A Simple Algorithm for Predicting Bacteremia Using Food Consumption and Shaking Chills: A Prospective Observational Study

Utility of shaking chills as a diagnostic sign for bacteremia in adults: a systematic review and meta-analysis

BACKGROUND

Accurate prediction of bacteremia is essential for guiding blood culture collection and optimal antibiotic treatment. Shaking chills, defined as a subjective chill sensation with objective body shivering, have been suggested as a potential predictor of bacteremia; however, conflicting findings exist. To address the evidence gap, we conducted a systematic review and meta-analysis of studies to assess the diagnostic accuracy of shaking chills for predicting bacteremia among adult patients.

METHODS

We included studies reporting the diagnostic accuracy of shaking chills or chills for bacteremia. Adult patients with suspected bacteremia who underwent at least one set of blood cultures were included. Our main analysis focused on studies that assessed shaking chills. We searched these studies through CENTRAL, MEDLINE, Embase, the World Health Organization ICTRP Search Portal, and ClinicalTrials.gov. Study selection, data extraction, evaluation for risk of bias, and applicability using the QUADAS-2 tool were conducted by two independent investigators. We estimated a summary receiver operating characteristic curve and a summary point of sensitivity and specificity of the index tests, using a hierarchical model and the bivariate model, respectively.

RESULTS

We identified 19 studies with a total of 14,641 patients in which the accuracy of shaking chills was evaluated. The pooled sensitivity and specificity of shaking chills were 0.37 (95% confidence interval [CI], 0.29 to 0.45) and 0.87 (95% CI, 0.83 to 0.90), respectively. Most studies had a low risk of bias in the index test domain and a high risk of bias and a high applicability concern in the patient-selection domain.

CONCLUSIONS

Shaking chills are a highly specific but less sensitive predictor of bacteremia. Blood cultures and early initiation of antibiotics should be considered for patients with an episode of shaking chills; however, the absence of shaking chills must not lead to exclusion of bacteremia and early antibiotic treatment.

Concurrent external validation of bloodstream infection probability models

OBJECTIVE

Accurately estimating the likelihood of bloodstream infection (BSI) can help clinicians make diagnostic and therapeutic decisions. Many multivariate models predicting BSI probability have been published. This study measured the performance of BSI probability models within the same patient sample.

METHODS

We retrieved validated BSI probability models included in a recently published systematic review that returned a patient-level BSI probability for adults. Model applicability, discrimination, and accuracy was measured in a simple random sample of 4485 admitted adults having blood cultures ordered in the emergency department or the initial 48 hours of hospitalization.

RESULTS

Ten models were included (publication years 1991-2015). Common methodological threats to model performance included overfitting and continuous variable categorization. Restrictive inclusion criteria caused seven models to apply to <15% of validation patients. Model discrimination was less than originally reported in derivation groups (median c-statistic 60%, range 48-69). The observed BSI risk frequently deviated from expected (median integrated calibration index 4.0%, range 0.8-12.4). Notable disagreement in expected BSI probabilities was seen between models (median (25th-75th percentile) relative difference between expected risks 68.0% (28.6-113.6%)).

DISCUSSION

In a large randomly selected external validation population, many published BSI probability models had restricted applicability, limited discrimination and calibration, and extensive inter-model disagreement. Direct comparison of model performance is hampered by dissimilarities between model-specific validation groups.

Development of a Risk Prediction Model of Subsequent Bloodstream Infection After Carbapenem-Resistant Enterobacteriaceae Isolated from Perianal Swabs in Hematological Patients

Purpose

Patients with hematological diseases are at high risk of carbapenem-resistant Enterobacteriaceae (CRE) infection, and CRE-related bloodstream infection (BSI) is associated with high mortality risk. Therefore, developing a predictive risk model for subsequent BSI in hematological patients with CRE isolated from perianal swabs could be used to guide preventive strategies.

