Epidemiology of biliary tract-associated bloodstream infections and adequacy of empiric therapy: an Australian population-based study.

PURPOSE: Although the biliary tract is a common source of invasive infections, the epidemiology of cholangitis- and cholecystitis-associated bloodstream infection (BSI) is not well defined. The objective of this study was to determine the incidence, clinical determinants, microbiology of biliary tract-associated BSI, and predicted adequacy of common empiric therapy regimens. METHODS: All biliary tract-associated BSI in Queensland during 2000-2019 were identified using state-wide data sources. Predicted adequacy of empiric antimicrobial therapy was determined according to microbiological susceptibility data. RESULTS: There were 3,698 episodes of biliary tract-associated BSI occurred in 3,433 patients of which 2,147 (58.1%) episodes were due to cholangitis and 1,551 (41.9%) cholecystitis, for age- and sex-standardized incidence rates of 2.7, and 2.0 per 100,000 population, respectively. An increasing incidence of biliary tract-associated BSI was observed over the study that was attributable to an increase in cholangitis cases. There was a significant increased risk for biliary tract-associated BSI observed with advancing age and male sex. Patients with cholangitis were older, more likely to have healthcare associated infection, and have more comorbidities most notably liver disease and malignancies as compared to patients with cholecystitis. The distribution of infecting pathogens was significantly different with polymicrobial aetiologies more commonly observed with cholangitis (18.4% vs. 10.5%; p < 0.001). The combination of ampicillin/gentamicin/metronidazole was predicted to have the overall highest adequacy (96.1%), whereas amoxicillin/clavulanate had the lowest (77.0%). Amoxicillin/clavulanate (75.2% vs. 79.4%, p:0.03) and ceftriaxone/metronidazole (83.4% vs. 89.6%; p < 0.001) showed significantly inferior predicted adequacy for cholangitis as compared to cholecystitis. CONCLUSIONS: Bloodstream infections related to cholecystitis and cholangitis exhibit different epidemiology, microbiology, and requirements for empiric therapy.

The interaction of net ultrafiltration rate with urine output and fluid balance after continuous renal replacement therapy initiation: A multi-Centre study.

PURPOSE: During continuous renal replacement therapy (CRRT), a high net ultrafiltration rate (NUF) may worsen the decrease in urine output (UO) associated with starting CRRT. However, fluid balance (FB) may modulate this association. We aimed to examine the relationship between NUF, UO and FB at the start of CRRT. METHODS: A retrospective cohort study of 1030 CRRT-treated patients admitted to two tertiary ICUs. RESULTS: Median age was 60 years (IQR, 48-70), median APACHE III was 94 (IQR, 76-114) and median NUF rate was 0.7 mL/kg/h. In the 24 h after CRRT started, the mean hourly UO decreased from 25.5 mL to 11.9 mL (P < 0.001). Moreover, after adjusting for multiple confounders on multivariable analysis, a higher NUF was not significantly associated with a lower UO (-1.5 mL/kg for every 1 mL/kg/h increase in NUF; 95% CI -3.1 to 0.04; p = 0.064). In addition, pre-CRRT FB did not modulate the above relationship between higher NUF and lower UO. CONCLUSION: A higher NUF rate was not significantly associated with a greater immediate and sustained reduction in UO after CRRT commencement. FB before CRRT was also not associated with a greater reduction in UO. These findings do not provide evidence for an effect of NUF on renal function.

How a positive fluid balance develops in acute kidney injury: A binational, observational study.

