© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Transplant Infectious Disease, ISSN 1398-2273
Short communication
Nosocomial bloodstream infections in a nationwide study: comparison between solid organ transplant patients and the general population L.F.A. Camargo, A.R. Marra, A.C.C. Pignatari, T. Sukiennik, P.P.P. Behar, E.A.S. Medeiros, J. Ribeiro, E. Gir~ao, L. Correa, C. Guerra, C. Brites, C.A.P. Pereira, I. Carneiro, M. Reis, M.A. Souza, C.U. Barata, M.B. Edmond, and the Brazilian SCOPE Study Group. Nosocomial bloodstream infections in a nationwide study: comparison between solid organ transplant patients and the general population. Transpl Infect Dis 2015: 17: 308–313. All rights reserved Abstract: Background. The incidence of bloodstream infection (BSI) varies according to the transplanted organ. Mortality can be as high as 24%, with a significant impact on graft survival. Transplantation is a risk factor for multidrug-resistant (MDR) organisms, but comparison with a non-transplanted population in a single large cohort has not been described. Methods. This is a prospective nationwide study (16 centers) reporting data on 2364 monomicrobial nosocomial BSIs, comparing 83 episodes in solid organ transplant patients with 2447 BSIs occurring in the general hospital population. Results. The prevalence of groups of infecting organisms (grampositive, gram-negative, and fungi) was similar between transplant patients and the general population and a similar crude mortality rate was observed (34.9% in transplant vs. 43.3% in non-transplant patients). Staphylococcus aureus was the single most frequently isolated organism in both groups, and Acinetobacter species was more frequently isolated in the general population. Regarding MDR organisms, Klebsiella species, and Enterobacter species resistant to cefepime, as well as Acinetobacter species resistant to meropenem, were significantly more frequent in transplant patients. Conclusion. Antimicrobial resistance is higher, particularly among gram-negative bacteria in the transplant population, although the overall mortality rate between transplant and non-transplant patients with nosocomial BSI is similar.
L.F.A. Camargo1,2, A.R. Marra1,2, A.C.C. Pignatari2,3, T. Sukiennik4, P.P.P. Behar5, E.A.S. Medeiros2, J. Ribeiro6, E. Gir~ao7, L. Correa8, C. Guerra9, C. Brites10, C.A.P. Pereira11, I. Carneiro12, M. Reis13,14, M.A. Souza15, C.U. Barata16, M.B. Edmond17, and the Brazilian SCOPE Study Group Hospital Israelita Albert Einstein, S~ao Paulo, Brazil, Universidade Federal de S~ao Paulo (UNIFESP), S~ao Paulo, Brazil, 3Hospital 9 de Julho, S~ao Paulo, Brazil, 4Santa Casa de Porto Alegre, Porto Alegre, Brazil, 5Hospital Conceicß~ao, Porto Alegre, Brazil, 6Hospital de Base, Brasılia, Brazil, 7 Hospital Walter Cantidio, Fortaleza, Brazil, 8Hospital do Rim e Hipertens~ao, S~ao Paulo, Brazil, 9Hospital de Diadema, S~ao Paulo, Brazil, 10Hospital Espanhol, Salvador, Brazil, 11Instituto de Oncologia Pediatrica – IOP/GRAAC, S~ao Paulo, Brazil, 12Santa Casa do Para, Para, Brazil, 13 Hospital do Coração, Natal, Brazil, 14Hospital da UNIMED, Natal, Brazil, 15Hospital das Clinicas de Goiânia, Goiânia, Brazil, 16Universidade Federal do Triangulo Mineiro, Uberaba, Minas Gerais, Brazil, 17Virginia Commonwealth University, Richmond, Virginia, USA 1 2
Key words: bloodstream infection; hospital; transplantation; epidemiology; surveillance Correspondence to: Luis Fernando A. Camargo, MD, Av. Albert Einstein, 627/701, Instituto Israelita de Ensino e Pesquisa – 2nd S floor, Morumbi, Sao Paulo 05651-901, Brazil Tel: (55) 21515108 Fax: (55) 21515108 E-mail: [email protected]
Received 30 April 2014, revised 4 July 2014, 22 August 2014, 19 November 2014, accepted for publication 11 December 2014 DOI: 10.1111/tid.12356 Transpl Infect Dis 2015: 17: 308–313
The incidence of bloodstream infection (BSI), including nosocomial BSI, varies according to the transplanted organ, with rates higher for liver and lung
308
transplantation and lower for kidney transplantation (1–6). Gram-positive bacteria predominate, except in kidney transplantation, where gram-negatives from the
Camargo et al: Bloodstream infection surveillance
urinary tract are the primary pathogens (1, 2). Some differences may occur related to the time period after transplantation, with gram-positive bacteria being more frequent in early periods (7, 8). The incidence of fungal infections, mainly Candida species infections, depends on the organ transplanted and the use of prophylaxis (2, 9, 10). Significant morbidity and mortality are related to BSI in transplant patients. Mortality can be as high as 24% (1, 2) and a significant impact on allograft survival occurs in kidney transplantation (11). Moreover, transplant patients seem to be at increased risk of infections caused by multidrug-resistant (MDR) organisms (12). Very few studies have compared nosocomial BSI in solid organ transplant (SOT) patients with the general population regarding outcomes and etiology. The Brazilian Surveillance and Control of Pathogens of Epidemiologic Importance (BrSCOPE) (13) was a nationwide study comprising >2500 BSIs, and we present a sub-analysis comparing SOT patients with the general hospitalized population.
