Acute Crit Care.  2018 May;33(2):73-82. 10.4266/acc.2017.00591.

Current Status and Survival Impact of Infectious Disease Consultation for Multidrug-Resistant Bacteremia in Ventilated Patients: A Single-Center Experience in Korea

• Kim I
• Kim WY
• Jeoung ES
• Lee K

• KMID: 2436314
• DOI: http://doi.org/10.4266/acc.2017.00591

Abstract

BACKGROUND
We evaluated the current status and survival impact of infectious disease consultation (IDC) in ventilated patients with multidrug-resistant (MDR) bacteremia.
METHODS
One hundred sixty-one consecutive patients from a single tertiary care hospital were enrolled over a 5-year period. Patients with at least one of the following six MDR bacteremias were included: methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), and vancomycin-resistant Enterococcus faecium.
RESULTS
Median patient age was 66 years (range, 18 to 95), and 57.8% of subjects were male. The 28-day mortality after the day of blood culture was 52.2%. An IDC was requested for 96 patients based on a positive blood culture (59.6%). Patients without IDC had significantly higher rate of hemato-oncologic diseases as a comorbidity (36.9% vs. 11.5%, P < 0.001). Patients without an IDC had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 20; range, 8 to 38 vs. median, 16; range, 5 to 34, P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (median, 9; range, 2 to 17 vs. median, 7; range, 2 to 20; P = 0.020) on the day of blood culture and a higher 28-day mortality rate (72.3% vs. 38.5%, P < 0.001). In patients with SOFA ≥9 (cut-off level based on Youden's index) on the day of blood culture and gram-negative bacteremia, IDC was also significantly associated with lower 28-day mortality (hazard ratio [HR], 0.298; 95% confidence interval [CI], 0.167 to 0.532 and HR, 0.180; 95% CI, 0.097 to 0.333; all P ≥ 0.001) based on multivariate Cox regression analysis.
CONCLUSIONS
An IDC for MDR bacteremia was requested less often for ventilated patients with greater disease severity and higher 28-day mortality after blood was drawn. In patients with SOFA ≥9 on the day of blood culture and gram-negative bacteremia, IDC was associated with improved 28-day survival after blood draw for culture.

Keyword

bacteremia; infectious disease medicine; intensive care units; prognosis

MeSH Terms

APACHE
Bacteremia*
Communicable Diseases*
Comorbidity
Enterococcus faecium
Gram-Negative Bacteria
Humans
Infectious Disease Medicine
Intensive Care Units
Klebsiella
Korea*
Male
Methicillin-Resistant Staphylococcus aureus
Mortality
Prognosis
Pseudomonas
Tertiary Healthcare

Figure

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  Figure 1. Kaplan-Meier curves of survival 28 days after the day of blood culture according to the presence or absence of infectious disease consultation (log-rank, 29.507, P < 0.001). ICU: intensive care unit.

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  Figure 2. Receiver operating characteristic curves for SOFA and APACHE II scores on the day of blood culture collection predicting 28-day mortality after blood was drawn. AUC for SOFA was 0.747 (95% CI, 0.673 to 0.813) vs. APACHE II with an AUC of 0.708 (95% CI, 0.632 to 0.777) (P = 0.039). SOFA: Sequential Organ Failure Assessment; APACHE: Acute Physiology and Chronic Health Evaluation; AUC: area under the curve; CI: confidence interval.

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