Healthcare-Associated Bloodstream Infection: A Distinct Entity?
Healthcare-Associated Bloodstream Infection: A Distinct Entity?
Objective: To gain a better understanding of the epidemiology, microbiology, and outcomes of early-onset, culture-positive, community-acquired, healthcare-associated, and hospital-acquired bloodstream infections.
Design: We analyzed a large U.S. database (Cardinal Health, MediQual, formerly MedisGroups) to identify patients with bacterial or fungal bloodstream isolates from 2002 to 2003.
Setting: The data set included administrative and clinical variables (physiologic, laboratory, culture, and other clinical) from 59 hospitals. Bloodstream infections were identified in those hospitals collecting clinical and culture data for at least the first 5 days of admission.
Patients: Patients with bloodstream infection within 2 days of admission were classified as having community-acquired bloodstream infection. Those with a prior hospitalization within 30 days, transfer from another facility, ongoing chemotherapy, or long-term hemodialysis were classified as having healthcare-associated bloodstream infection. Bloodstream infections that developed after day 2 of admission were classified as hospital-acquired bloodstream infection. A total of 6,697 patients were identified as having bloodstream infection.
Interventions: None.
Measurements and Main Results: Healthcare-associated bloodstream infection accounted for more than half (55.3%) of all bloodstream infections. Nearly two thirds (62.3%) of hospitalized patients with bloodstream infection suffered from either hospital-acquired bloodstream infection or healthcare-associated bloodstream infection and had higher morbidity and mortality rates than those with community-acquired bloodstream infection. Of all bloodstream infection pathogens, fungal organisms were associated with the highest crude mortality, longest length of stay in hospital, and greatest total charges. Of all bacterial bloodstream infections, methicillin-resistant Staphylococcus aureus was associated with the highest crude mortality rate (22.5%), the longest mean length of stay (11.1 ± 10.7 days), and the highest median total charges ($36,109). After we controlled for confounding factors, methicillin-resistant S. aureus was associated with the highest independent mortality risk (odds ratio 2.70; confidence interval 2.03-3.58). S. aureus was the most commonly encountered pathogen in all types of early-onset bacteremia.
Conclusions: Healthcare-associated bloodstream infection constitutes a distinct entity of bloodstream infection with its unique epidemiology, microbiology, and outcomes. Methicillin-resistant Staphylococcus aureus carries the highest relative mortality risk among all pathogens.
Bloodstream infections (BSIs) remain a leading cause of morbidity and mortality in the United States. Unadjusted mortality rates related to BSIs range from 30% to 40%, and prevention is a key focus. Crucial to improving outcomes for patients with BSIs is the administration of appropriate antibiotics in a timely manner. The prescription of anti-infectives that are not active against the culprit pathogen (e.g., inappropriate therapy) has been shown to be an independent predictor of mortality in multiple analyses. Central to efforts to design initially appropriate regimens is readily available and accurate epidemiologic information. With this type of data, clinicians can develop local treatment paradigms that both target prevalent organisms and acknowledge changing resistance patterns. Without such information, it may be difficult to enhance outcomes.
Infections are traditionally classified as either nosocomial or community acquired. However, dramatic changes in healthcare systems have shifted many healthcare services from hospitals to nursing homes, rehabilitation centers, physicians' offices, and other outpatient facilities. Although infections occurring in these healthcare-associated settings are traditionally classified as community-acquired, accumulating evidence suggests that healthcare-associated infections have a unique epidemiology, with the causative pathogens and related outcomes for these infections more closely resembling those seen with nosocomial infections. Some investigators have proposed a new class of healthcare-associated infection, distinct from both community-acquired and hospital-acquired infections. This new classification scheme reflects these changes in healthcare practice and provides a better evidence-based rubric for analysis.
We hypothesized that healthcare-associated BSIs (HCAB) would represent a distinct entity and share certain characteristics with traditional hospital-acquired BSIs (HAB). To examine this hypothesis, we explored a large U.S. database to characterize the epidemiology, microbiology, and outcomes of early-onset, culture-positive, community-acquired BSIs (CAB), HCAB, and HAB (defined in Table 1 ). We further evaluated the impact of different pathogens on clinical and economic outcomes in patients with BSI.
