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Bloodstream infections (BSI) cause substantial morbidity and mortality.


We explored the role of causative pathogens and patient characteristics on the outcome of community-acquired (CA) and healthcare-associated (HA) BSI, with particular interest in early death.


We used national register data to identify all BSI in Finland during 2004–18. We determined the origin of BSI, patients´ underlying comorbidities and deaths within 2 or 30 days from specimen collection. A time-dependent Cox model was applied to evaluate the impact of patient characteristics and causative pathogens on the hazard for death at different time points.


A total of 173,715 BSI were identified; 22,474 (12.9%) were fatal within 30 days and, of these, 6,392 (28.4%) occurred within 2 days (7.9 deaths/100,000 population). The 2-day case fatality rate of HA-BSI was higher than that of CA-BSI (5.4% vs 3.0%). Patients who died within 2 days were older than those alive on day 3 (76 vs 70 years) and had more severe comorbidities. Compared with other BSI, infections leading to death within 2 days were more often polymicrobial (11.8% vs 6.3%) and caused by (6.2% vs 2.0%), fungi (2.9% vs 1.4%) and multidrug-resistant (MDR) pathogens (2.2% vs 1.8%), which were also predictors of death within 2 days in the model.


Overrepresentation of polymicrobial, fungal, and MDR aetiology among BSI leading to early death is challenging concerning the initial antimicrobial treatment. Our findings highlight the need for active prevention and prompt recognition of BSI and appropriate antimicrobial treatment.


