Different impact of the appropriateness of empirical antibiotics for bacteremia among younger adults and the elderly in the ED

doi:10.1016/j.ajem.2012.07.024

The American Journal of Emergency Medicine

Volume 31, Issue 2, February 2013, Pages 282-290

https://doi.org/10.1016/j.ajem.2012.07.024 Get rights and content

Abstract

Objectives

To investigate the clinical impact of age on bacteremia among adults visiting the emergency department (ED).

Methods

Bacteremic adults visiting the ED from January 2008 to December 2008 were identified retrospectively. Demographic characteristics, severity, bacteremic pathogens with in vitro susceptibility, antimicrobial agents, and outcomes determined from chart records were analyzed as a case-control study.

Results

Of 518 eligible bacteremic adults, 288 (55.6%) elderly patients (≥ 65 years old) were case patients and 230 younger patients (< 65 years) were regarded as control patients. The 28-day mortality rate was higher in the case patients than that in the control patients (11.8% vs 6.1%, P = .02). The proportion of inappropriate empirical antibiotic therapy between the survivors and nonsurvivors was similar in control patients (69.4% vs 64.3%, P = .77); but for the case patients, the proportion of inappropriate empirical antibiotic therapy in the survivors was lower than that in the non-survivors (27.6% vs 44.1%, P = .04). Of note, inappropriate empirical antibiotic therapy was also one of independent risk factors of 28-day mortality by the multivariate analyses in the case patients (odds ratio [OR] 3.65; P = .049). Other independent predictors of 28-day mortality in case patients included a high Pittsburgh bacteremia score (≥ 4 points; OR 22.16; P < .001), bacteremia due to foci other than urinary tract infection (OR 9.07; P = .002), malignancy (OR 10.87; P < .001), coronary artery disease (OR 5.68; P = .01), and high serum creatinine (> 1.5 mg/dL; OR 3.44; P = .04).

Conclusions

For bacteremic adults, this study demonstrated the impact of inappropriate empirical antibiotic therapy on patients’ outcome in the elderly was greater than that in the younger adults.

Introduction

Bacteremia is a serious, life-threatening condition that is associated with high morbidity and mortality, with inhospital mortality rates of up to 30% [1], [2]. Early administration of appropriate empiric antibiotic therapy has repeatedly been shown to decrease mortality in patients with community-acquired and nosocomial bloodstream infections [3], [4], [5]. Aging is associated with significant changes in the adaptive humoral and cell-mediated immunity [6], [7], and poor cytokine responses to sepsis have been discovered in the elderly [8]. Therefore, a well-recognized increase in mortality among the elderly with bacteremia has been demonstrated in previous investigations [9], [10].

Apart from the ageing of the population, the increased prevalence of chronic-degenerative diseases, with susceptibility to frequent exacerbations, make the elderly frequent visitors of emergency department (ED) [11]. Focusing on the elderly with bacteremia, appropriate antibiotic therapy may reduce the mortality [12]. Therefore, for ED clinicians, empirical antimicrobial therapy has suggested to be initiated very often and soon among the elderly with suspected infections [7], either because of delayed diagnosis due to atypically clinical presentation [7], [13] or impossibility of diagnostic procedure [14]. However, a study emphasized the importance of appropriate empiric antibiotic therapy in elderly patients with bacteremia in the ED has not been reported in the English literature. Thus, we conduct this study to demonstrate the importance of appropriate empiric therapy in the elderly with bacteremia by comparing the impact of inappropriate empiric therapy on the clinical outcomes of elderly and young adult patients with bacteremia in the ED.

