title: Bloodstream infections in community hospitals in the 21st century: a multicenter cohort study.
abstract: BACKGROUND
  While the majority of healthcare in the US is provided in community hospitals, the epidemiology and treatment of bloodstream infections in this setting is unknown.
  
  
  RESULTS
  We undertook this multicenter, retrospective cohort study to 1) describe the epidemiology of bloodstream infections (BSI) in a network of community hospitals and 2) determine risk factors for inappropriate therapy for bloodstream infections in community hospitals. 1,470 patients were identified as having a BSI in 9 community hospitals in the southeastern US from 2003 through 2006. The majority of BSIs were community-onset, healthcare associated (n = 823, 56%); 432 (29%) patients had community-acquired BSI, and 215 (15%) had hospital-onset, healthcare-associated BSI. BSIs due to multidrug-resistant pathogens occurred in 340 patients (23%). Overall, the three most common pathogens were S. aureus (n = 428, 28%), E. coli (n = 359, 24%), coagulase-negative Staphylococci (n = 148, 10%), though type of infecting organism varied by location of acquisition (e.g., community-acquired). Inappropriate empiric antimicrobial therapy was given to 542 (38%) patients. Proportions of inappropriate therapy varied by hospital (median = 33%, range 21-71%). Multivariate logistic regression identified the following factors independently associated with failure to receive appropriate empiric antimicrobial therapy: hospital where the patient received care (p<0.001), assistance with ≥3 ADLs (p = 0.005), Charlson score (p = 0.05), community-onset, healthcare-associated infection (p = 0.01), and hospital-onset, healthcare-associated infection (p = 0.02). Important interaction was observed between Charlson score and location of acquisition.
  
  
  CONCLUSIONS
  Our large, multicenter study provides the most complete picture of BSIs in community hospitals in the US to date. The epidemiology of BSIs in community hospitals has changed: community-onset, healthcare-associated BSI is most common, S. aureus is the most common cause, and 1 of 3 patients with a BSI receives inappropriate empiric antimicrobial therapy. Our data suggest that appropriateness of empiric antimicrobial therapy is an important and needed performance metric for physicians and hospital stewardship programs in community hospitals.
authors.affiliation: Duke University Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America; Duke Infection Control Outreach Network, Durham, North Carolina, United States of America.
authors.forename: Deverick J
authors.initials: DJ
authors.lastname: Anderson
authors.affiliation: Duke University Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America; Duke Infection Control Outreach Network, Durham, North Carolina, United States of America.
authors.forename: Rebekah W
authors.initials: RW
authors.lastname: Moehring
authors.affiliation: Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, United States of America.
authors.forename: Richard
authors.initials: R
authors.lastname: Sloane
authors.affiliation: Department of Medicine-Geriatrics, Duke University Medical Center and Geriatric Research Education and Clinical Center (GRECC), Durham VA Medical Center, Durham, North Carolina, United States of America.
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Schmader
authors.affiliation: Department of Hospital Epidemiology, University of North Carolina Health System, Chapel Hill, North Carolina, United States of America.
authors.forename: David J
authors.initials: DJ
authors.lastname: Weber
authors.affiliation: Duke University Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America.
authors.forename: Vance G
authors.initials: VG
authors.lastname: Fowler
authors.affiliation: Duke Infection Control Outreach Network, Durham, North Carolina, United States of America.
authors.forename: Emily
authors.initials: E
authors.lastname: Smathers
authors.affiliation: Duke University Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, United States of America; Duke Infection Control Outreach Network, Durham, North Carolina, United States of America.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Sexton
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016470:Bacteremia / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D017714:Community-Acquired Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D024881:Drug Resistance, Bacterial; D004926:Escherichia coli / Q000187:drug effects / Q000254:growth & development / Q000302:isolation & purification; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D006764:Hospitals, Community; D006801:Humans; D008297:Male; D008508:Medication Errors; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011550:Pseudomonas aeruginosa / Q000187:drug effects / Q000254:growth & development / Q000302:isolation & purification; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D013211:Staphylococcus aureus / Q000187:drug effects / Q000254:growth & development / Q000302:isolation & purification; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents