Bloodstream infection (BSI) is a major cause of infectious disease morbidity and mortality worldwide. While a positive blood culture is mandatory for establishment of the presence of a BSI, there are ...a number of determinants that must be considered for establishment of this entity. Community-onset BSIs are those that occur in outpatients or are first identified <48 h after admission to hospital, and they may be subclassified further as health care associated, when they occur in patients with significant prior health care exposure, or community associated, in other cases. The most common causes of community-onset BSI include Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae. Antimicrobial-resistant organisms, including methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase/metallo-β-lactamase/carbapenemase-producing Enterobacteriaceae, have emerged as important etiologies of community-onset BSI.
Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality.
To ...describe the long-term survival and examine determinants of death among patients with prolonged ICU admission.
A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics.
During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14-20, 21-27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14-20, 21-27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214-1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model.
Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose of review
To review recently published evidence relevant to
Staphylococcus aureus
bacteremia (SAB).
Recent findings
Staphylococcus aureus
is the most common pathogen causing co-infections and ...superinfections in patients with COVID-19. Methicillin-resistant
Staphylococcus aureus
(MRSA) bacteremia ratios have sharply risen during the pandemic. SAB mortality is 18% at 1 month and 27% at 3 months but has gradually decreased over the last 30 years. Recurrences and reinfections are common (9%). Standardised items to define complicated SAB, and a new cut-off defining persisting bacteremia after 2 days with positive blood cultures have been proposed. Multiple antibiotic combinations have been trialled including vancomycin or daptomycin with β-lactams, fosfomycin, or clindamycin, without significant results. In the recently published guidelines, vancomycin remains the first line of treatment for MRSA bacteremia. For the management of methicillin-susceptible
Staphylococcus aureus
, cefazolin less frequently causes acute kidney injury than flucloxacillin, and when susceptibility is demonstrated, de-escalation to penicillin G is suggested.
Summary
Our review confirms that
Staphylococcus aureus
represents a special aetiology among all causes of bloodstream infections. Pending results of platform and larger trials, its distinct epidemiology and determinants mandate careful integration of clinical variables and best available evidence to optimize patient outcomes.
Abstract Purpose Although the biliary tract is a common source of invasive infections, the epidemiology of cholangitis- and cholecystitis-associated bloodstream infection (BSI) is not well defined. ...The objective of this study was to determine the incidence, clinical determinants, microbiology of biliary tract-associated BSI, and predicted adequacy of common empiric therapy regimens. Methods All biliary tract-associated BSI in Queensland during 2000–2019 were identified using state-wide data sources. Predicted adequacy of empiric antimicrobial therapy was determined according to microbiological susceptibility data. Results There were 3,698 episodes of biliary tract-associated BSI occurred in 3,433 patients of which 2,147 (58.1%) episodes were due to cholangitis and 1,551 (41.9%) cholecystitis, for age- and sex-standardized incidence rates of 2.7, and 2.0 per 100,000 population, respectively. An increasing incidence of biliary tract-associated BSI was observed over the study that was attributable to an increase in cholangitis cases. There was a significant increased risk for biliary tract-associated BSI observed with advancing age and male sex. Patients with cholangitis were older, more likely to have healthcare associated infection, and have more comorbidities most notably liver disease and malignancies as compared to patients with cholecystitis. The distribution of infecting pathogens was significantly different with polymicrobial aetiologies more commonly observed with cholangitis (18.4% vs. 10.5%; p < 0.001). The combination of ampicillin/gentamicin/metronidazole was predicted to have the overall highest adequacy (96.1%), whereas amoxicillin/clavulanate had the lowest (77.0%). Amoxicillin/clavulanate (75.2% vs. 79.4%, p:0.03) and ceftriaxone/metronidazole (83.4% vs. 89.6%; p < 0.001) showed significantly inferior predicted adequacy for cholangitis as compared to cholecystitis. Conclusions Bloodstream infections related to cholecystitis and cholangitis exhibit different epidemiology, microbiology, and requirements for empiric therapy.
