Episodes Of Staphylococcus Aureus Bacteremia Research Articles

Risk Factors and Outcomes Associated With Hospital-Onset Peripheral Intravenous Catheter-Associated Staphylococcus aureus Bacteremia.

BackgroundPeripheral venous catheters (PVCs) are common in hospitals, but the literature surrounding PVC-associated bacteremia is lacking. We describe incidence rates, risk factors, and outcomes related to PVC-associated Staphylococcus aureus bacteremia (SAB), a common cause of hospital-onset (HO) SAB.MethodsThis is a retrospective case–control study conducted at a 537-bed teaching community hospital during 2015–2016. Cases were adult inpatients with HO SAB with infectious diseases documentation of the PVC as the only source of bacteremia. Cases were matched 1:2 with controls on approximate PVC insertion date, age, mortality prediction score, and insurance type. Odds ratios (ORs) were estimated using conditional logistic regression. PVC utilization was estimated by a point-prevalence survey from July 2017.ResultsOf 205 SAB episodes, 160 were community-onset and 45 were HO; 16 (36%) HO cases were PVC-associated. Cases (n = 16) were more likely than controls (n = 32) to have a PVC placed in the antecubital area (odds ratio [OR], 11.9; 95% confidence interval [CI], 1.5–95.7; P = .02) and PVC duration ≥4 days (OR, 4.0; 95% CI, 1.1–15.2; P = .04). The point prevalence of at least 1 PVC in adult inpatients was 86%, and the incidence density of HO PVC–associated SAB was 0.15 per 1000 PVC-days. The mean length of stay for cases was 13.2 days. All cases successfully completed parenteral antibiotics with a mean treatment length of 23.6 days.ConclusionsPVC-associated SAB is a common cause of HO SAB that results in significant morbidity. PVC placement in the antecubital area and line duration should be minimized to reduce HO SAB.

1220. Impact of Mandatory Infectious Diseases Consultation on the Use of Core Measures and Mortality in Staphylococcus aureus Bacteremia (SAB) at an Academic Medical Center

BackgroundMultiple studies have shown that Infectious Diseases (ID) consultation significantly improves adherence to guidelines for patients with SAB and decreases mortality. Data from a prior retrospective study done at Hahnemann University Hospital showed that ID consultation improved the use of guideline-based core measures for SAB management. Based on these data, a mandatory ID consultation was established at our institution in November 2016.MethodsA retrospective, observational study was conducted to evaluate patient characteristics, adherence to core measures for SAB, and in-hospital mortality. All patients with at least one documented blood culture positive for S. aureus were stratified into two groups: pre-mandatory consult (January 1, 2014–November 1, 2016) and post mandatory consult (November 2, 2016–February 1, 2018).ResultsThree hundred seventy-three discrete episodes of SAB were included in the final analysis, 238 episodes before mandatory consult, and 135 episodes after the mandatory consult policy was enacted. Mandatory consultation significantly improved the use of the following core measures for SAB: surveillance blood cultures (87.7% pre vs. 99.2% post, P < 0.001), echocardiography (81.9% vs. 96.9%, P < 0.001), early targeted antimicrobial therapy with nafcillin or cefazolin in MSSA (71.7% vs. 88.6%, P < 0.001), and appropriateness of final antibiotic choice (80.2% vs. 95.2%, P < 0.001). In addition, in-hospital mortality (15.4% vs. 6.2%, P = 0.011), and infection-related mortality (14.3% vs. 5.6%, P = 0.011) were found to be statistically significantly lower in the post mandatory consultation patients.ConclusionImplementation of a mandatory ID consultation for patients with SAB at our institution was associated with increased adherence to guideline-based core measures for management of SAB, and decreased in-hospital and infection-related mortality. Our results suggest that mandatory ID consultation for SAB should be considered at all institutions.Disclosures All authors: No reported disclosures.

