scholarly journals The Changing Landscape of Uncomplicated Gram-Negative Bacteremia: A Narrative Review to Guide Inpatient Management

2020 ◽  
Vol 15 (12) ◽  
pp. 746-753 ◽  
Author(s):  
Jeannie D Chan ◽  
Chloe Bryson-Cahn ◽  
Zahra Kassamali-Escobar ◽  
John B Lynch ◽  
Anneliese M Schleyer
Keyword(s):  
Cost Effective ◽  
Hospital Length ◽  
Antimicrobial Treatment ◽  
Blood Cultures ◽  
Hospital Length Of Stay ◽  
Source Control ◽  
Gram Negative ◽  
Oral Agents ◽  
Gram Negative Bacteremia

Gram-negative bacteremia secondary to focal infection such as skin and soft-tissue infection, pneumonia, pyelonephritis, or urinary tract infection is commonly encountered in hospital care. Current practice guidelines lack sufficient detail to inform evidence-based practices. Specifically, antimicrobial duration, criteria to transition from intravenous to oral step-down therapy, choice of oral antimicrobials, and reassessment of follow-up blood cultures are not addressed. The presence of bacteremia is often used as a justification for a prolonged course of antimicrobial therapy regardless of infection source or clinical response. Antimicrobials are lifesaving but not benign. Prolonged antimicrobial exposure is associated with adverse effects, increased rates of Clostridioides difficile infection, antimicrobial resistance, and longer hospital length of stay. Emerging evidence supports shorter overall duration of antimicrobial treatment and earlier transition to oral agents among patients with uncomplicated Enterobacteriaceae bacteremia who have achieved adequate source control and demonstrated clinical stability and improvement. After appropriate initial treatment with an intravenous antimicrobial, transition to highly bioavailable oral agents should be considered for total treatment duration of 7 days. Routine follow-up blood cultures are not cost-effective and may result in unnecessary healthcare resource utilization and inappropriate use of antimicrobials. Clinicians should incorporate these principles into the management of gram-negative bacteremia in the hospital.

scholarly journals Predictive scoring models for persistent gram-negative bacteremia that reduce the need for follow-up blood cultures: a retrospective observational cohort study

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Jongtak Jung ◽  
Kyoung-Ho Song ◽  
Kang Il. Jun ◽  
Chang Kyoung Kang ◽  
Nak-Hyun Kim ◽  
...  
Keyword(s):  
Risk Factors ◽  
Treatment Response ◽  
Blood Cultures ◽  
Source Control ◽  
Care Hospital ◽  
Gram Negative ◽  
Scoring Model ◽  
Source Of Infection ◽  
Gram Negative Bacteremia

Abstract Background Although the risk factors for positive follow-up blood cultures (FUBCs) in gram-negative bacteremia (GNB) have not been investigated extensively, FUBC has been routinely carried out in many acute care hospitals. We attempted to identify the risk factors and develop a predictive scoring model for positive FUBC in GNB cases. Methods All adults with GNB in a tertiary care hospital were retrospectively identified during a 2-year period, and GNB cases were assigned to eradicable and non-eradicable groups based on whether removal of the source of infection was possible. We performed multivariate logistic analyses to identify risk factors for positive FUBC and built predictive scoring models accordingly. Results Out of 1473 GNB cases, FUBCs were carried out in 1268 cases, and the results were positive in 122 cases. In case of eradicable source of infection, we assigned points according to the coefficients from the multivariate logistic regression analysis: Extended spectrum beta-lactamase-producing microorganism (+ 1 point), catheter-related bloodstream infection (+ 1), unfavorable treatment response (+ 1), quick sequential organ failure assessment score of 2 points or more (+ 1), administration of effective antibiotics (− 1), and adequate source control (− 2). In case of non-eradicable source of infection, the assigned points were end-stage renal disease on hemodialysis (+ 1), unfavorable treatment response (+ 1), and the administration of effective antibiotics (− 2). The areas under the curves were 0.861 (95% confidence interval [95CI] 0.806–0.916) and 0.792 (95CI, 0.724–0.861), respectively. When we applied a cut-off of 0, the specificities and negative predictive values (NPVs) in the eradicable and non-eradicable sources of infection groups were 95.6/92.6% and 95.5/95.0%, respectively. Conclusions FUBC is commonly carried out in GNB cases, but the rate of positive results is less than 10%. In our simple predictive scoring model, zero scores—which were easily achieved following the administration of effective antibiotics and/or adequate source control in both groups—had high NPVs. We expect that the model reported herein will reduce the necessity for FUBCs in GNB cases.

