Bloodstream Infections In Patients Research Articles

Multi-drug resistant bacteria predict mortality in bloodstream infection in a tertiary setting in Tanzania.

Bloodstream infections (BSI) are serious and life-threatening, associated with high mortality and morbidity. In resource-limited settings, there is a paucity of data on predictors of outcome in patients with BSI. This study aimed at examining the predictors of mortality in patients with BSI as well as bacteria causing BSI. This was a cross-sectional study conducted at Muhimbili National Hospital between April and May 2018. Blood culture results from all inpatients at the clinical microbiology laboratory were recorded and clinical information was retrieved retrospectively from the files. Bacteria from positive blood culture were identified and antimicrobial susceptibility was performed. The overall prevalence of BSI was, 46/402 (11.4% 95% CI 8.6-15), with a case fatality rate of 37%. There was a significantly high rate of BSI in patients who had died (19.5%) compared to those who survived (9.2%) p = 0.008. Gram-negative bacteria (74%) were the common cause of BSI, with a predominance of Enterobacteriaceae (22), followed by Pseudomonas aeruginosa (11). The majority of bacteria (70.5%) isolated from patients with BSI were Multi-drug resistant (MDR). Forty-six percent of Pseudomonas aeruginosa were resistant to meropenem while 68% (15/22) of Enterobacteriaceae were extended-spectrum β lactamase producers. Carbapenemase production was detected in 27% (3/11) of Pseudomonas aeruginosa and one Proteus mirabilis. Forty percent of Staphylococcus aureus were methicillin-resistant Staphylococcus aureus. Positive blood culture (aOR 2.24, 95%CI 1.12-4.47, p 0.02) and admission to the intensive care unit (aOR 3.88, 95%CI 1.60-9.41, p = 0.003) were independent factors for mortality in suspected BSI. Isolation of MDR bacteria was an independent predictor for mortality in confirmed BSI (aOR 15.62, 95%CI 1.24-161.38, p = 0.02). The prevalence of BSI was 11.4%, with the majority of bacteria in BSI were MDR. Positive blood culture, admission to the ICU and MDR were predictors for mortality.

Characteristics and outcome of nosocomial bloodstream infection in patients with acute-on-chronic liver failure.

Patients with acute-on-chronic liver failure (ACLF) have a high risk of developing infections while hospitalized. Nosocomial bloodstream infection (BSI) is not uncommon, particular in patients who receive invasive operation, which may have negative impact on prognosis. In this study, we aim to investigate the characteristics and short-term outcome of nosocomial BSI in patients with ACLF. Sixty-three patients with ACLF and nosocomial BSI from January 2014 to December 2015 were retrospectively studied. Clinical characteristics and distribution of bacteria at the time of BSI onset and short-term mortality were collected. The most common etiology of ACLF was hepatitis B virus infection. Eighty-one percent of ACLF patients had other types of infections at BSI onset. Gram-negative bacteria (77.8%) were the main pathogens, among which Escherichia coli was responsible for 46.9%. Staphylococcus epidermidis was the main Gram-positive bacteria. The most prevalent multidrug resistance (MDR) bacteria was extended-spectrum β-lactamase (ESBL)-producing E. coli. The overall 28-day mortality rate was 42.9%. Multivariate analysis found that model for end-stage liver disease (MELD) score and number of organ failures were predictors of 28-day mortality. The area under the receiver operating characteristic of the numbers of organ failures to predict 28-day mortality was higher than MELD score (0.833 vs. 0.784, 0.4099), but without significant difference. Gram-negative bacteria were the most prevalent pathogens and ESBL-producing bacteria were responsible for most of the MDR bacteria in patients with ACLF and nosocomial BSI. Higher MELD score and multiorgan failure were associated with worse outcomes.

Colistin-Resistant Acinetobacter Baumannii Bacteremia: A Serious Threat for Critically Ill Patients.

The prevalence of acinetobacter baumannii (AB) as a cause of hospital infections has been rising. Unfortunately, emerging colistin resistance limits therapeutic options and affects the outcome. The aim of the study was to confirm our clinically-driven hypothesis that intensive care unit (ICU) patients with AB resistant-to-colistin (ABCoR) bloodstream infection (BSI) develop fulminant septic shock and die. We conducted a 28-month retrospective observational study including all patients developing AB infection on ICU admission or during ICU stay. From 622 screened patients, 31 patients with BSI sepsis were identified. Thirteen (41.9%) patients had ABCoR BSI and 18/31 (58.1%) had colistin-susceptible (ABCoS) BSI. All ABCoR BSI patients died; of them, 69% (9/13) presented with fulminant septic shock and died within the first 3 days from its onset. ABCoR BSI patients compared to ABCoS BSI patients had higher mortality (100% vs. 50%, respectively (p = 0.001)), died sooner (p = 0.006), had lower pH (p = 0.004) and higher lactate on ICU admission (p = 0.0001), and had higher APACHE II (p = 0.01) and Charlson Comorbidity Index scores (p = 0.044). In conclusion, we documented that critically ill patients with ABCoR BSI exhibit fulminant septic shock with excessive mortality. Our results highlight the emerging clinical problem of AB colistin resistance among ICU patients.