Impact of antimicrobial treatment duration on outcome of Staphylococcus aureus bacteraemia: a cohort study

ObjectivesTo assess the outcome of Staphylococcus aureus bacteraemia (SAB) according to factors associated with necessity for longer treatment in conjunction with the duration of treatment. MethodsWe prospectively collected the data of patients with SAB consecutively during 12 to 39 months from 11 hospitals. If multiple episodes of SAB occurred in one patient, only the first episode was enrolled. Factors associated with necessity for longer treatment were defined as follows: persistent bacteraemia, metastatic infection, prosthesis and endocarditis. If any of the factors were present, then the case was defined as longer antibiotic treatment warranted (LW) group; those without any factors were defined as shorter antibiotic treatment sufficient (SS) group. Poor outcome was defined as a composite of 90-day mortality or 30-day recurrence. Duration of antibiotic administration was classified as <14 or ≥14 days in the SS group and <28 or ≥28 days in the LW group. ResultsAmong 2098 cases, the outcome was analysed in 1866 cases, of which 591 showed poor outcome. The SS group accounted for 964 cases and the LW group for 852. On multivariate analysis, age over 65 years, pneumonia, higher Sequential Organ Failure Assessment (SOFA) score and chronic liver diseases were risk factors for poor outcome. Administration of antibiotics less than the recommendation was associated with poor outcome, but this significance was observed only in the LW group (adjusted odds ratio = 1.68; 95% confidence interval, 1.00–2.83; p 0.05). ConclusionsInappropriately short antibiotic treatment was associated with poor outcome in the LW group. Vigilant evaluation for risk factors to determine the duration of treatment may improve the outcome among patients with SAB.

Duration and Persistence of Staphylococcus Aureus Bacteremia: A Prospective Cohort Study

Background: The purpose of the study was to describe and compare duration of Staphylococcus aureus bacteremia (SAB) according to methicillin resistance and primary foci of infection. We also aimed to redefine persistent SAB considering those results. Methods: We analyzed non-duplicated episodes of SAB in adult patients from three prospective SAB cohorts encompassing 14 hospitals in Korea. The duration of SAB was defined as the number of days from the administration of a susceptible antibiotic after the onset of SAB to the last day of positive blood culture for S. aureus. SAB durations were described and compared based on methicillin resistance and the primary foci of infection. The Cox proportional hazards regression was performed to explore independent risk factors for prolonged bacteremia. Cases in the top quartile for the duration of bacteremia were designated as newly-defined persistent SAB. Findings: A total of 2050 cases were analyzed. The duration of SAB was longer in methicillin-resistant SAB (MRSAB) than in methicillin-susceptible SAB (MSSAB) (median [IQR], 1 [1-3] in MSSAB vs. 1 [0-7] in MRSAB, p < 0.001). While the duration of bacteremia was shortest in the skin and soft tissue infections, they were longer in endocarditis, bone and joint, and endovascular infections, and were independently associated with those foci of infection. Newly-defined persistent SAB showed independent association with in-hospital mortality (aOR, 1.99; 95% CI, 1.54-2.58; p < 0.001). Interpretation: Durations of SAB were dependent on methicillin resistance and the primary foci of infection. The newly-defined persistent SAB is independently associated with in-hospital mortality. Funding: Seoul National University Bundang Hospital Research Fund. Declaration of Interest: None to declare. Ethical Approval: The analyses of cases from April 2015 to February 2018 were approved by the institutional review board of Seoul National University Bundang Hospital (IRB No. B-1801-442-102).

Increased overall survival after introduction of structured bedside consultation in Staphylococcus aureus bacteraemia

