ABSTRACT
Increasing antibiotic resistance makes choosing antibiotics for suspected Gram-negative infection challenging. This study set out to identify key determinants of mortality among patients with Gram-negative bacteraemia, focusing particularly on the importance of appropriate empiric antibiotic treatment. We conducted a prospective observational study of 679 unselected adults with Gram-negative bacteraemia at ten acute english hospitals between October 2013 and March 2014. Appropriate empiric antibiotic treatment was defined as intravenous treatment on the day of blood culture collection with an antibiotic to which the cultured organism was sensitive in vitro. Mortality analyses were adjusted for patient demographics, co-morbidities and illness severity. The majority of bacteraemias were community-onset (70%); most were caused by Escherichia coli (65%), Klebsiella spp. (15%) or Pseudomonas spp. (7%). Main foci of infection were urinary tract (51%), abdomen/biliary tract (20%) and lower respiratory tract (14%). The main antibiotics used were co-amoxiclav (32%) and piperacillin-tazobactam (30%) with 34% receiving combination therapy (predominantly aminoglycosides). Empiric treatment was inappropriate in 34%. All-cause mortality was 8% at 7 days and 15% at 30 days. Independent predictors of mortality (p <0.05) included older age, greater burden of co-morbid disease, severity of illness at presentation and inflammatory response. Inappropriate empiric antibiotic therapy was not associated with mortality at either time-point (adjusted OR 0.82; 95% CI 0.35-1.94 and adjusted OR 0.92; 95% CI 0.50-1.66, respectively). Although our study does not exclude an impact of empiric antibiotic choice on survival in Gram-negative bacteraemia, outcome is determined primarily by patient and disease factors.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacteremia/drug therapy , Bacteremia/microbiology , Gram-Negative Bacterial Infections/drug therapy , Gram-Negative Bacterial Infections/microbiology , Aged , Aged, 80 and over , Anti-Bacterial Agents/pharmacology , Bacteremia/diagnosis , Bacteremia/mortality , Cause of Death , Comorbidity , England/epidemiology , Female , Gram-Negative Bacterial Infections/diagnosis , Gram-Negative Bacterial Infections/mortality , Humans , Male , Middle Aged , Prospective Studies , Risk Factors , Treatment OutcomeABSTRACT
Home-based care coverage in Africa is currently very low and likely to reduce drastically in the near future. This paper investigates the low coverage of home-based care programmes in Africa and uses two home-based care projects in Zambia as case studies. The very limited involvement of governments in the provision of home-based care services appears to be one of the main reasons behind the low coverage of home-based care in Africa. Governments therefore should provide some form of basic home-based care services and/or strengthen support to other institutions providing home-based care. In order to facilitate governments' involvement in home-based care activities, an analysis of tasks performed by community nurses and volunteers is used to identify tasks that government, missionary or NGO employed nurses may be able to provide without, or with very limited, donor assistance. However, further research and development is needed to develop affordable, feasible and sustainable home care programmes that can be implemented by staff working in government, NGO and missionary health facilities. In addition, innovative strategies are required to establish effective partnerships between the NGO, missionary and government health facilities.
