Blood Cultures for Community-Acquired Pneumonia: Can We Hit the Target Without a Shotgun?

Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock

Introduction

There have been conflicting data regarding the relationship between sepsis-bundle adherence and mortality. Moreover, little is known about how this relationship may be moderated by the anatomic source of infection or the location of sepsis declaration.

Methods

This was a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock. The study included patients who presented to one of three Los Angeles County Department of Health Services (DHS) full-service hospitals January 2012 to December 2014. The primary outcome of interest was the association between sepsis-bundle adherence and in-hospital mortality. Secondary outcome measures included in-hospital mortality by source of infection, and the location of sepsis declaration.

Results

Among the 4,582 patients identified with sepsis, overall mortality was lower among those who received bundle-adherent care compared to those who did not (17.9% vs. 20.4%; p=0.035). Seventy-five percent (n=3,459) of patients first met sepsis criteria in the ED, 9.6% (n=444) in the intensive care unit (ICU) and 14.8% (n=678) on the ward. Bundle adherence was associated with lower mortality for those declaring in the ICU (23.0% adherent [95% confidence interval{CI} {16.8–30.5}] vs. 31.4% non-adherent [95% CI {26.4–37.0}]; p=0.063), but not for those declaring in the ED (17.2% adherent [95% CI {15.8–18.7}] vs. 15.1% non-adherent [95% CI {13.0–17.5}]; p=0.133) or on the ward (24.8% adherent [95% CI {18.6–32.4}] vs. 24.4% non-adherent [95% CI {20.9–28.3}]; p=0.908). Pneumonia was the most common source of sepsis (32.6%), and patients with pneumonia had the highest mortality of all other subsets receiving bundle non-adherent care (28.9%; 95% CI [25.3–32.9]). Although overall mortality was lower among those who received bundle-adherent care compared to those who did not, when divided into subgroups by suspected source of infection, a statistically significant mortality benefit to bundle-adherent sepsis care was only seen in patients with pneumonia.

Conclusion

In a large public healthcare system, adherence with severe sepsis/septic shock management bundles was found to be associated with improved survival. Bundle adherence seems to be most beneficial for patients with pneumonia. The overall improved survival in patients who received bundle-adherent care was driven by patients declaring in the ICU. Adherence was not associated with lower mortality in the large subset of patients who declared in the ED, nor in the smaller subset of patients who declared in the ward.

Limited utility of blood cultures in the management of febrile outpatient kidney transplant recipients

BACKGROUND/PURPOSE

Blood cultures for patients suspected of having bacteremia are standard practice, although several studies demonstrate that blood cultures have limited utility because of a low true-positive rate and infrequent resultant changes in antibiotic treatment. However, most reports exclude immunocompromised patients such as transplant recipients. We assessed the utility of blood cultures in transplant recipients hospitalized for community-acquired infections and evaluated clinical characteristics to predict bacteremia.

METHODS

This retrospective study included 136 febrile cases in 97 kidney transplant recipients admitted to our hospital for whom blood cultures were performed between February 2001 and March 2013.

RESULTS

Among the 136 cases, blood cultures were positive, contaminated, and negative in seven (5.1%) cases, 12 (8.8%) cases, and 117 cases (86.1%), respectively. All bacteria detected in the seven cases were sensitive to the initial empirical antibiotics. Antibiotic treatment was changed based on the blood culture results only in one case for which the coverage was narrowed. The white blood cell count and C-reactive protein level were significantly higher in the patients with bacteremia. The predictive model based on these two factors successfully identified the high-risk group with a sensitivity and specificity of 86% and 91%, respectively.

CONCLUSION

Among the outpatient kidney transplant recipients, positive blood cultures were uncommon and scarcely affected antibiotic therapy, especially in patients with upper respiratory tract or urinary tract infections. Therefore, it may be reasonable to perform blood cultures only for patients with marked leukocytosis and high C-reactive protein level, even among transplant recipients.

