Peter Moss

Long-term mortality following bloodstream infection

Bloodstream infection is associated with significant short-term mortality, but less is known about long-term outcome. We describe factors affecting mortality up to 3 years after bloodstream infection in a cohort of patients reviewed at the bedside by an infection specialist. Patients seen by the bacteraemia service of our infectious diseases department between June 2005 and November 2008 were included in analyses. Routine clinical data collected at the time of consultation, together with laboratory, demographic and outcome data were analysed to identify factors predicting death at 30 days and 3 years after bloodstream infection. Cox regression models for both time-points were constructed, together with Kaplan-Meier survival curves. In all, 322 bloodstream infections were recorded in 304 patients. The 30-day mortality was 15%, with a 3-year mortality of 49%. At 30 days after bacteraemia, in the Cox regression model, increasing age (p 0.003) and lower serum albumin (p 0.014) were predictive of death. At 3 years, age (p <0.0001) and albumin (p 0.004) remained significant predictors of death, with the presence of vascular disease (p 0.05) also significantly associated with mortality. If temperature was treated as a continuous variable then urea was significant (p 0.044); however, if temperature was categorized into hypothermia and non-hypothermia, then the presence of hypothermia (p 0.008) and chronic renal disease (p 0.034) became significant. There is an appreciable and gradual increase in mortality after an episode of bloodstream infection. Although many factors may not be amenable to intervention, patients at high risk of long-term mortality might require further follow up and assessment for potentially modifiable factors.

An evaluation of the usefulness of Staphylococcus aureus serodiagnosis in clinical practice

The measurement of serum antibodies to Staphylococcus aureus has been used in the diagnosis of individuals with suspected deep-seated infection, particularly when culture is difficult or unproductive. The Health Protection Agency (HPA), UK, currently offers testing to detect antibodies to alpha haemolysin (staphylolysin) and the nuclease enzyme in parallel. However, a lack of high specificity and sensitivity of the anti-staphylolysin test has been demonstrated repeatedly in occult S. aureus infections [1–3], whilst there is little information on the usefulness of the anti-nuclease test. It is understood that serological tests, even in combination, are an imperfect marker of staphylococcal infection. It is unclear whether staphylococcal serological testing is useful in clinical practice. We undertook a retrospective evaluation of the use of staphylococcal serodiagnosis in the Hull and East Yorkshire NHS Trust. Our objectives were to determine the extent of testing, to identify the clinical context in which tests were requested, to ascertain whether the results contributed towards patient management and to inform the production of local guidelines. We retrospectively identified the results of serum antistaphylolysin and anti-nuclease titres collected from individuals presenting to a 1,500-bed teaching hospital over a 3-year period. Information concerning the demographics of the individual, their relevant hospital and/or outpatient attendances, past medical history, clinical diagnoses, microbiology, antimicrobial and medical management, and outcome was obtained from their clinical records and the trust pathology database. Test results were interpreted in accordance with HPA guidance [4]. A positive test was defined as an anti-staphylolysin titre of ≥8 units/ml and/or an anti-nuclease titre of >32 units/ml; an equivocal test (suggestive of staphylococcal infection), an antistaphylolysin titre of 4–6 units/ml and/or anti-nuclease titre of 32 units/ml; and a negative test (no evidence of staphylococcal infection or repeat testing required), an anti-staphylolysin titre of ≤2 units/ml and anti-nuclease titre of ≤16 units/ml. Serological testing was performed on 121 serum samples collected from 113 individuals between 1st September 2004 and 31st August 2007. Of these, 73 (65%) were male and their median age was 55 years (range 2–90). Testing was performed in both inpatient (81, 72%) and outpatient (32, 28%) hospital settings. Testing was requested on individuals managed by a variety of specialties, including infectious diseases (78, 70%), orthopaedics (11, 10%), cardiology (3, 2.7%), neurosurgery (3, 2.7%) and the acute medical admitting teams (16, 14.5%). Ninety (80%) individuals were managed as suspected or proven deep-seated infection, including cases of discitis, (20, 18%), prosthetic joint (15, 13%) and native (10, 9%) septic arthritis, osteomyelitis (18, 16%), soft tissue infection (15, 13%), infective endocarditis (10, 9%) and with bacteraemia of uncertain source (2, 1.7%). In the remainder (23, 20%), there was no evidence of infection. Test results were available a median of 14 days from the time of the serum sample collection. Repeat serology was performed on only six individuals. J. Elston (*) :M. Ling :B. Jeffs :K. Adams :H. Thaker : P. Moss :G. Barlow Department of Infection and Tropical Medicine, Main Administration block, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, UK e-mail: jameselston2003@yahoo.co.uk

Response from Hepatitis C Trust, BASL, BIA, BVHG, BSG, and BHIVA to article asking whether widespread screening for hepatitis C is justified

Koretz and colleagues argue that hepatitis C virus (HCV) screening should be delayed.1 We disagree. HCV transmission was common in the 1960s-80s, and because mortality occurs 30-40 years after infection deaths will rise exponentially over the next decade.2 Delaying effective intervention will have a massive impact. The authors argue that because a community study showed an increase in liver and non-liver mortality most infected people will not die from HCV. Infection can cause or exacerbate renal disease, diabetes, and dyslipidaemia and treatment reduces all cause mortality,3 indicating that both liver and non-liver related deaths are caused by …

as does policy on antibiotics

The Department of Health recently published a pathway for the hospital management of adults with swine flu.1 2 We have serious reservations about the antibiotic recommendations. The pathway recommends that all patients attending hospitals with “flu-like illness” receive an antibiotic regardless of the severity of illness or whether secondary bacterial infection is likely. It also states that …