PURPOSE: A positive fluid balance (FB) is associated with harm in intensive care unit (ICU) patients with acute kidney injury (AKI). We aimed to understand how a positive balance develops in such patients. METHODS: Multinational, retrospective cohort study of critically ill patients with AKI not requiring renal replacement therapy. RESULTS: AKI occurred at a median of two days after admission in 7894 (17.3%) patients. Cumulative FB became progressively positive, peaking on day three despite only 848 (10.7%) patients receiving fluid resuscitation in the ICU. In those three days, persistent crystalloid use (median:60.0 mL/h; IQR 28.9-89.2), nutritional intake (median:18.2 mL/h; IQR 0.0-45.9) and limited urine output (UO) (median:70.8 mL/h; IQR 49.0-96.7) contributed to a positive FB. Although UO increased each day, it failed to match input, with only 797 (10.1%) patients receiving diuretics in ICU. After adjustment, a positive FB four days after AKI diagnosis was associated with an increased risk of hospital mortality (OR 1.12;95% confidence intervals 1.05-1.19;p-value <0.001). CONCLUSION: Among ICU patients with AKI, cumulative FB increased after diagnosis and was associated with an increased risk of mortality. Continued crystalloid administration, increased nutritional intake, limited UO, and minimal use of diuretics all contributed to positive FB. KEY POINTS: Question How does a positive fluid balance develop in critically ill patients with acute kidney injury? Findings Cumulative FB increased after AKI diagnosis and was secondary to persistent crystalloid fluid administration, increasing nutritional fluid intake, and insufficient urine output. Despite the absence of resuscitation fluid and an increasing cumulative FB, there was persistently low diuretics use, ongoing crystalloid use, and a progressive escalation of nutritional fluid therapy. Meaning Current management results in fluid accumulation after diagnosis of AKI, as a result of ongoing crystalloid administration, increasing nutritional fluid, limited urine output and minimal diuretic use.

Proteus species bloodstream infections: Comparative epidemiology of three species.

BACKGROUND: Although Proteus species are occasional causes of serious infections, their epidemiology has not been well defined. The objective was to describe the overall and species-specific occurrence and determinants of Proteus species bloodstream infection (BSI) in a large Australian population. METHODS: All Queensland residents with Proteus species BSI identified within the publicly funded healthcare system between 2000 and 2019 were included. RESULTS: A total of 2,143 incident episodes of Proteus species BSI were identified among 2,079 Queensland residents. The prevalence of comorbid illness differed with higher Charlson comorbidity scores observed with P. penneri and P. vulgaris, and higher prevalence of liver disease with P. penneri, higher comorbid cancer with P. vulgaris, and lower diabetes and renal disease prevalence with P. mirabilis BSIs. CONCLUSION: This study provides novel information on the epidemiology of Proteus species BSI.

Bloodstream infections in neutropenic and non-neutropenic patients with haematological malignancies: epidemiological trends and clinical outcomes in Queensland, Australia over the last 20 years.

Knowledge of the epidemiology of bloodstream infection (BSI) in haematology patients is essential to guide patient management. We investigated the epidemiology of BSI in patients with haematological malignancies in Queensland over the last 20 years (2000-2019), including all episodes diagnosed by the state-wide microbiology service. We identified 7749 BSI in 5159 patients, 58% associated with neutropenia. Gram-negatives were the main causative pathogens (58.3%), more frequent in neutropenic than non-neutropenic patients (3308/5309, 62.3% vs 1932/3678, 52.5%, p < 0.001). Amongst 8987 isolates the most common were E. coli (15.4%) and Pseudomonas spp. (14.2%). Pseudomonas spp. (16.6% vs 10.7%, p < 0.001), Klebsiella spp. (11.6% vs 6.8%, p < 0.001), viridans-group streptococci (4.4% vs 1.2%, p < 0.001) and E. faecium (2.4% vs 0.9%, p < 0.001) were more common in neutropenic than non-neutropenic patients, while S. aureus was less common (5.9% vs 15.6%, p < 0.001). Several antimicrobial resistance rates increased over time and had higher prevalence in neutropenic than non-neutropenic patients, including ciprofloxacin-resistant E. coli (94/758, 12.4% vs 42/506, 8.3%, p = 0.021), trimethoprim-sulfamethoxazole-resistant E. coli (366/764, 47.9% vs 191/517, 36.9%, p < 0.001), penicillin-resistant streptococci (51/236, 21.6% vs 28/260, 10.8%, p < 0.001) and vancomycin-resistant enterococci (46/250, 18.4% vs 9/144, 6.3%, p < 0.001). Carbapenem-resistant Pseudomonas spp. (OR 7.32, 95%CI 2.78-19.32) and fungi, including yeasts and moulds (OR 3.33, 95%CI 2.02-5.48) were associated to the highest odds of 30-day case-fatality at a multivariable logistic regression analysis. Neutropenia was associated with survival (OR 0.66, 95%CI 0.55-0.78). Differences were observed in the BSI epidemiology according to neutropenic status, with an overall increase of resistance over time associated to adverse outcome.

