Care-associated Bloodstream Infections Research Articles

Population Dynamics of Escherichia coli Causing Bloodstream Infections over Extended Time Periods

ABSTRACTEscherichia coli is a leading cause of community-acquired and health care-associated bloodstream infections (BSIs) worldwide. Limited information is available regarding the changes in population dynamics of human E. coli over extended time periods, especially among nonbiased E. coli isolates in large well-defined geographical regions. Coque and colleagues (I. Rodríguez, A. S. Figueiredo, M. Sousa, S. Aracil-Gisbert, et al., mSphere 6:e00868-21, 2021, https://doi.org/10.1128/msphere.00868-21) conducted a longitudinal study of E. coli BSIs in a Madrid hospital over a 21-year period (1996 to 2016). Certain E. coli B2 phylogroups (i.e., ST131 and ST73) dominated the community E. coli population in Madrid. These community clones were often introduced into the hospital setting. This study and other longitudinal surveys from England and Canada showed that ST131 subclades C1 and C2 were mainly responsible for the increase in fluoroquinolone and cephalosporin resistance among E. coli during the mid- to late 2000s.

Neonatal Candidaemia in Tertiary Care Hospitals in Dhaka- A Comparison of Different Carbohydrate Assimilation Methods and Chromagar Technique for Speciation

Background: Nosocomial candidiasis are becoming increasingly important worldwide. Candida is a major causative agent of health care associated bloodstream infections, and lately non-albican Candida species are increasingly isolated from blood samples. Some of the Candida species have intrinsic and acquired resistance to the limited arsenal of antifungals; therefore early speciation is essential for the timely initiation of effective antifungal therapy. Methods: A hospital based cross-sectional study was conducted to evaluate the performance of different carbohydrate assimilation tests and commercially available HiCrome Candida Differential Media (CHROMagar) for the identification of Candida in the four tertiary level hospitals in Dhaka. Results: A total of 58 yeasts samples was included in this study. Non-albicans Candida accounted for 100% of the isolates of which C. tropicalis was the predominant species (81.03%) followed by C. parapsilosis (12.07%), C. auris (5.17%) and C. dubliniensis (1.72%). Swab auxanographic technique and microtitre plate based miniaturized CHO assimilation methods were equally effective in identification of Candida sp. in comparison to CHO impregnated YNB plate method (98.28% and 100% vs 89.66%). Conclusion: By using Chromogenic agar 75.86% yeasts were identified but it could not give the conclusive differentiating color between the species of C. parapsilosis and C. auris.

Characteristics of late recurrent candidemia in adult patients.

Candida species are one of the most common causes of health care-associated bloodstream infections. However, recurrent candidemia is rare, and the characteristics of late recurrent (LR) candidemia are partly unclear. Our aim was to evaluate the characteristics of LR candidemia in adult patients. A retrospective cohort study was performed in the hospital district of Helsinki and Uusimaa in Finland (2007-2016). All candidemia cases were searched in an electronic database during the study period. Patients with LR candidemia were compared with patients with a single candidemia episode to evaluate the characteristics of LR candidemia. LR candidemia was defined as having at least two episodes of candidemia more than 30days apart. We identified 24 episodes of LR candidemia in 20 patients. Patients with LR candidemia represented 6% of all patients with candidemia during the study period, and most of these cases were nosocomial. The median time between the first and the recurrent episode was 5.1months. One-year mortality in LR candidemia was 45%. Underlying gastrointestinal disease (OR 7.21, 95% CI 2.52-20.61) and history of intra-venous drug use (IVDU) (OR 3.62, 95% CI 1.03-12.69) were independent risk factors for LR candidemia in the multivariable analysis. Our study indicates that the gastrointestinal tract may be a continuous source of infection in patients with chronic gastrointestinal diseases. Gastrointestinal diseases and IVDU should be regarded as risk factors for LR candidemia.

Risk Factors for Candidemia After Open Heart Surgery: Results From a Multicenter Case-Control Study.