Section snippets

Study design and population

A retrospective case-control study was conducted between January 2008 and December 2008 at a medical center of approximately 1200 beds in southern Taiwan, and 67,585 annual visits to the emergency department (ED) were recorded during the study period, whereas the degree of ED overcrowding was calculated routinely every eight hours using the National Emergency Department Overcrowding Study (NEDOCS) score [15]. The local institutional review board has approved this study. The retrospective

Demographics and clinical characteristics of all bacteremic patients

During the 1-year period, blood culture samples have been collected from 14,482 patients, and 813 (5.6%) patients had bacterial growth in their respective blood cultures, whereas the mean (± SD) of the hospital-based NEDOS score was 142.8 (± 26.2), reaching the level of “severely overcrowded.” After excluding 273 patients with contaminated blood culture samples, 7 pediatric visitors, 13 patients with bacteremia diagnosed prior to visiting the ED, and 2 patients who were lost to follow-up within

Discussion

Several investigations have demonstrated the clinical impact of a delayed administration of the first dose of appropriate antibiotics to patients with severe infections, such as bacteremia, severe sepsis [23], pneumonia [24], or meningitis [25]. However, to our knowledge, there is no study focusing on the elderly (aged ≥ 65) with bacteremia to concern the impact of appropriate empiric therapy by the comparisons with the younger adults (aged < 65) in the English literature. By the multivariate

Conclusions

For bacteremic adults visiting the ED, this study demonstrated that clinical impact of appropriateness of empirical antibiotic therapy on patients’ outcome in the elderly and younger adults varied. Further studies focusing on different strategies for empiric treatment of bacteremia in the elderly and younger adults are warranted.

References (31)

S. Harbarth et al.
Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis
Am J Med
(2003)
B. Grubeck-Loebenstein et al.
The aging of the immune system
Adv Immunol
(2002)
G. Gavazzi et al.
Ageing and infection
Lancet Infect Dis
(2002)
G.R. Strange et al.
Use of emergency departments by elderly patients: projections from a multicenter data base
Ann Emerg Med
(1992)
F.G. Schellevis et al.
Comorbidity of chronic diseases in general practice
J Clin Epidemiol
(1993)
J.S. Garner et al.
CDC definitions for nosocomial infections, 1988
Am J Infect Control
(1988)
D.W. Bates et al.
How bad are bacteremia and sepsis? Outcomes in a cohort with suspected bacteremia
Arch Intern Med
(1995)
J.B. Haug et al.
Bloodstream infections at a Norwegian university hospital, 1974–1979 and 1988–1989: changing etiology, clinical features, and outcome
Clin Infect Dis
(1994)
L. Leibovici et al.
The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection
J Intern Med
(1998)
R. Salomao et al.
Nosocomial and community acquired bacteremia: variables associated with outcomes
Rev Paul Med
(1993)

S.M. Opal et al.

The immunopathogenesis of sepsis in elderly patients

Clin Infect Dis

(2005)

G.S. Martin et al.

The effect of age on the development and outcome of adult sepsis

Crit Care Med

(2006)

O. Lesens et al.

Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity

Infect Control Hosp Epidemiol

(2003)

J.P. Richardson

Bacteremia in the elderly

J Gen Intern Med

(1993)

P.G. Jarrett et al.

Illness presentation in elderly patients

Arch Intern Med

(1995)

Cited by (25)

