BSI involves various pathogenic microorganisms, such as bacteria or fungi, invading the blood circulation, reproducing in the blood, releasing toxins and metabolites, and inducing the release of cytokines. This can cause systemic multiple organ dysfunction syndrome MODS , a serious systemic infectious disease, and even death.
Moreover, BSI can increase the length of hospital stay, treatment costs, and complications after discharge, directly or indirectly affecting patient prognosis. Once resistant to carbapenem antibiotics, clinical treatment of this type of infection is very difficult. In recent years, the detection rate of carbapenem-resistant K. The emergence of CRKP makes the anti-infective treatment encounter great challenges globally Willyard, However, clinicians are more concerned about extensively drug-resistant XDR K.
XDR-KP is resistant to many antibiotics currently used in the clinic, except for tigecycline and polymyxin. But, emergence of high level of resistance against latest generation of tigecycline in animals and humans is concerning He et al. BSI caused by strain often aggravates the disease, resulting in difficult treatment and poor clinical prognosis. A large number of studies have shown that early identification and early appropriate antibiotic treatment are significantly related to the reduction of mortality Schwaber and Carmeli, ; Daikos et al.
Due to the lack of attention to high risk factors, late identification and inadequate antibacterial treatment increases mortality; thus, it is necessary to obtain cultures in the early stage of infection to determine specific pathogens, drug resistance, and reasonable antibiotic treatment. Previous studies have discussed BSIs caused by K. Pneumoniae Daikos et al. However, the risk factors for drug-resistant bacterial infection and death of patients with bacteremia are still inconsistent among the different studies; thus, these risk factors still need to be further improved and verified in clinical practice Du et al.
Early detection of risk factors and improving clinician awareness play a positive role in the prognosis of patients. Because inadequate anti-infective treatment can increase mortality, improving the identification of patients with high-risk drug-resistant bacteria is key. Once there are clinical symptoms, with respect to drug-resistant bacterial infection, whether combination therapy with anti-infective treatment is effective still needs to be further studied.
Some observational studies have shown that, when confirming CRKP infection, combination therapy is related to an improvement of survival rate, but the best treatment scheme has not been determined Gutierrez-Gutierrez et al.
Therefore, we conducted a single-center retrospective study to explore the clinical epidemiology, risk factor analysis, antimicrobial analysis, and prognosis analysis of BSI patients caused by K. We analyzed the demographic characteristics of these patients, the risk factors for drug-resistant bacterial infection and the risk factors for death. Additionally, the treatment schemes in the retrospective data were analyzed. The findings in this study are important for early detection, early treatment, and improving the prognosis of patients with BSI.
The inclusion criteria were as follows: 1. The patient was positive in multiple cultures, and the first culture was positive at the initial observation time. The hospitalized patient had complete clinical data. The exclusion criteria were as follows: 1. The patient was discharged within 24 hours of hospitalization. The patient had more than two kinds of bacterial BSIs.
The diagnostic criteria for septic shock were based on the Sepsis 3. The ventilator application included non-invasive ventilation and invasive ventilation. Non-invasive ventilation included mask ventilation and excluded high-flow nasal catheter oxygen therapy. Invasive ventilation included orotracheal intubation and tracheotomy connected to a ventilator. XDR is defined as insensitivity to almost all types of antibiotics except one or two types of antibiotics mainly polymyxin and tigecycline , and the determination of class resistance is the same as MDR.
Pandrug resistance PDR is defined as insensitivity to all types of antimicrobials currently used in the clinic. Combination therapy is defined as a regimen that is treated with two or more antibiotics approved by infectious disease specialists in the course of treatment. A direct rapid drug sensitivity test was conducted using the positive blood culture bottle and the disk diffusion method.
Previous cases were consulted and the data were collected as follows: General patient data i. Pre-hospitalization data, including hospitalization history, ICU hospitalization history, operation history, antibiotic use history, and glucocorticoid and immunosuppressant use history, were recorded. Past patient history was obtained, such as history of diabetes, hypertension, coronary heart disease, chronic kidney disease CKD , et al.
