Impact of Location of Acquisition of Gram-Positive Bloodstream Infections on Clinical Outcomes Among Patients Admitted to Community Hospitals

Figures & data

Table 1 Patient Demographics, Co-Morbidities, and Hospitalization Information*

	Total Cohort (N=750, 100%) n (%)	Community-Acquired (N=185, 25%), n (%)	Healthcare-Associated (N=431, 57%), n (%)	Hospital-Acquired (N=134, 18%) n (%)	P-value
Patient demographics
Age
(median; IQ1, IQ3)	64 (51, 77)	60 (48, 72)	66 (52, 79)	64 (52, 76)	0.84
(range)	(18–101)	(18–95)	(23–101)	(19–93)
Male Sex	383 (51)	112 (61)	200 (46)	71 (53)	0.005
Race					0.41
White	392 (52)	99 (54)	217 (50)	76 (57)
Black	342 (46)	82 (44)	204 (49)	56 (48)
Asian	3 (0.4)	0 (0)	2 (0.4)	1 (0.7)
Hispanic	3 (0.4)	0 (0)	3 (0.7)	0 (0)
Native American	3 (0.4)	0 (0)	3 (0.5)	0 (0)
Other	7 (0.9)	4 (2)	2 (0.5)	1 (0.7)
Insurance					<0.001
Medicare	493 (66)	96 (52)	315 (73)	82 (62)
Medicaid	70 (9)	13 (7)	45 (10)	12 (9)
Private	110 (15)	40 (22)	48 (11)	22 (17)
Unknown	12 (2)	3 (2)	6 (1)	4 (3)
None	61 (8)	32 (17)	17 (4)	12 (9)
BMI
(median; IQ1, IQ3)	27 (22, 33)	27 (22, 33)	26 (22, 32)	27 (23, 32)	0.51
(range)	(13–79)	(12–71)	(14–79)	(14–64)
Comorbid conditions at Admission
Need assistance with:
Ambulation	403 (54)	65 (35)	255 (59)	83 (62)	<0.001
Bathing	205 (27)	19 (10)	150 (35)	36 (27)	<0.001
Dressing	183 (24)	18 (10)	134 (31)	31 (23)	<0.001
Bowel continence	100 (13)	4 (2)	72 (16)	24 (18)	<0.001
Urine continence	170 (23)	20 (11)	117 (27)	33 (25)	<0.001
Feeding	139 (19)	10 (5)	104 (24)	25 (19)	<0.001
McCabe score at admission					<0.001
1	145 (19)	31 (17)	79 (19)	73 (26)
2	418 (56)	80 (43)	269 (63)	70 (53)
3	179 (24)	34 (40)	70 (40)	28 (21)
On immunosuppressive medication					0.99
Corticosteroid	65 (9)	15 (8)	36 (9)	14 (11)
Non-corticosteroid	13 (2)	3 (2)	8 (2)	2 (2)
Both	4 (0.5)	1 (0.5)	2 (0.5)	1 (0.8)
Comorbidities
Diabetes	330 (44)	81 (44)	197 (46)	52 (39)	0.33
Myocardial infarction	182 (24)	33 (18)	114 (26)	35 (26)	0.06
Congestive heart failure	176 (23)	22 (12)	119 (28)	35 (26)	<0.001
Peripheral vascular disease	121 (16)	17 (9)	79 (18)	25 (19)	0.01
Cerebrovascular disease	154 (21)	24 (13)	105 (24)	25 (19)	0.005
Dementia	92 (12)	8 (4)	71 (16)	13 (10)	<0.001
Chronic obstructive pulmonary disease	148 (20)	35 (20)	83 (19)	30 (22)	0.69
Connective tissue disease	9 (1)	4 (22)	5 (12)	0 (0)	0.21
Peptic ulcer disease	102 (14)	12 (6)	65 (15)	25 (19)	0.003
Hemiplegia	11 (1)	0 (0)	4 (0.9)	2 (1)	0.10
Liver disease	63 (8)	14 (8)	31 (7)	18 (13)	0.07
Renal dialysis	127 (17)	0 (0)	112 (26)	15 (11)	<0.001
History of malignancy	147 (20)	18 (10)	93 (22)	36 (27)	<0.001
HIV	27 (4)	7 (4)	16 (4)	4 (3)	0.91
Solid organ transplant	7 (0.9)	0 (0)	7 (2)	0 (0)
Charlson score
(median; IQ1, IQ3)	2 (1, 4)	1 (0, 3)	3 (1, 4)	3 (1, 4)	0.002
(range)	(0–12)	(0–9)	(0–11)	(0–12)
Tobacco use ongoing	192 (26)	63 (34)	90 (21)	39 (29)	0.002
Alcohol use ongoing	113 (15)	42 (23)	43 (10)	28 (21)	<0.001
Infection risks
AICD or Pacemaker present at admission	42 (6)	4 (2)	31 (7)	7 (5)	0.04
Documented decubitus at admission	123 (17)	23 (13)	83 (20)	17 (13)	0.04
Intravascular catheter present at admission	195 (26)	0 (0)	146 (34)	49 (37)	<0.001
Hemodialysis catheter	123 (31)	0 (0)	104 (42)	19 (24)
PICC line	30 (8)	0 (0)	17 (7)	13 (17)
Central venous catheter	21 (5)	0 (0)	7 (3)	14 (18)
Port	19 (5)	0 (0)	17 (7)	2 (3)
Urinary catheter present at admission	80 (11)	0 (0)	58 (14)	22 (16)	<0.001
PEG present at admission	50 (7)	0 (0)	35 (8)	15 (11)	<0.001
History of resistant organism					<0.001
MRSA	55 (8)	3 (2)	39 (9)	13 (10)
VRE	6 (0.8)	0 (0)	2 (0.4)	4 (3)
Hospitalization characteristics
Admitting service					0.002
Medicine	665 (89)	169 (92)	389 (90)	107 (80)
Surgery	35 (5)	8 (4)	13 (3)	14 (10)
Ob/Gyn	8 (1)	0 (0)	3 (0.7)	5 (4)
Pediatrics	1 (0.1)	0 (0)	0 (0)	1 (0.7)
Psychiatry	1 (0.1)	1 (0.5)	3 (0.7)	1 (0.7)
Urology	5 (0.7)	1 (0.5)	3 (0.7)	1 (0.7)
Orthopedics	5 (0.7)	5 (2)	20 (5)	5 (4)
Other	30 (4)
Admission source					<0.001
Home	542 (72)	181 (98)	275 (64)	86 (64)
Nursing Home	162 (22)	0 (0)	144 (33)	18 (13)
Rehab	11 (1)	0 (0)	7 (2)	4 (3)
Other Hospital	25 (3)	0 (0)	0 (0)	25 (19)
Hospitalized in prior 12 months	415 (55)	0 (0)	346 (81)	69 (51)	<0.001
If yes, same hospital?	384 (51)	0 (0)	324 (75)	60 (45)	<0.001