Objective: To gain a better understanding of the epidemiology, microbiology, and outcomes of early-onset, culture-positive, community-acquired, healthcare-associated, and hospital-acquired bloodstream infections.
Design: We analyzed a large U.S. database (Cardinal Health, MediQual, formerly MedisGroups) to identify patients with bacterial or fungal bloodstream isolates from 2002 to 2003.
Setting: The data set included administrative and clinical variables (physiologic, laboratory, culture, and other clinical) from 59 hospitals. Bloodstream infections were identified in those hospitals collecting clinical and culture data for at least the first 5 days of admission.
Patients: Patients with bloodstream infection within 2 days of admission were classified as having community-acquired bloodstream infection. Those with a prior hospitalization within 30 days, transfer from another facility, ongoing chemotherapy, or long-term hemodialysis were classified as having healthcare-associated bloodstream infection. Bloodstream infections that developed after day 2 of admission were classified as hospital-acquired bloodstream infection. A total of 6,697 patients were identified as having bloodstream infection.
Interventions: None.
Measurements and Main Results: Healthcare-associated bloodstream infection accounted for more than half (55.3%) of all bloodstream infections. Nearly two thirds (62.3%) of hospitalized patients with bloodstream infection suffered from either hospital-acquired bloodstream infection or healthcare-associated bloodstream infection and had higher morbidity and mortality rates than those with community-acquired bloodstream infection. Of all bloodstream infection pathogens, fungal organisms were associated with the highest crude mortality, longest length of stay in hospital, and greatest total charges. Of all bacterial bloodstream infections, methicillin-resistant Staphylococcus aureus was associated with the highest crude mortality rate (22.5%), the longest mean length of stay (11.1 ± 10.7 days), and the highest median total charges ($36,109). After we controlled for confounding factors, methicillin-resistant S. aureus was associated with the highest independent mortality risk (odds ratio 2.70; confidence interval 2.03-3.58). S. aureus was the most commonly encountered pathogen in all types of early-onset bacteremia.
Conclusions: Healthcare-associated bloodstream infection constitutes a distinct entity of bloodstream infection with its unique epidemiology, microbiology, and outcomes. Methicillin-resistant Staphylococcus aureus carries the highest relative mortality risk among all pathogens.
Bloodstream infections (BSIs) remain a leading cause of morbidity and mortality in the United States. Unadjusted mortality rates related to BSIs range from 30% to 40%, and prevention is a key focus. Crucial to improving outcomes for patients with BSIs is the administration of appropriate antibiotics in a timely manner. The prescription of anti-infectives that are not active against the culprit pathogen (e.g., inappropriate therapy) has been shown to be an independent predictor of mortality in multiple analyses. Central to efforts to design initially appropriate regimens is readily available and accurate epidemiologic information. With this type of data, clinicians can develop local treatment paradigms that both target prevalent organisms and acknowledge changing resistance patterns. Without such information, it may be difficult to enhance outcomes.
Infections are traditionally classified as either nosocomial or community acquired. However, dramatic changes in healthcare systems have shifted many healthcare services from hospitals to nursing homes, rehabilitation centers, physicians' offices, and other outpatient facilities. Although infections occurring in these healthcare-associated settings are traditionally classified as community-acquired, accumulating evidence suggests that healthcare-associated infections have a unique epidemiology, with the causative pathogens and related outcomes for these infections more closely resembling those seen with nosocomial infections. Some investigators have proposed a new class of healthcare-associated infection, distinct from both community-acquired and hospital-acquired infections. This new classification scheme reflects these changes in healthcare practice and provides a better evidence-based rubric for analysis.
We hypothesized that healthcare-associated BSIs (HCAB) would represent a distinct entity and share certain characteristics with traditional hospital-acquired BSIs (HAB). To examine this hypothesis, we explored a large U.S. database to characterize the epidemiology, microbiology, and outcomes of early-onset, culture-positive, community-acquired BSIs (CAB), HCAB, and HAB (defined in Table 1 ). We further evaluated the impact of different pathogens on clinical and economic outcomes in patients with BSI.
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