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Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: A comparison between middle-aged, old, and very old patients *
Abstract
Background: We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients.
Methods: In a single-center, historical cohort study (1992–2006), we compared middle-aged (45–64 years; n = 524), old (65–74 years; n = 326), and very old ICU patients (≥75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay.
Results: Although the total number of ICU admissions (patients aged ≥45 years) decreased by ∼10%, the number of very old patients increased by 33% between the periods 1992–1996 and 2002–2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992–1996) to 13.5% (1997–2001) and 17.4% (2002–2006) (p < 0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4‰ in middle-aged, 5.5‰ in old, and 4.6‰ in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0–1.5) and significant for very old age (hazard ratio, 1.8; 95% confidence interval, 1.4–2.4).
Conclusion: Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.
... This association was found for 30-day mortality (6) 90-day mortality (3) and in-hospital mortality (7). In-hospital mortality rate for age cutoff 60-70 accounted for between 19% and 49% and for age cutoff ≥ 75 was 15% to 56% (. 3,7,8). Many prognostic factors for mortality need to continue to be evaluated. ...
... Previous studies showed that mortality rates of BSI are at least three times higher among the elderly than among younger adult patients with the same disease and have suggested that mortality depends on age cutoff (21). For age cutoff of 60-69 and ≥70, the death rate was 19% -49% and 15% -56%, respectively (7,8). Studying 167 older patients with BSI in a French geriatric unit, Aurore Bulaud revealed that the mortality rate at 60 days was 32.3% and concluded that age is not a risk factor of mortality for BSI, and management of bacteremia has to be adapted to elderly (22). ...
... However, Ignacio Martin-Loeches identified that age was found to be an independent risk factor only in the very elderly group (13). Almost all investigations noted that increasing age was significantly associated with an increased odds ratio for attributable in-hospital death (8,23). Our result identified that older age >75 was an independent factor associated with in-hospital mortality (OR 1.86, 1.12-3.08, ...
Background: The rate of multi-drug antibiotic resistance in nosocomial bloodstream infections in elderly patients is increasing. This study examined the data for bloodstream infections to gain a better understanding of bacterial antibiotic resistance. Methods: This was a retrospective study of 817 patients with the first positive blood culture between January 1, 2016 and December 31, 2019. Results: Moyen’s age was 77.4 ± 9.8 years, male (52.4%) and SOFA 5.0 ± 4. ESBL(+) rate was 78/817 (9.5%). ESBL(+) rate for Escherichia coli and Klebsiella pneumoniae was 69/141 (48.9%) and 9/52 (17.3%), respectively. The most common isolates were Escherichia coli (17.3%), Stenotrophomonas maltophilia (13.7%), and Staphylococcus species (23.1%). The rate of septic shock and mortality accounted for 22.3% and 28.9%, respectively. Escherichia coli is highly sensitive to carbapenem, and resistant (>50%) with quinolone and aminoside. Klebsiella pneumoniae and Pseudomonas aeruginosa were highly sensitive to carbapenem. Acinetobacter baumannii was resistant to meropenem (75%). Stenotrophomonas maltophilia was sensitive to quinolone (13.8 %), and highly resistant to remaining antibiotics. Methicillin-resistant Staphylococcus aureus had a low resistance rate for vancomycin, teicoplanin, and linezolid. Multivariate analysis showed that the significant factors associated with mortality were age >75; SOFA >7; respiratory infection; intensive care unit treatment and presentation with septic shock. Conclusion: The mortality rate was still high, especially for antibiotic-resistant agents.
... Shifts in ICU cohort demographics and diagnoses are evident worldwide. Much of the data describe trends from 1990 to the mid-2010s, observing increases in average age and (concomitant 36 ) prevalence of comorbidities 36 and/or complications 37 across the United States, [37][38][39] Europe, [40][41][42] the United Kingdom, 43 and Australia and New Zealand. 44,45 Despite this increase in severity and complexity, mortality rates are dropping, 39,42,44 reflecting medical and technological advances in care. ...
... [73][74][75][76] Increasing patient complexity would match widely observed global trends in increasing comorbidities in intensive care patients. [36][37][38][39][40]42,44,45 Shifts in intensive care cohort demographics towards older and more severely ill, or more complex, patients are evident worldwide, [36][37][38][39][40][41][42][43] including Australia and New Zealand. 44,45 Of studies reporting severity scores, these scores (SAPS, APACHE) were generally stable 41 or decreased slightly. ...
... [73][74][75][76] Increasing patient complexity would match widely observed global trends in increasing comorbidities in intensive care patients. [36][37][38][39][40]42,44,45 Shifts in intensive care cohort demographics towards older and more severely ill, or more complex, patients are evident worldwide, [36][37][38][39][40][41][42][43] including Australia and New Zealand. 44,45 Of studies reporting severity scores, these scores (SAPS, APACHE) were generally stable 41 or decreased slightly. ...
Background
Critical care populations experience demographic shifts in response to trends in population and healthcare, with increasing severity and/or complexity of illness a common observation worldwide. Inflammation in critical illness impacts glucose–insulin metabolism, and hyperglycaemia is associated with mortality and morbidity. This study examines longitudinal trends in insulin sensitivity across almost a decade of glycaemic control in a single unit.
Methods
A clinically validated model of glucose–insulin dynamics is used to assess hour–hour insulin sensitivity over the first 72 h of insulin therapy. Insulin sensitivity and its hour–hour percent variability are examined over 8 calendar years alongside severity scores and diagnostics.
Results
Insulin sensitivity was found to decrease by 50–55% from 2011 to 2015, and remain low from 2015 to 2018, with no concomitant trends in age, severity scores or risk of death, or diagnostic category. Insulin sensitivity variability was found to remain largely unchanged year to year and was clinically equivalent (95% confidence interval) at the median and interquartile range. Insulin resistance was associated with greater incidence of high insulin doses in the effect saturation range (6–8 U/h), with the 75th percentile of hourly insulin doses rising from 4–4.5 U/h in 2011–2014 to 6 U/h in 2015–2018.
Conclusions
Increasing insulin resistance was observed alongside no change in insulin sensitivity variability, implying greater insulin needs but equivalent (variability) challenge to glycaemic control. Increasing insulin resistance may imply greater inflammation and severity of illness not captured by existing severity scores. Insulin resistance reduces glucose tolerance, and can cause greater incidence of insulin saturation and resultant hyperglycaemia. Overall, these results have significant clinical implications for glycaemic control and nutrition management.
... They are responsible for 40% to 60% of BSI in older people (1). Among them, Escherichia coli spp is the most common pathogen found, accounting for 40% of community-acquired BSI, and 10-20% of healthcareassociated BSI (7)(8)(9)(10)(11). In the last 20 years, the incidence of BSI has increased in the general population, and in-hospital casefatality ratio has decreased (12). ...
... Four studies evaluated intrahospital mortality rate in patients over 75 years of age, ranging from 15 to 56%. (11,(13)(14)(15). None of these studies assessed the mortality rate as a primary objective, and population and clinical characteristics varied considerably from one study to another. ...
... The risk of colonization with Gram-negative microorganisms increases with age, functional status, nursing home residency, hospitalization and respiratory disease. The mortality associated with BSI was significant (19%) but lower than what is reported in other studies (11,(13)(14)(15). Mortality varies according to the characteristics of the population studied. ...
Objectives:
To assess the prevalence of intra-hospital mortality and associated risk factors in older people aged 75+, admitted with blood stream infections (BSI).
Design:
Single center retrospective study performed in an 850-bed of the academic hospital of the Université Libre de Bruxelles.
Setting and participants:
From January 2015 to December 2017, all inpatients over 75 years old admitted with BSI were included.
Measures:
Demographical, clinical and microbiological data were collected.
Results:
212 patients were included: median age was 82 [79-85] years and 60 % were female. The in-hospital mortality rate was 19%. The majority of microorganisms were Gram-negative strains, of which Escherichia coli was the most common, and urinary tract infection was the most common origin of BSI. Compared to patients who survived, the non-survivor group had a higher SOFA score (6 versus 3, p<0.0001), a higher comorbidity score (5 versus 4, p<0.0001), more respiratory tract infections (28 vs 6 %, p < 0.0001) and fungal infections (5 vs 1 %, p = 0.033), bedridden status (60 vs 25 %, p < 0.0001), and healthcare related infections (60 vs 40 %, p = 0.019). Using Cox multivariable regression analysis, only SOFA score was independently associated with mortality (HR 1.75 [95%IC 1.52-2.03], p<0.0001).
Conclusions and implications:
BSI in older people are severe infections associated with a significant in-hospital mortality. Severity of clinical presentation at onset remains the most important predictor of mortality for BSI in older people. BSI originating from respiratory source and bedridden patients are at greater risk of intra-hospital mortality. Further prospective studies are needed to confirm these results.
... Most of the studies which included a comparison to younger patients demonstrated that BSI entails significantly higher rates of mortality in older age [14,35,[53][54][55][56]. The difference was shown to be significant regarding short-term survival (Table 1), 90-day survival [14] and 1-year survival [15]. ...
... The difference was shown to be significant regarding short-term survival (Table 1), 90-day survival [14] and 1-year survival [15]. Factors in association with worse prognosis in adults were: higher Charlson co-morbidity index scores [35,51,56,57] and lower functional capacity [7,35,51,58]; severity of presentation as reflected by hemodynamic instability or septic shock [17,38,52,53,[58][59][60]; biochemical markers such as lower albumin levels [52,56,58,61]; and higher CRP levels [56,61]. The association between low albumin and higher mortality reflects, among other things, the important correlation between malnutrition in the elderly and both risk for bacteremia [6] and for worse outcomes in bacteremic old patients [62]. ...
... The association between low albumin and higher mortality reflects, among other things, the important correlation between malnutrition in the elderly and both risk for bacteremia [6] and for worse outcomes in bacteremic old patients [62]. Source of infection was significantly associated with higher mortality in respiratory [17,21,53,58], intra-abdominal [17,38] or unknown origin [17,29,38,52,55]. Of note, inappropriate empirical treatment was associated with increased mortality [17,38,52,59,63]. ...
Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40–60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.
... Patients admitted to the intensive care units (ICU) are at increased risk of dying from systemic infections. A growing proportion of those cases are due to fungi, which have high mortality compared to bacterial infections and a considerable economic impact due to prolonged ICU stay [1][2][3][4]. With the advancement of medicine and supportive therapy in critically ill patients, increased number of elderly subjects is being admitted to the ICU, thereby substantially increasing the cumulative pool of patients at-risk for fungal infections over the past decade [3]. ...
... A growing proportion of those cases are due to fungi, which have high mortality compared to bacterial infections and a considerable economic impact due to prolonged ICU stay [1][2][3][4]. With the advancement of medicine and supportive therapy in critically ill patients, increased number of elderly subjects is being admitted to the ICU, thereby substantially increasing the cumulative pool of patients at-risk for fungal infections over the past decade [3]. The severity of the acute illness, use of broad-spectrum antimicrobials, status of infection prevention, and control practices are few important factors that contribute to the emergence of fungal infections in ICU patients. ...
Purpose of Review
Globally, a change has been noticed in the epidemiology of fungal infections in the intensive care units (ICUs). The current review provides an insight into the current epidemiology of emerging fungal infections with special reference to their prevalence, spectrum of pathogen, outbreaks, and emergence of antifungal resistance reported from different ICUs of the world.
Recent Findings
The ICUs across the world are witnessing multiple changes in the epidemiology of fungal infections including change in prevalence and spectrum of etiological agents, new susceptible risk groups, geographical variations, emergence of novel multi-drug resistant Candida auris, outbreak due to rare fungal species, emergence of antifungal resistance, etc. An understanding of the contemporary local epidemiology of fungal agents in ICU is essential for optimal patient management.
Summary
Invasive candidiasis and invasive aspergillosis continue to haunt as major pathogens in the ICU, and several new risk factors associated with these infections have surfaced up. There is a contrasting picture for the species distribution of Candida among the different countries of the world. C. auris, the yeast behaving like bacteria, has emerged as a potential threat to ICUs across the five continents. Other mycelial agents like Mucorales, Paecilomyces spp., Fusarium spp., and Cladosporium spp., although encountered infrequently, continue to be reported as serious infections in ICU. The ICUs are also vulnerable sites for fungal infection outbreaks due to several fungi including rare ones like Cryptococcus spp., Pichia anomala, and Kodamaea ohmeri.
... There should be a define time for admission to the ICU not transferring patients when every management fails with deteriorating health of the patients. Physiological host immune state can also determine the progress of sepsis in patients admitted to the ICU, viral and fungi infections flourishes in immune-compromised patients and the elderly [5,9,[13][14]. ...
... Although, Stephan concluded that age >75 years by itself does not appear to be a significant predictor of ICUacquired nosocomial infection or mortality rate [13]. The finding in this study was contrary to a cohort study by Blot who found that the incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4 per thousand in middle-aged, 5.5 per thousand in old, and 4.6 per thousand in very old patients [14]. This might be due to differences in In this study, bacteria were more isolated than fungi isolates (81.2% Vs 12.5%) and isolation rate of polymicrobial was 35.0%, this finding was similar to findings by Crowe [17]. ...
... Among the survivors, 36.7% of patients were discharged home. The median number of ICU-free days was 19 (IQR [11][12][13][14][15][16][17][18][19][20][21][22][23][24]. The median number of VFD was 21 (IQR 0-28), and the LOS was 24 (12-46) days. ...
... This likely reflects the common characteristics of individuals in developed countries, although it remains controversial whether the severity of diabetes mellitus itself is a risk factor for sepsis [11,12]. Previous studies have shown that aging and multiple comorbidities were the risk factors associated with poor outcome due to sepsis [1,7,[13][14][15][16]; however, a single comorbidity was not. The distribution of suspected infection sites was similar to that in previous reports [13,17]. ...
Background
Sepsis is a leading cause of death and long-term disability in developed countries. A comprehensive report on the incidence, clinical characteristics, and evolving management of sepsis is important. Thus, this study aimed to evaluate the characteristics, management, and outcomes of patients with severe sepsis in Japan.
Methods
This is a cohort study of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) study, which was a multicenter, prospective cohort study conducted at 59 intensive care units (ICUs) from January 2016 to March 2017. We included adult patients with severe sepsis based on the sepsis-2 criteria.
Results
In total, 1184 patients (median age 73 years, interquartile range (IQR) 64–81) with severe sepsis were admitted to the ICU during the study period. The most common comorbidity was diabetes mellitus (23%). Moreover, approximately 63% of patients had septic shock. The median Sepsis-related Organ Failure Assessment (SOFA) score was 9 (IQR 6–11). The most common site of infection was the lung (31%). Approximately 54% of the participants had positive blood cultures. The compliance rates for the entire 3-h bundle, measurement of central venous pressure, and assessment of central venous oxygen saturation were 64%, 26%, and 7%, respectively. A multilevel logistic regression model showed that closed ICUs and non-university hospitals were more compliant with the entire 3-h bundle. The in-hospital mortality rate of patients with severe sepsis was 23% (21–26%). Older age, multiple comorbidities, suspected site of infection, and increasing SOFA scores correlated with in-hospital mortality, based on the generalized estimating equation model. The length of hospital stay was 24 (12–46) days. Approximately 37% of the patients were discharged home after recovery.