Material and methods Study design The BrSCOPE is based at Universidade Federal de Sao Paulo, Sao Paulo, Brazil, and includes 16 hospitals of various sizes that are geographically dispersed throughout 5 different geographic regions of Brazil (North, Northeast, Middle-East, Southeast, and South). Clinical data were concurrently collected by local infection preventionists using a standardized casereport form and forwarded to the coordinating center along with each microbiological isolate. The study period reported here is June 12, 2007 to March 31, 2010. A nosocomial BSI was diagnosed if 1 or more blood cultures sampled at least 48 h after admission yielded a pathogenic organism. If the bloodstream isolate was a potential skin contaminant (e.g., diphtheroids, Propionibacterium species, Bacillus species, coagulase-negative staphylococci [CoNS], or micrococci), the presence of an intravascular catheter and the initiation of targeted antimicrobial therapy were required for the diagnosis, as well as at least 1 of the following findings: temperature of >38.0°C or
Short communication
Nosocomial bloodstream infections in a nationwide study: comparison between solid organ transplant patients and the general population L.F.A. Camargo, A.R. Marra, A.C.C. Pignatari, T. Sukiennik, P.P.P. Behar, E.A.S. Medeiros, J. Ribeiro, E. Gir~ao, L. Correa, C. Guerra, C. Brites, C.A.P. Pereira, I. Carneiro, M. Reis, M.A. Souza, C.U. Barata, M.B. Edmond, and the Brazilian SCOPE Study Group. Nosocomial bloodstream infections in a nationwide study: comparison between solid organ transplant patients and the general population. Transpl Infect Dis 2015: 17: 308–313. All rights reserved Abstract: Background. The incidence of bloodstream infection (BSI) varies according to the transplanted organ. Mortality can be as high as 24%, with a significant impact on graft survival. Transplantation is a risk factor for multidrug-resistant (MDR) organisms, but comparison with a non-transplanted population in a single large cohort has not been described. Methods. This is a prospective nationwide study (16 centers) reporting data on 2364 monomicrobial nosocomial BSIs, comparing 83 episodes in solid organ transplant patients with 2447 BSIs occurring in the general hospital population. Results. The prevalence of groups of infecting organisms (grampositive, gram-negative, and fungi) was similar between transplant patients and the general population and a similar crude mortality rate was observed (34.9% in transplant vs. 43.3% in non-transplant patients). Staphylococcus aureus was the single most frequently isolated organism in both groups, and Acinetobacter species was more frequently isolated in the general population. Regarding MDR organisms, Klebsiella species, and Enterobacter species resistant to cefepime, as well as Acinetobacter species resistant to meropenem, were significantly more frequent in transplant patients. Conclusion. Antimicrobial resistance is higher, particularly among gram-negative bacteria in the transplant population, although the overall mortality rate between transplant and non-transplant patients with nosocomial BSI is similar.
