Predictive factors of in-hospital mortality in patients with laboratory-confirmed Escherichia coli, Klebsiella species or Pseudomonas aeruginosa bloodstream infections.

Eleanor Mitchell,Julia Newton,Anthony Roberts,Mark Pearce,Justyna Gołębiewska

doi:10.1371/journal.pone.0259305

Abstract

Gram-negative bloodstream infections (GNBSI) are confirmed by the presence of gram-negative bacteria in the bloodstream and pose a significant healthcare issue as they increase the risk of sepsis and mortality. In England, the aim is to reduce GNBSI cases and further deterioration through enhanced population surveillance of patients with a laboratory-confirmed GNBSI to inform on healthcare policies. The objective of this study was to evaluate the factors associated with in-hospital mortality in patients with a laboratory-confirmed Escherichia coli, Klebsiella or Pseudomonas aeruginosa GNBSIs, with data obtained from the enhanced data capture for the surveillance of GNBSIs. All patients with a laboratory-confirmed GNBSI at a single centre, admitted between April 2017 and March 2019, were included in this retrospective observational study. Demographic and recent exposure to healthcare risk factors were collected and assessed for the association with in-hospital mortality. In 1113 patients with laboratory-confirmed GNBSIs, the in-hospital mortality rate was 13%. Multivariable analysis confirmed that patients with respiratory (OR = 3.73, 95%CI = 2.05–6.76), gastrointestinal (2.61; 1.22–5.58) or skin (3.61; 1.24–10.54) infection primary focus had a greater risk of in-hospital mortality, compared to upper urinary tract infections. Increased risk of in-hospital mortality was also observed in patients with hospital-onset GNBSIs (OR = 1.87; 1.17–2.97) compared with community-onset healthcare acquired GNBSIs, or who were on dialysis at the time of the GNBSI (3.28; 1.01–10.14), as well as in patients who had recently been discharged from hospital (1.55; 1.01–2.38), or had a vascular device recently manipulated (2.41; 1.01–5.74). Results confirm that the data obtained from the enhanced data capture for GNBSIs in England can predict in-hospital mortality in patients with a GNBSI. Several factors associated with an increased risk of in-hospital mortality have been identified. Results should be reported back to clinicians in order to identify patients at a greater risk of dying in-hospital who may benefit from further monitoring.

Highlights

Gram-negative bloodstream infections (GNBSI) are defined by the presence of gram-negative bacteria within the bloodstream [1]
Patients who died were significantly older males, more likely to have been in-hospital prior to the GNBSI episode, more likely to have a HOHA infection and more likely to have a respiratory infection as the primary focus. 24.84% of those who died had been on dialysis at the time of the GNBSI, 9.15% had had a vascular device in situ, or manipulated within 28 days prior to the GNBSI, and 7.84% had an open wound in the 28 days prior to the GNBSI
In this retrospective observational study of patients with a laboratory-confirmed GNBSI admitted to South Tees Hospitals NHS Foundation Trust (STHFT), it was observed that patients with HOHA infections, respiratory, skin and gastrointestinal infections leading to the GNBSI, being on dialysis at the time of the GNBSI, having a recent hospital discharge or a recent vascular device were at significant increased risk of in-hospital mortality

Summary

Introduction

Gram-negative bloodstream infections (GNBSI) are defined by the presence of gram-negative bacteria within the bloodstream [1]. 70% of all GNBSIs in England are due to Escherichia coli (E. coli), Klebsiella and Pseudomonas aeruginosa (P. aeruginosa) species. National surveillance programmes have been established in England to monitor these three main GNBSI associated species, with the aim to reduce rates of GNBSIs by 50% by 2024/5 [2, 3]. GNBSIs are a significant healthcare issue, as they are a leading cause of sepsis [1]. Sepsis is defined as a dysregulated host immune response to an infection and is a prominent healthcare issue, with 123,000 cases and 37,000 associated deaths each year [4,5,6]. Clinicians aim to detect and treat GNBSIs that may result in sepsis quickly and effectively, to prevent the development of sepsis and further deterioration [7]

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Conclusion