ANALYSIS OF RISK FACTORS FOR MORTALITY IN METHICILLIN-SENSITIVE STAPHYLOCOCCUS AUREUS BACTERAEMIA: CEFAZOLIN IS ASSOCIATED WITH BETTER OUTCOME/ STAPHYLOCOCCUS AUREUS BAKTERIYEMILERINDE MORTALITE RISK FAKTORLERININ ANALIZI: SEFAZOLIN DAHA IYI SONUCLA ILISKILI.
Methicillin-sensitive Staphylococcus aureus (MSSA) is one of the most frequently isolated causative agents of both healthcare-associated (HCA) and community-acquired (CA) bacteraemia. Mortality related to S. aureus bacteraemia is high, ranging from 20% to 30%, and varies as a function of underlying comorbid conditions, presence or absence of metastatic foci, and some features of the microorganism itself, such as a higher vancomycin minimum inhibitory concentration (MIC) level (1-6). Some studies reported an increased risk of mortality among patients with CA MSSA bacteraemia, but there are also reports with conflicting results (7, 8). Although cefazolin is the first choice in most of the current guidelines for the treatment of MSSA bacteraemia in the case of unavailability of anti-staphylococcal penicillins (ASP) like being in our country, other beta-lactams including ampicillin-sulbactam or other cephalosporins, glycopeptides and daptomycin are also used frequently (9). In this study, we analysed the risk factors for mortality among patients with MSSA bacteraemia with special emphasis on CA or HCA infections, and treatment with cefazolin and other antimicrobial treatment options.
MATERIALS AND METHODS
All adult (aged >18 years) patients who were hospitalized in our hospital and whose 2 blood cultures were positive for MSSA in the microbiology laboratory between January 2009 and December 2014 were included in the study. Patients with polymicrobial bacteraemia and those who died without antimicrobial therapy were excluded from the study.
Patients with positive blood cultures for MSSA and clinical and laboratory characteristics of them were retrospectively obtained from the laboratory and hospital databases. The following variables were recorded on previously prepared forms: age, sex, hospital ward (surgical or internal), requirement for intensive care unit (ICU) support, comorbid conditions (cancer, diabetes mellitus, cardiac valve disease, chronic renal failure, haemodialysis, cirrhosis, cerebrovascular accident), Charlson comorbidity index (CCI) (10), presence of echocardiographic examination and metastatic foci, laboratory values such as serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine, C-reactive protein (CRP) levels and white blood cell counts at the time of diagnosis of the infection, type of the antibacterial used for the treatment, outcome (mortality), and duration of hospitalization from the blood culture positivity until discharge from hospital or death.
MSSA bacteraemia was defined as the isolation of MSSA from at least two or more bottles of blood cultures with associated symptoms and signs of systemic infection.
Cases of S. aureus bacteraemia were classified as HCA or CA. CA bacteraemia was defined as a positive blood culture result obtained at the time of hospital admission or within 48 hours of hospital admission. HCA bacteraemia was defined either nosocomial, (as positive blood culture result obtained from patients who had been hospitalized for [greater than or equal to]48 hours), or non-nosocomial (as a positive blood culture result obtained from a patient within 48 hours of admission if the patient (a) had intravenous medical therapy in the previous 30 days; (b) attended a hospital or haemodialysis clinic or received intravenous chemotherapy in the previous 30 days; (c) was hospitalised in an acute care hospital for 2 days in the previous 90 days; or (d) resided in a nursing home or long-term care facility) (11).
A BacT/ALERT 3D (bioMerieux, Marcy l'Etoile, France) automatic blood culture system was used for blood cultures. Classic methods (Gram-staining, catalase, coagulase, DNAse and cefoxitine susceptibility tests) were used for the identification of MSSA.
Statistical analysis were performed using Statistical Package for the Social Sciences (SPSS) for Windows version 16.0 (SPSS Inc., Chicago, IL, USA). For analysis of risk factors for mortality and comparison of patients with CA and HA MSSA bacteraemia, [chi square] and Student's t-test were used for the univariate analysis of categorical and continuous variables of patients' characteristics, respectively. The univariate effect of the type of antimicrobial treatment on patient survival was investigated using log-rank test. Kaplan-Meier survival estimates were calculated. Cox regression analysis with backward selection was used to determine independent predictors of mortality. Variables found to be significant (p<0.05) in the univariate analysis or reported to be risk factors for mortality in the literature were included in the Cox regression analyses. Among correlated factors with similar effects on survival, only those with clinical significance were included. The proportional hazards assumption and model fit were assessed by means of residual (Schoenfeld and Martingale) analysis.
