S. Pitlik

Septic Shock in Bacteremic Patients: Risk Factors, Features and Prognosis

Of 4,289 episodes of bacteremia detected in 3,631 patients, septic shock was diagnosed in 453 episodes (10.5%). In 56% of shock episodes, septic shock developed more than 24 h after the first positive blood culture was taken. In a logistic regression analysis, variables predictive of septic shock were: advanced age [odds ratio (OR) of 1.015 for an increment of 1 year]; renal failure as an underlying disorder (OR = 1.47); neutropenia (OR of 2.26); curtailed functional capacity (OR of 1.54 for an increment of 1 category); unknown source of infection (OR = 1.66); anaerobic (OR = 2.86), polymicrobial bacteremia (OR = 1.54), or pathogens other than Streptococcus viridans (OR = 0.08 for Streptococcus viridans). The in-hospital mortality associated with septic shock was 80% vs 21% in episodes of bacteremia without shock, and shock episodes accounted for 31% of all deaths. The fatality rate in shock patients given appropriate empiric antibiotic treatment was 74.9% vs 84.7% in patients given inappropriate treatment (p = 0.01). Judging by the present results, host factors are more important determinants for development of septic shock in bacteremic patients than the type of pathogen. Even in patients with shock, appropriate empiric antibiotic treatment was associated with an improved chance of survival.

Acinetobacter baumannii: emergence and spread in Israeli hospitals 1997-2002

n Summaryn n The incidence of multi-drug-resistant Acinetobacter baumannii bloodstream infections (BSIs) increased two- to four-fold in three Israeli hospitals between 1997 and 2002, accounting for 3.5–18% of all hospital-acquired BSIs. This was associated with increasing carbapenem resistance reaching 35–54%, and by a dramatic increase in carbapenem consumption. In-hospital fatality rates ranged between 47% and 58% and were significantly higher than those seen with other nosocomial Gram-negative pathogens. A. baumannii was not restricted to intensive care units, but had spread to all hospital wards. Multi-drug-resistant A. baumannii has the potential to reach endemicity in hospitals and warrants more vigorous and innovative efforts to limit its spread.n n

Mortality of patients with antibiotic-associated diarrhoea: the impact of Clostridium difficile

Previous studies have shown conflicting results concerning mortality related to Clostridium difficile infection. The objective of this study was to determine the impact of C. difficile infection on short- and long-term mortality in hospitalised patients with antibiotic-associated diarrhoea. We therefore undertook a prospective case-control study of 217 hospitalised patients who received antibiotics, developed diarrhoea and underwent stool enzyme immunoassay for C. difficile TOX A/B. The Kaplan-Meier and the log-rank test were used to determine univariate survival analysis and a Cox regression model for multivariate analysis of 28 day and long-term mortality. Fifty-two (24%) of the 217 patients who met the study criteria were positive for C. difficile TOX A/B. The crude 28 day and long-term mortality rates of the entire cohort were 12.4% and 56%, respectively. On Cox regression analysis, hypoalbuminaemia, impaired functional capacity and elevated serum urea levels were found to be the only independent and statistically significant variables associated with long-term mortality. C. difficile toxin positivity per se was not associated with increased short- or long-term mortality rates. In conclusion, hypoalbuminaemia, renal failure, and impaired function capacity predict mortality due to antibiotic-associated diarrhoea, but C. difficile involvement by itself does not further increase the risk of death in these patients.

Five-year prospective study of bacteraemic urinary tract infection in a single institution

In order to determine the epidemiology, microbiology, and outcome of bacteraemia originating in the urinary tract in hospitalised patients, a prospective study was conducted in a large general hospital in Israel. Data from all patients with bacteraemia were collected prospectively, and a subgroup of patients with bacteraemia secondary to urinary tract infection was analysed. There were 702 episodes of bacteraemia secondary to urinary tract infection during a five-year period (33.9% of all episodes of bacteraemia). The mean age of the patients was 76 years, and the male: female ratio was 0.9∶1.0. The most common pathogens wereEscherichia coli (52%),Klebsiella spp. (14%), andProteus spp. (9%).Pseudomonas spp. were isolated from 8% of all patients, from 19% of those who had received antibiotics, and from 15% of males.Enterococcus spp. were isolated from 4% of males but from no females. Five percent of the episodes were polymicrobial, and 16% of the infections were hospital acquired. On logistic multivariate regression analysis, predictors of mortality were: hospitalisation in a medical department, hospital-acquired infection, inappropriate empiric antibiotic treatment, presence of decubitus ulcer(s), respiratory or renal failure, and elevated urea and decreased albumin levels.

Value of transrectal ultrasonography for diagnosis and treatment of prostatic abscess

A new diagnostic and therapeutic application of transrectal ultrasonography (TR-US) is described. TR-US demonstrated one or more well-defined hypoechogenic areas in the prostate gland of 6 patients who presented with clinical signs of urinary tract infection and had only partial response to antibiotic therapy. The presence of a collection of pus in the prostate was confirmed in 4 of 6 patients by transperineal aspiration guided by TR-US, and by prostatic massage or transurethral prostatectomy in the other 2 patients. Ultrasonography also confirmed the resolution of abscesses in 5 patients.

