Management Bundle Lowers Mortality in Enterococcal Bloodstream Infections

A management bundle including infectious disease consultation, echocardiography, follow-up blood cultures and targeted antimicrobial treatment was associated with a lower mortality in enterococcal bloodstream infection, according to a new study.

The study, published in Open Forum Infectious Diseases, included 368 patients with Enterococcus spp bloodstream infections at Sant’Orsola-Malpighi Hospital in northern Italy and found that introduction of the management bundle was associated with a lower 30-day mortality (20% compared with 32% before the bundle was introduced).

“Enterococcus spp is the fourth most common causative pathogen of bloodstream infection (BSI) in Europe after Escherichia coli, Staphylococcus aureus and Streptococcus pneumoniae,” the study noted. “The incidence of infections caused by Enterococcus spp has increased over the last decades probably because of the global aging of the population and the increasing prevalence of immunocompromised patients.”

Patients were evaluated in 2 phases—173 in a retrospective analysis of patients admitted from January 2014 to December 2015 before the management bundle was administered and an intervention cohort of 195 patients admitted from January 2016 to December 2017, after the bundle was introduced. Mortality at the 1-year follow-up was 68% for the phase 1 group and 50% for the phase 2 cohort.

Those in phase 2 were more likely to be visited by an infectious disease specialist (83%) than those in the phase 1 (45%), receive adequate first-line therapy (93% vs 65%), receive combination therapy (23% vs 14%), undergo echocardiography (73% vs 43%), and have follow-up blood cultures (75% vs 42%) All interventions in the bundle were applied in 61% of phase 2 patients and 15% of phase 1 patients. The rate of infective endocarditis was 19% in both groups.

An alert system facilitated communication between the microbiology laboratory and the infectious disease consultants, allowing for ID consultants to conduct bed-side evaluations and recommend echocardiography, follow-up blood cultures every 48 hours and targeted antibiotic treatment.

Average overall 30-day mortality was 26%. Factors associated with mortality included age (average age of those in the study was 70), ICU admission, health care associated and hospital-acquired infection. About 10% of all patients with bloodstream infections in the study had underlying endocarditis.

Mortality among patients with persistent bacteremia was 43% in the phase 1 group and 13% in the phase 2 group.

“Another important finding of our study is that the application of the bundle was able to improve the rate of adequate antibiotic treatment (83% vs 71%, P = 0.017),” the study noted. “Additionally, in a lower but significant proportion of cases, the number of patients receiving adequate therapy in the first 24 hours was higher after the systematic application of the bundle.”

Some limitations of the study include that patients weren’t randomized to receive specific interventions, so biases such as improvement in general patient care could have been a factor in the results. Survivor bias also couldn’t be ruled out. Further research is needed to confirm the results.

The study results were similar to those in previous research that evaluated a management bundle for Staphylococcus aureus.

Infectious disease consults also were found to decrease mortality rates among patients with fungal bloodstream infections by 20%, according to a recent study.

Another recent study found that patients with severe sepsis and septic shock who received an early treatment bundle and a consultation with an ID specialist within 12 hours of admission had a 40% risk reduction for in-hospital mortality.