Scedosporium species and Lomentospora prolificans fungaemia is uniformly fatal in patients with haematological malignancy.

Scedosporium and Lomentospora species are environmental moulds that are virulent in immunocompromised hosts and rarely cause bloodstream infection (BSI). Patients with Scedosporium and Lomentospora species BSI were identified by the state public laboratory service in Queensland, Australia, over a 20-year period. Twenty-two incident episodes occurred among 21 residents; one patient had a second episode 321 days following the first. Of these, 18 were Lomentospora prolificans, three were Scedosporium apiospermum complex and one was a nonspeciated Scedosporium species. Seventeen (81%) patients died during their index admission, and all-cause mortality at 30, 90 and 365 days was 73%, 82% and 91% respectively. All 20 patients with haematological malignancy died within 365 days of follow-up with a median time to death of 9 days (interquartile range, 6-20 days) following diagnoses of BSI.

Bloodstream Infection and Colorectal Cancer Risk in Queensland Australia, 2000-2019.

BACKGROUND: Bloodstream infections may occur as a complication of colorectal cancer or be a marker for its occult presence. The objectives of this study were to quantify the overall and etiology-specific risks for incident colorectal cancer-associated bloodstream infection. METHODS: Population-based surveillance for community-onset bloodstream infection was conducted among adults aged 20 years and older in Queensland, Australia between 2000 and 2019. Statewide databases were used to identify patients with incident colorectal cancer and collect clinical and outcome information. RESULTS: After exclusion of 1794 patients with prior colorectal cancer, a cohort of 84,754 patients was assembled, of which 1030 had colorectal cancer-associated bloodstream infection and 83,724 had no colorectal cancer. Bloodstream infection was associated with a 16-fold annualized increased risk for diagnosis of colorectal cancer (incidence rate ratio 16.1; 95% confidence interval [CI], 15.1-17.1) in the adult population. Patients who had colorectal cancer-associated bloodstream infection were more likely to be older and male, have hospital-onset and polymicrobial infections, and have fewer non-cancer-related comorbidities. The organisms associated with highest risk for colorectal cancer included Clostridium species (relative risk [RR] 6.1; 95% CI, 4.7-7.9); especially C. septicum (RR 25.0; 95% CI, 16.9-35.7), Bacteroides species (RR 4.7; 95% CI, 3.8-5.8); especially B. ovatus (RR 11.8; 95% CI, 2.4-34.5), Gemella species (RR 6.5; 95% CI, 3.0-12.5), Streptococcus bovis group (RR 4.4; 95% CI, 2.7-6.8); especially S. infantarius subsp. coli (RR 10.6; 95% CI, 2.9-27.3), Streptococcus anginosus group (RR 1.9; 95% CI, 1.3-2.7), and Enterococcus species (RR 1.4; 95% CI, 1.1-1.8). CONCLUSION: Although much attention has been afforded to S. bovis group over the past decades, there are many other isolates associated with higher risk for colorectal cancer-associated bloodstream infections.

Significant clinical differences but not outcomes between Klebsiella aerogenes and Enterobacter cloacae bloodstream infections: a comparative cohort study.

