Bloodstream infections in community hospitals in the 21st century: a multicenter cohort study.

Abstract

BACKGROUND: While the majority of healthcare in the US is provided in community hospitals, the epidemiology and treatment of bloodstream infections in this setting is unknown. METHODS AND FINDINGS: We undertook this multicenter, retrospective cohort study to 1) describe the epidemiology of bloodstream infections (BSI) in a network of community hospitals and 2) determine risk factors for inappropriate therapy for bloodstream infections in community hospitals. 1,470 patients were identified as having a BSI in 9 community hospitals in the southeastern US from 2003 through 2006. The majority of BSIs were community-onset, healthcare associated (n = 823, 56%); 432 (29%) patients had community-acquired BSI, and 215 (15%) had hospital-onset, healthcare-associated BSI. BSIs due to multidrug-resistant pathogens occurred in 340 patients (23%). Overall, the three most common pathogens were S. aureus (n = 428, 28%), E. coli (n = 359, 24%), coagulase-negative Staphylococci (n = 148, 10%), though type of infecting organism varied by location of acquisition (e.g., community-acquired). Inappropriate empiric antimicrobial therapy was given to 542 (38%) patients. Proportions of inappropriate therapy varied by hospital (median = 33%, range 21-71%). Multivariate logistic regression identified the following factors independently associated with failure to receive appropriate empiric antimicrobial therapy: hospital where the patient received care (p<0.001), assistance with ≥3 ADLs (p = 0.005), Charlson score (p = 0.05), community-onset, healthcare-associated infection (p = 0.01), and hospital-onset, healthcare-associated infection (p = 0.02). Important interaction was observed between Charlson score and location of acquisition. CONCLUSIONS: Our large, multicenter study provides the most complete picture of BSIs in community hospitals in the US to date. The epidemiology of BSIs in community hospitals has changed: community-onset, healthcare-associated BSI is most common, S. aureus is the most common cause, and 1 of 3 patients with a BSI receives inappropriate empiric antimicrobial therapy. Our data suggest that appropriateness of empiric antimicrobial therapy is an important and needed performance metric for physicians and hospital stewardship programs in community hospitals.

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Citation

Published Version (Please cite this version)

10.1371/journal.pone.0091713

Publication Info

Anderson, Deverick J, Rebekah W Moehring, Richard Sloane, Kenneth E Schmader, David J Weber, Vance G Fowler, Emily Smathers, Daniel J Sexton, et al. (2014). Bloodstream infections in community hospitals in the 21st century: a multicenter cohort study. PLoS One, 9(3). p. e91713. 10.1371/journal.pone.0091713 Retrieved from https://hdl.handle.net/10161/13315.

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Scholars@Duke

Anderson

Deverick John Anderson

Professor of Medicine

Hospital epidemiology, infection control, antibiotic stewardship, multidrug-resistant organisms, device-related infections, surgical site infections, catheter-associated bloodstream infections, cost of infections, infections in community hospitals

Moehring

Rebekah Moehring

Associate Professor of Medicine
Schmader

Kenneth Edwin Schmader

Professor of Medicine

Dr. Schmader’s areas of research include herpes zoster, infections, and vaccines in older adults.  He conducts translational, clinical trials and observational studies of zoster, influenza, and other infections funded by grants from the National Institute on Aging (NIA), National Institute of Allergy and Infectious Diseases (NIAID), Centers for Disease Control (CDC), VA Office of Research and Development, and Industry sources.  He has played a pivotal role in the development of zoster vaccines in older adults.  Dr. Schmader also performs research in medications and older adults, focusing on pharmacoepidemiology, optimal drug use and reduction of adverse drug reactions.

He is the Director of the NIA-funded P30 Duke Pepper Older Americans Independence Center and Co-PI of the NIAID funded Vaccine and Therapeutics Effectiveness Unit (VTEU) at Duke.  He serves on the Working Groups for the Herpes Zoster, Influenza, and General Adult Immunization Guidelines for the US Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) and is the American Geriatrics Society liaison to the ACIP.

Fowler

Vance Garrison Fowler

Florence McAlister Distinguished Professor of Medicine

Determinants of Outcome in Patients with Staphylococcus aureus Bacteremia
Antibacterial Resistance
Pathogenesis of Bacterial Infections
Tropical medicine/International Health

Sexton

Daniel John Sexton

Professor Emeritus of Medicine

During the past 8 years my research interests have changed from a focus on tick-borne disease and endocarditis to a primary focus on healthcare-associated infections (HAIs). Specifically, I have been interested in HAIs in community hospitals. Using prospective data collected as part of our surveillance activities in the Duke Infection Control Outreach Network (DICON), I and my colleagues have focused on these specific areas of research:

• The accuracy and reliability of surveillance definitions used to document and trend rates of HAIs
• Outcomes of HAIs (both financial and clinical) with particular emphasis on bloodstream and surgical site infections
• Trends in HAIs due to pathogens resistant to common antimicrobial agents
• Temporal and geographic variations in the occurrence of pathogens such as methicillin-resistant S. aureus, E coli and Klebsiella pneumonia
• The prevention and control of HAIs with particular emphasis on the potential role of the environment in the transmission of HAIs

As the principal investigator on one of the 5 national epicenter grants funded by the Centers for Disease control I, along with my co-investigators from the Duke and University of North Carolina Division of Infectious Disease, are involved in a 5-year prospective study of the potential benefit of enhanced cleaning methods (such as the use of ultraviolet light emitters) in the prevention of HAIs. This study involves 9 hospitals in North Carolina and Virginia and will include a trial of 4 different cleaning methods utilized sequentially but randomly in these study hospitals over a 28-month time period. Additionally the Duke Epicenter is also undertaking prospective trials investigating the utility and reliability of new (streamlined) definitions of ventilator-associated pneumonia.


Key words that characterize my work: surgical site infections and nosocomial infections.


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