Background Candida species are among the most frequent causative agents of health care–associated bloodstream infections, with mortality >40% in critically ill patients. Specific populations of critically ill patients may present peculiar risk factors related to their reason for intensive care unit admission. The primary objective of the present study was to assess the predictors of candidemia after open heart surgery.MethodsThis retrospective, matched case–control study was conducted in 8 Italian hospitals from 2009 to 2016. The primary study objective was to assess factors associated with the development of candidemia after open heart surgery.ResultsOverall, 222 patients (74 cases and 148 controls) were included in the study. Candidemia developed at a median time (interquartile range) of 23 (14–36) days after surgery. In multivariable analysis, independent predictors of candidemia were New York Heart Association class III or IV (odds ratio [OR], 23.81; 95% CI, 5.73–98.95; P < .001), previous therapy with carbapenems (OR, 8.87; 95% CI, 2.57–30.67; P = .001), and previous therapy with fluoroquinolones (OR, 5.73; 95% CI, 1.61–20.41; P = .007). Crude 30-day mortality of candidemia was 53% (39/74). Septic shock was independently associated with mortality in the multivariable model (OR, 5.64; 95% CI, 1.91–16.63; P = .002). No association between prolonged cardiopulmonary bypass time and candidemia was observed in this study.ConclusionsPrevious broad-spectrum antibiotic therapy and high NYHA class were independent predictors of candidemia in cardiac surgery patients with prolonged postoperative intensive care unit stay.

Diagnosis and Treatment of Candidemia in the Intensive Care Unit.

Candidemia is the fourth most frequent health care-associated bloodstream infection, and the most frequent severe fungal infection developing in critically ill patients in intensive care units (ICUs). Diagnosis of candidemia in ICU patients is a complex task made of both early and late assessments involving both conventional diagnostic methods and novel rapid tests. Management strategies to optimize treatment of candidemia can be challenging and include starting early adequate therapy, use of an adequate dose and duration of therapy, de-escalating treatment whenever possible, and early discontinuation of useless antifungals in those with no definitive diagnosis of fungal infection. Herein, we will discuss recent epidemiological data on candidemia in ICUs and current diagnostic techniques before concentrating on antifungal treatments.

Analysis on distribution and drug resistance of pathogen caused community-onset bloodstream infection

