Hospital-acquired E. coli bacteraemia at a large UK NHS Trust. A return towards baseline following implementation of a 5-year quality improvement programme.

Introduction: Until recently, healthcare-associated E. coli bacteraemia was a neglected area of infection prevention and control (IPC), despite a 30-day mortality of 15-20%. Recently, the UK Department of Health (DH) introduced a target to reduce hospital-acquired E. coli bacteraemias by 50% over a five-year period. Following implementation of multifaceted and multidisciplinary interventions, the aim of this study was to determine its impact on achieving this target. Methods: From April 2017 to March 2022, consecutive hospital-acquired E. coli bacteraemic inpatients within Barts Health NHS Trust were prospectively studied. Using quality improvement methodology, and implementing the plan, do, study, act (PDSA) cycle at each stage, antibiotic prophylaxis for high-risk procedures were modified and 'good practice' interventions around medical devices introduced. Characteristics of bacteraemic patients were analysed and trends in bacteraemic episodes recorded. Statistical analysis was undertaken in Stata SE (version 16). Results: There were 770 patients and 797 episodes of hospital-acquired E. coli bacteraemias. Following a baseline of 134 episodes in 2017-18, this peaked at 194 in 2019-20 before dropping to 157 in 2020-21 and 159 in 2021-22. Most hospital-acquired E. coli bacteraemias occurred in those aged > 50, 551 (69.1%), with the highest proportion occurring in those age > 70, 292 (36.6%). Hospital-acquired E. coli bacteraemia occurred more commonly between October to December.Most episodes occurred in either medicine or care of the elderly patients, 345 (43.3%), specialist surgery, 141 (17.7%), haematology/oncology, 127 (15.9%) and patients requiring critical care, 108 (13.6%). The urinary tract, 336 (42.2%), both catheter and non-catheter associated, was the commonest sites of infection. 175 (22.0%) of E. coli bacteraemic isolates were extended spectrum beta lactamase (ESB) producing. Co-amoxiclav resistance was 315 (39.5%), ciprofloxacin resistance 246 (30.9%) and gentamicin resistance 123 (15.4%). At 7 days, 77 patients (9.7%; 95% CI 7.4-12.2%) died and by 30 days this had risen to 129 (16.2%; 95% CI 13.7-19.9%). Conclusion: Despite implementation of quality improvement (QI) interventions, it was not possible to achieve a 50% reduction from baseline although an 18% reduction was achieved from 2019-20 onwards. Our work highlights the importance of antimicrobial prophylaxis and medical device 'good practice'. Over time, these interventions, if properly implemented, could further reduce healthcare-associated E. coli bacteraemic infection.

Blood urea nitrogen to serum albumin ratio independently predicts 30-day mortality and severity in patients with Escherichia coli bacteraemia.

BACKGROUND: Elevated blood urea nitrogen to serum albumin (BUN/ALB) ratio had been identified as an independent risk factor related to mortality in community-acquired and hospital-acquired pneumonia. This study aimed to investigate whether this clinical index can predict the clinical outcomes of E. coli bacteraemia. MATERIAL AND METHODS: Clinical data were collected from patients with E. coli bacteraemia attended at our hospital between January 2012 and December 2018. The endpoints were mortality within 30 days after the diagnosis of E. coli bacteraemia and intensive care (IC) requirement. Cox regression analysis was performed to evaluate the risk factors. RESULTS: A total of 398 patients with E. coli bacteraemia were enrolled in this study and 56 patients died within 30 days after bacteraemia onset. Multivariate Cox regression analysis showed that age greater than 65 years, lymphocyte count<.8×10e9/L, elevated BUN/ALB ratio, increased SOFA score, carbapenem resistance, central venous catheterization before onset of bacteraemia, and infection originating from abdominal cavity were independent risk factors for 30-day mortality (P<.05). The risk factors associated with IC requirement were similar to those for 30-day mortality except central venous catheterization before onset of bacteraemia. The area under the receiver-operating characteristic curve for BUN/ALB ratio predicting 30-day mortality and IC requirement was similar to that for SOFA score, but higher than that for lymphocyte count. The cut-off points of BUN/ALB ratio to predict 30-day mortality and IC requirement were both .3. CONCLUSIONS: BUN/ALB ratio is a simple but independent predictor of 30-day mortality and severity in E. coli bacteraemia. A higher BUN/ALB ratio at the onset of bacteraemia predicts a higher mortality rate and IC requirement.

