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PubMed1992

Optimal duration of therapy for catheter-related Staphylococcus aureus bacteremia: a study of 55 cases and review.

Over the last two decades, the optimal duration of therapy for catheter-related Staphylococcus aureus bacteremia has become the subject of controversy. A review of the literature revealed an occasional association between relapse of the infection and a short course of therapy (less than 10 days of iv antibiotic therapy). From records kept between 1983 and 1989 at the University of Florida's affiliated hospitals, we identified 55 patients with catheter-related S. aureus bacteremia. Nine patients (16%) developed acute early complications (e.g., endocarditis or osteomyelitis) while receiving antibiotics. The results of multivariate analysis showed that an early complicated course was characterized by fever and/or bacteremia that persisted for greater than 3 days after catheter removal (P = .02). The remaining 46 patients were followed up for at least 3 months. During follow-up, three of the 18 patients treated for less than 10 days with iv antibiotics developed relapsing septicemia, whereas none of the 28 patients treated for a longer period developed this condition (P = .05). Fever and/or bacteremia that persists for greater than 3 days after catheter removal and initiation of antibiotic therapy suggests an acutely complicated course requiring prolonged treatment. The duration of iv antibiotic therapy in uncomplicated cases should not be less than 10 days but need not be greater than 2 weeks.

Adolescent↗
PubMed1992

Bacteremia and fungemia of unknown origin in adults.

Two hundred fifteen (23%) of 955 episodes of bacteremia (defined as including fungemia) detected in adult patients during 2 years were of unknown origin. Sixty-six percent of episodes of unknown origin were hospital acquired. The median age of patients with bacteremia of unknown origin was 65 years, and their most common underlying disorders were solid malignancy (28% of patients) and diabetes mellitus (18%). Only three factors were associated with bacteremia of unknown origin (as opposed to episodes with a known source): peripheral venous catheterization, hemodialysis, and plasmapheresis. Gram-negative bacteria were isolated from the blood in 62% of episodes of unknown origin; 10% of episodes were polymicrobial. Staphylococci were isolated from 67% of patients undergoing hemodialysis and from 37% of those with diabetes; Pseudomonas species from 15% of patients with hospital-acquired episodes; and Candida species from 21% of patients with a central venous catheter. Fifteen percent of episodes in cancer patients were polymicrobial. Empirical antibiotic treatment was inappropriate in 49% of episodes of unknown origin and in 35% of episodes with a known source (P less than .001). Death rates were 44% and 25% in episodes of unknown and known origin, respectively. An unknown source of bacteremia was independently associated with a fatal outcome.

Adolescent↗
PubMed1992

Bacteremia in a long-term-care facility: a five-year prospective study of 163 consecutive episodes.

The clinical features, microbiological characteristics, and outcomes of 163 episodes of bacteremia occurring at a long-term-care facility were evaluated. The rate of nosocomial bacteremia increased from 0.20 to 0.36 cases/1,000 patient-days from 1985 to 1989; there was a parallel increase in the rate of all nosocomial infections combined. Bacteremia was documented in 6.5% of all hospital-acquired infections. The majority of isolates were gram-negative, and Providencia stuartii was the most common gram-negative species. Staphylococcus aureus was the most frequent isolate; one-third of S. aureus strains were resistant to methicillin. Bacteremia was polymicrobial in 36 episodes (22%), 14 of which involved an enterococcal species. Portals of entry included the urinary tract (55%), the respiratory tract (11%), and soft tissue (9%). Overall mortality was 21.5%. Death was significantly associated with residence on the intermediate-care unit, the presence of a respiratory infection, a change in mental status, and relatively recent admission. Optimal management of bacterial infection in a long-term-care setting requires the availability of blood culture results. Initial decisions about antibiotic therapy should be made in light of the likelihood of infection with multiresistant organisms and of polymicrobial infection.

Adult↗
PubMed1993

Bacterial adhesins and host factors: role in the development and outcome of Escherichia coli bacteremia.