Summary The medical community relies on clinical expertise and published guidelines to assist physicians with choices in empirical therapy for system-based infectious syndromes, such as ...community-acquired pneumonia and urinary-tract infections (UTIs). From the late 1990s, multidrug-resistant Enterobacteriaceae (mostly Escherichia coli ) that produce extended-spectrum β lactamases (ESBLs), such as the CTX-M enzymes, have emerged within the community setting as an important cause of UTIs. Recent reports have also described ESBL-producing E coli as a cause of bloodstream infections associated with these community-onset UTIs. The carbapenems are widely regarded as the drugs of choice for the treatment of severe infections caused by ESBL-producing Enterobacteriaceae, although comparative clinical trials are scarce. Thus, more rapid diagnostic testing of ESBL-producing bacteria and the possible modification of guidelines for community-onset bacteraemia associated with UTIs are required.
Older individuals (i.e. age ≥65 years) are at increased risk for development of infections including those due to antimicrobial-resistant bacteria, and transmission may occur between institutional ...and community settings.
This article reviews infections in older individuals with a specific focus on healthcare-related and antimicrobial resistant infections. A structured narrative review was performed to identify articles published in English since 2010. Themes included defining the scope of the problem, establishing characteristics of older individuals that impact the burden of resistant infections, and interventions aimed at minimizing their impact.
Older individuals suffer a high burden of illness related to antimicrobial resistant infections. Individuals with chronic illnesses, frailty, and residents of nursing homes are at highest risk. Clinical trials have shown that antimicrobial stewardship interventions may reduce antibiotic use in nursing homes without compromising safety. Antimicrobial resistant bacteria are prevalent among nursing home residents, and bundled infection prevention and control interventions can reduce their transmission. Transmission of antimicrobial resistant bacteria occurs among older adults across hospital and institutional settings, which may further spread to the community. The burden of infections in older adults is expected to increase in the coming years and represents a healthcare and research priority.
Background. Reports have suggested that the epidemiological profile of invasive Staphylococcus aureus infections is changing. We sought to describe the epidemiological profile of S. aureus bacteremia ...and to assess whether the incidence and severity of and the antimicrobial resistance rates associated with this bacteremia are increasing. Methods. Population-based surveillance for S. aureus bacteremias was conducted in the Calgary Health Region (population, 1.2 million) during 2000–2006. Results. The annual incidence of S. aureus bacteremia was 19.7 cases/100,000 population. Although rates of health care-associated and nosocomial methicillin-susceptible S. aureus (MSSA) bacteremia were similar throughout the study, rates of community-acquired MSSA bacteremia gradually decreased, and rates of methicillin-resistant S. aureus (MRSA) bacteremia dramatically increased. The clonal type predominantly isolated was CMRSA-2 (i.e., Canadian C MRSA-2), but CMRSA-10 (USA300) strains have been increasingly isolated, especially from community-onset infections, since 2004. Dialysis dependence, organ transplantation, HIV infection, cancer, and diabetes were the most important risk factors and were comparable for MSSA and MRSA bacteremias. The overall case-fatality rate was higher among individuals with MRSA (39%) than among those with MSSA (24%; P<.0001). The annual overall population mortality rate associated with S. aureus bacteremia did not significantly change during the study. Conclusions. Although the overall influence of S. aureus bacteremia has not significantly changed, MRSA has emerged as an important etiology in our region.
Fever, commonly defined by a temperature of ≥38.3°C (101°F), occurs in approximately one half of patients admitted to intensive care units. Fever may be attributed to both infectious and ...noninfectious causes, and its development in critically ill adult medical patients is associated with an increased risk for death. Although it is widespread and clinically accepted practice to therapeutically lower temperature in patients with hyperthermic syndromes, patients with marked hyperpyrexia, and selected populations such as those with neurologic impairment, it is controversial whether most medical patients with moderate degrees of fever should be treated with antipyretic or direct cooling therapies. Although treatment of fever may improve patient comfort and reduce metabolic demand, fever is a normal adaptive response to infection and its suppression is potentially harmful. Clinical trials specifically comparing fever management strategies in neurologically intact critically ill medical patients are needed.
Author Affiliation: (1) Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Level 3 Ned Hanlon Building, Butterfield Street, 4029, Brisbane, QLD, Australia (2) Queensland ...University of Technology (QUT), Brisbane, QLD, Australia (3) Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland (4) National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College of London, London, UK (a) Kevin.laupland@qut.edu.au Article History: Registration Date: 02/15/2021 Received Date: 02/01/2021 Accepted Date: 02/15/2021 Online Date: 02/27/2021 Byline:
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