Conclusion
Our prospective study showed that sepsis management in Japan was characterized by a high compliance rate for the 3-h bundle and low compliance rate for central venous catheter measurements. The in-hospital mortality rate in Japan was comparable to that of other developed countries. Only one third of the patients were discharged home, considering the aging population with multiple comorbidities in the ICUs in Japan.
Trial registration
UMIN-CTR, UMIN000019742. Registered on 16 November 2015.
Electronic supplementary material
The online version of this article (10.1186/s13054-018-2186-7) contains supplementary material, which is available to authorized users.
... De acuerdo con los hallazgos descritos en la literatura, hay un incremento de la incidencia de septicemia a medida que incrementa la edad, siendo los gérmenes Gram negativos los principales agentes aislados, de los cuales la Escherichia coli se ha demostrado hasta en un 40% de los hemocultivos positivos en las infecciones adquiridas en la comunidad (10). ...
Introducción: El 30% de los casos de sepsis son de origen urinario, del 25-35% progresan a choque séptico con mayor velocidad respecto a otros focos infecciosos, 4.7 (±) 2.4 vs 7.2 (±) 4.5 horas, su mortalidad a los 30 días desde la atención en urgencias es del 10%, pero en casos más severos del 25- 50%. Objetivos: Describir la población con sepsis urinaria atendidos en emergencias del hospital universitario clínica San Rafael (Bogotá D.C.) desde diciembre de 2018 hasta diciembre de 2019. Materiales y Métodos: Se realizó un estudio retrospectivo de corte transversal durante 12 meses, se aplicó muestreo probabilístico aleatorio para 70 pacientes, se realizó el análisis univariado con frecuencias absolutas y relativas y los multivariados con regresión logística. Resultados: El 60% de los pacientes con urosepsis fueron mujeres, el 77,1% tenían diabetes tipo 2, se obtuvieron resultados positivos en hemocultivos y urocultivos en un 34.2% y 84.2% respectivamente. El 21.4% progresaron a choque séptico. La mediana de Sofa score fue 3.0. Se demostró asociación significativa de desenlaces fatales con: Sexo masculino (14.2% vs 7.1% OR 4.0 IC95% 1.06-17.3 p= 0.03), alteración de la conciencia (11.4 vs 7.1% OR: 10.8 IC95% 2.38-56.2 p<0.01), choque séptico (12.8% vs 8.5% OR: 11.5 IC95% 2.67-57.4 p<0.01) y edad mayor de 79.5 años (AUC 0.67 IC95% 0.51-0.83). Conclusión: La sepsis urinaria en nuestra población fue más prevalente en mujeres, adultos mayores y en diabéticos, el 21.4% progresaron a choque séptico, se demostró asociación significativa con la mortalidad en hombres, en mayores de 79 años y en pacientes con alteración de la conciencia.
... The score has several advantages, including: its ease of establishment since all the variables are accessible in the pre-hospital setting, its inter-observer reproducibility, and the possibility of being repeated over time in order to evaluate the treatment effect. However, one of the weakness is that NEWS-2 does not include age and major comorbidities, both reflecting frailty [46,47] and associated with poor sepsis outcome [48][49][50]. ...
Background
The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU).
Methods
Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports.
Results
Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39–3.95], 2.08 [1.33–3.25] and 2.22 [1.38–3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively.
Conclusion
A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.
... Notwithstanding important medical advances, sepsis even now poses a major challenge for both clinicians and trialists, with its treatment still limited to antibiotics, fluid therapy and organ supportive therapy. As for many years no new therapies have become available, it is still very difficult to deal with and continues to be a leading cause of mortality worldwide, affecting both resource-rich and resourcerestricted countries [3,4] and taking its toll across all age groups [5][6][7][8][9][10][11]. A recent study estimated that in 2017 sepsis occurred in 48.9 million people globally, and was responsible for 11 million deaths [12]. ...
Sepsis, defined as the life-threatening dysregulated host response to an infection leading to organ dysfunction, is considered as one of the leading causes of mortality worldwide, especially in intensive care units (ICU). Moreover, sepsis remains an enigmatic clinical syndrome, with complex pathophysiology incompletely understood and a great heterogeneity both in terms of clinical expression, patient response to currently available therapeutic interventions and outcomes. This heterogeneity proves to be a major obstacle in our quest to deliver improved treatment in septic critical care patients; thus, identification of clinical phenotypes is absolutely necessary. Although this might be seen as an extremely difficult task, nowadays, artificial intelligence and machine learning techniques can be recruited to quantify similarities between individuals within sepsis population and differentiate them into distinct phenotypes regarding not only temperature, hemodynamics or type of organ dysfunction, but also fluid status/responsiveness, trajectories in ICU and outcome. Hopefully, we will eventually manage to determine both the subgroup of septic patients that will benefit from a therapeutic intervention and the correct timing of applying the intervention during the disease process.
... [20] Lower respiratory tract infection appears to be associated with poor outcome. [21,22,24,25] In a previous study, the yield of blood cultured strains increased significantly with the severity of pneumonia, [26] especially among elderly, chronically bedridden, and immunocompromised patients. ...
Background:
Community-acquired bloodstream infections (CABSIs) are common in the emergency departments, and some progress to sepsis and even lead to death. However, limited information is available regarding the prediction of patients with high risk of death.
Methods:
The Emergency Bloodstream Infection Score (EBS) for CABSIs was developed to visualize the output of a logistic regression model and was validated by the area under the curve (AUC). The Mortality in Emergency Department Sepsis (MEDS), Pitt Bacteremia Score (PBS), Sequential Organ Failure Assessment (SOFA), quick Sequential Organ Failure Assessment (qSOFA), Charlson Comorbidity Index (CCI), and McCabe-Jackson Comorbid Classification (MJCC) for patients with CABSIs were computed to compare them with EBS in terms of the AUC and decision curve analysis (DCA). The net reclassification improvement (NRI) index and integrated discrimination improvement (IDI) index were compared between the SOFA and EBS.
Results:
A total of 547 patients with CABSIs were included. The AUC (0.853) of the EBS was larger than those of the MEDS, PBS, SOFA, and qSOFA (all P<0.001). The NRI index of EBS in predicting the in-hospital mortality of CABSIs patients was 0.368 (P=0.04), and the IDI index was 0.079 (P=0.03). DCA showed that when the threshold probability was < 0.1, the net benefit of the EBS model was higher than those of the other models.
Conclusion:
The EBS prognostic models were better than the SOFA, qSOFA, MEDS, and PBS models in predicting the in-hospital mortality of patients with CABSIs.
... Tis fnding was much lower than that in Egypt, where the prevalence rate of HA-BSI was 75 per 1000 ICU admissions [36]. In Belgium Ghent University Hospital, the prevalence of HA-BSI among patients older than 45 years was 27.7 per 1000 ICU admissions from 1992 to 2006 [37]. In our study, most HA-BSI cases were reported in the medical ward (42.37%). ...
Background:
Data from developed/developed countries have shown that hospital-acquired blood infections (HA-BSIs) are one of the most severe nosocomial infections and constitute 20%-60% of hospitalization-related deaths. Despite the high morbidity and mortality rates and the enormous burden of health care costs associated with HA-BSIs, to our knowledge, there are few published reports on HA-BSI prevalence estimates in Arab countries, including Oman.
Objectives:
This study aims to explore the HA-BSI prevalence estimates over selected sociodemographic characteristics among admitted patients at a tertiary hospital in Oman over five years of follow-up. The regional variations in Oman were also examined in this study.
Methods:
This hospital-based cross-sectional study reviewed reports of hospital admissions over 5 years of retrospective follow-ups at a tertiary hospital in Oman. HA-BSI prevalence estimates were calculated over age, gender, governorate, and follow-up time.
Results:
In total, 1,246 HA-BSI cases were enumerated among a total of 139,683 admissions, yielding an overall HA-BSI prevalence estimate of 8.9 cases per 1000 admissions (95% CI: 8.4, 9.4). HA-BSI prevalence was higher among males compared to females (9.3 vs. 8.5). HA-BSI prevalence started as relatively high in the group aged 15 years or less (10.0; 95% CI 9.0, 11.2) and then declined as age increased from 36 to 45 years (7.0; 95% CI 5.9, 8.3) when it started to increase steadily with increasing age in the group aged 76 or more (9.9; 95% CI 8.1, 12.1). The governorate-specific estimate of HA-BSI prevalence was the highest among admitted patients who resided in Dhofar governorate, while the lowest estimate was reported from the Buraimi governorate (5.3).
Conclusion:
The study provides supportive evidence for a steady increase in HA-BSI prevalence over age categories and years of follow-up. The study calls for the timely formulation and adoption of national HA-BSI screening and management programs centered on surveillance systems based on real-time analytics and machine learning.
... The aimed patient was a naïve adult (i.e., without any antimicrobial and medical therapy prior to ED arrival) with community-onset bacteremia in the ED. According to the cutoff age suggested in the previously established study (10), the eligible patients were grouped as the following: middle aged (45-64 years), old (65-74 years), and very old (≥75 years). This study was approved by the Institutional Review Board of study hospitals, and the requirement of obtaining informed consent was waived. ...
Background
Studies have reported the effects of delayed administration of appropriate antimicrobial therapy (AAT) on the short-term prognosis of patients with bloodstream infections; however, whether there is an age-related difference in these effects remains debated.
Methods
In this 4-year multicenter case-control study, patients with community-onset bacteremia were retrospectively categorized into the “middle-aged” (45–64 years), “old” (65–74 years), and “very old” (≥75 years) groups. Two methods were adopted to investigate the prognostic effects of delayed AAT in each age group. First, its effects were, respectively, investigated, after adjustment for the independent predictors of 30-day mortality. Second, patients in each age group were matched by the closest propensity-score (PS), which was calculated by independent predictors of mortality; the survival curves and Pearson chi-square tests were adopted to disclose its effects in each PS-matching group.
Results
Each hour of delayed AAT resulted in an average increase in the 30-day crude mortality rate of 0.2% ( P = 0.03), 0.4% ( P < 0.001), and 0.7% ( P < 0.001) in middle-aged (968 patients), old (683), and very old (1,265) patients, after, respectively, adjusting the independent predictors of mortality in each group. After appropriate PS-matching, no significant proportion differences in patient demographics, bacteremia characteristics, severity of bacteremia and comorbidities, and 15-day or 30-day crude mortality rates were observed between three matched groups (582 patients in each group). However, significant differences in survival curves between patients with delayed AAT > 24 or >48 h and those without delayed administration were demonstrated in each age group. Furthermore, the odds ratios of 30-day mortality for delayed AAT > 24 or >48 h were 1.73 ( P = 0.04) or 1.82 ( P = 0.04), 1.84 ( P = 0.03) or 1.95 ( P = 0.02), and 1.87 ( P = 0.02) or 2.34 ( P = 0.003) in the middle-aged, old, and very old groups, respectively. Notably, the greatest prognostic impact of delayed AAT > 24 or >48 h in the very old group and the smallest impact in the middle-aged group were exhibited.
Conclusion
For adults (aged ≥45 years) with community-onset bacteremia, the delayed AAT significantly impacts their short-term survival in varied age groups and the age-related differences in its prognostic impact might be evident.
... Age has been widely described in the literature as a poor prognostic factor in patients with bacteraemia. Different authors have found 21-35% higher short-and long-term mortality in patients older than 80 years with respect to the rest of the geriatric population [5,[18][19][20], and Nielsen et al. [17] suggested that age may be a more important risk factor for mortality than bacteraemia itself, since the higher risks of mortality (compared to controls) were described in young patients without comorbidities. There are no studies comparing the risk in patients aged 80-89 years vs. 90 years or older, but our data show a 50% higher risk of death in the older group, both at 30 days and 1 year. ...
Background
In older adult patients, bloodstream infections cause significant mortality. However, data on long-term prognosis in very elderly patients are scarce. This study aims to assess 1-year mortality from bacteraemia in very elderly patients.
Methods
Retrospective cohort study in inpatients aged 80 years or older and suspected of having sepsis. Patients with (n = 336) and without (n = 336) confirmed bacteraemia were matched for age, sex, and date of culture, and their characteristics were compared. All-cause mortality and risk of death were assessed using the adjusted hazard ratio (aHR).
Results
Compared to controls, cases showed a higher 1-year mortality (34.8% vs. 45.2%) and mortality rate (0.46 vs. 0.69 deaths per person-year). Multivariable analysis showed significant risk of 1-year mortality in patients with bacteraemia (aHR: 1.31, 95% confidence interval [CI] 1.03–1.67), quick Sepsis Related Organ Failure Assessment (qSOFA) score of 2 or more (aHR: 2.71, 95% CI 2.05–3.57), and age of 90 years or older (aHR 1.53, 95% CI 1.17–1.99).
Conclusions
In elderly patients suspected of sepsis, bacteraemia is associated with a poor prognosis and higher long-term mortality. Other factors related to excess mortality were age over 90 years and a qSOFA score of 2 or more.
... Due to the severity of acute illness, ICU patients are in any case prone to IC. Moreover, the great progress made in critical care medicine with an ever-growing number of invasive procedures, the widespread use of broad-spectrum antibiotics, the increasingly aggressive immunosuppressive treatments, the increased survival and incidence of elderly patients admitted to ICU, have contributed to the increase of IC [5]. So, it represents a serious problem for ICU, associated with a significant impact on morbidity, length of stay in the ICU, mortality (39-60%) [6] and health care costs [7][8][9][10][11][12][13][14][15][16][17][18]. ...
Invasive candidiasis (IC) has emerged in the last decades as an important cause of morbidity, mortality, and economic load in the intensive care unit (ICU). The epidemiology of IC is still a difficult and unsolved enigma for the literature. Accurate estimation of the true burden of IC is difficult due to variation in definitions and limitations inherent to available case-finding methodologies. Candidemia and intra-abdominal candidiasis (IAC) are the two predominant types of IC in ICU. During the last two decades, an increase in the incidence of candidemia has been constantly reported particularly in the expanding populations of elderly or immunosuppressed patents, with a parallel change in Candida species (spp.) distribution worldwide. Epidemiological shift in non-albicans spp. has reached worrisome trends. Recently, a novel, multidrug-resistant Candida spp., Candida auris, has globally emerged as a nosocomial pathogen causing a broad range of healthcare-associated invasive infections. Epidemiological profile of IAC remains imprecise. Though antifungal drugs are available for Candida infections, mortality rates continue to be high, estimated to be up to 50%. Increased use of fluconazole and echinocandins has been associated with the emergence of resistance to these drugs, which affects particularly C. albicans and C. glabrata. Crucial priorities for clinicians are to recognize the epidemiological trends of IC as well as the emergence of resistance to antifungal agents to improve diagnostic techniques and strategies, develop international surveillance networks and antifungal stewardship programmes for a better epidemiological control of IC.
... New positive blood cultures within 30 days from the incident candidemia were considered part of the same episode [18]. BSI was considered as nosocomial if diagnosed at least 48 h after hospital admission [19,20]. We evaluated the clinical manifestations and host factors when confirming whether it was genuine candidemia. ...