To assess the contributions of bacterial virulence factors and defects in host defense to Escherichia coli bacteremia, we examined isolates and available medical records from 169 episodes at two hospitals. Adhesins and hemolysin virulence factors were documented in 84% of bacteremia-associated isolates originating from the urinary and respiratory tracts and in 50% of such isolates originating from other extraurinary foci. Of the evaluable episodes of bacteremia involving 35 adhesin-negative isolates, 21 (60%) were in patients who had mucocutaneous defects at the primary site of infection, and another 13 (37%) were in patients who had comorbid systemic diseases (i.e., chronic renal failure or alcoholism) associated with impaired leukocyte function. In contrast, of 93 evaluable episodes with adhesin-positive isolates, 22 (24%) were in patients who had none of these host conditions (P = .008). Overall, of evaluable episodes of bacteremia involving 128 isolates, 71 (55%) had both bacterial virulence-associated and host-related risk factors. Mortality was related to the severity of comorbid illnesses and was not affected by the presence of the bacterial virulence factors assessed.

Adhesins, Escherichia coli↗
PubMed1993

Bacteremia due to Enterococcus avium.

Enterococcus avium, formerly "group Q streptococcus," has rarely been reported as a pathogen in humans. To determine the clinical significance of this organism, we reviewed the records of all patients whose blood cultures were positive for E. avium who were seen at our institution from 1986 through 1991 and identified nine cases of bacteremia due to E. avium. All isolates were believed to be clinically significant. Five of nine cases developed in patients with significant gastrointestinal illnesses. The remaining clinical scenarios included intravenous catheter sepsis and factitious disorders. E. avium bacteremias were polymicrobial in seven cases; in six cases, the coisolates were gastrointestinal organisms. These observations suggest that E. avium bacteremia most often originated from a gastrointestinal tract source. We conclude that, though rare, E. avium can be pathogenic in humans and that E. avium bacteremia is associated with gastrointestinal abnormalities.

Adult↗
PubMed1994

Bacteremia with Acinetobacter species: risk factors and prognosis in different clinical settings.

Acinetobacter species are widespread environmental gram-negative coccobacilli that are associated with nosocomial infections; these bacteria are considered to be of relatively low virulence and rarely cause invasive disease. Fifty-two cases of bacteremic episodes due to Acinetobacter species were reviewed, and risk factors and outcomes of these cases were examined. It was noted that these cases belonged to a few clinical groups with markedly different outcomes. Eighteen patients had malignancies (predominantly hematologic), and bacteremia often developed after respiratory infection. Nine patients suffered traumatic injuries and developed bacteremia with Acinetobacter species after endotracheal intubation in the intensive care unit and respiratory colonization. Four burn patients, three of whom had burns covering > or = 50% of their body surface areas, had burn infections prior to bacteremia. While many patients had central venous catheters, in only four cases were the catheters clearly infected prior to the positive blood culture. Prior use of antibiotics was widespread in all groups of patients, and isolates showed high levels of antimicrobial resistance, particularly to beta-lactam agents. The outcome of infection correlated more closely with the type of underlying illness than with other factors such as biovar, polymicrobial bacteremia, or appropriate therapy. Patients with malignancies and burn patients fared poorly (10 of 18 and 2 of 4 patients, respectively, died), while trauma patients and patients with other illnesses did well.

Acinetobacter↗
PubMed1995

Aeromonas bacteremia: review of 59 episodes.