Staphylococcus aureus bacteraemia (SAB) is a common and severe disease. In 2012, a structured bedside consultation (SBC) was introduced at Rijnstate Hospital. We analysed the effect of this SBC on the overall survival of patients with SAB and the effect on the diagnostic workup. We performed a retrospective cohort study, including all patients over 18years with SAB from 2009 until 2017. The cases preceding versus those after implementation of SBC in 2012 were compared. In total, 613 episodes of SAB were analysed: 234 cases before and 379 cases since SBC. In 484 patients at risk for a complicated course, there was no significant difference in the 30-day survival (77 versus 82%, p = 0.18); however, an increase in 365-day survival was seen (56 versus 64%, p = 0.05). Overall, more patients received adequate therapy, both in the first 2weeks (67.8 versus 86.7%, p < 0.001), as in complicated SAB (70.5 versus 93.2%, p < 0.001). In 21% of patients with transoesophageal echocardiogram (TEE) following a negative or inconclusive TTE, endocarditis was diagnosed. In patients at risk for complicated SAB, the PET scan revealed a metastatic infection which was not clinically suspected in 65% of positive PET scans. Structured bedside consultation is associated with a better 365-day survival in patients at risk for complicated SAB. Moreover, the additional value of TEE and the PET scan was shown. We strongly advise compliance to SBC in all patients at risk for complicated SAB and the use of both TEE and PET scans in these patients. Even in uncomplicated SAB, TEE or PET scan can reveal metastatic infections.

Clinical variation in the use of echocardiography in Staphylococcus aureus bacteraemia: a multi-centre cohort study.

The objective of this investigation was to assess whether between-hospital variation in echocardiography usage for patients with Staphylococcus aureus bacteraemia (SAB) is explained by differences in patients' pre-test probability of endocarditis. This was a retrospective cohort study at three neighbouring hospitals in Australia. Consecutive episodes of SAB were reviewed for the presence of three endocarditis risk factors (community onset, prolonged bacteraemia and the presence of an intracardiac prosthetic device) and the performance and results of all echocardiography studies within 30days. Multivariate logistic regression was used to examine the effect of hospital site on the performance of (i) transoesophageal and (ii) transthoracic echocardiography controlling for major endocarditis risk factors. Significant variation in echocardiography usage was demonstrated between sites in a total cohort of 1167 episodes of SAB. None of the three sites were found to exhibit echocardiography usage that could be considered consistent with current guidelines, and each differed from the guidelines in different ways. Hospital site, rather than endocarditis risk factors, was the strongest predictor of transthoracic echocardiography use; however, the use of transoesophageal echocardiography was strongly predicted by endocarditis risk factors. Variation in echocardiography use between these hospitals is not adequately explained by differences in the risk factor profile of their SAB cohorts.

The Scottish enhanced Staphylococcus aureus bacteraemia surveillance programme: the first 18 months of data in adults

Staphylococcus aureus bacteraemia (SAB) is the second most common source of positive blood cultures, after Escherichia coli, reported within NHS Scotland. Laboratory surveillance has been mandatory in Scotland for SAB since 2001. To gain an understanding of the epidemiology of SAB cases and associated risk factors for healthcare and true community onset. Identification of these factors and the patient populations at greatest risk enables the development of focused improvement plans. All NHS boards within NHS Scotland take part in the mandatory enhanced surveillance, with data collected by trained data collectors using nationally agreed definitions. Between 1st October 2014 and 31st March 2016, 2256 episodes of SAB in adults were identified. The blood cultures were taken in 58 hospitals and across all 15 Scottish health boards. The data demonstrated that approximately one-third of all SAB cases are true community cases. Vascular access devices continue to be the most reported entry point (25.7%) in individuals who receive health care, whereas skin and soft tissue risk factors are present in all origins. A significant risk factor unique to community cases is illicit drug injection. Improvement plans for reduction of SAB should be targeted more widely than hospital care settings alone.

Administrative data has poor accuracy for surveillance of Staphylococcus aureus bacteraemia

