Inappropriate Initial Antibiotic Treatment Research Articles

A Large Multicenter Prospective Study of Community-Onset Healthcare Associated Bacteremic Urinary Tract Infections in the Era of Multidrug Resistance: Even Worse than Hospital Acquired Infections?

IntroductionHealthcare-associated (HCA) infections represent a growing public health problem. The aim of this study was to compare community-onset healthcare associated (CO-HCA) bacteremic urinary tract infections (BUTI) and hospital-acquired (HA)-BUTI with special focus on multidrug resistances (MDR) and outcomes.MethodsITUBRAS-project is a prospective multicenter cohort study of patients with HCA-BUTI. All consecutive hospitalized adult patients with CO-HCA-BUTI or HA-BUTI episode were included in the study. Exclusion criteria were: patients < 18 years old, non-hospitalized patients, bacteremia from another source or primary bacteremia, non-healthcare-related infections and infections caused by unusual pathogens of the urinary tract. The main outcome variable was 30-day all-cause mortality with day 1 as the first day of positive blood culture. Logistic regression was used to analyze factors associated with clinical cure at hospital discharge and with receiving inappropriate initial antibiotic treatment. Cox regression was used to evaluate 30-day all-cause mortality.ResultsFour hundred forty-three episodes were included, 223 CO-HCA-BUTI. Patients with CO-HCA-BUTI were older (p < 0.001) and had more underlying diseases (p = 0.029) than those with HA-BUTI. The severity of the acute illness (Pitt score) was also higher in CO-HCA-BUTI (p = 0.026). Overall, a very high rate of MDR profiles (271/443, 61.2%) was observed, with no statistical differences between groups. In multivariable analysis, inadequate empirical treatment was associated with MDR profile (aOR 3.35; 95% CI 1.77–6.35), Pseudomonas aeruginosa (aOR 2.86; 95% CI 1.27–6.44) and Charlson index (aOR 1.11; 95% CI 1.01–1.23). Mortality was not associated with the site of acquisition of the infection or the presence of MDR profile. However, in the logistic regression analyses patients with CO-HCA-BUTI (aOR 0.61; 95% CI 0.40–0.93) were less likely to present clinical cure.ConclusionThe rate of MDR infections was worryingly high in our study. No differences in MDR rates were found between CO-HCA-BUTI and HA-BUTI, in the probability of receiving inappropriate empirical treatment or in 30-day mortality. However, CO-HCA-BUTIs were associated with worse clinical cure.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00537-0.

Multidrug-Resistant Healthcare-Associated Infections in Neonates with Severe Respiratory Failure and the Impacts of Inappropriate Initial Antibiotic Therap.

Background: Multidrug-resistant (MDR) pathogens have emerged as an important issue in neonatal intensive care units (NICUs), especially in critically ill neonates with severe respiratory failure. We aimed to investigate neonatal healthcare-associated infections (HAIs) caused by MDR pathogens and the impacts of inappropriate initial antibiotic therapy on the outcomes. Methods: We retrospectively analyzed all cases of HAIs in neonates with severe respiratory failure in a tertiary-level NICU in Taiwan between January 2014 and May 2020. All clinical features, microbiology, therapeutic interventions, and outcomes were compared between the MDR-HAI and non-MDR HAI groups. Multivariate regression analyses were used to investigate independent risk factors for sepsis-attributable mortality. Results: A total of 275 critically ill neonates with severe respiratory failure who had HAIs were enrolled. Ninety-five cases (34.5%) were caused by MDR pathogens, and 141 (51.3%) cases had positive bacterial cultures from multiple sterile sites. In this cohort, the MDR-HAI group was more likely to receive inappropriate initial antibiotic therapy (51.0% versus 4.7%, respectively; p < 0.001) and exhibit delayed control of the infectious focus (52.6% versus 37.8%, respectively; p = 0.021) compared with the non-MDR HAI group. The sepsis-attributable and final in-hospital rates were 21.8% and 37.1%, respectively, and they were comparable between the MDR-HAI and non-MDR HAI groups. Empirically broad-spectrum antibiotics were prescribed in 76.7% of cases, and inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. Independent risk factors for sepsis-attributable mortality in neonates with severe respiratory failure included the presence of septic shock (OR: 3.61; 95% CI: 1.54–8.46; p = 0.003), higher illness severity (OR: 1.33; 95% CI: 1.04–1.72; p = 0.026), and neonates with bronchopulmonary dysplasia (OR: 2.99; 95% CI: 1.47–6.09; p = 0.003). Conclusions: MDR pathogens accounted for 34.5% of all neonatal HAIs in the NICU, but neither MDR pathogens nor inappropriate initial antibiotics were associated with final adverse outcomes. Because the overuse of broad-spectrum antibiotics has emerged as an important issue in critically ill neonates, the implementation of antimicrobial stewardship to promote the appropriate use of antimicrobials is urgently needed.