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethic Review Board of Hospital.
A total of 147 adult patients with clinically significant MSSA bacteraemia were identified between January 2009 and December 2014 from the database of the microbiology laboratory. Twenty patients were excluded from the study; 16 were excluded because they received outpatient management, and 4 patients died without receiving antimicrobial treatment. A total of 127 patients were included in the final analysis. Eighty-two (64.6%) patients were men and the median age was 54.4[+ or -]17.0 years. One hundred five of the 127 (82.7%) patients had HCA MSSA, and 22 (17.3%) had CA MSSA. The comparison of patients with HCA MSSA and CA MSSA is shown in Table 1.
Presence of intravenous catheters (52.4% vs 0%, p<0.001), chronic renal failure (30.5% vs 4.5%, p=0.014) and higher CCI (Charlson comorbidity index) (4.83 vs 3.04, p=0.001) were more frequently seen in patients with HCA MSSA than patients with CA-MSSA. Patients with CA-MSSA underwent more frequent echocardiographic investigations (68% vs 40%, p=0.016), were more likely to have heart valve disease (40.9% vs 17.1%, p=0.013), infective endocarditis (36% vs 3%, p<0.001), bone and joint infection (22.7% vs 0.9%, p=0.001), metastatic focus (59% vs 10%, p<0.001) and had higher WBC count (15.459 vs 11.831, p=0.019) than patients with HCA-MSSA. The mean mortality rate of patients was 20.5% and did not differ between patients with either CA or HCA MSSA (p=0.77). The comparison of patients' characteristics with and without mortality is shown in Table 2.
Vancomycin alone was used for 5 patients because of empiric choice and allergies against beta-lactam in 3 and 2 patients, respectively. Combined vancomycin and beta-lactam treatment were given empirically to the patients with either health-care (16 patients) or community acquired (2 patients) sepsis. Daptomycin was given to 3 patients with health-care associated infections empirically.
Durations of treatment were not found to be different among patients treated with different types of antimicrobials (p>0.005). Mean durations (+SD) of treatment were found to be 25[+ or -]24 and 18[+ or -]18 days for patients treated with cefazolin and other antimicrobials, respectively (p=0.073); 19[+ or -]18 and 20[+ or -]20 days for patients treated with ampicilllin-sulbactam and other antimicrobials, respectively (p=0.935); and 22[+ or -]19 and 19[+ or -]19 days for patients treated with vancomycin + other beta-lactams and other antimicrobials, respectively (p=0.483).
In the univariate analysis, the requirement for ICU support (p<0.001), higher CCI (p=0.001), AST level (p=0.003) and treatment with antimicrobials other than cefazolin (p=0.038) or other beta-lactams (including piperacillin-tazobactam, ceftriaxone, imipenem, meropenem) (p=0.022) were determined as risk factors for mortality among patients with MSSA.
In the analysis of the univariate effect of types of antimicrobial treatment on survival, it was found that cefazolin was associated with improved survival (log-rank test p=0.023).
In the subgroup analysis of patients treated with either cefazolin (n=30) or ampicillin-sulbactam (n=47), it was found that the mortality rate of patients treated with cefazolin (2/30, 6.6%) was lower than in patients treated with ampicillin-sulbactam (9/47, 19%); however, it did not reach statistical significance (log-rank p=0.082) (Figure 1).
In the multivariate analysis, higher CCI (HR 1.557), presence of metastatic foci (HR 2.883), and requirement for ICU support (HR 16.239) were found as independent risk factors for mortality among patients with MSSA, and cefazolin use was found to protect against mortality (HR 0.178).