Abstract Background To determine the accuracy of the International Classification of Diseases (ICD-10) coding for Staphylococcus aureus bacteremia (SAB) compared with laboratory results during a ten-year period (January 2002–December 2011). Methods A retrospective comparison of ICD-10 code A41.0 for S. aureus sepsis with SAB identified from the laboratory information system (LIS). Patients with LIS identified SAB (LIS+) and/or the ICD-10 A41.0 code (ICD-10) were identified and classified as concordant (LIS+/ICD+) or discordant (LIS+/ICD− or LIS-/ICD+). From July 2010 an additional code for healthcare associated SAB (HA-SAB), U90.0, was introduced and evaluated against prospectively designated episodes of HA-SAB. Results and Conclusions There were 740 laboratory confirmed episodes of SAB however, only 408 of these were recorded by ICD-10 A41.0whilst 106 patients with negative blood cultures were miscoded as ICD-10 A41.0. The sensitivity and PPV for ICD-10 A41.0 were 55% [95% CI: 51–59%] and 72% [95% CI: 68–76%]. For the subset of HA-SAB, the sensitivity and PPV for ICD-10 U90.0 were only 12% [95% CI: 5–24%] and 32% [95% CI: 15–54%] respectively. Surveillance based solely on ICD-10 A41.0, code underestimates the true incidence of SAB even while including non-bacteremic episodes. ICD-10 U90.0 for HA-SAB has even poorer sensitivity and PPV. Laboratory culture results should become the major criterion for ICD-10 coding for SAB to improve the accuracy of surveillance data.

Epidemiology and Mortality of Staphylococcus aureus Bacteremia in Australian and New Zealand Children.

Staphylococcus aureus bacteremia (SAB) in children causes significant morbidity and mortality, but the epidemiology in children is not well characterized. To describe the epidemiology of SAB in children and adolescents younger than 18 years from Australia and New Zealand. A prospective cohort study, using data from the Australian New Zealand Cooperative on Outcomes in Staphylococcal Sepsis cohort for 1153 children with SAB from birth to less than 18 years in pediatric and general hospitals across Australia and New Zealand, collected between January 1, 2007, and December 31, 2012. Multivariate analysis was performed to identify risk factors for mortality. Incidence calculations were calculated separately for Australasian children younger than 15 years using postcode population denominator data from Australian and New Zealand census data. Demographic data, hospital length of stay, principal diagnosis, place of SAB onset (community or hospital), antibiotic susceptibility and principal antibiotic treatment, and 7- and 30-day mortality. Of the 1153 children with SAB, complete outcome data were available for 1073 children (93.1%); of these, males accounted for 684 episodes (63.7%) of SAB. The median age was 57 months (interquartile range, 2 months to 12 years). The annual incidence of SAB for Australian children was 8.3 per 100 000 population and was higher in indigenous children (incident rate ratio, 3.0 [95% CI, 2.4-3.7]), and the incidence for New Zealand children was 14.4 per 100 000 population and was higher in Māori children (incident rate ratio, 5.4 [95% CI, 4.1-7.0]). Community-onset SAB occurred in 761 cases (70.9%), and 142 cases (13.2%) of the infections were methicillin-resistant S aureus (MRSA). Bone or joint infection was most common with 348 cases (32.4%), and endocarditis was uncommon with 30 cases (2.8%). Seven- and 30-day mortality rates were 2.6% (n = 28) and 4.7% (n = 50), respectively. Risk factors for mortality were age younger than 1 year; Māori or Pacific ethnicity; endocarditis, pneumonia, or sepsis; and receiving no treatment or treatment with vancomycin. Mortality was 14.0% (6 of 43) in children with methicillin-susceptible S aureus (MSSA) treated with vancomycin compared with 2.6% (22 of 851) in children treated with alternative agents (OR, 6.1 [95% CI, 1.9-16.7]). MRSA infection was associated with increased length of stay but not mortality. In this large cohort study of the epidemiology of SAB in children, death was uncommon, but the incidence was higher for infants and varied by treatment, ethnicity, and clinical presentation. This study provides important information on the epidemiology of SAB in children and risk factors for mortality.

Paediatric Staphylococcus aureus bacteraemia: A single-centre retrospective cohort.