Background
The incidence of Candida bloodstream infections (BSIs), has increased over time. In this study, we aimed to describe the current epidemiology of Candida BSI in a large tertiary care hospital in Shanghai and to determine the risk factors of 28-day mortality and the impact of antifungal therapy on clinical outcomes.
Methods
All consecutive adult inpatients with Candida BSI at Ruijin Hospital between January 1, 2008, and December 31, 2018, were enrolled. Underlying diseases, clinical severity, species distribution, antifungal therapy, and their impact on the outcomes were analyzed.
Results
Among the 370 inpatients with 393 consecutive episodes of Candida BSI, the incidence of nosocomial Candida BSI was 0.39 episodes/1000 hospitalized patients. Of the 393 cases, 299 (76.1%) were treated with antifungal therapy (247 and 52 were treated with early appropriate and targeted antifungal therapy, respectively). The overall 28-day mortality rate was 28.5%, which was significantly lower in those who received early appropriate (25.5%) or targeted (23.1%) antifungal therapy than in those who did not (39.4%; P = 0.012 and P = 0.046, respectively). In multivariate Cox regression analysis, age, chronic renal failure, mechanical ventilation, and severe neutropenia were found to be independent risk factors of the 28-day mortality rate. Patients who received antifungal therapy had a lower mortality risk than did those who did not.
Conclusions
The incidence of Candida BSI has increased steadily in the past 11 years at our tertiary care hospital in Shanghai. Antifungal therapy influenced short-term survival, but no significant difference in mortality was observed between patients who received early appropriate and targeted antifungal therapy.
... Eligible patients were categorized as "middle aged" (45-64 years), "old" (65-74 years), and "very old" (≥ 75 years) according to the cut-off age used in a previous study [12]. Community-onset bacteremia refers to bacteremic episodes with onset in the community and includes healthcare facility-acquired and community-acquired bacteremia [4,13]. ...
Background: Studies have reported the effects of delayed administration of appropriate empirical antimicrobial (AEA) on the prognosis of patients with bloodstream infections; however, whether there is an age-related difference in these effects remains debated.
Methods: In this 4-year multicenter cohort study, patients with community-onset bacteremia were retrospectively included and categorized into “middle aged” (45–64 years), “old” (65–74 years), and “very old” (≥75 years) groups. To determine the timing of AEA administration for each patient, all causative microorganisms were prospectively obtained. For each age group, the effects of delayed AEA administration on 30-day mortality were investigated after adjustment for the independent predictors of 30-day mortality determined using a logistic regression model.
Results: Significant differences were observed in the distribution of comorbidity types, comorbidity severity, bacteremia sources, bacteremia severity, and causative microorganisms among 968 (33.2%) middle-aged, 683 (23.4%) old, and 1,265 (43.4%) very old patients. Although significant effects (adjusted odds ratio [AOR], 1.002; P = 0.07) of delayed AEA administration on prognosis were not observed in middle-aged patients, each hour of AEA delay resulted in an average increase in the 30-day crude mortality of 0.036% (AOR, 1.0036; P < 0.001) and 0.38% (AOR, 1.0038; P < 0.001) in old and very old patients, respectively. Practically in critically ill patients, each hour of delayed AEA administration resulted in an average increase of 0.03% (AOR, 1.003; P = 0.04), 0.4% (AOR, 1.004; P < 0.001), and 0.5% (AOR, 1.005; P = 0.001) in 30-day crude mortality in middle-aged, old, and very old patients, respectively.
Conclusions: Regardless of bacteremia severity, the adverse effects of delayed AEA administration on the survival of patients with community-onset bacteremia increased with patients’ age. To achieve favorable outcomes, rapid AEA administration is recommended in older patients.
... Angus et al. reported that there was a steadily increased mortality associated with age, with a highly significant peak of about 40% in patients >85 years [9]. Blot et al. reported in a large cohort study that mortality rates went up with age: about 43%, 49%, and 56% in middle-aged, old, and very old patients [10]. ...
Introduction
Chronic liver disease (CLD) or Cirrhosis is one of the most common causes of morbidity as well as mortality. Child-Turcotte-Pugh (CTP) score and the model for end-stage liver disease (MELD) are useful to assess the long-term prognosis of a patient with CLD. When a patient with CLD is admitted with an acute illness leading to systemic inflammatory response syndrome (SIRS), these scores may not be reliable to predict the short-term prognosis and survival. Absolute eosinophils count (AEC) allows the rapid identification of patients at increased risk for sepsis-related mortality in patients.
Methods
This was a cross-sectional study conducted among patients in a tertiary care hospital in South India during a period of one and a half years between October 2018 and April 2020. Cirrhotic patients with SIRS aged between 16 years and 80 years were included in the study. AEC was measured as a part of automated complete blood counts. Patient demographics, lab parameters, and outcomes in terms of mortality were studied. Continuous variables were expressed as mean ± SD/median and categorical variables were expressed in frequency. Receiver operating characteristic (ROC) curve analysis was used to find an ideal cutoff for AEC in predicting hospital mortality. Multi-variate Cox regression analysis was performed to find predictors of mortality.
Results
A total of 100 patients who fit the pre-determined criteria for cirrhosis with SIRS were enrolled in the study. Sixteen (16%) patients died at the end of the study while 84 (84%) were alive. Using a ROC curve, the area under the curve (AUC) was 0.716 with 95% CI of AUC (0.564-0.867), the p-value was found to 0.006, a cut-off of eosinophil count of 198.5 cells/uL was found to be the cut-off for the prediction of in-hospital mortality in this subset of patients with cirrhosis and sepsis with SIRS, with a sensitivity of 75% and specificity of 38.1%. In a multi-variate Cox regression analysis, only age (hazard ratio {HR}: 1.175, 95%CI, 1.084 to 1.275, p<0.001) , CRP (HR : 1.008, 95%CI, 1.00 to 1.015, p=0.042) values, total leukocyte counts (TLC) (HR: 1.226, 95%CI, 1.116 to 1.346, p<0.001) and AEC (HR: 0.993, 95%CI, 0.987 to 0.999, p=0.016) were found to be statistically significant independent predictors of mortality.
Conclusions
The presence of eosinopenia may be considered as an in-expensive warning biomarker for poorer clinical outcomes in the form of in-hospital mortality in hospitalized cirrhotic patients. Other biomarkers such as CRP and TLC could also play a role both independently and in conjunction with AEC to predict outcomes and mortality in cirrhotic patients with sepsis and SIRS.
... Despite a 48% increase in the proportion of those 80 years or older in the Hong Kong population, this did not translate to a higher proportion of ICU patients who were ≥ 80 years old [23]. In contrast, most longitudinal studies have found an increase in ICU admission age over time, particularly those aged ≥ 80 years old [2][3][4][5][6][7][30][31][32]. Moreover, our median APACHE IV scores of 61 to 64 were higher than severity of illness reported elsewhere [4,8,24,33,34]. ...
Background
Globally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong.
Methods
This was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed.
Results
From 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by − 0.15 (95% CI − 0.18 to − 0.11) per year (Pearson’s R = − 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer–Lemeshow test p < 0.001).
Conclusions
Despite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong.
... The population is aging rapidly, and life expectancy is becoming higher. In parallel, there is an increasing number of ICU admissions of patients older than 75 years and of cardiac arrests [23]. Furthermore, elderly people's health conditions are better than before, as is the quality of post-resuscitation therapy [24]. ...
Aim:
We investigated the effect of age on post-cardiac arrest treatment outcomes in an elderly population, based on a local database and a systemic review of the literature.
Methods:
Data were collected retrospectively from medical charts and reports. Sixty-one comatose patients, cooled to 32-34 °C for 24 h, were categorized into three groups: younger group (≤65 years), older group (66-75 years), and very old group (>75 years). Circumstances of cardiopulmonary resuscitation (CPR), patients' characteristics, post-resuscitation treatment, hemodynamic monitoring, neurologic outcome and survival were compared across age groups. Kruskal-Wallis test, Chi-square test and binary logistic regression (BLR) were applied. In addition, a literature search of PubMed/Medline database was performed to provide a background.
Results:
Age was significantly associated with having a cardiac arrest on a monitor and a history of hypertension. No association was found between age and survival or neurologic outcome. Age did not affect hemodynamic parameter changes during target temperature management (TTM), except mean arterial pressure (MAP). Need of catecholamine administration was the highest among very old patients. During the literature review, seven papers were identified. Most studies had a retrospective design and investigated interventions and outcome, but lacked unified age categorization. All studies reported worse survival in the elderly, although old survivors showed a favorable neurologic outcome in most of the cases.
Conclusion:
There is no evidence to support the limitation of post-cardiac arrest therapy in the aging population. Furthermore, additional prospective studies are needed to investigate the characteristics and outcome of post-cardiac arrest therapy in this patient group.
... Sensitivity analysis using the Cox regression was conducted by adding parameters with significant difference between the non-elderly and elderly patients including comorbidities as covariates. Sensitivity analyses using age cutoffs of 65, 70, and 80 years old for significant discovery results were conducted [24][25][26][27][28]. Interactions between age and BT for mortality were tested using Cox regression analysis. ...
Background:
Elderly patients have a blunted host response, which may influence vital signs and clinical outcomes of sepsis. This study was aimed to investigate whether the associations between the vital signs and mortality are different in elderly and non-elderly patients with sepsis.
Methods:
This was a retrospective observational study. A Japanese multicenter sepsis cohort (FORECAST, n = 1148) was used for the discovery analyses. Significant discovery results were tested for replication using two validation cohorts of sepsis (JAAMSR, Japan, n = 624; SPH, Canada, n = 1004). Patients were categorized into elderly and non-elderly groups (age ≥ 75 or < 75 years). We tested for association between vital signs (body temperature [BT], heart rate, mean arterial pressure, systolic blood pressure, and respiratory rate) and 90-day in-hospital mortality (primary outcome).
Results:
In the discovery cohort, non-elderly patients with BT < 36.0 °C had significantly increased 90-day mortality (P = 0.025, adjusted hazard ratio 1.70, 95% CI 1.07-2.71). In the validation cohorts, non-elderly patients with BT < 36.0 °C had significantly increased mortality (JAAMSR, P = 0.0024, adjusted hazard ratio 2.05, 95% CI 1.29-3.26; SPH, P = 0.029, adjusted hazard ratio 1.36, 95% CI 1.03-1.80). These differences were not observed in elderly patients in the three cohorts. Associations between the other four vital signs and mortality were not different in elderly and non-elderly patients. The interaction of age and hypothermia/fever was significant (P < 0.05).
Conclusions:
In septic patients, we found mortality in non-elderly sepsis patients was increased with hypothermia and decreased with fever. However, mortality in elderly patients was not associated with BT. These results illuminate the difference in the inflammatory response of the elderly compared to non-elderly sepsis patients.
... Respiratory tract infections are also more common causes of sepsis in elderly patients [21]. Relative to the non-elderly, we found that elderly sepsis patients had a higher 28-day mortality rate and that sepsis was more likely to be caused by a respiratory tract infection, in agreement with previous studies [18,22]. In contrast, we found that sepsis in non-elderly patients was more likely to be caused by skin and soft tissue infections. ...
Purpose: The objective of this study is to assess the clinical usefulness of lactate as a predictor of 28-day mortality and the relationship between lactate and 28-day mortality in non-elderly (<65 years) and elderly (≥65 years) sepsis patients who were admitted to an intensive care unit (ICU).
Methods: This retrospective study used the Medical Information Mart for Intensive Care Ⅲ, a publicly available database of ICUs. Prognosis was evaluated using receiver operating characteristic (ROC) analysis. Univariate and multivariable binary logistic regression models were used to identify the association lactate with 28-day mortality. We converted continuous variable lactate into a categorical variable based on tri-segment quantile to explore segmentation effects.
Results: The average age of 2848 patients was 68.01 years old, and about 55.40% of them were male. The overall 28-day mortality was 30.41%, and the rate in elderly patients was 65.82%. Among non-survivors, the lactate level was significantly greater for the non-elderly than the elderly. Lactate level was positively associated with risk of 28-day mortality of the non-elderly sepsis patients (p for trend < 0.001), but there was no significant association between lactate level and 28-day mortality in the elderly group (p for trend = 0.830). The association between lactate and 28-day mortality for sepsis patients without liver cirrhosis was stronger than for sepsis patients with liver cirrhosis (OR 1.28 vs. OR 1.10, P =0.027).
Conclusion: Increased lactate level is associated with higher 28-day mortality in the non-elderly sepsis patients, but there is no significant association between the lactate level and 28-day mortality in the elderly group.
... In a retrospective study a steadily increased mortality has been reported in middle-aged (45-64 years), compared to old (65-74 years) and very old ICU patients (> 75 years) [25], with rates increasing from 42.9% to 49.1% and to 56%, respectively. In our study CFR in subjects ≥80 was as high as 35.6%, but the range was extremely wide in relation to the risk score. ...
Background The burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score. Methods We performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009-2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk . Results 2,492 subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009-2010) to 5.4% (2015-2016); P
... In a retrospective study a steadily increased mortality has been reported in middle-aged (45-64 years), compared to old (65-74 years) and very old ICU patients (> 75 years) [25], with rates increasing from 42.9% to 49.1% and to 56%, respectively. In our study CFR in subjects ≥80 was as high as 35.6%, but the range was extremely wide in relation to the risk score. ...
Background: The burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score.Methods: We performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009-2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk . Results: 2,492 subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009-2010) to 5.4% (2015-2016); P
... Respiratory tract infections are also more common causes of sepsis in elderly patients [15]. Relative to the non-elderly, we found that elderly sepsis patients had a higher 28-day mortality rate and that sepsis was more likely to be caused by a respiratory tract infection, in agreement with previous studies [16,17]. In contrast, we found that sepsis in non-elderly patients was more likely to be caused by skin and soft tissue infections. ...
Purpose: We co mpared the use of lactate level for predicting 28-day mortality in non-elderly (<65 years) and elderly (≥65 years) sepsis patients who were admitted to an intensive care unit (ICU). A multivariate logistic regression model was established to predict 28-day mortality for each group.
Methods: This retrospective study used the Medical Information Mart for Intensive Care Ⅲ, a publicly available database of ICUs. Eligible sepsis patients were at least 18 years-old, hospitalized for at least 24 h, and had lactate levels measured in the ICU. Univariate logistic regression analysis and step-wise multivariable logistic regression models were used to identify factors associated with 28-day mortality.
Results: The 28-day mortality was 30.9% among the 2482 patients, and was significantly greater in elderly than non-elderly patients. Within each age group, the lactate level was greater for non-survivors than survivors. Among non-survivors, the lactate level was significantly higher for the non-elderly than the elderly. Adjusted logistic regression analysis showed that non-elderly patients with lactate levels of 2.0–4.0 mmol/L and above 4.0 mmol/L had greater risk of death than those with normal lactate levels. For all patients, the stepwise logistic regression model had an area under the receiver operating curve (AUROC) of 0.752; for non-elderly patients, the model had an AUROC of 0.793; for elderly patients, the model had an AUROC of 0.711. The Hosmer-Lemeshow test indicated acceptable goodness-of-fit for each group (P=0.206, P=0.646, and P= 0.482, respectively).
