Reemergence of Gram-negative Health Care–Associated Bloodstream Infections

Albrecht, Svenja; Fishman, Neil O.; Kitchen, Jennifer; Nachamkin, Irving; Bilker, Warren B.; Hoegg, Cindy; Samel, Carol; Barbagallo, S; Arentzen, Judy; Lautenbach, Ebbing

doi:10.1001/archinte.166.12.1289

Cited by 84 publications

(57 citation statements)

References 39 publications

(43 reference statements)

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“…Therefore, changes in our demographics do not appear to be the primary driver of this pathogenic shift. Similar trends in rates of fungal infection have been demonstrated elsewhere, although the most common Candida species differs by institution [13,[15][16][17][18]. One study found blood transfusion to be an independent risk factor for non-Candida albicans fungemia [19].…”

Section: Discussionsupporting

confidence: 67%

“…Albrecht et al reported a similar increase in gram-negative BSI, which was correlated with greater hospital-wide utilization of levofloxacin. However, our fluoroquinolone utilization remained stable over the study period [13]. Further study will be required to evaluate what impact, if any, shifting trends in antimicrobial utilization have on the spectrum of BSI pathogens in our institution.…”

Section: Discussionmentioning

confidence: 87%

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Temporal Trends in Blood Stream Infection Isolates from Surgical Patients

Guidry

Rosenberger

Petroze

et al. 2015

Surgical Infections

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Background: Blood stream infections (BSIs) are a common source of morbidity and death in hospitalized patients. We hypothesized that the proportions of bacteremia from gram-positive and fungal pathogens have decreased over time, whereas rates of gram-negative bacteremia have increased as a result of better central venous catheter management. Methods: All U.S. Centers for Disease Control and Prevention-defined BSIs in patients treated on the general surgery and trauma services at our institution between January 1, 1998, and December 31, 2009 were identified prospectively. These cases were analyzed on a yearly basis to compare rates of various infections over time. The Cochran-Armitage test for trend was used to evaluate categorical data, whereas the Jonckheere-Terpstra test for ordered values was used to analyze continuous data. Results: A total of 1,040 patients had 1,441 episodes of BSI caused by 1,632 strains of bacteria or fungi. There was no difference over time in the proportion of BSI among overall infections. Rates of BSI for gramnegative and fungal pathogens increased over time (p = 0.03 and < 0.0001, respectively), whereas rates of grampositive BSI decreased (p < 0.0001). Positive changes in anaerobic BSI approached statistical significance. Conclusion: Although our hypothesis was only partly true, over the last 12 y, our institution clearly has witnessed a shift in the types of organisms causing BSIs. There was a decrease in the rates of BSI caused by gram-positive pathogens with an associated increase in the rates of BSI of infections by fungal and gramnegative pathogens. Interventions to reduce institutional rates of BSI should include targeted therapies based on historical institutional trends.

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Section: Discussionsupporting

confidence: 67%

Section: Discussionmentioning

confidence: 87%

Temporal Trends in Blood Stream Infection Isolates from Surgical Patients

Guidry

Rosenberger

Petroze

et al. 2015

Surgical Infections

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“…Recently, the reemergence of Gram-negative organisms as a cause of primary BSIs has also been reported (1). In the United States, Escherichia coli is the fifth most common cause of nosocomial BSIs and is the first most common cause among Gram-negative organisms, and BSIs caused by E. coli are reported to be associated with a crude mortality rate of 22% (34); in Spain, it is the second most common cause of nosocomial BSIs (23).…”

mentioning

confidence: 99%

Risk Factors and Prognosis of Nosocomial Bloodstream Infections Caused by Extended-Spectrum-β-Lactamase-Producing Escherichia coli

