Excess risk of death from intensive care unit-acquired nosocomial bloodstream infections: a reappraisal.
BACKGROUND
Overall rates of bloodstream infection (BSI) are often used as quality indicators in intensive care units (ICUs). We investigated whether ICU-acquired BSI increased mortality (by > or = 10%) after adjustment for severity of infection at ICU admission and during the pre-BSI stay.


METHODS
We conducted a matched, risk-adjusted (1:n), exposed-unexposed study of patients with stays longer than 72 h in 12 ICUs randomly selected from the Outcomerea database.


RESULTS
Patients with BSI after the third ICU day (exposed group) were matched on the basis of risk-exposure time and mortality predicted at admission using the Three-Day Recalibrated ICU Outcome (TRIO) score to patients without BSI (unexposed group). Severity was assessed daily using the Logistic Organ Dysfunction (LOD) score. Of 3247 patients with ICU stays of >3 days, 232 experienced BSI by day 30 (incidence, 6.8 cases per 100 admissions); among them, 226 patients were matched to 1023 unexposed patients. Crude hospital mortality was 61.5% among exposed and 36.7% among unexposed patients (P<.0001). Attributable mortality was 24.8%. The only variable associated with both BSI and hospital mortality was the LOD score determined 4 days before onset of BSI (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.03-1.16; P = .0025). The adjusted OR for hospital mortality among exposed patients (OR, 3.20; 95% CI, 2.30-4.43) decreased when the LOD score determined 4 days before onset of BSI was taken into account (OR, 3.02; 95% CI, 2.17-4.22; P<.0001). The estimated risk of death from BSI varied considerably according to the source and resistance of organisms, time to onset, and appropriateness of treatment.


CONCLUSIONS
When adjusted for risk-exposure time and severity at admission and during the ICU stay, BSI was associated with a 3-fold increase in mortality, but considerable variation occurred across BSI subgroups. Focusing on BSI subgroups may be valuable for assessing quality of care in ICUs.
Garrouste-Orgeas
Maite
M
Medical-Surgical Intensive Care Unit, Saint Joseph Hospital, Paris, France [corrected] mgarrouste@hopital-saint-joseph.org
Timsit
Jean Francois
JF
Tafflet
Muriel
M
Misset
Benoit
B
Zahar
Jean-Ralph
JR
Soufir
Lilia
L
Lazard
Thierry
T
Jamali
Samir
S
Mourvillier
Bruno
B
Cohen
Yves
Y
De Lassence
Arnaud
A
Azoulay
Elie
E
Cheval
Christine
C
Descorps-Declere
Adrien
A
Adrie
Christophe
C
Costa de Beauregard
Marie-Alliette
MA
Carlet
Jean
J
D002138:Calibration; D003428:Cross Infection / Q000097:blood* / Q000453:epidemiology / Q000401:mortality*; D016208:Databases, Factual; D005602:France; D006801:Humans; D007362:Intensive Care Units; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome