Analysis of Characteristics and Prognosis of Healthcare-Associated Secondary Bloodstream Infection

Ju Yeon Song; Ihn Sook Jeong; Sookyung Hyun

doi:10.14192/kjhaicp.2017.22.2.43

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Song, Jeong, and Hyun: Analysis of Characteristics and Prognosis of Healthcare-Associated Secondary Bloodstream Infection

Original Article

Korean J Healthc Assoc Infect Control Prev 2017;22(2):43-55.

Published online: 26 December 2017

DOI: https://doi.org/10.14192/kjhaicp.2017.22.2.43

Analysis of Characteristics and Prognosis of Healthcare-Associated Secondary Bloodstream Infection

Ju Yeon Song¹, Ihn Sook Jeong², Sookyung Hyun²

¹Infection Control Unit, Pusan National University Yangsan Hospital, Yangsan, Korea

²College of Nursing, Pusan National University, Yangsan, Korea

Correspondence to: Ihn Sook Jeong, College of Nursing, Pusan National University, 49 Busandaehak-ro, Mulgeumeup, Yangsan 50612, Korea Tel: 051-510-8342, Fax: 051-510-8308 E-mail: jeongis@pusan.ac.kr

Received 24 July 2017 Revised 13 October 2017 Accepted 12 November 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Bloodstream infections are the most common type of healthcare-associated infections in which the proportion of secondary bloodstream infections (SBSIs) is noticeably high. SBSIs can result in negative patient outcomes and additional care costs. The purpose of this study was to describe the characteristics of SBSIs among hospitalized patients, identify potential predictors of SBSIs, and explore the prognoses of community-acquired and healthcare-associated SBSIs.

Methods

This study was conducted with 237 adult patients with SBSIs in a general hospital in 2015.

Results

The most common primary infection among SBSIs was urinary tract infection (UTI). The most common pathogens were Escherichia coli for UTI and Staphylococcus aureus for pneumonia. Mortality due to SBSIs was 4.24 times higher among patients in intensive care units than among those in general units; mortality also increased by 1.24 times as the APACHE II scores increased by 1 point.

Conclusion

Patients with UTI and pneumonia are at high risk for developing SBSIs. Further research is needed to identify risk factors for SBSIs by comparing SBSI and non-SBSI cases in a case-control study.

Keywords: Bacteremia, Infection, Infection control

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Table 1.

Comparisons of patients’ characteristics between community-acquired and hospital-acquired secondary bloodstream infections N (%)

		Total (N=237)	Community-acquired SBSIs (n=152)	Hospital-acquired SBSIs (n=85)	X²/t/Z	P
Gender	Male	128 (54.0)	75 (49.3)	53 (62.4)	3.72	0.054
Gender	Female	109 (46.0)	77 (50.7)	32 (37.6)
Age	＜65	106 (44.7)	60 (39.5)	46 (54.1)	4.73	0.030
	≥65	131 (55.3)	92 (60.5)	39 (45.9)
	Mean±SD	65.0±14.0	66.4±13.5	62.4±14.4	2.14^*	0.033
Specialty	Medical	143 (60.3)	100 (65.8)	43 (50.6)	24.59	＜0.001
	Surgical	76 (32.1)	34 (22.4)	42 (49.4)
	Emergency department	18 (7.6)	18 (11.8)	0 (0.0)
Presence of Comorbidity	Absent	106 (44.9)	65 (42.8)	41 (48.8)	0.80	0.371
Presence of Comorbidity	Present	130 (55.1)	87 (57.2)	43 (51.2)
Comorbid condition (multiple response)	Hypertension	83 (35.0)	58 (38.2)	25 (29.4)	0.23	0.636
	Diabetes	65 (27.4)	47 (30.9)	18 (21.2)	2.60	0.107
	Liver disease	19 (8.0)	7 (4.6)	12 (14.1)	6.69	0.010
	Others	6 (2.5)	3 (2.0)	3 (3.5)	0.54	0.670
Admitted via	Outpatient clinic	32 (13.5)	7 (4.6)	25 (29.4)	28.72	＜0.001
Admitted via	Emergency department	205 (86.5)	145 (95.4)	60 (70.6)
Length of stay (days)	≤7	46 (19.4)	46 (30.3)	0 (0.0)	31.92	＜0.001
	＞8	191 (80.6)	106 (69.7)	85 (100.0)	−8.15^†	＜0.001
	Mean±SD	38.9±52.5	23.6±36.4	66.1±64.8
Transplantation	Yes	21 (8.9)	4 (2.6)	17 (20.0)	20.36	＜0.001
Transplantation	No	216 (91.1)	148 (97.4)	68 (80.0)
Operation/procedure	Yes	36 (15.2)	11 (7.2)	25 (29.4)	20.81	＜0.001
Operation/procedure	No	201 (84.8)	141 (92.8)	60 (70.6)
APACHE II (at SBSI onset)	Mean±SD	13.1±7.2	12.0±6.4	15.2±8.1	−3.18^*	0.002