Conclusion: In our population of sepsis patients, the lactate level was about 0.9 mmol/L lower in elderly non-survivors than non-elderly survivors. A plasma lactate level above 2.0 mmol/L was an independent risk factor for death at 28-days among non-elderly patients. Our logistic regression models effectively predicted 28-day mortality of sepsis patients in different age groups.
... In a retrospective study a steadily increased mortality has been reported in middle-aged (45-64 years), compared to old (65-74 years) and very old ICU patients (> 75 years) [26], with rates increasing from 42.9 to 49.1% and to 56%, respectively. In our study CFR in subjects ≥80 was as high as 35.6%, but the range was extremely wide in relation to the risk score. ...
Background:
The burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score.
Methods:
We performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009-2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk.
Results:
Two thousand four hundred ninety-two subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009-2010) to 5.4% (2015-2016); P < 0.001, accompanied by a reduced CFR (from 38.0 to 18.4%; P < 0.001). A group of 10 variables (admission to intensive care unit, cardio-vascular dysfunction, HIV infection, diabetes, age ≥ 80 years, respiratory diseases, number of organ dysfunction, digestive diseases, dementia and cancer) were selected by the logistic model to predict CFR with good accuracy: AUC 0.873 [0.009]. Along the years CFR decreased from 31.8% (2009-2010) to 25.0% (2015-2016); P = 0.007. The relative proportion of subjects ≥80 years (overall, 52.9% of cases) and classified as high-risk did not change along the years. CFR decreased only in low-risk subjects (from 13.3 to 5.2%; P < 0.001), and particularly in those aged ≥80 (from 18.2 to 6.6%; P = 0.003), but not in high-risk individuals (from 69.9 to 64.2%; P = 0.713).
Conclusion:
Between 2009 and 2016 the incidence of sepsis-related hospitalization increased in a general Italian hospital, with a downward trend in CFR, only limited to low-risk patients and particularly to subjects ≥80 years.
... 6 Os fatores de risco para mortalidade em idosos descritos na literatura são a idade, especialmente acima de 80 anos; escores de gravidade por ponto, como o Acute Physiology and Chronic Health Evaluation (APACHE II); alteração no nível de consciência; presença de infecção; lesão renal aguda (LRA); pós-operatório, principalmente de cirurgia de urgência; e insuficiência cardíaca aguda. [7][8][9][10] O objetivo deste estudo foi avaliar fatores de risco para mortalidade em pacientes idosos com internação em uma UTI. Foram coletados dados clínicos e laboratoriais de todos os pacientes da admissão em UTI até a alta hospitalar ou óbito. ...
... A algunos de los que se intervinieron en el programa de la mañana se les ofreció la posibilidad de irse de alta por la tarde; los que aceptaron, lo hicieron sin que surgiera ningún problema. La estancia media de 1.2 días es acorde a la descrita por otros autores, lo que minimiza el riesgo de una infección nosocomial y limita la morbilidad operatoria 55 . ...
Resumen:
Introducción: La presencia de una masa inguinoescrotal puede plantear dudas en el diagnóstico diferencial entre procesos herniarios y tumores paratesticulares. La mayor parte de estos tumores son benignos, normalmente lipomas. De los malig-nos los más frecuentes son los liposarcomas, la mayoría bien diferenciados pero con capacidad de invasión y recidiva local. Los rabdomiosarcomas son especial-mente agresivos y además muestran tendencia a producir metástasis a distancia.
Caso clínico: Se presenta el caso de un paciente de 76 años intervenido de her-nioplasia inguinal izquierda tipo Lichtenstein que al tercer mes de la cirugía pre-sentó una masa inguinoescrotal de crecimiento lento compatible clínica y ecográfi-camente con recidiva herniaria. El hallazgo intraoperatorio de un tumor graso que infiltraba los elementos del cordón espermático hizo sospechar malignidad. Se realizó tumorectomía, orquiectomía y linfadenectomía locorregional. La confirma-ción diagnóstica se basó en la inmunohistoquímica. Los estudios de extensión y seguimiento no han mostrado evidencias de recidiva tumoral.
Discusión: Se concluye que los liposarcomas del cordón espermático probable-mente estén infradiagnosticados e infratratados al simular tumores benignos como los lipomas.
... Angus et al. reported a steadily increased mortality with patients' age, with a significant peak of almost 40% in patients older Table 2 Risk factors for hospital mortality between elderly and very elderly patients APACHE II acute physiology and chronic health evaluation II, ICU intensive care unit, LOS length of stay, UTI urinary tract infection, SSTI soft and skin tissue infections, ED emergency department *χ2 tests; Ç Student's t tests, $ sepsis resuscitation bundle (six tasks that should begin immediately and be accomplished within the first 6 h of presentation) and the sepsis management bundle (four tasks that should begin immediately and be completed within 24 h of presentation) [8]. In a historical cohort study comparing middle-aged (45-64 years), old (65-74 years), and very old ICU patients (> 75 years), Blot et al. [21] found that mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively. In our study, the very elderly cohort had a lower implementation of resuscitation bundles after sepsis diagnosis. ...
Background
Age has been traditionally considered a risk factor for mortality in elderly patients admitted to intensive care units. The aim of this prospective, observational, multicenter cohort study is to determine the risk factors for mortality in elderly and very elderly critically ill patients with sepsis.
Results
A total of 1490 patients with ≥ 65 years of age were included in the study; most of them 1231 (82.6%) had a cardiovascular failure. The mean age (± SD) was 74.5 (± 5.6) years, and 876 (58.8%) were male. The patients were divided into two cohorts: (1) elderly: 65–79 years and (2) very elderly: ≥ 80 years. The overall hospital mortality was 48.8% (n = 727) and was significantly higher in very elderly compared to elderly patients (54.2% vs. 47.4%; p = 0.02). Factors independently associated with mortality were APACHE II score of the disease, patient location at sepsis diagnosis, development of acute kidney injury, and thrombocytopenia in the group of elderly patients. On the other hand, in the group of very elderly patients, predictors of hospital mortality were age, APACHE II score, and prompt adherence of the resuscitation bundle.
Conclusion
This prospective multicenter study found that patients aged 80 or over had higher hospital mortality compared to patients between 65 and 79 years. Age was found to be an independent risk factor only in the very elderly group, and prompt therapy provided within the first 6 h of resuscitation was associated with a reduction in hospital mortality in the very elderly patients.
... In the United States, over the past ten years, the number of ICU beds per adult population mainly grew in regions with the largest elderly populations [28], with approximately 55% of all intensive care beds being occupied by patients aged 65 or more with 14% of patients 85 or more dying in the ICU setting. A Dutch study, that compared 1996 with 2006, found a 33% increase in number of patients aged 75 or more that needed critical care [29]. This rise in demand for critical care has been reported in North America, Europe, Australia and other regions, but not all patients meeting critical care admission criteria are admitted to such facilities [30,31]. ...
Abstract Background Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009–2013. Methods Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables. Results Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p
... Despite this low admission rate of the elderly into the ICU, it has been projected that the number will steadily increase. Blot and colleagues reported that the number of elderly patients aged 75 years and older rose by about 33% between 1992-1996 and 2002-2006 [8]. This may be due to an increasing demand for ICU care due to aging of the population and increase in conditions like severe sepsis or highrisk surgery that will require care in the ICU [9]. ...
BACKGROUND: The management and outcome of elderly
patients aged 65 years and above admitted to the intensive care
unit (ICU) are often complicated by the presence of comorbidities
and reduced physiological reserve.
METHODOLOGY: This was a retrospective, case-control study.
Patients aged 65 years and above admitted to the unit from
January 2012 to June 2013 were included in the study.
Admission and discharge register in the ICU was examined. A
patient before and after each elderly patient were recruited to
serve as controls in the study.
RESULTS: Seventy-nine (79) elderly patients were admitted to
the ICU and it constituted 12.6% of total ICU admission with
a mortality rate of 49.6%. Male:Female ratio was 2:1.
Postoperative care constituted the highest indication for ICU
admission (41.8%) followed by cerebrovascular accident
(stroke), 12.6%. Younger patients were about twice more
likely to be mechanically ventilated than elderly patients.
(p=0.05, OR=1.855)
CONCLUSION: The mortality rate of elderly patients admitted
to the ICU was high. Appropriate admission criteria and
protocol for the management of elderly patients in the ICU
should, therefore, be developed to improve outcome. WAJM
2018; 35(2): 75–78.
The aim: In order to assess the degree of transforming danger, for face masks, used in the providing respiratory support process to specialized department patients with varying degrees of the COVID-19 course severity, we conducted a series of bacteriological studies into an additional opportunistic bacteria reservoir. With the purpose of assessment of the face respiratory masks inner surface bacterial contamination intensity during their use to provide respiratory support to patients with COVID-19. Materials and methods: A bacteriological study of the inner surface of 60 disposable individual face respiratory masks was carried out at different times of providing respiratory support to patients with COVID-19. Results: It is shown that during use, the inner surface of the respiratory mask is colonized by staphylococci and gram-negative opportunistic bacteria. With increasing time of the mask using, the density of colonization of its inner surface increases. Conclusions: In the process of long-term non-invasive lung ventilation and oxygen therapy for patients with COVID-19, the inner surface of face respiratory masks is colonized with opportunistic bacteria, which creates the risk of contamination by the latter of the pathologically changed lung parenchyma and the addition of secondary bacterial infection.
Introduction
After cardiac surgery, patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have a higher risk of nosocomial infection in the intensive care unit (ICU). We aimed to establish an intuitive nomogram to predict the probability of nosocomial infection in patients on VA-ECMO after cardiac surgery.
Methods
We included patients on VA-ECMO after cardiac surgery between January 2011 and December 2020 at a single center. We developed a nomogram based on independent predictors identified using univariate and multivariate logistic regression analyses. We selected the optimal model and assessed its performance through internal validation and decision-curve analyses.
Results
Overall, 503 patients were included; 363 and 140 patients were randomly divided into development and validation sets, respectively. Independent predictors derived from the development set to predict nosocomial infection included older age, white blood cell (WBC) count abnormality, ECMO environment in the ICU, and mechanical ventilation (MV) duration, which were entered into the model to create the nomogram. The model showed good discrimination, with areas under the curve (95% confidence interval) of 0.743 (0.692–0.794) in the development set and 0.732 (0.643–0.820) in the validation set. The optimal cutoff probability of the model was 0.457 in the development set (sensitivity, 0.683; specificity, 0.719). The model showed qualified calibration in both the development and validation sets (Hosmer–Lemeshow test, p > .05). The threshold probabilities ranged from 0.20 to 0.70.
Conclusions
For adult patients receiving VA-ECMO treatment after cardiac surgery, a nomogram-monitoring tool could be used in clinical practice to identify patients with high-risk nosocomial infections and provide an early warning.
Available data show that the enormous increasing of the geriatric population registered in the last decades has widely impacted with the daily practice in surgery, anesthesia, and intensive care [1]. Not only the volume of surgical interventions performed on older patients and the age at which patients are fit enough to undergo surgery has dramatically increased worldwide, but also, due to both the expanding of the clinical practice and the accumulation of research work, surgical operations today performed on the elderly include a wide spectrum of long-lasting and invasive procedures [2], many of which may require postoperative admission to the ICU. This poses a number of clinical, organizational, economic, and ethical problems.
By completing this chapter, the reader will be able to:
Recognize and define the subject group of interest in the context of this book.
Identify the individual roles caregivers fulfill.
Relate the concept of caregiver burden to caregiving activities including post-intensive care syndrome (PICS-F).
Describe individual consequences and effects of caregiving activities on the caregiver.
Describe coping and support strategies that may be adopted to overcome negative aspects of caregiving.
KeywordsCaregiverCarerCaretakerRelativesFamily members
Aim:
An aging population will lead to an increasing demand for critical care resources. Hence, we evaluated the potential influence of age, comorbidities and sex in plastic and reconstructive patients ≥75 years that were admitted to the intensive care unit (ICU).
Methods:
We included 304 patients who required intensive care between 2000 and 2019. Besides patient demographics, medical case characteristics were statistically evaluated.
Results:
In this study, 184 patients were female (61%) (120 male), the median age was 81.8 years (25th and 75th percentiles: 77.4-87.2) with a range of 75.0-98.9 years. The median length of stay in the ICU was 12 days (25th and 75th percentiles: 3-28) with a range of 0-382 days. The reasons for admission were burn injury (n = 230, 76%), necrotizing fasciitis (n = 34, 11%), non-combustion-related traumas (n = 22, 7%) and postoperative observation after plastic surgery procedures (n = 18, 6%). In total, 108 patients (36%), who were significantly older (P = 0.005) and had a significantly shorter stay (P < 0.001) compared with the surviving cohort, died during their stay in the ICU. Our multivariable logistic regression model revealed that age (odds ratio: 1.05 [1.01, 1.09]; P = 0.017) and number of operations (odds ratio: 0.75 [0.60, 0.96]; P = 0.023) were significant predictors for death in the ICU.
Discussion:
Age plays a critical role in determining fatal outcome of old patients requiring intensive care. In contrast, sex and number of comorbidities shows no significant influence. Geriatr Gerontol Int 2022; ••: ••-••.
BACKGROUND
The objective of this study is to describe the epidemiology and age-related mortality in older critically ill adults with intra-abdominal infections.
METHODS
This is a secondary analysis of a prospective, multinational, observational study (AbSeS, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 ICUs in 42 countries (January-December, 2016). Mortality was considered as ICU mortality with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis.
RESULTS
The cohort included 2337 patients. Four age groups were defined: middle-aged patients as reference category (40-59 years; n=659 [28.2%]), young-old (60-69 years; n=622 [26.6%]), middle-old (70-79 years; n=667 [28.5%]) and very-old patients (≥80 years; n=389 [16.6%]). Secondary peritonitis was the predominant infection (68.7%) and equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old, 31.2% in middle-old, and 44.7% in very-old patients (p<0.001). Compared to middle-aged patients, young-old age (OR 1.62, 95% CI 1.21-2.17), middle-old age (OR 1.80, 95% CI 1.35-2.41), and very-old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes, and malnutrition.
CONCLUSIONS
For ICU patients with intra-abdominal infections, age above 60 years was associated with mortality while patients above 80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all these factors are non-modifiable it remains unclear how to improve outcomes.
Background
Older adults are increasingly admitted to the intensive care unit (ICU) and those with disabilities, dementia, frailty and multimorbidity are vulnerable to adverse outcomes. Little is known about how pre-existing geriatric conditions have changed over time.
Research Question
How have changes in disability, dementia, frailty, and multimorbidity in older adults admitted to the ICU changed from 1998-2015?