To investigate the distribution and drug resistance of pathogen caused community-onset bloodstream infection (COBSI) in patients of affiliated hospital of university, and to provide evidence for the clinical therapy. The clinical data of patients with COBSI in emergency department admitted to Huashan North Hospital Affiliated to Fudan University from January 2014 to December 2017 were collected, and the distribution and drug resistance of pathogen were retrospectively analyzed. The patients were divided into community-acquired bloodstream infection (CABSI) group and health care-associated bloodstream infection (HCABSI) group according to clinical diagnosis. The source of patients, past health status, blood culture isolation of pathogens, drug sensitivity test results were recorded, and the trend of drug resistance of main pathogens to common antibiotics from 2014 to 2017 were analyzed. A total of 258 pathogens were isolated from patients, including 186 Gram-negative pathogens (G- pathogens, 72.09%) and 72 Gram-positive pathogens (G+ pathogens, 27.91%), while the fungal strain was not isolated. The two most frequently isolated G- pathogens causing CABSI were Escherichia coli (80 isolates, 65.57%) and Klebsiella pneumonia (24 isolates, 19.67%), including extended-spectrum beta-lactamases (ESBLs)-producing Escherichia coli (37 isolates) and Klebsiella pneumonia (3 isolates), the average detection rates were 46.25% and 12.50% respectively. The two most frequently isolated G+ pathogens were Streptococcus (32 isolates, 57.14%) and Staphylococcus (15 isolates, 26.79%), but methicillin-resistant Staphylococcus aureus (MRSA) had not been isolated. The two most frequently isolated G- pathogens causing HCABSI were Escherichia coli (45 isolates, 70.32%) and Klebsiella pneumonia (7 isolates, 10.94%), including ESBLs-producing Escherichia coli (20 isolates) and Klebsiella pneumonia (1 isolate), the average detection rate was 44.44% and 14.29%, respectively. The most frequently isolated G+ pathogens were Staphylococcus (10 isolates, 62.50%), Streptococcus (3 isolates, 18.75%) and Enterococcus faecium (3 isolates, 18.75%), including MRSA (3 isolates). ESBLs-positive Escherichia coli and Klebsiella pneumoniae were almost completely resistant to cefazolin and highly resistant to ampicillin, ampicillin sodium and sulbactam sodium, ceftriaxone and furadantin, with the drug resistance rates of higher than 50%, and the drug resistance rate was significantly higher than that of corresponding ESBLs-producing negative pathogens. Escherichia coli were completely sensitive to piperacillin tazobactam, imipenem, and ertapenem, but Klebsiella pneumoniae had some resistance to piperacillin tazobactam and imipenem. Methicillin-resistant coagulase-negative Staphylococci (MRCNS) were highly resistant to common antibiotics, while Streptococcus strains and MRSA had low resistance rates, and all pathogens were completely sensitive to linezolid and vancomycin. The average annual resistance rate of Escherichia coli to common antibiotics in CABSI group was increased, but the difference was significant only for ciprofloxacin (from 2014 to 2017, they were 37.5%, 28.6%, 52.6%, 65.2%, respectively, Z = 5.076, P = 0.024). The average annual resistance rate of Klebsiella pneumonia to cefazolin and ciprofloxacin in CABSI group and that of Escherichia coli to ceftriaxone in HCABSI group showed an increasing trend without significant differences. Escherichia coli and Klebsiella pneumoniae were the main pathogens of emergency COBSI, ESBLs-producing Escherichia coli were more common, and the average annual drug resistance rate to common clinical antibiotics was increasing. The drug resistance of ESBLs-producing Escherichia coli and Klebsiella pneumoniae was more serious than that of ESBLs-producing negative pathogens, so antibiotics should be used rationally.

English

Candidemia is an important cause of health care-associated bloodstream infections. Appropriate antifungal therapy is crucial to reduce morbidity and mortality. A previous randomized clinical trial compared the clinical effectiveness of caspofungin 50 mg, micafungin 100 mg (M100), and micafungin 150 mg (M150) in treating invasive candidiasis and candidemia. M100 treatment success was non-inferior to caspofungin, while M150 yielded less favourable clinical and mycological responses. Pharmacodynamic (PD) variables were explored to assess the effect of caspofungin, M100 and M150 on the following outcomes: mycological eradication, clinical success, days to eradication, recurrence, and emergent infection for cases of candidemia only from the aforementioned clinical trial. Univariate and multivariate analyses were performed to evaluate the ratio of area under the concentration curve to minimum inhibitory concentration [AUC:MIC] for the treatment arms. AUC:MIC >1500 conferred better mycological eradication, but an inverse relationship between micafungin and mycological eradication based on an AUC:MIC ≥7500 was found. M150 required more days to eradication than M100 (p<0.03) and caspofungin (p<0.02). A correlation was also noted for days to eradication with several other risk factors, including race, Candida parapsilosis, and neutropenia. Key words: Micafungin and caspofungin, echinocandins,

Incidence and Determinants of Health Care-Associated Blood Stream Infection at a Neonatal Intensive Care Unit in Ujjain, India: A Prospective Cohort Study.