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  1. Goto M, Al-Hasan MN. Overall burden of bloodstream infection and nosocomial bloodstream infection in North America and Europe. Clin Microbiol Infect. 2013;19(6):501-9.  https://doi.org/10.1111/1469-0691.12195  PMID: 23473333 
  2. Rodríguez-Baño J, López-Prieto MD, Portillo MM, Retamar P, Natera C, Nuño E, et al. Epidemiology and clinical features of community-acquired, healthcare-associated and nosocomial bloodstream infections in tertiary-care and community hospitals. Clin Microbiol Infect. 2010;16(9):1408-13.  https://doi.org/10.1111/j.1469-0691.2010.03089.x  PMID: 19845694 
  3. Søgaard M, Nørgaard M, Dethlefsen C, Schønheyder HC. Temporal changes in the incidence and 30-day mortality associated with bacteremia in hospitalized patients from 1992 through 2006: a population-based cohort study. Clin Infect Dis. 2011;52(1):61-9.  https://doi.org/10.1093/cid/ciq069  PMID: 21148521 
  4. Lenz R, Leal JR, Church DL, Gregson DB, Ross T, Laupland KB. The distinct category of healthcare associated bloodstream infections. BMC Infect Dis. 2012;12(1):85.  https://doi.org/10.1186/1471-2334-12-85  PMID: 22487002 
  5. Holmbom M, Giske CG, Fredrikson M, Östholm Balkhed Å, Claesson C, Nilsson LE, et al. 14-Year survey in a Swedish county reveals a pronounced increase in bloodstream infections (BSI). Comorbidity - an independent risk factor for both BSI and mortality. PLoS One. 2016;11(11):e0166527.  https://doi.org/10.1371/journal.pone.0166527  PMID: 27835663 
  6. Martínez Pérez-Crespo PM, López-Cortés LE, Retamar-Gentil P, García JFL, Vinuesa García D, León E, et al. Epidemiologic changes in bloodstream infections in Andalucía (Spain) during the last decade. Clin Microbiol Infect. 2021;27(2):283.e9-16.  https://doi.org/10.1016/j.cmi.2020.05.015  PMID: 32470569 
  7. Pedersen G, Schønheyder HC, Sørensen HT. Source of infection and other factors associated with case fatality in community-acquired bacteremia--a Danish population-based cohort study from 1992 to 1997. Clin Microbiol Infect. 2003;9(8):793-802.  https://doi.org/10.1046/j.1469-0691.2003.00599.x  PMID: 14616699 
  8. Laupland KB, Svenson LW, Gregson DB, Church DL. Long-term mortality associated with community-onset bloodstream infection. Infection. 2011;39(5):405-10.  https://doi.org/10.1007/s15010-011-0149-x  PMID: 21706223 
  9. Skogberg K, Lyytikäinen O, Ollgren J, Nuorti JP, Ruutu P. Population-based burden of bloodstream infections in Finland. Clin Microbiol Infect. 2012;18(6):E170-6.  https://doi.org/10.1111/j.1469-0691.2012.03845.x  PMID: 22512663 
  10. Kontula KSK, Skogberg K, Ollgren J, Järvinen A, Lyytikäinen O. Population-based study of bloodstream infection incidence and mortality rates, Finland, 2004-2018. Emerg Infect Dis. 2021;27(10):2560-9.  https://doi.org/10.3201/eid2710.204826  PMID: 34546161 
  11. Statistics Finland. Statistical data. Helsinki: Statistics Finland. [Accessed: 30 Nov 2019]. Available from: https://www.stat.fi/index_en.html
  12. Laupland KB, Lyytikäinen O, Søgaard M, Kennedy KJ, Knudsen JD, Ostergaard C, et al. , International Bacteremia Surveillance Collaborative. The changing epidemiology of Staphylococcus aureus bloodstream infection: a multinational population-based surveillance study. Clin Microbiol Infect. 2013;19(5):465-71.  https://doi.org/10.1111/j.1469-0691.2012.03903.x  PMID: 22616816 
  13. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-83.  https://doi.org/10.1016/0021-9681(87)90171-8  PMID: 3558716 
  14. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130-9.  https://doi.org/10.1097/01.mlr.0000182534.19832.83  PMID: 16224307 
  15. Thomsen RW, Hundborg HH, Lervang HH, Johnsen SP, Sørensen HT, Schønheyder HC. Diabetes and outcome of community-acquired pneumococcal bacteremia: a 10-year population-based cohort study. Diabetes Care. 2004;27(1):70-6.  https://doi.org/10.2337/diacare.27.1.70  PMID: 14693969 
  16. Søgaard M, Schønheyder HC, Riis A, Sørensen HT, Nørgaard M. Short-term mortality in relation to age and comorbidity in older adults with community-acquired bacteremia: a population-based cohort study. J Am Geriatr Soc. 2008;56(9):1593-600.  https://doi.org/10.1111/j.1532-5415.2008.01855.x  PMID: 18691276 
  17. Finnish Institute for Health and Welfare. Infectious diseases and vaccinations. Surveillance of antimicrobial resistance. Helsinki: Finnish Institute for Health and Welfare. [Accessed: 25 Jul 2022]. Available from: https://thl.fi/en/web/infectious-diseases-and-vaccinations/surveillance-and-registers/surveillance-of-antimicrobial-resistance
  18. Micek ST, Lloyd AE, Ritchie DJ, Reichley RM, Fraser VJ, Kollef MH. Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment. Antimicrob Agents Chemother. 2005;49(4):1306-11.  https://doi.org/10.1128/AAC.49.4.1306-1311.2005  PMID: 15793102 
