Christina Forstner1, Vladimir Patchev2, Gernot Rohde3, Jan Rupp4, Martin Witzenrath5, Tobias Welte6, Heinz Burgmann7, Mathias W Pletz8. 1. Institute of Infectious Diseases and Infection Control, University Hospital, Jena, Germany; Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria. Electronic address: christina.forstner@med.uni-jena.de. 2. Institute of Infectious Diseases and Infection Control, University Hospital, Jena, Germany. 3. Medical Department I, Department of Respiratory Medicine, Goethe University Hospital, Frankfurt/Main, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL); CAPNETZ Stiftung, Hannover, Germany. 4. CAPNETZ Stiftung, Hannover, Germany; Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Lübeck, Germany; German Center for Infection Research (DZIF), partner site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany. 5. CAPNETZ Stiftung, Hannover, Germany; Department of Infectious Diseases and Pulmonary Medicine and the Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. 6. Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL); CAPNETZ Stiftung, Hannover, Germany; Department of Pneumology, Hannover Medical School, Hannover, Germany. 7. Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria. 8. Institute of Infectious Diseases and Infection Control, University Hospital, Jena, Germany; CAPNETZ Stiftung, Hannover, Germany.
Abstract
BACKGROUND: Although blood cultures (BCs) are the "gold standard" for detecting bacteremia, the utility of BCs in patients with community-acquired pneumonia (CAP) is controversial. This study describes the proportion of patients with CAP and afebrile bacteremia and identifies the clinical characteristics predicting the necessity for BCs in patients who are afebrile. METHODS: Bacteremia rates were determined in 4,349 patients with CAP enrolled in the multinational cohort study The Competence Network of Community-Acquired Pneumonia (CAPNETZ) and stratified by presence of fever at first patient contact. Independent predictors of bacteremia in patients who were afebrile were determined using logistic regression analysis. RESULTS: Bacteremic pneumonia was present in 190 of 2,116 patients who were febrile (8.9%), 101 of 2,149 patients who were afebrile (4.7%), and one of 23 patients with hypothermia (4.3%). Bacteremia rates increased with the CURB-65 score from 3.5% in patients with CURB-65 score of 0 to 17.1% in patients with CURB-65 score of 4. Patients with afebrile bacteremia exhibited the highest 28-day mortality rate (9.9%). Positive pneumococcal urinary antigen test (adjusted OR [AOR], 4.6; 95% CI, 2.6-8.2), C-reactive protein level > 200 mg/L (AOR, 3.1; 95% CI, 1.9-5.2), and BUN level ≥ 30 mg/dL (AOR, 3.1; 95% CI, 1.9-5.3) were independent positive predictors, and antibiotic pretreatment (AOR, 0.3; 95% CI, 0.1-0.6) was an independent negative predictor of bacteremia in patients who were afebrile. CONCLUSIONS: A relevant proportion of patients with bacteremic CAP was afebrile. These patients had an increased mortality rate compared with patients with febrile bacteremia or nonbacteremic pneumonia. Therefore, the relevance of fever as an indicator for BC necessity merits reconsideration.
BACKGROUND: Although blood cultures (BCs) are the "gold standard" for detecting bacteremia, the utility of BCs in patients with community-acquired pneumonia (CAP) is controversial. This study describes the proportion of patients with CAP and afebrile bacteremia and identifies the clinical characteristics predicting the necessity for BCs in patients who are afebrile. METHODS:Bacteremia rates were determined in 4,349 patients with CAP enrolled in the multinational cohort study The Competence Network of Community-Acquired Pneumonia (CAPNETZ) and stratified by presence of fever at first patient contact. Independent predictors of bacteremia in patients who were afebrile were determined using logistic regression analysis. RESULTS:Bacteremic pneumonia was present in 190 of 2,116 patients who were febrile (8.9%), 101 of 2,149 patients who were afebrile (4.7%), and one of 23 patients with hypothermia (4.3%). Bacteremia rates increased with the CURB-65 score from 3.5% in patients with CURB-65 score of 0 to 17.1% in patients with CURB-65 score of 4. Patients with afebrile bacteremia exhibited the highest 28-day mortality rate (9.9%). Positive pneumococcal urinary antigen test (adjusted OR [AOR], 4.6; 95% CI, 2.6-8.2), C-reactive protein level > 200 mg/L (AOR, 3.1; 95% CI, 1.9-5.2), and BUN level ≥ 30 mg/dL (AOR, 3.1; 95% CI, 1.9-5.3) were independent positive predictors, and antibiotic pretreatment (AOR, 0.3; 95% CI, 0.1-0.6) was an independent negative predictor of bacteremia in patients who were afebrile. CONCLUSIONS: A relevant proportion of patients with bacteremic CAP was afebrile. These patients had an increased mortality rate compared with patients with febrile bacteremia or nonbacteremic pneumonia. Therefore, the relevance of fever as an indicator for BC necessity merits reconsideration.
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Authors: Mathias W Pletz; Andreas Vestergaard Jensen; Christina Bahrs; Claudia Davenport; Jan Rupp; Martin Witzenrath; Grit Barten-Neiner; Martin Kolditz; Sabine Dettmer; James D Chalmers; Daiana Stolz; Norbert Suttorp; Stefano Aliberti; Wolfgang M Kuebler; Gernot Rohde Journal: Respir Res Date: 2022-09-10