Very little is known about laboratory-confirmed blood stream infections (LCBIs) in neonatal intensive care units (NICUs) in resource-limited settings. The aim of this cohort study was to determine the incidence, risk factors, and causative agents of LCBIs in a level-2 NICU in India. The diagnosis of LCBIs was established using the Centre for Disease Control, USA criteria. A predesigned questionnaire containing risk factors associated with LCBIs was filled-in. A total of 150 neonates (43% preterm) were included in the study. The overall incidence of LCBIs was 31%. The independent risk factors for LCBIs were: preterm neonates (relative risk (RR) 2.23), duration of NICU stay more than 14 days (RR 1.75), chorioamnionitis in the mother (RR 3.18), premature rupture of membrane in mothers (RR 2.32), neonate born through meconium-stained amniotic fluid (RR 2.32), malpresentation (RR 3.05), endotracheal intubation (RR 3.41), umbilical catheterization (RR 4.18), and ventilator-associated pneumonia (RR 3.17). The initiation of minimal enteral nutrition was protective from LCBIs (RR 0.22). The predominant causative organisms were gram-negative pathogens (58%). The results of the present study can be used to design and implement antibiotic stewardship policy and introduce interventions to reduce LCBIs in resource-limited settings.

A comparison of blood stream infections with extended spectrum beta-lactamase-producing and non-producing Klebsiella pneumoniae in pediatric patients

BackgroundRapid development and global spread of multidrug resistant Klebsiella pneumonia (K. pneumoniae) as a major cause of nosocomial infections is really remarkable. The aim of this study was to explore risk factors for health care associated blood stream infections (BSI) caused by ESBL-producing K. pneumoniae in children and analyze clinical outcomes.MethodsA retrospective review of patients younger than 18 years-old with blood stream infection caused by K. pneumoniae was performed. Patients with ESBL-producing K. pneumoniae isolates were compared with ESBL-non-producing isolates in terms of risk factors, outcome and mortality.ResultsAmong 111 K. pneumoniae isolates 62% (n = 69) were ESBL –producing K. pneumoniae. The median total length of hospitalization and median length of stay in hospital before infection was significantly higher in patients with ESBL-producing isolates than ESBL-non-producing. Use of combined antimicrobial treatment was significantly different between ESBL-producing and ESBL-non-producing groups, 75.4% and 24.6%, respectively (p = 0.001). Previous aminoglycoside use was higher in cases with ESBL –producing isolates (p = 0.001). Logistic regression analysis showed a significant correlation between mortality and use of combined antibiotics (OR 4.22; p = 0.01).ConclusionESBL production in K. pneumoniae isolates has a significant impact on clinical course of BSIs. Total length of hospitalization, length of hospital stay before infection, prior combined antibiotic use and use of aminoglycosides were significant risk factors for development of ESBL-producing K. pneumoniae related BSI.

Prognostic factors of health care–associated bloodstream infection in adult patients ≥40 years of age

We investigated 401 geriatric patients and 453 middle-aged patients with health care-associated bloodstream infection (HABSI) at a medical center during January-December 2014. Compared with middle-aged patients, the geriatric group had higher 30-day mortality (31.2% vs 23.4%, P = .01). Body mass index, serum albumin concentration, Charlson comorbidity index score, vancomycin-resistant Enterococcus bacteremia, and high C-reactive protein levels predict poor outcomes for HABSI among adult patients.

Risk for Health Care-Associated Bloodstream Infections in Pediatric Oncology Patients With Various Malignancies.

This was a retrospective cohort study to identify the rates, predictors, and outcomes of health care-associated bloodstream infections (HA-BSI) among children with solid tumors, lymphoma, lymphoid leukemia, and myeloid leukemia. The study population included 4500 children ≤18 years old at a pediatric hospital in New York City from 2006 to 2014. A total of 147 HA-BSI cases were identified; using multivariable logistic regression modeling, children with a hematologic diagnosis (lymphoma, lymphoid leukemia, myeloid leukemia) were at greater risk for HA-BSI than those with a solid tumor diagnosis (all P values <.0001). The odds of mortality for patients with HA-BSI were 6.98 (95% confidence interval 3.02-16.10) times that of those without HA-BSI. Although malignancy type was identified as risk factor for HA-BSI, there was no significant difference in overall mortality from HA-BSI by tumor type ( P = .51).

Clinical and Microbiological Characteristics of Heteroresistant and Vancomycin-Intermediate Staphylococcus aureus from Bloodstream Infections in a Brazilian Teaching Hospital.

