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Enterococcal bacteremia: to treat or not to treat, a reappraisal
C W Hoge1, J Adams, B Buchanan
1Department of Medicine, Francis Scott Key Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Insights
Enterococcal bacteremia, even when of uncertain significance, is linked to high mortality. However, specific antibiotic therapy for Enterococcus species significantly reduces in-hospital deaths in clinically significant infections.
Area of Science:
- Infectious Diseases
- Clinical Microbiology
- Internal Medicine
Background:
- Enterococcal bacteremia treatment is controversial, especially when not linked to endocarditis.
- Defining the clinical significance of enterococcal bacteremia is crucial for guiding therapy.
- High mortality rates are associated with enterococcal bloodstream infections.
Purpose of the Study:
- To evaluate the impact of specific antibiotic therapy on mortality in enterococcal bacteremia.
- To assess the prognostic value of enterococcal bacteremia based on clinical significance.
- To determine if specific therapy improves outcomes in clinically significant enterococcal bacteremia.
Main Methods:
- Retrospective review of 81 episodes of enterococcal bacteremia.
- Categorization of bacteremia episodes based on strict clinical significance criteria.
- Statistical analysis to assess the association between specific antibiotic therapy and mortality, adjusting for confounding factors.
Main Results:
- Mortality was high (51% and 50%) for both clinically significant and uncertain significance bacteremia.
- Specific antibiotic therapy was associated with reduced in-hospital mortality in clinically significant infections (RR = 0.46).
- Early mortality (within 7 days) was significantly reduced with specific therapy (RR = 0.17).
Conclusions:
- Enterococcal bacteremia, regardless of initial perceived significance, indicates a poor prognosis.
- Strict case definitions are essential for identifying clinically significant enterococcal bacteremia.
- Appropriate, specific antibiotic therapy improves outcomes in clinically significant enterococcal bacteremia.
Abstract:
The treatment of enterococcal bacteremia not associated with endocarditis has been controversial. We retrospectively reviewed 81 episodes of enterococcal bacteremia and categorized them as to their clinical significance, using a strict case definition. Of the 81 episodes, 41 met our criteria for clinical significance. Mortality was 51% among the 41 patients with clinically significant bacteremia and 50% among the 40 patients with bacteremia of uncertain clinical significance. Despite these equivalent overall mortality figures, antibiotic therapy specific for Enterococcus species was associated with reduced in-hospital mortality among patients with clinically significant infections (relative risk [RR] = 0.46, 95% confidence interval [CI] = 0.27-0.77); mortality was also reduced in the first 7 days after the detection of bacteremia, when death was relatively likely to be directly due to the bacteremic episode (RR = 0.17, CI = 0.04-0.74). The association between appropriate antibiotic therapy and reduced mortality remained statistically significant when adjustments were made for a number of other factors related to mortality, including age, underlying conditions, prior use of antibiotics, nosocomial acquisition, polymicrobial etiology, prior surgery, and source of infection. Thus enterococcal isolates from the blood, even when of doubtful clinical significance, are poor prognostic markers associated with high mortality. However, when the clinical significance of bacteremia is defined by strict criteria, specific therapy against Enterococcus species is associated with improved outcome.