  19. Kontula KS, Skogberg K, Ollgren J, Järvinen A, Lyytikäinen O. Early deaths in bloodstream infections: a population-based case series. Infect Dis (Lond). 2016;48(5):379-85.  https://doi.org/10.3109/23744235.2015.1131329  PMID: 26763410 
  20. McDonald JR, Friedman ND, Stout JE, Sexton DJ, Kaye KS. Risk factors for ineffective therapy in patients with bloodstream infection. Arch Intern Med. 2005;165(3):308-13.  https://doi.org/10.1001/archinte.165.3.308  PMID: 15710794 
  21. Hattori H, Maeda M, Nagatomo Y, Takuma T, Niki Y, Naito Y, et al. Epidemiology and risk factors for mortality in bloodstream infections: A single-center retrospective study in Japan. Am J Infect Control. 2018;46(12):e75-9.  https://doi.org/10.1016/j.ajic.2018.06.019  PMID: 30172607 
  22. Mehl A, Åsvold BO, Lydersen S, Paulsen J, Solligård E, Damås JK, et al. Burden of bloodstream infection in an area of Mid-Norway 2002-2013: a prospective population-based observational study. BMC Infect Dis. 2017;17(1):205.  https://doi.org/10.1186/s12879-017-2291-2  PMID: 28284196 
  23. Laupland KB, Pasquill K, Parfitt EC, Dagasso G, Gupta K, Steele L. Inhospital death is a biased measure of fatal outcome from bloodstream infection. Clin Epidemiol. 2019;11:47-52.  https://doi.org/10.2147/CLEP.S187381  PMID: 30655704 
  24. Pedersen G, Schønheyder HC. Patients with bacteremia dying before notification of positive blood cultures: a 3-year clinical study. Scand J Infect Dis. 1997;29(2):169-73.  https://doi.org/10.3109/00365549709035879  PMID: 9181654 
  25. Søgaard M, Schønheyder HC, Riis A, Sørensen HT, Nørgaard M. Short-term mortality in relation to age and comorbidity in older adults with community-acquired bacteremia: a population-based cohort study. J Am Geriatr Soc. 2008;56(9):1593-600.  https://doi.org/10.1111/j.1532-5415.2008.01855.x  PMID: 18691276 
  26. Lee CC, Lee CH, Yang CY, Hsieh CC, Tang HJ, Ko WC. Beneficial effects of early empirical administration of appropriate antimicrobials on survival and defervescence in adults with community-onset bacteremia. Crit Care. 2019;23(1):363.  https://doi.org/10.1186/s13054-019-2632-1  PMID: 31747950 
  27. Holmbom M, Möller V, Nilsson LE, Giske CG, Rashid MU, Fredrikson M, et al. Low incidence of antibiotic-resistant bacteria in south-east Sweden: An epidemiologic study on 9268 cases of bloodstream infection. PLoS One. 2020;15(3):e0230501.  https://doi.org/10.1371/journal.pone.0230501  PMID: 32218575 
  28. Rinta-Kokko H, Palmu AA, Auranen K, Nuorti JP, Toropainen M, Siira L, et al. Long-term impact of 10-valent pneumococcal conjugate vaccination on invasive pneumococcal disease among children in Finland. Vaccine. 2018;36(15):1934-40.  https://doi.org/10.1016/j.vaccine.2018.03.001  PMID: 29526371 
  29. Harboe ZB, Dalby T, Weinberger DM, Benfield T, Mølbak K, Slotved HC, et al. Impact of 13-valent pneumococcal conjugate vaccination in invasive pneumococcal disease incidence and mortality. Clin Infect Dis. 2014;59(8):1066-73.  https://doi.org/10.1093/cid/ciu524  PMID: 25034421 
  30. de Kraker ME, Jarlier V, Monen JC, Heuer OE, van de Sande N, Grundmann H. The changing epidemiology of bacteraemias in Europe: trends from the European Antimicrobial Resistance Surveillance System. Clin Microbiol Infect. 2013;19(9):860-8.  https://doi.org/10.1111/1469-0691.12028  PMID: 23039210 
  31. Diekema DJ, Hsueh PR, Mendes RE, Pfaller MA, Rolston KV, Sader HS, et al. The microbiology of bloodstream infection: 20-year trends from the SENTRY antimicrobial surveillance program. Antimicrob Agents Chemother. 2019;63(7):e00355-19.  https://doi.org/10.1128/AAC.00355-19  PMID: 31010862 
  32. Retamar P, Portillo MM, López-Prieto MD, Rodríguez-López F, de Cueto M, García MV, et al. Impact of inadequate empirical therapy on the mortality of patients with bloodstream infections: a propensity score-based analysis. Antimicrob Agents Chemother. 2012;56(1):472-8.  https://doi.org/10.1128/AAC.00462-11  PMID: 22005999 
  33. Gradel KO, Jensen US, Schønheyder HC, Østergaard C, Knudsen JD, Wehberg S, et al. Impact of appropriate empirical antibiotic treatment on recurrence and mortality in patients with bacteraemia: a population-based cohort study. BMC Infect Dis. 2017;17(1):122.  https://doi.org/10.1186/s12879-017-2233-z  PMID: 28166732 
  34. Kadri SS, Lai YL, Warner S, Strich JR, Babiker A, Ricotta EE, et al. Inappropriate empirical antibiotic therapy for bloodstream infections based on discordant in-vitro susceptibilities: a retrospective cohort analysis of prevalence, predictors, and mortality risk in US hospitals. Lancet Infect Dis. 2021;21(2):241-51.  https://doi.org/10.1016/S1473-3099(20)30477-1  PMID: 32916100 
  35. Paulsen J, Askim Å, Mohus RM, Mehl A, Dewan A, Solligård E, et al. Associations of obesity and lifestyle with the risk and mortality of bloodstream infection in a general population: a 15-year follow-up of 64 027 individuals in the HUNT Study. Int J Epidemiol. 2017;46(5):1573-81.  https://doi.org/10.1093/ije/dyx091  PMID: 28637260 

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