Abstract
Staphylococcus aureus bacteremia (SAB) is common and associated with poor long-term outcomes. Previous studies have demonstrated an association between infectious diseases (ID) consultation and improved short-term (ie, within 90 days) outcomes for patients with SAB, but associations with long-term outcomes are unknown. To investigate the association of ID consultation with long-term (ie, 5 years) postdischarge outcomes among patients with SAB. This cohort study included all patients (N = 31 002) with a first episode of SAB who were discharged alive from 116 acute care units of the nationwide Veterans Health Administration where ID consultation was offered. Data were collected from January 2003 to December 2014, with follow-up through September 30, 2018. Data analysis was conducted from February to December 2019. Infectious diseases consultation during the index hospital stay. The primary outcome was time to development of a composite event of all-cause mortality or recurrence of SAB within 5 years of discharge. As secondary outcomes, SAB recurrence and all-cause mortality with and without recurrence were analyzed while accounting for semicompeting risks. The cohort included 31 002 patients (30 265 [97.6%] men; median [interquartile range] age at SAB onset, 64.0 [57.0-75.0] years). Among 31 002 patients, there were 18 794 (60.6%) deaths, 4772 (15.4%) SAB recurrences, and 20 414 (65.8%) composite events during 5 years of follow-up; 12 773 deaths (68.0%) and 2268 recurrences (47.5%) occurred more than 90 days after discharge. Approximately half of patients (15 360 [49.5%]) received ID consultation during the index hospital stay; ID consultation was associated with prolonged improvement in the composite outcome (adjusted hazard ratio at 5 years, 0.71; 95% CI, 0.68-0.74; P < .001). Infectious diseases consultation was also associated with improved outcomes when all-cause mortality without recurrence and SAB recurrence were analyzed separately (all-cause mortality without recurrence: adjusted hazard ratio at 5 years, 0.77; 95% CI, 0.74-0.81; P < .001; SAB recurrence: adjusted hazard ratio at 5 years, 0.68; 95% CI, 0.64-0.72; P < .001). Having an ID consultation during the index hospital stay among patients with SAB was associated with improved postdischarge outcomes for at least 5 years, suggesting that contributions of ID specialists to management during acute infection may have a substantial influence on long-term outcomes. Further investigations of the association of ID consultation with outcomes after S aureus should include long-term follow-up.
Highlights
Infectious diseases consultation was associated with improved outcomes when all-cause mortality without recurrence and Staphylococcus aureus bacteremia (SAB) recurrence were analyzed separately
Having an infectious diseases (ID) consultation during the index hospital stay among patients with SAB was associated with improved postdischarge outcomes for at least 5 years, suggesting that contributions of ID specialists to management during acute infection may have a
In subgroup analyses between patients with methicillin-susceptible S aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA), ID consultation was associated with higher event-free survival probability in both groups, the association was more prominent in the MSSA group
Summary
Staphylococcus aureus bacteremia (SAB) is common and frequently associated with poor outcomes, with 30-day case-fatality rates ranging from 15% to 30% in recent studies.[1,2,3,4] In addition, SAB is associated with a high frequency of recurrence after the completion of therapy, especially in the absence of definitive source control.[5,6,7,8,9,10,11] Previous studies have demonstrated an association between receipt of infectious diseases (ID) consultation and improved short-term outcomes among patients with SAB, including reduced mortality and SAB recurrence within 90 days.[10,11,12,13,14,15,16] Possible mechanisms explaining the improved short-term outcomes among patients receiving ID consultation include early identification and management of sources of infection, documentation of bacteremia clearance, appropriate choice and duration of antibiotic therapy, and close follow-up and monitoring of therapy.[2,14,17]It is plausible that ID consultation in the early phase of SAB care (ie, during the initial hospitalization) could lead to long-term improvements in patient outcomes after discharge, far beyond 90 days. Staphylococcus aureus bacteremia may recur several years after the initial infection if primary sources are not adequately controlled or infected medical devices are left in place.[2,23,24] Improved management of SAB through ID consultation during the acute illness could potentially reduce late SAB recurrence and long-term sequelae, including death. If true, this would expand our understanding of the benefits of ID consultations for patients with SAB. Prior studies have not examined outcomes after 90 days among patients with and without ID consultation
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