Fifty-nine episodes of bacteremia due to Aeromonas species occurred within a 5-year period in one medical center in southern Taiwan. Underlying diseases in the 58 patients included hepatic cirrhosis (36%) and cancer (24%). Patients with aeromonas bacteremia more often had underlying hepatic cirrhosis than did those with bacteremia due to other gram-negative bacilli. Males (67%) outnumbered females. The cases appeared to cluster in the summer and fall months. Thirty-two percent were polymicrobial infections; often the Aeromonas pathogens were accompanied by other gram-negative bacilli. Aeromonas hydrophila was the most common species isolated (69%). In addition to fever, hypotension and jaundice were the common clinical manifestations of aeromonas sepsis. In cirrhotic patients, spontaneous bacterial peritonitis, altered mental status, and jaundice were most common, and aeromonas bacteremia in such patients was monomicrobial and community-acquired more often than in noncirrhotic patients. In vitro aeromonads were generally susceptible to aminoglycosides, cefuroxime, the third-generation cephalosporins, and quinolones. The overall crude fatality rate was 36%. Predictors of fatal outcome for cirrhotic patients included spontaneous bacterial peritonitis, hypotension on admission, diabetes mellitus, and high Pugh scores.

Adolescent↗
PubMed1995

Shewanella (Pseudomonas) putrefaciens bacteremia.

Shewanella (Pseudomonas) putrefaciens is a rare pathogen in humans, and to our knowledge only 13 cases of S. putrefaciens bacteremia have ever been reported in the literature. In this retrospective study we describe 28 cases of S. putrefaciens bacteremia: 16 in premature and 1-day-old neonates, 9 in adults, and 3 in children younger than 1 year of age. All the babies presented with respiratory distress and/or pneumonia. Six of the adults had associated traumatic lesions of the lower extremity, and of the eight patients who died of sepsis, six were neutropenic. Polymicrobial bacteremia was seen in 18 cases. Three syndromes of bacteremic infection with S. putrefaciens appear to exist: the first is associated with prematurity and congenital pneumonia; the second with ulceration of the lower extremities; and the third (which is more fulminant), with an underlying debility. The findings in these 28 cases confirm the fact that S. putrefaciens can invade the bloodstream; however, the presence of concurrent bacteremia makes it difficult to determine the pathogenic role of this organism in septicemia.

Adolescent↗
PubMed1995

Attributable mortality of bacteremia associated with the Bacteroides fragilis group.

Uncontrolled studies have suggested that Bacteroides fragilis group bacteremia has an attributable mortality rate between 13% and 33%. To determine the true attributable mortality rate and the mortality risk ratio associated with bacteremia due to the B. fragilis group, we conducted a matched-pair study in which cases were matched to controls for age, gender, year of admission, principal discharge diagnosis, and types of major surgery by an investigator blinded to survival status. Cases and controls were comparable in demographic and clinical characteristics. Cases had a significantly higher mortality rate (28% vs. 8.7%, P = .002, McNemar's test), with an attributable mortality rate of 19.3% (95% CI, 8%-30%; P = .003) and a mortality risk ratio of 3.2. In a multivariate analysis, three clinical factors were independently correlated with mortality: the presence of B. fragilis group bacteremia (RR: 4.9; 95% CI: 3.7-6.0; P = .009), congestive heart failure (RR: 8.0; 95% CI: 6.6-9.3; P = .003) or chronic liver disease (RR: 6.3; 95% CI: 4.8-7.7; P = .01). Cases also had a 16-day-longer stay in the hospital (P = .0007, Wilcoxon's signed rank test) compared with controls. Thus, B. fragilis group bacteremia contributes significantly to morbidity and mortality.

Bacteremia↗
PubMed1995

Spectrum and significance of bacteremia due to Moraxella catarrhalis.

Fifty-eight cases of bacteremia due to Moraxella catarrhalis, including seven that occurred in patients treated at our facilities, are analyzed. The host's medical history plays a major role in the presentation and outcome of M. catarrhalis bacteremia. Bacteremia is typically accompanied by pneumonia in adults with underlying respiratory disease. Many neutropenic patients do not manifest a focus of infection; in contrast, the source identified in healthy, immunocompetent patients is usually the upper airway or the ears. In the recent literature, it has been reported that a rash is typically absent in adults with bacteremic pneumonia and in immunocompetent hosts and that only some neutropenic patients have a rash. The prognosis is grave for patients with endocarditis and for patients with immunoglobulin deficiency or neutropenia not related to a hematologic malignancy. In addition, mortality is substantial among bacteremic patients with respiratory conditions or other chronic debilities, especially when respiratory copathogens are present. The prognosis is good for febrile neutropenic patients with underlying leukemia or lymphoma when the neutropenia resolves. When healthy, immunocompetent individuals are affected with M. catarrhalis bacteremia, their presentations range from self-limited febrile illness to life-threatening disease.