Study Design and Methods
Medicare-linked Health and Retirement Survey (HRS) data identifying patients age ≥65 years admitted to an ICU between 1998 and 2015. ICU admission was the unit of analysis. Year of ICU admission was the exposure. Disability, dementia, frailty and multimorbidity were identified based on responses to HRS surveys prior to ICU admission. Disability represented the need for assistance with ≥1 activity of daily living. Dementia used cognitive and functional measures. Frailty included deficits in ≥2 domains (physical, nutritive, cognitive or sensory function). Multimorbidity represented ≥3 self-reported chronic diseases. Time trends in geriatric conditions were modeled as a function of year of ICU admission and adjusted for age, gender, race/ethnicity and proxy interview status.
Results
Across 6084 ICU patients, age at admission increased from 77.6 years (95% CI, 76.7-78.4) in 1998 to 78.7 years (95% CI, 77.5-79.8) in 2015 (p<0.001 for trend). The adjusted proportion of ICU admissions with pre-existing disability rose from 15.5% (95% CI, 12.1-18.8%) in 1998 to 24.0% (95% CI, 18.5-29.6%) in 2015 (p=0.001). Rates of dementia did not change significantly (p=0.21). Frailty increased from 36.6% (95% CI, 30.9-42.3%) in 1998 to 45.0% (95% CI, 39.7-50.2%) in 2015 (p=0.04); multimorbidity rose from 54.4% (95% CI, 49.2-59.7%) in 1998 to 71.8% (95% CI, 66.3-77.2%) in 2015 (p<0.001).
Interpretation
Rates of pre-existing disability, frailty, and multimorbidity in older adults admitted to ICUs increased over time. Geriatric principles need to be deeply integrated into the ICU setting.
Emergence and spread of MDR pathogens have become a major leading cause of death worldwide and a major problem in ICU patients . ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Escherichia coli/Enterobacter cloacae) reflect the strongest challenge today. The increasing prevalence of MDR bacteria is associated with increased 3rd generation cephalosporins-resistant K. pneumoniae and cephalosporins-resistant E. coli which lead to more frequent use of carbapenems and to the emergence of XDR and/
or PDR Enterobacteriaceae. The emergence of carbapenemase producing K. pneumoniae [carbapenemase-producing Enterobacterales (CPE)] is of particular concern in Italy and Greece, the prevalence of vancomycin-resistant Enterococcus (VRE) has also increased, ceftazidime-resistant P. aeruginosa remains stable while a decrease of methicillin-resistant Staphylococcus aureus (MRSA) was observed. These differences vary according to the bacterial species and geographical region. The unsafety of intensivists against a probable infection lead to a massive consumption of antibiotics (up 50% of ICU patients
under empirical antibiotic therapy have no confirmed infection) while de-escalation and shortened treatment duration are considered insufficiently in those with documented infection, promoting substantial ecological side effects and dissemination of MDR pathogens.
Purpose
Older patients are the fastest expanding subgroup of intensive care units (ICU) and are particularly susceptible to bacterial infections and sepsis. The aim of this study was to address the epidemiology and the main determinants of outcome of infection in old and very old patients admitted to ICU.
Methods
We performed a post hoc analysis of all infected patients admitted to ICU enrolled in a 1-year prospective, observational, multipurpose study. Patients aged < 65, 65–74 and ≥ 75 years were compared.
Results
Of the 1652 patients included, 50% were older than 65 years. There were no significant differences between young, old and very old patients in either ICU, hospital length of stay, or nosocomial infection. All-cause mortality was significantly higher in participants aged ≥ 75. Increased Gram-negative microorganisms’ isolates occurred in > 65 years (25% versus 31%; p = 0.034). Multidrug-resistant (MDR) microorganisms were directly associated to inappropriate empiric antibiotic therapy (OR 4.73; 95% CI 2.99–7.47) and inversely associated with community-acquired infection (OR 0.39; 95% CI 0.19–0.83). Age (65–74 years: OR 1.10; 95% CI 0.64–1.90 and ≥ 75 years: OR 1.52; 95% CI 0.89–2.59) and sepsis severity (sepsis: OR 0.67; 95% CI 0.18–2.46; severe sepsis: OR 1.17; 95% CI 0.40–3.44; septic shock: OR 0.77; 95% CI 0.27–2.24) were not associated to MDR bacteria.
Conclusion
Patients > 65 years accounted for 50% of infected patients admitted to an ICU. ICU and hospital length of stay, and nosocomial infection did not increase with age. Age did predispose to increased risk for infection by Gram-negatives. These findings may optimize strategies for infection management in older patients.
Purpose
To provide population-level estimates of the association of frailty with one-year outcomes after critical illness.
Materials and methods
Retrospective cohort study of patients who survived an ICU admission between April 2002 and March 2015. Pre-existing frailty was classified using the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable Cox regression and Fine and Gray models were used to examine the association between frailty and mortality and hospital readmission.
Results
Of 534,991 patients, 19.3% had pre-existing frailty. Compared to non-frail survivors, at one-year frail patients had higher mortality (18.3% vs 9.5%, adjusted HR 1.17 95% CI: 1.15–1.19) and hospital readmission (44.4% vs 36.6%, adjusted HR 1.10 95% CI: 1.08–1.11) and a CAN$19,628 (95% CI: $19,279–$19,997) greater increase in healthcare costs compared to the year prior to hospitalization. The association between frailty and mortality was stronger among older individuals, but the risk of readmission among frail patients decreased with age.
Conclusion
Patients with pre-existing frailty who develop critical illness have higher rates of hospital readmission and death than patients without frailty, and age modifies these associations. These data highlight the importance of considering both frailty and age when seeking to identify at-risk patients who might benefit from closer follow-up after discharge.
Background
In the pre-hospital setting the early identification of septic shock (SS) patients presenting with a high risk of poor outcome remains a daily challenge. The development of a simple score to quickly identify these patients is essential to optimize triage towards the appropriate unit: emergency department (ED) or intensive care unit (ICU).
We report the association between the new SIGARC score and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU).
Methods
SS patients cared for by a MICU between 2017, April 15th, and 2019, December 1st were included in this retrospective study. The SIGARC score consists of the addition of 5 following items (1 point for each one): shock index≥1, Glasgow coma scale<13, age > 65, respiratory rate > 22 and comorbidity defined by the presence of at least 2 underlying conditions among: hypertension, coronaropathy, chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, diabetes mellitus, history of cancer and human immunodeficiency virus infection. A threshold of SIGARC score ≥ 2 was arbitrarily chosen to define severity for its usefulness in clinical practice.
Results
Data from 406 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 71 ± 15 years and 268 of the patients (66%) were male. The presumed origin of SS was pulmonary (42%), digestive (25%) or urinary (17%) infection. Overall in-hospital mortality was 31% with, 30 and 90-day mortality was respectively 28% and 33%. A prehospital SIGARC score ≥ 2 is associated with an increase in 30 and 90-day mortality with HR = 1.57 [1.02–2.42] and 1.82 [1.21–2.72], respectively.
Conclusion
A SIGARC score ≥ 2 is associated with an increase in in-hospital, 30 and 90-day mortality of SS patients cared for by a MICU in the prehospital setting. These observational results need to be confirmed by prospective studies.
Introduction: Elderly patients are at increased risk of developing sepsis and its adverse outcomes. Diagnosing and prognosing sepsis is particularly challenging in older patients, especially early at emergency department (ED) arrival. We aimed to study and compare the characteristics of elderly and very elderly ED patients with sepsis and determine baseline factors associated with in-hospital mortality. We also compared prognostic accuracy of the criteria for systemic inflammatory response syndrome, quick sequential organ failure assessment (qSOFA), and the National Early Warning Score in predicting mortality. Methods: We conducted a retrospective study at the ED of Siriraj Hospital Mahidol University in Bangkok, Thailand. Patients over 18 years old who were diagnosed and treated for sepsis in the ED between August 2018–July 2019 were included. We categorized patients into non-elderly (aged 80 years) groups. The primary outcome was in-hospital mortality. Baseline demographics, comorbidities, source and etiology of sepsis, including physiologic variables, were compared and analyzed to identify predictors of mortality. We calculated and compared the area under the receiver operator characteristics curves (AUROC) of early warning scores. Results: Of 1616 ED patients with sepsis, 668 (41.3%) were very elderly, 512 (31.7%) were elderly, and 436 (27.0%) were non-elderly. The mortality rate was highest in the very elderly, followed by the elderly and the non-elderly groups (32.3%, 25.8%, and 24.8%, respectively). Factors associated with mortality in the very elderly included the following: age; do-not-resuscitate (DNR) status; history of recent admission
Objective: to analyze the international scientific production on elderly patient safety in Intensive Care Unit. Method: bibliometric study carried out on ISI Web of Knowledge / Web of ScienceTM database, with the search terms: “Patient Safety”, “Elderly”, “Intensive Care Units”, performed from exporting these data for the bibliometric analysis software HistCiteTM. Results: 103 publication records were identified, in 85 different journals, written by 679 authors that are associated with 224 institutions, located in 30 countries. In analysis of number of citations count, the h-index value is equal to 24. Conclusion: the theme is presented in a broad and diverse way, without demonstrating the existence of a good articulation among the studies, authors and institutions around the world. There is a need to construct knowledge networks in the field that make possible further studies able to contribute to improve elderly patient safety in intensive care.
Background: A facility within a hospital where surgical operations are carried out in a sterile environment is an operating theatre also known as an operating suite, operation theatre or operation suite. In past, the operation theatre was a place where there was an educational setting have had raised tables or chairs at the centre for performing operations surrounded by several rows of seats for students and other spectators to observe the case in progress. The objective of this research is that to better the efficacy of sterilization of operation theatre to reduce the surgical site infection and contamination at highest level.
Methodology: Data was collected from surgical department of Gulab Devi Chest Hospital. Carbolization was employed to disinfect operating room and fumigation to sterilize. After neutralization with ammonia, culture swabs were collected from OT table, OT light, OT floor, OT wall, anaesthesia machine and OT trolley. Efficacy of fumigation was concluded using statistical tools.
Results: There were no positive results prior and even after the fumigation.
Conclusion: There was no organism growth in OT. There was no evidence of Escherichia coli,
Proteus Mirabilis, Proteus vulgaris, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus spp., E. faecalis, Coagulase negative staph and Salmonella choleraesius.
Cambridge Core - Geriatrics - Principles of Geriatric Critical Care - edited by Shamsuddin Akhtar
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
To evaluate outcome and risk factors, particularly the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, for in-hospital mortality in very elderly patients after admission to an intensive care unit (ICU).
Retrospective chart review of patients > or =85 years admitted to the ICU. We recorded age, sex, previous medical history, primary diagnosis, date of admission and discharge or death, APACHE II score on admission, use of mechanical ventilation and inotropics, and complications during ICU admission.
104 patients > or =85 years (1.3% of all ICU admissions) were studied. The ICU and in-hospital mortality rates for these patients were 22 and 36% respectively. Factors correlated with a greater in-hospital mortality were: an admission diagnosis of acute respiratory failure (chi2; P = 0.007), the use of mechanical ventilation (chi2; P = 0.00005) and inotropes (chi2; P = 0.00001), complications during ICU admission (chi2; P = 0.004), in particular acute renal failure (chi2; P = 0.005), and an APACHE II score > or =25 (chi2; P = 0.001). The APACHE II scoring system and the use of inotropes were independently correlated with mortality.
ICU and in-hospital mortality are higher in very elderly patients, particularly in those with an APACHE II score > or =25. The most important predictors of mortality are the use of inotropes and the severity of the acute illness.
All patients admitted to the medical and surgical intensive care units of a 500-bed nonteaching suburban hospital were followed
prospectively for the occurrence of nosocomial primary bloodstream infections for 21 months. The incidence of primary bloodstream
infection was 38 (1%) of 3163 patients; among patients with central venous catheters, it was 34 (4%) of 920 patients, or 4.0
infections per 1000 catheter-days. Ventilator-associated pneumonia, congestive heart failure, and each intravascular catheter
inserted were independently associated with the development of a nosocomial primary bloodstream infection. Among infected
patients, the crude mortality rate was 53%, and these patients had longer stays in intensive care units and the hospital than
did uninfected patients. Bloodstream infection, however, was not an independent risk factor for death. The incidence, risk
factors, and serious outcomes of bloodstream infections in a nonteaching community hospital were similar to those seen in
tertiary-care teaching hospitals.
A population-based active-surveillance study of the Calgary Health Region (population, 929,656) was conducted from May 1999
to April 2000, to define the epidemiology of invasive Staphylococcus aureus (ISA) infections. The annual incidence was 28.4 cases/100,000 population; 46% were classified as nosocomial. Infection was
most common in people at the extremes of the age spectrum and in males. Several conditions were associated with acquisition
of ISA infection, and the highest risk was observed in persons undergoing hemodialysis or peritoneal dialysis and in persons
infected with human immunodeficiency virus. Forty-six patients (19%) died. Significant independent risk factors for mortality
included positive blood-culture result, respiratory focus, empirical antibiotic therapy, and older age. A higher systolic
blood pressure at presentation was associated with reduced case-fatality rate. ISA infections are common, with several definable
groups of patients at increased risk for acquisition and death from these infections. This study provides important data on
the burden of ISA disease and identifies risk groups that may potentially benefit from preventive efforts
Few studies have investigated the epidemiology of sepsis and septic shock in a large population and none have been from Canada. The objective of this study was to define the epidemiology of bloodstream infection (BSI)-associated sepsis and septic shock among all critically ill patients in a large, fully integrated health region in Canada.
All critically ill adults admitted to multidisciplinary intensive care units (ICU) in the Calgary Health Region during May 1, 1999 to April 30, 2000 were included. Clinical, microbiologic and outcome information was obtained from regional databases.
We surveyed 1981 patients having at least one ICU admission. Systemic inflammatory response syndrome (SIRS) was diagnosed in 92%, BSI-associated sepsis (BSI with SIRS) in 6% and BSI-associated septic shock (BSI with SIRS and hypotension) in 3%; respective hospital mortality rates were 36%, 40% and 49%. The most common BSI etiologies were Staphylococcus aureus, Escherichia coli and Streptococcus species; only one isolate (1%) was highly antibiotic resistant. Independent risk factors for death among patients with SIRS included age (>or= 65), hypothermia (< 35 degrees C), and higher APACHE II and TISS scores. A surgical diagnosis was associated with decreased mortality risk. Neither a positive blood culture nor hypotension at presentation independently predicted death.
Knowledge of the epidemiology of these syndromes is important for assessing the burden of disease and providing background information for investigating new therapies.
The long-term mortality outcome associated with sepsis and septic shock has not been well defined in a nonselected critically ill population. This study investigated the occurrence and the role of bloodstream infection (BSI) associated sepsis and septic shock at time of intensive care unit (ICU) admission on the 1-year mortality of patients admitted to a regional critical care system.
Population-based inception cohort in all adult multidisciplinary and cardiovascular ICUs in the Calgary Health Region (population approx. 1 million) between 1 July 1999 and 31 March 2002.
Adults (>/=18 years; n=4,845) who had at least one ICU admission to CHR ICUs.
In 251 (5%) patients there was BSI-associated sepsis at presentation to ICU, and 159 of these also had septic shock. The 28-day, 90-day, and 1-year mortality rates overall were 18%, 21%, and 24%: 23%, 30%, and 36% for BSI-associated sepsis without shock, and 51%, 57%, and 61% with shock, respectively. Surgical diagnosis, BSI-associated sepsis, and increasing age were independently associated with late (28-day to 1-year) mortality whereas higher APACHE II and TISS scores were associated with reduced odds in logistic regression analysis.