Note: *Comparisons were made between each location of acquisition designation and the total cohort.

Table 2 Clinical Outcomes*

	Total Cohort (N=750, 100%) n (%)	Community-Acquired (N=185, 25%) n (%)	Healthcare-Associated (N=431, 57%) n (%)	Hospital-Acquired (N=134, 18%) n (%)	P-value
Within week following BSI
Admitted to ICU	225 (30)	61 (33)	104 (24)	60 (45)	<0.001
CVC placed	197 (26)	43 (23)	108 (25)	46 (35)	0.06
Intubated	107 (14)	28 (15)	40 (9)	39 (29)	<0.001
On pressors	97 (13)	22 (12)	48 (11)	27 (20)	0.02
Procedure performed for BSI					0.002
I&D	59 (8)	16 (9)	34 (8)	9 (7)
Prosthesis removal	9 (1)	0 (0)	7 (2)	2 (2)
Other surgery	52 (7)	1 (0.6)	45 (11)	6 (5)
Pacemaker/AICD removal	1 (0.1)	0 (0)	1 (0.2)	0 (0)
Percutaneous drain placed	2 (0.2)	0 (0)	2 (0.4)	0 (0)
Total duration of hospitalization	8	7	7	23
(median; IQ1, IQ3)	(4, 14)	(3, 10)	(4, 12)	(12, 39)
(range)	0–161	0–69	0–78	3–161	<0.001
PICC placed for outpatient IV antibiotics	79 (11)	16 (9)	50 (12)	13 (10)	0.54
Died in the Hospital	148 (20)	17 (9)	95 (22)	36 (27)	<0.001
Discharge status					<0.001
Home	308 (41)	107 (58)	166 (39)	35 (26)
Home Health	51 (7)	14 (8)	23 (5)	14 (10)
Rehab	36 (5)	11 (6)	16 (4)	9 (7)
Nursing Home	139 (19)	10 (5)	98 (23)	31 (23)
Tertiary care hospital	52 (7)	19 (10)	28 (6)	5 (4)
AMA	3 (0.4)	1 (0.5)	1 (0.2)	1 (0.7)
Other	11 (1)	4 (2)	4 (0.9)	3 (2)
Readmitted within 90 days	212 (28)	34 (18)	138 (32)	40 (30)	0.002

Note: *Comparisons were made between each location of acquisition designation and the total cohort.