We aimed to describe the clinical epidemiology of Staphylococcus aureus bacteraemia (SAB) at a large, tertiary/quaternary children's hospital in Australia. We performed a retrospective chart review of SAB cases at the Children's Hospital at Westmead (CHW) over 5 years; 2006-2011. We compared frequency, clinical profile and outcomes of SAB with published data from CHW; 1994-1998. We compared health-care associated with community-associated (HCA-SAB and CA-SAB; defined epidemiologically) and methicillin-resistant with methicillin susceptible S. aureus (MRSA and MSSA). We identified 174 episodes of paediatric SAB with an average annual admission rate of 1.3/1000 which has not increased compared with a decade earlier. Half of the cases (49%) were CA-SAB; 18% were MRSA. The proportion of CA-MRSA bacteraemia (22%) has increased. The proportion of SAB associated with central venous access devices (CVADs; 40%) has increased. CA-SAB cases were more likely to present with a tissue focus of disease (e.g. osteo-articular, pneumonia) and often required surgery. HCA-SAB less frequently required surgery, a minority is MRSA, and vascular device intervention (removal, sterilisation) is common. Six cases (4%) of infective endocarditis (IE) were identified; three with a history of congenital heart disease, two with CVADs in situ. There were no deaths in this cohort. Over an 18-year period, the proportion of SAB due to CA-MRSA and SAB associated with CVADs has increased. Categorisation of SAB as HCA and CA reveals two broad phenotypes of paediatric SAB. SAB in children is infrequently associated with IE. The health-care burden of paediatric SAB is considerable', but mortality is low.

Enhanced surveillance of Staphylococcus aureus bacteraemia to identify targets for infection prevention

Surveillance of Staphylococcus aureus bacteraemia (SAB) in Scotland is limited to the number of infections per 100,000 acute occupied bed-days and susceptibility to meticillin. To demonstrate the value of enhanced SAB surveillance to identify targets for infection prevention. Prospective cohort study of all patients identified with SAB over a five-year period in a single health board in Scotland. All patients were reviewed at the bedside by a clinical microbiologist. In all, 556 SAB episodes were identified: 261 (46.6%) were hospital-acquired; 209 (37.9%) were healthcare-associated; 80 (14.4%) were community-acquired; and in six (1.1%) the origin of infection was not hospital-acquired, but could not be separated into healthcare-associated or community-acquired. These were classified as non-hospital-acquired. Meticillin-resistant S.aureus (MRSA) bacteraemia was associated with hospital-acquired and healthcare-associated infections. In addition, there was a significantly higher 30-day mortality associated with hospital-acquired (31.4%) and healthcare-associated (16.3%) infections compared to community-acquired SAB (8.7%). Vascular access devices were associated with hospital-acquired SAB and peripheral venous cannulas were the source for most of these (43.9%). Community-acquired infections were associated with intravenous drug misuse, respiratory tract infections and skeletal and joint infections. Skin and soft tissue infections were more widely seen in healthcare-associated infections. The data indicate that enhanced surveillance of SAB by origin of infection and source of bacteraemia has implications for infection prevention, empirical antibiotic therapy, and health improvement interventions.

Reduction in Staphylococcus aureus bacteraemia rates in patients receiving haemodialysis following alteration of skin antisepsis procedures

This study examined all cases of Staphylococcus aureus bacteraemia (SAB) in the haemodialysis cohort at the Royal Darwin Hospital, Australia over a seven-year period. Midway through this period, antisepsis for arteriovenous fistulae (AVF) and central venous catheters (CVC) changed from 0.5% chlorhexidine solution to 2% chlorhexidine solution. Rates of SAB episodes were calculated using registry data. Trends in SAB over time were analysed using an interrupted regression analysis. Following the change to 2% chlorhexidine, average SAB rates decreased by 68%, and it is estimated that 0.111 cases of SAB/patient-year were prevented. CVC-related SAB rates remained low throughout. These results support the use of 2% chlorhexidine in skin antisepsis for patients with AVF.

Performance of processes of care and outcomes in patients with Staphylococcus aureus bacteremia.

Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality in hospitalized adults. We aimed to identify current practice patterns in the management of SAB, and to evaluate their association with clinical outcomes. Retrospective cohort study. A 1558-bed tertiary care teaching hospital. Adult patients hospitalized between January 1, 2012 through April 30, 2013, who had at least 1 positive blood culture with S aureus. None Electronic medical records were reviewed and the processes of care in the management of SAB were identified. The main outcome was clinical failure, defined as a composite endpoint of in-hospital mortality and persistent bacteremia. Two hundred fifty episodes of SAB occurred in 241 patients, and 78 (32.4%) had clinical failure. Processes of care that impacted the risk of clinical failure included: timing of follow-up blood cultures (delays of >4 days had a relative risk [RR] of 6.6; 95% confidence interval [CI]: 2.1-20.5; P = 0.001), consultation with infectious diseases specialist within 6 days from diagnosis of SAB (RR: 0.3; 95% CI: 0.1-0.9; P = 0.03), and use of β-lactams in patients with methicillin-susceptible S aureus bacteremia (RR: 0.1; 95% CI: 0.04-0.5; P = 0.002). The processes of care identified in our study could serve as quality and patient safety indicators for the management of SAB.

Echocardiography has minimal yield and may not be warranted in Staphylococcus aureus bacteremia without clinical risk factors for endocarditis.

Current guidelines recommend performing echocardiography in all patients with Staphylococcus aureus bacteremia (SAB), but patients at very low risk of endocarditis may not benefit from this investigation. This study seeks to identify patients at very low risk of endocarditis. A retrospective single-center consecutive case series of patients with SAB was examined. Microbiological and echocardiographic data were used to identify patients with community onset, prolonged bacteremia, and intracardiac prosthetic devices. The diagnostic performance of these criteria for endocarditis as measured against transesophageal echocardiography (TEE) was calculated. 593 episodes of SAB were examined over a period of 6 years. 10 % were excluded from analysis due to death or discharge less than 48 h after the first positive blood culture or no admission to hospital, leaving 532 episodes for analysis. 64 % of the included episodes were investigated with echocardiography: 39 % with TEE and 26 % with transthoracic echocardiography (TTE) only. 16 % of the episodes investigated with echocardiography were demonstrated to have endocarditis. The rate of endocarditis was higher for episodes undergoing TEE (24 %) than TTE only (5 %). There were no instances of endocarditis amongst the 23 episodes investigated with TEE where none of the three risk factors were present. This group represented 57 % of the nosocomial (non-community-onset) episodes investigated with TEE. Patients with none of the three criteria examined in this study have a very low rate of endocarditis and may fall below the test threshold for echocardiography.

Association Between Vancomycin Minimum Inhibitory Concentration and Mortality Among Patients WithStaphylococcus aureusBloodstream Infections

Staphylococcus aureus bacteremia (SAB) is a worldwide problem. It is unclear whether higher-vancomycin minimum inhibitory concentration (MIC) is associated with mortality. This potential association has direct consequences for patients and public health. PubMed, Embase, the Cochrane Library, Evidence-based Medicine BMJ, and the American College of Physicians Journal Club were searched from inception through April 2014. Studies reporting mortality and vancomycin MIC in patients with SAB were included. Two authors performed the literature search and the study selection separately. Random-effects modeling was used for all analyses. All-cause mortality. Among 38 included studies that involved 8291 episodes of SAB, overall mortality was 26.1%. The estimated mortality was 26.8% among SAB episodes (n = 2740) in patients with high-vancomycin MIC (≥1.5 mg/L) compared with 25.8% mortality among SAB episodes (n = 5551) in patients with low-vancomycin MIC (<1.5 mg/L) (adjusted risk difference [RD], 1.6% [95% CI, -2.3% to 5.6%]; P = .43). For the highest-quality studies, the estimated mortality was 26.2% among SAB episodes (n = 2318) in patients with high-vancomycin MIC compared with 27.8% mortality among SAB episodes (n = 4168) in patients with low-vancomycin MIC (RD, 0.9% [95% CI, -2.9% to 4.6%]; P = .65). In studies that included only methicillin-resistant S aureus infections (n = 7232), the mortality among SAB episodes (n = 2384) in patients with high-vancomycin MIC was 27.6% compared with mortality of 27.4% among SAB episodes (n = 4848) in patients with low-vancomycin MIC (adjusted RD, 1.6% [95% CI, -2.3% to 5.5%]; P = .41). No significant differences in risk of death were observed in subgroups with high-vancomycin MIC vs low-vancomycin MIC values across different study designs, microbiological susceptibility assays, MIC cutoffs, clinical outcomes, duration of bacteremia, previous vancomycin exposure, and treatment with vancomycin. In this meta-analysis of SAB episodes, there were no statistically significant differences in the risk of death when comparing patients with S aureus exhibiting high-vancomycin MIC (≥1.5 mg/L) to those with low-vancomycin MIC (<1.5 mg/L), although the findings cannot definitely exclude an increased mortality risk. These findings should be considered when interpreting vancomycin susceptibility and in determining whether alternative antistaphylococcal agents are necessary for patients with SAB with elevated but susceptible vancomycin MIC values.