In our study, MSSA bacteraemias mainly resulted from HCA infections, 82.7% of the cases had either nosocomial (acquired during hospitalization) or non-nosocomial (acquired in other type of health-care centers like haemodialysis units, nursing home or long-term care facility, etc). The reported rate of HCA infections among MSSA bacteraemia cases is wide ranging, between 27 and 81%, because the increasing numbers of individuals who are treated in outpatient programs make CA and HCA infections progres-sively overlapped (6, 12-14). Especially after the definition of non-nosocomial HCA infections, it was noticed that like MRSA bacteraemia, MSSA bacteraemia also originated mainly from healthcare-associated infections (15). It is especially important to be aware of preventable risk factors that predispose patients to MSSA bacteraemia because the mortality rate of MSSA bacteraemia is still very high, 20% in our study, which is in accordance with the other reports (16, 17) and healthcare associated infections can be prevented. In a study from Australia, at least one preventable risk factor was defined among 33% of MSSA blood stream infections, and feedback about preventable factors was associated with a reduction in HCA S. aureus bacteraemia rates (18). In our study, 43% and 10% of MSSA bacteraemias resulted from IV catheter or surgical site infections, respectively. As a result, nearly 50% of cases had at least one preventable factor of this blood stream infection. Fourteen percent of our patients had undergone haemodialysis and this finding once again highlights the increased risk of this group of patients for MSSA bacteraemia (1). Patients with HCA MSSA had higher CCI and more frequent catheter-related infections and surgical unit hospitalization (p<0.05) than patients with CA MSSA, and patients with CA MSSA were more frequently associated with IE, bone and joint infections, metastatic foci, and underwent more echocardiographic evaluations and cefazolin treatment (p<0.05) than those with HCA MSSA. The mortality rate of HCA and CA MSSA bacteraemia did not differ significantly in our study (p=0.77). The increased risk of mortality reported among patients with HCA S. aureus bacteraemia could be attributed to the inclusion of patients with MRSA, confusion of community-onset HCA with community-onset CA infections, or increased risk of comorbidities among HCA infections (1, 7-9). After eliminating all of these confounding factors through the inclusion of only MSSA bacteraemia, using up-to-date definitions for HCA and CA bacteraemia, and analysing independent risk factors, the mortality rate of MSSA bacteraemia was found the same between HCA and CA MSSA bacteraemia in our study. There are also some reports of increased risk of mortality among CA MSSA bacteraemia related to increased complications, especially metastatic foci due to delayed diagnosis and treatment of disease (19). The diagnosis of HCA MSSA bacteraemia could be more rapid than the diagnosis of CA MSSA, which probably contributed to the increased risk of complication and death among patients with CA MSSA reported in some studies (20, 21). In accordance with some published studies (4), the higher CCI of patients with HCA MSSA and higher incidence of metastatic foci among patients with CA MSSA probably contributed to the lack of difference in mortality rates between patients with HCA or CA MSSA in our study.
The presence of metastatic foci was found to be an independent risk factor for mortality in our study and confirms results of other studies (20). It has been clearly described that risk of metastatic foci is significantly increased with prolonged duration of bacteraemia (19). Since the tendency of S. aureus for metastatic infection is well known, it is especially important to search with a clinical scoring system, TEE or PET/CT, to find and treat properly metastatic foci in order to decrease the risk of mortality in patients with MSSA bacteraemia (20, 22, 23). Comorbid conditions defined as increased CCI and severity of infection documented as a need to ICU support were found to increase mortality significantly in our study, which have already been demonstrated in several other studies (9, 22).
Cefazolin was found as an independent protective factor against mortality in our study. Although cefazolin has been shown to be effective equally with anti-staphylococcal penicillins (24-28) or have a mortality benefit (29) for treatment of MSSA bacteremia, there have not been studies comparing the effectivenes of cefazolin and other beta-lactams for this indication in situations where ASPs are not availible. In accordance with our study, in a retrospective cohort study of 498 patients with MSSA bacteraemia, treatment with cefazolin was not significantly different from treatment with cloxacillin, whereas treatment with other beta-lactams, including beta-lactam/beta-lactamase inhibitors, second- and third-generation cephalosporins, were associated with higher mortality (12). In a recent study of patients with MSSA bacteraemia and penicillin allergy, cefazolin was found superior to vancomycin for the treatment of MSSA bacteraemia, with significant difference in mortality rates between patients treated with either cefazolin or vancomycin (19.6% vs 5.9%) (30). It is common practice to use either cefazolin or ampicillin-sulbactam for the treatment of infections caused by MSSA in our country because ASPs are not available. Therefore, we performed a subgroup analysis of patients treated with either cefazolin or ampicillin-sulbactam and found that the mortality rate of patients treated with cefazolin was lower than in patients treated with ampicillin-sulbactam (6.6 % versus 19.1%), although it did not reach statistical significance because of the lower number of patients. Additonal studies are needed to compare the effectiveness of cefazolin and specific beta-lactam agents including ampicillin-sulbactam in the treatment of MSSA bacteraemia.