Recent invasive procedures were also noted, such as central venous catheter CVC placement, temporary dialysis tube placement, arterial puncture, tracheal intubation, et al. The results of the blood culture and drug sensitivity tests were recorded. The antibiotic treatment plan and the clinical data of the patients after commencing treatment were recorded. The main outcome index was the day mortality after the diagnosis of BSI, and the secondary outcome indicators included total hospital stay duration, ICU hospital stay duration, mechanical ventilation time, vasoactive drug use, acute renal failure, and MODS.
In this study, only the age data had a normal distribution, and the age comparison between the two groups was analyzed using two independent sample t-tests. Data with a non-normal distribution were calculated using the Mann-Whitney U test. The risk factors for drug-resistant bacterial infection and the independent predictors of day mortality were determined using binomial logistic regression.
A p value less than 0. This retrospective observational study included patients with K. Among the positive blood culture results, there were sensitive K. There were no PDR bacteria in these patients. The demographics and clinical characteristics of the three groups are shown in Table 1. There was no difference in sex and age between the different groups. Despite the lack of statistical significance, there were more cases of dialysis tube placement in the drug-resistant group, suggesting that such cases require more attention from clinicians.
Since fewer patients with a history of organ transplantation, corticosteroid use, or immunosuppressant use were included in the study, the clinical reference value of the comparison between the two groups was small. We also included the basic information of the patients from the day of the BSI diagnosis. Clinical characteristics of patients in different groups before diagnosis of bloodstream infection.
Chi-Square Test is used to calculate the two-category variables, t-test is used to calculate the normal distribution variables, and Mann-Whitney U Test is used to calculate the variables with non-normal distribution and uneven variance.
Univariate analysis showed that recent hospitalization history, ICU hospitalization history, operation history, invasive operation history, antibiotic application history, hospitalization time, the hospitalization ward, scores, respiratory failure, MODS, and septic shock were the risk factors for K.
The results of the multivariate analysis are shown in Table 2. By dividing the hospitalization time before infection into three groups 1 week, 2 weeks, and more than 2 weeks , we found that patients with more than 2 weeks of hospitalization before BSI were 4.
Logistic regression analysis of risk factors of drug-resistant K. Taking death within 28 days after BSI diagnosis as the main end point, the results showed that cases died and cases survived. The day mortality rate of patients with K. We compared patients with different clinical outcomes, and the results obtained by univariate analysis are shown in Table 3.
We compared the results of the drug sensitivity test between the survival group and the death group, and the proportion of S-KP patients in the survival group was higher, while the proportion of XDR-KP patients in the death group was higher. The drug-resistance of patients in the survival group and the death group were compared one by one, as shown in Table 4. It was observed that the proportion of drug resistance to penicillins, cephalosporins, and carbapenems in the death group was statistically significantly higher than that in the survival group.
According to the clinical data from the day of BSI diagnosis to before discharge, the risk of accident was higher in the day death group. In this study, binomial logistic regression was used to evaluate the impact of the above suspicious risk factors on the day survival rate of the subjects. The studentized residual of seven patients was more than three times the standard deviation, but remained in the analysis. The model can correctly classify The sensitivity, specificity, positive predictive value, and negative predictive value of the model were The specific information is shown in Table 6.
Endotracheal intubation increased the risk of death by 2. Patients with hypoalbuminemia had a 2. The risk of death for patients with MODS was increased by 3. Patients with a SOFA score greater than 6 had a 3. With regard to resistance to carbapenem antibiotics, the risk of death in CRKP infections was 2.
Logistic regression analysis of risk factors of death in patients with KP bloodstream infections. Among the patients with K. Among them, 81 patients were treated with single antibiotic The combined use of antibiotics did not appear to improve the prognosis.
Specifically, carbapenem antibiotics accounted for half of the monotherapy cases, while the remaining cases were treated with cefoperazone sulbactam In the combined therapy cases, there were 10 cases in which carbapenem was used and four cases in which tigecycline was used, of which one case was treated with triple antibiotics. Among them, the number of cases treated with monotherapy was relatively less than that of the sensitive group Among them, 18 cases died within 28 days, of which 13 cases Tigecycline was mainly used for combination treatment The mortality rate in the single drug treatment group is higher than that in the combination treatment group, which deserves the attention of clinicians.
