Prospective Trials Are Required to Alter Practice for Follow-up Blood Cultures for Gram-Negative Bacilli Bacteremia

Abstract Background As opposed to Staphylococcus. aureus bacteremia, there are no guidelines to recommend repeating blood cultures in Gram-negative bacilli bacteremia (GNB). Several studies have questioned the utility of follow-up blood cultures (FUBCs) in GNB, but the impact of this practice on clinical outcomes is not fully understood. Our aim was to study the practice of obtaining FUBCs in GNB at our institution and to assess it’s impact on clinical outcomes. Methods We conducted a retrospective, single-center study of adult patients, ≥ 18 years of age admitted with GNB between January 2017 and December 2018. We aimed to compare clinical outcomes in those with and without FUBCs. Data collected included demographics, comorbidities, presumed source of bacteremia and need for intensive care unit (ICU) admission. Presence of fever, hypotension /shock and white blood cell (WBC) count on the day of FUBC was recorded. The primary objective was to compare 30-day mortality between the two groups. Secondary objectives were to compare differences in 30-day readmission rate, hospital length of stay (LOS) and duration of antibiotic treatment. Mean and standard deviation were used for continuous variables, frequency and proportion were used for categorical variables. P-value < 0.05 was defined as statistically significant. Results 482 patients were included, and of these, 321 (67%) had FUBCs. 96% of FUBCs were negative and 2.8% had persistent bacteremia. There was no significant difference in 30-day mortality between those with and without FUBCs (2.9% and 2.7% respectively), or in 30-day readmission rate (21.4% and 23.4% respectively). In patients with FUBCs compared to those without FUBCs, hospital LOS was longer (7 days vs 5 days, P < 0.001), and mean duration of antibiotic treatment was longer (14 days vs 11 days, P < 0.001). A higher number of patients with FUBCs needed ICU care compared to those without FUBCs (41.4% and 25.5% respectively, P < 0.001) Microbiology of index blood culture in those with and without FUBCs Outcomes in those with and without FUBCs FUBCs characteristics Conclusion Obtaining FUBCs in GNB had no impact on 30-day mortality or 30-day readmission rate. It was associated with longer LOS and antibiotic duration. Our findings suggest that FUBCs in GNB are low yield and may not be recommended in all patients. Prospective studies are needed to further examine the utility of this practice in GNB. Disclosures All Authors: No reported disclosures

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Impact of follow up blood cultures on outcomes of patients with community-onset gram-negative bloodstream infection

EClinicalMedicine ◽

10.1016/j.eclinm.2021.100811 ◽

2021 ◽

Vol 34 ◽

pp. 100811

Author(s):

Rajiv Amipara ◽

Hana Rac Winders ◽

Julie Ann Justo ◽

P. Brandon Bookstaver ◽

Joseph Kohn ◽

...

Keyword(s):

Bloodstream Infection ◽

Blood Cultures ◽

Gram Negative ◽

Community Onset

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Positive follow-up blood cultures identify high mortality risk among patients with Gram-negative bacteraemia

Clinical Microbiology and Infection ◽

10.1016/j.cmi.2020.01.025 ◽

2020 ◽

Vol 26 (7) ◽

pp. 904-910 ◽

Cited By ~ 5

Author(s):

S.A. Maskarinec ◽

L.P. Park ◽

F. Ruffin ◽

N.A. Turner ◽

N. Patel ◽

...

Keyword(s):

High Mortality ◽

Mortality Risk ◽

Blood Cultures ◽

High Mortality Risk ◽

Gram Negative

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Utility of follow-up blood cultures for Gram-negative rod bacteremia in children

Journal of Infection and Chemotherapy ◽

10.1016/j.jiac.2019.04.014 ◽

2019 ◽

Vol 25 (9) ◽

pp. 738-741 ◽

Cited By ~ 2

Author(s):

Erika Uehara ◽

Kensuke Shoji ◽

Masashi Mikami ◽

Akira Ishiguro ◽

Isao Miyairi

Keyword(s):

Blood Cultures ◽

Gram Negative

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Follow-up blood cultures are associated with improved outcome of patients with gram-negative bloodstream infections: retrospective observational cohort study

Clinical Microbiology and Infection ◽

10.1016/j.cmi.2020.01.023 ◽

2020 ◽

Vol 26 (7) ◽

pp. 897-903 ◽

Cited By ~ 4

Author(s):

M. Giannella ◽

R. Pascale ◽

L. Pancaldi ◽

C. Monari ◽

S. Ianniruberto ◽

...