Impacts of Multidrug-Resistant Pathogens and Inappropriate Initial Antibiotic Therapy on the Outcomes of Neonates with Ventilator-Associated Pneumonia.

: BackgroundIt is unknown whether neonatal ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) pathogens and inappropriate initial antibiotic treatment is associated with poor outcomes after adjusting for confounders. Methods: We prospectively observed all neonates with a definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and March 2020. All clinical features, therapeutic interventions, and outcomes were compared between the MDR–VAP and non-MDR–VAP groups. Multivariate regression analyses were used to investigate independent risk factors for treatment failure. Results: Of 720 neonates who were intubated for more than 2 days, 184 had a total of 245 VAP episodes. The incidence rate of neonatal VAP was 10.1 episodes/per 1000 ventilator days. Ninety-six cases (39.2%) were caused by MDR pathogens. Neonates with MDR–VAP were more likely to receive inadequate initial antibiotic therapy (51.0% versus 4.7%; p < 0.001) and had delayed resolution of clinical symptoms (38.5% versus 25.5%; p = 0.034), although final treatment outcomes were comparable with the non-MDR–VAP group. Inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. The VAP-attributable mortality rate and overall mortality rate of this cohort were 3.7% and 12.0%, respectively. Independent risk factors for treatment failure included presence of concurrent bacteremia (OR 4.83; 95% CI 2.03–11.51; p < 0.001), septic shock (OR 3.06; 95% CI 1.07–8.72; p = 0.037), neonates on high-frequency oscillatory ventilator (OR 4.10; 95% CI 1.70–9.88; p = 0.002), and underlying neurological sequelae (OR 3.35; 95% CI 1.47–7.67; p = 0.004). Conclusions: MDR–VAP accounted for 39.2% of all neonatal VAP in the neonatal intensive care unit (NICU), but neither inappropriate initial antibiotics nor MDR pathogens were associated with treatment failure. Neonatal VAP with concurrent bacteremia, septic shock, and underlying neurological sequelae were independently associated with final worse outcomes.

Epidemiology of Febrile Neutropenia Episodes with Gram-Negative Bacteria Infection in Patients Who HaveUndergone Chemotherapy for Hematologic Malignancies: A Retrospective Study of 10 Years' Data from a Single Center.

BackgroundThe epidemiology of Gram-negative bacteria in patients with febrile neutropenia (FN) and their susceptibility to initial empirical antibiotic therapy is key to successful treatment during the treatment of hematologic malignancies.MethodsA retrospective study was conducted. Patients with FN and confirmed laboratory results of Gram-negative bacteria infections were included. If no direct sensitivity of the identified pathogen to the initially prescribed antibiotic regimen was confirmed, it was defined as inappropriate initial antibiotic treatment (IIAT).ResultsA total of 247 patients with FN were proven to be infected with Gram-negative bacteria, and 200 were diagnosed with acute leukemia. The most commonly detected bacteria were Escherichia coli (40%), Klebsiella pneumoniae (20%), and Pseudomonas aeruginosa (11%). In sum, 176 patients were classified as IIAT. The mortality rate in the IIAT group was significantly higher (37.7% vs 23.9%, P=0.038). With monotherapy as empirical treatment, high possibility of IIAT with fluoroquinolones (52%) and cephalosporins (35%) was detected, while more sensitivity to carbapenems (16%) and glycopeptides antibiotics (19%) was noticed. With combined treatment, cephalosporins/carbapenems had with the lowest percentage of IIAT (18%).ConclusionIn conclusion, inappropriate initial empirical antibiotic treatments were associated with higher mortality in patients with hematologic malignancies. The current empirical antibiotic regimen needs to be further optimized.