PURPOSE: Although Klebsiella aerogenes (formerly Enterobacter aerogenes) and Enterobacter cloacae share many phenotypic characteristics, controversy exists as to whether they cause clinically distinguishable infections. The objective of this study was to determine the comparative incidence, determinants, and outcomes of K. aerogenes and E. cloacae bloodstream infections (BSI). METHODS: Population-based surveillance was conducted among residents aged ≥ 15 years of Queensland, Australia during 2000-2019. RESULTS: Overall 695 and 2879 incident K. aerogenes and E. cloacae BSIs were identified for incidence rates of 1.1 and 4.4 per 100,000 population, respectively. There was a marked increase in incidence associated with older age and with males with both species. Patients with K. aerogenes BSIs were older, were more likely male, to have community-associated disease, and to have a genitourinary source of infection. In contrast, E. cloacae were more likely to have co-morbid diagnoses of liver disease and malignancy and be associated with antimicrobial resistance. Enterobacter cloacae were significantly more likely to have repeat episodes of BSI as compared to K. aerogenes. However, no differences in length of stay or all cause 30-day case-fatality were observed. CONCLUSION: Although significant demographic and clinical differences exist between K. aerogenes and E. cloacae BSI, they share similar outcomes.

Excess burden of critical illness related to inflammatory bowel disease.

BACKGROUND: Although inflammatory bowel disease (IBD) is associated with major morbidity and mortality, few studies have evaluated its associated burden of critical illness. AIMS: To examine the epidemiology and outcome of intensive care unit (ICU) admission among patients with IBD in North Brisbane, Australia. METHODS: A population-based cohort design was used. All admissions to ICU serving the Metro North Hospital and Health Service among adult residents during 2017-2019 were included. Data were obtained from ICU clinical information systems with linkages to statewide admissions and death registries. RESULTS: Among 9011 ICU admissions, 101 (1.1%) were among patients with IBD, of which 57 (0.6%) and 44 (0.5%) had ulcerative colitis (UC) and Crohn disease (CD) respectively. The incidence of ICU admission was 379, 1336, 1514 and 1429 per 100 000 annually among those without IBD, CD, UC and IBD respectively. Patients with IBD were at excess risk for admission across all age groups, with women aged <50 years at highest risk and men thereafter. The all-cause 90-day case-fatality rates following ICU admission were not significantly different among patient groups and were 18%, 12%, 15% and 12% for CD, UC, IBD and non-IBD respectively. However, as compared with non-IBD patients, those with CD (151.8 vs 39.4 per 100 000; relative risk (RR) 3.85; 95% confidence interval (CI) 1.25-9.02; P = 0.013), UC (159.4 vs 39.4 per 100 000; RR 4.05; 95% CI 1.48-8.84; P = 0.005) and IBD (155.6 vs 39.4 per 100 000; RR 3.95; 95% CI 1.96-7.10; P = 0.002) were at significantly higher risk for mortality. CONCLUSIONS: Patients with IBD suffer a major burden of critical illness.

Population-based study of Morganella-Proteus-Providencia group bloodstream infections.

Background: There is a paucity of studies investigating the population-based epidemiology of Morganella-Proteus-Providencia (MPP) group infections. Our objective was to determine the incidence, risk factors, and outcome of MPP group bloodstream infections (BSI), and explore species-specific differences. Methods: Population-based surveillance was conducted in the western interior of British Columbia, Canada, between April 1, 2010 and March 30, 2020. Results: Sixty-two incident MPP group BSI occurred for an annual incidence of 3.4 per 100,000 residents; rates for Morganella morganii, Proteus mirabilis, and Providencia species were 0.5, 2.6, and 0.3 per 100,000 population, respectively. The median year of age was 72.5 and was different (p = 0.03) among the groups. Most (92%) MPP group BSIs were of community-onset. Significant differences were observed in the distribution of clinical focus of infection, with most notably 81% of P. mirabilis BSI due to genitourinary focus as compared to 60% and 22% for Providencia species and M. morganii, respectively. Comorbid illnesses that increased the risk for development of MPP group BSI (incidence rate ratio; 95% CI) were HIV infection (37.0; 4.4-139.6), dementia (11.5; 6.1-20.7), cancer (6.4; 3.2-11.9), stroke 6.5 (2.8-13.3), and diabetes 2.7 (1.3-5.0). Thirteen, one, and none of the cases with P. mirabilis, M. morganii, and Providencia species BSI died within 30 days of index culture for respective all cause case-fatalities of 27%, 11%, and 0% (p = 0.1). Conclusions: Although collectively responsible for a substantial burden of illness, the epidemiology of MPP group BSI varies significantly by species.