Among the patients treated with antibiotic, The case fatality rate of the combined treatment group was A total of six patients were treated with triple antibiotics, of which one patient died. Since the beginning of this century, K.
It has gained the attention of clinical workers: on the one hand, the increase in the detection rate of drug-resistant bacteria has made it more difficult for clinicians to choose antibiotics; on the other hand, drug-resistant K. It has been recommended that a combination of antibiotics be used to treat K. Therefore, we collected the clinical data of patients with K. We collected and analyzed the clinical data of patients with K.
Of the patients, S-KP accounted for only Reviewing data on K. In , a number of studies found the bla KPC-2 gene present in CRKP isolates and, at one time, there was an epidemic in two separate hospitals Maltezou et al. In this study, we did not explore the molecular epidemiology, but put more emphasis on the clinician perspective.
We compared the clinical characteristics of K. Patients with recent ICU hospitalization history, recent surgical history, recent antibiotic use history, mechanical ventilation history, and hospitalization more than two weeks before the BSI diagnosis were more likely to be infected with drug-resistant bacteria.
It is suggested that clinicians be more vigilant against the possibility of drug-resistant bacterial infections when facing the clinical manifestations of BSIs in these kinds of patients, such as fever, increased procalcitonin PCT , or even shock. At the same time, several other possible risk factors should not be ruled out, such as patients with a recent history of invasive surgery, patients in the ICU ward, patients with diabetes, and patients with severe clinical symptoms.
Mantzarlis et al. However, all the patients included were ICU patients, and the samples included blood and airway secretions, as well as other infectious secretions. Freeman et al. However, fewer cases were included in this study, and there was no age limit. At the same time, patients who do not have ESBL-KP may also have carbapenem or even a variety of antibiotic-resistant bacteria. In this study, based on the results of the drug sensitivity test that clinicians are typically most concerned about, we analyzed the epidemiological characteristics, high risk factors, and prognosis for drug-resistant bacterial infections.
In this study, the day all-cause mortality rate of the included patients was Patients were divided into groups according to the results of the different drug sensitivity tests. The results showed that the mortality rate of patients with S-KP bacteremia was Studies by Hoxha et al. However, the inclusion population included all patients with K. Studies by Borer et al. It was also found that the mortality rate of patients with MODS was Only adult patients with clinically diagnosed BSI and only K.
The mortality data obtained are higher than that in previous studies. On the other hand, because the outcome index uses a survival condition of 28 days after the BSI diagnosis, this study pertains to all-cause mortality rather than hospital mortality. We analyzed the patients with different clinical prognoses. Secondary outcome was the relation between age-related decisions in the initial management of injuries and withdrawal of life-sustaining therapy WLST during hospital stay.
Graphs were prepared with GraphPad Prism version 8. Results are presented as median and interquartile range IQR. Comparison of continuous variables was done using Kruskal—Wallis. Variables with univariate statistical significance were included in a multinominal logistic regression analysis.
Patients received 4. Patients stayed 6 2—11 days on the ventilator, 7 3—13 days in ICU and 20 11—31 days in the hospital. When analyzing different age groups, it was noted that with increasing age more females sustained severe injury. AIS head, face, chest and external were similar between age groups.
There were no differences in crystalloid and blood product resuscitation between the age groups. Further, there was no difference in ventilator days, days in ICU nor in hospital, although the elderly had less ventilator-free days. The majority of patients in all age groups died of TBI. Elderly patients died more often of respiratory insufficiency compared to other age groups. The other 4 developed respiratory insufficiency on the ward where it was decided, in close harmony with patient if possible and family, against readmission to ICU for invasive ventilator support.
Multinominal logistic regression analysis was performed to identify possible independent outcome predictors for different age groups. In this prospective cohort study of polytrauma mortality was highest in elderly patients. Additionally, Hatton et al. This is accompanied by worse outcomes compared with patients presenting with shock, because of either worsened underlying physiology or lack of timely detection and prompt treatment of this hypoperfusion [ 22 ].