BSI-associated sepsis and septic shock are associated with increased risk of mortality persisting after 28-days up to 1 year or more. Follow-up duration beyond 28 days better defines the burden of illness associated with these syndromes.
Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients.
A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1:2 or 1:1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n = 176) were matched with control subjects (n = 315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patient's hospital invoices.
The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs.
In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.
Malnutrition and its impact on clinical outcome may be underestimated in hospitalised elderly as many screening procedures require measurements of weight and height that cannot often be undertaken in sick elderly patients. The 'Malnutrition Universal Screening Tool' ('MUST') has been developed to screen all adults, even if weight and/or height cannot be measured, enabling more complete information on malnutrition prevalence and its impact on clinical outcome to be obtained. In the present study, 150 consecutively admitted elderly patients (age 85 (sd 5.5) years) were recruited prospectively, screened with 'MUST' and clinical outcome recorded. Although only 56 % of patients could be weighed, all (n 150) could be screened with 'MUST'; 58 % were at malnutrition risk and these individuals had greater mortality (in-hospital and post-discharge, P<0.01) and longer hospital stays (P=0.02) than those at low risk. Both 'MUST' categorisation and component scores (BMI, weight loss, acute disease) were significantly related to mortality (P<0.03). Those patients with no measured or recalled weight ('MUST' subjective criteria used) had a greater risk of malnutrition (P=0.01) and a poorer clinical outcome (P<0.002) than those who could be weighed and, within both groups, clinical outcome was worse in those at risk of malnutrition. The present study suggests that 'MUST' predicts clinical outcome in hospitalised elderly, in whom malnutrition is common (58 %). In those who cannot be weighed, a higher prevalence of malnutrition and associated poorer clinical outcome supports the importance of routine screening with a tool, like 'MUST', that can be used to screen all patients.
Overall rates of bloodstream infection (BSI) are often used as quality indicators in intensive care units (ICUs). We investigated whether ICU-acquired BSI increased mortality (by > or = 10%) after adjustment for severity of infection at ICU admission and during the pre-BSI stay.
We conducted a matched, risk-adjusted (1:n), exposed-unexposed study of patients with stays longer than 72 h in 12 ICUs randomly selected from the Outcomerea database.
Patients with BSI after the third ICU day (exposed group) were matched on the basis of risk-exposure time and mortality predicted at admission using the Three-Day Recalibrated ICU Outcome (TRIO) score to patients without BSI (unexposed group). Severity was assessed daily using the Logistic Organ Dysfunction (LOD) score. Of 3247 patients with ICU stays of >3 days, 232 experienced BSI by day 30 (incidence, 6.8 cases per 100 admissions); among them, 226 patients were matched to 1023 unexposed patients. Crude hospital mortality was 61.5% among exposed and 36.7% among unexposed patients (P<.0001). Attributable mortality was 24.8%. The only variable associated with both BSI and hospital mortality was the LOD score determined 4 days before onset of BSI (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.03-1.16; P = .0025). The adjusted OR for hospital mortality among exposed patients (OR, 3.20; 95% CI, 2.30-4.43) decreased when the LOD score determined 4 days before onset of BSI was taken into account (OR, 3.02; 95% CI, 2.17-4.22; P<.0001). The estimated risk of death from BSI varied considerably according to the source and resistance of organisms, time to onset, and appropriateness of treatment.
When adjusted for risk-exposure time and severity at admission and during the ICU stay, BSI was associated with a 3-fold increase in mortality, but considerable variation occurred across BSI subgroups. Focusing on BSI subgroups may be valuable for assessing quality of care in ICUs.
A point-prevalence study was performed to determine the prevalence of nosocomial infections in University Clinical Center of Kosova. Of 167 surveyed patients, 27 had a total of 29 nosocomial infections, with an overall prevalence rate of 17.4%. Nosocomial bloodstream infections were most prevalent (62%). The prevalence was highest among neonates in intensive-care units (77.8%).
Study objective:
To evaluate the clinical impact of nosocomial Enterobacter bacteremia in critically ill patients.
Design:
Retrospective (January 1992 to December 2000) matched cohort study.
Setting:
Fifty-four-bed ICU (including medical, surgical, cardiosurgical ICU, and burns unit) from a university hospital.
Patients:
Sixty-seven ICU patients with Enterobacter bacteremia (case patients) and 134 control patients.
Intervention:
Matching of control patients (1:2 ratio) was on the basis of the APACHE (acute physiology and chronic health evaluation) II system. As expected, mortality can be derived from this severity-of-disease classification system; this matching procedure results in an equal expected mortality rate for patients with Enterobacter bacteremia and control patients.
Results:
The overall rate of appropriate antibiotic therapy in patients with Enterobacter bacteremia was high (96%) and initiated soon after the onset of the bacteremia (0.5 ± 0.9 days). Patients with Enterobacter bacteremia had more hemodynamic instability (p = 0.015), longer ICU stay (p < 0.001), and ventilator dependence (p < 0.001). No differences between case and control patients were found in age (52 years vs 53 years, p = 0.831), prevalence of acute renal failure (16% vs 16%, p = 0.892), and acute respiratory failure (93% vs 84%, respectively; p = 0.079). In-hospital mortality rates for case and control patients were not different (34% vs 39%, respectively; p = 0.536).
Conclusion:
After accurate adjustment for severity of underlying disease and acute illness, no difference was found between ICU patients with Enterobacter bacteremia and matched control patients. In the presence of fast and appropriate antibiotic therapy, Enterobacter bacteremia does not adversely affect the outcome in ICU patients.
Objective.
—To delineate long-term survival after an episode of bacteremia or fungemia and risk factors for mortality.Design.
—Cohort study.Setting.
—A 900-bed university hospital in Israel.Patients.
—Study group comprising 1991 patients 18 years of age or older in whom bacteremia or fungemia were detected between March 1988 and October 1992, and a control group comprising 1991 inpatients without any infectious diseases, matched for age, sex, department, date of admission, and underlying disorders.Interventions.
—None.Measurements.
—Interval from the date of the first positive blood culture (study group) or from date of the identical hospital day (in the matched control patient) to the date of death as recorded in the Israeli National Population registry or, if alive, to June 1, 1994.Results.
—The median age of patients was 72 years. In the study group, the mortality rate was 26% at 1 month, 43% at 6 months, 48% at 1 year, and 63% at 4 years, and the median survival was 16.2 months. In the control group, the mortality rate was 7% at 1 month, 27% at 1 year, and 42% at 4 years, and the median survival was greater than 75 months (P<.001). Factors significantly and independently associated with mortality in bacteremic patients were functional class (median survival, 0.5 month in bedridden patients), septic shock (median survival, 0.2 month), serum albumin (median survival, 1.1 months in the lowest quartile), serum creatinine (median survival, 2.9 months in the highest quartile), age (median survival, 2.9 months in the highest quartile [age >80 years]), inappropriate empirical antibiotic treatment (median survival, 4.9 months), nosocomial infection (median survival, 9.6 months), and malignancy (median survival, 2.4 months).Conclusions.
—Bacteremia is associated with high short-term mortality, but also a sign of severely curtailed long-term prognosis, especially in patients with low functional capacity, low serum albumin, high serum creatinine, nosocomial infections, malignancy, inappropriate antimicrobial treatment, and septic shock and in elderly patients.(JAMA. 1995;274:807-812)
Objective.
—To determine the prevalence of intensive care unit (ICU)—acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality.
Background. Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients.Methods. A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1 : 2 or 1 : 1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n=176) were matched with control subjects (n=315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patient's hospital invoices.Results. The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs.Conclusions. In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.
To determine the excess mortality attributable to hospital-acquired bloodstream infections, we applied the acute physiology and chronic health evaluation (APACHE) II classification to 34 critically ill patients with this complication. The study included primary bloodstream infections, defined by a positive blood culture at least three days after hospitalization, in the absence of any other apparent source of infection. The most frequent blood isolates included Staphylococcus aureus (39 percent), Gram-negative rods (24 percent), and Candida albicans (15 percent); the spectrum of blood isolates suggested that most infections were related to intravascular catheters. In a control group of intensive care unit patients (n = 384), the death rate predicted by APACHE II was similar to the observed death rate (35.3 vs 37.8 percent). In a subgroup of control patients (n = 34), chosen for APACHE II scores that matched the patients with bloodstream infections, predicted and observed death rates were also similar (53.1 vs 52.9 percent). For patients with bloodstream infections, however, observed mortality (82.4 percent) significantly exceeded the predicted value (54.1 percent, p = 0.025). We conclude that critically ill patients who develop nosocomial bloodstream infections are at greater risk of death than patients with comparable severity of illness without this complication. The difference between the observed and predicted death rates, 28 percent, represents the excess mortality associated with bloodstream infection in critically ill patients.
The influence of patients' age on survival, level of therapy and length of stay was analyzed from data collected in 792 consecutive admissions to eight intensive care units. Mortality rate increased progressively with age; over 65 years of age, it was more than double that of patients under 45 years (36.8% versus 14.8%). However, mortality rate in patients over 75 years was equal to that observed in the 55 to 59 years group. There was a significant relationship between age and acute physiology score (APS) and the influence of age upon outcome decreased when APS increased. The number of TISS (therapeutic intervention scoring system) points delivered to patients increased slightly but significantly with age (r = 0.14). Standard care was responsible for the main part of this increase. Both in survivors and in non-survivors the length of stay was not different comparing the stay of the oldest patient with that of the younger age groups. We conclude that, in ICU patients, age is an important factor of prognosis but not as important as the severity of illness, and that there is no major difference in outcome of patients over 65 years of age compared to the entire study group of ICU patients.
To determine the prevalence of intensive care unit (ICU)-acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality.
A 1-day point-prevalence study.
Intensive care units in 17 countries in Western Europe, excluding coronary care units and pediatric and special care infant units.
All patients (> 10 years of age) occupying an ICU bed over a 24-hour period. A total of 1417 ICUs provided 10 038 patient case reports.
Rates of ICU-acquired infection, prescription of antimicrobials, resistance patterns of microbiological isolates, and potential risk factors for ICU-acquired infection and death.
A total of 4501 patients (44.8%) were infected, and 2064 (20.6%) had ICU-acquired infection. Pneumonia (46.9%), lower respiratory tract infection (17.8%), urinary tract infection (17.6%), and bloodstream infection (12%) were the most frequent types of ICU infection reported. Most frequently reported micro-organisms were Enterobacteriaceae (34.4%), Staphylococcus aureus (30.1%;[60% resistant to methicillin], Pseudomonas aeruginosa (28.7%), coagulase-negative staphylococci (19.1%), and fungi (17.1%). Seven risk factors for ICU-acquired infection were identified: increasing length of ICU stay (> 48 hours), mechanical ventilation, diagnosis of trauma, central venous, pulmonary artery, and urinary catheterization, and stress ulcer prophylaxis. ICU-acquired pneumonia (odds ratio [OR], 1.91; 95% confidence interval[Cl], 1.6 to 2.29), clinical sepsis (OR, 3.50; 95% Cl, 1.71 to 7.18), and bloodstream infection (OR, 1.73; 95% Cl, 1.25 to 2.41) increased the risk of ICU death.
ICU-acquired infection is common and often associated with microbiological isolates of resistant organisms. The potential effects on outcome emphasize the importance of specific measures for infection control in critically ill patients.
To delineate long-term survival after an episode of bacteremia or fungemia and risk factors for mortality.
Cohort study.
A 900-bed university hospital in Israel.
Study group comprising 1991 patients 18 years of age or older in whom bacteremia or fungemia were detected between March 1988 and October 1992, and a control group comprising 1991 inpatients without any infectious diseases, matched for age, sex, department, date of admission, and underlying disorders.
None.
Interval from the date of the first positive blood culture (study group) or from date of the identical hospital day (in the matched control patient) to the date of death as recorded in the Israeli National Population registry or, if alive, to June 1, 1994.
The median age of patients was 72 years. In the study group, the mortality rate was 26% at 1 month, 43% at 6 months, 48% at 1 year, and 63% at 4 years, and the median survival was 16.2 months. In the control group, the mortality rate was 7% at 1 month, 27% at 1 year, and 42% at 4 years, and the median survival was greater than 75 months (P < .001). Factors significantly and independently associated with mortality in bacteremic patients were functional class (median survival, 0.5 month in bedridden patients), septic shock (median survival, 0.2 month), serum albumin (median survival, 1.1 months in the lowest quartile), serum creatinine (median survival, 2.9 months in the highest quartile), age (median survival, 2.9 months in the highest quartile [age > 80 years]), inappropriate empirical antibiotic treatment (median survival, 4.9 months), nosocomial infection (median survival, 9.6 months), and malignancy (median survival, 2.4 months).
Bacteremia is associated with high short-term mortality, but also a sign of severely curtailed long-term prognosis, especially in patients with low functional capacity, low serum albumin, high serum creatinine, nosocomial infections, malignancy, inappropriate antimicrobial treatment, and septic shock and in elderly patients.
To evaluate the influence of functional status on the outcome in older patients with bacteremia.
Prospective study of all episodes of bacteremia that occurred in adults during a 27-month period (January 1991 to March 1993).
A 280-bed community hospital.
During the study period, bacteremia was diagnosed in 242 consecutive patients (incidence of 11.2 bacteremic episodes per 1000 hospital admissions). One hundred twenty-seven of these patients were 65 years of age or older, and 115 were less than age 65.
On identification of a positive blood culture, data on demographics, clinical findings, and a series of factors frequently cited as predisposing to infection were collected. The patient's functional status was assessed using the Barthel index (a score of < 60 identifies moderately and highly dependent patients).
The overall mortality rate was 14.9% (36 of 242). In the univariate analysis, mortality was associated significantly with age greater than 65 years, nosocomial infection, absence of fever, shock, leukocytosis or leukopenia, inappropriate therapy, more than one underlying disease, immuno-compromised state, and limited functional status. Multiple logistic regression analysis revealed that shock (OR = 27.6, 95% CI 5.7-133), a Barthel score less than 60 (OR = 11.7, 95% CI 3.2-43), nosocomial infection (OR = 6.7, 95% CI 1.8-25.5), absence of fever (OR = 5.2, 95% CI 1.05-26), and immunocompromised state (OR = 15.6, 95% CI 2.4-101.5) were significantly associated with death attributable to bacteremia.
The main prognostic factors in a patient with bacteremia were the presence of shock, impaired functional status, immunodeficiency state, acquisition of infection in the hospital, and absence of fever on admission. Age alone did not influence outcome.