Contexte: Il y a peu d'études qui ont étudié l'épidémiologie basée sur la population de Morganella-Proteus-Infections du groupe Providencia (MPP). L'objectif de cette étude était de déterminer l'incidence, les facteurs de risque et les résultats des bactériémies du groupe MPP (BSI) et explorer les différences spécifiques aux espèces. Méthodes: Surveillance basée sur la population a été menée auprès de résidents de l'intérieur ouest de la Colombie-Britannique, au Canada, entre le 1er avril 2010 et le 30 mars 2020. Résultats: Soixante-deux incidents du groupe MPP BSI ont été identifiés pour une incidence annuelle de 3,4 pour 100 000 habitants ; tarifs pour Morganelle morganii, Proteus mirabilis et Providencia étaient respectivement de 0,5, 2,6 et 0,3 pour 100 000 habitants. L'année médiane d'âge était de 72,5 ans et était significativement différent (p = 0,03) entre les trois groupes. La plupart (92 %) des BSI du groupe MPP étaient d'origine communautaire. Des différences significatives ont été observées dans la distribution du foyer clinique de l'infection, avec notamment 81% de P. mirabilis BSI due à la focalisation génito-urinaire par rapport à 60% et 22% pour les espèces Providencia et M. morganii, respectivement. Maladies comorbides qui augmentaient significativement le risque de développement de BSI du groupe MPP (rapport des taux d'incidence ; IC à 95 %) étaient l'infection par le VIH (37,0 ; 4,4 à 139,6), démence (11,5 ; 6,1 à 20,7), cancer (6,4 ; 3,2 à 11,9), accident vasculaire cérébral 6,5 (2,8 à 13,3) et diabète 2,7 (1,3 à 5,0). Treize, un et aucun des cas avec P. mirabilis, M. morganii et les espèces Providencia BSI sont décédés dans les 30 jours suivant la culture index pour toutes causes respectives létalités de 27 %, 11 % et 0 % (p = 0,1). Conclusions: Bien que collectivement responsables d'un lourd fardeau de maladie, l'épidémiologie des BSI du groupe MPP varie considérablement selon les espèces.

Morganella morganii, an Emerging Cause of Bloodstream Infections.

Although recent reports of extensively antibiotic-resistant strains have highlighted the importance of Morganella morganii as an emerging pathogen, the epidemiology of serious infections due to this organism is not well defined. The objective of this study was to determine the incidence, determinants, and outcomes of Morganella morganii bloodstream infections (BSIs). Retrospective, population-based surveillance for Morganella morganii BSIs was conducted in Queensland, Australia, in 2000 to 2019; 709 cases were identified, for an annual incidence of 9.2 cases per million population. Most cases were of community onset, with 280 (39.5%) community-associated cases and 226 (31.9%) health care-associated cases. Morganella morganii BSIs were rare in children and young adults, and the incidence increased markedly with advancing age. The most common foci of infection were skin and soft tissue (131 cases [18.5%]), genitourinary (97 cases [13.7%]), and intraabdominal (90 cases [12.7%]). Most patients (580 cases [81.8%]) had at least one comorbid medical illness, with diabetes mellitus (250 cases [35.3%]), renal disease (208 cases [29.3%]), and congestive heart failure (167 cases [23.6%]) being most prevalent. Resistance to one or more of quinolones, co-trimoxazole, aminoglycosides, or carbapenems was observed in 67 cases (9.5%), and this did not change significantly over the study. The 30-day all-cause case fatality rate was 21.2%, and increasing age, nonfocal infection, heart failure, dementia, and cancer were independently associated with increased risk of death. Morganella morganii BSIs are increasing in our population, and elderly male subjects and individuals with comorbidities are at highest risk. Although antibiotic resistance is not a major contributor to the current burden in Queensland, ongoing surveillance is warranted. IMPORTANCE Recent reports of extensively antibiotic-resistant strains have highlighted the importance of Morganella morganii as an emerging pathogen. Despite its present and evolving importance as an agent of human disease, there is a limited body of literature detailing the epidemiology of serious infections due to Morganella morganii. Therefore, the objectives of this study were to examine the incidence and determinants of Morganella morganii BSIs and to examine risk factors for death in a large Australian population in 2000 to 2019.

