Kate Nambiar1, Harald Seifert2, Siegbert Rieg3, Winfried V Kern3, Matt Scarborough4, N Claire Gordon4, Hong Bin Kim5, Kyoung-Ho Song5, Robert Tilley6, Hannah Gott7, Chun-Hsing Liao8, Jonathan Edgeworth9, Emmanuel Nsutebu10, Luis Eduardo López-Cortés11, Laura Morata12, A Sarah Walker13, Guy Thwaites14, Martin J Llewelyn1, Achim J Kaasch15. 1. Department of Microbiology and Infectious Diseases, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom. 2. Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University of Cologne, Goldenfelsstr. 19, 50935 Cologne, Germany; German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany. 3. Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg 79106, Freiburg, Germany. 4. Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Headington, Oxford, OX3 9DU, United Kingdom. 5. Department of Internal Medicine, Seoul National University College of Medicine and Division of Infectious Diseases, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Republic of Korea. 6. Department of Microbiology, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, PL6 8DH, United Kingdom. 7. Department of Research and Development, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, PL6 8DH, United Kingdom. 8. Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Section 2, Nanya South Road, Banchio District, New Taipei City 220, Taiwan; Department of Medicine, Yang-Ming University, No. 155, Section 2, Linong Street, Taipei 112, Taiwan. 9. Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom. 10. Tropical & Infectious Disease Unit, Royal Liverpool and Broadgreen University Teaching Hospital, Prescot Street, Liverpool, L7 8XP, United Kingdom. 11. Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena /CSIC / Instituto de Biomedicina de Sevilla (IBiS), Avda Dr Fedriani, s/n. 41003 Seville, Spain. 12. Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain. 13. Medical Research Council Clinical Trials Unit at University College London, University College London, United Kingdom; Nuffield Department of Medicine, University of Oxford, Level 7 Microbiology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom. 14. Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom. 15. Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany. Electronic address: achim.kaasch@hhu.de.
Abstract
BACKGROUND: Staphylococcus aureus bloodstream infection (SAB) is a common, life-threatening infection with a high mortality. Survival can be improved by implementing quality of care bundles in hospitals. We previously observed marked differences in mortality between hospitals and now assessed whether mortality could serve as a valid and easy to implement quality of care outcome measure. METHODS: We conducted a prospective observational study between January 2013 and April 2015 on consecutive, adult patients with SAB from 11 tertiary care centers in Germany, South Korea, Spain, Taiwan, and the United Kingdom. Factors associated with mortality at 90 days were analyzed by Cox proportional hazards regression and flexible parametric models. RESULTS: 1851 patients with a median age of 66 years (64% male) were analyzed. Crude 90-day mortality differed significantly between hospitals (range 23-39%). Significant variation between centers was observed for methicillin-resistant S. aureus, community-acquisition, infective foci, as well as measures of comorbidities, and severity of disease. In multivariable analysis, factors independently associated with mortality at 90 days were age, nosocomial acquisition, unknown infective focus, pneumonia, Charlson comorbidity index, SOFA score, and study center. The risk of death varied over time differently for each infective focus. Crude mortality differed markedly from adjusted mortality. DISCUSSION: We observed significant differences in adjusted mortality between hospitals, suggesting differences in quality of care. However, mortality is strongly influenced by patient mix and thus, crude mortality is not a suitable quality indicator.
BACKGROUND:Staphylococcus aureus bloodstream infection (SAB) is a common, life-threatening infection with a high mortality. Survival can be improved by implementing quality of care bundles in hospitals. We previously observed marked differences in mortality between hospitals and now assessed whether mortality could serve as a valid and easy to implement quality of care outcome measure. METHODS: We conducted a prospective observational study between January 2013 and April 2015 on consecutive, adult patients with SAB from 11 tertiary care centers in Germany, South Korea, Spain, Taiwan, and the United Kingdom. Factors associated with mortality at 90 days were analyzed by Cox proportional hazards regression and flexible parametric models. RESULTS: 1851 patients with a median age of 66 years (64% male) were analyzed. Crude 90-day mortality differed significantly between hospitals (range 23-39%). Significant variation between centers was observed for methicillin-resistant S. aureus, community-acquisition, infective foci, as well as measures of comorbidities, and severity of disease. In multivariable analysis, factors independently associated with mortality at 90 days were age, nosocomial acquisition, unknown infective focus, pneumonia, Charlson comorbidity index, SOFA score, and study center. The risk of death varied over time differently for each infective focus. Crude mortality differed markedly from adjusted mortality. DISCUSSION: We observed significant differences in adjusted mortality between hospitals, suggesting differences in quality of care. However, mortality is strongly influenced by patient mix and thus, crude mortality is not a suitable quality indicator.
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