Escherichia coli blood stream infection in cancer patients: a multicentre, multidisciplinary collaborative audit to identify risk factors in order to target preventative strategies for improvement of patient care and outcomes

Background Escherichia coli is a common cause of blood stream infections (BSI) in the UK. Published figures for E. coli BSI show higher rates in specialist cancer centres than in other hospitals, but the aetiology in oncology patients is not fully understood. Methods Five UK cancer centres coll aborated to review how E. coli affects oncology patients. A key part of this work has been an audit of all cases of E.coli BSI in patients in 2019 that met UK HCAI surveillance definitions. A multidisciplinary team of clinicians, nurses and pharmacists designed the audit to include >60 variables which may affect cancer patients. Results The risk factors for E. coli BSI among these cancer patients showed marked differences from those seen in the general UK population. The affected population was younger; there was higher rate of hospital-onset infections ; and, taking into account a number of healthcare interactions, the potential for healthcare associated infections was much higher. There was also a higher associated 30-day mortality and high rates of antimicrobial resistance in BSI isolates. Common univariate risk factors associated with BSI included use of SACT, neutropaenia, presence of acute kidney injury, presence of an invasive device, antimicrobial therapy, use of PPIs and a lack of independent hydration. By contrast, haematopoietic stem cell transplantation, mucositis and recent surgery were less common associations. Conclusion This audit demonstrates differences between risk factors seen in cancer patients with E.coli BSI and may explain why rates are higher in cancer centres.

Prevalence and characteristics of pks gene cluster harbouring Klebsiella pneumoniae from bloodstream infection in China.

Bloodstream infection (BSI), caused by Klebsiella pneumoniae, is associated with high morbidity and mortality, where the pks gene cluster plays a major role in their occurrence and prevalence. Information on the prevalence and characteristics of this gene cluster in K. pneumoniae is currently limited in mainland China. We therefore undertook a multicentre longitudinal study which revealed the prevalence, overall, community-onset and hospital-acquired BSI to be 20.5%, 28.3% and 13.0%, respectively. Compared to pks-negative, pks-positive isolates were significantly more susceptible to antimicrobial agents with a low incidence (5.1%) of multidrug-resistance and with infrequent extended-spectrum beta-lactamase (ESBL) production. Among pks-positive isolates, ST23 (78/117) and ST65 (20/117) were the dominant sequence types, and the majority harboured virulence genes. Community-onset BSI patients infected with pks-positive isolates had a higher proportion of liver abscesses and a lower proportion of biliary obstructions (P < 0.05). The pks-positive isolates were mostly sporadic in the phylogenetic tree, with a 65.8 and 47.0 average allele difference between Clade 1 and Clade 2, respectively. We concluded that although pks-positive K. pneumoniae were generally susceptible to antimicrobials, the high prevalence of such isolates in community cases and the genotoxicity, merits further investigation.

16S rDNA droplet digital PCR for monitoring bacterial DNAemia in bloodstream infections.

Repeated quantitative measurement of bacterial DNA on whole blood has been shown to be a promising method for monitoring bloodstream infection (BSI) with selected bacterial species. To enable broad use of this method, we developed a quantitative droplet digital PCR (ddPCR) method for 16S rDNA. It was validated with species-specific ddPCRs for Staphylococcus aureus (nuc), Streptococcus pneumoniae (lytA), and Escherichia coli (uidA) on spiked whole blood samples and on repeated whole blood samples (days 0, 1–2, 3–4, 6–8, and 13–15) from 83 patients with BSI with these pathogens. In these patients, 16S rDNA and species-specific DNA were detected in 60% and 61%, respectively, at least at one time-point. The highest positivity rates were seen in S. aureus BSI, where 92% of the patients were 16S rDNA-positive and 85% nuc-positive. Quantitative 16S rDNA and species-specific DNA showed strong correlations in spiked samples (r = 0.98; p < 0.0001) and clinical samples (r = 0.84; p < 0.0001). Positivity for 16S rDNA was rapidly cleared in patients with S. pneumoniae and E. coli BSI, but more slowly and sometimes persisted, in those with S. aureus BSI. The initial 16S rDNA load was higher in BSI patients with sepsis (Sepsis-3 definition) than without sepsis (median 2.38 vs. 0 lg10 copies/mL; p = 0.031) and in non-survivors than in survivors (median 2.83 vs. 0 lg10 copies/mL; p = 0.006). 16S rDNA ddPCR appears to be a promising method for bacterial DNA monitoring during BSI. The clinical value of such monitoring should be further studied.

