Attributable mortality of ICU-acquired bloodstream infections: Impact of the source, causative micro-organism, resistance profile and antimicrobial therapy - 18/04/17

Doi : 10.1016/j.jinf.2016.11.001

Christophe Adrie ^a,^⁎ , Maité Garrouste-Orgeas ^b,^c, Wafa Ibn Essaied ^b, Carole Schwebel ^d, Michael Darmon ^e, Bruno Mourvillier ^b,^f, Stéphane Ruckly ^b,^g, Anne-Sylvie Dumenil ^h, Hatem Kallel ⁱ, Laurent Argaud ^j, Guillaume Marcotte ^k, Francois Barbier ^l, Virginie Laurent ^m, Dany Goldgran-Toledano ⁿ, Christophe Clec'h ^b,^o, Elie Azoulay ^p, Bertrand Souweine ^q, Jean-François Timsit ^b,^f
on behalf of
the OUTCOMEREA Study Group*^{^r}
The study is set up and conducted by the Outcomerea network. The members of the OUTCOMEREA Study Group* are listed in the ‘‘Appendix’’.
Jean-François Timsit ^r, Elie Azoulay ^s, Yves Cohen ^t, Maïté Garrouste-Orgeas ^u, Lilia Soufir ^u, Alban Le Monnier ^v, Jean-Ralph Zahar ^w, Christophe Adrie ^x,^af,^ag, Michael Darmon ^y, Corinne Alberti ^z,^ab, Christophe Clec'h ^t, Jean-Francois Timsit ^aa, Sebastien Bailly ^ac, Stéphane Ruckly ^ad, Cecile Pommier ^ad, Wafa Ifn Essaeid ^ae, Aurélien Vannieuwenhuyze ^ae, Bernard Allaouchiche ^ah, Claire Ara-Somohano ^ai, Laurent Argaud ^aj, Francois Barbier ^ak, Jean-Pierre Bedos ^al, Agnès Bonadona ^ai, Anne-Laure Borel ^am, Caroline Bornstain ^an, Lila Bouadma ^ao, Alexandre Boyer ^ap, Jean-Pierre Colin ^aq, Anne-Sylvie Dumenil ^ar, Antoine Gros ^al, Rebecca Hamidfar-Roy ^as, Hakim Haouache ^at, Samir Jamali ^aq, Hatem Kallel ^au, Guillaume Marcotte ^ah, Alexandre Lautrette ^aw, Christian Laplace ^av, Benoit Misset ^u, Laurent Montesino ^ax, Bruno Mourvillier ^ax, Benoît Misset ^u, Guillaume Lacave ^al, Virgine Lemiale ^s, Virginie Laurent ^al, Eric Marriotte ^ax, Benjamin Planquette ^al, Jean Reignier ^ay, Romain Sonneville ^ax, Bertrand Souweine ^aw, Carole Schwebel ^ai, Gilles Troché ^al, Marie Thuong ^az, Dany Goldgran-Toledano ^ba, Eric Vantalon ^u, Caroline Tournegros, Loïc Ferrand, Nadira Kaddour, Boris Berthe, Kaouttar Mellouk, Sophie Letrou, Igor Théodose, Julien Fournier, Véronique Deiler
^r ICU, Bichat Hospital and UMR 1137-Paris Diderot University, Paris, France
^s ICU, Saint-Louis Hospital, Paris, France
^t ICU, Avicenne Hospital, Bobigny, France
^u ICU, Saint-Joseph Hospital, Paris, France
^v Microbiology, Saint-Joseph Hospital, Paris, France
^w Microbiology, CHU Angers, France
^x ICU, Cochin Hospital, Paris, France
^y ICU, CHU Saint-Etienne, France
^z Robert Debré Hospital, Paris, France
^aa Bichat Hospital and UMR 1137-Paris Diderot University, Paris, France
^ab Medical Computer Sciences and Biostatistics Department, Robert Debré, Paris, France
^ac Integrated Research Center U823, Grenoble, France
^ad Outcomerea, INSERM UMR 1137, Paris, France
^ae Tourcoing, France
^af ICU, Delafontaine Hospital, Saint Denis, France
^ag Physiology Department, Cochin Hospital, Paris, France
^ah Surgical ICU, Edouard Herriot Hospital, Lyon, France
^ai CHU A. Michallon, Grenoble, France
^aj Medical ICU, Edouard Herriot Hospital, Lyon, France
^ak ICU, Orleans, France
^al ICU, CH A. Mignot, Versailles, France
^am Nutrition Department, Grenoble, France
^an ICU, Montfermeil Hospital, France
^ao ICU, Bichat Claude Bernard Hospital, Paris, France
^ap ICU, Pellegrin Hospital, Bordeaux, France
^aq ICU, Dourdan Hospital, Dourdan, France
^ar A. Béclère Hospital, Clamart, France
^as CHU A Michallon, Grenoble, France
^at ICU, CHU H. Mondor, Créteil, France
^au ICU, Cayenne General Hospital, Guyane, France
^av ICU, Kremlin-Bicêtre Hospital, Bicêtre, France
^aw ICU, CHU G.Montpied, Clermont-Ferrand, France
^ax ICU, Bichat Hospital, Paris, France
^ay ICU, CH La Roche-sur-Yon, France
^az ICU, CH Pontoise, France
^ba CH Gonnesse, France

