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Community-Acquired Bloodstream Infection in Critically Ill Adult Patients^*

Impact of Shock and Inappropriate Antibiotic Therapy on Survival

Jordi Vallés, MD, PhD; Jordi Rello, MD, PhD; Ana Ochagavía, MD; José Garnacho, MD, PhD and Miguel Angel Alcalá, MD; for the Spanish Collaborative Group for Infections in Intensive Care Units of Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias

^* From the Intensive Care Department (Drs. Vallés and Ochagavía), Hospital de Sabadell, Sabadell; Critical Care Department (Dr. Rello), Hospital Joan XXIII, University Rovira i Virgili, Tarragona; Intensive Care Department (Dr. Garnacho), Hospital Universitario Virgen del Rocío, Seville; and Intensive Care Department (Dr. Alcalá), Fundación Jiménez Díaz, Madrid, Spain. The other members of the Spanish Collaborative Group for Infections in Intensive Care Units are listed in the ^Appendix.

Correspondence to: Jordi Vallés, MD, PhD, Intensive Care Department, Hospital Sabadell, Parc Taulí s/n, 08208 Sabadell, Spain

Design: The objectives were to characterize the prognostic factors and evaluate the impact of inappropriate empiric antibiotic treatment and systemic response on the outcome of critically ill patients with community-acquired bloodstream infection (BSI).

Patients: A prospective, multicenter, observational study was carried out in 339 patients admitted in 30 ICUs for BSI.

Results: Crude mortality was 41.5%. Septic shock was present in 184 patients (55%). The pathogens most frequently associated with septic shock or death were Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae, which accounted for approximately half of the deaths. Antibiotic treatment was found to be inappropriate in 14.5% of episodes. Patients in septic shock with inappropriate treatment had a survival rate below 20%. Multivariate analysis identified a significant association between septic shock and four variables: age 60 years (odds ratio [OR], 1.96), previous corticosteroid therapy (OR, 2.58), leukopenia (OR, 2.32), and BSI secondary to intra-abdominal (OR, 2.38) and genitourinary tract (OR, 2.29) infections. The variables that independently predicted death at ICU admission were APACHE (acute physiology and chronic health evaluation) II score 15 (OR, 2.42), development of septic shock (OR, 3.22), and inappropriate empiric antibiotic treatment (OR, 4.11). This last variable was independently associated with an unknown source of sepsis (OR, 2.49). Mortality attributable to inappropriate antibiotic treatment increased with the severity of illness at ICU admission (10.7% for APACHE II score < 15 and 41.8% for APACHE II score 25, p < 0.01).

Conclusions: Inappropriate antimicrobial treatment is the most important influence on outcome in patients admitted to the ICU for community-acquired BSI, particularly in presence of septic shock or high degrees of severity. Initial broad-spectrum therapy should be prescribed to septic patients in whom the source is unknown or in those requiring vasopressors.

Key Words: appropriate antibiotic treatment • bacteremia • community-acquired infection • outcome • septic shock

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