Incidence of Bloodstream Infections, Length of Hospital Stay, and Survival in Patients With Recurrent Clostridioides difficile Infection Treated With Fecal Microbiota Transplantation or Antibiotics: A Prospective Cohort Study.

Clostridioides difficile infection (CDI) is a risk factor for bloodstream infection (BSI). Fecal microbiota transplantation (FMT) is more effective than antibiotics in treating recurrent CDI, but its efficacy in preventing CDI-related BSI is uncertain. To assess incidence of primary BSI in patients with recurrent CDI treated with FMT versus antibiotics. Prospective cohort study. Patients treated with FMT and those treated with antibiotics were matched on propensity score. Single academic medical center. 290 inpatients with recurrent CDI (57 patients per treatment in matched cohort). FMT or antibiotics. The primary outcome was primary BSI within 90 days. Secondary outcomes were length of hospitalization and overall survival (OS) at 90 days. Of the 290 patients, 109 were treated with FMT and 181 received antibiotics. Five patients in the FMT group and 40 in the antibiotic group developed BSI. Because of differences in the patients treated with FMT versus antibiotics in many baseline characteristics, including number of recurrences and CDI severity, comparative analyses were limited to the matched cohort. Risk for BSI was 23 percentage points (95% CI, 10 to 35 percentage points) lower in the FMT group; the FMT group also had 14 fewer days of hospitalization (CI, 9 to 20 fewer days) and a 32-percentage point increase in OS (CI, 16 to 47 percentage points) compared with the antibiotic group. Nonrandomized study with potential for unmeasured or residual confounding; limited generalizability of the propensity score-matched cohort. In a propensity score-matched cohort, patients with recurrent CDI treated with FMT were less likely to develop primary BSI. None.

Nadir lymphocytopenia as a risk factor of bloodstream infection during molecular targeting pharmacotherapy in multiple myeloma.

Molecular targeting pharmacotherapy (MTP) with proteasome inhibitors and immunomodulatory drugs has led to a remarkable improvement in the effectiveness of multiple myeloma (MM) therapy. However, the effect of MTP on the occurrence of infections in patients with MM remains unclear. We aimed to identify the incidence of and risk factors for bloodstream infection (BSI) in patients with MM undergoing MTP. We conducted a retrospective cohort study. We reviewed the medical records of 108 inpatients with MM at the National Defense Medical College Hospital between January 2010 and January 2017. Univariate and multivariate analyses were conducted to identify risk factors for BSI. The incidence of BSI in patients with MM receiving MTP (n = 188) was 6.9%, which was significantly lower than the 52.6% in patients receiving cytotoxic chemotherapy (n = 57). We found that the most important risk factor for BSI in patients receiving MTP was lymphocytopenia at nadir (< 200/µL). In contrast, the risk factor for BSI in patients receiving cytotoxic chemotherapy was the number of regimens performed. Our study suggests that the incidence of BSI is lower in patients with MM receiving MTP than in those receiving cytotoxic chemotherapy and that lymphocytopenia at nadir may be a risk factor for BSI in patients with MM receiving MTP. Since previous clinical trials with MTP showed that the frequency of myelosuppression and infections was high in the Japanese population, these findings might provide novel insights into MTP for Japanese patients with MM. .

Evaluation of neutrophil-lymphocyte ratio in predicting bloodstream infection.

Aim: The prognostic role of neutrophil-to-lymphocyte ratio (NLR) in bloodstream infection (BSI) deserves further investigation. Patients & methods: The NLR values were measured and compared in BSI patients and healthy controls. The receiver operating characteristic of NLR and cut-off values were measured in BSI patients and subgroups. Results: We have measured the NLR of study group with 2160 BSI patients and normal group with 2523 healthy controls, which was significantly high in study group (11.36 ± 21.38 vs 2.53 ± 0.86; p < 0.001) and the area under the curve was 0.834 (95% CI: 0.825-0.842; p < 0.001). The critical value of NLR for diagnosis of BSI was 3.09, with a sensitivity of 75.3%, and a specificity of 93.6%. Conclusion: NLR is an effective diagnostic indicator of including BSIs of Gram-negative bacteria, Gram-positive bacteria and fungus.

Risk factors and outcomes in non-transplant patients with extended-spectrum beta-lactamase-producing Escherichia coli bacteremia: a retrospective study from 2013 to 2016

BackgroundEscherichia coli is one of the most common strains of extended-spectrum β-lactam (ESBL)-producing bacteria, and the prevention and treatment of ESBL-producing E. coli infections is an ongoing challenge. The clinical characteristics and outcomes of ESBL-producing E. coli bacteremia in non-transplant patients remain to be elucidated.MethodsThis retrospective study included 491 non-transplant patients with E. coli bloodstream infections (BSIs) from January 2013 to December 2016 and was conducted to investigate the risk factors, clinical features, and outcomes of these infections.ResultsOf the 491 E. coli BSI patients, 57.6% suffered from infections with ESBL-producing strains. A multivariate analysis showed that urinary tract infection, prior use of cephalosporin, and treatment with β-lactam-β-lactamase inhibitor (BLBLI) combination antibiotics were independent risk factors for the development of ESBL-producing E. coli BSIs. The overall mortality rate in E. coli BSI patients was 14.46%, and there was no significant difference in the 28 day mortality rate between ESBL-producing E. coli and non-ESBL-producing E. coli BSI patients (14.8% vs. 14.0%, respectively; P = 0.953). Similarly, there was no difference between the community-acquired infection group and the nosocomial infection group. Hepatobiliary disease, carbapenem exposure, high APACHE II score, and hypoproteinemia were independent risk factors for death in E. coli BSI patients. Multivariate analysis showed that hypoproteinemia and severe disease were independent risk factors for death from ESBL-producing E. coli BSIs. Furthermore, there was no significant difference in the 28 day mortality between patients with ESBL-producing E. coli BSIs treated with carbapenem monotherapy versus those treated with BLBLI combination antibiotics (12.8% vs. 17.9%, respectively; P = 0.384).ConclusionsPrior use of cephalosporin or BLBLI combination antibiotics increased the risk ratio for ESBL-producing E. coli infection. Hypoproteinemia and severe disease are independent risk factors for death in patients with E. coli BSIs. There was no significant difference in the 28 day prognosis of patients with ESBL-producing E. coli and those with non-ESBL-producing E. coli BSIs. These data do not support the conclusion that carbapenems might be more effective than BLBLI antibiotics for treatment of patients with BSIs caused by ESBL-producing E. coli.

Temporal trend of microbiological profiles among patients with bloodstream infections: A comparison between cancer and noncancer patients in a nationwide database.

e13078 Background: Bloodstream infection (BSI) is a leading cause of in-hospital mortality for cancer patients. Our goal is to describe the temporal trend of microbiological profiles and inpatient outcomes through a large national database. Methods: National Inpatient Sample is the largest U.S. database of hospitalized patients including 20% of patients from 4,378 hospitals. Hospitalizations of patients with BSI were identified by ICD-9 codes for bacteremia and fungemia from 2006-2014. 21 common microorganisms were identified by ICD-9-CM codes as the cause of BSI. We assessed the trend of incidence and mortality by linear regression and compared the in-hospital mortality between cancer and noncancer BSI patients by propensity score adjusted Cox proportional hazard model. Results: A total of 13,996,374 patients with BSI were identified (cancer 13.6%, noncancer 86.4%). Among cancer patients, gram positive bacteria (GPB) are the leading pathogens (27.38%), followed by gram negative bacteria (GNB) (23.59%), fungus (4.81%) and anaerobe (1.21%). Anaerobe had the fastest annual increase rate of incidence (16.54%), followed by GNB (15.77%), fungus (11.61%) and GPB (7.41%). Cancer patients had a faster increase rate of incidence than noncancer patients. The in-hospital mortality was highest for anaerobe (16.14%), followed by fungus (15.71%), GPB (13.65%) and GNB (12.14%). Except for fungal BSI, the mortality for other types of BSI decreased significantly. GNB had the most annual mortality decrease (-2.51%), followed by GPB (-2.48%) and anaerobe (-1.47%). Cancer patients had higher in-hospital mortality than noncancer patients (PS-matched HR 1.25, 95%CI: 1.24, 1.26), especially in GNB BSI (PS-matched HR 1.29, 95%CI: 1.27, 1.31). Using breast cancer patients as reference, lung cancer BSI patients had the worst relative mortality risk (1.65, 95%CI: 1.60, 1.69). Conclusions: The incidence of BSI increased steadily among cancer patients from 2006-2014, with GNB BSI increasing at the highest rate. Except for fungus, mortality of GNB, GPB and anaerobe decreased continually. Compared with noncancer patients, cancer patients had a larger increase in the incidence of all types of BSI, especially anaerobes, and higher mortality than noncancer patients. BSI in lung cancer patients was associated with the highest mortality rate.