This study analyzed clinical and microbiological characteristics of heteroresistant (hVISA) and vancomycin-intermediate Staphylococcus aureus (VISA) from bloodstream infections (BSI) in a Brazilian teaching hospital, between 2011 and 2013. Minimum inhibitory concentrations (MIC) of antimicrobials were determined by broth microdilution method and SCCmec was detected by PCR. Isolates with a vancomycin MIC ≥ 2mg/L were cultured on BHI agar with 3, 4 or 6 mg/L (BHIa3, BHIa4 or BHIa6) of vancomycin and BHIa4 with casein (BHIa4ca). Macromethod Etest® and Etest® Glicopeptides Resistance Detection were also used. VISA and hVISA isolates were confirmed by the population analysis profile then typed by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing. Medical data from the patients were obtained from their medical records. Among 110 consecutive isolates, 31 (28%) were MRSA and carried the SCCmec type II (15 isolates) or IV (16 isolates). Vancomycin MIC50 and MIC90 were 1 and 2 mg/L, respectively. MRSA isolates had increased non-susceptibility to daptomycin (p = 0.0003). Six (5%) isolates were VISA, four of which were MRSA, three SCCmec type II/USA100/ST5 and one type IV/USA800/ST3192. One MRSA SCCmec II isolate grew on agar BHIa3, BHIa4 and BHIa4ca, and it was confirmed as hVISA. Among the six VISA isolates, five (83%) grew on BHIa3 and three (50%) on BHI4ca. Four of the six VISA isolates and the one hVISA isolate were from patients who had undergone dialysis. Thus, a possible dissemination of the SCCmec II/USA100/ST5 lineage may have occurred in the hospital comprising the VISA, hVISA and daptomycin non-susceptible S. aureus Brazilian isolates from health care associated bloodstream infections.

Risk Factors for Health Care-Associated Bloodstream Infections in a Neonatal Intensive Care Unit.

BackgroundHealthcare-associated bloodstream infections (HCA-BSI) are a major cause of morbidity and mortality in neonatal intensive care units (NICUs).ObjectivesWe aimed to determine the causative organisms and risk factors of HCA-BSIs in NICUs.MethodsThis study was performed between January 2011 and December 2014 in the neonatal intensive care unit of Dicle university, Turkey. The study consisted of 126 patients (infected group) with positive blood culture and 126 randomly selected patients (uninfected control group) with negative blood culture after four days of hospitalization.ResultsWe found that the most common causative agents isolated from nosocomial infections (NIs) were 20.7% Staphylococcus epidermidis, 26.7% Klebsiella spp., and 13.3% Acinetobacter spp. Incidences of low gestational age, low birth weight, vaginal birth type, and long length of hospitalization were higher in the infected neonates than in the uninfected neonates. In the univariate analysis, surgical operation, ventriculoperitoneal shunt, use of umbilical catheter, nasogastric or orogastric tube, urinary catheter, mechanical ventilation, surfactant treatment, erythrocyte transfusion, plasma transfusion, thrombocyte transfusion, total parenteral nutrition infusion, intracranial hemorrhage, length of hospital stay, fifth-minute Apgar score, and total parenteral nutrition time were significantly associated with NIs. In the multiple logistic regression analysis, fifth-minute Apgar, use of erythrocyte transfusion and surgical operation were found as the independent risk factors for HCA-BSI.ConclusionsThis study determined the causative organisms and risk factors of HCA-BSIs in NICUs.

Characterising health care-associated bloodstream infections in public hospitals in Queensland, 2008-2012.