Methods

This was a single-center retrospective cohort study at a tertiary blood diseases hospital, including all hematological patients hospitalized from 10 October 2017 to 31 July 2021. We developed a predictive model using multivariable logistic regression and internally validated it using enhanced bootstrap resampling.

Results

Of 421 included patients with CRE isolated from perianal swabs, BSI due to CRE occurred in 59. According to the multivariate logistic analysis, age (OR[odds ratio]=1.04, 95% CI[confidence interval]: 1.01-1.06, P=0.004), both meropenem and imipenem minimal inhibitory concentration (MIC) of the isolate from perianal swabs>8ug/mL (OR=5.34, 95% CI: 2.63-11.5, P<0.001), gastrointestinal symptoms (OR=3.67, 95% CI: 1.82-7.58, P<0.001), valley absolute neutrophil count (10⁹/L)>0.025 (OR=0.07, 95% CI: (0.02-0.19, P<0.001) and shaking chills at peak temperature (OR=6.94, 95% CI: (2.60-19.2, P<0.001) were independently associated with CRE BSI within 30 days and included in the prediction model. At a cut-off of prediction probability ≥ 21.5% the model exhibited a sensitivity, specificity, positive predictive value and negative predictive value of 79.7%, 85.6%, 96.27% and 47.47%. The discrimination and calibration of the prediction model were good on the derivation data (C-statistics=0.8898; Brier score=0.079) and enhanced bootstrapped validation dataset (adjusted C-statistics=0.881; adjusted Brier score=0.083). The risk prediction model is freely available as a mobile application at https://liujia1992.shinyapps.io/dynnomapp/.

Conclusion

A prediction model based on age, meropenem and imipenem MIC of isolate, gastrointestinal symptoms, valley absolute neutrophil count and shaking chills may be used to better inform interventions in hematological patients with CRE isolated from perianal swabs.

Diagnostic accuracy of quick SOFA score and inflammatory biomarkers for predicting community-onset bacteremia

The potential use of quick SOFA (qSOFA) score and inflammatory biomarkers as bacteremia predictors is unelucidated. Herein the aim of this study was to evaluate the diagnostic accuracy of the qSOFA score and biomarkers for predicting community-onset bacteremia. We enrolled adult outpatients with blood culture samples drawn between 2018 and 2020. Contamination, intensive care unit admission, and hemodialysis were excluded. We performed a case-control study, and analyzed 115 patients (58 with bacteremia and 57 without bacteremia). The positive likelihood ratio (LR) for bacteremia was 2.46 (95% confidence interval [CI] 0.76–9.05) for a qSOFA score ≥ 2, and 4.07 (95% CI 1.92–9.58) for tachypnea (≥ 22/min). The highest performing biomarkers were procalcitonin (area under the curve [AUC] 0.80; 95% CI 0.72–0.88), followed by presepsin (AUC 0.69; 95% CI 0.60–0.79), and C-reactive protein (AUC 0.60; 95% CI 0.49–0.70). The estimated optimal cut-off value of procalcitonin was 0.377 ng/mL, with a sensitivity of 74.1%, a specificity of 73.7%, and a positive LR of 2.82. Presepsin was 407 pg/mL, with a sensitivity of 60.3%, a specificity of 75.4%, and a positive LR of 2.46. Procalcitonin was found to be a modestly useful biomarker for predicting non-severe community-onset bacteremia. Tachypnea (≥ 22/min) itself, rather than the qSOFA score, can be a diagnostic predictor. These predictors may aid decision-making regarding the collection of blood culture samples in the emergency department and outpatient clinics.