An easy-to-use scoring system for predicting bacteraemia with third-generation cephalosporin-resistant Enterobacterales in a low-resistance setting

Background: The incidence of third-generation cephalosporin-resistant Enterobacterales (3GCR-E) is increasing and a growing number of patients risk receiving inappropriate initial antibiotic treatment. Published scoring systems for predicting 3GCR-E bacteraemia are mostly based on studies from countries with a high incidence. In this study, we aimed to create an easy-to-use scoring system for predicting bacteraemia with these bacteria in a low-resistance setting.Materials and methods: Factors associated with 3GCR-E were studied retrospectively in a cohort of patients with Enterobacterales bacteraemia using uni- and multivariate analysis. A scoring system was constructed and was validated in a separate cohort of patients with Enterobacterales bacteraemia.Results: The derivation cohort comprised 625 cases of Enterobacterales bacteraemia. Three variables (previous hospital care abroad, 3GCR-E in a previous blood or urine culture and 3GCR-E in a previous rectal swab culture) were significantly associated with 3GCR-E bacteraemia. A scoring system, where at least one positive parameter equalled a positive score, was studied in the validation cohort, which comprised 675 cases of Enterobacterales bacteraemia. The sensitivity and specificity of the score were 53% and 95%, respectively. Positive and negative predictive values were 38% and 97%, respectively.Conclusions: This study presents an easy-to-use scoring system for predicting bacteraemia with 3GCR-E. The performance of the score is similar to that of several other, more complicated, scoring systems, developed in countries with higher rates of resistance. The minimal extra effort required to use this new score could facilitate its introduction into clinical routine.

Ignorance of pre-ED healthcare setting is a factor leading to inappropriate initial antibiotic treatment of sepsis in ED and poor outcomes in ICU.

Appropriate initial antibiotic therapy is critical for successfully treating sepsis. In the emergency department (ED), clinicians often rely on septic symptoms to guide empirical therapy. The aim of this study was to investigate whether history of contacting pre-ED healthcare setting is easy to be neglected and whether the patients received more inappropriate initial antibiotic therapy and developed poorer outcomes. Septic patients (n=453) admitted from ED to the intensive care unit (ICU) between 2014 and 2017 were retrospectively selected. Appropriate antibiotic treatment or not was determined by checking whether the selected antibiotics can effectively eradicate the bacteria identified. Various indexes were compared between patients with appropriate and inappropriate initial antibiotic treatments, including septic symptoms (qSOFA scores) in ED, septic-severity change in ICU (SOFA-score ratios), and septic outcomes (APACHE II scores, stay length, 30-day survival probability). These indexes were also compared between pre-ED healthcare and pre-ED community patients. In comparison with pre-ED community patients, pre-ED healthcare patients received more inappropriate initial antibiotic treatment in ED, showing poorer outcomes in ICU, including septic severity, stay-lengths in ICU and 30-day survival probabilities. Pre-ED settings is more significant than qSOFA scores to predict the inappropriate initial antibiotic treatment. Pre-ED healthcare settings, which are indexes for infection with antibiotic resistant pathogens, are easy to be neglected in the first hour in ED. We suggested that standard operating procedure for getting enough information of pre-ED settings should be incorporated to the 1h bundle of sepsis guideline.

