David Zhang1, Danny Yang2, Anil N Makam3. 1. Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas. 2. Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas. 3. Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas; Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California.
Abstract
INTRODUCTION: Blood cultures are of limited utility in nonsevere community-acquired pneumonia, though routinely recommended for severe community-acquired pneumonia or health care-associated pneumonia due to perceived greater bacteremia risk, particularly with multidrug-resistant organisms. The utility of this practice is unknown. METHODS: In this observational cohort study, we abstracted data from medical records for consecutive hospitalizations for pneumonia by adults to an academic medical center from 2014-2015. The primary outcomes included bacteremia, multidrug-resistant organism bacteremia, and appropriate management changes attributed to culture results, stratified by pneumonia classification (nonsevere community-acquired pneumonia, severe community-acquired pneumonia, or health care-associated pneumonia) and likelihood the bacteremia was due to pneumonia vs another infection. We assessed the diagnostic test performance of one or more guideline-defined risk factors for bacteremia in nonsevere community-acquired pneumonia, for whom cultures are routinely recommended. RESULTS: Of 456 pneumonia hospitalizations, 30 (6.6%) had bacteremia, with a greater incidence in severe community-acquired pneumonia (14.7%) than nonsevere community-acquired pneumonia (7.8%) and health care-associated pneumonia (6.6%; P = .12). Seventeen bacteremia cases were likely due to pneumonia (3.7%). Only 2 (0.4%) had multidrug-resistant organisms (both health care-associated pneumonia), one of whom was due to pneumonia. Appropriate management changes occurred in 8 cases (1.8%; 7 de-escalation and 1 escalation of antibiotics); only 1 with bacteremia likely due to pneumonia (de-escalation). The one case of appropriate antibiotic escalation occurred in a patient with vancomycin-resistant Enterococcus unrelated to pneumonia. Having one or more guideline-defined risk factors did not identify bacteremia in nonsevere community-acquired pneumonia (positive likelihood ratio, 1.10; 95% confidence interval, 0.61-1.99). CONCLUSION: Routine blood cultures in pneumonia have extremely low yield and utility irrespective of severity and risk.
INTRODUCTION: Blood cultures are of limited utility in nonsevere community-acquired pneumonia, though routinely recommended for severe community-acquired pneumonia or health care-associated pneumonia due to perceived greater bacteremia risk, particularly with multidrug-resistant organisms. The utility of this practice is unknown. METHODS: In this observational cohort study, we abstracted data from medical records for consecutive hospitalizations for pneumonia by adults to an academic medical center from 2014-2015. The primary outcomes included bacteremia, multidrug-resistant organism bacteremia, and appropriate management changes attributed to culture results, stratified by pneumonia classification (nonsevere community-acquired pneumonia, severe community-acquired pneumonia, or health care-associated pneumonia) and likelihood the bacteremia was due to pneumonia vs another infection. We assessed the diagnostic test performance of one or more guideline-defined risk factors for bacteremia in nonsevere community-acquired pneumonia, for whom cultures are routinely recommended. RESULTS: Of 456 pneumonia hospitalizations, 30 (6.6%) had bacteremia, with a greater incidence in severe community-acquired pneumonia (14.7%) than nonsevere community-acquired pneumonia (7.8%) and health care-associated pneumonia (6.6%; P = .12). Seventeen bacteremia cases were likely due to pneumonia (3.7%). Only 2 (0.4%) had multidrug-resistant organisms (both health care-associated pneumonia), one of whom was due to pneumonia. Appropriate management changes occurred in 8 cases (1.8%; 7 de-escalation and 1 escalation of antibiotics); only 1 with bacteremia likely due to pneumonia (de-escalation). The one case of appropriate antibiotic escalation occurred in a patient with vancomycin-resistant Enterococcus unrelated to pneumonia. Having one or more guideline-defined risk factors did not identify bacteremia in nonsevere community-acquired pneumonia (positive likelihood ratio, 1.10; 95% confidence interval, 0.61-1.99). CONCLUSION: Routine blood cultures in pneumonia have extremely low yield and utility irrespective of severity and risk.
Authors: Lionel A Mandell; Richard G Wunderink; Antonio Anzueto; John G Bartlett; G Douglas Campbell; Nathan C Dean; Scott F Dowell; Thomas M File; Daniel M Musher; Michael S Niederman; Antonio Torres; Cynthia G Whitney Journal: Clin Infect Dis Date: 2007-03-01 Impact factor: 9.079
Authors: Amartya Mukhopadhyay; Mahendran Maliapen; Venetia Ong; Rupert W Jakes; Linda M Mundy; Li Jialiang; Paul A Tambyah Journal: Clin Infect Dis Date: 2017-05-15 Impact factor: 9.079
Authors: Kate E Dingle; Xavier Didelot; T Phuong Quan; David W Eyre; Nicole Stoesser; Tanya Golubchik; Rosalind M Harding; Daniel J Wilson; David Griffiths; Alison Vaughan; John M Finney; David H Wyllie; Sarah J Oakley; Warren N Fawley; Jane Freeman; Kirsti Morris; Jessica Martin; Philip Howard; Sherwood Gorbach; Ellie J C Goldstein; Diane M Citron; Susan Hopkins; Russell Hope; Alan P Johnson; Mark H Wilcox; Timothy E A Peto; A Sarah Walker; Derrick W Crook Journal: Lancet Infect Dis Date: 2017-01-25 Impact factor: 71.421