title: Risk factors for ineffective therapy in patients with bloodstream infection.
abstract: BACKGROUND
  Infections occurring among outpatients having recent contact with the health care system have been termed health care-associated infections. The objective of this study was to analyze the impact of health care-associated status on effectiveness of initial therapy in hospitalized patients with bloodstream infections.
  
  
  METHODS
  Prospective cohort study of adults with bloodstream infections at 3 North Carolina hospitals. Bloodstream infection was defined as health care-associated if it occurred within the first 48 hours after hospitalization and if patients had 1 of the following characteristics: had received home health services, outpatient intravenous therapy, or outpatient renal dialysis in the 30 days prior to hospital admission; had been hospitalized within 90 days prior to admission; or lived in a long-term care facility.
  
  
  RESULTS
  Of 466 bloodstream infections, 132 (28%) were community-acquired, 178 (38%) were health care-associated, and 156 (33%) were nosocomial. Multivariable logistic regression using community-acquired status as a reference identified health care-associated status (odds ratio, 3.1; 95% confidence interval, 1.6-6.1) and nosocomial status (odds ratio, 4.3; 95% confidence interval, 2.2-8.3) as independent predictors of ineffective initial antibiotic therapy. Among health care-associated characteristics, hospitalization in the 90 days prior to admission was independently associated with ineffective initial therapy (odds ratio, 2.4; 95% confidence interval, 1.4-4.2).
  
  
  CONCLUSIONS
  Among patients treated in the hospital for bloodstream infection, health care-associated status was an independent predictor of ineffective initial antibiotic therapy. Hospitalization within 90 days prior to hospital admission was the component of health care-associated status most strongly associated with ineffective initial therapy.
authors.affiliation: Division of Infectious Diseases, Duke University Medical Center, Durham, NC 27710, USA. mcdon034@mc.duke.edu
authors.forename: Jay R
authors.initials: JR
authors.lastname: McDonald
authors.forename: N Deborah
authors.initials: ND
authors.lastname: Friedman
authors.forename: Jason E
authors.initials: JE
authors.lastname: Stout
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Sexton
authors.forename: Keith S
authors.initials: KS
authors.lastname: Kaye
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D004352:Drug Resistance, Microbial; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology* / Q000517:prevention & control; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009657:North Carolina / Q000453:epidemiology; D011446:Prospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D017211:Treatment Failure
chemical_list: D000900:Anti-Bacterial Agents