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Chest

Volume 123, Issue 5, May 2003, Pages 1615-1624
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Clinical Investigations in Critical Care
Community-Acquired Bloodstream Infection in Critically Ill Adult Patients: Impact of Shock and Inappropriate Antibiotic Therapy on Survival

https://doi.org/10.1378/chest.123.5.1615Get rights and content

Design:

The objectives were to characterize the prognostic factors and evaluate the impact of inappropriate empiric antibiotic treatment and systemic response on the outcome of critically ill patients with community-acquired bloodstream infection (BSI).

Patients:

A prospective, multicenter, observational study was carried out in 339 patients admitted in 30 ICUs for BSI.

Results:

Crude mortality was 41.5%. Septic shock was present in 184 patients (55%). The pathogens most frequently associated with septic shock or death were Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae, which accounted for approximately half of the deaths. Antibiotic treatment was found to be inappropriate in 14.5% of episodes. Patients in septic shock with inappropriate treatment had a survival rate below 20%. Multivariate analysis identified a significant association between septic shock and four variables: age ≥ 60 years (odds ratio [OR], 1.96), previous corticosteroid therapy (OR, 2.58), leukopenia (OR, 2.32), and BSI secondary to intra-abdominal (OR, 2.38) and genitourinary tract (OR, 2.29) infections. The variables that independently predicted death at ICU admission were APACHE (acute physiology and chronic health evaluation) II score ≥ 15 (OR, 2.42), development of septic shock (OR, 3.22), and inappropriate empiric antibiotic treatment (OR, 4.11). This last variable was independently associated with an unknown source of sepsis (OR, 2.49). Mortality attributable to inappropriate antibiotic treatment increased with the severity of illness at ICU admission (10.7% for APACHE II score < 15 and 41.8% for APACHE II score ≥ 25, p < 0.01).

Conclusions:

Inappropriate antimicrobial treatment is the most important influence on outcome in patients admitted to the ICU for community-acquired BSI, particularly in presence of septic shock or high degrees of severity. Initial broad-spectrum therapy should be prescribed to septic patients in whom the source is unknown or in those requiring vasopressors.

Section snippets

Study Location and Patients

This prospective, multicenter study was carried out in 30 ICUs in Spain. All adults admitted to the 30 participating ICUs during two 9-month periods (April 1993 through December 1993, and April 1998 through December 1998) who presented at least one true-positive blood culture finding on ICU admission or within the first 48 h of ICU stay were considered eligible for the study. Further episodes were excluded from analysis. The participating institutions were either primary or tertiary care

Results

During the two study periods, a total of 33,211 patients were admitted to the 30 participating ICUs. Three hundred thirty-nine patients with a mean ± SD APACHE II score of 19 ± 7 and a mean age of 58 ± 18 years presented true BSI on ICU admission, accounting for a BSI rate of 10.2 episodes per 1,000 ICU admissions (9.2 episodes in 1993 and 11.1 episodes in 1998 per 1,000 ICU admissions). One hundred forty-one of these 339 patients died in the ICU, representing an ICU crude mortality of 41.6%

Discussion

This study is the first to correlate timing of ICU death with presence of septic shock and inappropriate antibiotic therapy in a cohort of adults hospitalized in the ICU for community-acquired BSI. We found that inadequate antibiotic therapy is the most important determinant of survival. Initial appropriate empiric antibiotic therapy is critical, particularly in patients with vasopressors or unknown source of sepsis, who may die immediately if adequate antibiotic treatment is not administered.

Appendix

The other members of the Spanish Collaborative Group for Infections in the Intensive Care Units are as follows: C. Ortiz Leyba and J. Jiménez (Hospital Universitario Virgen del Rocío, Sevilla); E. Quintana, E. Ormaechea, C. Fernández, and J. Bellapart (Hospital Santa Creu y Sant Pau, Barcelona); A. Mateu, H. Torrado, L. Corral, and D. Rodríguez (Hospital de Bellvitge, Hospitalet de Llobregat); E. Arnau, A. Planes, M. Palomar, and J. Serra (Hospital del Valle Hebrón, Barcelona); J.M. Flores

ACKNOWLEDGMENT

We thank Michael Maudsley (University of Barcelona) for editing the manuscript, and Montse Rué, Marta Roqué, and Jordi Real for review of the statistical analysis and database development and management.

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    This study was partially supported by an unrestricted research grant from Wyeth.

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    Copyright © 2003 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.