et al. 2010

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Extended-spectrum-␤-lactamase (ESBL)-producing Escherichia coli (ESBLEC) is an increasing cause of community and nosocomial infections worldwide. However, there is scarce clinical information about nosocomial bloodstream infections (BSIs)caused by these pathogens. We performed a study to investigate the risk factors for and prognosis of nosocomial BSIs due to ESBLEC in 13 Spanish hospitals. Risk factors were assessed by using a case-control-control study; 96 cases (2 to 16% of all nosocomial BSIs due to E. coli in the participating centers) were included; the most frequent ESBL was CTX-M-14 (48% of the isolates). We found CTX-M-15 in 10% of the isolates, which means that this enzyme is emerging as a cause of invasive infections in Spain. By repetitive extragenic palindromic sequence-PCR, most isolates were found to be clonally unrelated. By multivariate analysis, the risk factors for nosocomial BSIs due to ESBLEC were found to be organ transplant (odds ratio [OR] ‫؍‬ 4.8; 95% confidence interval [CI] ‫؍‬ 1.4 to 15.7), the previous use of oxyimino-␤-lactams (OR ‫؍‬ 6.0; 95% CI ‫؍‬ 3.0 to 11.8), and unknown BSI source (protective; OR ‫؍‬ 0.4; 95% CI ‫؍‬ 0.2 to 0.9), and duration of hospital stay (OR ‫؍‬ 1.02; 95% CI ‫؍‬ 1.00 to 1.03). The variables independently associated with mortality were a Pitt score of >1 (OR ‫؍‬ 3.9; 95% CI ‫؍‬ 1.2 to 12.9), a high-risk source (OR ‫؍‬ 5.5; 95% CI ‫؍‬ 1.4 to 21.9), and resistance to more than three antibiotics, apart from penicillins and cephalosporins (OR ‫؍‬ 6.5; 95% CI ‫؍‬ 1.4 to 30.0). Inappropriate empirical therapy was not associated with mortality. We conclude that ESBLEC is an important cause of nosocomial BSIs. The previous use of oxyimino-␤-lactams was the only modifiable risk factor found. Resistance to drugs other than penicillins and cephalosporins was associated with increased mortality.Gram-negative organisms are an important cause of nosocomial bloodstream infections (BSIs) (33), particularly when the source of the BSI is the urinary, respiratory, or gastrointestinal tract. Recently, the reemergence of Gram-negative organisms as a cause of primary BSIs has also been reported (1). In the United States, Escherichia coli is the fifth most common cause of nosocomial BSIs and is the first most common cause among Gram-negative organisms, and BSIs caused by E. coli are reported to be associated with a crude mortality rate of 22% (34); in Spain, it is the second most common cause of nosocomial BSIs (23).In recent years, extended-spectrum ß-lactamases (ESBLs), particularly those of the CTX-M family, have spread worldwide among E. coli strains inside and outside hospitals (20,26); consequently, the prevalence of BSIs caused by ESBL-producing E. coli has significantly increased (24, 28). ESBLs confer resistance to penicillins and cephalosporins and are frequently associated with resistance to fluoroquinolones, aminoglycosides, and trimethoprim-sulfamethoxazole (18); thus, ESBLproducing microorganisms are frequently truly multidrug resistant. Both antibiotic resistance a...

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“…Therefore, our results are not necessarily applicable to other settings and populations. However, the bloodstream isolates we encountered are representative of those commonly reported in Italian hospitals and in other parts of the world as well (52,53). Almost half (47.9%) of the microorganisms responsible for our patients' BSIs were Gram-negative bacilli, many of which were multidrug-resistant (data not shown).…”

Section: Discussionmentioning

confidence: 66%

Performance of Two Resin-Containing Blood Culture Media in Detection of Bloodstream Infections and in Direct Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF MS) Broth Assays for Isolate Identification: Clinical Comparison of the BacT/Alert Plus and Bactec Plus Systems

et al. 2014

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We compared the clinical performances of the BacT/Alert Plus (bioMérieux) and Bactec Plus (Becton Dickinson) aerobic and anaerobic blood culture (BC) media with adsorbent polymeric beads. Patients >16 years old with suspected bloodstream infections (BSIs) were enrolled in intensive care units and infectious disease wards. A single 40-ml blood sample was collected from each and used to inoculate (10 ml/bottle) one set of BacT/Alert Plus cultures and one set of Bactec Plus cultures, each set consisting of one aerobic and one anaerobic bottle. Cultures were incubated <5 days in the BacT/Alert 3D and Bactec FX instruments, respectively. A total of 128 unique BSI episodes were identified based on the recovery of clinically significant growth in 212 aerobic cultures (106 BacT/Alert and 106 Bactec) and 151 anaerobic cultures (82 BacT/Alert and 69 Bactec). The BacT/Alert aerobic medium had higher recovery rates for Gram-positive cocci (P ‫؍‬ 0.024), whereas the Bactec aerobic medium was superior for recovery of Gram-negative bacilli (P ‫؍‬ 0.006). BacT/Alert anaerobic medium recovery rates exceeded those of the Bactec anaerobic medium for total organisms (P ‫؍‬ 0.003), Gram-positive cocci (P ‫؍‬ 0.013), and Escherichia coli (P ‫؍‬ 0.030). In terms of capacity for diagnosing the 128 septic episodes, the BacT/Alert and Bactec sets were comparable, although the former sets diagnosed more BSIs caused by Gram-positive cocci (P ‫؍‬ 0.008). They also allowed earlier identification of coagulase-negative staphylococcal growth (mean, 2.8 h; P ‫؍‬ 0.003) and growth in samples from patients not on antimicrobial therapy that yielded positive results (mean, 1.3 h; P < 0.001). Similarly high percentages of microorganisms in BacT/Alert and Bactec cultures (93.8% and 93.3%, respectively) were identified by direct matrix-assisted laser desorption ionization-time of flight mass spectrometry assay of BC broths. The BacT/Alert Plus media line appears to be a reliable, timesaving tool for routine detection of BSIs in the population we studied, although further studies are needed to evaluate their performance in other settings.

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Reemergence of Gram-negative Health Care–Associated Bloodstream Infections

Cited by 84 publications

References 39 publications

Temporal Trends in Blood Stream Infection Isolates from Surgical Patients

Temporal Trends in Blood Stream Infection Isolates from Surgical Patients

Risk Factors and Prognosis of Nosocomial Bloodstream Infections Caused by Extended-Spectrum-β-Lactamase-Producing Escherichia coli

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