Multiplex polymerase chain reaction to diagnose bloodstream infections in patients after cardiothoracic surgery

BackgroundSepsis and other infectious complications are major causes of mortality and morbidity in patients after cardiac surgery. Whereas conventional blood culture (BC) suffers from low sensitivity as well as a reporting delay of approximately 48–72 h, real-time multiplex polymerase chain reaction (PCR) based technologies like “SeptiFast” (SF) might offer a fast and reliable alternative for detection of bloodstream infections (BSI). The aim of this study was to compare the performance of SF with BC testing in patients suspected of having BSI after cardiac surgery.MethodsTwo hundred seventy-nine blood samples from 169 individuals with suspected BSI were analyzed by SF and BC. After excluding results attributable to contaminants, a comparison between the two groups were carried out. Receiver operating characteristic (ROC) curves were generated to determine the accuracy of clinical and laboratory values for the prediction of positive SF results.Results14.7% (n = 41) of blood samples were positive using SF and 17.2% (n = 49) using BC (n.s. [p > 0.05]). In six samples SF detected more than one pathogen. Among the 47 microorganisms identified by SF, only 11 (23.4%) could be confirmed by BC. SF identified a higher number of Gram-negative bacteria than BC did (28 vs. 12, χ2 = 7.97, p = 0.005). The combination of BC and SF increased the number of detected microorganisms, including fungi, compared to BC alone (86 vs. 49, χ2 = 13.51, p < 0.001). C-reactive protein (CRP) (21.7 ± 11.41 vs. 16.0 ± 16.9 mg/dl, p = 0.009), procalcitonin (28.7 ± 70.9 vs. 11.5 ± 30.4 ng/dl, p = 0.015), and interleukin 6 (IL 6) (932.3 ± 1306.7 vs. 313.3 ± 686.6 pg/ml, p = 0.010) plasma concentrations were higher in patients with a positive SF result. Using ROC analysis, IL-6 (AUC 0.836) and CRP (AUC 0.804) showed the best predictive values for positive SF results.ConclusionThe SF test represent a valuable method for rapid etiologic diagnosis of BSI in patients after cardiothoracic surgery. In particular this method applies for individuals with suspected Gram-negative blood stream. Due to the low performance in detecting Gram-positive pathogens and the inability to determine antibiotic susceptibility, it should be used in addition to BC only (Pilarczyk K, et al., Intensive Care Med Exp ,3(Suppl. 1):A884, 2015).

Impact of Reported β-Lactam Allergy on Management of Methicillin-Sensitive Staphylococcus aureus Bloodstream Infections

Background: Antistaphylococcal β-lactams antibiotics are the preferred treatment for methicillin-sensitive Staphylococcus aureus (MSSA) infections. Patient-reported β-lactam allergies may complicate antibiotic decision-making and delay optimal therapy, with potential implications on patient outcomes. Objective: To determine the impact of reported β-lactam allergies on the receipt of optimal therapy and outcomes for MSSA bloodstream infections (BSI). Methods: Retrospective, matched cohort of MSSA BSI patients with and without a reported β-lactam allergy. The primary end point was receipt of optimal therapy, defined as an antistaphylococcal β-lactam. Results: Two hundred twelve patients were included: 53 with reported β-lactam allergy and 159 without β-lactam allergy. Commonly reported β-lactam allergies were 26 (49%) immune-mediated reaction and 8 (15%) intolerance, with 19 (36%) having no documented reaction. Optimal antibiotics were given to 135 patients without a β-lactam allergy and 37 patients with a reported β-lactam allergy (85% vs 70%, P = .015). Among reported β-lactam allergy patients, those without a documented reaction were less likely to receive optimal therapy (47% vs 79%, P = .042). Reported β-lactam allergy was not associated with clinical response (P = .61) or MSSA-related mortality (P = .83). When adjusting for immunosuppression, variables independently associated with optimal therapy were β-lactam allergy (adjusted odds ratio [adjOR], 0.3; 95% confidence interval [CI], 0.1-0.6) and infectious diseases consultation (adjOR, 6.1; 95%CI, 2.7-13.9). Optimal antibiotic use was associated with decreased all-cause 90-day mortality (adjOR, 0.23; 95%CI, 0.09-0.54). Conclusions: Patients with reported β-lactam allergies, particularly those without a documented reaction, were less likely to receive optimal antibiotics for MSSA BSI. Patient outcomes may be improved with enhanced quality of allergy history and routine infectious disease consultation.

