Bloodstream Infections in Community Hospitals in the 21st Century: A Multicenter Cohort Study

Abstract

BackgroundWhile the majority of healthcare in the US is provided in community hospitals, the epidemiology and treatment of bloodstream infections in this setting is unknown.Methods and FindingsWe undertook this multicenter, retrospective cohort study to 1) describe the epidemiology of bloodstream infections (BSI) in a network of community hospitals and 2) determine risk factors for inappropriate therapy for bloodstream infections in community hospitals. 1,470 patients were identified as having a BSI in 9 community hospitals in the southeastern US from 2003 through 2006. The majority of BSIs were community-onset, healthcare associated (n = 823, 56%); 432 (29%) patients had community-acquired BSI, and 215 (15%) had hospital-onset, healthcare-associated BSI. BSIs due to multidrug-resistant pathogens occurred in 340 patients (23%). Overall, the three most common pathogens were S. aureus (n = 428, 28%), E. coli (n = 359, 24%), coagulase-negative Staphylococci (n = 148, 10%), though type of infecting organism varied by location of acquisition (e.g., community-acquired). Inappropriate empiric antimicrobial therapy was given to 542 (38%) patients. Proportions of inappropriate therapy varied by hospital (median = 33%, range 21–71%). Multivariate logistic regression identified the following factors independently associated with failure to receive appropriate empiric antimicrobial therapy: hospital where the patient received care (p<0.001), assistance with ≥3 ADLs (p = 0.005), Charlson score (p = 0.05), community-onset, healthcare-associated infection (p = 0.01), and hospital-onset, healthcare-associated infection (p = 0.02). Important interaction was observed between Charlson score and location of acquisition.ConclusionsOur large, multicenter study provides the most complete picture of BSIs in community hospitals in the US to date. The epidemiology of BSIs in community hospitals has changed: community-onset, healthcare-associated BSI is most common, S. aureus is the most common cause, and 1 of 3 patients with a BSI receives inappropriate empiric antimicrobial therapy. Our data suggest that appropriateness of empiric antimicrobial therapy is an important and needed performance metric for physicians and hospital stewardship programs in community hospitals.

Effects of a bundled Antimicrobial Stewardship Program on mortality: a cohort study

“…The 10% absolute risk reduction between groups can be considered as an important clinical effect. Previous studies 14,16 used regression techniques or different periods to assess the effects of ASP implementation, which is different from our study design; we compared different ASP strategies. Nonetheless, we conducted a retrospective cohort study and future prospective investigations -randomized controlled trials -would be important to answer whether different types of ASP strategies result in different outcomes.…”

“…Previously, a multicenter (9 hospitals) cohort study 16 showed that 206 (38%) out of 542 patients received inappropriate use of ADT. Such rate of inadequate ADT reassures why bundled strategy may have performed so many interventions to optimize antibiotics use.…”

Fast detection of volatile organic compounds from Staphylococcal blood cultures by CDI-MS

“…Recently, CNS was recognized as etiologic agents of a wide variety of infections and was found to be the most frequent organisms isolated from blood cultures. 4,5 Staphylococcus aureus (S. aureus), a major human pathogen, and resistant strains, especially meticillin-resistant S. aureus (MRSA), play important roles in nosocomial infection. Rapid detection of S. aureus and CNS in humans is a serious challenge in clinical research.…”

Evaluation of real-time PCR and pyrosequencing for screening incubating blood culture bottles from adults with suspected bloodstream infection

“…Hospital-acquired BSI is the third most common cause of hospital mortality in the US [1, 2] while community-onset BSI is comparable to acute myocardial infarction, stroke and major trauma in burden of illness [3, 4]. Anderson et al looked at BSI in community level hospitals in a multicenter cohort study and concluded that 1 in 3 patients with a culture confirmed BSI receives inappropriate empiric therapy [5] and in a prospective cohort study, Retamar et al found that inappropriate empiric therapy is associated with worse outcomes [6]. Therefore, providing more rapid test results for ruling in or ruling out BSI could reduce the amount of delayed treatment while also promoting antimicrobial stewardship by decreasing the use of inappropriate, ineffective or unnecessary empiric antimicrobial therapy.…”