Comparison of antibiotic resistance rates and outcomes among older adult patients with urinary tract infections living in long- term care hospitals and the community
2023, Geriatric Nursing
In this study, we compared the proportion of antibiotic resistance between patients who visited the emergency department (ED) with urinary tract infection (UTI) from long-term care hospitals (LTCH), which is a type of long-term care facilities (LTCF) and the community. We assessed the resulting difference in prognosis.
Older adults who visited the ED between January and December 2019 and were diagnosed with UTI were divided into community residents and LTCH residents. We investigated the antibiotics sensitivity rates, end of therapy (EOT), and the patient's outcomes were evaluated.
The antibiotic resistance rate was higher in LTCH residents. LTCH residents had a higher in hospital mortality rate compared to community residents. EOT was found to be longer, and admission rate and in-hospital mortality rate were also higher in LTCH residents.
LTCF residents had a higher rate of antibiotic resistance and a poor prognosis.
Prognostic Effects of Delayed Administration of Antimicrobial Therapy in Older Persons Experiencing Bacteremia With or Without Initial Sepsis Presentations
2022, Journal of the American Medical Directors Association
Citation Excerpt :
In line with the results of other studies dealing with the older patients with bacteremia,9,10 the prognostic effect of prompt AAT administration was evidenced herein. Superior to these previously established reports,9,10 our study also revealed that delayed AAT had both impacts on the older patients with and without initial sepsis presentations and the clinical application of the Sepsis-3 criteria in the older individuals was first reported. In previous investigations on community-onset bacteremia, the prognostic impact of delayed AAT was recognized in both noncritically and critically ill patients.7,8
To investigate the prognostic effects of delayed administration of appropriate antimicrobial therapy (AAT) in older persons experiencing bacteremia with and without initial sepsis syndrome, respectively.
A 4-year multicenter cohort study.
Older people (≥65 years of age) with community-onset bacteremia in the emergency department (ED) of 3 participating hospitals.
Clinical data were retrospectively collected and causative microorganisms were prospectively collected for susceptibilities to determine the period of delayed AAT for each bacteremia episode. Sepsis was defined based on the Sepsis-3 criteria. A multivariable regression model was used to investigate the prognostic effects of delayed AAT, after adjusting independent determinants of 30-day mortality.
Of the total 2357 patients, their median (interquartile range) age was 78 (72–84) years and septic patients accounted for 48.4% (1140 patients) of the overall patients. Compared with nonseptic patients, septic individuals exhibited the shorter period of delayed AAT (median, 2.0 vs 2.5 hours; P < .001), longer hospitalization (median, 11 vs 9 days; P < .001), and higher crude mortality rates at 15 (28.9% vs 2.1%; P < .001) and 30 days (34.6% vs 4.0%; P < .001). In multivariable regression analyses, each hour of delayed AAT resulted in average increases in the 30-day crude mortality rates of 0.38% [adjusted odds ratio (AOR) 1.0038; P < .001), 0.42% (AOR 1.0042; P < .001), and 0.31% (AOR 1.0031; P = .04) among overall, septic, and nonseptic patients, respectively.
For older persons with community-onset bacteremia, irrespective of whether or not patients experiencing initial sepsis presentations, the prognostic impacts of delayed AAT have been evidenced. Notably, because of the longer period of delayed AAT in patients without fulfilling the Sepsis-3, adopting a stricter sepsis definition and/or early bacteremia predictor to avoid delayed AAT and unfavorable prognoses in patients with bacteremia is necessary.
Effect of the inadequacy of antibiotic therapy in the Emergency Department on hospital stays
2017, Enfermedades Infecciosas y Microbiologia Clinica
El objetivo principal fue determinar la frecuencia de pacientes que reciben terapia antibiótica inapropiada y evaluar los resultados en términos de estancia media, reingreso y mortalidad a 30 días.
Estudio observacional de cohortes retrospectivo que incluyó a todos los pacientes ingresados por infección desde un Servicio de Urgencias (SU) durante un mes. Se recogieron variables demográficas, comorbilidad, factores de riesgo de multirresistencia, foco de infección, resultados microbiológicos y antibiótico prescrito en el SU. Las variables de resultado fueron el tiempo de estancia, y la mortalidad y el reingreso a 30 días.