Bandemia as an Early Predictive Marker of Bacteremia: A Retrospective Cohort Study

This single-center retrospective observational study aimed to verify whether a diagnosis of bandemia could be a predictive marker for bacteremia. We assessed 970 consecutive patients (median age 73 years; male 64.8%) who underwent two or more sets of blood cultures between April 2015 and March 2016 in both inpatient and outpatient settings. We assessed the value of bandemia (band count > 10%) and the percentage band count for predicting bacteremia using logistic regression models. Bandemia was detected in 151 cases (15.6%) and bacteremia was detected in 188 cases (19.4%). The incidence of bacteremia was significantly higher in cases with bandemia (52.3% vs. 13.3%; odds ratio (OR) = 7.15; 95% confidence interval (CI) 4.91–10.5). The sensitivity and specificity of bandemia for predicting bacteremia were 0.42 and 0.91, respectively. The bandemia was retained as an independent predictive factor for the multivariable logistic regression model (OR, 6.13; 95% CI, 4.02–9.40). Bandemia is useful for establishing the risk of bacteremia, regardless of the care setting (inpatient or outpatient), with a demonstrable relationship between increased risk and bacteremia. A bandemia-based electronic alert for blood-culture collection may contribute to the improved diagnosis of bacteremia.

A bacteraemia risk prediction model: development and validation in an emergency medicine population

OBJECTIVE

Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection.

METHODS

This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value < 0.05 were introduced in the univariate analysis together with those of clinical significance. The final selection of variables for the scoring scale was made by logistic regression with selection by introduction. The results obtained were internally validated by dividing the sample in a derivation and a validation cohort.

RESULTS

A total of 4,439 infectious episodes were included. Of these, 899 (20.25%) were considered as true bacteraemia. A predictive model for bacteraemia was defined with seven variables according to the Bacteraemia Prediction Model of the INFURG-SEMES group (MPB-INFURG-SEMES). The model achieved an area under the curve-receiver operating curve of 0.924 (CI 95%:0.914-0.934) in the derivation cohort, and 0.926 (CI 95%: 0.910-0.942) in the validation cohort. Patients were then split into ten risk categories, and had the following rates of risk: 0.2%(0 points), 0.4%(1 point), 0.9%(2 points), 1.8%(3 points), 4.7%(4 points), 19.1% (5 points), 39.1% (6 points), 56.8% (7 points), 71.1% (8 points), 82.7% (9 points) and 90.1% (10 points). Findings were similar in the validation cohort. The cut-off point of five points provided the best precision with a sensitivity of 95.94%, specificity of 76.28%, positive predictive value of 53.63% and negative predictive value of 98.50%.

CONCLUSION

The MPB-INFURG-SEMES model may be useful for the stratification of risk of bacteraemia in adult patients with infection in EDs, together with clinical judgement and other variables independent of the process and the patient.

Time Trend of the Sensitivity of the Pneumococcal Urinary Antigen Test for Diagnosing Pneumococcal Community-Acquired Pneumonia: An Analysis of 15-Year, Prospective Cohort Data

Introduction

Whether the sensitivity of the BinaxNOW Streptococcus pneumoniae urinary antigen test kit (BinaxNOW), adjusted by some variables including vital signs, laboratory examinations and pneumonia severity, has been decreasing is unknown. The aim of the present study was to investigate whether BinaxNOW sensitivity has decreased recently and to identify the predictors of the BinaxNOW result, including the time trend.

Methods

This prospective cohort study enrolled consecutive patients with pneumococcal community-acquired pneumonia who were hospitalised at Kurashiki Central Hospital from January 2001 to December 2015. Pneumococcal community-acquired pneumonia was defined as positive blood or pleural effusion or sputum culture results. To evaluate the effect of the time trend for the sensitivity of BinaxNOW, time series regression analysis was performed. In addition, predictors of the BinaxNOW result were examined by multivariable analysis using variables such as sex, vital signs, blood tests such as C-reactive protein, albumin, blood urea nitrogen, creatinine, white blood cell count, haematocrit and platelets, antibiotic pre-treatment, bacteraemia, and pneumonia severity, in addition to time trend and seasonality.