Sphingomonas paucimobilis bloodstream infection is a predominantly community-onset disease with significant lethality.

BACKGROUND: Small case series and reports suggest that Sphingomonas paucimobilis is predominantly a cause of nosocomial bloodstream infections (BSI) with very low associated mortality. Our objective was to describe the epidemiology and outcome of Sphingomonas species BSI in a large Australian population. METHODS: We included all residents of Queensland, Australia, with BSI because of Sphingomonas species identified within the publicly funded system from 2000 to 2019. RESULTS: A total of 282 incident episodes of Sphingomonas species BSI were identified for an age- and sex-adjusted incidence of 3.2 per million population annually. Incidence rates were highest in the tropical regions of the state. Most (94%) of the isolates were confirmed as Sphingomonas paucimobilis. In addition, 77% of the infections were community-onset, of which 48% were community-associated, and 30% were healthcare-associated. The very young, the old, and male patients were at the highest risk. Patients with community-associated disease were, on average, younger, had fewer co-morbidities, and were less likely to have polymicrobial infections. At least 1 co-morbidity was identified in 62% of patients, with malignancy, diabetes, and lung disease most prevalent. The overall all-cause 30-day case-fatality rate was 6%. CONCLUSION: Sphingomonas paucimobilis BSI is a predominantly community-onset disease associated with a significant risk of death.

Determinants of research productivity during postgraduate medical education: a structured review.

BACKGROUND: Although formal participation in research is an integral and often mandatory component of clinical training programs, resulting productivity is highly variable. The objective of this review was to identify determinants of successful research performance among graduate medical education trainees. METHODS: A structured review of the published literature was performed by searching PubMed, CINAHL, and EMBASE from inception through to 7 April, 2021. Articles examining graduate medical education trainee research productivity evidenced by publications in peer-reviewed journals were included. RESULTS: Eighty-five articles were included of which most (66; 78%) were reported from the USA or Canada (10; 12%). A wide range of disciplines were represented with the most common being general surgery, internal medicine, orthopedic surgery, and pediatrics. Themes (number of reports) included trainee characteristics (n = 24), project characteristics (n = 8), mentoring/supervision (n = 11), and programmatic aspects (n = 57). Although variable results were observed, research productivity tended to be higher with prior research experience, later years of training, male gender, and pursuit of a postgraduate degree. Few project related aspects of success were identified. Trainee publication was associated with mentors with higher rank, publication productivity, and supportive academic environments. Training programs with organised programs/curricula including protection of time for research were associated with increased productivity as were provision of incentives or rewards but not mandatory requirements. CONCLUSION: This review identifies several trainee characteristics, project and mentor aspects, and programmatic aspects associated with increased productivity that may serve as a useful resource for trainees and graduate medical education training programs.

Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia.

BACKGROUND: Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality. OBJECTIVE: To describe the long-term survival and examine determinants of death among patients with prolonged ICU admission. METHODS: A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics. RESULTS: During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14-20, 21-27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14-20, 21-27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214-1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model. CONCLUSIONS: Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.

