Abstract
BackgroundEscherichia coli is the most common cause of bloodstream infections (BSIs) and mortality is an important aspect of burden of disease. Using a multinational population-based cohort of E. coli BSIs, our objectives were to evaluate 30-day case fatality risk and mortality rate, and determine factors associated with each.MethodsDuring 2014–2018, we identified 30-day deaths from all incident E. coli BSIs from surveillance nationally in Finland, and regionally in Sweden (Skaraborg) and Canada (Calgary, Sherbrooke, western interior). We used a multivariable logistic regression model to estimate factors associated with 30-day case fatality risk. The explanatory variables considered for inclusion were year (2014–2018), region (five areas), age (< 70-years-old, ≥70-years-old), sex (female, male), third-generation cephalosporin (3GC) resistance (susceptible, resistant), and location of onset (community-onset, hospital-onset). The European Union 28-country 2018 population was used to directly age and sex standardize mortality rates. We used a multivariable Poisson model to estimate factors associated with mortality rate, and year, region, age and sex were considered for inclusion.ResultsFrom 38.7 million person-years of surveillance, we identified 2961 30-day deaths in 30,923 incident E. coli BSIs. The overall 30-day case fatality risk was 9.6% (2961/30923). Calgary, Skaraborg, and western interior had significantly increased odds of 30-day mortality compared to Finland. Hospital-onset and 3GC-resistant E. coli BSIs had significantly increased odds of mortality compared to community-onset and 3GC-susceptible. The significant association between age and odds of mortality varied with sex, and contrasts were used to interpret this interaction relationship. The overall standardized 30-day mortality rate was 8.5 deaths/100,000 person-years. Sherbrooke had a significantly lower 30-day mortality rate compared to Finland. Patients that were either ≥70-years-old or male both experienced significantly higher mortality rates than those < 70-years-old or female.ConclusionsIn our study populations, region, age, and sex were significantly associated with both 30-day case fatality risk and mortality rate. Additionally, 3GC resistance and location of onset were significantly associated with 30-day case fatality risk. Escherichia coli BSIs caused a considerable burden of disease from 30-day mortality. When analyzing population-based mortality data, it is important to explore mortality through two lenses, mortality rate and case fatality risk.
Highlights
Escherichia coli is the most common cause of bloodstream infections (BSIs) and mortality is an important aspect of burden of disease
We found 11.4% (336/2961) of the E. coli BSIs that resulted in 30-day deaths were resistant to Third-generation cephalosporin (3GC) and this ranged from 3.5% (5/142) in Skaraborg to 24.2% (109/450) in Calgary
Most of the E. coli BSIs that resulted in 30-day deaths were community-onset E. coli BSIs (67.1%, 1987/2961); this proportion was lowest in Finland (65.4%, 1472/2252) and highest in Skaraborg (78.2%, 111/142)
Summary
Escherichia coli is the most common cause of bloodstream infections (BSIs) and mortality is an important aspect of burden of disease. Using a multinational population-based cohort of E. coli BSIs, our objectives were to evaluate 30-day case fatality risk and mortality rate, and determine factors associated with each. Two general approaches for analyzing mortality data from population-based studies include evaluation of mortality rates and case fatality risks, which provide distinct yet complementary results [3, 5]. A small number of published population-based studies have reported mortality data for E. coli BSIs, they did not all use the same definition of mortality [1, 6,7,8,9,10,11]. Mortality rates for E. coli BSIs were only reported by three studies [3] (in-hospital mortality rate of 2.9 deaths/100,000 person-years, and 30-day mortality rates of 7 and 10.3 deaths/100,000 person-years) [6, 10, 11]
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