L.F.A. Camargo1,2, A.R. Marra1,2, A.C.C. Pignatari2,3, T. Sukiennik4, P.P.P. Behar5, E.A.S. Medeiros2, J. Ribeiro6, E. Gir~ao7, L. Correa8, C. Guerra9, C. Brites10, C.A.P. Pereira11, I. Carneiro12, M. Reis13,14, M.A. Souza15, C.U. Barata16, M.B. Edmond17, and the Brazilian SCOPE Study Group Hospital Israelita Albert Einstein, S~ao Paulo, Brazil, Universidade Federal de S~ao Paulo (UNIFESP), S~ao Paulo, Brazil, 3Hospital 9 de Julho, S~ao Paulo, Brazil, 4Santa Casa de Porto Alegre, Porto Alegre, Brazil, 5Hospital Conceicß~ao, Porto Alegre, Brazil, 6Hospital de Base, Brasılia, Brazil, 7 Hospital Walter Cantidio, Fortaleza, Brazil, 8Hospital do Rim e Hipertens~ao, S~ao Paulo, Brazil, 9Hospital de Diadema, S~ao Paulo, Brazil, 10Hospital Espanhol, Salvador, Brazil, 11Instituto de Oncologia Pediatrica – IOP/GRAAC, S~ao Paulo, Brazil, 12Santa Casa do Para, Para, Brazil, 13 Hospital do Coração, Natal, Brazil, 14Hospital da UNIMED, Natal, Brazil, 15Hospital das Clinicas de Goiânia, Goiânia, Brazil, 16Universidade Federal do Triangulo Mineiro, Uberaba, Minas Gerais, Brazil, 17Virginia Commonwealth University, Richmond, Virginia, USA 1 2
Key words: bloodstream infection; hospital; transplantation; epidemiology; surveillance Correspondence to: Luis Fernando A. Camargo, MD, Av. Albert Einstein, 627/701, Instituto Israelita de Ensino e Pesquisa – 2nd S floor, Morumbi, Sao Paulo 05651-901, Brazil Tel: (55) 21515108 Fax: (55) 21515108 E-mail: [email protected]
Received 30 April 2014, revised 4 July 2014, 22 August 2014, 19 November 2014, accepted for publication 11 December 2014 DOI: 10.1111/tid.12356 Transpl Infect Dis 2015: 17: 308–313
The incidence of bloodstream infection (BSI), including nosocomial BSI, varies according to the transplanted organ, with rates higher for liver and lung
308
transplantation and lower for kidney transplantation (1–6). Gram-positive bacteria predominate, except in kidney transplantation, where gram-negatives from the
Camargo et al: Bloodstream infection surveillance
urinary tract are the primary pathogens (1, 2). Some differences may occur related to the time period after transplantation, with gram-positive bacteria being more frequent in early periods (7, 8). The incidence of fungal infections, mainly Candida species infections, depends on the organ transplanted and the use of prophylaxis (2, 9, 10). Significant morbidity and mortality are related to BSI in transplant patients. Mortality can be as high as 24% (1, 2) and a significant impact on allograft survival occurs in kidney transplantation (11). Moreover, transplant patients seem to be at increased risk of infections caused by multidrug-resistant (MDR) organisms (12). Very few studies have compared nosocomial BSI in solid organ transplant (SOT) patients with the general population regarding outcomes and etiology. The Brazilian Surveillance and Control of Pathogens of Epidemiologic Importance (BrSCOPE) (13) was a nationwide study comprising >2500 BSIs, and we present a sub-analysis comparing SOT patients with the general hospitalized population.
Material and methods Study design The BrSCOPE is based at Universidade Federal de Sao Paulo, Sao Paulo, Brazil, and includes 16 hospitals of various sizes that are geographically dispersed throughout 5 different geographic regions of Brazil (North, Northeast, Middle-East, Southeast, and South). Clinical data were concurrently collected by local infection preventionists using a standardized casereport form and forwarded to the coordinating center along with each microbiological isolate. The study period reported here is June 12, 2007 to March 31, 2010. A nosocomial BSI was diagnosed if 1 or more blood cultures sampled at least 48 h after admission yielded a pathogenic organism. If the bloodstream isolate was a potential skin contaminant (e.g., diphtheroids, Propionibacterium species, Bacillus species, coagulase-negative staphylococci [CoNS], or micrococci), the presence of an intravascular catheter and the initiation of targeted antimicrobial therapy were required for the diagnosis, as well as at least 1 of the following findings: temperature of >38.0°C or