Results

A total of 446 patients were included. BinaxNOW sensitivity showed a significant, gradual decrease from 2001 (81.3%) to 2015 (48.7%). On multivariable analysis [odds ratio (95% confidence interval)], bacteraemia [2.516 (1.387–4.561), P = 0.002] was a predictor of a positive BinaxNOW result, whereas male sex [0.467 (0.296–0.736), P = 0.001], white blood cell count [0.959 (0.930–0.989), P = 0.008] and the time trend per year [0.900 (0.859–0.943), P < 0.001] were predictors of a negative BinaxNOW result.

Conclusions

The sensitivity of BinaxNOW decreased over a 15-year period. We should be careful when interpreting BinaxNOW results in daily clinical practice, and the development of a new kit with good sensitivity is anticipated.

Trial registration number

UMIN000004353.

Diagnostic performance of food consumption for bacteraemia in patients admitted with suspected infection: a prospective cohort study

OBJECTIVES

A previous study reported that food consumption is useful to rule out bacteraemia in hospitalised patients. We aimed to validate the diagnostic performance of (1) food consumption and (2) a previously reported algorithm using food consumption and shaking chills for bacteraemia in patients admitted to hospital with suspected infection.

DESIGN

Prospective cohort study.

SETTING

Department of General Medicine in two acute care hospitals in Japan.

PARTICIPANTS

A total of 2009 adult patients who underwent at least two blood cultures on admission.

PRIMARY OUTCOME MEASURES

The reference standard for bacteraemia was judgement by two independent specialists of infectious diseases. Food consumption was evaluated by the physician in charge asking the patient or their caregivers the following question on admission: 'What percentage of usual food intake were you able to eat during the past 24 hours?'

RESULTS

Among 2009 patients, 326 patients were diagnosed with bacteraemia (16.2%). Diagnostic performance of food consumption was sensitivity of 84.4% (95% CI 80.1 to 88), specificity of 19.8% (95% CI 18 to 21.8), positive predictive value (PPV) of 16.9% (95% CI 15.2 to 18.9) and negative predictive value (NPV) of 86.8% (95% CI 83.1 to 89.8). The discriminative performance was an area under the curve of 0.53 (95% CI 0.50 to 0.56). The performance of the algorithm using food consumption and shaking chills was sensitivity of 89% (95% CI 85.1 to 91.9), specificity of 18.8% (95% CI 17 to 20.7), PPV of 17.5% (95% CI 15.7 to 19.4) and NPV of 89.8% (95% CI 86.2 to 92.5).

CONCLUSION

Our results did not show the usefulness of food consumption and the algorithm using food consumption and shaking chills for the diagnosis of bacteraemia in patients admitted to hospital with suspected infection.

[Predictive factors of bacteraemia in the patients seen in emergency departments due to infections]

Objetivos

Analizar los factores predictivos de bacteriemia en los pacientes atendidos en el servicio de urgencias (SU) por un episodio de infección.

Pacientes y métodos

Estudio observacional, retrospectivo, descriptivo y analítico de todos los hemocultivos extraídos en un SU en los pacientes adultos (≥ 18 años) atendidos por infección desde el 1-1-2018 hasta el 1-7-2018. Se realizó seguimiento durante 30 días. Se analizaron 38 variables independientes (epidemiológicas, de comorbilidad, funcionales, clínicas y analíticas) que pudieran predecir la existencia de bacteriemia. Se realizó un estudio univariado y multivariante mediante regresión logística.

Resultados

Se incluyeron 1.425 episodios de hemocultivos extraídos. De ellos se consideraron como bacteriemias verdaderas 179 (12,6 %) y como HC negativos 1.246 (87,4 %). Entre los negativos, 1.130 (79,3%) no tuvieron crecimiento y 116 (8,1%) se consideraron contaminados. Cinco variables se asociaron de forma significativa como predictoras de bacteriemia verdadera: procalcitonina (PCT) sérica ≥ 0,51 ng/ml [odds ratio (OR): 4,52; intervalo de confianza (IC) al 95%: 4,20-4,84; p <0,001], temperatura > 38,3°C [OR: 1,60; IC al 95%: 1,29-1,90; p <0,001], presión arterial sistólica (PAS) < 100 mmHg [OR: 3,68; IC al 95%: 2,78-4,58; p <0,001], shock séptico [OR: 2,96; IC al 95%: 1,78-4,13; p <0,001] y la existencia de neoplasia [OR: 1,73; IC al 95%: 1,27-2,20; p <0,001].