Procalcitonin as a marker of Gram-negative bloodstream infections in hematological patients with febrile neutropenia

The aim of this study was to explore the predictive value of procalcitonin (PCT) in Gram-negative bloodstream infections (BSIs) in hematological patients with febrile neutropenia. A total of 1466 samples (396 blood culture (BC)-positive, 1052 BC-negative, and 18 contaminated specimens) were included, comprising 268 Gram-negative, 88 Gram-positive, 19 fungal, and 21 polymicrobial BSIs. Median PCT value (0.72 ng/mL; IQR: 0.23–3.87) was significantly higher in Gram-negative than Gram-positive (0.34 ng/mL; IQR: 0.14–2.23; p < .01), or fungal (0.27 ng/mL; IQR: 0.13–0.40; p < .01) BSIs. In mono-microbial BSIs, the best PCT cutoff distinguishing Gram-negative BSIs from all other fever causes was 0.56 ng/ml, with a specificity of 76.8%. PCT levels were significantly higher in BSIs from multidrug-resistant (MDR) Gram-negative strains than from non-MDR (p < .01). This study confirms that elevated PCT may predict Gram-negative BSIs in hematological patients with febrile neutropenia, and demonstrates higher PCT levels in MDR Gram-negative BSIs in these patients.

Predictors of Bloodstream Infection in Patients Presenting With Cardiovascular Implantable Electronic Device Pocket Infection.

BackgroundGenerator pocket infection is the most frequent presentation of cardiovascular implantable electronic device (CIED) infection. We aim to identify predictors of underlying bloodstream infection (BSI) in patients presenting with CIED pocket infection.MethodsWe retrospectively reviewed all adults with CIED pocket infection cared for at our institution from January 2005 through January 2016. The CIED pocket infection cases were then subclassified as with or without associated BSI. Variables with P values <.05 at univariate analysis were included in a multivariable model to identify independent predictors of underlying BSI.ResultsWe screened 429 cases of CIED infection, and 95 met the inclusion criteria. Of these, 68 cases (71.6%) were categorized as non-BSI and 27 (28.4%) as BSI. There were no statistically significant differences in patient comorbid conditions or device characteristics between the 2 groups. In multivariable analysis, the presence of systemic inflammatory response syndrome criteria (tachycardia, tachypnea, fever or hypothermia, and leukocytosis or leukopenia) and hypotension were independent predictors of underlying BSI in patients presenting with CIED pocket infection. Overall, patients in the non-BSI group who did not receive pre-extraction antibiotics had a higher frequency of positive intraoperative pocket/device cultures than those with pre-extraction antibiotic exposure (79.4% vs 58.6%; P = .06).ConclusionsPatients with CIED pocket infection who meet systemic inflammatory response syndrome criteria and/or are hypotensive at admission are more likely to have underlying BSI and should be started on empiric antibiotics after blood cultures are obtained. If these features are absent, it may be reasonable to withhold empiric antibiotics to optimize yield of pocket/device cultures during extraction.

Extensively drug-resistant Gram-negative bacterial bloodstream infection in hematological disease.

BackgroundExtensively drug-resistant Gram-negative bacterial (XDR-GNB) bloodstream infection (BSI) is difficult to treat and is associated with a high mortality rate in patients with hematological diseases. The aim of this study is to investigate the predisposing risk factors and the efficacy of the antibiotic treatment in these patients, including exploration of efficacy and adverse effects of high-dose tigecycline.MethodsBetween January 2013 and December 2017, 27 XDR-GNB BSI patients with hematological diseases were diagnosed and retrospectively reviewed in the current study.ResultsClinical response in patients with severe complications (such as severe neutropenia >10 days, grade III–IV acute graft-versus-host disease (aGVHD), and concurrent pneumonia) was significantly lower than in patients without or with only mild complications (P=0.033). The efficacy rate was 62.5% (10/16) in patients with tigecycline-based combination therapy regimen, 77.8% (7/9) with a high-dose tigecycline regimen, and 42.9% (3/7) with a standard-dose tigecycline regimen (P=0.36). The 30-day survival rates of patients undergoing high-dose or standard-dose tigecycline treatment were 66.7% (95% CI: 28.2–87.8) and 57.1% (95% CI: 17.2–83.7), respectively, (P=0.603). Patients with mild complications were associated with superior 30-day survival rates than patients with severe complications (93.8% vs 36.4%, P=0.001), >10 days of neutropenia (90.9% vs 33.3%, P=0.012), severe aGVHD (100% vs 40%, P=0.049), and concurrent pneumonia (84.6% vs 57.1%, P=0.048).ConclusionOur study indicated that XDR-GNB BSI in patients of hematological diseases with severe complications, such as long duration of neutropenia (>10 days) and severe aGVHD were associated with poor clinical response and short survival. We first indicated that these patients undergoing high-dose tigecycline treatment had an improved clinical response and an increased 30-day survival rate compared with the standard-dose group, although the differences were not statistically significant. This might be due to more severe complicated patients enrolled in high-dose group and the limited number size in our study.