Se incluyeron 376 pacientes con una edad media de 71,1 (DE 21) años. Las infecciones más frecuentes fueron respiratoria (45,7%) y urinaria (23,9%). El número de pacientes con una estancia superior a la mediana (≥ 9 días), reingreso y mortalidad a los 30 días fue de 165 (46,1%), 74 (19,7%) y 44 (11,7%) pacientes, respectivamente. La prescripción inapropiada del tratamiento antibiótico en el SU se produjo en 42 (11,2%) casos. Tras ajustar por los datos demográficos, la comorbilidad, los factores de riesgo para patógenos resistentes, la presencia de sepsis en el SU y el foco de infección, la prescripción inapropiada se asoció a una estancia prolongada (OR 2,22; IC95% 1,07-4,60; p = 0,032), pero no a un aumento de la mortalidad (p = 0,271) o de los reingresos (p = 0,784) a los 30 días.
La prescripción inapropiada del tratamiento antibiótico empírico en los pacientes ingresados por un proceso infeccioso desde el SU provoca una estancia prolongada, pero no un incremento de la mortalidad o del reingreso.
The main objective of the study was to determine the frequency of patients receiving inappropriate empiric antibiotic therapy and to assess the impact in terms of increase length of hospital stay, 30-day re-admissions, and 30-day mortality.
An observational retrospective cohort study was conducted over a one-month period that included all patients hospitalised from an Emergency Department (ED) due to infection. Demographic variables, comorbidity, multi-resistance risk factors, site of infection, microbiological findings, and antibiotic prescribed in ED were collected. Outcomes were length of hospital stay, 30-day re-admissions, and 30-day mortality.
A total of 376 patients were included, with a mean age of 71.1 (SD 21) years. The most frequent causes were respiratory (45.7%) and urine (23.9%) infections. The number of patients with length of stay over the median (≥ 9 days) was 165 (46.1%), with re-admissions 74 (19.7%), and mortality at 30 days 44 (11.7%). There was inappropriate antibiotic treatment in 42 (11.2%) cases. After adjusting for demographic data, comorbidity, risk factors for multidrug resistant organism, presence of sepsis criteria in ED, and site of infection, inappropriate treatment was associated with an extended length of hospital stay (OR 2.22; 95% CI; 1.07-4.60; P = .032), but did not to an increase in mortality (P = .271) or re-admission (P = .784) at 30 days.
The inappropriate empirical antibiotic therapy in patients admitted from the ED leads to an extended hospital stay, but did not increase mortality or readmission.
Profile and initial management of infection in elderly patients in an Emergency Department
2017, Revista Espanola de Geriatria y Gerontologia
Determinar el perfil clínico y el manejo inicial de los pacientes ancianos atendidos por infección aguda en los servicios de Urgencias hospitalarios españoles y estudiar si existen diferencias en relación con los adultos más jóvenes.
Estudio descriptivo transversal multicéntrico a partir de los datos del registro INFURG-SEMES, que incluye a 79.654 pacientes de 15 años o más atendidos por una infección aguda en 49 servicios de Urgencias hospitalarios españoles entre el 10 octubre del 2010 y el 20 de septiembre del 2011. Se recogieron variables demográficas, del perfil clínico y de la atención en Urgencias. La variable clasificadora fue tener 65 años o más.
Del total de 11.399 casos, 4.255 (37,3%) tenían 65 años o más. Al comparar a los ancianos con los adultos más jóvenes, se encontraron diferencias estadísticamente significativas en cuanto a la presencia de alta comorbilidad (p < 0,001), de al menos un factor de riesgo de multirresistencia (p < 0,001) o de síndrome séptico (p < 0,001), el tipo de infección (p < 0,001), la toma de muestra para al menos un cultivo (p < 0,001), la determinación de antígenos en orina (p < 0,001), el tratamiento antibiótico pautado en Urgencias (p < 0,001) y el destino final (p < 0,001).
Existen importantes diferencias en el perfil y el manejo de los pacientes con infección aguda atendidos en los SUH españoles en función de la edad, que deben ser tenidas en cuenta de cara a desarrollar estrategias de mejora de la calidad y posibles líneas de investigación futura.
To determine the clinical profile and the initial management of elderly patients with acute infections attending Spanish Emergency Departments (EDs), and to analyse whether there are any differences compared to younger adults.
A descriptive, cross-sectional, multicentre study using the data recorded in the INFURG-SEMES register. It included a total of 79,654 of 15 years or over treated for an acute infection in 49 Spanish EDs between 10 October 2010 and 20 September 2011. Demographic variables, clinical profile, and care in the ED, were collected. The classifying variable was to be 65 years or over.
Of the total of 11,399 cases, 4,255 (37.3%) were 65 years or over. Statistically significant differences were found on comparing the elderly with the younger adults as regards the presence of a high comorbidity (P<.001), of at least one risk factor for multidrug resistance (P<.001), or septic syndrome (P<.001), type of infection (P<.001), taking of the specimen for blood culture (P<.001), determination of antigens in urine (P<.001), the antibiotic prescribed in the ED (P<.001), and final destination (P<.001).