^a Physiology Department, Cochin University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Descartes University, Paris, France
^b INSERM, IAME, UMR 1137, Team DesCID, F-75018 Paris, France
^c Medical-Surgical Intensive Care Unit, Saint Joseph Hospital, Paris, France
^d Medical Intensive Care Unit, Michallon University Hospital, Grenoble, France
^e Medical ICU, Saint-Etienne University Hospital, Saint-Priest en Jarez, France
^f Medical Intensive Care Unit, Assistance Publique des Hôpitaux de Paris (AP-HP), Bichat University Hospital, Paris, France
^g Outcomerea Network, Paris, France
^h Medical-Surgical Intensive Care Unit, Antoine Béclère University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Clamart, France
ⁱ Medical-Surgical Intensive Care Unit, Centre hospitalier de Cayenne, Guyane, France
^j Medical-Intensive Care Unit, Edouard Heriot Hospital, Lyon University Hospital, Lyon, France
^k Surgical-Intensive Care Unit, Edouard Heriot Hospital, Lyon University Hospital, Lyon, France
^l Medical Intensive Care Unit, La Source Hospital – CHR Orléans, Orléans, France
^m Medical-Surgical Intensive Care Unit, André Mignot Hospital, Versailles-Le Chesnay, France
ⁿ Medical-Surgical Intensive Care Unit, Gonesse Hospital, Gonesse, France
^o Medical Intensive Care Unit, Assistance Publique des Hôpitaux de Paris (AP-HP), Avicenne University Hospital, Bobigny, France
^p Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
^q Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France

^∗Corresponding author. Physiology Department, Hôpital Cochin, Université Paris-Descartes, 27 rue du Faubourg Saint Jacques, 75014 Paris, France. Fax: +33 158412 345.Physiology DepartmentHôpital CochinUniversité Paris-Descartes27 rue du Faubourg Saint JacquesParis75014France

Summary

Objectives

ICU-acquired bloodstream infection (ICU-BSI) in Intensive Care unit (ICU) is still associated with a high mortality rate. The increase of antimicrobial drug resistance makes its treatment increasingly challenging.

Methods

We analyzed 571 ICU–BSI occurring amongst 10,734 patients who were prospectively included in the Outcomerea Database and who stayed at least 4 days in ICU. The hazard ratio of death associated with ICU–BSI was estimated using a multivariate Cox model adjusted on case mix, patient severity and daily SOFA.

Results

ICU–BSI was associated with increased mortality (HR, 1.40; 95% CI, 1.16–1.69; p = 0.0004). The relative increase in the risk of death was 130% (HR, 2.3; 95% CI, 1.8–3.0) when initial antimicrobial agents within a day of ICU–BSI onset were not adequate, versus only 20% (HR, 1.2; 95% CI, 0.9–1.5) when an adequate therapy was started within a day. The adjusted hazard ratio of death was significant overall, and even higher when the ICU–BSI source was pneumonia or unknown origin. When treated with appropriate antimicrobial agents, the death risk increase was similar for ICU–BSI due to multidrug resistant pathogens or susceptible ones. Interestingly, combination therapy with a fluoroquinolone was associated with more favorable outcome than monotherapy, whereas combination with aminoglycoside was associated with similar mortality than monotherapy.

Conclusions

ICU–BSI was associated with a 40% increase in the risk of 30-day mortality, particularly if the early antimicrobial therapy was not adequate. Adequacy of antimicrobial therapy, but not pathogen resistance pattern, impacted attributable mortality.

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Highlights

•	Bloodstream Infection acquired in ICU was associated with an increase in the risk mortality.
•	Early adequate antimicrobial therapy was associated with a better outcome.
•	This was true whatever the susceptibility of the causative bacteria.
•	Fluoroquinolone use, but not aminoglycoside use, was associated with an improved outcome.

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Keywords : Bloodstream infection, Nosocomial, Outcome, Antimicrobial therapy

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Vol 74 - N° 2

P. 131-141 - février 2017 Retour au numéro

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Attributable mortality of ICU-acquired bloodstream infections: Impact of the source, causative micro-organism, resistance profile and antimicrobial therapy - 18/04/17

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