Table 3 Infection Data*

	Total Cohort (N=750, 100%) n (%)	Community-Acquired (N=185, 25%) n (%)	Healthcare-Associated (N=431, 57%) n (%)	Hospital-Acquired (N=134, 18%) n (%)	P-value
BSI Data
Type of BSI					0.02
Primary	619 (83)	141 (76)	369 (86)	109 (81)
Secondary	131 (17)	44 (24)	62 (14)	25 (19)	0.008
Urine	28 (21)	5 (11)	15 (23)	8 (32)
Wound	28 (21)	7 (16)	19 (30)	2 (8)
LRTI	47 (35)	25 (56)	16 (25)	12 (24)
Other	29 (22)	8 (18)	12 (19)	9 (36)
In ICU prior to BSI	57 (8)	0 (0)	9 (2)	48 (36)	<0.001
In ICU at time of BSI	152 (23)	37 (22)	62 (17)	53 (42)	<0.001
Central line present at time of BSI	190 (26)	0 (0)	128 (31)	62 (47)	<0.001
Organism					<0.001
MRSA	192 (26)	20 (11)	134 (31)	38 (28)
MSSA	209 (28)	51 (28)	127 (29)	31 (23)
Coagulase-Negative Staphylococcus	135 (18)	17 (9)	76 (18)	42 (31)
Enterococcus	29 (4) VRE=4	4 (2) VRE=0	17 (4) VRE=2	8 (6) VRE=2
Group B Streptococci	42 (6)	18 (10)	22 (5)	2 (1)
Group A Streptococci	15 (2)	8 (4)	6 (1)	1 (0.7)
Viridans group Streptococci	8 (1)	3 (2)	4 (0.9)	1 (0.7)
Other Streptococci	114 (15)	64 (35)	42 (10)	8 (6)
Peptostreptococcus	2 (0.2)	0 (0)	1 (0.2)	1 (0.7)
Multidrug-Resistant Gram-positive	235 (31)	27 (15)	159 (37)	49 (37)	<0.001
Multidrug-Resistant MRSA	185 (25)	19 (10)	129 (30)	37 (28)	<0.001
Multidrug-Resistant Coagulase-negative Staphylococcus	50 (7)	8 (4)	30 (7)	12 (9)	0.24
Polymicrobial	21 (3)	0 (0)	16 (4)	5 (4)	0.03
APACHE score at time of BSI (median; IQ1, IQ3) (range)	14 (11, 17) 4–30	13 (10, 15) 5–25	15 (12, 18) 4–30	14 (10, 17) 4–30	0.28

Note: *Comparisons were made between each location of acquisition designation and the total cohort.

Table 4 Appropriate Antibiotics*

	Total Cohort (N=750, 100%) n (%)	Community-Acquired (N=185, 25%) n (%)	Healthcare-Associated (N=431, 57%) n (%)	Hospital-Acquired (N=134, 18%) n (%)	P-value
Any appropriate antibiotics	594 (80)	140 (77)	342 (80)	112 (84)	0.39
Appropriate antibiotics within 24 hours of BSI	425 (57)	119 (66)	244 (57)	62 (46)	0.002

Note: *Comparisons were made between each location of acquisition designation and the total cohort.

Table 5 Association Between Clinical Risk Factors, BSI Location of Acquisition, and Selected Outcomes (Adjusted Multivariable Model; in Comparison to Community-Acquired BSI)

Outcomes	HAS BSI	HAQ BSI
ICU Admission within 1 week of BSI	0.61 (0.40–0.91)	1.35 (0.83–2.20)
Intubation within 1 week of BSI	0.61 (0.34–1.10)	1.99 (1.08–3.68)
Need for Pressors	0.71 (0.40–1.29)	1.39 (0.72–2.69)
Procedure for BSI	2.18 (1.17–4.22)	1.17 (0.52–2.63)
Received Appropriate Antibiotics within 24 hours of BSI	0.89 (0.57–1.38)	0.48 (0.28–0.82)
Death during Hospitalization	2.10 (1.17–3.95)	2.54 (1.29–5.12)
Readmission in 90 days	2.11 (1.39–3.26)	1.91 (1.13–3.24)