Extra-cardiac endovascular infections in the critically ill.

Vascular infections are associated with high complication rates and mortality. While there is an extensive body of literature surrounding cardiac infections including endocarditis, this is less so the case for other endovascular infections. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe vascular infections exclusive of those involving the heart. Endovascular infections may involve either the arterial or venous vasculature and may arise in native vessels or secondary to implanted devices. Management is complex and requires multi-disciplinary involvement from the outset. Infective arteritis or device-related arterial infection involves removal of the infected tissue or device. In cases where complete excision is not possible, prolonged courses of antimicrobials are required. Serious infections associated with the venous system include septic thrombophlebitis of the internal jugular and other deep veins, and intracranial/venous sinuses. Source control is of paramount importance in these cases with adjunctive antimicrobial therapy. The role of anticoagulation is controversial although recommended in the absence of contraindications. An improved understanding of the management of these infections, and thus improved patient outcomes, requires multi-center, international collaboration.

Population-based risk factors for community-onset bloodstream infections.

Although a number of comorbidities have been associated with development of bloodstream infection, actual risk factors have not been well defined and quantified in nonselected populations. We sought to quantify population-based risk factors for development of community-onset bloodstream infection (COBSI). Surveillance was conducted among all residents of the Western Interior of British Columbia, Canada, during 2011-2018. Risks were expressed as incidence rate ratios (IRR) with 95% confidence intervals (CI). The annual incidence was 147.1 per 100,000 and older individuals, and males were at overall higher risk. The median Charlson score was 2 (IQR, 0-3), and this was higher among those with healthcare-associated (2; IQR, 1-4) as compared to community-associated (1; IQR, 0-2; P < 0.0001) COBSI. Risk factors for development of COBSI included (IRR; 95% CI): HIV infection (8.89; 5.17-14.27), cancer (6.80; 6.13-7.54), congestive heart failure (4.68; 4.00-5.46), dementia (3.31; 2.82-3.87), diabetes mellitus (3.10; 2.80-3.42), cerebrovascular accident (2.79; 2.34-3.31), renal dysfunction (2.75; 2.33-3.22), chronic lung disease (2.03; 1.79-2.28), peripheral vascular disease (1.68; 1.39-2.01), and rheumatic disease (1.44; 1.14-1.79). Patients with multiple comorbid illnesses were older, more likely to be male, and have healthcare-associated BSI, higher rates of antimicrobial resistance, and different clinical foci of infection. A number of demographic and comorbid conditions significantly increase the risk for development of COBSI.

Occurrence and determinants of Klebsiella species bloodstream infection in the western interior of British Columbia, Canada.

BACKGROUND: Klebsiella species are among the most common causes of bloodstream infection (BSI). However, few studies have evaluated their epidemiology in non-selected populations. The objective was to define the incidence of, risk factors for, and outcomes from Klebsiella species BSI among residents of the western interior of British Columbia, Canada. METHODS: Population-based surveillance was conducted between April 1, 2010 and March 31, 2017. RESULTS: 151 episodes were identified for an incidence of 12.1 per 100,000 population per year; the incidences of K. pneumoniae and K. oxytoca were 9.1 and 2.9 per 100,000 per year, respectively. Overall 24 (16%) were hospital-onset, 90 (60%) were healthcare-associated, and 37 (25%) were community-associated. The median patient age was 71.4 (interquartile range, 58.8-80.9) years and 88 (58%) cases were males. Episodes were uncommon among patients aged < 40 years old and no cases were observed among those aged < 10 years. A number of co-morbid medical illnesses were identified as significant risks and included (incidence rate ratio; 95% confidence interval) cerebrovascular accident (5.9; 3.3-9.9), renal disease 4.3; 2.5-7.0), cancer (3.8; 2.6-5.5), congestive heart failure (3.5; 1.6-6.6), dementia (2.9; 1.5-5.2), diabetes mellitus (2.6; 1.7-3.9), and chronic obstructive pulmonary disease (2.3; 1.5-3.5). Of the 141 (93%) patients admitted to hospital, the median hospital length stay was 8 days (interquartile range, 4-17). The in-hospital and 30-day all cause case-fatality rates were 24/141 (17%) and 27/151 (18%), respectively. CONCLUSIONS: Klebsiella species BSI is associated with a significant burden of illness particularly among those with chronic co-morbid illnesses.

