Risk of Mortality with a Bloodstream Infection Is Higher in the Less Severely Ill at Admission

Kim, Peter W.; Perl, Trish M.; Keelaghan, Eithne F.; Langenberg, Patricia; Perencevich, Eli N.; Harris, Anthony D.; Song, Xiaoyan; Roghmann, Mary-Claire

doi:10.1164/rccm.200407-916oc

Cited by 36 publications

(32 citation statements)

References 19 publications

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“…Our data show that carbapenem resistance was associated with significantly increased 30-day mortality rates but that the relationship depended on the degree of severity of the underlying disease (19,30). In fact, our study describes an interaction between carbapenem resistance and underlying conditions, with an impact on mortality that is significantly higher for less severely ill patients.…”

Section: Discussionmentioning

confidence: 53%

Prospective Multicenter Study of the Impact of Carbapenem Resistance on Mortality in Pseudomonas aeruginosa Bloodstream Infections

Peña

Suárez

Gozalo

et al. 2012

Antimicrob Agents Chemother

133

112

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The impact of antimicrobial resistance on clinical outcomes is the subject of ongoing investigations, although uncertainty remains about its contribution to mortality. We investigated the impact of carbapenem resistance on mortality in Pseudomonas aeruginosa bacteremia in a prospective multicenter (10 teaching hospitals) observational study of patients with monomicrobial bacteremia followed up for 30 days after the onset of bacteremia. The adjusted influence of carbapenem resistance on mortality was studied by using Cox regression analysis. Of 632 episodes, 487 (77%) were caused by carbapenem-susceptible P. aeruginosa (CSPA) isolates, and 145 (23%) were caused by carbapenem-resistant P. aeruginosa (CRPA) isolates. The median incidence density of nosocomial CRPA bacteremia was 2.3 episodes per 100,000 patient-days (95% confidence interval [CI], 1.9 to 2.8). The regression demonstrated a time-dependent effect of carbapenem resistance on mortality as well as a significant interaction with the Charlson index: the deleterious effect of carbapenem resistance on mortality decreased with higher Charlson index scores. The impact of resistance on mortality was statistically significant only from the fifth day after the onset of the bacteremia, reaching its peak values at day 30 (adjusted hazard ratio for a Charlson score of 0 at day 30, 9.9 [95% CI, 3.3 to 29.4]; adjusted hazard ratio for a Charlson score of 5 at day 30, 2.6 [95% CI, 0.8 to 8]). This study clarifies the relationship between carbapenem resistance and mortality in patients with P. aeruginosa bacteremia. Although resistance was associated with a higher risk of mortality, the study suggested that this deleterious effect may not be as great during the first days of the bacteremia or in the presence of comorbidities. Pseudomonas aeruginosa is a leading cause of nosocomial infections, which are often severe (26, 43) and difficult to treat because of their limited susceptibility to antimicrobial agents (35) and the frequent emergence of antibiotic-resistant mutants during therapy (8). Factors related to the host, the organism, and the treatment may increase mortality. With regard to the host, the severity of the underlying disease may be synergistic with infection due to resistant organisms; concomitantly, increased virulence could explain the adverse impact of resistant pathogens on clinical outcomes, although this association has not been demonstrated to date. In addition, factors such as decreased antibiotic effectiveness or a delay in the initiation of therapy may contribute to adverse outcomes in patients infected by resistant pathogens (17).The problem of antibiotic-resistant organisms is increasing (18), and the impact of antimicrobial resistance on clinical outcomes is the subject of ongoing investigations (2, 5, 9, 15, 25-28, 32, 33, 40, 41, 43), although its contribution to mortality remains uncertain. Measurements of its impact on patients are, by necessity, derived essentially from observational studies, and therefore, an adequate control of confound...

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Section: Discussionmentioning

confidence: 53%

Prospective Multicenter Study of the Impact of Carbapenem Resistance on Mortality in Pseudomonas aeruginosa Bloodstream Infections

Peña

Suárez

Gozalo

et al. 2012

Antimicrob Agents Chemother

133

112

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“…Clearly, microbiologically adequate antibiotic therapy for severe infections decreases the excess mortality and failure rate. The detrimental effects of inadequate antibiotic therapy seem to become weaker in nonsevere infections and in infections in the most severely ill patients with short life expectancies [38]. b-Lactam and aminoglycoside combination therapy does not seem to improve clinical outcomes in sepsis caused by gram-negative bacteria.…”

Section: Discussionmentioning

confidence: 99%

Healthcare Epidemiology: Does Antibiotic Selection Impact Patient Outcome?

Harbarth¹,

Nobre²,

Pittet³

2007

CLIN INFECT DIS

116

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Inadequate antibiotic therapy, generally defined as microbiologically ineffective anti-infective therapy against the causative pathogen, can influence patient outcome. However, the detrimental effects of inadequate antibiotic therapy seem to become weaker in the most severely ill patients with short life expectancies. In addition to severity of illness, other methodological issues should be carefully examined in studies assessing the excess mortality due to inadequate therapy. To adjust for confounding as much as possible in order to obtain an unbiased estimate of the magnitude of the effect of inadequate therapy is a key methodological challenge for future research. With regard to the choice of antibiotic agents, beta-lactam and aminoglycoside combination therapy does not seem to improve clinical outcome in most cases of sepsis caused by gram-negative bacteria, including Pseudomonas aeruginosa bacteremia. A potential benefit of combination therapy in the treatment of severe pneumococcal sepsis has been suggested in several observational studies, but recently published data have disputed this hypothesis. Finally, better risk scores and laboratory tools are urgently needed to improve the adequacy of empirical antibiotic therapy and patient outcomes.

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“…However, this is not a systematic observation. Kim et al [4] recently reported that ICU bacteremic patients with an APACHE II score on admission less than 20 had a significantly increased risk for mortality compared to those with APACHE II score above 20, indicating that the impact of bacteremia on mortality is higher in the less severely ill patients. According to the results of the present study, the ability of both APACHE II and SOFA scores on admission, to discriminate survivors and non-survivors bacteremic ICU patients is insufficient.…”

Section: Discussionmentioning

confidence: 99%

“…Patients hospitalized in intensive care units (ICUs) carry the highest rates of bacteraemias, with a reported incidence ranging from 2.7 to 10 episodes per 100 ICU admissions [1][2][3][4], which is up to 32 times higher than in other hospital departments [3]. The clinical significance of bacteremia is of great interest, because the fatality rate associated with these infections approximates 56%, ranging from 32 to 82% [1,2].…”

Section: Introductionmentioning

confidence: 99%

Application of the Sequential Organ Failure Assessment (SOFA) Score to Bacteremic ICU Patients

et al. 2007

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Risk of Mortality with a Bloodstream Infection Is Higher in the Less Severely Ill at Admission

Cited by 36 publications

References 19 publications

Prospective Multicenter Study of the Impact of Carbapenem Resistance on Mortality in Pseudomonas aeruginosa Bloodstream Infections

Prospective Multicenter Study of the Impact of Carbapenem Resistance on Mortality in Pseudomonas aeruginosa Bloodstream Infections

Healthcare Epidemiology: Does Antibiotic Selection Impact Patient Outcome?

Application of the Sequential Organ Failure Assessment (SOFA) Score to Bacteremic ICU Patients

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