scholarly journals Are Follow-Up Blood Cultures Useful in the Antimicrobial Management of Gram Negative Bacteremia? A Reappraisal of Their Role Based on Current Knowledge

Antibiotics ◽  
2020 ◽  
Vol 9 (12) ◽  
pp. 895
Author(s):  
Francesco Cogliati Dezza ◽  
Ambrogio Curtolo ◽  
Lorenzo Volpicelli ◽  
Giancarlo Ceccarelli ◽  
Alessandra Oliva ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Current Knowledge ◽  
Bloodstream Infections ◽  
Blood Cultures ◽  
Source Control ◽  
Candida Spp ◽  
Gram Negative ◽  
Gram Negative Bacteremia

Bloodstream infections still constitute an outstanding cause of in-hospital morbidity and mortality, especially among critically ill patients. Follow up blood cultures (FUBCs) are widely recommended for proper management of Staphylococcus aureus and Candida spp. infections. On the other hand, their role is still a matter of controversy as far as Gram negative bacteremias are concerned. We revised, analyzed, and commented on the literature addressing this issue, to define the clinical settings in which the application of FUBCs could better reveal its value. The results of this review show that critically ill patients, endovascular and/or non-eradicable source of infection, isolation of a multi-drug resistant pathogen, end-stage renal disease, and immunodeficiencies are some factors that may predispose patients to persistent Gram negative bacteremia. An analysis of the different burdens that each of these factors have in this clinical setting allowed us to suggest which patients’ FUBCs have the potential to modify treatment choices, prompt an early source control, and finally, improve clinical outcome.

scholarly journals Predictive scoring models for persistent gram-negative bacteremia that reduce the need for follow-up blood cultures: a retrospective observational cohort study

2020 ◽  
Author(s):  
Jongtak Jung ◽  
Kyoung-Ho Song ◽  
Kang Il Jun ◽  
Chang Kyoung Kang ◽  
Nak-Hyun Kim ◽  
...  
Keyword(s):  
Risk Factors ◽  
Treatment Response ◽  
Blood Cultures ◽  
Source Control ◽  
Gram Negative ◽  
Scoring Model ◽  
Source Of Infection ◽  
Gram Negative Bacteremia ◽  
Positive Results

Abstract Background: Although the risk factors for positive follow-up blood cultures (FUBCs) in gram-negative bacteremia (GNB) have not been investigated extensively, FUBC has been routinely carried out in many acute care hospitals. We attempted to identify the risk factors and develop a predictive scoring model for positive FUBC in GNB cases.Methods: All adults with GNB in a tertiary care hospital were retrospectively identified during a 2-year period, and GNB cases were assigned to eradicable and non-eradicable groups based on whether removal of the source of infection was possible. We performed multivariate logistic analyses to identify risk factors for positive FUBC and built predictive scoring models accordingly. Results: Out of 1,473 GNB cases, FUBCs were carried out in 1,268 cases, and 122 produced positive results. In patient with eradicable source of infection, we assigned points according to the coefficients from the multivariate logistic regression analysis: Extended spectrum beta-lactamase producing microorganism (+1 point), Catheter-related bloodstream infection(+1), unfavorable treatment response (+1), and quick sequential organ failure assessment score of 2 points or more (+1), administration of effective antibiotics (-1), and adequate source control (-2). In non-eradicable source of infection, assigned points were end-stage renal disease on hemodialysis (+1), unfavorable treatment response (+1) and the administration of effective antibiotics (-2). The areas under the curves were 0.861 (95% confidence interval [95CI] 0.806-0.916) and 0.792 (95CI, 0.724-0.861), respectively. When we applied a cut-off of 0, the specificities and negative predictive values (NPVs) in the eradicable and non-eradicable sources of infection groups were 95.6/92.6% and 95.5/95.0%, respectively.Conclusions: FUBC is commonly carried out in GNB cases, but the rate of positive results is less than 10%. In our simple predictive scoring model, zero scores—which were easily achieved following the administration of effective antibiotics and/or adequate source control in both groups—had high NPVs. We expect that the model reported herein will reduce the necessity for FUBCs in GNB cases.