Adult↗
PubMed1996

Achromobacter xylosoxidans bacteremia: report of four cases and review of the literature.

Seventy-seven cases of bacteremia due to Achromobacter xylosoxidans were reviewed, and susceptibility studies were performed on 11 clinical isolates of A. xylosoxidans. Nosocomial bacteremia was noted in 54 of 77 patients (70%), and 28 (36%) had infection associated with an outbreak or acquired from a discrete point source. The most common underlying illnesses were malignancies (30%) and cardiac disease (21%); immunosuppression affected 27%. The most common clinical syndromes were primary and catheter-associated bacteremia (19% each) and pneumonia (16%). The case-fatality rate was 30%; only 3% of patients with primary or catheter-associated bacteremia died, but 65% of patients with meningitis, endocarditis, and pneumonia died. The case-fatality rate in neonates was 80%. Susceptibility studies showed that all strains were resistant to aminoglycosides, most were resistant to quinolones, and all were susceptible to broad-spectrum penicillins, imipenem, ceftazidime, and trimethoprim-sulfamethoxazole. Two-disk approximation and time-kill studies showed synergy or additive effects for the combination of gentamicin and piperacillin against most strains.

Adolescent↗
PubMed1997

Nosocomial bacteremia in critically ill patients: a multicenter study evaluating epidemiology and prognosis. Spanish Collaborative Group for Infections in Intensive Care Units of Sociedad Espanola de Medicina Intensiva y Unidades Coronarias (SEMIUC).

A total of 590 consecutive episodes of nosocomial bacteremia were prospectively followed in 30 intensive care units (ICUs) over a 9-month period. The crude and directly related mortality rates were 41.6% and 19%, respectively. The predominant pathogens were coagulase-negative staphylococci (24.4%) and coagulase-positive staphylococci (17.5%). The most frequent sources of infection were intravenous catheters (37.1%). Multivariate analysis defined seven variables as independently influencing crude mortality: adult respiratory distress syndrome (ARDS), septic shock, multiorgan failure (MOF), mechanical ventilation, chronic hepatic failure, acute renal failure, and APACHE II score of > or = 15 at diagnosis. Variables associated with a higher directly related mortality were septic shock, ARDS, acute renal failure, MOF, gram-negative or candidal bacteremia, source of bacteremia other than intravascular catheter, and severe sepsis. We conclude that preventing catheter colonization is crucial in reducing the incidence of bacteremia in an ICU, while improving outcome depends on better management of septic shock and associated complications.

Adult↗
PubMed1994

Autopsy findings in AIDS patients with Mycobacterium avium complex bacteremia.

To study the pathogenesis of Mycobacterium avium complex (MAC) bacteremia, the extent of organ involvement was determined in a retrospective cohort of 44 AIDS patients with MAC bacteremia and complete autopsies between 1988 and 1992. Clinical and microbiologic histories were reviewed and lymph nodes, spleen, liver, bone marrow, small intestine, and colon from each autopsy were systematically evaluated for the presence of mycobacteria or foamy histiocytes. Of the patients, 30% had no histologic evidence of MAC. In the remaining 70%, reticuloendothelial and gastrointestinal involvement was most common, but the number and distribution of involved sites was highly variable. The risk of developing detectable histologic involvement was related to the duration of bacteremia. In contrast to the prevailing concept, our data suggest that MAC bacteremia may precede widespread tissue disease.