To describe the epidemiology and rates of all health care-associated bloodstream infections (HA-BSIs) and of specific HA-BSI subsets in public hospitals in Queensland. Standardised HA-BSI surveillance data were collected in 23 Queensland public hospitals, 2008-2012. HA-BSIs were prospectively classified in terms of place of acquisition (inpatient, non-inpatient); focus of infection (intravascular catheter-associated, organ site focus, neutropenic sepsis, or unknown focus); and causative organisms. Inpatient HA-BSI rates (per 10,000 patient-days) were calculated. There were 8092 HA-BSIs and 9418 causative organisms reported. Inpatient HA-BSIs accounted for 79% of all cases. The focus of infection in 2792 cases (35%) was an organ site, intravascular catheters in 2755 (34%; including 2240 central line catheters), neutropenic sepsis in 1063 (13%), and unknown in 1482 (18%). Five per cent (117 of 2240) of central line-associated BSIs (CLABSIs) were attributable to intensive care units (ICUs). Eight groups of organisms provided 79% of causative agents: coagulase-negative staphylococci (18%), Staphylococcus aureus (15%), Escherichia coli (11%), Pseudomonas species (9%), Klebsiella pneumoniae/oxytoca (8%), Enterococcus species (7%), Enterobacter species (6%), and Candida species (5%). The overall inpatient HA-BSI rate was 6.0 per 10,000 patient-days. The rates for important BSI subsets included: intravascular catheter-associated BSIs, 1.9 per 10,000 patient-days; S. aureus BSIs, 1.0 per 10,000 patient-days; and methicillin-resistant S. aureus BSIs, 0.3 per 10,000 patient-days. The rate of HA-BSIs in Queensland public hospitals is lower than reported by similar studies elsewhere. About one-third of HA-BSIs are attributable to intravascular catheters, predominantly central venous lines, but the vast majority of CLABSIs are contracted outside ICUs. Different sources of HA-BSIs require different prevention strategies.

A multimodality approach to prevent catheter-related bloodstream infections: the role of chlorhexidine-alcohol as a skin antiseptic before intravascular catheter insertion.

Health care-associated infection is an increasing threat to patient safety. Over 400,000 patients in the intensive care units (ICUs) and 1.2 million patients outside the ICUs were affected by hospital care-associated infections, with >30,000 deaths attributed to hospital care-associated bloodstream infections in United States in 2002 (1). Intravascular catheters play a pivotal role in the management of both ICU and non-ICU patients, but inadequate infection control precautions in using these devices may lead to catheter-related bloodstream infection (CR-BSI) resulting in prolonged hospital stay and excessive mortality (2). As such, having the best strategy to prevent CR-BSI has a potential huge benefit on both patient outcome and healthcare cost (3).

Risk Factors for Health Care-Associated Sepsis in Critically Ill Neonates Stratified by Birth Weight.

Health care-associated bloodstream infection (HABSI) is a frequent complication in neonatal intensive care. Research on risk factors stratified by birth weight and adjusted for severity of illness and comorbidities is limited. Our objective is to describe independent risk factors for HABSI in critically ill neonates with emphasis on risk variation between birth weight groups. We performed a single-center historical cohort study in a tertiary referral center. A neonatal intensive care-audit system was used to identify eligible neonates admitted for ≥72 hours (2002-2011). HABSI is defined according to National Institute of Child Health and Human Development criteria. Risk factors for HABSI were assessed by univariate and logistic regression analysis for the total cohort and for birth weight subgroups, that is, neonates ≤1500 g and >1500 g. A total of 342 neonates developed HABSI in 5134 admissions of ≥72 hours (6.7%). Very low birth weight, total parenteral nutrition (TPN), mechanical ventilation, gastrointestinal disease, surgery (cardiac and other type), and renal insufficiency are independent risk factors for the total cohort. Gastrointestinal disease and cardiac surgery are independent risk factors in both birth weight groups; mechanical ventilation (odds ratio [OR]: 2.6; confidence interval [CI]: 1.6-4.0) and other type of surgery (OR: 4.3; CI: 2.1-8.8) are solely independent risk factors in the ≤1500-g cohort; TPN is exclusively an independent risk factor (OR: 7.9; CI: 3.9-16.2) in the >1500-g cohort. In our neonatal intensive care unit, risk stratification by birth weight revealed some difference. Special attention concerning infection control practices is for neonates receiving TPN, mechanical ventilation, cardiac surgery, and with a gastrointestinal disease.