Primary nosocomial bloodstream infection (BSI) is a common occurrence in the intensive care unit (ICU) and is associated with a crude mortality of 31.5 to 82.4%. However, an accurate estimate of the attributable mortality has been limited because of confounding by severity of illness. We undertook this study to assess the attributable mortality and costs associated with an episode of BSI. Infected patients were defined as those who had an episode of BSI during the study period. Uninfected control subjects were matched to the infected patients based upon a number of factors, including predicted mortality on the day prior to infection. The main outcome measures were crude ICU mortality, length of stay, and costs. We found no difference in the crude mortality for the infected and the uninfected patients (35.3 and 30.9%, respectively, p = 0.51). However, among survivors, the patients with nosocomial bloodstream infections did have excess length of stay (mean, 10 d; median, 5 d; p = 0.007) and increased direct costs (mean difference, $34,508; p = 0.008). After matching for severity of illness, we could not detect an association between primary nosocomial bloodstream infections and increased ICU mortality. We did find that primary nosocomial bloodstream infections increased ICU length of stay and costs.
To study the outcomes of elderly patients in a high-dependency care unit and to evaluate the costs and benefits of a geriatric high-dependency unit (GHDU).
Prospective data collection and analysis.
Geriatric high-dependency unit.
One hundred fifty patients > or =70 yrs of age who had been admitted to the GHDU over a 10-month period were investigated during their treatment and rehabilitation.
The patients' Acute Physiology and Chronic Health Evaluation (APACHE) II scores and Simplified Acute Physiology Scores (SAPS) were recorded. The APACHE II scores and SAPSs provided a close correlation with the patients' mortality (correlation coefficients were 0.97 and 0.92, respectively). The SAPS proved to have a better linear relationship with the elderly patients' mortality in comparison with APACHE II scores. Most of the elderly patients included in the study were suffering from multiple premorbid medical problems. Overall, the mortality rate up to 1 month after discharge from the hospital was 48%. For patients ranging in age from 70 to 84 yrs, the 1-month mortality was 39.6%; however, for patients > or =85 yrs of age, the 1-month mortality was 68.1%. The mortality ratio was 0.96 (for all patients), 0.88 (for those ages 70-84 yrs), and 1.05 (for those age 85 yrs and above). For patients with nil organ system failure, the mortality rate was 32%. For patients with one organ system failure, the mortality increased to 48%. For patients with two organ system failures, the mortality rate was 86%. Survival for patients with three or more organ system failures was unprecedented. Survivors and nonsurvivors were compared. Three poor-prognosis groups were identified: group 1, patients who had received preadmission cardiopulmonary resuscitation; group 2, patients with a recent history of malignant diseases; and group 3, patients who had been mechanically ventilated. All three groups had a significantly higher mortality than those without these factors (p<.05). Patients in the 85 yrs and above group had a significantly higher mortality rate than those in the 70- to 84-yr age group (p<.05). Patients with SAPS and APACHE II scores >20 and >30, respectively, had a poor prognosis. The geriatric outcome scoring system (GOSS) was used as the functional outcome test for the survivors. The GOSS has three components: activities of daily living, mobility status, and social condition. At 1 month after discharge, 66.7% of the survivors returned to their premorbid activities of daily living abilities, 79.5% maintained their mobility status, and 91.7% remained at the same social environment. No survivors deteriorated more than one grade in any of the three components measured by the GOSS. The severity-of-illness scores, percentage of mechanical ventilation utilization, mortality rate, length of GHDU stay, and total hospital stay were comparable with those of other intensive care units (ICUs). The cost of 1 GHDU bed-day was equivalent to 24% of 1 ICU bed-day.
The prognostic information that we gathered from an unselected group of critically ill elderly patients is useful. The GHDU achieved treatment results similar to those achieved by an ICU and is therefore seen as an innovative way of treating critically ill elderly patients. High-dependency care for the elderly patient is worthwhile.
The elderly population will grow rapidly over the next 25 years. The majority of patients with serious or life-threatening infections will be old. It is imperative that primary care physicians and infectious diseases specialists become aware of and knowledgeable about the special and unique aspects of infections in the geriatric population.
Infections in the elderly, similar to other acute illnesses in this age group, may present in atypical, nonclassical fashions.
Fever, the cardinal sign of infection, may be absent or blunted 20%–30% of the time. An absent or blunted fever response may
in turn contribute to diagnostic delays in this population, which is already at risk for increased morbidity and mortality
due to infection. On the other hand, the presence of a fever in the geriatric patient is more likely to be associated with
a serious viral or bacterial infection than is fever in a younger patient. Finally, a diagnosis can be made in the majority
of cases of fever of unknown origin (FUO) in the elderly. FUO is often associated with treatable conditions in this age group.
To examine the outcome, functional autonomy, and quality of life of elderly patients (> or = 70 yrs old) hospitalized for >30 days in an intensive care unit (ICU).
Prospective cohort study.
A ten-bed, medical-surgical ICU in a 460-bed, acute care, tertiary, university hospital.
A consecutive cohort of 75 patients, >70 yrs old, admitted to the ICU from January 1, 1993, to August 1, 1998, for >30 days.
None.
Severity at admission and of the underlying disease was estimated according to the Simplified Acute Physiologic Score (SAPS II), the Organ Dysfunction and/or Infection (ODIN) score, the McCabe score, and the Knaus classification. Therapeutic intensity was measured through the French Omega scoring system. All patients were mechanically ventilated during their ICU stay. Outcome measurements were made by two cross-sectional studies using telephone interviews on the first week of September 1996 and 1998 with a questionnaire including measures of functional capacity by Katz's Activities of Daily Living, modified Patrick's Perceived Quality of Life score, and the Nottingham Health Profile. The survival rate was 67% in the ICU and 47% in the hospital. A total of 30 patients were alive and able to participate in at least one of the cross-sectional studies. Independence in activities of daily living was decreased significantly after the ICU stay, except for feeding. However, most of the 30 patients remained independent (class A of the Activities of Daily Living index) with the possibility of going home. Perceived Quality of Life scores remained good, even if the patients estimated a decrease in their quality of life for health and memory. Return to society appeared promising regarding patient self respect and happiness with life. The estimated cost by survivor was of 55,272 EUR ($60,246 US).
This study suggests that persistent high levels of ICU therapeutic intensity were associated with a reasonable hospital survival in elderly patients experiencing prolonged mechanical ventilatory support. These patients presented a moderate disability that influenced somewhat their perceived quality of life. These results are sufficient to justify prolonged ICU stays for elderly patients.
In a retrospective study (1 January 1992-12 December 1998), we investigated population characteristics and outcome in critically ill patients with fungaemia involving C. albicans (n=41) and C. glabrata (n=15). Patients with C. glabrata fungaemia were significantly older compared with patients in the C. albicans group (P=0.024). There were no other differences in population characteristics or severity of illness. Logistic regression analysis showed age (P=0.021), the presence of a polymicrobial blood stream infection (P=0.039), and renal failure (P=0.044) to be independent predictors of mortality. There was no significant difference in in-hospital mortality between the C. glabrata and C. albicans groups (60.0% vs. 41.5%; P=0.24). Since age was an independent predictor of mortality, the trend towards a higher mortality in patients with C. glabrata can be explained by this population being significantly older. In conclusion, we found no difference in mortality between patients with fungaemia involving C. albicans and C. glabrata.
The relation between older age and nosocomial infection and mortality in the intensive care unit (ICU) is still a controversial issue.
The authors prospectively studied 406 patients admitted to a surgical ICU, 106 of whom were more than 75 yr old. Information concerning ICU-acquired nosocomial infections, severity of illness, therapeutic activity, and hospital outcome was collected. A Cox proportional hazard analysis was used to evaluate potential risk factors for ICU-acquired nosocomial infections, ICU, and hospital death.
During their ICU stay, 23 elderly patients experienced 40 nosocomial infections, 28 "young" patients (< 60 yr) experienced 54 nosocomial infections, and 52 "intermediate age" patients (60-75 yr) experienced 98 nosocomial infections. Incidence density of nosocomial infections was 4.9% patient days for elderly patients, 4.7% for young patients, and 6.0% for intermediate age patients (no significance). The frequency distribution of the various microorganisms isolated was similar between the three groups. Compared with younger patients, elderly patients had a higher Acute Physiology and Chronic Health Evaluation II score and a higher ICU and hospital mortality rate. Despite a higher level of severity of illness, elderly patients had a reduction of therapeutic activity. However, Cox proportional hazard analysis showed that age more than 75 yr was not a risk factor for ICU-acquired nosocomial infection, ICU, or hospital death.
In patients referred to a surgical ICU after a surgical procedure, age more than 75 yr by itself does not appear to be a significant predictor of ICU-acquired nosocomial infection or mortality rate during the ICU stay. However, it appears that patients more than 60 yr have a higher incidence of nosocomial infection in ICU.
We studied a cohort of 2201 patients hospitalized in 15 French intensive care units (ICUs) for > or = 48 h during a 4-mo period to assess the incidence and outcomes of primary and definite catheter-related bloodstream (CRB) or secondary nosocomial bloodstream infection (NBSI). Variables associated with ICU death and duration of stay were determined by logistic regression, and attributable mortality and length of stay (LOS) from a nested matched case-control (96 pairs) study, stratified on the source of bacteremia. Bacteremia occurred in 5% (95% CI 4.1-6%) of patients with > or = 48 h ICU stay. Primary, CRB, and secondary NBSI accounted for 29%, 26%, and 45% of the 111 episodes, respectively. NBSI was associated with a markedly increased risk of death (OR = 4.6; 95% CI 2.9-7.1) and an attributable mortality of 35% (95% CI, 28%-47%). In the case-control study, the excess mortality was 20% (p = 0.03) in patients with primary bacteremia and CRB, and 55% (p < 0.001) for secondary bacteremia; in patients with CRB only, the excess mortality was 11.5%. The median excess ICU LOS in survivors of NBSI was 9.5 d, and was similar, irrespective of its source. The risk of mortality associated with primary and catheter-related bacteremia appears much lower than that of secondary bacteremia, but is sizable, and the excess LOS incurred by the various categories of bacteremia is comparable. Differentiating catheter-related bacteremia from both primary and other secondary bacteremia appears warranted in studies conducted in critically ill patients.
Population characteristics and outcomes were retrospectively compared for critically ill patients with nosocomial bacteremia
caused by antibiotic-susceptible (AB-S; n = 208) or antibiotic-resistant (AB-R; n = 120) gram-negative bacteria. No significant differences in severity of illness and comorbidity factors were seen between
groups. Patients with bacteremia caused by AB-R strains had a longer hospitalization before the onset of the bacteremia. The
in-hospital mortality for patients with bacteremia caused by AB-S strains was 41.8%; for patients infected with AB-R strains,
it was 45.0% (P = .576). A multivariate survival analysis demonstrated that older age (P = .009), a high-risk source of bacteremia (abdominal and lower respiratory tract; P = .031), and a high acute physiology and chronic health evaluation II-related expected mortality (P = .032) were independently associated with in-hospital mortality (P < .05). Antibiotic resistance in nosocomial bacteremia caused by gram-negative bacteria does not adversely affect the outcome
for critically ill patients.
In order to determine the clinical impact of Klebsiella bacteremia on critically ill patients, a matched cohort study was conducted between January 1992 and December 2000. During the study period, all intensive care unit (ICU) patients with nosocomial Klebsiella bacteremia were defined as cases (n=52), but two of these patients were excluded from the matched cohort due to incomplete medical records. The remaining 50 patients were matched at a ratio of 1:2 with control patients (n=100) on the basis of the APACHE II severity of disease classification system. Patients with Klebsiella bacteremia experienced acute renal failure and hemodynamic instability more often than controls. They also had a longer ICU stay and longer ventilator dependence. In-hospital mortality rates for cases and controls were nearly equal (36% vs. 37%, respectively; P=0.905). In conclusion, after adjusting accurately for severity of underlying disease and acute illness, no difference in mortality was found between ICU patients with Klebsiella bacteremia and their matched control subjects.
Throughout the history of mankind, infectious diseases have remained a major cause of death and disability. Although industrialized nations, such as the United States, have experienced significant reductions in infection-related mortality and morbidity since the beginning of the "antibiotic era," death and complications from infectious diseases remain a serious problem for older persons. Pneumonia is the major infection-related cause of death in older persons, and urinary tract infection is the most common bacterial infection seen in geriatric patients. Other serious and common infections in older people include intra-abdominal sepsis, bacterial meningitis, infective endocarditis, infected pressure ulcers, septic arthritis, tuberculosis, and herpes zoster. As a consequence, frequent prescribing of antibiotics for older patients is common practice. The large volume of antibiotics prescribed has contributed to the emergence of highly resistant pathogens among geriatric patients, including methicillin-resistant Staphylococcus aureus, penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant enterococci, and multiple-drug-resistant gram-negative bacilli. Unless preventive strategies coupled with newer drug development are established soon, eventually clinicians will be encountering infections caused by highly resistant pathogens for which no effective antibiotics will be available. Clinicians could then be experiencing the same frustrations of not being able to treat infections effectively as were seen in the "pre-antibiotic era."
To compare the epidemiological and microbiological characteristics of bloodstream infection (BSI) between the young old (65-75), old (76-85), and old old (>85).
Retrospective study.
Forty-six hospitals in southeast France.
One thousand seven hundred forty patients aged 65 and older with BSI, seen between January 1 and December 31, 1998.
Epidemiological and microbiological data and outcome.
Community-acquired BSIs (CABSIs) were significantly more frequent in the old old, but microbiological data were similar to those in the young-old group. Conversely, microbiological data were significantly different for nosocomial BSIs (NSBIs). Escherichia coli was the main pathogen in the old old and Staphylococcus aureus in the young old. Mortality was independently associated with the presence of methicillin-resistant S. aureus in NSBI and CABSI.
The differences in NBSI are important in serious infectious diseases and often require empirical antibiotic therapy. Age is also a risk factor but only for CABSI and suggests that the old-old patients represent a frail population in the community. Further prospective studies are needed to confirm these findings and analyze predisposing factors.
Average life expectancy throughout developed countries has rapidly increased during the latter half of the 20th century and geriatric infectious diseases have become an increasingly important issue. Infections in the elderly are not only more frequent and more severe, but they also have distinct features with respect to clinical presentation, laboratory results, microbial epidemiology, treatment, and infection control. Reasons for increased susceptibility include epidemiological elements, immunosenescence, and malnutrition, as well as a large number of age-associated physiological and anatomical alterations. Moreover, ageing may be the cause of infection but infection can also be the cause of ageing. Mechanisms may include enhanced inflammation, pathogen-dependent tissue destruction, or accelerated cellular ageing through increased turnover. In most instances, treatment of infection leads to a satisfactory outcome in the elderly. However, in palliative care situations and in patients with terminal dementia, the decision whether or not to treat an infectious disease is becoming a difficult ethical issue.
To determine whether nosocomial candidemia is associated with increased mortality in intensive care unit (ICU) patients.
We performed a retrospective (1992 to 2000) cohort study of 73 ICU patients with candidemia and 146 matched controls. Controls were matched based on disease severity as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/- 1 point), diagnostic category, and length of ICU stay before onset of candidemia.