When practice and policy conflict: blood cultures in community-acquired pneumonia

Optimal evidence-based management of patients with uncomplicated community-acquired pneumonia in the emergency department (ED) setting remains a topic of discussion. This discussion was recently revitalized by a 2014 study published in JAMA Internal Medicine by Makam et al showing an increase in the use of blood cultures for patients with community-acquired pneumonia during ED visits from 29.4% of patients in 2002 to 51.1% in 2010. As the authors acknowledge, one of the most likely explanations could be the former pneumonia core measures required by the Centers for Medicaid & Medicare Services and the Joint Commission, potentially encouraging both ED and inpatient providers to reflexively order cultures. As these measures were the subject of fierce debate in the emergency medicine literature almost a decade ago, with recent policy changes affecting practicing clinicians, we aimed to briefly revisit the developments and concerning guidelines and discuss some important potentials for research in this setting.

Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia

This clinical policy from the American College of Emergency Physicians focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED)with community-acquired pneumonia. It is an update of the 2001 clinical policy for the management and risk stratification of adult patients presenting to the ED with community-acquired pneumonia. A subcommittee reviewed the current literature to derive evidence-based recommendations to help answer the following questions: (1) Are routine blood cultures indicated in patients admitted with community-acquired pneumonia? (2) In adult patients with community-acquired pneumonia without severe sepsis, is there a benefit in mortality or morbidity from the administration of antibiotics within aspecific time course? The evidence was graded and recommendations were given based on the strength of evidence.

Usefulness of initial blood cultures in patients admitted with pneumonia from an emergency department in Japan

Guidelines recommend obtaining blood cultures for all patients admitted with pneumonia. However, recent American studies have reported the low impact of these cultures on antibiotic therapy. Our aim was to investigate the incidence of bacteremia and change of therapy in admitted pneumonia patients from whom blood cultures were obtained in the emergency department (ED). A retrospective, observational, cohort study was conducted on consecutive patients (age >/=12 years) with pneumonia hospitalized through the ED between January 1 and December 31, 2006, in an urban teaching hospital in Japan. Data were collected on antibiotic sensitivities, empirical antibiotics, and changes of antibiotic management. Blood cultures were classified as positive, negative, or contaminant, based on previously established criteria. Out of 164 consecutive cases, blood cultures were positive in 6 patients (3.7%; 95% confidence interval [CI], 0.8%-6.6%), contaminated in 6 (3.7%), and negative in 152 (92.7%). Of the 6 bacteremic patients, 2 cases were likely to have been caused by concomitant diseases. Blood culture results altered therapy for 4 patients (2.4% of 164; 95% CI, 0.7%-6.1%), of whom 2 patients (1.2%; 95% CI, 0.1%-4.3%) had their coverage narrowed, 1 patient (0.6%; 95% CI, 0.0%-3.4%) had coverage broadened, and 1 patient had altered therapy before the drug sensitivities were reported. Considering cost and workload, the overall total annual cost was <euro>758 631 (<euro>107 = 1 $US in June 2008). Blood cultures could identify organisms in only a few patients with pneumonia and rarely altered antibiotic management even in patients with positive cultures. It may not be necessary to obtain blood cultures for patients admitted with pneumonia.

Health care-associated pneumonia: identification and initial management in the ED

Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these "risk factors" have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.

Pneumonia in the emergency department

Pneumonia remains one of the most common reasons for admission of emergency department (ED) patients to the hospital. Pneumonia also remains one of the most common causes of death in our patients. As with many emergent conditions, the ED management of these patients initiated by ED physicians contributes greatly to the survival and successful management of these patients. Specifically, the recognition of severe pneumonias, precise choice of diagnostic tests, and appropriate antibiotics can have an impact on the outcome.

Diagnosis and management of pneumonia in the emergency department

Pneumonia is a condition that is often treated by emergency physicians. This article reviews the diagnosis and management of pneumonia in the emergency department and highlights dilemmas in diagnostic testing, use of blood and sputum cultures, hospital admission decisions, infection control, quality measures for pneumonia care, and empiric antimicrobial therapy.

Effect of Emergency Department Crowding on Time to Antibiotics in Patients Admitted With Community-Acquired Pneumonia

STUDY OBJECTIVE

We hypothesize that emergency department (ED) volume and increased patient complexity are associated with lower quality of care, as measured by time to antibiotics for patients being admitted with community-acquired pneumonia.

