Respond Early to Hospital-Acquired Bloodstream Infections

WASHINGTON — Mortality from hospital-acquired bloodstream infections is greater when the causal organism is not susceptible to initial antibiotic choice.

“We need to know the antibiogram and select broadly enough to cover the likely organism in the first 24 hours,” Dr. Richard Wenzel said at the annual meeting of the American College of Physicians.

He recommended using systemic inflammatory response syndrome (SIRS) criteria to identify sepsis patients early. SIRS is defined as the presence of two or more of these variables:

▸ A body temperature of more than 38° C or less than 36° C.

▸ A heart rate of more than 90 beats per minute.

▸ A respiratory rate of more than 20 breaths per minute (or an arterial partial pressure of carbon dioxide [PaCO₂] level of less than 32 mm Hg).

▸ An abnormal white blood cell count (greater than 12,000/mcL or less than 4,000/mcL, or greater than 10% bands).

Two SIRS criteria plus any evidence of infection define sepsis, he said. Severe sepsis involves any end-organ dysfunction plus sepsis. Septic shock is defined as severe sepsis with a blood pressure of less than 90 mm Hg after a 500-mL fluid bolus.

Coagulase-negative staphylococcus organisms are the No. 1 cause of crude mortality among patients with bloodstream infections. Other potentially deadly organisms include Staphylococcus aureus, enterococcus, Candida species, gram-negative rods, and Pseudomonas aeruginosa.

Two culprits—Candida species and P. aeruginosa—predict outcome after correction for the underlying disease, noted Dr. Wenzel, professor and chair of the department of internal medicine at Virginia Commonwealth University, Richmond.

The duration of hypotension prior to the initiation of effective treatment is another critical factor in survival. “Treat the patients early. Resuscitate them early. Move them to the ICU early,” Dr. Wenzel advised.

The use of five evidence-based interventions—hand hygiene, a skin preparation with chlorhexidine, barrier precautions, preferred use of the subclavian vein, and catheter removal as soon as possible—can reduce catheter-associated bloodstream infections by as much as two-thirds according to some studies, he said.

For skin antisepsis, 2% chlorhexidine is now preferred over alcohol to reduce bloodstream infections. Another important element of hand hygiene may be eradication of nasal carriage through use of mupirocin. “Forty to fifty percent of people who are nasal carriers have the same organism on their hands,” he said.

Technology-based approaches—including antibiotic-coated catheters, vancomycin lock solutions, chlorhexidine-impregnated dressings, and daily bathing of ICU patients with chlorhexidine—also show some promise, Dr. Wenzel added.

WASHINGTON — Mortality from hospital-acquired bloodstream infections is greater when the causal organism is not susceptible to initial antibiotic choice.

“We need to know the antibiogram and select broadly enough to cover the likely organism in the first 24 hours,” Dr. Richard Wenzel said at the annual meeting of the American College of Physicians.

He recommended using systemic inflammatory response syndrome (SIRS) criteria to identify sepsis patients early. SIRS is defined as the presence of two or more of these variables:

▸ A body temperature of more than 38° C or less than 36° C.

▸ A heart rate of more than 90 beats per minute.

▸ A respiratory rate of more than 20 breaths per minute (or an arterial partial pressure of carbon dioxide [PaCO₂] level of less than 32 mm Hg).

▸ An abnormal white blood cell count (greater than 12,000/mcL or less than 4,000/mcL, or greater than 10% bands).

Two SIRS criteria plus any evidence of infection define sepsis, he said. Severe sepsis involves any end-organ dysfunction plus sepsis. Septic shock is defined as severe sepsis with a blood pressure of less than 90 mm Hg after a 500-mL fluid bolus.

Coagulase-negative staphylococcus organisms are the No. 1 cause of crude mortality among patients with bloodstream infections. Other potentially deadly organisms include Staphylococcus aureus, enterococcus, Candida species, gram-negative rods, and Pseudomonas aeruginosa.

Two culprits—Candida species and P. aeruginosa—predict outcome after correction for the underlying disease, noted Dr. Wenzel, professor and chair of the department of internal medicine at Virginia Commonwealth University, Richmond.

The duration of hypotension prior to the initiation of effective treatment is another critical factor in survival. “Treat the patients early. Resuscitate them early. Move them to the ICU early,” Dr. Wenzel advised.

The use of five evidence-based interventions—hand hygiene, a skin preparation with chlorhexidine, barrier precautions, preferred use of the subclavian vein, and catheter removal as soon as possible—can reduce catheter-associated bloodstream infections by as much as two-thirds according to some studies, he said.

For skin antisepsis, 2% chlorhexidine is now preferred over alcohol to reduce bloodstream infections. Another important element of hand hygiene may be eradication of nasal carriage through use of mupirocin. “Forty to fifty percent of people who are nasal carriers have the same organism on their hands,” he said.

Technology-based approaches—including antibiotic-coated catheters, vancomycin lock solutions, chlorhexidine-impregnated dressings, and daily bathing of ICU patients with chlorhexidine—also show some promise, Dr. Wenzel added.

WASHINGTON — Mortality from hospital-acquired bloodstream infections is greater when the causal organism is not susceptible to initial antibiotic choice.

“We need to know the antibiogram and select broadly enough to cover the likely organism in the first 24 hours,” Dr. Richard Wenzel said at the annual meeting of the American College of Physicians.

He recommended using systemic inflammatory response syndrome (SIRS) criteria to identify sepsis patients early. SIRS is defined as the presence of two or more of these variables:

▸ A body temperature of more than 38° C or less than 36° C.

▸ A heart rate of more than 90 beats per minute.

▸ A respiratory rate of more than 20 breaths per minute (or an arterial partial pressure of carbon dioxide [PaCO₂] level of less than 32 mm Hg).

▸ An abnormal white blood cell count (greater than 12,000/mcL or less than 4,000/mcL, or greater than 10% bands).

Two SIRS criteria plus any evidence of infection define sepsis, he said. Severe sepsis involves any end-organ dysfunction plus sepsis. Septic shock is defined as severe sepsis with a blood pressure of less than 90 mm Hg after a 500-mL fluid bolus.

Coagulase-negative staphylococcus organisms are the No. 1 cause of crude mortality among patients with bloodstream infections. Other potentially deadly organisms include Staphylococcus aureus, enterococcus, Candida species, gram-negative rods, and Pseudomonas aeruginosa.

Two culprits—Candida species and P. aeruginosa—predict outcome after correction for the underlying disease, noted Dr. Wenzel, professor and chair of the department of internal medicine at Virginia Commonwealth University, Richmond.

The duration of hypotension prior to the initiation of effective treatment is another critical factor in survival. “Treat the patients early. Resuscitate them early. Move them to the ICU early,” Dr. Wenzel advised.

The use of five evidence-based interventions—hand hygiene, a skin preparation with chlorhexidine, barrier precautions, preferred use of the subclavian vein, and catheter removal as soon as possible—can reduce catheter-associated bloodstream infections by as much as two-thirds according to some studies, he said.

For skin antisepsis, 2% chlorhexidine is now preferred over alcohol to reduce bloodstream infections. Another important element of hand hygiene may be eradication of nasal carriage through use of mupirocin. “Forty to fifty percent of people who are nasal carriers have the same organism on their hands,” he said.

Technology-based approaches—including antibiotic-coated catheters, vancomycin lock solutions, chlorhexidine-impregnated dressings, and daily bathing of ICU patients with chlorhexidine—also show some promise, Dr. Wenzel added.