High Attributable Mortality Research Articles

Nosocomial bloodstream infection in human immunodeficiency virus-infected patients in Taiwan: descriptive epidemiology and risk factors for mortality.

Nosocomial bloodstream infection (NBSI) is common in patients with human immunodeficiency virus (HIV) infection. This study evaluated the incidence, causative pathogens, and outcome of NBSIs in hospitalized HIV-infected patients at a university hospital in Taiwan. The medical records of all HIV-infected patients who developed NBSIs from June 1994 to June 2003 were retrospectively reviewed. A standardized case record form was used to collect demographic, clinical, laboratory, and microbiologic data. During the study period, 57 episodes of NBSIs occurred in 51 HIV-infected patients whose median age was 37 years (range, 23 to 60 years). All of the patients were at HIV infection stage C. The incidence of NBSIs was 2.3 per 1000 person-days of hospitalization (41.4 per 1000 discharges). More than three-fourths of the 57 episodes (77.2%) were classified as primary NBSIs. Other infection foci included respiratory tract (6 episodes), urinary tract (3), surgical site (2), and skin (2). Staphylococcus species were the leading pathogens (42.1%). The crude and attributable mortality rates in patients with NBSIs during the study period were 38.6% and 26.1%, respectively. Multivariate analysis using a logistic regression model revealed that shock and hypoalbuminemia at the onset of NBSIs were the 2 factors predictive of mortality. NBSIs in hospitalized patients in the late stage of HIV infection were associated with a high attributable mortality rate. Staphylococcus species were the leading pathogen responsible for NBSIs. Presentations of shock and hypoalbuminemia were predictive of mortality.

The attributable cost, length of hospital stay, and mortality of central line-associated bloodstream infection in intensive care departments in Argentina: A prospective, matched analysis

Background Limited information is available on the financial impact of central venous catheter-associated bloodstream infection (BSI) in Argentina. To calculate the cost of BSIs in the intensive care department (ICU), a 5-year prospective nested case-control study was undertaken at 3 hospitals in Argentina. Methods We studied 6 adult ICUs from 3 hospitals. In all, 142 patients with BSI and 142 control patients without BSI were matched for hospital, type of ICU, year of admission, length of stay, sex, age, and average severity of illness score. Patients' length of stay in the ICU was obtained prospectively on daily rounds. The hospitals' finance departments provided the cost of each ICU day. The hospitals' pharmacies provided the cost of antibiotics prescribed for BSIs. Results The mean extra length of stay for patients with BSI compared with control patients was 11.9 days, the mean extra antibiotic defined daily dose was 22.6, the mean extra antibiotic cost was $1913, the mean extra cost was $4888.42, and the excess mortality was 24.6%. Conclusions In this study, patients with central venous catheter-associated BSI experienced significant prolongation of hospitalization, increased use of health care costs, and a higher attributable mortality. These findings support the need to implement preventative interventions for patients hospitalized with central venous catheters in Argentina.

Secretion of the toxin ExoU is a marker for highly virulent Pseudomonas aeruginosa isolates obtained from patients with hospital-acquired pneumonia.

Overall, hospital-acquired pneumonia (HAP) caused by Pseudomonas aeruginosa is associated with high attributable mortality. Although the intrinsic virulence of P. aeruginosa undoubtedly contributes to this phenomenon, it is unclear whether all strains share this property or whether only a subpopulation of strains are capable of causing such severe disease. In this study, the virulence of 35 P. aeruginosa isolates obtained from patients with HAP by use of a cytolytic cell-death assay, an apoptosis assay, and a mouse model of pneumonia. The virulence of individual isolates differed significantly from one to another in each of these assays. Increased virulence was associated with the secretion of ExoU, a toxin transported by the P. aeruginosa type III secretion system. Secretion of ExoS or ExoY, 2 other proteins transported by this system, was not consistently associated with increased virulence. Together, these findings suggest that secretion of ExoU is a marker for highly virulent strains of P. aeruginosa.

Attributable Mortality of Nosocomial Candidemia, Revisited

We reexamined the attributable mortality of nosocomial candidemia 15 years after a retrospective cohort study performed at our hospital demonstrated an attributable mortality of 38%. For all episodes of nosocomial candidemia between 1 July 1997 and 30 June 2001, we matched control patients with case patients by age, sex, date of hospital admission, underlying disease(s), length of time at risk, and surgical procedure(s). We analyzed 108 matched pairs. There were no statistically significant differences in age, sex, underlying disease(s), time at risk, surgical procedure, or vital signs at admission between cases and controls. The crude mortality among case patients was 61% (66 of 108 patients), compared with 12% (13 of 108) among control patients, for an attributable mortality of 49% (95% CI, 38%-60%). Nosocomial candidemia is still associated with an extremely high crude and attributable mortality--much higher than that expected from underlying disease alone.

