Duke University Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America; Duke Infection Control Outreach Network, Durham, North Carolina, United States of America.
Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America.
PLoS One. 2014 Mar 18;9(3):e91713. doi: 10.1371/journal.pone.0091713. eCollection 2014.
While the majority of healthcare in the US is provided in community hospitals, the epidemiology and treatment of bloodstream infections in this setting is unknown.
We undertook this multicenter, retrospective cohort study to 1) describe the epidemiology of bloodstream infections (BSI) in a network of community hospitals and 2) determine risk factors for inappropriate therapy for bloodstream infections in community hospitals. 1,470 patients were identified as having a BSI in 9 community hospitals in the southeastern US from 2003 through 2006. The majority of BSIs were community-onset, healthcare associated (n = 823, 56%); 432 (29%) patients had community-acquired BSI, and 215 (15%) had hospital-onset, healthcare-associated BSI. BSIs due to multidrug-resistant pathogens occurred in 340 patients (23%). Overall, the three most common pathogens were S. aureus (n = 428, 28%), E. coli (n = 359, 24%), coagulase-negative Staphylococci (n = 148, 10%), though type of infecting organism varied by location of acquisition (e.g., community-acquired). Inappropriate empiric antimicrobial therapy was given to 542 (38%) patients. Proportions of inappropriate therapy varied by hospital (median = 33%, range 21-71%). Multivariate logistic regression identified the following factors independently associated with failure to receive appropriate empiric antimicrobial therapy: hospital where the patient received care (p<0.001), assistance with ≥3 ADLs (p = 0.005), Charlson score (p = 0.05), community-onset, healthcare-associated infection (p = 0.01), and hospital-onset, healthcare-associated infection (p = 0.02). Important interaction was observed between Charlson score and location of acquisition.
Our large, multicenter study provides the most complete picture of BSIs in community hospitals in the US to date. The epidemiology of BSIs in community hospitals has changed: community-onset, healthcare-associated BSI is most common, S. aureus is the most common cause, and 1 of 3 patients with a BSI receives inappropriate empiric antimicrobial therapy. Our data suggest that appropriateness of empiric antimicrobial therapy is an important and needed performance metric for physicians and hospital stewardship programs in community hospitals.
虽然美国大多数医疗保健服务都是在社区医院提供的，但目前尚不清楚该环境中血流感染的流行病学和治疗方法。
我们进行了这项多中心回顾性队列研究，目的是 1）描述社区医院网络中血流感染（BSI）的流行病学情况，以及 2）确定社区医院血流感染治疗不当的危险因素。2003 年至 2006 年期间，在美国东南部的 9 家社区医院中，我们共确定了 1470 名患有 BSI 的患者。大多数 BSI 是社区发病的，与医疗保健相关（n=823，56%）；432 名（29%）患者患有社区获得性 BSI，215 名（15%）患者患有医院获得性、与医疗保健相关的 BSI。340 名（23%）患者感染的病原体是多药耐药病原体。总的来说，三种最常见的病原体是金黄色葡萄球菌（n=428，28%）、大肠杆菌（n=359，24%）和凝固酶阴性葡萄球菌（n=148，10%），但感染病原体的类型因感染部位不同而有所不同（例如，社区获得性）。542 名（38%）患者接受的经验性抗菌治疗不当。各医院治疗不当的比例（中位数为 33%，范围为 21%-71%）不同。多变量逻辑回归确定了与未能接受适当经验性抗菌治疗相关的以下因素：患者接受治疗的医院（p<0.001）、辅助日常生活活动（ADL）≥3 项（p=0.005）、Charlson 评分（p=0.05）、社区发病、与医疗保健相关的感染（p=0.01）和医院发病、与医疗保健相关的感染（p=0.02）。还观察到 Charlson 评分与感染部位之间存在重要的相互作用。
我们的大型多中心研究提供了迄今为止美国社区医院血流感染最完整的描述。社区医院血流感染的流行病学发生了变化：社区发病、与医疗保健相关的 BSI 最为常见，金黄色葡萄球菌是最常见的病原体，每 3 名 BSI 患者中就有 1 名接受不适当的经验性抗菌治疗。我们的数据表明，经验性抗菌治疗的适当性是社区医院医生和医院管理计划的一个重要且必要的绩效指标。