AIDS-Related Opportunistic Infections↗
PubMed1995

The clinical and molecular epidemiology of bacteremias at a university hospital caused by pneumococci not susceptible to penicillin.

To determine the epidemiology of bacteremias due to pneumococci not susceptible to penicillin (PNSP) at a university hospital, active microbiologic surveillance of bacteremias due to PNSP was done for 28 months. Controls were bacteremias caused by penicillin-susceptible pneumococci. Antimicrobial susceptibilities for alternative antibiotics were determined. Pulsed-field gel electrophoresis (PFGE) and serotyping were used as markers of strain identity. Of 113 pneumococcal isolates, 14 (13%) were intermediate or resistant to penicillin (MIC > or = 0.1 microgram/mL). Twelve PNSP were resistant to other drugs: chloramphenicol (5), tetracycline (6), trimethoprim-sulfamethoxazole (5), cefotaxime (1), and erythromycin (1). Independently significant risk factors associated with PNSP bacteremia were sepsis and prior treatment with beta-lactam antibiotics. PFGE revealed 10 distinguishable patterns among 12 isolates available for typing. In general, PFGE typing correlated with serotyping. It also distinguished some isolates of the same serotype. PFGE typing and serotyping suggest that the frequency of PNSP in the San Antonio, Texas, area is not due to dissemination of a single clonal strain.

Adolescent↗
PubMed1997

Bacteremia in young urban women admitted with pyelonephritis.

The objective of this study was to determine the rate of bacteremia in young women admitted to the hospital with presumed pyelonephritis and compare it with other published rates. The study design was a retrospective, structured chart review and a review of published reports of bacteremic pyelonephritis. An urban county teaching hospital provided the setting for the study. The patients were nonpregnant women (n = 98) 44 years of age or younger who were without bladder dysfunction and who had not been admitted to an intensive care unit. Further criteria for participation included discharge with the diagnosis of acute pyelonephritis. Blood cultures were ordered for 69 women; the results of 64 were noted in the chart. Twenty-three women (35.9% of those cultured; 23.4% of all patients) were diagnosed with bacteremia. In patients for whom blood culture results were obtained, trends developed between those patients with bacteremia and those with complicated pyelonephritis, defined as a known or newly discovered genitourinary abnormality or a risk factor (P = 0.044), those who were black (P = .044), those with higher pulses on admission (P = .050), those with more white blood cells per high-powered field after urinalysis (P = 0.007), and those whose fever lasted longer (P = 0.033). Blood culture results were positive in two patients whose urine cultures were negative. This comparatively high bacteremia rate supports routine ordering of blood cultures for urban women suspected of having pyelonephritis.

Adolescent↗
PubMed1997

Geographic and seasonal variation in Mycobacterium avium bacteremia among North American patients with AIDS.

Analysis of geographic risk was performed for Mycobacterium avium complex (MAC) bacteremia among North American patients with AIDS. Monthly mycobacterial blood cultures were taken from patients who were placebo recipients in a prospective evaluation of MAC prophylaxis. Of 571 patients, 102 (17.9%) acquired MAC bacteremia during an average follow-up of 256 days. The area with the highest risk for MAC was the South Central region (27.9%; P < 0.02), whereas the area with the lowest risk was Canada (11.3%; P = 0.12). When the southern states were combined and compared with the northern states and Canada, the incidence of MAC bacteremia was higher in the southern states (21.6% versus 14.0%, P < 0.03). Proportional hazards analysis was performed for the difference between the North and South and controlled for baseline CD4 cell count. In this analysis, time to MAC was significantly longer in the North (hazard ratio = 0.587, 95% confidence interval 0.390 to 0.883, P = 0.01). Although overall variation in seasonality was not marked, there was a significant decrease in cases in the North during the summer months (P < 0.01). We conclude that geographic location is a risk factor for MAC bacteremia in patients with advanced AIDS, with decreased risk in northern North America.

