The impact of hospital-acquired bloodstream infections.
Nosocomial bloodstream infections are a leading cause of death in the United States. If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States. Because most risk factors for dying after bacteremia or fungemia may not be changeable, prevention efforts must focus on new infection-control technology and techniques. 
Health Care–Associated Bloodstream Infections in Adults: A Reason To Change the Accepted Definition of Community-Acquired Infections
Bloodstream infections occurring in persons residing in the community, regardless of whether those persons have been receiving health care in an outpatient facility, have traditionally been categorized as community-acquired infections.
To develop a new classification scheme for bloodstream infections that distinguishes among community-acquired, health care–associated, and nosocomial infections.
Prospective observational study.
One academic medical center and two community hospitals.
All adult patients admitted to the hospital with bloodstream infection.
Demographic characteristics, living arrangements before hospitalization, comorbid medical conditions, factors predisposing to bloodstream infection, date of hospitalization, dates and number of positive blood cultures, results of microbiological susceptibility testing, dates of hospital discharge or death, and mortality rates at 3 to 6 months of follow-up.
504 patients with bloodstream infections were enrolled; 143 (28%) had community-acquired bloodstream infections, 186 (37%) had health care–associated bloodstream infections, and 175 (35%) had nosocomial bloodstream infections. Of the 186 patients with health care–associated bloodstream infection, 29 resided in a nursing home, 64 were receiving home health care, 78 were receiving intravenous or intravascular therapy at home or in a clinic, and 117 had been hospitalized in the 90 days before their bloodstream infection. Cancer was more common in patients with health care–associated or nosocomial bloodstream infection than in patients with community-acquired bloodstream infection. Intravascular devices were the most common source of health care–associated and nosocomial infections, and Staphylococcus aureus was the most frequent pathogen in these types of infections. Methicillin-resistant S. aureus occurred with similar frequency in the groups with health care–associated infection (52%) and nosocomial infection (61%) but was uncommon in the group with community-acquired bloodstream infection (14%) (P = 0.001). Mortality rate at follow-up was greater in patients with health care–associated infection (29% versus 16%; P = 0.019) or nosocomial infection (37% versus 16%; P < 0.001) than in patients with community-acquired infection.
Health care–associated bloodstream infections are similar to nosocomial infections in terms of frequency of various comorbid conditions, source of infection, pathogens and their susceptibility patterns, and mortality rate at follow-up. A separate category for health care–associated bloodstream infections is justified, and this new category will have obvious implications for choices about empirical therapy and infection-control surveillance. 
Nosocomial Bloodstream Infections in US Hospitals: Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study
Background. Nosocomial bloodstream infections (BSIs) are important causes of morbidity and mortality in the United States.
Methods. Data from a nationwide, concurrent surveillance study (Surveillance and Control of Pathogens of Epidemiological Importance [SCOPE]) were used to examine the secular trends in the epidemiology and microbiology of nosocomial BSIs.
Results. Our study detected 24,179 cases of nosocomial BSI in 49 US hospitals over a 7-year period from March 1995 through September 2002 (60 cases per 10,000 hospital admissions). Eighty-seven percent of BSIs were monomicrobial. Gram-positive organisms caused 65% of these BSIs, gram-negative organisms caused 25%, and fungi caused 9.5%. The crude mortality rate was 27%. The most-common organisms causing BSIs were coagulase-negative staphylococci (CoNS) (31% of isolates), Staphylococcus aureus (20%), enterococci (9%), and Candida species (9%). The mean interval between admission and infection was 13 days for infection with Escherichia coli, 16 days for S. aureus, 22 days for Candida species and Klebsiella species, 23 days for enterococci, and 26 days for Acinetobacter species. CoNS, Pseudomonas species, Enterobacter species, Serratia species, and Acinetobacter species were more likely to cause infections in patients in intensive care units (P < .001). In neutropenic patients, infections with Candida species, enterococci, and viridans group streptococci were significantly more common. The proportion of S. aureus isolates with methicillin resistance increased from 22% in 1995 to 57% in 2001 (P < .001, trend analysis). Vancomycin resistance was seen in 2% of Enterococcus faecalis isolates and in 60% of Enterococcus faecium isolates.
Conclusion. In this study, one of the largest multicenter studies performed to date, we found that the proportion of nosocomial BSIs due to antibiotic-resistant organisms is increasing in US hospitals. 
Antimicrobial Resistance in Pathogens Causing Pediatrics Bloodstream Infections in a Saudi Hospital
Background: Bloodstream infection (BSI) is one of the most common life-threatening conditions in hospitalized pediatrics especially if associated with resistant microbes.
