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Trends and outcome of 1121 nosocomial bloodstream infections in intensive care units in a Brazilian hospital, 1999–2003

2008; Elsevier BV; Volume: 12; Issue: 6 Linguagem: Inglês

10.1016/j.ijid.2008.03.011

1878-3511

Evelyne Santana Girão, Anna S. Levin, Matteo Basso, S. Gobara, L.B. Gomes, Eduardo Alexandrino Medeiros, Antonio Barone, Sílvia Figueiredo Costa,

Antibiotic Use and Resistance

Nosocomial bloodstream infections (BSI) are associated with high morbidity and mortality resulting in increased healthcare costs.1Pittet D. Tarara D. Wenzel R.P. Nosocomial bloodstream infection in critically ill patients.JAMA. 1994; 271: 1598-1601Crossref PubMed Scopus (1279) Google Scholar, 2Warren D.K. Zack J.E. Elward A.M. Nosocomial primary bloodstream infections in intensive care unit patients in a nonteaching community medical center: a 21- month prospective study.Clin Infect Dis. 2001; 33: 1329-1335Crossref PubMed Scopus (80) Google Scholar BSI rates in Latin America range from 11.3 to 23 cases per 1000 catheter-days and are higher than those in the USA and Europe.3Ramirez Barba E.J. Rosenthal V.D. Higuera F. Oropeza M.S. Hernández H.T. López M.S. et al.Device-associated nosocomial infection rates in intensive care units in four Mexican public hospitals.Am J Infect Control. 2006; 4: 244-247Abstract Full Text Full Text PDF Scopus (61) Google Scholar, 4Moreno C.A. Rosenthal V.D. Olarte N. Gomez W.V. Sussmann O. Agudelo J.G. et al.Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium.Infect Control Hosp Epidemiol. 2006; 4: 349-356Crossref Scopus (96) Google Scholar, 5Rosenthal V.D. Maki D.G. Salomao R. Moreno C.A. Mehta Y. Higuera F. et al.International Nosocomial Infection Control Consortium. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries.Ann Intern Med. 2006; 8: 582-591Crossref Scopus (385) Google Scholar This study characterized the trends in the agents causing BSI in intensive care units (ICUs), and the risk factors associated with death, at a large university hospital in Brazil. All cases of BSI were identified by surveillance using Centers for Disease Control and Prevention criteria.6Gardner J.S. Jarvis W.R. Emori T.G. CDC definitions for nosocomial infections.Am J Infect Control. 1988; 116: 128-140Abstract Full Text PDF Scopus (5166) Google Scholar Crude mortality and mortality that occurred during the14 days from first blood isolation were evaluated. The Chi-square test for linear trends was used to evaluate the distribution of the most common agents. A logistic regression model was developed to identify factors associated with mortality. Over 5 years, 1121 episodes of BSI were detected in 1004 patients. The incidence of BSI did not change significantly, ranging from 11.2 to 10.2 episodes per 1000 catheter-days (p = 0.61). Forty-nine percent of the episodes were caused by Gram-negative rods, 45% by Gram-positive cocci, and 6% by fungi. The incidence of Gram-negative rods increased (p = 0.04), Gram-positive cocci decreased (p = 0.01), and fungi remained stable (p = 0.20). The mean time from admission into the ICU to the development of BSI was 16.9 days, ranging from 6 (coagulase-negative staphylococci) to 31 days (Proteus mirabilis). The most frequent underlying diseases were neurological (13.1%), followed by cardiovascular (10.4%) and gastrointestinal diseases (10%). Central venous catheters were present in 93% of patients. Staphylococcus aureus (24.4%) was the most common agent, followed by Acinetobacter baumannii (19.2%), coagulase-negative staphylococci (11.3%), Pseudomonas aeruginosa (8.2%), Klebsiella pneumoniae (7.1%), Enterococcus faecalis (6.8%), and Candida spp (5.6%). The resistance to imipenem increased among Acinetobacter baumannii from 12% to 41% (p = 0.0002). The overall mortality rate was 38%. The mortality related to the agents is shown in Table 1. Age over 60 years was the only risk factor independently associated with death and trauma; burns and neurological disease were associated with lower mortality risk.Table 1Main pathogens causing bloodstream infections (BSI) and their 14 day-mortality and crude mortality over a 5-year period at the Hospital das Clínicas of the University of São Paulo, Brazila1121 episodes of bloodstream infection yielding 1286 isolates in 1004 patients.PathogenNumber of deaths/total BSI (%)14-day mortalityCrude mortalityPseudomonas aeruginosa55/104 (53%)81/104 (78%)Candida non-albicans20/40 (50%)32/40 (80%)Candida albicans15/33 (45%)24/33 (73%)Klebsiella pneumoniae41/100 (41%)57/100 (57%)Acinetobacter baumannii97/246 (39%)163/246 (66%)Staphylococcus aureus110/312 (35%)191/312 (61%)Enterococcus faecalis26/88 (30%)57/88 (65%)Coagulase-negative staphylococci41/142 (29%)72/142 (51%)Enterobacter spp16/81 (20%)45/81 (56%)a 1121 episodes of bloodstream infection yielding 1286 isolates in 1004 patients. Open table in a new tab Our results show a Gram-negative predominance, with a significant increase in the incidence of A. baumannii and K. pneumoniae over time. Acinetobacter spp has been particularly problematic in Latin American hospitals, with a high frequency of isolates and high rates of resistance.7Sader H.S. Jones R.N. Gales A.C. Antimicrobial susceptibility patterns for pathogens isolated from patients in Latin American medical centers with a diagnosis of pneumonia: analysis of results from the SENTRY Antimicrobial Surveillance Program (1997). SENTRY Latin America Study Group.Diagn Microbiol Infect Dis. 1998; 32: 289-301Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 8Sader H.S. Gales A.C. Pfaller M.A. Pathogen frequency and resistance patterns in Brazilian hospitals: summary of results from three years of the SENTRY Antimicrobial Surveillance Program.Brazilian J Infect Dis. 2001; 5: 200-214PubMed Google Scholar Data from other developing countries have also shown the importance of Gram-negative bacteria as agents of BSI.9Wu C.J. Lee H.C. Lee N.Y. Shih H.I. Ko N.Y. Wang L.R. et al.Predominance of Gram-negative bacilli and increasing antimicrobial resistance in nosocomial bloodstream infections at a university hospital in southern Taiwan, 1996–2003.J Microbiol Immunol Infect. 2006; 2: 135-143Google Scholar, 10Hsueh P.R. Chen W.H. Luh K.T. Relationships between antimicrobial use and antimicrobial resistance in Gram-negative bacteria causing nosocomial infections from 1991–2003 at a university hospital in Taiwan.Int J Antimicrob Agents. 2005; 6: 463-472Abstract Full Text Full Text PDF Scopus (209) Google Scholar Our BSI rates remained stable over the study period and are lower than other reports from Latin America, however they are higher than those found in American and European hospitals. Conflict of interest: No conflict of interest to declare.