title: Comparison of the systemic inflammatory response syndrome between monomicrobial and polymicrobial Pseudomonas aeruginosa nosocomial bloodstream infections.
abstract: BACKGROUND
  Some studies of nosocomial bloodstream infection (nBSI) have demonstrated a higher mortality for polymicrobial bacteremia when compared to monomicrobial nBSI. The purpose of this study was to compare differences in systemic inflammatory response and mortality between monomicrobial and polymicrobial nBSI with Pseudomonas aeruginosa.
  
  
  METHODS
  We performed a historical cohort study on 98 adults with P. aeruginosa (Pa) nBSI. SIRS scores were determined 2 days prior to the first positive blood culture through 14 days afterwards. Monomicrobial (n = 77) and polymicrobial BSIs (n = 21) were compared.
  
  
  RESULTS
  78.6% of BSIs were caused by monomicrobial P. aeruginosa infection (MPa) and 21.4% by polymicrobial P. aeruginosa infection (PPa). Median APACHE II score on the day of BSI was 22 for MPa and 23 for PPa BSIs. Septic shock occurred in 33.3% of PPa and in 39.0% of MPa (p = 0.64). Progression to septic shock was associated with death more frequently in PPa (OR 38.5, CI95 2.9-508.5) than MPa (OR 4.5, CI95 1.7-12.1). Maximal SIR (severe sepsis, septic shock or death) was seen on day 0 for PPa BSI vs. day 1 for MPa. No significant difference was noted in the incidence of organ failure, 7-day or overall mortality between the two groups. Univariate analysis revealed that APACHE II score > or = 20 at BSI onset, Charlson weighted comorbidity index > or = 3, burn injury and respiratory, cardiovascular, renal and hematologic failure were associated with death, while age, malignant disease, diabetes mellitus, hepatic failure, gastrointestinal complications, inappropriate antimicrobial therapy, infection with imipenem resistant P. aeruginosa and polymicrobial nBSI were not. Multivariate analysis revealed that hematologic failure (p < 0.001) and APACHE II score > or = 20 at BSI onset (p = 0.005) independently predicted death.
  
  
  CONCLUSIONS
  In this historical cohort study of nBSI with P. aeruginosa, the incidence of septic shock and organ failure was high in both groups. Additionally, patients with PPa BSI were not more acutely ill, as judged by APACHE II score prior to blood culture positivity than those with MPa BSI. Using multivariable logistic regression analysis, the development of hematologic failure and APACHE II score > or = 20 at BSI onset were independent predictors of death; however, PPa BSI was not.
authors.affiliation: Department of Infectious Diseases, Universidade Federal de São Paulo, São Paulo, Brazil. a.marra@uol.com.br
authors.forename: Alexandre R
authors.initials: AR
authors.lastname: Marra
authors.forename: Gonzalo M L
authors.initials: GM
authors.lastname: Bearman
authors.forename: Richard P
authors.initials: RP
authors.lastname: Wenzel
authors.forename: Michael B
authors.initials: MB
authors.lastname: Edmond
mesh_terms: D018806:APACHE; D015331:Cohort Studies; D003428:Cross Infection / Q000150:complications* / Q000382:microbiology* / Q000401:mortality; D024881:Drug Resistance, Bacterial; D005260:Female; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D011552:Pseudomonas Infections / Q000150:complications* / Q000382:microbiology / Q000401:mortality; D012189:Retrospective Studies; D018805:Sepsis / Q000150:complications* / Q000382:microbiology / Q000401:mortality; D018746:Systemic Inflammatory Response Syndrome / Q000209:etiology* / Q000382:microbiology; D013997:Time Factors