There are significant age-dependent differences in the profile and management of patients with infections that attend Spanish EDs, which must be taken into account when developing strategies for improving quality, as well as for future lines of research.
Neurologic Emergencies in the Elderly
2016, Emergency Medicine Clinics of North America
Citation Excerpt :
Additionally, due to a proven mortality benefit, adjunctive dexamethasone therapy should be initiated in all patients with suspected bacterial meningitis before or with the first dose of antibiotics.100,104,105 Inappropriately selected empiric antibiotics have a greater effect on patients older than 65 and is an independent predictor of 28-day mortality.106 Admission to the hospital with respiratory isolation for 24 hours is indicated for patients with suspected meningococcal infection.104
Clinical features and impact of empirical therapy in cirrhotic adults with community-onset bacteremia
2015, American Journal of Emergency Medicine
Citation Excerpt :
These microorganisms were major bacteremic pathogens in our population; and therefore, it is not surprising to find that the Pittsburgh bacteremia score was an important predictor of mortality in our study. An additional prognostic factor was high serum creatinine at the onset of bacteremia; this finding was compatible with the results of our previous ED-based study [31]. Another factor was airway infection as the source of bacteremia, and this was compatible with the coexistence of bacteremia and pneumonia with high risk of short-term mortality established in a previous finding [32].
The objectives were to investigate the clinical characteristics of community-onset bacteremia in cirrhotic adults visiting the emergency department (ED), as well as the clinical impact of empirical antibiotics on their outcome.
Cirrhotic adults with community-onset bacteremia who visited the ED from January 2005 to December 2009 were included retrospectively. Clinical data and outcome were collected from the medical chart. The in vitro susceptibility was measured by the broth microdilution method.
Of the 246 bacteremic episodes in cirrhotic patients, the major sources of bacteremia included intraabdominal infections (111, 45.1%), primary bacteremia (43, 17.5%), urinary tract infection (39, 15.9%), and soft tissue infection (22, 8.9%). Of the 258 bacteremic pathogens identified, Escherichia coli (83 isolates, 33.7%) and Klebsiella pneumoniae (61, 23.6%) were the most common microorganisms. In the multivariate analysis, delayed appropriate antibiotic therapy (> 72 hours; odds ratio [OR], 4.29; P = .003), serum creatinine greater than 1.5 mg/dL at the ED (OR, 3.12; P = .005), severe sepsis (OR, 3.61; P = .01), Pittsburgh bacteremia score of at least 4 (OR, 2.66; P = .04), bacteremia due to pneumonia (OR, 5.44; P = .02), and a comorbidity of diabetes mellitus (OR, 3.54; P = .004) were independently associated with the 28-day mortality.
Focusing on cirrhotic adults with community-onset bacteremia, we emphasized that the cirrhosis severity is one of the critical factors when choosing empirical antimicrobial therapy and that the strategy of empirical therapy is warranted for cirrhotic adults with severe decompensation (Child's C group). For critically ill patients, especially in those with Child's C group, only piperacillin/tazobactam, ertapenem, or imipenem treatment was warranted because of susceptibility rate of greater than 90%.

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Original ContributionDifferent impact of the appropriateness of empirical antibiotics for bacteremia among younger adults and the elderly in the ED

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Study design and population

Demographics and clinical characteristics of all bacteremic patients

Discussion

Conclusions

Am J Med

Adv Immunol

Lancet Infect Dis

Ann Emerg Med

J Clin Epidemiol

Am J Infect Control

How bad are bacteremia and sepsis? Outcomes in a cohort with suspected bacteremia

Arch Intern Med

Bloodstream infections at a Norwegian university hospital, 1974–1979 and 1988–1989: changing etiology, clinical features, and outcome

Clin Infect Dis

The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection

J Intern Med

Nosocomial and community acquired bacteremia: variables associated with outcomes

Rev Paul Med

The immunopathogenesis of sepsis in elderly patients

Clin Infect Dis

The effect of age on the development and outcome of adult sepsis

Crit Care Med

Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity

Infect Control Hosp Epidemiol

Bacteremia in the elderly

J Gen Intern Med

Illness presentation in elderly patients

Arch Intern Med

Original Contribution
Different impact of the appropriateness of empirical antibiotics for bacteremia among younger adults and the elderly in the ED