Development and Validation of a Clinical Prediction Rule for Bacteremia among Maintenance Hemodialysis Patients in Outpatient Settings

Abstract

BackgroundTo our knowledge, no reliable clinical prediction rule (CPR) for identifying bacteremia in hemodialysis (HD) patients has been established. The aim of this study was to develop a CPR for bacteremia in maintenance HD patients visiting the outpatient department.MethodsThis multicenter cohort study involved consecutive maintenance HD patients who visited the outpatient clinic or emergency room of seven Japanese institutions between August 2011 and July 2013. The outcome measure was bacteremia diagnosed based on the results of blood cultures. The candidate predictors for bacteremia were extracted through a literature review. A CPR for bacteremia was developed using a coefficient-based multivariable logistic regression scoring method, and calibration was performed. The test performance was then assessed for the CPR.ResultsOf 507 patients eligible for the study, we analyzed the 293 with a complete dataset for candidate predictors. Of these 293 patients, 48 (16.4%) were diagnosed with bacteremia. At the conclusion of the deviation process, body temperature ≥ 38.3°C, heart rate ≥ 125 /min, C-reactive protein ≥ 10 mg/dL, alkaline phosphatase >360 IU/L, and no prior antibiotics use within the past week were retained and scored. The CPR had a good fit for the model on calibration. The AUC of the CPR was 0.76, and for score CPR ≥ 2, the sensitivity and specificity were 89.6% and 51.4%, respectively.ConclusionsWe established a simple CPR for bacteremia in maintenance HD patients using routinely obtained clinical information in an outpatient setting. This model may facilitate more appropriate clinical decision making.

Early Detection of Bacteraemia Using Ten Clinical Variables with an Artificial Neural Network Approach

“…Testing alkaline phosphatase has several advantages, even if it is not usually considered a significant predictor of infection or bacteraemia. Several studies showed the elevation of alkaline phosphatase count in patients with bacteraemia [44,45]. Alkaline phosphatase levels can be determined relatively fast (usually in an hour).…”

External validation of the quick Sequential Organ Failure Assessment score for mortality and bacteraemia risk evaluation in Japanese patients undergoing haemodialysis: a retrospective multicentre cohort study

“…We also proposed a clinical prediction rule for bacteraemia among haemodialysis outpatients with suspicion of bacteraemia (BAC-HD) 13. The BAC-HD score takes into account body temperature, heart rate, C-reactive protein levels, alkaline phosphatase levels and use of antibiotics within the week leading up to the assessment.…”

“…The BAC-HD score takes into account body temperature, heart rate, C-reactive protein levels, alkaline phosphatase levels and use of antibiotics within the week leading up to the assessment. A BAC-HD score ≥2 was useful for predicting bacteraemia in haemodialysis patients (sensitivity, 89.6%; specificity, 51.4%; positive likelihood ratio, 1.8; negative likelihood ratio, 0.2; area under the curve (AUC), 0.76) 13…”

Incidental detection of Corynebacterium jeikeium endocarditis via regular blood examination in an afebrile hemodialysis patient

“…Therefore, physicians might not always suspect bacteremia even if patients have elevated CRP levels. Sasaki et al have reported the "use of the BAC-HD score," which is a clinical predictive score including CRP level for bacteremia in hemodialysis patients [8]. In this case, the patient had CRP level > 10 mg/dL, ALP level > 360 U/L, and no prior antibiotic use within 1 week; therefore, the patient's BAC-HD score was 3.…”