Bloodstream Infection Due to Vancomycin-resistant Enterococcus Is Associated With Increased Mortality After Hematopoietic Cell Transplantation for Acute Leukemia and Myelodysplastic Syndrome: A Multicenter, Retrospective Cohort Study.

We examined the impact of vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI) on outcomes of allogeneic hematopoietic cell transplantation (HCT) utilizing the Center for International Blood and Marrow Transplant Research database. Adult and pediatric patients (N = 7128) who underwent first HCT for acute leukemia or myelodysplastic syndrome from 2008 through 2012 were analyzed as 3 groups-VRE BSI, non-VRE BSI, without BSI-according to BSI status at 100 days (D100) after allogeneic HCT. Multivariable models examined the effect of VRE BSI for overall survival (OS) and nonrelapse mortality (NRM) at 1 year. Of 7128 patients, 258 (3.2%) had VRE BSI, 2398 (33.6%) had non-VRE BSI, and 4472 (63%) had no BSI. The median time to VRE BSI and non-VRE BSI were D11 and D15, respectively. Compared with non-VRE BSI patients, VRE BSI patients were older, had advanced-stage acute leukemia, and received umbilical cord blood (UCB) allografts. In multivariable models, VRE BSI was associated with lower OS (relative risk [RR], 2.9;(99% confidence interval [CI], 2.2-3.7) and increased NRM (RR, 4.7; 99% CI, 3.6-6.2) (P < .0001) for both. Other predictors for worse OS and increased NRM were non-VRE BSI, older age, advanced disease stage, UCB allograft, - mismatch, comorbidity index ≥3, and cytomegalovirus seropositivity (P < .001 for all variables). VRE BSI is associated with lowest OS and highest NRM compared with patients without BSI or non-VRE BSI. Novel interventions that address the pathophysiology of VRE BSI have the potential of improving survival after HCT.

The diagnostic ability of procalcitonin to differentiate Gram-negative bacteria from Gram-positive bacteria and fungal bloodstream infections in critically ill patients

Bloodstream infection (BSI) is a severe infectious complication in critically ill patients. This study was aimed to investigate the diagnostic accuracy of procalcitonin (PCT) to differentiate Gram-negative bacteria (Gram-neg) from Gram-positive bacteria (Gram-pos) and fungal BSI. PCT and other inflammation markers of monomicrobial BSI patients were retrospectively collected and compared between patients with Gram-neg, Gram-pos, or fungal BSI. The differential diagnosis performance of PCT was evaluated by receiver operating characteristic curves (ROC). The area under curve (AUC) of PCT for differentiating Gram-neg BSI from Gram-pos BSI was 0.95 with an optimal cut-off value of 4.15 ng/mL, a sensitivity of 82.05%, and a specificity of 96.15%. AUC of PCT for differentiating Gram-neg BSI from fungal BSI was 0.92 with an optimal cut-off value of 3.13 ng/mL, a sensitivity of 84.62%, and a specificity of 88.89%. Serum PCT concentration can be used to differentiate Gram-neg from Gram-pos and fungal BSI.

Risk Factors for Bloodstream Infections Among an Urban Population with Skin and Soft Tissue Infections: A Retrospective Unmatched Case-Control Study.

IntroductionThe prevalence of acute bacterial skin and skin structure infections (ABSSSIs) continues to increase. Bloodstream infection (BSI) is a severe secondary complication of ABSSSI. The objective of this study was to determine clinical and sociodemographic risk factors for BSI in patients with acute bacterial skin and skin structure infections (ABSSSIs) and to determine if sociodemographic factors impact severity at presentation.MethodsThis was a retrospective unmatched (1:1) case-control study. Predictors of BSI and severe infection were sought through multivariable logistic regression analyses. Cases and controls were collected from two major medical centers located in downtown Detroit, Michigan: the Detroit Medical Center and the Henry Ford Health System. The population of interest included adult patients with community-onset (CO) ABSSSI treated at a participating hospital between January 2010 and December 2015. Cases were defined as those developing BSI within 48 h of admission with CO-ABSSSI as the primary source, while controls were those with CO-ABSSSI without BSI.ResultsA total of 392 patients (196 cases, 196 controls) were included. Independent predictors of BSI were male gender (aOR 1.85: 95% CI 1.11, 3.66), acute renal failure (aOR 2.08: 95% CI 1.18, 3.66), intravenous drug use (aOR 4.38, 95% CI 2.22, 8.62), and prior hospitalization (aOR 2.41, 95% CI 1.24, 4.93). African American race (aOR 2.18, 95% CI 1.38, 3.4), leukocytosis (aOR 2.24, 95% CI 1.41, 3.55), and prior hospitalization (aOR 2.07, 95% CI 1.19, 3.00) were significantly associated with infection severity.ConclusionBoth clinical and sociodemographic factors were associated with BSI and severe infection underscoring the importance of social determinants of health in outcomes among underserved populations.

