Candidaemia in a London teaching hospital: analysis of 128 cases over a 7-year period.

In a retrospective analysis of 128 cases of Candida bloodstream infections in a London teaching hospital between 1995 and 2001, the incidence of candidaemia increased from 0.2/1000 admissions in 1995 to 0.5 and 0.4/1000 admissions in 2000 and 2001, respectively. Risk factors for candidaemia included the presence of intravascular (IV) lines (88%), admission to intensive care (51%), parenteral nutrition (35%), multiple antibiotics (74%), corticosteroid therapy (12%), cancer chemotherapy (11%), renal transplantation (5%) and neutropenia (3%). The sources of infection were IV lines (77%), the urinary tract (7%) and the gastrointestinal tract (7%). Serious infective complications (endocarditis, endophthalmitis or brain abscess) were noted in 6% of cases. The most frequently isolated species were Candida albicans (64%), C. glabrata (20%), C. tropicalis (9%) and C. parapsilosis (5%). The overall fluconazole-resistance rate of Candida spp. was 7% (MIC > or = 64 mg l-1). All the C. albicans isolates were sensitive to fluconazole (MIC < or = 8 mg l-1) whereas 20% of non-C. albicans isolates (27% of C. glabrata and 14%C. tropicalis) were resistant. The mortality rate (35%) was lower than in other reports and may be due to the early recognition of candidaemia and the prompt removal of IV lines together with the initiation of appropriate antifungal therapy. Regular surveillance of local Candida species, resistance profiles and risk factors is important in order to identify patients at risk and to develop empirical treatment protocols to reduce the incidence and mortality of candidaemia.

Is methicillin-resistant Staphylococcus aureus more virulent than methicillin-susceptible S. aureus? A comparative cohort study of British patients with nosocomial infection and bacteremia.

Staphylococcus aureus is the most common cause of hospital-acquired bacteremia. From 1995 through 2000, data on age, sex, patient specialty at time of first bacteremia, primary and secondary sites of infection, delay in initiating antimicrobial therapy, and patient outcome were prospectively recorded for 815 patients with nosocomial S. aureus bacteremia. The proportion of patients whose death was attributable to methicillin-resistant S. aureus (MRSA) was significantly higher than that for methicillin-susceptible S. aureus (MSSA) (11.8% vs. 5.1%; odds ratio [OR], 2.49; 95% confidence interval [CI], 1.46-4.24; P<.001). After adjustment for host variables, the OR decreased to 1.72 (95% CI, 0.92-3.20; P=.09). There was no significant difference between rates of disseminated infection (7.1% vs. 6.2% for MRSA-infected patients and MSSA-infected patients, respectively; P=.63), though the rate of death due to disseminated infection was significantly higher than death due to uncomplicated infection (37% vs. 10% for MRSA-infected patients [P<.001] and 37% vs. 3% for MSSA-infected patients [P<.001]). There was a strong statistical trend toward death due to nosocomial MRSA infection and bacteremia, compared with MSSA.

Management and outcome of bloodstream infections due to Candida species in England and Wales.

This two-year prospective hospital population-based study of candidaemia is the first to be conducted in the UK. It was carried out on behalf on the British Society for Medical Mycology (BSMM) as part of the European Confederation of Medical Mycology (ECMM) epidemiological survey of candidaemia. Six hospitals in England and Wales acted as sentinel hospitals. Main outcome measures were hospital population-based incidence and 30-day mortality. There were 18.7 episodes of candidaemia per 100,000 finished consultant episodes or 3.0/100,000 bed days and 45.4% cases occurred in intensive care unit (ICU) patients. Candida albicans was isolated in 64.7% of confirmed cases. The majority of isolates were sensitive to standard antifungal agents, including fluconazole. The overall 30-day mortality was 26.4% and removal of the central venous catheter was associated with a significant reduction in mortality. In conclusion, the incidence of candidaemia in England and Wales is similar to that of the USA, the majority of isolates remain sensitive to commonly used antifungal agents and mortality associated with this infection appears to be falling.

A case of Fournier gangrene complicating idiopathic nephrotic syndrome of childhood.