Infection in premature neonates is not associated with higher attributable mortality, but with more neurologic sequellae

Infection in premature neonates is not associated with higher attributable mortality, but with more neurologic sequellae

Etiology and Risk Factors of 339 Cases of Infective Endocarditis: Report from a 10-year National Prospective Survey in the Slovak Republic

The authors studied the etiology, outcome and risk factors of 339 cases of infective endocarditis (IE) in Slovakia over the last 10 years. Aortic valve was infected in 59.9%, mitral in 38.1% and tricuspidal/pulmonary in 5.0% of cases. The majority of IE were caused by staphylococci (29.2%), 15.0% were due to viridans streptococci, 7.4% due to Enterococcus faecalis, 3.9% due to the HACEK group (Haemophilus spp., Actinobacillus spp., Corynebacterium spp., Eikenella spp., Kingella spp.) and 39.2% were culture negative.The following risk factors were the most frequently identified: rheumatic fever in 24.2%, dental surgery in 13.3%, previous cardiosurgery in 7.1% and neoplasia in 7.1%. All patients were treated with antimicrobials and 42.5% of patients also with surgery (valvular prosthesis replacement): 61 (18.0%) died, and 278 (82.0%) survived at day 60 after the diagnosis of endocarditis was made. Univariate analysis did not show significant differences in most of the recorded risk factors between patients who died and those who survived: apart from staphylococcal etiology (44.3% vs. 26.6%, P <0.01), persistent bacteremia (with three or more positive blood cultures 24.6% vs. 9.7% P <0.002) which were significantly associated with higher attributable mortality, as was absence of surgery (55.7% vs. 6.1% P < 0.001), whereas antibiotic therapy in combination with surgery significantly predicted better outcome (P <0.001).We compared risk factors, etiology, therapeutic strategies and outcome of IE in two periods: from 1991-1997 (180 cases) and from 1998-2001 (159 cases). Rheumatic fever was less commonly observed in second period (1998-2001) P <0.01 since its prevalence in Slovakia is rapidly decreasing. Dental surgery was less frequent as well (20.5% vs. 5.0% P <0.001). There was a significant shift in etiology within the second study period: negative-culture endocarditis (despite better bacteriological techniques) (P <0.001) was more frequently observed in the 1st period and represented 53.3% of all cases in 1998-2001 in comparison to 26.7% in 1991-1997. Enterococci (P <0.0002) were also more frequent in the 2nd period. Persistent bacteremia (3 or more positive blood cultures 20.5% vs. 3.1%, P <0.001 was less commonly observed within the 2nd period (1998-2001) in comparison to 1991-1997.More patients in the second period (1998-2001) had complications of IE (P<0.001) than in the 1st period. However mortality was lower (22.2% vs. 13.2%, P <0.044) because of more surgical intervention in the 2nd period (52.8% vs. 33.3%, P <0.001).

Infection in immunocompromised premature neonates are not associated with higher attributable mortality, but with neurologic sequelae

Infection in immunocompromised premature neonates are not associated with higher attributable mortality, but with neurologic sequelae

Invasive fungal infections: evolving challenges for diagnosis and therapeutics

Invasive fungal infections (IFI) parallel the explosive increase in the immunocompromized patient population, and are characterized by diagnostic difficulties and extreme mortality. Candidemia in a tertiary referral hospital in the Middle East confirms the current epidemiologic shift in this common blood stream pathogen towards non-malignancy cases (38%) and antifungal prophylaxis failure (20%), high presentation sepsis scores and attributable mortality (32%). Invasive aspergillosis (IA) is also associated with high mortality. Use of non-invasive computerized tomographic (CT) radiologic scanning linked to early administration of high dose liposomal amphotericin B (LAB) is associated with a reduced mortality of 9.5% compared to historical experience of 28%. Life threatening invasive aspergillosis also occurs in patients who are less obviously immunocompromized. Investigations may reveal subtle immune deficits which could place the patient at some risk for an invasive mycosis. Antifungal treatment used in combination with progenitor cell growth factors and γ-interferon has proved successful in such situations of progressive fungal disease unresponsive to antifungal therapy alone. Pharmacologic remodeling of existing compounds by lipidisation reduces both the toxicity denominator and the efficacy numerator of the therapeutic index when compared to the parent drug. A comparative dose study of liposomal amphotericin B in aspergillosis has demonstrated equi-efficacy, generated debate over the ability of the controlled clinical trial to be capable of assessing antifungal efficacy, and illustrated that recovery from an invasive fungal infection may require maximum tolerated doses and immunomanipulation. Several new antifungal strategies are under clinical investigation. These include reformulating existing antifungals, exploitation of the growing knowledge of virulence factors to synthesize antagonists, immune reconstitution and immunoprotection. An interim analysis of an ongoing placebo controlled study of recombinant interleukin-11 to assess its efficacy in reducing sepsis in leukemia patients through prevention of chemotherapy induced gut epithelial cell apoptosis, has demonstrated a difference in the two study arms in sepsis rates and preservation of gastrointestinal epithelial cell integrity. The unique and special challenges presented by the dynamic epidemiologics of invasive fungal infections are demanding and attracting considerable responses, in the fields of diagnosis and therapeutics. Current strategies need considerable improvement, yet ongoing collaborative efforts will have a positive impact on our understanding of the fungus–host interaction and ultimately our ability to offer better care for our patients with invasive mycoses.

Pneumococcal peritonitis in adult patients: report of 64 cases with special reference to emergence of antibiotic resistance.

Few data are available regarding pneumococcal peritonitis. We studied the clinical characteristics of intra-abdominal infections caused by Streptococcus pneumoniae and its prognosis in relation to antibiotic resistance. We reviewed all cases of culture-proved pneumococcal peritonitis. Patients with liver cirrhosis and primary pneumococcal peritonitis were compared with patients with Escherichia coli peritonitis. Between January 1, 1979, and December 31, 1998, we identified 45 cases of primary pneumococcal peritonitis in patients with cirrhosis and 19 cases of secondary (or tertiary) pneumococcal peritonitis. Patients with cirrhosis and primary pneumococcal peritonitis vs those with primary E coli peritonitis had more frequent community-acquired infection, 73% vs 47%; pneumonia, 36% vs 2%; and bacteremia, 76% vs 33%; and higher attributable mortality (early mortality), 27% vs 9% (P<.05 for all). Secondary (or tertiary) pneumococcal peritonitis was associated with upper or lower gastrointestinal tract diseases; in most cases, the infection appeared after surgery. A hematogenous spread of S pneumoniae from a respiratory tract infection might be the most important origin of peritonitis; also, S pneumoniae might directly reach the gastrointestinal tract favored by endoscopic procedures or hypochlorhydria. There was an increased prevalence of penicillin and cephalosporin resistance up to 30.7% and 17.0%, respectively, although it was not associated with increased mortality rates. Primary pneumococcal peritonitis in patients with cirrhosis more often spread hematogenously from the respiratory tract and was associated with early mortality. In secondary (and tertiary) pneumococcal peritonitis, a transient gastrointestinal tract colonization and inoculation during surgery might be the most important mechanisms. Current levels of resistance were not associated with increased mortality rates.

Experimental Trichosporon infection in persistently granulocytopenic rabbits: implications for pathogenesis, diagnosis, and treatment of an emerging opportunistic mycosis.

Disseminated Trichosporon infection, an uncommon but emerging opportunistic mycosis due to Trichosporon beigelii, is frequently difficult to diagnose, refractory to treatment, and associated with a high attributable mortality. Models of disseminated and gastrointestinal Trichosporon infection were developed in persistently granulocytopenic rabbits. The patterns of infection resembled those of clinical disease, including cutaneous lesions, chorioretinitis, renal infection, pulmonary infection, and antigenemia cross-reactive with cryptococcal capsular polysaccharide. Antigenemia, an early manifestation of disseminated Trichosporon infection, originated in vivo from a fibrillar extracellular matrix. Trichosporon organisms disseminated from the gastrointestinal tract to visceral tissue in colonized immunosuppressed rabbits, whereas there was no dissemination from the gastrointestinal tract of otherwise normal rabbits. The antifungal triazoles, fluconazole and SCH 39304, were most active; maximum tolerated doses of amphotericin B and liposomal amphotericin B were ineffective. Trichosporon antigenemia declined in response to antifungal therapy. These findings contribute to improved understanding of the pathogenesis, diagnosis, and treatment of disseminated Trichosporon infection.

Infection control: opportunistic fungal infections--the increasing importance of Candida species.

Candida spp are clearly among the most important of the opportunistic fungal pathogens that cause nosocomial infections. Given the increasing incidence, high attributable mortality and excess length of stay associated with nosocomial candidemia, it is imperative that more effective preventive, diagnostic and therapeutic measures be developed to deal with this emerging group of pathogens. Implicit in these issues is the need for an increased understanding of the epidemiology of nosocomial candidiasis. The development of new epidemiologic typing methods provides useful tools that can assist in clinical and epidemiologic investigation. These studies are essential to the rational development of effective measures to prevent and to control nosocomial infections caused by Candida spp.

The Prediction of Adverse Outcomes in Antepartum Hypertension

A cohort of 180 women with antepartum hypertension were studied in order to develop a method of identifying those women most likely to experience adverse outcomes from hypertension early in pregnancy so that future work could be directed toward prevention. Women with known chronic hypertension delivered an excess of small for dates, low and very low birth weight infants with a high attributable perinatal mortality. They were prognostically distinct from the women with mild blood pressure elevations first documented early in pregnancy, who experienced excellent pregnancy outcomes. Second trimester mean arterial pressure was the only early predictor of subsequent severe hypertension (P<.001). Severe hypertension, in turn, was the only predictor of adverse infant outcomes (P<.001).Since chronic hypertension can be identified before conception and is associated with an excess of adverse outcomes, it presents a unique opportunity for prospective studies of early intervention(s) aimed at prevention. Future rese...