^* t-test.

^† Mann-Whitney U test.

Abbreviations: SBSI, secondary bloodstream infection; SD, standard deviation; APACHE II, Acute Physiology and Chronic Health Evaluation II.

Table 2.

Comparisons of infection-related characteristics and prognosis between community-acquired and hospital-acquired secondary bloodstream infections N (%)

		Total (N=237)	Community-acquired SBSIs (n=152)	Hospital-acquired SBSIs (n=85)	X²	P
<Infection-related characteristics>
Primary	Urinary tract infection	90 (38.0)	65 (42.7)	25 (29.4)	4.13	0.042
Infection site	Pneumonia	36 (15.2)	8 (5.3)	28 (33.0)	32.42	＜0.001
	Abdominal infection	81 (34.1)	60 (39.5)	21 (24.7)	5.29	0.022
	Others^*	30 (12.7)	19 (12.5)	11 (12.9)	0.01	0.922
Setting where the infection Identified	General unit	58 (24.5)	12 (7.9)	46 (54.1)	176.36	＜0.001
	Emergency department	135 (56.9)	135 (88.8)	0 (0.0)
	Intensive care unit	44 (18.6)	5 (3.3)	39 (45.9)
Pathogen (multiple response)	S. aureus	34 (14.3)	21 (13.8)	13 (15.3)	0.10	0.759
	E. coli	92 (38.8)	72 (47.4)	20 (23.5)	13.05	＜0.001
	Klebsiella spp.	46 (19.4)	37 (24.3)	9 (10.6)	6.59	0.010
	Candida spp.	11 (4.6)	1 (0.7)	10 (11.8)	15.20	＜0.001
Antibiotic-resistant	Yes	89 (37.6)	54 (35.5)	35 (41.2)	0.74	0.389
Antibiotic-resistant	No	148 (62.4)	98 (64.5)	50 (58.8)
Type of Antibiotic-resistant	MRSA	24 (10.1)	14 (9.2)	10 (11.8)	0.39	0.532
	ESBL	56 (23.6)	38 (25.0)	18 (21.2)	0.44	0.506
	Others	9 (3.8)	2 (1.3)	7 (8.2)	7.15	0.008
<Prognosis>
Patient outcome	Alive	178 (75.1)	130 (85.5)	48 (56.5)	26.62	＜0.001
Patient outcome	Died	59 (24.9)	22 (14.5)	37 (43.5)

^* Others: Bone infection 10, skin infection 8, surgical wound site infection 7, chest infection 4, Genitourinary infection 3.

Abbreviations: SBSI, secondary bloodstream infection; SD, standard deviation; APACHE II, Acute Physiology and Chronic Health Evaluation II; MRSA, methicillin-resistant S. aureus; ESBL, extended-spectrum beta-lactamase.

Table 3.