Impact of infectious diseases consultation on the management of Staphylococcus aureus bacteraemia in children

ObjectivesInfectious diseases consultation (IDC) in adults with Staphylococcus aureus bacteraemia (SAB) has been shown to improve management and outcome. The aim of this study was to evaluate the impact of...

Staphylococcus aureus bacteraemia in a UK tertiary referral centre: a 'transoesophageal echocardiogram for all' policy

Infective endocarditis (IE) is a feared complication in up to 38% of cases of Staphylococcus aureus bacteraemia (SAB). BSAC guidelines recommend echocardiography in all cases of SAB. The aim of this study was to determine the incidence of IE in SAB using transoesophageal echocardiography (TOE) as the first step in diagnostic imaging. This study also sought to identify clinical predictors that could improve stratification of those with and without IE. A guideline was implemented that any SAB resulted in the microbiology department (i) recommending that the patient be referred for TOE and (ii) notifying the echocardiography department, resulting in streamlined listing of the patient for TOE. All cases of SAB were then assessed prospectively at University Hospitals Birmingham NHS Foundation Trust between September 2011 and October 2012. Previously identified risk factors for complicated S. aureus bacteraemia were recorded. There were 98 SAB episodes in total. TOE was performed in 58 (59%) with a further 22 episodes imaged by transthoracic echocardiography alone. IE was diagnosed overall in 13 (16%) cases investigated with echocardiography. No risk factor for IE other than presence of a cardiac device was detected in this group (P = 0.013). The rate of IE found in SAB is high when TOE is performed first line. There are no clear risk factors to improve yield or the type of echocardiography to be performed. Echocardiography should be performed in all cases and TOE should be considered where it is expected to influence management, as long as local resources allow.

732Predictors of Cardiac Implantable Electronic Device Infection in Patients with Staphylococcus Aureus Bacteremia

Background Staphylococcus aureus bacteremia (SAB) is commonly associated with cardiac implantable electronic device infection (CIED-I). This usually requires explantation of the device. In cases of SAB in the presence of CIED that is not obviously infected (after examination of the pocket and transesophageal echocardiogram), decision about device removal is less clear. Predicting CIED-I in those cases would be helpful. Methods: This case-control study included all adults admitted to the University of Kansas Medical Center with SAB in the presence of a CIED between 1/1/2007 and 12/31/2012, using ICD 9 codes, CIED registry, and microbiology database. Cases had device infection evidenced by pocket infection or CIED related endocarditis; controls did not, over a 12 weeks follow up period. Clinical predictors of CIED-I were evaluated using logistic regression. Mortality was evaluated at 30 and 365 days. Results: We identified 64 patients with CIED who had 70 separate episodes of SAB during the study period. Of all 70 episodes of SAB, 74.3% were in males, 74.3% were in white, and mean age was 65.3 years. MRSA accounted for 48.6% of SAB. There were 31 episodes involving the device (44.3%, cases) and 39 SAB without CIED-I (55.7%, controls). On univariate analysis, factors associated with increased risk of device infection included fever (Odds ratio [OR] 5.65, 95% confidence interval [CI] [1.45-22.04], pvalue 0.011), persistent bacteremia at 72h (OR 2.89, CI [0.978.60], p-value 0.052), and tachycardia (OR 2.41, CI [0.827.10], p-value 0.098). Factors associated with decreased risk of device infection included end stage renal disease (ESRD) (OR 0.24, CI [0.07 0.81], p-value 0.029) and immunosuppression in the past 3 months (OR 0.23, CI [0.051.16], p-value 0.096). On multivariate analysis only fever remained significantly associated with device infection (OR 6.58, CI [1.20-36.04]). Mortality at 30 and 365 days was not significantly different between cases and controls. Conclusion: Fever, tachycardia and persistent bacteremia were associated with increased risk of CIED-I among patient with SAB, while ESRD and immunosuppression were protective on univariate analysis. Only fever remained significantly associated with CIED infection on multivariate analysis.  Retrospective review of all patients with SAB who had CIED at the same time between 1/1/2007 and 12/31/2012