A cohort study of bacteremic pneumonia

Bacteremic pneumonia is usually associated with greater mortality. However, risk factors associated with hospital mortality in bacteremic pneumonia are inadequately described.The study was a retrospective cohort study, conducted in Barnes-Jewish Hospital (2008-2015). For purposes of this investigation, antibiotic susceptibility was determined according to ceftriaxone susceptibility, as ceftriaxone represents the antimicrobial agent most frequently recommended for hospitalized patients with community-acquired pneumonia as opposed to nosocomial pneumonia. Two multivariable analyses were planned: the first model included resistance to ceftriaxone as a variable, whereas the second model included the various antibiotic-resistant species (methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae).In all, 1031 consecutive patients with bacteremic pneumonia (mortality 37.1%) were included. The most common pathogens associated with infection were S aureus (34.1%; methicillin resistance 54.0%), Enterobacteriaceae (28.0%), P aeruginosa (10.6%), anaerobic bacteria (7.3%), and Streptococcus pneumoniae (5.6%). Compared with ceftriaxone-susceptible pathogens (46.8%), ceftriaxone-resistant pathogens (53.2%) were significantly more likely to receive inappropriate initial antibiotic treatment (IIAT) (27.9% vs 7.1%; P < 0.001) and to die during hospitalization (41.5% vs 32.0%; P = 0.001). The first logistic regression analysis identified IIAT with the greatest odds ratio (OR) for mortality (OR 2.2, 95% confidence interval [CI] 1.5-3.2, P < 0.001). Other independent predictors of mortality included age, mechanical ventilation, immune suppression, prior hospitalization, prior antibiotic administration, septic shock, comorbid conditions, and severity of illness. In the second multivariable analysis that included the antibiotic-resistant species, IIAT was still associated with excess mortality, and P aeruginosa infection was identified as an independent predictor of mortality (OR 1.6, 95% CI 1.1-2.2, P = 0.047), whereas infection with ceftriaxone-resistant Enterobacteriaceae (OR 0.6, 95% CI 0.4-1.0, P = 0.050) was associated with lower mortality.More than one-third of our patients hospitalized with bacteremic pneumonia died. IIAT was identified as the most important risk factor for hospital mortality and the only risk factor amenable to potential intervention. Specific antibiotic-resistant pathogen species were also associated with mortality.

Tigecycline Therapy for Nosocomial Pneumonia due to Carbapenem-Resistant Gram-Negative Bacteria in Critically Ill Patients Who Received Inappropriate Initial Antibiotic Treatment: A Retrospective Case Study

Background. Nosocomial pneumonia due to carbapenem-resistant Gram-negative bacteria (CRGNB) is a growing concern because treatment options are limited and the mortality rate is high. The effect of tigecycline (TGC) on nosocomial pneumonia due to CRGNB in patients who have received inappropriate initial empiric antibiotic treatment (IIAT) is unclear. Therefore, this study aimed to examine the effect of TGC on nosocomial pneumonia due to CRGNB in critically ill patients who had received IIAT. Methods. A retrospective study was conducted in an adult respiratory intensive care unit. Data were obtained and analyzed for all patients who were treated with TGC ≥ 3 days for microbiologically confirmed nosocomial pneumonia due to CRGNB and had experienced initial antibiotic failure. Clinical and microbiological outcomes were investigated. Results. Thirty-one patients with hospital-acquired pneumonia or ventilator-associated pneumonia were included in the study. The majority of the responsible organisms were carbapenem-resistant Acinetobacter baumannii (67.7%), followed by Klebsiella pneumoniae (16.1%) and Escherichia coli (9.7%). Twenty patients were treated with high-dose TGC therapy (100 mg every 12 h after a 200 mg loading dose), and the others received a standard-dose therapy (50 mg every 12 h after a 100 mg loading dose). The duration of TGC therapy was 14.3 ± 2.8 days. The global clinical cure rate and the microbiological eradication rate were 48.4% and 61.3%, respectively. The overall ICU mortality rate was 45.2%. A higher score on the Acute Physiology and Chronic Health Evaluation II and a longer duration of IIAT were associated with clinical failure. High-dose TGC therapy had a higher clinical success rate [65.0% (13/20) versus 18.2% (2/11), P = 0.023] and a lower ICU mortality rate [30.0% (6/20) versus 72.7% (8/11), P = 0.031] than the standard-dose therapy. Conclusions. TGC, especially a high-dose regimen, might be a justifiable option for critically ill patients with nosocomial pneumonia due to CRGNB who have received IIAT when the options for these patients are limited.

