Bloodstream infections in critically ill patients: an expert statement

Abstract

Bloodstream infection (BSI) is defined by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary-that is, without identified origin. Community-acquired BSIs in immunocompetent adults usually involve drug-susceptible bacteria, while healthcare-associated BSIs are frequently due to multidrug-resistant (MDR) strains. Early adequate antimicrobial therapy is a key to improve patient outcomes, especially in those with criteria for sepsis or septic shock, and should be based on guidelines and direct examination of available samples. Local epidemiology, suspected source, immune status, previous antimicrobial exposure, and documented colonization with MDR bacteria must be considered for the choice of first-line antimicrobials in healthcare-associated and hospital-acquired BSIs. Early genotypic or phenotypic tests are now available for bacterial identification and early detection of resistance mechanisms and may help, though their clinical impact warrants further investigations. Initial antimicrobial dosing should take into account the pharmacokinetic alterations commonly observed in ICU patients, with a loading dose in case of sepsis or septic shock. Initial antimicrobial combination attempting to increase the antimicrobial spectrum should be discussed when MDR bacteria are suspected and/or in the most severely ill patients. Source identification and control should be performed as soon as the hemodynamic status is stabilized. De-escalation from a broad-spectrum to a narrow-spectrum antimicrobial may reduce antibiotic selection pressure without negative impact on mortality. The duration of therapy is usually 5-8 days though longer durations may be discussed depending on the underlying illness and the source of infection. This narrative review covers the epidemiology, diagnostic workflow and therapeutic aspects of BSI in ICU patients and proposed up-todate expert statements.

Treatment of Bloodstream Infections Due to Gram-Negative Bacteria with Difficult-to-Treat Resistance

“…Among the pathogens causing concern, Gram-negative bacteria (GNB) have raised the most attention, due to the rapid increase in their association with morbidity and mortality all over the world [ 1 ]. Bloodstream infections (BSI), present in 40% of cases of community-acquired and hospital-acquired sepsis and septic shock, are associated with poor outcomes, especially with delayed adequate antimicrobial therapy and source control [ 2 ]. GNB BSI isolates represent an usufeul surveillance target for the monitoring of resistance, as cultures from sterile sites avoid the problem of confounding colonizing agents.…”

“…The rising incidence of BSI due to GNB with DTR is a matter of serious concern, both in the community and in the hospital setting [ 2 , 9 ]. The aim of this review is to provide a comprehensive assessment of the currently available and emerging treatment options for BSI caused by GNB with DTR, namely extended-spectrum Beta-lactamase (ESBL)-producing Enterobacteriales ; carbapenem-resistant Enterobacteriales (CRE); DTR Pseudomonas aeruginosa ; and DTR Acinetobacter baumannii .…”

Quick BSI Score to Identify Bloodstream Infection at the Emergency Department

“…Incidence of bloodstream infection increased to 38.1 persons per 100000 per year in 2010, while mortality rate may be as high as 50% [3]. Early diagnosis and appropriate antimicrobial therapy are a key to improve patient outcomes [4], particularly among individuals displaying either septic shock or sepsis [5,6].…”

Antibiotic treatment duration for patients with bloodstream infection: a systematic review and meta-analysis

“…Bloodstream infection (BSI) is de ned by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary-that is, without identi ed origin [1]. Timely administration of the appropriate antibiotic treatment remains the cornerstone for favorable clinical outcome in patients with BSI [2][3][4].…”