etiology (53% of the 1996 cases). PCR typing of S aureus isolates from 1996 demonstrated five different strains, the most common having six isolates. The use of CVCs as a means of vascular access abruptly increased in the unit in January 1996, from <30% of dialysis runs in 1995 to >40% in 1996 (P<.001), associated with structural changes in healthcare delivery in the region resulting in delays in performing surgical procedures, such as creation of vascular grafts and fistulae. CONCLUSION: A marked increase in hemodialysis bacteremia occurred in 1996, associated with increased reliance on CVCs for vascular access in hemodialysis patients during a period of healthcare restructuring.

Adult↗
PubMed2001

Is helium insufflation superior to carbon dioxide insufflation in bacteremia and bacterial translocation with peritonitis?

PURPOSE: To evaluate the effects of CO2 or helium insufflation on bacteremia and bacterial translocation in rats with peritonitis. MATERIALS AND METHODS: Forty male Wistar-Albino rats were divided into four groups, each containing 10 rats. The rats in the first group were injected only with E. coli into their peritoneal cavities with no further manipulation. The second group, following E. coli injection, underwent midline laparotomy without manipulation of the viscera for 1 hour. After the injection of E. coli in the third and fourth groups, CO2 and helium pneumoperitoneum, respectively, were maintained for 1 hour under 14 mm Hg pressure. At the end of the sixth hour, tissue samples were taken from the liver, spleen, lung, and mesenteric lymph nodes in order to evaluate bacterial translocation. During the study, blood samples were taken from each rat at 0, 1, 2, 4, and 6 hours to demonstrate bacteremia. RESULTS: There was a significant increase in bacteremia in the CO2 pneumoperitoneum group compared with the laparotomy-only and helium groups at 1 and 2 hours. Although all the blood samples at the fourth hour were positive for E. coli in every rat of all groups, helium was associated with a lower incidence of bacteremia at the sixth hour compared with other groups (P < 0.05). The CO2 pneumoperitoneum caused bacterial translocation to all organs from which tissue samples were taken. Although there was an insignificant decrease in translocation to the liver, spleen, and lung with helium compared with CO2 insufflation, helium did not increase bacterial translocation to the spleen compared with laparotomy alone, as did CO2 (P < 0.05). CONCLUSION: Helium might be an alternative to CO2 insufflation in patients with peritonitis if these results are confirmed by further experimental and clinical trials.

Analysis of Variance↗
PubMed1998

The absolute neutrophil count: is it the best indicator for occult bacteremia in infants?

Occult bacteremia affects approximately 5% of febrile children ages 2 to 36 months. Many physicians empirically treat children who have a temperature higher than 39 degrees C, a white blood cell (WBC) count of more than 15.0 x 10(9)/L, and no focus of infection with antibiotics. We undertook this investigation to better define predictive indicators for bacteremia. Specifically we were concerned with determining whether the absolute neutrophil count (ANC) is a better diagnostic indicator than the total WBC count and whether the manual differential (which includes a band cell count) is necessary or helpful. Three separate groups of patients aged 2 to 36 months were assessed retrospectively. Group A consisted of febrile children (temperature, > 39 degrees C) who had positive blood cultures (50 patients). Group B included febrile children (temperature, > 39 degrees C) who had negative blood cultures (59 patients). Group C, nonfebrile children admitted to the hospital was the control group (61 patients). The ANC and the total WBC count were significantly higher in group A than in group B. Although they were equally sensitive, the ANC was more specific than the total WBC count. Band cell counts of greater than 10% and the percentage of total neutrophils also were greater in group A than in group B. The values for group C were not significantly different from those for group B. Although a total WBC count of 15.0 x 10(9)/L is currently used to identify children at risk for occult bacteremia, the ANC seems to be as sensitive an indicator and may be more specific. Our study demonstrated that (1) the WBC count is a good indicator of occult bacteremia, (2) the ANC is as sensitive as the WBC count and may be more specific, (3) automated ANCs are comparable to manual ANCs, and (4) the band cell count is insensitive as an indicator and does not add any predictive value.

Bacteremia↗
PubMedDate not supplied

Anaerobic bacteremia: decreasing rate over a 15-year period.

At the Mayo Clinic, the number of cases of anaerobic bacteremia decreased 45% between 1974 and 1988. In addition, the percentage of blood cultures positive for anaerobes decreased significantly even though the total number of blood cultures performed increased. The number of anaerobic bacteremias per 100,000 patient-days also declined over the 15-year period. Organisms of the Bacteroides fragilis group ranked third in frequency with respect to other organisms that caused aerobic and anaerobic bacteremia in 1974 but ranked only seventh in 1988 and caused slightly less than one-half of the anaerobic bacteremias. The mechanisms responsible for these changes are unclear but might relate to earlier recognition and treatment of localized anaerobic infection, widespread preoperative use of agents prior to bowel surgery, and use of broad-spectrum antimicrobial regimens that include agents with activity against anaerobes.

Bacteremia↗
PubMedDate not supplied

Detection of the source of recurrent Staphylococcus aureus bacteremia by ultrafast computerized tomography.

A patient with spina bifida secondary to an Arnold-Chiari deformity experienced seven episodes of sustained bacteremia due to Staphylococcus aureus over 2 years. Despite an extensive diagnostic evaluation the source of the recurrent bacteremia remained obscure. The patient's mother eventually recalled that a procedure for replacement of a ventriculoatrial shunt performed 16 years earlier had been complicated by retention of a shunt fragment in the bloodstream. Standard radiographic techniques failed to identify an intravascular foreign body; however, ultrafast computerized tomography of the heart demonstrated a density in the right atrium. Atriotomy was performed and a plastic catheter fragment was excised. Bacteremia has not recurred during a follow-up period of 24 months. Patients with recurrent unexplained bacteremia should be evaluated carefully for the presence of occult intravascular catheter fragments that may be retained after surgical procedures or intravascular instrumentation. Ultrafast computed tomographic scanning of the heart is a useful technique for detecting intracardiac catheter fragments.

Adolescent↗