A 10-year-old boy presenting with steroid resistant nephrotic syndrome developed Fournier gangrene of the scrotum. Antimicrobial drug therapy, intravenous albumin, excision of necrotic scrotum and left orchidectomy followed by skin grafting 3 weeks later led to an excellent cosmetic and medical result. Six months later he remains nephrotic on diuretic and angiotensin converting enzyme inhibitor medication.

Approaches to the diagnosis and prevention of intravascular catheter-related infection.

Intravascular catheter-related infections remain a significant cause of morbidity and mortality despite clear guidelines on insertion and care, which should aid in their prevention. New approaches in the diagnosis of these infections, which do not require removal of the catheter, and novel technologies, including the application of antimicrobial agents to the catheter, have demonstrated some degree of success in prevention.

Septicaemia in the newborn and elderly.

Analysis of 5304 episodes of septicaemia at St Thomas' Hospital showed that both the elderly (> 65 years) and neonates accounted for increasing proportions between 1969 and 1992. In particular the increase was greatest for patients aged over 84 years who accounted for 3% of episodes in adults with community-acquired septicaemia in the 1970s compared with 13% in the 1990s. The change may be explained partly by demographic factors. The majority (85-90%) of elderly patients presented with fever, or leucocytosis or both. The urinary and gastrointestinal tracts were the most common foci for the elderly and they were less likely than other adults to have iv access associated sepsis. Among neonates Escherichia coli septicaemia became less common whereas there was little changes in the incidence of group B streptococcal septicaemia; coagulase-negative staphylococcal infection became more common. Overall mortality declined for both neonates and elderly patients. Poor outcome appeared related to the focus of infection, febrile response and age in the elderly and to the time of onset and organism in neonates.

Towards a statistically oriented decision support system for the management of septicaemia.

The first decision-support system designed for the management of septicaemia was MYCIN. Although MYCIN played a vital role in the conception of knowledge-based systems, it never became an established clinical system. This paper describes an alternative decision-support system for septicaemia management currently under development at St. Thomas' Hospital (London) where a large database of septicaemia episodes has been compiled. The three statistical approaches that have been considered are described. These are (i) relative frequencies, (ii) the naive Bayes method and (iii) logistic regression. We also discuss how the concept of probabilistic influence diagrams could be of benefit to the development and implementation of the decision-support system.

Clinical index to predict bacteraemia caused by staphylococci.

OBJECTIVES: To define risk factors associated with bacteraemia caused by Staphylococcus aureus or coagulase-negative staphylococci; and to use them to define patients in need of empiric anti-staphylococcal antibiotic treatment. DESIGN: Derivation set: observational, prospective study; validation set: retrospective analysis of a prospectively collected database. SETTING: Derivation set: Beilinson Medical Centre, Petah Tiqva, Israel--a 900-bed university hospital. Validation set: St Thomas's Hospital, London, UK--an 800-bed teaching hospital. SUBJECTS: All episodes of bacteraemia detected at Beilinson Medical Centre between March 1988 and September 1990 (derivation set, n = 1410), and at St Thomas's Hospital during 1987-1990 (validation set, n = 1040). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Percentage of staphylococcal bacteraemia in groups of patients defined by the models. RESULTS: The following factors were associated with Staphylococcus aureus bacteraemia: focus of infection (whether high or low risk), haemodialysis, intravenous drug abuse and infection acquired in the orthopaedic ward. A logistic model was used to divide the derivation set into three groups with percentages of Staphylococcus aureus bacteraemia of 1.8%, 13.2% and 33.7% (P < 0.0001); and the validation group 2.5%, 18.2% and 53.2% (P < 0.0001). Factors associated with coagulase-negative staphylococcal bacteraemia were: central or peripheral intravenous catheter as the focus of infection, a preterm neonate, the presence of a central intravenous catheter, low temperature, and a low white blood cell count. A second model including those factors was used to divide the derivation set into three groups with percentages of coagulase-negative staphylococcal bacteraemia of 1.9%, 22.8%, and 43% (P < 0.0001). In the validation set, the percentages were 2.9%, 22.4% and 31.0% (P < 0.001). CONCLUSIONS: The present study defines groups at high risk for staphylococcal bloodstream infection, in which empiric treatment should include an anti-staphylococcal drug.