Our study has some limitations. Although the first choice of S. aureus bacteremia is anti-staphylococcal penicillins (ASP) at the moment, we were unable to use them because of the unavailability of this agents in our country. As well as vancomycin and daptomycin are not recommended treatments for MSSA bacteremia, some of our patients were given either vancomycin combined with other beta-lactams or daptomycin because of severe health-care associated sepsis. Some of the variables that could have an effect on the mortality rate such as the duration of blood culture positivity could not be obtained because of retrospective design of the study. Also, metastatic foci could not be investigated properly with TEE or PET/CT in most patients.
Either HAC or CA, MSSA bacteraemia is associated with a high mortality rate, reaching 20%. Like MRSA bacteraemia, the proportion of nosocomial and non-nosocomial HCA infections is quite high, also in MSSA bacteraemia. Consequently, preventive measures are of vital importance. Patients with MSSA bacteraemia should be treated with cefazolin instead of other options including other beta-lactams, glycopeptides and daptomycin because of the associated lower mortality rate with cefazolin, especially in countries where anti-staphylococcal penicillins are not available or in patients who cannot tolerate anti-staphylococcal penicillins.
Ethics Committee Approval: Ethics committee approval was received for this study from the local ethics committee.
Informed Consent: Informed consent was not received due to the retrospective nature of the study.
Peer Review: Externally peer-reviewed.
Author Contributions: Conception/Design of Study S.B., S.S.Y., A.C., A.O.; Data Acquisition- B.S.C, A.Y.; Data Analysis/Interpretation-S.B., S.S.Y., H.O., H.E.; Drafting Manuscript- S.B., S.S.Y., B.S.C., A.Y.; Critical Revision of Manuscript- A.C., O.O., H.O., H.E.; Final Approval and Accountability- S.B., S.S.Y., B.S.C., A.Y., A.C., O.O., H.O., H.E.; Technical or Material Support- S.B., S.S.Y., B.S.C., A.Y.; Supervision- A.C., O.O., H.O., H.E.
Conflict of Interest: Authors declared no conflict of interest.
Financial Disclosure: Authors declared no financial support.
Etik Komite Onayi: Etik komite onayi bu calisma icin, yerel etik komiteden alinmistir.
Bilgilendirilmis Onam: Retrospektif bir calisma oldugundan bilgilendirilmis onam alinmamistir.
Hakem Degerlendirmesi: Dis bagimsiz.
Yazar Katkilari: Calisma Konsepti/Tasarim- S.B., S.S.Y., A.C., A.O.; Veri Toplama- B.S.C, A.Y.; Veri Analizi/Yorumlama- S.B., S.S.Y., H.O., H.E.; Yazi Taslagi- S.B., S.S.Y., B.S.C., A.Y.; Icerigin Elestirel Incelemesi- A.C., O.O., H.O., H.E.; Son Onay ve Sorumluluk-S.B., S.S.Y., B.S.C., A.Y., A.C., O.O., H.O., H.E.; Malzeme ve Teknik Destek- S.B., S.S.Y., B.S.C., A.Y.; Supervizyon- A.C., O.O., H.O., H.E..
