1441. Epidemiology of Bacteremia in an HIV-infected Cohort with Cryptococcal Meningitis
Session: Poster Abstract Session: Fungal Infections
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
Background:   Cryptococcal meningitis is a leading cause of death in AIDS patients in sub-Saharan Africa.  Prolonged inpatient hospitalization necessary for optimal management may predispose to hospital acquired infections.  We hypothesized that bacterial sepsis events were a significant cause of mortality in persons with Cryptococcus.  

Methods: We describe the epidemiology of bacterial sepsis in an HIV-infected cohort with cryptococcal meningitis in Kampala, Uganda (n=115) and Cape Town, South Africa (n=72).  Data were obtained as a substudy of the COAT trial, a randomized strategy trial assessing the optimal timing of ART initiation (n=142), and a prospective observational cohort (n=44).  We characterize the microbiology, risk factors, empiric treatment, and clinical outcomes of those with bacteremia. 

Results: In 186 persons with cryptococcal meningitis, 43 episodes of suspected bacteremia occurred in 40 patients.  Six blood cultures were negative, and 37 were positive.  After chart review, seven were thought to be contaminants.  Thus, 30 blood cultures (16% of patients) were considered true positives, related to bacterial sepsis. The most frequent microbiologic etiologies were Staphylococcus aureus (n=10), Klebsiella (n=9),  and Pseudomonas (n=3).  The median time from admission to sepsis syndrome was 13 days (IQR: 9, 17) days. Potential precipitating risk factors included: drip-site phlebitis (22 episodes), bed sores (2), and diarrhea (2 episodes).  The most common empiric antibiotic was ceftriaxone, of which 20/30 (67%) isolates were resistant.  Of the 30 bacteremic patients, 18 died (60%).  In comparison, the 4 week mortality rate was 22.7% (27/119) among COAT trial participants without sepsis (bacteremia relative risk=2.6, 95%CI: 1.7-4.1, P<.001).

Conclusion: Confirmed bacteremia occurred in 16% of patients with cryptococcosis, the majority during the 2nd-3rd week of hospitalization, suggesting nosocomial acquisition, with a high rate of cephalosporin resistance.  Bacteremia increased the risk of death 2.6-fold and sepsis was the second leading cause of death. Possible precipitating factors include phlebitis.  Studies to address methods of prevention are required, along with implementation of better infection control measures.

Radha Rajasingham1,2,3, James Scriven4, Darlisha Williams, MPH5, David Meya6, Graeme Meintjes, MD7 and David Boulware, MD, MPH2, (1)Beth Israel Deaconess Medical Center, Boston, MA, (2)University of Minnesota, Minneapolis, MN, (3)Infectious Disease Institute, Kampala, Uganda, (4)Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa, (5)Univ of Minnesota, Minneapolis, MN, (6)Infectious Diseases Institute, Makerere University, Kampala, Uganda, (7)University of Cape Town, Cape Town, South Africa

Disclosures:

R. Rajasingham, None

J. Scriven, None

D. Williams, None

D. Meya, None

G. Meintjes, None

D. Boulware, None

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