Keyword(s):

Cohort Study ◽

Bloodstream Infections ◽

Observational Cohort Study ◽

Blood Cultures ◽

Gram Negative ◽

Observational Cohort ◽

Retrospective Observational Cohort Study ◽

Improved Outcome

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The Changing Landscape of Uncomplicated Gram-Negative Bacteremia: A Narrative Review to Guide Inpatient Management

Journal of Hospital Medicine ◽

10.12788/jhm.3414 ◽

2020 ◽

Vol 15 (12) ◽

pp. 746-753 ◽

Cited By ~ 1

Author(s):

Jeannie D Chan ◽

Chloe Bryson-Cahn ◽

Zahra Kassamali-Escobar ◽

John B Lynch ◽

Anneliese M Schleyer

Keyword(s):

Cost Effective ◽

Hospital Length ◽

Antimicrobial Treatment ◽

Blood Cultures ◽

Hospital Length Of Stay ◽

Source Control ◽

Gram Negative ◽

Oral Agents ◽

Gram Negative Bacteremia

Gram-negative bacteremia secondary to focal infection such as skin and soft-tissue infection, pneumonia, pyelonephritis, or urinary tract infection is commonly encountered in hospital care. Current practice guidelines lack sufficient detail to inform evidence-based practices. Specifically, antimicrobial duration, criteria to transition from intravenous to oral step-down therapy, choice of oral antimicrobials, and reassessment of follow-up blood cultures are not addressed. The presence of bacteremia is often used as a justification for a prolonged course of antimicrobial therapy regardless of infection source or clinical response. Antimicrobials are lifesaving but not benign. Prolonged antimicrobial exposure is associated with adverse effects, increased rates of Clostridioides difficile infection, antimicrobial resistance, and longer hospital length of stay. Emerging evidence supports shorter overall duration of antimicrobial treatment and earlier transition to oral agents among patients with uncomplicated Enterobacteriaceae bacteremia who have achieved adequate source control and demonstrated clinical stability and improvement. After appropriate initial treatment with an intravenous antimicrobial, transition to highly bioavailable oral agents should be considered for total treatment duration of 7 days. Routine follow-up blood cultures are not cost-effective and may result in unnecessary healthcare resource utilization and inappropriate use of antimicrobials. Clinicians should incorporate these principles into the management of gram-negative bacteremia in the hospital.

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Risk Factors for Positive Follow-Up Blood Cultures in Gram-Negative Bacilli Bacteremia: Implications for Selecting Who Needs Follow-Up Blood Cultures

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa110 ◽

2020 ◽

Vol 7 (4) ◽

Cited By ~ 2

Author(s):

Hayato Mitaka ◽

Tessa Gomez ◽

Young Im Lee ◽

David C Perlman

Keyword(s):

Risk Factors ◽

Cohort Study ◽

Blood Culture ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Multivariate Logistic Regression Analysis ◽

Blood Cultures ◽

Gram Negative ◽

Intravascular Devices

Abstract Background The value of follow-up blood cultures (FUBCs) to document clearance of bacteremia due to Gram-negative bacilli (GNB) has not been well established. Although previous studies suggested that the yield of FUBCs for GNB bacteremia is low, it remains to be elucidated for whom FUBC may be beneficial and for whom it is unnecessary. Methods A retrospective cohort study was performed at 4 acute care hospitals to identify risk factors for positive FUBCs with GNB bacteremia and to better guide clinicians’ decisions as to which patients may or may not benefit from FUBCs. Participants included adult patients with GNB bacteremia who had FUBCs and were admitted between January 2017 and December 2018. The primary outcomes were the factors associated with positive FUBCs and the yield of FUBCs with and without the factors. Results Of 306 patients with GNB bacteremia who had FUBCs, 9.2% (95% confidence interval, 6.2%–13.0%) had the same GNB in FUBCs. In the multivariate logistic regression analysis, end-stage renal disease on hemodialysis, intravascular device, and bacteremia due to extended-spectrum β-lactamase or carbapenemase-producing organism were identified as independent predictors of positive FUBCs with GNB bacteremia. Approximately 7 FUBCs and 30 FUBCs were needed for patients with ≥1 or no risk factors, respectively, to yield 1 positive result. SummaryThis multi-site retrospective cohort study found that among patients with gram-negative bacilli (GNB) bacteremia, having ESRD on hemodialysis, intravascular devices, or bacteremia due to multi-drug resistant GNB were each independently associated with having a positive follow-up blood culture. Conclusions Follow-up blood culture may not be necessary for all patients with GNB bacteremia and has the highest yield in patients with 1 or more risk factors.

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Predictive scoring models for persistent gram-negative bacteremia that reduce the need for follow-up blood cultures: a retrospective observational cohort study

BMC Infectious Diseases ◽

10.1186/s12879-020-05395-8 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 2

Author(s):

Jongtak Jung ◽

Kyoung-Ho Song ◽

Kang Il. Jun ◽

Chang Kyoung Kang ◽

Nak-Hyun Kim ◽

...