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Seniha BASARAN (1) [iD], Serap SIMSEK YAVUZ (1) [iD], Betul SADIC COPUR (1) [iD], Asiye YIR (1) [iD], Atahan CAGATAY (1) [iD], Oral ONCUL (1) [iD], Halit OZSUT (1) [iD], Haluk ERAKSOY (1) [iD]
(1) Istanbul University, Istanbul Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
ORCID IDs of the authors: S.B. 0000-0002-3402-2510; S.S.Y. 0000-0002-4675-169X; B.S.C. 0000-0001-5534-1388; A.Y. 0000-0001-9473-5099; A.C. 0000-0002-3051-8199; O.O. 0000-0002-1681-1866; H.O. 0000-0002-5222-9320; H.E. 0000-0002-5790-0806
Cite this article as: Basaran S, Simsek-Yavuz S, Sadic-Copur B, Yir A, Cagatay A, Oncul O, Ozsut H, Eraksoy H. Analysis of risk factors for mortality in methicillin-sensitive staphylococcus aureus bacteraemia: cefazolin is associated with better outcome. J Ist Faculty Med 2019;82(3):131-8. doi: 10.26650/IUITFD.2019.0009
Corresponding author/Iletisim kurulacak yazar: email@example.com
Submitted/Basvuru: 22.01.2019 * Accepted/Kabul: 26.03.2019 * Published Online/Online Yayin: 29.04.2019
Table 1. Comparison of patients with community acquired methicillin-sensitive Staphylococcus aureus bacteraemia and health-care associated methicillin-sensitive Staphylococcus aureus bacteraemia. Characteristics All patients Community-acquired (n=127) MSSA bacteraemia (n=22) Sex (male), n (%) 82 (64.6) 17 (77.3) Age (mean[+ or -]SD) 54.38[+ or -]16.98 49.91[+ or -]16.41 Hospital service 87 (68.5) 21 (95.5) (medical), n (%) Duration of hospital 20.10[+ or -]19.82 25.64[+ or -]19.39 stay, (mean[+ or -]SD) Need for ICU 33 (26.0) 6 (27.3) support, n (%) Charlson comorbidity 4.52[+ or -]2.41 3.04[+ or -]1.61 index (mean[+ or -]SD) Echocardiographic 57 (44.9) 15 (68.2) investigation, n (%) Presence of 24 (18.9) 13 (59.1) metastatic foci, n (%) WBC, (mean[+ or -]SD) 12459[+ or -]8348 15459[+ or -]7265 Serum CRP level 209[+ or -]138 208[+ or -]108 (mean[+ or -]SD) Serum ALT level 61[+ or -]120 54[+ or -]62 (mean[+ or -]SD) Serum AST level 60[+ or -]123 60[+ or -]104 (mean[+ or -]SD) Serum creatinine level 1.95[+ or -]2.01 1.22[+ or -]0.79 (mean[+ or -]SD) Mortality, n (%) 26 (20.5) 5 (22.7) Comorbid conditions Malignity, n (%) 44 (34.6) 4 (18.2) Diabetes mellitus, n (%) 27 (21.3) 4 (18.2) Chronic renal 33 (26.0) 1 (4.5) failure, n (%) Heart valve 27 (21.3) 9 (40.9) disease, n (%) Cerebrovascular 9 (7.1) 0 accident, n (%) Cirrhosis, n (%) 4 (3.1) 0 Immunosuppressive 13 (10.2) 1 (4.5) treatment, n (%) None, n (%) 18 (14.2) 5 (22.7) Source of bacteraemia Intravenous 55 (43.3) 0 catheter, n (%) Primary, n (%) 16 (12.6) 4 (18.2) Pneumonia, n (%) 15 (11.8) 3 (13.6) Surgical site 13 (10.2) 0 infection, n (%) Skin and soft tissue 11 (8.7) 2 (9.1) infection, n (%) Infective 11 (8.7) 8 (36.4) endocarditis, n (%) Bone and joint 6 (4.7) 5 (22.7) infection, n (%) Antimicrobial treatment Ampicillin-sulbactam, 47 (37.0) 7 (31.8) n (%) Cefazolin, n (%) 30 (23.6) 9 (40.9) Other 24 (18.9) 2 (9.1) beta-lactams (1), n (%) Vancomycin, n (%) 5 (3.9) 2 (9.1) Vancomycin plus 18 (14.2) 2 (9.1) beta-lactam, n (%) Daptomycin, n (%) 3 (2.4) 0 Characteristics Healthcare-associated p MSSA bacteraemia (n=105) Sex (male), n (%) 65 (61.9) 0.171 Age (mean[+ or -]SD) 55.31[+ or -]17.03 0.116 Hospital service 66 (62.9) 0.002 (medical), n (%) Duration of hospital 18.94[+ or -]19.80 0.092 stay, (mean[+ or -]SD) Need for ICU 27 (25.7) 0.880 support, n (%) Charlson comorbidity 4.83[+ or -]2.44 0.001 index (mean[+ or -]SD) Echocardiographic 42 (40.0) 0.016 investigation, n (%) Presence of 11 (10.5) <0.001 metastatic foci, n (%) WBC, (mean[+ or -]SD) 11831[+ or -]8454 0.019 Serum CRP level 209[+ or -]144 0.731 (mean[+ or -]SD) Serum ALT level 62[+ or -]129 0.443 (mean[+ or -]SD) Serum AST level 60[+ or -]127 0.426 (mean[+ or -]SD) Serum creatinine level 2.10[+ or -]2.14 0.475 (mean[+ or -]SD) Mortality, n (%) 21 (20.0) 0.773 Comorbid conditions Malignity, n (%) 40 (38.1) 0.088 Diabetes mellitus, n (%) 23 (21.9) 1.000 Chronic renal 32 (30.5) 0.014 failure, n (%) Heart valve 18 (17.1) 0.013 disease, n (%) Cerebrovascular 9 (8.6) 0.357 accident, n (%) Cirrhosis, n (%) 4 (3.8) 1.000 Immunosuppressive 12 (11.4) 0.464 treatment, n (%) None, n (%) 13 (12.4) 0.206 Source of bacteraemia Intravenous 55 (52.4) <0.001 catheter, n (%) Primary, n (%) 12 (11.4) 0.477 Pneumonia, n (%) 12 (11.4) 0.724 Surgical site 13 (12.4) 0.123 infection, n (%) Skin and soft tissue 9 (8.6) 1.000 infection, n (%) Infective 3 (2.9) <0.001 endocarditis, n (%) Bone and joint 1 (0.9) 0.001 infection, n (%) Antimicrobial treatment Ampicillin-sulbactam, 40 (38.1) 0.579 n (%) Cefazolin, n (%) 21 (20.0) 0.036 Other 22 (21.0) 0.245 beta-lactams (1), n (%) Vancomycin, n (%) 3 (2.9) 0.207 Vancomycin plus 16 (15.1) 0.737 beta-lactam, n (%) Daptomycin, n (%) 3 (2.9) 1.000 MSSA: methicillin-sensitive Staphylococcus aureus; ICU: intensive care unit; WBC: white blood cell, CRP: C-reactive protein; ALT: alanine aminotransferase; AST: aspartate aminotransferase (1) Other beta-lactams (number of patients): Piperacillin-tazobactam (16), ceftriaxone (4), imipenem (2), meropenem (2). Table 2. Comparison of methicillin-sensitive Staphylococcus aureus bacteraemia patients with and without mortality. Characteristics Patients Patients without with mortality mortality (n=101) (n=26) Age, year 53.55[+ or -]16.76 57.58[+ or -]17.80 (mean[+ or -]SD) Sex (male), n (%) 62 (61.4) 20 (76.9) Hospital service 70 (69.3) 17 (65.4) (medical), n (%) Community acquired 17 (16.8) 5 (19.2) infection, n (%) Duration of hospital 23.04[+ or -]20.28 8.69[+ or -]12.8 stay, (mean[+ or -]SD) Need for ICU 12 (11.9) 21 (80.8) support, n (%) Presence of 17 (16.8) 7 (26.9) metastatic foci, n (%) Echocardiographic 49 (48.5) 8 (30.8) investigation, n (%) WBC, (mean[+ or -]SD) 12491[+ or -]8394 12336[+ or -]8332 Serum CRP level 197.9[+ or -]127.8 253.7[+ or -]171.1 (mean[+ or -]SD) Serum ALT level 43.7[+ or -]58.0 132.1[+ or -]229.9 (mean[+ or -]SD) Serum AST level 38.0[+ or -]50.50 149[+ or -]238.4 (mean[+ or -]SD) Serum creatinine 1.94[+ or -]2.12 1.97[+ or -]1.52 level (mean[+ or -]SD) Charlson comorbidity 2.98[+ or -]1.75 4.15[+ or -]1.59 index (mean[+ or -]SD) Comorbid conditions Malignity, n (%) 34 (33.6) 10 (38.5) Diabetes 22 (21.8) 5 (19.2) mellitus, n (%) Chronic renal 25 (24.7) 8 (30.8) failure, n (%) Heart valve 19 (18.8) 8 (30.8) disease, n (%) Cerebrovascular 7 (6.9) 2 (7.7) accident, n (%) Cirrhosis, n (%) 2 (1.9) 2 (7.7) Immunosuppressive 12 (11.9) 1 (3.8) treatment, n (%) Hemodialysis, n (%) 15 (14.9) 3 (11.5) None, n (%) 17 (16.8) 1 (3.8) Source of bacteraemia Intravenous 47 (46.5) 8 (30.8) catheter, n (%) Primary, n (%) 11 (10.9) 5 (19.2) Pneumonia, n (%) 9 (8.9) 6 (23.1) Surgical site 9 (8.9) 4 (15.4) infection, n (%) Skin and soft 11 (10.9) 0 tissue infection, n (%) Infective 8 (7.9) 3 (11.5) endocarditis, n (%) Bone and joint 6 (5.9) 0 infection, n (%) Antimicrobial treatment Ampicillin-sulbactam, 38 (37.6) 9 (34.6) n (%) Cefazolin, n (%) 28 (27.7) 2 (7.7) Other 15 (13.5) 9 (34.6) beta-lactams (1), n (%) Vancomycin, n (%) 3 (3.0) 2 (7.7) Vancomycin plus 15 (14.8) 3 (11.5) beta-lactam, n (%) Daptomycin, n (%) 2 (2.0) 1 (3.8) Characteristics p p HR %95 CI (univariate (multivariate analysis) analysis) Age, year 0.286 (mean[+ or -]SD) Sex (male), n (%) 0.140 Hospital service 0.701 (medical), n (%) Community acquired 0.773 infection, n (%) Duration of hospital <0.001 stay, (mean[+ or -]SD) Need for ICU <0.001 <0.001 16.239 6.021-43.799 support, n (%) Presence of 0.241 0.047 2.883 1.013-8.210 metastatic foci, n (%) Echocardiographic 0.105 investigation, n (%) WBC, (mean[+ or -]SD) 0.903 Serum CRP level 0.158 (mean[+ or -]SD) Serum ALT level 0.065 (mean[+ or -]SD) Serum AST level 0.003 (mean[+ or -]SD) Serum creatinine 0.423 level (mean[+ or -]SD) Charlson comorbidity 0.001 <0.001 1.557 1.234-1.964 index (mean[+ or -]SD) Comorbid conditions Malignity, n (%) 0.647 Diabetes 0.772 mellitus, n (%) Chronic renal 0.533 failure, n (%) Heart valve 0.184 disease, n (%) Cerebrovascular 1.000 accident, n (%) Cirrhosis, n (%) 0.186 Immunosuppressive 0.302 treatment, n (%) Hemodialysis, n (%) 1.000 None, n (%) 0.119 Source of bacteraemia Intravenous 0.148 catheter, n (%) Primary, n (%) 0.253 Pneumonia, n (%) 0.046 Surgical site 0.466 infection, n (%) Skin and soft 0.118 tissue infection, n (%) Infective 0.695 endocarditis, n (%) Bone and joint 0.346 infection, n (%) Antimicrobial treatment Ampicillin-sulbactam, 0.824 n (%) Cefazolin, n (%) 0.038 0.037 0.178 0.035-0.904 Other 0.022 beta-lactams (1), n (%) Vancomycin, n (%) 0.271 Vancomycin plus 1.000 beta-lactam, n (%) Daptomycin, n (%) 0.500 ICU: intensive care unit; WBC: white blood cell, CRP: C-reactive protein; ALT: alanine aminotransferase; AST: aspartate aminotransferase (1) Other beta-lactams (number of patients): Piperacillin-tazobactam (16), ceftriaxone (4), imipenem (2), meropenem (2).
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|Title Annotation:||ARASTIRMA / RESEARCH|
|Author:||Basaran, Seniha; Yavuz, Serap SImsek; Copur, Betul Sadic; YIr, Asiye; Cagatay, Atahan; Oncul, Oral;|
|Publication:||Journal of Istanbul Faculty of Medicine|
|Date:||Sep 1, 2019|
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