Going for GNBSI

We’ll be publishing the results of the vote on whether or not we can halve HA-GNBSI by 2021 later this week. Right now, it looks like Martin is heading for a comfortable, if somewhat depressing victory (“No, we can’t halve GNBSI by 2021”) but there’s still time to ride a wave of positivity and vote with me that “Yes, we can halve GNBSI by 2021”. So, I thought that now would be an appropriate time to review the recent JHI paper that both Martin and I referred to, providing some enhanced epidemiological data on E. coli BSIs in England.

The paper outlines the findings of enhanced surveillance around E. coli BSIs (strictly speaking bacteraemias) in England. The burden of these cases is large, with approaching 40,000 cases per annum, with something in the region of 5,000 deaths (not necessarily attributable). The data reported in the study comes from 1731 cases of E. coli BSI from 35 NHS Trusts who participated in sentinel enhanced surveillance for 3 months in 2012/13. Healthcare exposure was defined as an IV device, urinary catheterisation, other device, a procedure of some kind, or antibiotic exposure. I could be wrong here, but it doesn’t seem like an inpatient stay was classified as healthcare exposure if it didn’t include one of these specific risk factors.

These are the key findings:

  • Around 2/3 of the cases were identified in the first 2 days of hospital admission – however, half of these had a healthcare exposure in the previous month, so around 2/3 of the cases were ultimately healthcare-associated.
  • The most common healthcare exposure was antibiotics, in 1/3 of patients.
  • 22% of the patients had an IV device in situ when the BSI was detected – or had been removed shortly beforehand.
  • 21% of the patients had a urinary catheter inserted, removed, or manipulated in the 7 days before the BSI.
  • 12 % of patients had a procedure of some kind in the 4 weeks before the BSI.
  • 7% of patients had some other device in situ or removed in the 4 weeks before the BSI.
  • Half of the cases were in patients >75 years old.
  • The figure below shows the underlying focus of the coli BSIs, with almost half related to the urogenital tract, 16% hepatobiliary, 15% unknown, and 7% gastrointestinal. Only 1% were related to IV devices.
  • Risk factors for a urogenital focus were: treatment for UTI, a recent UTI, urinary catheterisation for incontinence, whereas male gender, unknown presence of a catheter, general speciality, and hospital onset BSI were protective.
  • Approaching half of the isolates were resistant to trimethoprim and co-amoxiclav, whereas resistance to nitrofurantoin and carbapenems was reassuringly rare. This pretty much throws trimethoprim under the bus for empiric therapy for UTIs in the community! Nitrofurantoin seems like a better bet for this. Either that, or ibuprofen.
  • Trimethoprim resistance was more common in patients with a urogenital focus of infection.
  • Antibiotic resistance increases were associated with hospitalisation for co-amoxiclav and pip/tazo.

Figure: Underlying focus of infection for 1688 E. coli BSIs

This is quite a ‘facty’ blog from quite a ‘facty’ paper – but this reinforces my view that there is much to go for in preventing E. coli BSI (and probably also GNBSI) in terms of improving management of urinary infections and surgical infections, and opening the ‘unknown’ box accounting for 15% of BSIs to identify new areas for prevention.

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