Conclusiones

. Existen varios factores disponibles tras una primera valoración en el SU, entre ellos la PCT sérica, la temperatura, la hipotensión con/sin criterios de shock séptico y la existencia de neoplasia, que predicen la existencia de bacteriemia verdadera.

Internal medicine residents' evaluation of fevers overnight

Background Scant data exists to guide the work-up for fever in hospitalized patients, and little is known about what diagnostic tests medicine residents order for such patients. We sought to analyze how cross-covering medicine residents address fever and how sign-out systems affect their response. Methods We conducted a prospective cohort study to evaluate febrile episodes that residents responded to overnight. Primary outcomes included diagnostic tests ordered, if an in-person evaluation occurred, and the effect of sign-out instructions that advised a "full fever work-up" (FFWU). Results Investigators reviewed 253 fevers in 155 patients; sign-out instructions were available for 204 fevers. Residents evaluated the patient in person in 29 (11%) episodes. The most common tests ordered were: blood cultures (48%), urinalysis (UA) with reflex culture (34%), and chest X-ray (30%). If the sign-out advised an FFWU, residents were more likely to order blood cultures [odds ratio (OR) 14.75, 95% confidence interval (CI) 7.52-28.90], UA with reflex culture (OR 12.07, 95% CI 5.56-23.23), chest X-ray (OR 16.55, 95% CI 7.03-39.94), lactate (OR 3.33, 95% CI 1.47-7.55), and complete blood count (CBC) (OR 3.16, 95% CI 1.17-8.51). In a multivariable regression, predictors of the number of tests ordered included hospital location, resident training level, timing of previous blood culture, in-person evaluation, escalation to a higher level of care, and sign-out instructions. Conclusions Sign-out instructions and a few patient factors significantly impacted cross-cover resident diagnostic test ordering for overnight fevers. This practice can be targeted in resident education to improve diagnostic reasoning and stewardship.

Stability of intrinsic rhythm in pacemaker-dependent patients during pacemaker replacement: Can we predict the need for temporary pacing?

BACKGROUND

In pacemaker-dependent patients, the risk of asystole must be managed during device replacement. This study aimed to examine whether we could predict the indication for temporary pacing (TP) during the generator replacement.

METHODS

We studied 105 consecutive patients who underwent pacemaker replacement due to battery depletion at Juntendo Nerima Hospital between September 2005 and December 2016. We examined the relationship between the stability of the intrinsic rhythm (IR) during pacemaker replacement and several clinical factors including age, gender, sick sinus syndrome or atrioventricular (AV) block, duration of pacing, structural heart disease, use of anti-arrhythmic drugs, and the presence/absence of a stable IR (>40 bpm) at the outpatient clinic (OPC) just before pacemaker replacement.

RESULTS

Of the 105 patients, we excluded 1 patient who required TP because of bradycardia-dependent torsades de points. Therefore, we evaluated 104 patients for the indication for TP. TP was underwent in 19 patients (18%) because of an absence or instability of the IR during pacemaker replacement. The indication for TP was significantly correlated with AV block (84% vs 48%, P = .0044) and the absence of a stable IR at the last OPC visit (89% vs 24%, P < .0001). For predicting the indication for TP, the following values of no stable IR at the last OPC visit were obtained: 89% sensitivity, 77% specificity, 46% positive predictive value, and 97% negative predictive value.

CONCLUSIONS

The presence of a stable IR at the last OPC visit was a good predictor (97%) of no indication for TP during pacemaker replacement.