Background. Nosocomial bloodstream infections (BSIs) are important causes of morbidity and mortality in the United States. Methods. Data from a nationwide, concurrent surveillance study (Surveillance and Control of Pathogens of Epidemiological Importance [SCOPE]) were used to examine the secular trends in the epidemiology and microbiology of nosocomial BSIs. Results. Our study detected 24,179 cases of nosocomial BSI in 49 US hospitals over a 7-year period from March 1995 through September 2002 (60 cases per 10,000 hospital admissions). Eighty-seven percent of BSIs were monomicrobial. Gram-positive organisms caused 65% of these BSIs, gram-negative organisms caused 25%, and fungi caused 9.5%. The crude mortality rate was 27%. The most-common organisms causing BSIs were coagulasenegative staphylococci (CoNS) (31% of isolates), Staphylococcus aureus (20%), enterococci (9%), and Candida species (9%). The mean interval between admission and infection was 13 days for infection with Escherichia coli, 16 days for S. aureus, 22 days for Candida species and Klebsiella species, 23 days for enterococci, and 26 days for Acinetobacter species. CoNS, Pseudomonas species, Enterobacter species, Serratia species, and Acinetobacter species were more likely to cause infections in patients in intensive care units ( ). In neutropenic patients, infections P ! .001 with Candida species, enterococci, and viridans group streptococci were significantly more common. The proportion of S. aureus isolates with methicillin resistance increased from 22% in 1995 to 57% in 2001 ( , trend P ! .001 analysis). Vancomycin resistance was seen in 2% of Enterococcus faecalis isolates and in 60% of Enterococcus faecium isolates. Conclusion. In this study, one of the largest multicenter studies performed to date, we found that the proportion of nosocomial BSIs due to antibiotic-resistant organisms is increasing in US hospitals.

/pdf/nosocomial-bloodstream-infections-in-us-hospitals-analysis-2s0njwczt7.pdf

Nosocomial Bloodstream Infections in US Hospitals: Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

Ventilator-associated pneumonia.

Bacteria belonging to the genus Klebsiella frequently cause human nosocomial infections. In particular, the medically most important Klebsiella species, Klebsiella pneumoniae, accounts for a significant proportion of hospital-acquired urinary tract infections, pneumonia, septicemias, and soft tissue infections. The principal pathogenic reservoirs for transmission of Klebsiella are the gastrointestinal tract and the hands of hospital personnel. Because of their ability to spread rapidly in the hospital environment, these bacteria tend to cause nosocomial outbreaks. Hospital outbreaks of multidrug-resistant Klebsiella spp., especially those in neonatal wards, are often caused by new types of strains, the so-called extended-spectrum-β-lactamase (ESBL) producers. The incidence of ESBL-producing strains among clinical Klebsiella isolates has been steadily increasing over the past years. The resulting limitations on the therapeutic options demand new measures for the management of Klebsiella hospital infections. While the different typing methods are useful epidemiological tools for infection control, recent findings about Klebsiella virulence factors have provided new insights into the pathogenic strategies of these bacteria. Klebsiella pathogenicity factors such as capsules or lipopolysaccharides are presently considered to be promising candidates for vaccination efforts that may serve as immunological infection control measures.

/pdf/klebsiella-spp-as-nosocomial-pathogens-epidemiology-taxonomy-1qbzenizx4.pdf

Klebsiella spp. as Nosocomial Pathogens: Epidemiology, Taxonomy, Typing Methods, and Pathogenicity Factors

After virtue, a study in moral theory

Over the five-year period 1977-1981, we studied 1,186 episodes of bacteremia due to Enterobacteriaceae and Pseudomonadaceae in the four non-university hospitals of a single metropolitan area. Overall patient mortality was 36.3%, and mortality attributed specifically to infection was 19.0%. The importance of severity of underlying disease, site of infection, microorganism, and age--previously determined to be prognostic factors in studies conducted at tertiary-care centers--was confirmed. Appropriate initial antimicrobial therapy (defined as the administration of an effective agent in adequate dose and by a suitable route of administration on the first calendar day on which blood cultures were positive) did not improve survival compared with the use of an ineffective antimicrobial agent or no therapy at all. However, appropriate antimicrobial therapy subsequent to the first calendar day on which blood cultures were positive clearly affected survival. These findings confirm previous conclusions regarding the frequency and severity of gram-negative bacteremia and the overall impact of antimicrobial therapy on this condition. These studies also suggest the possibility that the definition of optimal initial therapy in some groups of patients should be reconsidered.

Analysis of 1,186 episodes of gram-negative bacteremia in non-university hospitals: the effects of antimicrobial therapy.

• We studied 104 episodes of bacteremia in 102 patients with decubitus ulcers observed over five years in the hospitals of one metropolitan area. The ulcers were considered to be the "probable" source of bacteremia in 49% of episodes. Another site of infection was documented in 86% of patients. Proteus mirabilis, Staphylococcus aureus , and Escherichia coli were the most frequent blood isolates in these patients, but only Bacteroides species correlated with "probable" origin of bacteremia from the ulcers. The overall mortality was 55%, with 51% of deaths being attributed to infection. These findings emphasize the importance of decubitus ulcers as potential sources of bacteremia in hospitalized patients. ( Arch Intern Med 1983;143:2093-2095)

Bacteremia Associated With Decubitus Ulcers

Organized by topic and thoroughly indexed, this elegant new leather-bound deluxe edition expands ACP Press' perennial bestseller to include never-before-published photographs, 50 new quotes, and several new essays. The deluxe edition also has a gold-stamped cover, splendid end papers, and a page-marking ribbon. The Quotable Osler makes a fine gift for a physician, medical student, or graduating resident, and is the ideal resource for those seeking an apt quote or looking to sample Osler's thought-provoking and uplifting messages.

The quotable Osler

Nonbacterial thrombotic endocarditis with malignant tumors.

Between 1977 and 1981, there were 4.9 episodes of community-acquired bacteremia and 5.1 episodes of hospital-acquired bacteremia per 1,000 patients in the four major hospitals of one metropolitan area. Case fatality rates were 30.1 per cent based on deaths due to all causes and 14.7 per cent based on deaths attributed specifically to bacteremia. Patients who experienced bacteremia had a 12-fold excess in mortality compared with other patients. Bacteremia occurred more frequently and was associated with greater case fatality rates at university-affiliated teaching hospitals compared with nonteaching community hospitals. At the nonteaching community hospitals, the odds of mortality for patients with bacteremia were lower even after adjustment for age, sex, severity of underlying medical problems, and severity of infection. Patients on private services at a teaching municipal hospital experienced greater odds of mortality compared with private patients at two nonteaching community hospitals. These latter observations may reflect, at least in part, limitations in the standard parameters used for determining severity of underlying medical problems and severity of infection.

Endemic bacteremia in columbia, south carolina

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