Risk factors for 30-day mortality in patients with pneumonia who receive appropriate initial antibiotics: an observational cohort study

Appropriate initial antibiotics are essential for the treatment of infectious diseases. However, some patients with pneumonia might develop adverse outcomes, despite receiving appropriate initial antibiotics. We aimed to clarify the risk factors for 30-day mortality in patients who received appropriate initial antibiotics and to identify potential candidates who would benefit from adjunctive therapy. From March 15, to Dec 22, 2010, we did a prospective, observational study at ten medical institutions in hospitalised patients (aged ≥20 years) with pneumonia. We did a multivariable logistic regression analysis to calculate odds ratios (ORs) and 95% CI to assess the risk factors for 30-day mortality. This study was registered with the University Medical Information Network in Japan, number UMIN000003306. The 30-day mortality was 11% (61 of 579 patients) in the appropriate initial antibiotic treatment group and 17% (29 of 168) in the inappropriate initial antibiotic treatment group. Albumin concentration of less than 30 mg/L (adjusted OR 3·39, 95% CI 1·83-6·28), non-ambulatory status (3·34, 1·84-6·05), pH of less than 7·35 (3·13, 1·52-6·42), respiration rate of at least 30 breaths per min (2·33, 1·28-4·24), and blood urea nitrogen of at least 7·14 mmol/L (2·20, 1·13-4·30) were independent risk factors in patients given appropriate initial antibiotic treatment. The 30-day mortality was 1% (one of 126 patients), 1% (two of 168), 17% (23 of 137), 22% (20 of 89), and 44% (14 of 32) for patients with no, one, two, three, and four or five risk factors, respectively. Patients with two or more risk factors were at a higher risk of death during the 30 days assessed than were individuals with no or one risk factor, despite appropriate initial antibiotic treatment. Therefore, adjunctive therapy might be important for improving outcomes in patients with two or more risk factors. Central Japan Lung Study Group.

Prognostic factors associated with mortality of drug-resistant Acinetobacter baumannii ventilator-associated pneumonia.

BackgroundVentilator-associated pneumonia (VAP) caused by drug-resistant Acinetobacter baumannii is associated with high mortality in critically ill patients. We identified the prognostic factors of 30-day mortality in patients with VAP caused by drug-resistant A. baumannii and compared survival outcomes among multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) A. baumannii VAP.MethodsA retrospective cohort study was conducted in the Medical Intensive Care Unit at Chiang Mai University Hospital, Thailand. All adult patients diagnosed with A. baumannii VAP between 2005 and 2011 were eligible. Univariable and multivariable Cox’s proportional hazards regression were performed to identify the prognostic factors of 30-day mortality.ResultsA total of 337 patients with microbiologically confirmed A. baumannii VAP were included. The proportion of drug-sensitive (DS), MDR, XDR, and PDR A. baumannii were 9.8%, 21.4%, 65.3%, and 3.6%, respectively. The 30-day mortality rates were 21.2%, 31.9%, 56.8%, and 66.7%, respectively. The independent prognostic factors were SOFA score >5 (hazard ratio (HR) = 3.33, 95% confidence interval (CI) 1.94–5.72, P < 0.001), presence of septic shock (HR = 2.66, 95% CI 1.71–4.12, P < 0.001), Simplified Acute Physiology Score (SAPS) II >45 (HR = 1.58, 95% CI 1.01–2.46, P = 0.045), and inappropriate initial antibiotic treatment (HR = 1.53, 95% CI 1.08–2.20, P = 0.016).ConclusionsDrug-resistant A. baumannii, particularly XDR and PDR, was associated with a high mortality rate. Septic shock, high SAPS II, high SOFA score, and inappropriate initial antibiotic treatment were independent prognostic factors for 30-day mortality.

Emergence of antibiotic-resistant bacteria in patients with Fournier gangrene.