Peripheral intravenous catheter‐associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services

To determine the incidence, risk factors for and outcomes of Staphylococcus aureus bacteraemia (SAB) associated with peripheral intravenous catheters (PIVCs). A review of prospectively collected data from two tertiary health services on all health care-associated SAB episodes occurring in adults aged >172013s from January 2007to July 2012. Numbers of health care-associated SAB episodes; device type, location of insertion, device dwell time and outcome at 7and 30days for all SAB episodes associated with use of a PIVC; rates of SAB per 10000occupied bed-days (OBDs). Overall, 137of 583health care-associated-SAB episodes (23.5%) were deemed to be PIVC associated, with an incidence of 0.26/10000OBD. The mean dwell time for PIVCs was 3.5days (range, 0.25-9days) and 45.2% of SABs occurred in PIVCs with a dwell time ≥4days. Of the PIVC-associated SAB episodes, 39.6% involved PIVCs inserted in the ED, 39.6% involved PIVCs inserted on wards and 20.8% involved PIVCs inserted by the ambulance service. Of the PIVC-associated SABs occurring within 4days of insertion, 61% were inserted by ED staff or the ambulance service. PIVC-associated SAB were associated with a 30-day all-cause mortality rate of 26.5%. PIVC-associated SAB is an under-recognised complication. The high incidences of SAB associated with PIVCs inserted in emergency locations and with prolonged dwell times support recommendations in clinical guidelines for routine removal of PIVCs.

Telephone Consultation Cannot Replace Bedside Infectious Disease Consultation in the Management of Staphylococcus aureus Bacteremia

Infectious disease specialist (IDS) consultation improves the outcome of Staphylococcus aureus bacteremia (SAB). Although telephone consultations constitute a substantial part of IDS consultations, their impact on treatment outcome lacks evaluation. We retrospectively followed 342 SAB episodes with 90-day follow-up, excluding 5 methicillin-resistant S. aureus SAB cases. Patients were grouped according to bedside, telephone, or no IDS consultation within the first week. Patients with fatal outcome within 3 days after onset of SAB were excluded to allow for the possibility of death occurring before IDS consultation. Seventy-two percent of patients received bedside, 18% telephone, and 10% no IDS consultation. Patients with bedside consultation were less often treated in an intensive care unit during the first 3 days compared to those with telephone consultation (odds ratio [OR], 0.53; 95% confidence interval [CI], .29-.97; P = .037; 21% vs 34%), with no other initial differences between these groups. Patients with bedside consultation more often had deep infection foci localized as compared to patients with telephone consultation (OR, 3.11; 95% CI, 1.74-5.57; P < .0001; 78% vs 53%). Patients with bedside consultation had lower mortality than patients with telephone consultation at 7 days (OR, 0.09; 95% CI, .02-.49; P = .001; 1% vs 8%), at 28 days (OR, 0.27; 95% CI, .11-.65; P = .002; 5% vs 16%) and at 90 days (OR, 0.25; 95% CI, .13-.51; P < .0001; 9% vs 29%). Considering all prognostic markers, 90-day mortality for telephone-consultation patients was higher (OR, 2.31; CI, 95% 1.22-4.38; P = .01) as compared to bedside consultation. Telephone IDS consultation is inferior to bedside IDS consultation.