Importance Staphylococcus aureus bacteremia is common and frequently associated with poor outcomes. Evidence indicates that specific care processes are associated with improved outcomes for patients with S aureus bacteremia, including appropriate antibiotic prescribing, use of echocardiography to identify endocarditis, and consultation with infectious diseases (ID) specialists. Whether use of these care processes has increased in routine care for S aureus bacteremia or whether use of these processes has led to large-scale improvements in survival is unknown. Objective To examine the association of evidence-based care processes in routine care for S aureus bacteremia with mortality. Design, Setting, and Participants This retrospective observational cohort study examined all patients admitted to Veterans Health Administration (VHA) acute care hospitals who had a first episode of S aureus bacteremia from January 1, 2003, through December 31, 2014. Exposures Use of appropriate antibiotic therapy, echocardiography, and ID consultation. Main Outcomes and Measures Thirty-day all-cause mortality. Results Analyses included 36 868 patients in 124 hospitals (mean [SD] age, 66.4 [12.5] years; 36 036 [97.7%] male), including 19 325 (52.4%) with infection due to methicillin-resistant S aureus and 17 543 (47.6%) with infection due to methicillin-susceptible S aureus. Risk-adjusted mortality decreased from 23.5% (95% CI, 23.3%-23.8%) in 2003 to 18.2% (95% CI, 17.9%-18.5%) in 2014. Rates of appropriate antibiotic prescribing increased from 2467 (66.4%) to 1991 (78.9%), echocardiography from 1256 (33.8%) to 1837 (72.8%), and ID consultation from 1390 (37.4%) to 1717 (68.0%). After adjustment for patient characteristics, cohort year, and other care processes, receipt of care processes was associated with lower mortality, with adjusted odds ratios of 0.74 (95% CI, 0.68-0.79) for appropriate antibiotics, 0.73 (95% CI, 0.68-0.78) for echocardiography, and 0.61 (95% CI, 0.56-0.65) for ID consultation. Mortality decreased progressively as the number of care processes that a patient received increased (adjusted odds ratio for all 3 processes compared with none, 0.33; 95% CI, 0.30-0.36). An estimated 57.3% (95% CI, 48.4%-69.9%) of the decrease in mortality between 2003 and 2014 could be attributed to increased use of these evidence-based care processes. Conclusions and Relevance Mortality associated with S aureus bacteremia decreased significantly in VHA hospitals, and a substantial portion of the decreasing mortality may have been attributable to increased use of evidence-based care processes. The experience in VHA hospitals demonstrates that increasing application of these care processes may improve survival among patients with S aureus bacteremia in routine health care settings.

中文翻译：

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循证护理过程与退伍军人健康管理医院金黄色葡萄球菌菌血症死亡率的关联，2003-2014

重要性 金黄色葡萄球菌菌血症很常见，常常与不良结局相关。有证据表明，特定的护理过程与金黄色葡萄球菌菌血症患者的预后改善有关，包括适当的抗生素处方、使用超声心动图识别心内膜炎以及咨询传染病 (ID) 专家。这些护理程序在金黄色葡萄球菌菌血症的常规护理中的使用是否有所增加，或者这些程序的使用是否已导致存活率的大规模改善尚不清楚。目的 研究金黄色葡萄球菌菌血症常规护理中循证护理过程与死亡率的关联。设计，设置，和参与者 这项回顾性观察性队列研究检查了所有在 2003 年 1 月 1 日至 2014 年 12 月 31 日期间入住退伍军人健康管理局 (VHA) 急性护理医院并首次出现金黄色葡萄球菌菌血症的患者。 暴露 使用适当的抗生素治疗、超声心动图，和身份证咨询。主要结果和措施 30 天全因死亡率。结果 分析包括124家医院的36 868例患者（平均[SD]年龄，66.4 [12.5]岁；36 036 [97.7%]男性），其中耐甲氧西林金黄色葡萄球菌感染19 325例（52.4%），17 543例(47.6%) 因甲氧西林敏感的金黄色葡萄球菌感染。风险调整死亡率从 2003 年的 23.5% (95% CI, 23.3%-23.8%) 下降到 2014 年的 18.2% (95% CI, 17.9%-18.5%)。适当抗生素处方率从 2467 (66. 4%) 到 1991 (78.9%)，超声心动图从 1256 (33.8%) 到 1837 (72.8%)，ID 咨询从 1390 (37.4%) 到 1717 (68.0%)。在调整患者特征、队列年份和其他护理过程后，接​​受护理过程与较低的死亡率相关，适当抗生素的调整比值比为 0.74（95% CI，0.68-0.79），0.73（95% CI，0.68） -0.78）用于超声心动图，0.61（95% CI，0.56-0.65）用于 ID 咨询。随着患者接受的护理过程数量的增加，死亡率逐渐下降（所有 3 个过程的调整优势比与没有相比，0.33；95% CI，0.30-0.36）。估计 2003 年至 2014 年间死亡率下降的 57.3%（95% CI，48.4%-69.9%）可归因于这些循证护理流程的使用增加。结论和相关性 VHA 医院与金黄色葡萄球菌菌血症相关的死亡率显着下降，死亡率下降的很大一部分可能归因于循证护理程序的使用增加。VHA 医院的经验表明，越来越多地应用这些护理程序可能会提高常规医疗保健环境中金黄色葡萄球菌菌血症患者的生存率。