Strategies to reduce 28-day mortality in adult patients with bacteremia in the emergency department.

BACKGROUND

Bacteremia, a common emergency department presentation, has a high burden of mortality, cost and morbidity. We aimed to identify areas for potential improvement in emergency department bacteremia management.

METHODS

This retrospective cohort study included adults with bacteremia in an emergency department in 2019 and 2022. The primary outcome was 28-day mortality. Descriptive analyses evaluated demographics, comorbidities and clinical characteristics. Univariate and multivariate analyses identified mortality predictors.

RESULTS

Overall, 433 patients were included [217 males (50.1%), mean ± SD age: 74.1 ± 15.2 years]. The 28-day mortality rate was 15.2% (n = 66). In univariate analysis, age ≥ 70 years, arrival by ambulance, arrhythmia, congestive heart failure, recent steroid use, hypotension (< 90/60 mmHg), mechanical ventilation, cardiac arrest, intensive care unit (ICU) admission, intravenous antibiotics, pneumonia as bacteremia source, non-urinary tract infections, no infectious disease consultation, no antibiotic adjustment and no control blood cultures were significantly associated with 28-day mortality (p < 0.05). Malignancy showed a statistical trend (0.05 < p < 0.15). The above-stated sixteen variables, identified in univariate analysis, were assessed via multivariate analysis. Primarily, clinical relevance and, secondarily, statistical significance were used for multivariate model creation to prioritize pertinent variables. Five risk factors, significantly associated with mortality (p < 0.05), were included in the model: ICU admission [adjusted OR (95% CI): 6.03 (3.08-11.81)], pneumonia as bacteremia source [4.94 (2.62-9.32)], age ≥ 70 [3.16 (1.39-7.17)], hypotension [2.12 (1.02-4.40)], and no infectious disease consultation [2.02 (1.08-3.78)]). Surprisingly, initial antibiotic administration within 6 h, inappropriate initial antibiotic regimen and type of bacteria (Gram-negative, Gram-positive) were non-significant (p > 0.05).

CONCLUSIONS

We identified significant mortality predictors among emergency department patients presenting with bacteremia. Referral to an infectious disease physician is the only modifiable strategy to decrease 28-day mortality with long-term effect and should be prioritized.