Abstract
BackgroundBloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. The effects of early administration of appropriate antimicrobials on the prognosis and timing of defervescence of bacteremic patients remain under debate.MethodsIn a 6-year retrospective, multicenter cohort, adults with community-onset bacteremia at the emergency departments (EDs) were analyzed. The period from ED arrival to appropriate antimicrobial administration and that from appropriate antimicrobial administration to defervescence was regarded as the time-to-appropriate antibiotic (TtAa) and time-to-defervescence (TtD), respectively. The primary study outcome was 30-day mortality after ED arrival. The effects of TtAa on 30-day mortality and delayed defervescence were examined after adjustment for independent predictors of mortality, which were recognized by a multivariate regression analysis.ResultsOf the total 3194 patients, a TtAa-related trend in the 30-day crude (γ = 0.919, P = 0.01) and sepsis-related (γ = 0.909, P = 0.01) mortality rate was evidenced. Each hour of TtAa delay was associated with an average increase in the 30-day crude mortality rate of 0.3% (adjusted odds ratio [AOR], 1.003; P < 0.001) in the entire cohort and 0.4% (AOR, 1.004; P < 0.001) in critically ill patients, respectively, after adjustment of independent predictors of 30-day crude mortality. Of 2469 febrile patients, a TtAa-related trend in the TtD (γ = 0.965, P = 0.002) was exhibited. Each hour of TtAa delay was associated with an average 0.7% increase (AOR, 1.007; P < 0.001) in delayed defervescence (TtD of ≥ 7 days) after adjustment of independent determinants of delayed defervescence. Notably, the adverse impact of the inappropriateness of empirical antimicrobial therapy (TtAa > 24 h) on the TtD was noted, regardless of bacteremia severity, bacteremia sources, or causative microorganisms.ConclusionsThe delay in the TtAa was associated with an increasing risk of delayed defervescence and 30-day mortality for adults with community-onset bacteremia, especially for critically ill patients. Thus, for severe bacteremia episodes, early administration of appropriate empirical antimicrobials should be recommended.
Highlights
Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs
Prognostic impact of time-to-appropriate antibiotic (TtAa) in the entire cohort For 3194 patients, the association of clinical variables, in terms of patient demography, bacteremia severity, bacteremia sources, comorbidity severity, and major comorbidities, with 30-day crude mortality was examined in the univariate analysis
The following variables were positively associated with 30-day mortality: the elderly, male, nursing-home residents, inadequate source control, fatal comorbidities (McCabe classification), a critical illness at Emergency department (ED) arrival, bacteremic pneumonia, and comorbidities with malignancies, neurological disorders, or liver cirrhosis (Table 2)
Summary
Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. In septic patients presenting with a critical illness, inappropriate empirical therapy is associated with increased mortality [4, 5]. Bloodstream infections lead to high morbidity and mortality and substantially contribute to healthcare costs [6]. Whether appropriate initial antimicrobial administration has beneficial effects on the outcome of patients with bloodstream infections remains debated [4, 7,8,9,10,11]. We hypothesized that timely appropriate antimicrobial therapy heralds a favorable outcome and speedy defervescence, and a large cohort of adults with community-onset bacteremia was studied
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