This might partly explain worse outcomes in elderly with similar physiological parameters compared to their younger counterparts. Further, the observed lower hemoglobin in ED with similar acidosis compared to other age groups could possibly be explained by the fact that elderly have lower baseline hemoglobin due to various reasons poor nutrition, anticoagulants, decreased bone marrow function.
The odds of thrombo-embolic complications in elderly was even 10 times lower than the reference group, this is possibly related to higher anticoagulant usage in the eldest age group. Another reason could be a decline in immune function seen in the elderly as postulated by Smith [ 23 ].
This could influence the ability to mount a normal immune response to major stress, so maybe elderly are at reduced risk of an immune modulated MODS or ARDS while more susceptible to post-injury infection due to reduced immune response to a new antigen. There is however little definitive evidence of this theory, and in the current study elderly did not develop more infectious complications than other age groups.
It is tempting to argue that the elderly did not live long enough to develop complications, however, this is contradicted by the length of hospital admission that was comparable to other age groups. In almost half the patients who later died withdrawal of life-sustaining therapy WLST was executed.
In our institution age alone is not an exclusion for equal treatment in comparison with younger patients with adequate imaging and resuscitation, urgent surgery if necessary, and ICU admission. Our policy of no discrimination based on age alone is confirmed by current data with similarities between age groups regarding resuscitation volumes, urgent surgery rates, ventilator days, ICU and hospital length of stay.
Others have shown similar data of less aggressive treatment in the elderly [ 6 ]. Sometimes chance of recovery to an acceptable quality of life is low and a no return to ICU policy could be advocated. This decision implicates that these elderly patients might expire from respiratory insufficiency if this would develop at a later stage during a hospital stay.
Additionally, there were few patients in a persistent vegetative state in all age groups. This is in agreement with our previous data on outcome in patients with moderate to severe isolated TBI [ 24 ]. We have previously speculated that these differences may be partly due to cultural differences [ 24 ]. In Glasgow outcome score there is no measured difference between patients who are discharged to a nursing home or to a rehabilitation facility both GOS 3.
Since these GOS data were calculated at discharge from hospital, an amelioration in recovery could be expected over time. One of the limitations of this study is that was conducted at a single institution in which the clinical treatment and research were conducted by the same clinicians. Another limitation is that no detailed past medical history data nor any data on GOS after discharge were collected.
This cut-off point is somewhat artificial since it was based on age groups that were previously defined. In practice it is more likely there is a sliding scale for increasing mortality rather than an exact age cut-off point. Age alone should not exclude elderly from initial aggressive treatment although restrictive treatment measurements later during hospital stay should be considered if it becomes apparent that chances of recovery to an acceptable quality of life are low.
The dataset supporting the conclusions of this article are available upon reasonable request from the corresponding author. Working group on multiple trauma of the german society of trauma. Mortality in severely injured elderly trauma patients—when does age become a risk factor? World J Surg.
Ann Emerg Med. Opportunities for improved trauma care of the elderly - a single center analysis of severely injured patients. Arch Gerontol Geriatr. Factors affecting mortality in older trauma patients-A systematic review and meta-analysis. Polytrauma in the elderly: specific considerations and current concepts of management. Eur J Trauma Emerg Surg.
Severe and multiple trauma in older patients; incidence and mortality. Age and mortality after injury: is the association linear? Defining geriatric trauma: when does age make a difference? Impact of age on the clinical outcomes of major trauma.
Registry-based mortality analysis reveals a high proportion of patient decrees and presumed limitation of therapy in severe geriatric trauma. J Clin Med. It is time for a change in the management of elderly severely injured patients! Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med. The effect of age, severity, and mechanism of injury on risk of death from major trauma in Western Australia.
J Trauma Acute Care Surg. Major trauma registry of Navarre Spain : the accuracy of different survival prediction models. Demographic patterns and outcomes of patients in level-1 trauma centers in three international trauma systems. Changes in the epidemiology and prediction of multiple-organ failure after injury. Comparison of postinjury multiple-organ failure scoring systems: Denver versus sequential organ failure assessment. Early predictors of postinjury multiple organ failure. Arch Surg.
ARDS definition task force. Acute respiratory distress syndrome: the Berlin Definition.
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