scholarly journals Follow-up Blood Cultures: A 2.0 Diagnostic Tool in Patients With Gram-Negative Bacteremia and Septic Thrombophlebitis

2017 ◽  
Vol 66 (7) ◽  
pp. 1154-1155 ◽  
Author(s):  
Giancarlo Ceccarelli ◽  
Simone Giuliano ◽  
Marco Falcone ◽  
Mario Venditti
Keyword(s):  
Diagnostic Tool ◽  
Blood Cultures ◽  
Septic Thrombophlebitis ◽  
Gram Negative ◽  
Gram Negative Bacteremia

scholarly journals Practice Patterns of Infectious Diseases Physicians in Transitioning From Intravenous to Oral Therapy in Patients With Bacteremia

2019 ◽  
Vol 7 (12) ◽  
Author(s):  
Duane R Hospenthal ◽  
C Dustin Waters ◽  
Susan E Beekmann ◽  
Philip M Polgreen
Keyword(s):  
Infectious Diseases ◽  
Oral Therapy ◽  
Source Control ◽  
Oral Antibiotics ◽  
Emerging Infections ◽  
Gram Positive ◽  
Gram Negative ◽  
Oral Agents ◽  
Gram Negative Bacteremia ◽  
Rapid Transition

Abstract Background Bacteremia in adult patients has traditionally been treated with extended courses of intravenous antibiotics. Data on the use of (or rapid transition to) oral therapy are limited. Methods Adult infectious disease physicians participating in the Infectious Diseases Society of America Emerging Infections Network (EIN) were surveyed regarding their use of oral antibiotics in patients with bacteremia. Respondents were asked to assume that patients were hemodynamically stable, recovered bacteria were susceptible to potential antibiotics, adequate source control had been achieved, and patients had adequate gastrointestinal absorption. Variables of specific bacteria, oral agent, and associated infection were included. Results A total of 655 (50%) of 1321 EIN participants responded. Under certain conditions, 88% would transition patients with Gram-negative bacteremia to complete a course of therapy with oral antibiotics; 71% would transition patients with Gram-positive bacteremia to oral agents. Only 78 (12%) respondents would not treat any bacteremic patient with oral agents. Most respondents (≥75%) were comfortable treating infections secondary to Enterobacteriaceae, Salmonella, Pseudomonas, Stenotrophomonas, Streptococcus pneumoniae, and β-hemolytic streptococci with oral agents. Fewer than 20% endorsed use of oral antibiotics for Staphylococcus aureus or in cases of endocarditis. Fluoroquinolones and trimethoprim-sulfamethoxazole were the preferred agents in Gram-negative bacteremia; linezolid and β-lactams were the preferred agents in Gram-positive bacteremia. Conclusions In select circumstances, the majority of respondents would transition patients to oral antibiotics, in both Gram-negative and Gram-positive bacteremia. Most agreed with the use of oral agents in Gram-negative bacteremia caused by Enterobacteriaceae, but they would not use oral agents for Gram-positive bacteremia caused by S aureus or in endocarditis.

scholarly journals Follow-up Blood Cultures in Gram-Negative Bacteremia: Are They Needed?