A Web-Based, Hospital-Wide Health Care-Associated Bloodstream Infection Surveillance and Classification System: Development and Evaluation.

BackgroundSurveillance of health care-associated infections is an essential component of infection prevention programs, but conventional systems are labor intensive and performance dependent.ObjectiveTo develop an automatic surveillance and classification system for health care-associated bloodstream infection (HABSI), and to evaluate its performance by comparing it with a conventional infection control personnel (ICP)-based surveillance system.MethodsWe developed a Web-based system that was integrated into the medical information system of a 2200-bed teaching hospital in Taiwan. The system automatically detects and classifies HABSIs.ResultsIn this study, the number of computer-detected HABSIs correlated closely with the number of HABSIs detected by ICP by department (n=20; r=.999 P<.001) and by time (n=14; r=.941; P<.001). Compared with reference standards, this system performed excellently with regard to sensitivity (98.16%), specificity (99.96%), positive predictive value (95.81%), and negative predictive value (99.98%). The system enabled decreasing the delay in confirmation of HABSI cases, on average, by 29 days.ConclusionsThis system provides reliable and objective HABSI data for quality indicators, improving the delay caused by a conventional surveillance system.

Prediction models for neonatal health care-associated sepsis: a meta-analysis.

Blood culture is the gold standard to diagnose bloodstream infection but is usually time-consuming. Prediction models aim to facilitate early preliminary diagnosis and treatment. We systematically reviewed prediction models for health care-associated bloodstream infection (HABSI) in neonates, identified superior models, and pooled clinical predictors. LibHub, PubMed, and Web of Science. The studies included designed prediction models for laboratory-confirmed HABSI or sepsis. The target population was a consecutive series of neonates with suspicion of sepsis hospitalized for ≥ 48 hours. Clinical predictors had to be recorded at time of or before culturing. Methodologic quality of the studies was assessed. Data extracted included population characteristics, total suspected and laboratory-confirmed episodes and definition, clinical parameter definitions and odds ratios, and diagnostic accuracy parameters. The systematic search revealed 9 articles with 12 prediction models representing 1295 suspected and 434 laboratory-confirmed sepsis episodes. Models exhibit moderate-good methodologic quality, large pretest probability range, and insufficient diagnostic accuracy. Random effects meta-analysis showed that lethargy, pallor/mottling, total parenteral nutrition, lipid infusion, and postnatal corticosteroids were predictive for HABSI. Post hoc analysis with low-gestational-age neonates demonstrated that apnea/bradycardia, lethargy, pallor/mottling, and poor peripheral perfusion were predictive for HABSI. Limitations include clinical and statistical heterogeneity. Prediction models should be considered as guidance rather than an absolute indicator because they all have limited diagnostic accuracy. Lethargy and pallor and/or mottling for all neonates as well as apnea and/or bradycardia and poor peripheral perfusion for very low birth weight neonates are the most powerful clinical signs. However, the clinical context of the neonate should always be considered.

Chlorhexidine bathing and health care-associated infections: a randomized clinical trial.

Daily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care-associated infections. To determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections. A pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013. Units performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study. The primary prespecified outcome was a composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care-associated bloodstream infections, and rates of the primary outcome by ICU. During the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, -0.04; 95% CI, -1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit. In this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine. clinicaltrials.gov Identifier: NCT02033187.

Incidence and determinants of health care associated blood stream infections at a neonatal intensive care unit in Ujjain, India: Results of a prospective cohort study

this overall underprivileged population, factors found to be associated with colonization were mostly indicative of a somewhat higher socioeconomic status, potentially linked to a better access to healthcare services (and opportunities for ESBL-PE transmission or antibiotics prescription). While not found to be a significant factor in multivariate analysis, antibiotics use deserves to be further explored. Funding: Principality of Monaco