Community-acquired secondary bloodstream infections: general characteristics and infection-related characteristics by prognosis N (%)

		Alive (n=130)	Died (n=22)	X²/t/Z	P
<General Characteristics>
Gender	Male	65 (50.0)	10 (45.5)	0.16	0.693
Gender	Female	65 (50.0)	12 (54.5)
Age	＜65	54 (41.5)	6 (27.3)	1.60	0.244
	≥65	76 (58.5)	16 (72.7)
	Mean±SD	66.0±13.9	68.9±10.9	−0.93^*	0.356
Specialty	Medical	86 (66.2)	14 (63.6)	3.47	0.177
	Surgical	31 (23.8)	3 (13.6)
	Others	13 (10.0)	5 (22.7)
Presence of Comorbidity	Absent	59 (45.4)	6 (27.3)	2.52	0.112
Presence of Comorbidity	Present	71 (54.6)	16 (72.7)
Comorbid condition (multiple response)	Hypertension	52 (40.0)	6 (27.3)	1.29	0.256
	Diabetes	35 (26.9)	12 (54.5)	6.72	0.010
	Liver disease	5 (3.8)	2 (9.1)	1.18	0.278
Admitted via	Outpatient clinic	6 (4.6)	1 (4.5)	0.00	0.988
Admitted via	Emergency department	124 (95.4)	21 (95.5)
Length of stay (days)	Mean±SD	25.0±38.6	15.5±17.2	−1.56^†	0.118
Transplantation	Yes	4 (3.1)	0 (0.0)		1.000^‡
Transplantation	No	126 (96.9)	22 (100.0)
Operation or procedure	Yes	11 (8.5)	0 (0.0)		0.368^‡
Operation or procedure	No	119 (91.5)	22 (100.0)
APACHE II (Mean±SD)	On admission	10.7±5.3	19.1±8.4	−4.52^*	＜0.001
APACHE II (Mean±SD)	At SBSI Onset	10.7±5.1	19.4±7.9	−5.00^*	＜0.001
<Infection-related characteristics>
Primary infection site	Urinary tract infection	57 (43.8)	8 (36.4)	0.43	0.512
	Pneumonia	3 (2.3)	5 (22.7)		0.002^‡
	Abdominal infection	55 (42.3)	5 (22.7)	3.02	0.082
Setting	General unit	10 (83.3)	2 (16.7)		0.175^‡
	Emergency department	117 (86.7)	18 (13.3)
	Intensive care unit	3 (60.0)	2 (40.0)
Pathogen (multiple response)	S. aureus	14 (10.8)	7 (31.8)		0.016^‡
	E. coli	65 (50.0)	7 (31.8)	2.50	0.114
	Klebsiella spp.	30 (23.1)	7 (31.8)	0.78	0.377
	Candida spp.	1 (0.8)	0 (0.0)		1.000^‡
Antibiotic-resistant	Yes	40 (30.8)	14 (63.6)	8.87	0.003
Antibiotic-resistant	No	90 (69.2)	8 (36.4)
Type of antibiotic-resistant	MRSA	8 (6.2)	6 (27.3)	10.04	0.002
Type of antibiotic-resistant	ESBL	30 (23.1)	8 (36.4)	1.77	0.183

^* t-test.

^† Mann-Whitney U test.

^‡ Fisher exact test.

Abbreviations: SD, standard deviation; APACHE II, Acute Physiology and Chronic Health Evaluation II; SBSI, secondary bloodstream infection; MRSA, methicillin-resistant S. aureus; ESBL, extended-spectrum beta-lactamase.

Table 4.