Aims: To determine the incidence, predisposing factors, microbiological and antimicrobial resistance patterns in suspected BSI pediatric patients in a Saudi hospital.
Place and Duration of Study: Different wards of Madinah Maternity and Children’s Hospital, Saudi Arabia, during one year period from July 1, 2009 to June 30, 2010.
Methodology: Blood cultures were performed to all cases (n= 11968) using Bactec 9240 instrument Blood Culture Systems. Microorganisms were identified by colony morphology, Gram stain and biochemical profiles. BD Phoenix™ was used in confirmation of identification of all BSI Gram-negative isolates. Antibiotic susceptibility pattern of isolates was further done by using disk diffusion method.
Results: 728 cases (6.1%) were diagnosed with BSI after having a one positive blood culture. The overall mortality rate was 11%. Gram-positive, Gram-negative and yeast accounted for 63.8%, 31.6% and 4.6% of the total isolates, respectively. Coagulase-negative staphylococci were the most prevalent Gram-positive isolates (44%); while Serratia marcescens and Klebsiella pneumoniae were the most common Gram-negatives. Gram-positive bacteria were mostly sensitive to cephalothin (82.3%) and vancomycin (72.2%), while Gram-negative bacteria were mostly sensitive to ciprofloxacin (93%), piperacillin/tazobactam (92.9%), and meropenem (89.8%).
Conclusion: The incidence rate of BSI is highest in ICU neonates. Therefore, special attention should be given to the quality of care provided for them to improve safety. There was appreciable resistance to commonly used antibiotics; and continued monitoring of antibiotic resistance is of great importance to ensure the proper use of antibiotics and to detect any increasing trends in resistance. 
A Quality Improvement Program to Reduce Central Line Associated Blood Stream Infections in Neonates
Introduction: Late onset sepsis is a common problem among neonatal intensive care unit (NICU) population with central venous catheter (CVC) being the primary source of infection in the majority of the cases. Central line associated bloodstream infections (CLABSIs) have been significantly reduced by care bundles implanted in NICUs. This study is conducted to detect the overall CLABSI rate, by comparing the rate per 1000 line days in the pre-intervention to that in the post-intervention periods, to prove that change could be attributed to the quality improvement bundles.
Methods: This was a retrospective observational study. It included all patients with central line inserted at NICU of MGH from January 2012 to February 2014 and compared these patients with historical cohort from 22 months of 2010 and 2011. Specific interventions were designed for the central line related practices. Specific interventions according to CDC recommendations emphasize best practices in all areas of central line care: reduction of line entries, aseptic entries into the line, and aseptic procedures when changing line components.
Results: Overall, CLABSI rates, in our NICU, declined significantly by 57.3% from 15 CLABSI per 1000 central line days in the pre-intervention period to 6.4 CLABSI in 1000 central line days in the post-intervention period (P<0.05). Significant reductions in CLABSI rates were noted for neonates with birth weight less than <1000g and neonates between 1001 g and 1500 g during the post-intervention period, compared with the CLABSI rates for neonates from pre-intervention period.
Conclusion: We found that our efforts didn’t result in a decrease in the use of CVC among neonates. Hence, central line utilization rate was not associated, in our study, with CLABSI risk. Our quality improvement effort was successful in significantly reduced CLABSI rates. The majority of our success can be linked to educational efforts based on pertinent and timely data and literature. 
 Wenzel, R.P. and Edmond, M.B., 2001. The impact of hospital-acquired bloodstream infections. Emerging infectious diseases, 7(2), p.174.
 Friedman, N.D., Kaye, K.S., Stout, J.E., McGarry, S.A., Trivette, S.L., Briggs, J.P., Lamm, W., Clark, C., MacFarquhar, J., Walton, A.L. and Reller, L.B., 2002. Health care–associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Annals of internal medicine, 137(10), pp.791-797.
 Wisplinghoff, H., Bischoff, T., Tallent, S.M., Seifert, H., Wenzel, R.P. and Edmond, M.B., 2004. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clinical infectious diseases, 39(3), pp.309-317.
 A. Abo-Shadi, M., A. Al-Johani, A. and A. Bahashwan, A. (2012) “Antimicrobial Resistance in Pathogens Causing Pediatrics Bloodstream Infections in a Saudi Hospital”, Microbiology Research Journal International, 2(4), pp. 212-227. doi: 10.9734/BMRJ/2012/2033.
 Mais, A. A., Hajar, F. and Rajab, M. (2015) “A Quality Improvement Program to Reduce Central Line Associated Blood Stream Infections in Neonates”, Journal of Advances in Medicine and Medical Research, 7(8), pp. 638-646. doi: 10.9734/BJMMR/2015/12976.