Assessing Neighborhood Characteristics As Risk Factors for Bloodstream Infection in Children with Acute Leukemia

IntroductionInfection is the most important cause of treatment-related mortality in leukemia. Recent adult data have associated gut microbiome alterations with systemic infection. As environmental and dietary factors influence the microbiome, we sought to explore neighborhood factors associated with blood stream infection (BSI) and specifically mucosal barrier injury (MBI) BSI in patients receiving treatment for leukemia.MethodsWe assembled two retrospective cohorts, ALL and AML patients, treated at the Children's Hospital of Philadelphia between 2006-2015. Type of leukemia and therapy start and end dates were manually abstracted from the electronic medical record (EMR). Then, we used an automated REDCapTM-Epic data query tool to interrogate the EMR and capture patient demographics, residential addresses and all blood cultures. Data were extracted from date of presentation until end of therapy, stem cell transplant, relapse or death. The primary outcome was incident BSI. A secondary outcome was incident mucosal barrier injury (MBI) BSI per the CDC definition. To define neighborhood factors, addresses at treatment start were matched to geo-coordinates that linked each patient to a census-derived block group. Block groups were then connected with a priori chosen socioeconomic variables (poverty and neighborhood disorganization index), expenditure data (spending on fresh produce, fast food and tobacco products) and environmental characteristics (air quality indices and lead exposure) hypothesized to impact the microbiome. Neighborhood poverty was defined as the proportion of people in the block group with income below the federal poverty level.Risk of first BSI and first MBI BSI were estimated from a generalized linear model with a binary distribution. Spline regression was used to confirm a linear association between neighborhood poverty and BSI risk. Several additional exploratory analyses were performed to evaluate the impact of neighborhood factors on BSI at specific timepoints including BSI within 30 days of therapy start and outpatient BSIs (defined by a positive blood culture collected while outpatient or on the day of admission).ResultsThere were 378 patients with ALL and 74 with AML. The median proportion of people below the poverty limit in patient neighborhoods was 5% (IQR: 2-12%) in ALL and 7% (IQR: 2-18%) in AML. Demographics by disease and neighborhood poverty are shown in table 1.One fifth of ALL patients and 68.9% of AML patients had at least one BSI. Overall, 51.6% of incident BSI events were classified as MBI BSI (ALL 36%, AML 74.5%). The median time to first BSI was 91 days in ALL and 65 days in AML. In ALL patients, the onset of BSI was in the outpatient setting 54.7% of the time, whereas only 15.7% of BSIs were outpatient in AML.Among patients with AML, the proportion of neighborhood poverty was inversely associated with incident BSI and MBI BSI: the relative risk per percent increase in population below the poverty level was .27 (95% CI = .06 - 1.16) and .12 (95% CI = .01 - 1.08), respectively. These estimates were robust to adjustment. No other neighborhood factors were associated with BSI or MBI BSI. For ALL patients the association between neighborhood poverty and BSI was similar to that found in the AML cohort but with less precision (RR = .48, 95% CI: .07 - 3.18). The point estimates using specific BSI timepoints were less suggestive of an association in either direction.ConclusionsIn a cohort of children with AML, we found that the proportion of neighborhood poverty was inversely associated with BSI and MBI BSI. While not statistically significant, the magnitude of the association was striking. A similar trend was noted in ALL patients. Other neighborhood factors - including diet and tobacco expenditures, pollution and lead exposure - showed no association.Although poverty is generally associated with poor health outcomes, mechanisms can be proposed to explain an association between poverty and BSI in either direction. Poverty may lead to gut dysbiosis and subsequent BSI by limiting access to healthy foods; alternatively, poverty-associated environmental exposures and less antibiotic use could increase microbiome diversity and protect against BSI. These data suggest the latter. Larger, geographically diverse studies are needed to further explore this association, as well as translational studies evaluating the human microbiota in the context of neighborhood factors. DisclosuresFisher:Merck: Research Funding; Pfizer: Research Funding.