This study was conducted to investigate the bacteriology and associated patterns of antibiotic resistance Fournier gangrene. Patients with Fournier's gangrene from 2008 to 2012 were identified from the computerized database in a medical center in southern Taiwan. The medical records of all patients with Fournier's gangrene were reviewed retrospectively. There were 61 microorganisms, including 60 bacteria and one Candida spp, isolated from clinical wound specimens from 32 patients. The most common isolates obtained were Streptococcus spp. (n=12), Peptoniphilus spp. (n=8), Staphylococcus aureus (n=7), Escherichia coli (n=7), and Klebsiella pneumoniae (n=7). Among 21 strains of gram-negative bacilli, five (23.8%) were resistant to fluoroquinolones, and three isolates were resistant to ceftriaxone. Two E. coli strains produced extended-spectrum beta-lactamase. Four of the seven S. aureus isolates were methicillin-resistant. Among 15 anaerobic isolates, nine (60%) were resistant to penicillin, and eight (53.3%) were resistant to clindamycin. Four (26.7%) isolates were resistant to metronidazole. The only independent risk factor associated with mortality was inappropriate initial antibiotic treatment (p=0.021). Antibiotic-resistant bacteria are emerging in the clinical setting of Fournier gangrene. Clinicians should use broad-spectrum antibiotics initially to cover possible antibiotic-resistant bacteria.

Inappropriate initial antibiotic treatment for complicated skin and soft tissue infections in hospitalized patients: incidence and associated factors

We analyzed 525 hospitalized adults treated with intravenous antibiotic(s) for complicated skin and soft tissue infections (cSSTIs) to assess incidence of, and risk factors associated with, inappropriate initial antibiotic treatment (IIAT). IIAT was given to 22.5% of enrolled patients. The rate of IIAT did not vary by type of facility (academic versus community) but was significantly higher in rural than urban hospitals (38.9% versus 21.3%, P = 0.02). Pathogens were exclusively gram-positive in 68% of patients, exclusively gram-negative in 13%, and mixed in 19%. Staphylococcus aureus was the most frequently isolated pathogen (in 65%), 54% of which were methicillin-resistant. Significant independent risk factors for IIAT were: admission to a rural hospital (odds ratio = 2.34; 95% confidence interval: 1.06–5.19), dialysis treatment (3.86; 1.15–12.93), cancer other than non-melanoma skin cancer (5.23; 1.78–15.36), and infection with gram-negative (3.43; 1.79–6.60) or mixed (4.52; 2.62–7.78) pathogens. IIAT for cSSTIs was relatively frequent in these hospitalized patients, especially those with selected risk factors.

Economic outcomes of inappropriate initial antibiotic treatment for complicated skin and soft tissue infections: a multicenter prospective observational study

This study examined economic outcomes associated with inappropriate initial antibiotic treatment (IIAT) in complicated skin and soft tissue infections using data from adults hospitalized and treated with intravenous antibiotic therapy. We specifically analyzed for the subsets of patients infected with methicillin-resistant Staphylococcus aureus (MRSA), with healthcare-associated (HCA) infections, or both. Data from 494 patients (HCA: 360; MRSA:175; MRSA + HCA: 129) showed the overall mean length of stay (LOS) was 7.4 days and 15.0% had the composite economic outcome of any subsequent hospital admissions, emergency department visits, or unscheduled visits related to the study infection. A total of 23.1% of patients had IIAT; after adjustments, these patients had longer LOS than patients without IIAT in the HCA cohort (marginal LOS = 1.39 days, P = 0.03) and the MRSA + HCA cohort (marginal LOS = 2.43 days, P = 0.01) and were significantly more likely to have the composite economic outcome in all study cohorts (odds ratio: overall = 1.79; HCA = 3.09; MRSA = 3.66; MRSA + HCA = 6.92; all P < 0.05).

Catheter management in neonates with bloodstream infection and a percutaneously inserted central venous catheter in situ: Removal or not?