2017 ◽  
Vol 65 (11) ◽  
pp. 1776-1779 ◽  
Author(s):  
Christina N Canzoneri ◽  
Bobak J Akhavan ◽  
Zehra Tosur ◽  
Pedro E Alcedo Andrade ◽  
Gabriel M Aisenberg
Keyword(s):  
Blood Cultures ◽  
Gram Negative ◽  
Gram Negative Bacteremia

Incidence and utility of follow-up blood cultures in cancer patients with gram-negative bacteremia

2021 ◽  
pp. 115444
Author(s):  
Amber B Clemmons ◽  
Henry N Young ◽  
Christopher M Bland ◽  
Brittany Jackson ◽  
Miki Hayashi ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Blood Cultures ◽  
Gram Negative ◽  
Gram Negative Bacteremia

scholarly journals 198. Evaluation of Oral Step-down versus Continued Intravenous Antimicrobial Therapy in Immunocompromised Patients Hospitalized with Gram-Negative Bacteremia

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S207-S207
Author(s):  
Heather Savage ◽  
Catherine H Vu ◽  
DeMaurian Mitchner ◽  
Amir Zaki
Keyword(s):  
Length Of Stay ◽  
Academic Medical Center ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Immunocompromised Patients ◽  
Clinical Failure ◽  
Gram Negative ◽  
Gram Negative Bacteremia ◽  
Step Down

Abstract Background Bloodstream infections are associated with considerable morbidity and mortality in the United States. Most patients initially receive parenteral antibiotics for gram-negative bacteremia, and more data is emerging supporting de-escalation to oral (PO) antibiotics to complete treatment. Previous studies evaluating PO antibiotics for gram-negative bacteremia often exclude or have underrepresented immunocompromised patients. This study evaluated clinical failure in immunocompromised patients receiving intravenous (IV) antibiotics compared to patients transitioned to PO antibiotics for gram-negative bacteremia. Methods A single center, retrospective cohort study was conducted at 446-bed academic medical center. Patients were included if they were immunocompromised and admitted with a positive blood culture for E. coli, Klebsiella spp., Citrobacter spp., Serratia spp., Enterobacter spp., Proteus spp., P. aeruginosa. between November 4, 2017 to November 4, 2020. Patients were excluded from this study if they had polymicrobial bacteremia, no source control within the first 5 days, or an indication for prolonged duration of treatment. The primary endpoint of this study was clinical failure defined as an escalation from PO to IV antibiotics, worsening clinical status, or readmission for the same infection within 30 days of discharge. The secondary endpoints included 30-day mortality, 90-day mortality, 30-day readmission, and time to microbiologic clearance. Results A total of 31 immunocompromised patients were included in the study with 26 patients receiving PO step-down therapy and 5 patients being continued on IV treatment for gram-negative bacteremia. There was no difference in the primary outcome of clinical failure between the PO step-down group versus the IV therapy group (15.4% vs 20%; p = 0.613). The most common immunocompromised state in both groups was being HIV positive. Patients in the PO step-down group had a significantly shorter hospital length of stay (7.4 days vs. 13.6 days; p = 0.016). Conclusion Oral step-down therapy for gram-negative bacteremia showed similar clinical failure rates to continuous IV therapy in the immunocompromised patient population and may be an option to shorten hospital length of stay. Disclosures All Authors: No reported disclosures

scholarly journals 188. Which patients with gram-negative bacteremia need follow-up blood cultures?

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S114-S114
Author(s):  
Jongtak Jung ◽  
Song Mi Moon ◽  
Eu Suk Kim ◽  
Hong Bin Kim ◽  
Ji Hwan Bang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Treatment Response ◽  
Source Control ◽  
Care Hospital ◽  
Predictive Values ◽  
Gram Negative ◽  
Negatively Associated ◽  
Source Of Infection ◽  
Gram Negative Bacteremia

