title: Breakthrough bacteremia in the neonatal intensive care unit: incidence, risk factors, and attributable mortality.
abstract: BACKGROUND
  An episode of breakthrough bacteremia, which was defined as positive blood cultures despite appropriate antibiotic therapy, imposes a treatment challenge in the neonatal intensive care unit (NICU).
  
  
  METHODS
  All episodes of breakthrough bacteremia from a tertiary level NICU in Taiwan between 2004 and 2011 were analyzed and compared with nonbreakthrough bacteremia.
  
  
  RESULTS
  Breakthrough bacteremia was identified in 7.6% (72/942) of neonatal bacteremia, and 43 (59.7%) occurred as recurrent episodes. Gram-negative organisms (41.7%) and fungi (15.3%) accounted for more than half of all microorganisms in breakthrough bacteremia. Compared with nonbreakthrough bacteremia, breakthrough bacteremia was significantly associated with more severe disease, was more likely to require aggressive therapies, and had a higher rate of infectious complications. Previous use of broad-spectrum antibiotics (odds ratio [OR], 7.54; P < .001) and particular microbial etiologies (Pseudomonas aeruginosa: OR, 4.40; P = .025; fungi: OR, 2.70; P = .013) were independent risk factors for developing breakthrough bacteremia. The crude sepsis-attributable mortality rate was greater in breakthrough bacteremia episodes (16.7% vs 6.4%; P = .004), and this condition was independently associated with an increased risk of death (OR, 2.14; 95% confidence interval, 1.04-4.40; P = .040).
  
  
  CONCLUSIONS
  Breakthrough bacteremia is not uncommon (7.6% of all bacteremia) in NICUs and represents a more severe form of neonatal bacteremia that is independently associated with an increased risk of death.
authors.affiliation: Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan.
authors.forename: Ming-Horng
authors.initials: MH
authors.lastname: Tsai
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Shih-Ming
authors.initials: SM
authors.lastname: Chu
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Jen-Fu
authors.initials: JF
authors.lastname: Hsu
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Reyin
authors.initials: R
authors.lastname: Lien
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Hsuan-Rong
authors.initials: HR
authors.lastname: Huang
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Ming-Chou
authors.initials: MC
authors.lastname: Chiang
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Ren-Huei
authors.initials: RH
authors.lastname: Fu
authors.affiliation: Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan; Division of Basic Medical Sciences, Department of Nursing, Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi, Taiwan.
authors.forename: Chiang-Wen
authors.initials: CW
authors.lastname: Lee
authors.affiliation: College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Infectious Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. Electronic address: ychuang@adm.cgmh.org.tw.
authors.forename: Yhu-Chering
authors.initials: YC
authors.lastname: Huang
mesh_terms: D016470:Bacteremia / Q000453:epidemiology* / Q000401:mortality*; D005260:Female; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D008297:Male; D012307:Risk Factors; D016019:Survival Analysis; D013624:Taiwan / Q000453:epidemiology; D062606:Tertiary Care Centers
keywords: Bloodstream infection; Breakthrough bacteremia; Late-onset sepsis; Prediction; Risk factors