This study investigated whether removal of a percutaneously inserted central venous catheter (PICC) is compulsory in neonates with bloodstream infection (BSI), and also examined the risk factors for infectious complications when a PICC is retained in these patients. This was a cohort study of neonates with a PICC who developed a BSI between 2001 and 2007. BSI was defined according to Centers for Disease Control and Prevention criteria. Of the 234 neonates in the cohort, 99 had early removal of PICC (ER-PICC, defined as removal within 3 days after the onset of clinical sepsis), and 135 had late removal of PICC (LR-PICC, defined as retention for more than 3 days after the onset of clinical sepsis). Resolution of clinical sepsis within 2 days was more frequent in the ER-PICC group compared with the LR-PICC group (80.8% vs 57.8%; P < .001). There was no significant difference between the 2 groups in terms of infectious complications and case fatalities, but the LR-PICC group had a significantly higher incidence of recurrence within 1 month after BSI (P= .002). Inappropriate initial antibiotic treatment was the only variable independently associated with infectious complications (odds ratio, 11.4; 95% confidence interval, 3.34∼39.2; P < .001). PICCs should be removed in neonates with BSI, because retention of PICCs for more than 3 days is associated with delayed resolution of clinical sepsis and a higher incidence of recurrence within 1 month.

Healthcare-associated pneumonia: Diagnostic criteria and distinction from community-acquired pneumonia

Traditionally, pneumonia developing in patients who receive healthcare services in the outpatient environment has been classified as community-acquired pneumonia (CAP). However, recent investigations suggest that this type of infection, known as healthcare-associated pneumonia (HCAP), is distinct from CAP in terms of its epidemiology, etiology, and risk for infection with multidrug-resistant (MDR) pathogens. A Medline literature review of available clinical studies using the term HCAP was conducted to determine outcomes compared to CAP and effective empiric treatment strategies. Analysis of multi-institutional clinical data showed that mortality in hospitalized patients with HCAP is greater than that in CAP, and patients with HCAP received inappropriate initial empiric antibiotic treatment more frequently than CAP patients. The bacterial pathogens associated with HCAP also differed from CAP with potentially MDR Gram-positive and Gram-negative bacteria being more common in HCAP. All patients hospitalized with suspected HCAP should be evaluated for their underlying risk of infection with MDR pathogens. Because HCAP is similar to hospital-acquired pneumonia (HAP), both clinically and etiologically, it should be treated as HAP until culture data become available.

Health Care-Associated Pneumonia

Traditionally, pneumonia developing in patients who receive health care services in the outpatient environment, such as nursing homes, long-term care facilities, and dialysis centers, has been classified and treated as community-acquired pneumonia (CAP). Recent studies, however, have shown that this type of infection, known as health care-associated pneumonia (HCAP) is distinct from CAP in terms of its epidemiology and etiology, and increases the risk for infection with multidrug-resistant (MDR) pathogens. A review of available clinical data about HCAP was conducted to determine effective empiric treatment strategies and improve clinical outcomes. Analysis of multi-institutional clinical data showed that mortality associated with HCAP is higher than with CAP, suggesting that patients with HCAP may have been treated as hospitalized patients with CAP and received inappropriate initial empiric antibiotic treatment. All patients presenting to the hospital with suspected HCAP or CAP should be evaluated for their underlying risk of infection with MDR pathogens. Because HCAP may be similar to hospital-acquired pneumonia (HAP) both clinically and etiologically, it should be treated as HAP until culture data become available. A greater recognition of HCAP as a new class of pneumonia with a distinct epidemiologic, microbiologic, and clinical profile should lead physicians to initiate appropriate empiric antibiotic therapy more often, thereby improving the likelihood for optimal clinical outcomes and patient care.

Attributable Mortality of Stenotrophomonas Maltophilia Infections: A Systematic Review of the Literature

Although Stenotrophomonas maltophilia is commonly isolated from clinical specimens, mainly of immunocompromised patients, mortality directly attributable to this organism is controversial. We searched PubMed, Scopus and Cochrane and assessed the available literature regarding mortality attributable to infection with S. maltophilia. Crude mortality and mortality of case patients receiving appropriate or inappropriate initial antibiotic treatment were evaluated. A total of 15 articles (six matched case-control, seven case-control and two controlled cohort studies) were identified; 13 studies (the six matched case-control and the seven case-control studies) were included in the analysis. In seven studies, mortality of cases differed significantly from that of controls. Mortality was significantly higher in cases than controls in six of these studies; it was lower in cases than controls in the one study where controls had Pseudomonas aeruginosa bacteremia. In six studies, mortality of cases did not differ significantly compared with the respective controls. In three of four studies providing relevant data, mortality of cases treated with inappropriate initial antibiotic treatment was significantly higher compared with cases treated with appropriate initial antibiotic treatment. A considerable mortality rate (up to 37.5%) can be attributed to S. maltophilia infection. Thus, clinicians should not underestimate the clinical significance of S. maltophilia infections.