Blood urea nitrogen to serum albumin ratio independently predicts 30-day mortality and severity in patients with Escherichia coli bacteraemia

Background: Elevated blood urea nitrogen to serum albumin (BUN/ALB) ratio had been identified as an independent risk factor related to mortality in community-acquired and hospital-acquired pneumonia. This study aimed to investigate whether this clinical index can predict the clinical outcomes of E. coli bacteraemia.Material and methodsClinical data were collected from patients with E. coli bacteraemia attended at our hospital between January 2012 and December 2018. The endpoints were mortality within 30 days after the diagnosis of E. coli bacteraemia and intensive care (IC) requirement. Cox regression analysis was performed to evaluate the risk factors.ResultsA total of 398 patients with E. coli bacteraemia were enrolled in this study and 56 patients died within 30 days after bacteraemia onset. Multivariate Cox regression analysis showed that age greater than 65 years, lymphocyte count<.8×10e9/L, elevated BUN/ALB ratio, increased SOFA score, carbapenem resistance, central venous catheterization before onset of bacteraemia, and infection originating from abdominal cavity were independent risk factors for 30-day mortality (P<.05). The risk factors associated with IC requirement were similar to those for 30-day mortality except central venous catheterization before onset of bacteraemia. The area under the receiver-operating characteristic curve for BUN/ALB ratio predicting 30-day mortality and IC requirement was similar to that for SOFA score, but higher than that for lymphocyte count. The cut-off points of BUN/ALB ratio to predict 30-day mortality and IC requirement were both .3.ConclusionsBUN/ALB ratio is a simple but independent predictor of 30-day mortality and severity in E. coli bacteraemia. A higher BUN/ALB ratio at the onset of bacteraemia predicts a higher mortality rate and IC requirement. (AU)

Antecedentes: Se ha identificado la elevación de la proporción de nitrógeno ureico en sangre con respecto a albúmina sérica (NUS/ALB) como un factor de riesgo independiente asociado a la mortalidad de la neumonía adquirida en la comunidad y la neumonía intrahospitalaria. El objetivo de este estudio fue investigar si este índice clínico puede predecir los resultados clínicos de bacteremia por E. coli.Material y métodosSe recopilaron los datos clínicos de los pacientes con bacteremia por E. coli atendidos en nuestro hospital entre enero de 2012 y diciembre de 2018. Las variables de evaluación fueron la mortalidad a 30 días tras el diagnóstico de bacteremia por E. coli y la necesidad de cuidados intensivos (CI). Se realizó un análisis de regresión de Cox para evaluar los factores de riesgo.ResultadosSe incluyó en el estudio a un total de 398 pacientes con bacteremia por E. coli, falleciendo 56 pacientes en el plazo de 30 días tras el inicio de la bacteremia. El análisis de regresión de Cox multivariante reflejó que la edad superior a 65 años, el recuento linfocitario <0,8×109/l, la elevación del ratio NUS/ALB, el incremento de la puntuación SOFA, la resistencia al carbapenem, la cateterización venosa central anterior al inicio de la bacteremia y la infección originada por la cavidad abdominal eran factores de riesgo independientes de la mortalidad a 30 días (p<0,05). Los factores de riesgo asociados a la necesidad de CI fueron similares a los de la mortalidad a 30 días, exceptuando la cateterización venosa central anterior al inicio de la bacteremia. El área bajo la curva característica operador-receptor para el ratio NUS/ALB que predice la mortalidad a 30 días, y la necesidad de CI fue similar a la puntuación SOFA, aunque superior a la correspondiente al recuento linfocitario. Los puntos de corte del ratio NUS/ALB para predecir la mortalidad a 30 días y la necesidad de CI se situaron en 0,3. (AU)