Hospital-acquired secondary bloodstream infections: general characteristics and infection-related characteristics by prognosis N (%)

		Alive (n=48)	Died (n=37)	X²/t/Z	P
<General Characteristics>
Gender	Male	29 (60.4)	24 (64.9)	0.18	0.675
Gender	Female	19 (39.6)	13 (35.1)
Age	＜65	25 (52.1)	21 (56.8)	0.18	0.668
	≥65	23 (47.9)	16 (43.2)
	Mean±SD	63.4±12.5	61.1±16.7	0.74^*	0.461
Specialty	Medical	18 (37.5)	25 (67.6)	7.56	0.006
Specialty	Surgical	30 (62.5)	12 (32.4)
Presence of Comorbidity	Absent	21 (44.7)	20 (54.1)	0.73	0.394
Presence of Comorbidity	Present	26 (55.3)	17 (45.9)
Comorbid condition (multiple response)	Hypertension	15 (31.3)	10 (27.0)	0.18	0.672
	Diabetes	36 (75.0)	31 (83.8)	1.00	0.326
	Liver disease	9 (18.8)	3 (8.1)	1.95	0.162
Admitted via	Outpatient clinic	15 (31.3)	10 (27.0)	0.18	0.672
Admitted via	Emergency department	33 (68.8)	27 (73.0)
Length of stay (days)	Mean±SD	79.8±74.0	48.3±45.5	−1.90^†	0.057
Transplantation	Yes	10 (20.8)	7 (18.9)	0.05	0.827
Transplantation	No	38 (79.2)	30 (81.1)
Operation/procedure	Yes	15 (31.3)	10 (27.0)	0.18	0.672
Operation/procedure	No	33 (68.8)	27 (73.0)
APACHE II (Mean±SD)	On admission	8.8±5.0	11.8±7.7	−2.01^*	0.050
APACHE II (Mean±SD)	At SBSI Onset	10.9±5.8	20.8±7.2	−6.91^*	<0.001
<Infection-related characteristics>
Primary	Urinary tract infection	20 (41.7)	5 (13.5)	7.98	0.005
Infection site	Pneumonia	9 (18.8)	19 (51.4)	10.05	0.002
Infection site	Abdominal infection	12 (25.0)	9 (24.3)	0.01	0.943
Setting where the infection identified	General unit	36 (78.3)	10 (21.7)	19.37	<0.001
Setting where the infection identified	Intensive care unit	12 (30.8)	27 (69.2)
Times to bacteremia (days)	Mean±SD	26.3±31.8	25.5±20.9	−0.96^†	0.336
Pathogen (multiple response)	S. aureus	7 (14.6)	6 (16.2)	0.04	0.836
	E. coli	14 (29.2)	6 (16.2)	1.95	0.163
	Klebsiella spp.	6 (12.5)	3 (8.1)	0.43	0.514
	Candida spp.	4 (8.3)	6 (16.2)	1.25	0.263
Antibiotic-resistant	Yes	20 (41.7)	15 (40.5)	0.01	0.917
Antibiotic-resistant	No	28 (58.3)	22 (59.5)
Type of antibiotic-resistant	MRSA	5 (10.4)	5 (13.5)	0.19	0.660
Type of antibiotic-resistant	ESBL	13 (27.1)	5 (13.5)	2.31	0.129

^* t-test.

^† Mann-Whitney U test.

Table 5.

Predictors of death due to secondary bloodstream infections

	Adjusted OR	95% CI	P
Community-acquired SBSIs
Comorbid condition (Diabetes=1)	3.76	1.12-12.57	0.032
APACHE II (at SBSI Onset)	1.21	1.09-1.35	＜0.001
Primary infection site (pneumonia=1)	6.05	0.73-50.15	0.095
Pathogen (S. aureus)	2.50	0.61-10.22	0.201
Antibiotic-resistant (yes=1)	2.63	0.81-8.56	0.108
Hospital-acquired SBIs
Specialty (surgical=1)	3.46	0.98-12.22	0.054
APACHE II (at SBSI Onset)	1.26	1.09-1.46	0.001
Primary infection site (urinary tract infection=1)	0.32	0.07-1.57	0.159
Primary infection site (pneumonia=1)	0.26	0.05-1.47	0.128
Setting where the infection identified (ICU=1)	1.97	0.34-11.55	0.452

Abbreviations: APACHE II, Acute Physiology and Chronic Health Evaluation II; SBSI, secondary bloodstream infection; ICU, intensive care unit; OR, odds ratio; CI, confidence interval.

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