Streptococcus anginosus group bloodstream infections in the western interior of British Columbia, Canada.

BACKGROUND: The epidemiology of Streptococcus anginosus group (SaG) bloodstream infections (BSI) has not been well defined in non-selected populations. The objective of this study was to determine the incidence, risk factors and outcome associated with SaG BSI. METHODS: Population-based surveillance was conducted in the western interior region of British Columbia, Canada between 1 April 2010 and 31 March 2017. RESULTS: Forty-six episodes were identified for an overall annual incidence of 3.7 per 100,000 population. The incidence increased with older age and males were at significantly higher risk (5.2 vs. 2.1 per 100,000; incidence rate ratio, 2.5; 95% confidence interval, 1.3-5.1; p = .004). Nearly one-half (22; 48%) of patients had no chronic co-morbid illness, whereas 17 (40%) had 1-2, six (13%) had 3-4 and one (2%) had 5 Charlson scores with diabetes and cancer being the most common. Predisposing factors for development of SaG BSI were identified in 30 (65%) cases. The gastro-intestinal tract was the most common focus of infection (13; 28%) followed by cardiovascular and skin/soft tissue (six cases each; 13%) and in seven (15%) cases no focus was identified. Drainage procedures were required in 21 (46%) patients of whom seven (15%) patients had percutaneous drains and 14 (30%) required surgical operations. Forty-one (89%) patients were admitted to hospital for a median hospital length stay of 11 (interquartile range, 7-18) days. The in-hospital and 30-day all cause case-fatality rates were 3/41 (7%) and 4/46 (9%), respectively. CONCLUSION: SaG BSI is an important cause of morbidity and mortality.

Pyrexia: aetiology in the ICU.

Elevation in core body temperature is one of the most frequently detected abnormal signs in patients admitted to adult ICUs, and is associated with increased mortality in select populations of critically ill patients. The definition of an elevated body temperature varies considerably by population and thermometer, and is commonly defined by a temperature of 38.0 °C or greater. Terms such as hyperthermia, pyrexia, and fever are often used interchangeably. However, strictly speaking hyperthermia refers to the elevation in body temperature that occurs without an increase in the hypothalamic set point, such as in response to specific environmental (e.g., heat stroke), pharmacologic (e.g., neuroleptic malignant syndrome), or endocrine (e.g., thyrotoxicosis) stimuli. On the other hand, pyrexia and fever refer to the classical increase in body temperature that occurs in response to a vast list of infectious and noninfectious aetiologies in association with an increase in the hypothalamic set point. In this review, we examine the contemporary literature investigating the incidence and aetiology of pyrexia and hyperthermia among medical and surgical patients admitted to adult ICUs with or without an acute neurological condition. A temperature greater than 41.0 °C, although occasionally observed among patients with infectious or noninfectious pyrexia, is more commonly observed in patients with hyperthermia. Most episodes of pyrexia are due to infections, but incidence estimates of infectious and noninfectious aetiologies are limited by studies with small sample size and inconsistent reporting of noninfectious aetiologies. Pyrexia commonly triggers a full septic work-up, but on its own is a poor predictor of culture-positivity. In order to improve culturing practices, and better guide the diagnostic approach to critically ill patients with pyrexia, additional research is required to provide more robust estimates of the incidence of infectious and noninfectious aetiologies, and their relationship to other clinical features (e.g., leukocytosis). In the meantime, using existing literature, we propose an approach to identifying the aetiology of pyrexia in critically ill adults.