Tuberculosis mimicking cancer—A reminder

The charts of 26 patients who were referred with a presumptive diagnosis of neoplasms and who were ultimately found to have only tuberculosis were reviewed. Twenty-one patients (81 percent) were born in the United States, and only three patients had a history of exposure to tuberculosis. Most patients had few symptoms, and the average duration of symptoms was 2.8 +/- 1.5 months. Classic symptoms of tuberculosis, like fever, hemoptysis, and weight loss, were uncommon. Chest roentgenographic abnormalities were present in 62 percent of the patients. Although some of the patients had undergone nondiagnostic biopsy procedures before referral, none had had skin tests for tuberculosis. Underlying conditions were found in eight patients, and alcoholism was the most common. Laboratory abnormalities were rare with the exception of increased platelet counts, which were found in eight patients. The most common form of tuberculosis was pulmonary (14 patients) followed by lymphadenitis (nine patients). Tuberculosis remains an elusive disease even in countries with advanced medical technology. In some cases, its presentation may suggest the presence of malignancy.

Home intravenous antibiotic therapy for patients with infective endocarditis.

Abstractu2002Although home intravenous antibiotic therapy (HIAT) is increasingly being used for various infectious diseases, outpatient treatment of infective endocarditis (IE) is still uncommon. Recently, the American Heart Association recommended outpatient treatment of endocarditis only for infections with streptococci that are highly susceptible to penicillin. Herein, the experience with HIAT in patients with IE due to a diversity of pathogens is presented. During a 3-year period, 37 patients with IE who were in a stable condition and were cooperative were enrolled in a service for HIAT after completion of diagnostic procedures. Of the 37 patients, 21 were male; mean age was 64.3u2009years (range 20–87u2009years); in most cases (26/37), IE involved a native valve. Causative organisms were Streptococcus spp. (20), Staphylococcus spp. (10), Enterococcus spp. (2), Enterobacter spp. (1), and Erysipelothrix rhusiopathiae (1), while three were unknown. The most common antibiotics used were ceftriaxone and vancomycin. Almost three-quarters of the intravenous lines were peripheral. The mean duration of HIAT was 26.2±8.5u2009days, with 92% of the patients cured by it. Most complications were minor. Six patients were rehospitalised and two of them required valve replacement. In half of the rehospitalised patients, the complication was unrelated to HIAT. Surprisingly, almost all of the complications necessitating rehospitalisation occurred in patients with streptococcal IE and most involved native valves. HIAT may be suitable for IE due to a diversity of pathogens and involving prosthetic as well as native heart valves, provided there are proper patient and antibiotic selections, good follow-up, and vigilant monitoring of complications.

Clinical index to predict bacteraemia caused by staphylococci

Abstract. Objectives. To define risk factors associated with bacteraemia caused by Staphylococcus aureus or coagulase‐negative staphylococci; and to use them to define patients in need of empiric anti‐staphylococcal antibiotic treatment.

Patients at risk for inappropriate antibiotic treatment of bacteraemia

Abstract. In order to define patients at high risk for inappropriate antibiotic treatment of bacteraemia, we compared 682 bacteraemic patients, treated with an antibiotic drug to which the infecting micro‐organism was susceptible, with 419 patients who were inappropriately treated. On a multivariate logistic regression analysis including only clinical variables, four factors were found to be both significantly and independently associated with inappropriate antibiotic treatment: hospital‐acquired bacteraemia (oddsratio (OR) of 1.9), antibiotic treatment in the month prior to the bacteraemia (OR 1.9), residence in a nursing home (OR 1.8), and the presence of a central line (OR 1.7). A second model, including bacteriological data, showed four micro‐organisms to be independently associated with inappropriate antibiotic treatment: Candida sp. (OR 14.2), Acinetobacter sp. (OR 5.0), Enterococcus sp. (OR 3.6) and Pseudomonas sp. (OR 2.2). In this model, only two clinical features were included: hospital‐acquired infection and previous antibiotic treatment. Special efforts should be made to improve empirical antibiotic treatment in the groups defined above, and to facilitate early laboratory diagnosis of the micro‐organisms associated with inappropriate treatment.

Soluble triggering receptor expressed on myeloid cells-1 for distinguishing bacterial from aseptic meningitis in adults

The aim of the present study was to evaluate whether soluble triggering receptor expressed on myeloid cells (sTREM-1) is present in the cerebrospinal fluid (CSF) of patients with acute meningitis and if its presence can predict bacterial infection. We found elevated levels of sTREM-1 in the CSF of seven of the nine (78%) patients with culture-positive specimens and in none of 12 (0%) patients with culture-negative specimens (sensitivity: 78%; specificity: 100%). The area under the receiver operating characteristic curve for sTREM-1 in the CSF as a predictor for bacterial meningitis was 0.889. This suggests that sTREM-1 is upregulated in the CSF of patients with bacterial meningitis with high specificity and that its presence can potentially assist clinicians in the diagnosis of bacterial meningitis.