Keyword(s):

Risk Factors ◽

Treatment Response ◽

Blood Cultures ◽

Source Control ◽

Care Hospital ◽

Gram Negative ◽

Scoring Model ◽

Source Of Infection ◽

Gram Negative Bacteremia

Abstract Background Although the risk factors for positive follow-up blood cultures (FUBCs) in gram-negative bacteremia (GNB) have not been investigated extensively, FUBC has been routinely carried out in many acute care hospitals. We attempted to identify the risk factors and develop a predictive scoring model for positive FUBC in GNB cases. Methods All adults with GNB in a tertiary care hospital were retrospectively identified during a 2-year period, and GNB cases were assigned to eradicable and non-eradicable groups based on whether removal of the source of infection was possible. We performed multivariate logistic analyses to identify risk factors for positive FUBC and built predictive scoring models accordingly. Results Out of 1473 GNB cases, FUBCs were carried out in 1268 cases, and the results were positive in 122 cases. In case of eradicable source of infection, we assigned points according to the coefficients from the multivariate logistic regression analysis: Extended spectrum beta-lactamase-producing microorganism (+ 1 point), catheter-related bloodstream infection (+ 1), unfavorable treatment response (+ 1), quick sequential organ failure assessment score of 2 points or more (+ 1), administration of effective antibiotics (− 1), and adequate source control (− 2). In case of non-eradicable source of infection, the assigned points were end-stage renal disease on hemodialysis (+ 1), unfavorable treatment response (+ 1), and the administration of effective antibiotics (− 2). The areas under the curves were 0.861 (95% confidence interval [95CI] 0.806–0.916) and 0.792 (95CI, 0.724–0.861), respectively. When we applied a cut-off of 0, the specificities and negative predictive values (NPVs) in the eradicable and non-eradicable sources of infection groups were 95.6/92.6% and 95.5/95.0%, respectively. Conclusions FUBC is commonly carried out in GNB cases, but the rate of positive results is less than 10%. In our simple predictive scoring model, zero scores—which were easily achieved following the administration of effective antibiotics and/or adequate source control in both groups—had high NPVs. We expect that the model reported herein will reduce the necessity for FUBCs in GNB cases.

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118. Factors Associated with Positive Follow-up Blood Cultures in Gram-Negative Septicemia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.193 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S90-S90

Author(s):

Orly Hadar ◽

Amy Van ◽

Carla McWilliams ◽

Luis Wulff ◽

Linda Godinez

Keyword(s):

Odds Ratio ◽

Central Line ◽

Blood Cultures ◽

Cardiac Device ◽

Gram Negative ◽

Factors Associated ◽

Central Line Infection ◽

Line Infection

Abstract Background Bloodstream infections remain a significant cause of morbidity and mortality. No guidelines for the management of noncatheter-associated Gram-negative septicemia exist. There is considerable debate regarding the role of follow-up blood cultures. Studies have shown inadequate antibiotic therapy increases mortality in Gram-negative sepsis. We evaluated factors associated with a higher likelihood of positive follow-up blood cultures (FUBC). Methods A retrospective cohort study was conducted to look at factors associated with an increased likelihood of positive FUBC. Data were obtained via Epic chart review. Empiric antimicrobial regimens were reviewed in all patients with MDRO infections. Results We identified 1,527 patients ≥18 years admitted with gram-negative septicemia from January 1, 2013 through January 1, 2018. A total of 8.4% had positive FUBC. Patients with positive FUBC had a younger median age than the no-growth group (64.7 vs. 69.4, P <0.001). Admission systolic blood pressure was lower in the group with positive FUBC than the no-growth group (107 vs. 116, P = 0.008). The odds ratio for positive FUBC for cardiac device was 2.08 (95% CI = [0.97, 4.35], P = 0.061); central line infection (vs. urinary tract infection) adjusted odds ratio was 2.08 (95% CI = [1.10, 3.95], P = 0.025). The positive FUBC group had a larger proportion of multidrug-resistant organisms (MDRO) (21.9% vs. 10.4%, P < 0.001) with an odds ratio of 2.40 (95% CI = [1.53, 3.78]). In this group, those who received inadequate empiric antibiotics had a significantly higher percentage of repeat positive results (78.6% vs. 57.1%, P = 0.033). In summary, patients with either an MDRO, a central line infection (vs. urinary tract infection), or the presence of a cardiac device (vs. no cardiac device present) had over twice the odds of positive FUBC than those without. Conclusion Though the role of FUBC for Gram-negative septicemia has been brought into question, our results show that the presence of central lines, cardiac devices, infections with MDRO organisms, or inadequate empiric antibiotics on admission were factors strongly correlated with subsequent positive FUBC. Therefore, we believe that repeating blood cultures in this subset of patients require further study and consideration. Disclosures All authors: No reported disclosures.

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