AIDS-Related Opportunistic Infections↗
PubMed1998

Long-term outcomes of treatment of Mycobacterium avium complex bacteremia using a clarithromycin-containing regimen.

OBJECTIVES: To describe the long-term outcomes of treatment of AIDS-related Mycobacterium avium complex (MAC) bacteremia using a standard clarithromycin-based regimen. DESIGN: Retrospective study of patients with MAC bacteremia diagnosed between April 1992 and April 1995. SETTING: An urban AIDS clinic SUBJECTS: One hundred seventy-six consecutive patients with MAC bacteremia. INTERVENTIONS: Clarithromycin 500 mg twice daily, ethambutol 800 or 1200 mg daily, and clofazimine 100 mg daily. MAIN OUTCOME MEASURES: Late treatment failure (defined as a positive blood culture more than 90 days after starting treatment), clarithromycin susceptibility of initial and treatment-failure isolates, DNA fingerprinting of isolates from treatment failures. RESULTS: Two out of 176 (1.1%) baseline isolates were resistant to clarithromycin. One hundred and fifty-one patients were treated for MAC bacteremia, 144 (95%) with the standard regimen. Of the 117 patients who survived > 90 days after starting therapy, 25 (21%) met the criteria for late treatment failure. Of the 22 treatment-failure isolates available for susceptibility testing, 19 (86%) were resistant to clarithromycin. Therefore, 13% of patients treated using the standard regimen (19 out of 144) had treatment failure associated with the emergence of clarithromycin resistance. Using logistic regression, non-compliance was associated with treatment failure (P = 0.02). Fourteen out of the 17 (82%) evaluable paired isolates had identical DNA fingerprint patterns, whereas three pairs showed that a different strain of MAC was present at the time of treatment failure. CONCLUSIONS: Initial resistance to clarithromycin was rare during this period. However, late treatment failure associated with the emergence of clarithromycin resistance was relatively common during long-term follow-up. Most late treatment failures represented emergence of clarithromycin resistance in the initial strain.

AIDS-Related Opportunistic Infections↗
PubMed2002

Effect of histamine H3 receptor blockade on venous return and splanchnic hemodynamics in experimental bacteremia.

OBJECTIVE: In the heart, histamine H3 receptors may function as inhibitory presynaptic receptors that decrease adrenergic neural norepinephrine release in conditions of enhanced sympathetic tone. In a previous study, we found that H3 receptor blockade improved cardiac contractility and systemic hemodynamics in experimental bacteremia in dogs. Because histamine H3 receptors have been found in the splanchnic circulation in other animal models, it was not clear the extent to which H3 receptor blockade may have altered splanchnic hemodynamics, and variables of venous return, that in turn contributed to the overall improvement in systemic hemodynamics observed in the previous experiment. In the present study, we examined splanchnic hemodynamics in the presence of H3 receptor blockade in a canine model of Escherichia coli bacteremia. DESIGN: Bacteremia was produced by intravenous infusion of live E. coli administered throughout the experiment. Variables of venous return included mean systemic pressure, resistance to venous return, and mean right atrial pressure. Splanchnic measurements included hepatic and portal pressures and flows. Measurements were obtained before and after H3 receptor blockade with thioperamide maleate. The animals were studied while ventilated and anesthetized. RESULTS: H3 receptor blockade caused a decrease in mean right atrial pressure from 5.9 mm Hg pretreatment to 3.5 mm Hg posttreatment (p < .05), although it did not affect mean systemic pressure or resistance to venous return. There were no changes in portal or hepatic flows after H3 receptor blockade. The cardiac function curve after H3 receptor blockade was shifted upward and to the left compared with the pretreatment curve. CONCLUSIONS: The results showed that the primary effect of H3 receptor blockade in experimental bacteremia was attributable to an increase in inotropy. There was no evidence to indicate that H3 receptor activation contributed to altered splanchnic hemodynamics in this model.

Analysis of Variance↗