Abstract Background Universal follow-up blood culture (FUBC) in gram-negative bacteremia (GNB) is not recommended, but it has been routinely conducted in many acute-care hospitals. In contrast with Staphylococcus aureus bacteremia, risk factors for positive FUBC in GNB have not been well investigated. Therefore, we tried to identify the risk factors for and develop predictive scores of positive FUBC. Methods All adults (≥18 years-old) with GNB were identified in a tertiary-care hospital during the 2-year period, retrospectively. Death within 2 days of GNB and polymicrobial infection with gram-positive bacteria or fungus were excluded. GNB were classified into eradicable and non-eradicable source of infection groups, according to the possibility of source removal. We performed multivariate analyses for identifying risk factors for positive FUBC and built prediction scores using the coefficients of the multivariate logistic regression models. Results Of total 1,473 GNB, FUBC was drawn in 1,268 (86%) patients and 122 (9.6%) had positive results. In patients with eradicable source of infection, ESBL-producing microorganism, catheter-related bloodstream infection, unfavorable treatment response, and quick sequential organ failure assessment (qSOFA) score (≥2) were associated. On the other hand, administration of effective antibiotics and adequate source control were negatively associated with positive FUBC. In non-eradicable source of infection, end-stage renal disease on hemodialysis, and unfavorable treatment response were related to positive FUBC and administration of effective antibiotics was negatively associated (Table 1). When we built prediction scores according to the coefficients, the areas under the curves were 0.864 (95% confidence interval [CI95] 0.816–0.912) and 0.792 (CI95, 0.721–0.861), respectively. When we applied a cutoff of 0, specificities/negative predictive values in eradicable and non-eradicable source of infection groups were 84.7%/95.6% and 95.5%/95.0%, respectively (Table 2). Conclusion Our prediction scores based on adequate source control and use of effective antibiotics showed high specificities and negative predictive values. Therefore, we could expect these score systems to contribute to reducing unnecessary FUBC in GNB. Disclosures All authors: No reported disclosures.

scholarly journals Impact of Accelerate Pheno and BacT/ALERT VIRTUO on Clinical Processes and Outcomes in Patients with Sepsis and Concurrent Gram-Negative Bacteremia

2021 ◽  
Author(s):  
Faith Babowicz ◽  
Reid LaPlante ◽  
Colby Mitchell ◽  
J. Nicholas O’Donnell ◽  
Ellis Tobin ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Blood Culture ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Gram Stain ◽  
Inpatient Mortality ◽  
Gram Negative ◽  
Narrow Spectrum ◽  
Gram Negative Bacteremia ◽  
The Impact

Background: Accelerate Pheno system and BacT/ALERT VIRTUO may improve bacteremia management. This study evaluated the impact of both devices on outcomes in patients with sepsis and concurrent gram-negative bacteremia. Methods: This quasi-experimental study included a retrospective pre-implementation and a prospective post-implementation group. Patients ≥18 years old with gram-negative bacteremia were included. Patients with neutropenia, pregnancy, were transferred from an outside hospital with active bloodstream infection, or polymicrobial bacteremia were excluded. Blood culture incubation in the BacT/ALERT 3D and microdilution antimicrobial susceptibility testing from culture plate growth was used prior to implementation of BacT/ALERT VIRTUO and Accelerate Pheno. MALDI-TOF identification directly from blood culture was used pre- and post-implementation. Time to gram-stain, identification, susceptibility reporting, initiation of narrow spectrum gram-negative therapy at 72 hours, 30-day inpatient mortality, sepsis resolution, and hospital length of stay were evaluated. Results: 116 patients were included (63 pre-implementation, 53 post-implementation). Median time to gram-stain and susceptibility results were significantly shorter post-implementation (P < 0.001). The post-implementation group had an improved hazard for narrow spectrum gram-negative therapy at 72 hours (HR [95% CI] = 2.685 [1.348 – 5.349]), reduced hazard for 30-day inpatient mortality (aHR: 0.150 [0.026 – 0.846]) and improved sepsis resolution (77.8% vs. 92.5%, P = 0.030). Hospital length of stay was unchanged between groups. Conclusion: The implementation of BacT/Alert VIRTUO and the Accelerate Pheno system improved microbiology laboratory processes, antibiotic utilization processes and clinical outcomes. These data support the use of rapid diagnostics in sepsis with concurrent gram-negative bacteremia.

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