METHODS

This was a cross-sectional study at a university tertiary care hospital ED. Community-acquired pneumonia patients admitted from the ED and discharged between January 2004 and June 2005 were reviewed by our institution for The Joint Commission's antibiotic timing core measure. Medical records were abstracted for patient age, sex, race, mode of transport, arrival time, triage acuity, inpatient level of care, and arrival-to-antibiotic-administration times. Controlling for patient characteristics, multivariate logistic regression determined association of antibiotic administration within 4 hours of arrival, with total ED volume at the time of the community-acquired pneumonia patient's arrival, and with number of ED patients requiring admission at the time of arrival.

RESULTS

Four hundred eighty-six patients were eligible for the study; antibiotic administration time was available for 405. Sixty-one percent of patients received antibiotics within 4 hours. Antibiotic administration within 4 hours was less likely with a greater number of patients (odds ratio 0.96 per additional patient; 95% confidence interval 0.93 to 0.99) and a greater number of patients ultimately admitted (odds ratio 0.93 per patient; 95% confidence interval 0.88 to 0.99) in the ED. The effect of additional patients was present below total ED capacity.

CONCLUSION

As ED volume increases, ED patients with community-acquired pneumonia are less likely to receive timely antibiotic therapy. The effect of additional patients appears to occur even at volumes below the maximum bed capacity. Measures to ensure that quality targets are met in the ED should consider the impact of ED volume.

Approaches to treatment of community-acquired pneumonia in the emergency department and the appropriate role of fluoroquinolones

The Emergency Department is a critical point of care for patients presenting with signs and symptoms of community-acquired pneumonia (CAP). The initial diagnosis, the decision to admit or discharge, the timing of initiating treatment, and appropriateness of the empirical therapy are key factors in successful management. Rising resistance rates to commonly used CAP antibiotics has complicated empirical treatment. Respiratory fluoroquinolones represent an important therapeutic option for patients with co-morbidities and risk factors for penicillin-, macrolide-, and multi-drug-resistant S. pneumoniae infections. Ensuring appropriate use is required to maintain their high level of effectiveness in key respiratory pathogens. Treatment guidelines from the Infectious Diseases Society of America, American Thoracic Society, and Centers for Disease Control and Prevention are available to assist emergency physicians in developing clinical pathways to ensure appropriate use of available therapies.

Blood cultures do not change management in hospitalized patients with community-acquired pneumonia

OBJECTIVES

To determine if blood cultures identify organisms that are not appropriately treated with initial empiric antibiotics in hospitalized patients with community-acquired pneumonia, and to calculate the costs of blood cultures and cost savings realized by changing to narrower-spectrum antibiotics based on the results.

METHODS

This was a retrospective observational study conducted in an urban academic emergency department (ED). Patients with an ED and final diagnosis of community-acquired pneumonia admitted between January 1, 2001, and August 30, 2003, were eligible when the results of at least one set of blood cultures obtained in the ED were available. Exclusion criteria included documented human immunodeficiency virus infection, immunosuppressive illness, chronic renal failure, chronic corticosteroid therapy, documented hospitalization within seven days before ED visit, transfer from another hospital, nursing home residency, and suspected aspiration pneumonia. The cost of blood cultures in all patients was calculated. The cost of the antibiotic regimens administered was compared with narrower-spectrum and less expensive alternatives based on the results.

RESULTS

A total of 480 patients were eligible, and 191 were excluded. Thirteen (4.5%) of the 289 enrolled patients had true bacteremia; the organisms isolated were sensitive to the empiric antibiotics initially administered in all 13 cases (100%; 95% confidence interval = 75% to 100%). Streptococcus pneumoniae and Haemophilus influenzae were isolated in 11 and two patients, respectively. The potential savings of changing the antibiotic regimens to narrower-spectrum alternatives was only 170 dollars.

CONCLUSIONS

Appropriate empiric antibiotics were administered in all bacteremic patients. Antibiotic regimens were rarely changed based on blood culture results, and the potential savings from changes were minimal.