Health-Care-Associated Pneumonia

Health-Care-Associated Pneumonia

Epidemiology of early-onset bloodstream infection and implications for treatment

HEALTH CARE-ASSOCIATED INFECTIONS: For over 35 years, infections have been divided into hospital acquired or community acquired. In 2002, in a study of bloodstream infections (BSIs), Friedman et al first suggested creating a new classification: health care-associated BSIs. Kollef et al furthered the concept of health care-associated infection in a 2005 population-based study of culture-positive pneumonia cases. Although the site of infection differed, Kollef et al's results supported Friedman et al's original concept. Then in 2006, Kollef et al reported a population-based study focused specifically on BSIs. Of 6697 reported cases, 468 (7%) had hospital-acquired BSIs; 3705 (55.3%) health care-associated BSIs; and 2524 (37.7%) community-acquired BSIs. The clinical features of those with health care-associated BSIs differed from those with community-acquired BSIs. For several organisms, including Staphylococcus aureus, Streptococcus pneumoniae, and gram-negative organisms, the frequencies for health care-associated and hospital-acquired BSIs were similar to each other but significantly different from community-acquired BSIs. After controlling for several clinical features, methicillin-resistant Staphylococcus aureus had the largest odds ratio for predicting in-hospital mortality. Both hospital-acquired and health care-acquired cases were independent risk factors for in-hospital mortality. Is more aggressive, empiric, gram-positive therapy warranted for this potentially sicker patient group? Wunderink pointed out the potential unintended consequences of such an approach and the paucity of good tools for early recognition of sickest patients. A study by Shorr et al of systemic inflammatory response syndrome, organ dysfunction, and mortality suggested that there may be approaches that could be used to stratify cases into high-risk groups who may benefit from more aggressive therapy. Most recently, Micek et al found that in health care-associated pneumonia cases, inappropriate initial empiric antibiotic treatment is an independent predictor of mortality. Treatment recommendations are evolving. For pneumonia and BSIs, health care-associated infections appear to be distinct entities. However, operational definitions still vary. Compared with hospital-acquired cases, health care-associated cases have different clinical characteristics. The outcomes of health care-associated infections tend to be intermediate of the community-acquired and hospital-acquired groups. Further research is urgently needed on the implications of health care-associated infection for early therapy.

Risk factors for relapse of ventilator-associated pneumonia related to nonfermenting Gram negative bacilli: A case–control study

The aim of this study was to determine risk factors for relapse of ventilator-associated pneumonia (VAP) related to nonfermenting Gram negative bacilli (NF-GNB). This is a retrospective case-control study based on prospectively collected data. Two hundred and seventy six patients with monobacterial VAP related to NF-GNB were eligible. Patients with subsequent superinfection or persistent pulmonary infection were excluded. Patients with relapse of NF-GNB VAP were matched (1:2) with patients without relapse. Matching criteria included the duration of mechanical ventilation before VAP relapse, age+/-5 years, SAPS II at ICU admission+/-5, and the date of admission. Univariate and multivariate analyses were used to determine risk factors for relapse of NF-GNB VAP in cases and controls. Thirty (10%) patients developed a relapse of NF-GNB VAP, 27 (90%) patients were successfully matched with 54 controls. Inappropriate initial antibiotic treatment was the only variable independently associated with relapse of VAP related to NF-GNB (OR [95% CI]=8.1 [2-33], p=0.003). Although ICU-mortality rate was similar in cases and controls (55% vs 72%, p=0.132), the duration of mechanical ventilation and ICU stay were significantly higher in cases than in controls. Inappropriate initial antibiotic treatment is independently associated with relapse of VAP related to NF-GNB.