Time to positivity in Staphylococcus aureus bacteremia:: Possible correlation with the source and outcome of infection

Background. Staphylococcus aureus bacteremia often persists and causes metastatic infections. It is unknown whether the time between blood culture incubation and growth detection (i.e., the time to positivity) in a continuously monitored system - a probable surrogate marker of bacteremia severity - correlates with outcome. Methods. We performed a prospective, observational study involving adult inpatients who had S. aureus bacteremia between 1 January 2002 and 30 June 2003 at a 600-bed teaching hospital. Measurements included time to positivity in initial blood culture series, duration of bacteremia, rate of metastatic infection, and outcome. Results. A total of 376 S. aureus bacteremias (>= 1 positive blood culture result) were reported for 357 patients aged 18 - 103 years (median age, 59 years); 64 bacteremias were excluded because blood was drawn after antibiotic therapy was started (n = 59) or through an intravascular catheter (n = 5). The source of infection was identified in 244 series (78.2%). Metastatic infection was detected in 25 bacteremias (8.0%). The mortality rate was 25.6%. The duration of bacteremia (determined in 251 series) was 1 - 59 days (median duration, 1 day; 70th percentile, 3 days). The time to positivity ranged from 4.2 to 98.2 h (median time to positivity, 15.5 h) and was significantly shorter for patients with an endovascular source of infection (14.9 +/- 5.4 vs. 19.5 +/- 10.6 P < .0005 h;), extended duration (i.e., >= 3 days) of bacteremia (14.1 +/- 4.2 vs. 18.6 +/- 9.2 h; P < .0005), and metastatic infection (12.9 +/- 5.9 vs 18.0 +/- 9.3 h; P = .007). Analysis of a range of cutoff values demonstrated that a time to positivity of <= 14 h yielded the best sensitivity and specificity for predicting the source and outcome of infection. Logistic regression analyses revealed that a time to positivity of <= 14 h was an independent predictor of an endovascular source of infection (P < .0005), extended bacteremia (P < .0005), metastatic infection (P < .0005), and attributable mortality (P = .017). Conclusions. Time to positivity in S. aureus bacteremia may provide useful diagnostic and prognostic information. Growth of S. aureus within 14 h after the initiation of incubation may identify patients with a high likelihood of endovascular infection sources, delayed clearance, and complications.