In comparison with the control group, patients with candidemia developed more acute respiratory failure (97% [n = 71] vs. 88% [n = 129], P = 0.03) during their ICU stay. They were mechanically ventilated for a longer period (29 +/- 26 days vs. 19 +/- 19 days, P<0.01) and had a longer stay in the ICU (36 +/- 33 days vs. 25 +/- 23 days, P = 0.02) as well as in the hospital (77 +/- 81 days vs. 64 +/- 69 days, P = 0.04). There was no difference in in-hospital mortality between the groups (48% [n = 35] vs. 43% [n = 62], P = 0.44), a difference of 5% (95% confidence interval [CI]: -8% to 19%). In a multivariate analysis, older age (hazard ratio [HR] = 1.13 per 10 years; 95% CI: 1.04 to 1.23; P = 0.004), acute renal failure (HR = 1.4; 95% CI: 1.1 to 2.0; P = 0.02), and unfavorable APACHE II scores (HR = 1.10 per 5 points; 95% CI: 1.00 to 1.20; P = 0.05) were independent predictors of mortality. Candidemia was not associated with mortality in a model that adjusted for these factors (HR = 0.9; 95% CI: 0.7 to 1.2; P = 0.53).
Nosocomial candidemia does not adversely affect the outcome in ICU patients in whom mortality is attributable to age, the severity of underlying disease, and acute illness.
In a retrospective study, population characteristics and outcome were investigated in intensive care unit (ICU) patients with hospital-acquired Pseudomonas aeruginosa bacteraemia admitted over a seven-year period (January 1992 through December 1998). A matched cohort study was performed in which all ICU patients with P. aeruginosa bacteraemia were defined as cases (N=53). Matching (1:2 ratio) of the controls (N=106) was based on the APACHE II classification: an equal APACHE II score (+/-1 point) and an equal diagnostic category. Patients with P. aeruginosa bacteraemia had a higher incidence of acute respiratory failure, haemodynamic instability, a longer ICU stay and length of ventilator dependence (P<0.05). In-hospital mortalities for cases and controls were 62.3 vs. 47.2% respectively (P=0.073). Thus, the attributable mortality was 15.1% (95% confidence intervals: -1.0-31.2). In a multivariate survival analysis the APACHE II score was the only variable independently associated with mortality. In conclusion, P. aeruginosa bacteraemia is associated with a clinically relevant attributable mortality (15%). However, we could not find statistical evidence of P. aeruginosa being an independent predictor of mortality.
To determine epidemiology and risk factors for nosocomial infections in intensive care unit (ICU). DESIGN. Prospective incidence survey.
An adult general ICU in a university hospital in western Turkey.
All patients who stayed more than 48 h in ICU during a 2-year period (2000-2001).
The study included 434 patients (7394 patient-days). A total of 225 infections were identified in 113 patients (26%). The incidence and infection rates were 56.8 in 1000-patient days and 51.8%, respectively. The infections were pneumonia (40.9%), bloodstream (30.2%), urinary tract (23.6%) and surgical site infections (5.3%). Pseudomonas aeruginosa (22.6%), methicillin-resistant Staphylococcus aureus (22.2%) and Acinetobacter spp. (11.9%) were frequently isolated micro-organisms. Median length of stay with nosocomial infection and without were 13 days (Interquartile range, IQR, 20) and 2 days (IQR, 2), respectively ( P<0.0001). In logistic regression analysis, mechanical ventilation [odds ratio (OR): 16.35; 95% confidence interval (CI): 8.26-32.34; P<0.0001), coma (OR: 15.04; 95% CI: 3.41-66.33; P=0.0003), trauma (OR: 10.27; 95% CI: 2.34-45.01; P=0.002), nasogastric tube (OR: 2.94; 95% CI: 1.47-5.90; P=0.002), tracheotomy (OR: 5.77; 95% CI: 1.10-30.20; P=0.04) and APACHE II scores 10-19 (OR: 10.80; 95% CI: 1.10-106.01; P=0.04) were found to be significant risk factors for nosocomial infection. Rate of nosocomial infection increased with the number of risk factors (P<0.0001). Mortality rates were higher in infected patients than in non-infected patients (60.9 vs 22.1%; P<0.0001).
These data suggest that, in addition to underlying clinical conditions, some invasive procedures can be independent risk factors for nosocomial infection in ICU.
To evaluate excess mortality in critically ill patients with Escherichia coli bacteremia after adjustment for severity of illness.
Retrospective (1992-2000), pairwise-matched (1:2), risk-adjusted cohort study.
Fifty-four-bed ICU in a university hospital including a medical and surgical ICU, a unit for care after cardiac surgery, and a burns unit.
ICU patients with nosocomial E. coli bacteremia (defined as cases; n = 64) and control-patients without nosocomial bloodstream infection (n = 128).
Case-patients were matched with control-patients on the basis of the Acute Physiology and Chronic Health Evaluation (APACHE) II system: an equal APACHE II score (+/- 2 points) and diagnostic category. In addition, control-patients were required to have an ICU stay at least as long as that of the respective case-patients prior to onset of the bacteremia.
The overall rate of appropriate antibiotic therapy in patients with E. coli bacteremia was high (93%) and such therapy was initiated soon after onset of the bacteremia (0.6 +/- 1.0 day). ICU patients with E. coli bacteremia had more acute renal failure. No differences were noted between case-patients and control-patients in incidence of acute respiratory failure, hemodynamic instability, or age. No differences were observed in length of mechanical ventilation or length of ICU stay. In-hospital mortality rates for cases and controls were not different (43.8% and 45.3%, respectively; P = .959).
After adjustment for disease severity and acute illness and in the presence of adequate antibiotic therapy, no excess mortality was found in ICU patients with E. coli bacteremia.
Critically ill patients, eligible for admission into intensive care units (ICUs), are often hospitalized in other wards due to a lack of ICU beds. Differences in morbidity between patients managed in ICUs and elsewhere are unknown, specifically the morbidity related to hospital-acquired infection. Patients fitting ICU admission criteria were identified by screening five entire hospitals on four separate days. Hospital infections within a 30-day follow-up period were compared in ICU patients and in patients on other wards using Kaplan-Meier curves. Residual differences in the patients' case mix between ICUs and other wards were adjusted for utilizing multivariate Cox models. Of 13415 patients screened, 668 were critically ill. The overall infection rates (per 100 patient-days) were 1.2 for bloodstream infection (BSI) and 1.9 for urinary tract infection (UTI). The adjusted hazard ratios in ICU patients compared with patients on regular wards were 3.1 (P<0.001) for BSI and 2.5 (P<0.001) for UTI. This increased risk persisted even after adjusting for the disparity in the number of cultures sent from ICUs compared with ordinary wards. No interdepartmental differences were found in the rates of pneumonia, surgical wound infections and other infections. Minimizing the differences between characteristics of patients hospitalized in ICUs and in other wards, and controlling for the higher frequency of cultures sent from ICUs did not eliminate the increased risk of BSI and UTI associated with admission into ICUs.
To evaluate the impact of methicillin resistance in Staphylococcus aureus on mortality, length of hospitalization, and hospital charges.
A cohort study of patients admitted to the hospital between July 1, 1997, and June 1, 2000, who had clinically significant S. aureus bloodstream infections.
A 630-bed, urban, tertiary-care teaching hospital in Boston, Massachusetts.
Three hundred forty-eight patients with S. aureus bacteremia were studied; 96 patients had methicillin-resistant S. aureus (MRSA). Patients with methicillin-susceptible S. aureus (MSSA) and MRSA were similar regarding gender, percentage of nosocomial acquisition, length of hospitalization, ICU admission, and surgery before S. aureus bacteremia. They differed regarding age, comorbidities, and illness severity score.
Similar numbers of MRSA and MSSA patients died (22.9% vs 19.8%; P = .53). Both the median length of hospitalization after S. aureus bacteremia for patients who survived and the median hospital charges after S. aureus bacteremia were significantly increased in MRSA patients (7 vs 9 days, P = .045; 19,212 dollars vs 26,424 dollars, P = .008). After multivariable analysis, compared with MSSA bacteremia, MRSA bacteremia remained associated with increased length of hospitalization (1.29 fold; P = .016) and hospital charges (1.36 fold; P = .017). MRSA bacteremia had a median attributable length of stay of 2 days and a median attributable hospital charge of 6916 dollars.
Methicillin resistance in S. aureus bacteremia is associated with significant increases in length of hospitalization and hospital charges.
To evaluate the clinical impact of nosocomial Enterobacter bacteremia in critically ill patients.
Retrospective (January 1992 to December 2000) matched cohort study.
Fifty-four-bed ICU (including medical, surgical, cardiosurgical ICU, and burns unit) from a university hospital.
Sixty-seven ICU patients with Enterobacter bacteremia (case patients) and 134 control patients.
Matching of control patients (1:2 ratio) was on the basis of the APACHE (acute physiology and chronic health evaluation) II system. As expected, mortality can be derived from this severity-of-disease classification system; this matching procedure results in an equal expected mortality rate for patients with Enterobacter bacteremia and control patients.
The overall rate of appropriate antibiotic therapy in patients with Enterobacter bacteremia was high (96%) and initiated soon after the onset of the bacteremia (0.5 +/- 0.9 days). Patients with Enterobacter bacteremia had more hemodynamic instability (p = 0.015), longer ICU stay (p < 0.001), and ventilator dependence (p < 0.001). No differences between case and control patients were found in age (52 years vs 53 years, p = 0.831), prevalence of acute renal failure (16% vs 16%, p = 0.892), and acute respiratory failure (93% vs 84%, respectively; p = 0.079). In-hospital mortality rates for case and control patients were not different (34% vs 39%, respectively; p = 0.536).
After accurate adjustment for severity of underlying disease and acute illness, no difference was found between ICU patients with Enterobacter bacteremia and matched control patients. In the presence of fast and appropriate antibiotic therapy, Enterobacter bacteremia does not adversely affect the outcome in ICU patients.
To study the occurrence of multiple-drug-resistant pathogens in nosocomial bloodstream infection associated with pneumonia. To evaluate prediction of multiple drug resistance by systematic surveillance cultures.
A retrospective study of a prospectively gathered cohort.
Fifty-four-bed adult medical-surgical intensive care unit of a tertiary hospital.
One hundred twelve intensive care unit patients with nosocomial bloodstream infection associated with pneumonia from 1992 through 2001.
None.
Concordance of blood cultures with prior surveillance culture was assessed. Surveillance cultures were taken routinely as thrice weekly urinary cultures and oral swabs, once weekly anal swabs, and thrice weekly tracheal aspirates in intubated patients. Tracheal surveillance cultures from 48 to 96 hrs before bloodstream infection and surveillance cultures from any site during the same intensive care unit episode but >or=48 hrs before bloodstream infection were evaluated separately. Forty-four bloodstream infections (39%) were caused by a multiple-drug-resistant pathogen. Multiple-drug-resistant pathogens were predicted by tracheal surveillance culture in 70% (concordant); in 15%, tracheal surveillance culture grew a multiple-drug-resistant pathogen not found in blood cultures (discordant). Multiple-drug-resistant pathogens were predicted by any surveillance culture in 88%, but these surveillance cultures grew additional multiple-drug-resistant pathogens not causing bloodstream infection in up to 46% of patients. In 86% of bloodstream infections, early (i.e., within 48 hrs) antibiotic therapy was appropriate. Patients were divided into four risk categories for multiple-drug-resistant bloodstream infection based on length of prior intensive care unit stay and prior antibiotic exposure. In patients with two risk factors, knowledge of surveillance cultures increased appropriateness of early antibiotic therapy from 75-79% to 90% (p<.05) while limiting use of broad-spectrum antibiotics such as antipseudomonal betalactams, fluoroquinolones, and carbapenems.
In our intensive care unit, tracheal surveillance culture predicted multiple-drug-resistant etiology of bloodstream infection associated with pneumonia in 70% of patients but yielded discordant resistant pathogens in 15%. In the subgroup of patients with two risk factors for multiple-drug-resistant infection, incorporating results of surveillance cultures moderately contributed to adequacy of early antibiotic therapy while limiting antibiotic consumption.
Intensive care unit-acquired (ICU-acquired) bloodstream infections (BSI) are an important complication of critical illness. The objective of this study was to quantify the excess length of stay, mortality and cost attributable to ICU-acquired BSI. A matched cohort study was conducted in all adult ICUs in the Calgary Health Region between 1 May 2000 and 30 April 2003. One hundred and forty-four patients with ICU-acquired BSI were matched (1:1) to patients without ICU-acquired BSI. Patients with ICU-acquired BSI had a significantly increased median length of ICU stay {15.5 [interquartile range (IQR) 8-26] days vs 12 [IQR 7-18.5] days, P=0.003} and median costs of hospital care [85,137 dollars (IQR 45,740-131,412 dollars) vs 67,879 dollars (IQR 35,043-115,915 dollars, P=0.02) compared with patients without ICU-acquired BSI. The median excess length of ICU stay was two days and the median cost attributable to ICU-acquired BSI was 12,321 dollars per case. Sixty (42%) of the cases died compared with 37 (26%) of the controls [P=0.002, attributable mortality 16%, 95% confidence interval (CI) 5.9-26.0%]. Patients with ICU-acquired BSI were at increased risk for in-hospital death (odds ratio=2.64, 95%CI 1.40-5.29). Among survivor-matched pairs, the median excess lengths of ICU and hospital stay attributable to development of ICU-acquired BSI were two and 13.5 days, respectively, and the attributable cost due to ICU-acquired BSI was 25,155 dollars per case survivor. Critically ill patients who develop ICU-acquired BSI suffer excess morbidity and mortality, and incur significantly increased healthcare costs. These data support expenditures on infection prevention and control programmes and further research into reducing the impact of these infections.
To determine whether the systemic inflammatory response syndrome (SIRS), clinical course, and outcome of monomicrobial nosocomial bloodstream infection (BSI) due to Pseudomonas aeruginosa or Enterococcus spp. is different in elderly patients than in younger patients.
Historical cohort study.
An 820-bed tertiary care facility.
One hundred twenty-seven adults with P. aeruginosa or enterococcal BSI.
SIRS scores were determined 2 days before the first positive blood culture through 14 days afterwards. Elderly patients (> or =65, n=37) were compared with nonelderly patients (<65, n=90). Variables significant for predicting mortality in univariate analysis were entered into a logistic regression model.
No difference in SIRS was detected between the two groups. No significant difference was noted in the incidence of organ failure, 7-day mortality, or overall mortality between the two groups. Univariate analysis revealed that Acute Physiology And Chronic Health Evaluation (APACHE) II score of 15 or greater at BSI onset; adjusted APACHE II score (points for age excluded) of 15 or greater at BSI onset; and respiratory, cardiovascular, renal, hematological, and hepatic failure were predictors of mortality. Age, sex, use of empirical antimicrobial therapy, and infection with imipenem-resistant P. aeruginosa or vancomycin-resistant enterococci did not predict mortality. Multivariate analysis revealed that hematological failure (odds ratio (OR)=8.1, 95% confidence interval (CI)=2.78-23.47), cardiovascular failure (OR=4.7, 95% CI=1.69-13.10), and adjusted APACHE II > or = 15 at BSI onset (OR=3.1, 95% CI=1.12-8.81) independently predicted death.
Elderly patients did not differ from nonelderly patients with respect to severity of illness before or at the time of BSI. Elderly patients with pseudomonal or enterococcal BSIs did not have a greater mortality than nonelderly patients.