Predictors of Mortality in Bloodstream Infections: Pathogens, Infection Sources, and Comorbidities

Predictors of Mortality in Bloodstream Infections: Pathogens, Infection Sources, and Comorbidities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictors of Mortality in Bloodstream Infections: Pathogens, Infection Sources, and Comorbidities Feng Qiangsheng, Song Yuejuan, Yuan xing, Ha Xiaoqin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8426546/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objective To identify risk factors influencing mortality in critically ill patients with bloodstream infections (BSIs). Methods We analyzed 2789 BSI patients diagnosed by positive blood culture between 2013 and 2023. Multivariate regression analysis was employed to assess the impact of pathogen type, underlying diseases, and infection sources on mortality. Results Overall in-hospital death was 32.3%in BSIs. Predominant pathogens were Escherichia coli (31.7%), and Klebsiella pneumoniae (14.3%). Common comorbidities included cancer (15.6%), and hematologic malignancies (14.5%). Primary infection sources were urinary tract (17.0%) and biliary tract (12.7%). Significant mortality predictors were: polymicrobial infection (OR 2.3, 95% CI 1.7-4.0), Acinetobacter baumannii (OR 2.9, 95% CI 1.7-5.0), Candida spp. (OR 6.7, 95% CI 3.5-12.9), Enterococcus spp. (OR 2.4, 95% CI 1.4-4.0), Streptococcus pneumoniae (OR 2.2, 95% CI 1.1-4.43); pulmonary (OR 2.1, 95% CI 1.6-2.8), abdominal (OR 1.9, 95% CI 1.4-2.7), intracranial (OR 2.7, 95% CI 1.4-5.3), and enterogenic BSIs (OR 1.7, 95% CI 1.3-2.3); solid tumors (OR 2.4, 95% CI 1.9-3.18), hematologic malignancies (OR 2.5, 95% CI 1.9-3.2), cerebrovascular disease (OR 2.4, 95% CI 1.6-3.5), multiple trauma (OR 1.8, 95% CI 1.3-2.6), and digestive tract damage (OR 2.1, 95% CI 1.3-3.6). All reported associations were statistically significant (p<0.01). Conclusion In this cohort, BSIs due to Candida , pulmonary or abdominal sources, and in patients with cancers or hematologic malignancies were associated with higher mortality predictors of death. BSIs Underlying diseases Infection source Mortality Risk factors Figures Figure 1 Figure 2 Figure 3 Highlights We found BSIs 28d survival rate were 0.630 ± 0.014 days. We found cancers were the frequently underlying disease with BSIs, followed by hematologic malignancy, uremia, gallstones and cholecystitis, and type 2 diabetes. We also found that the first infection source with BSIs was UTIs, followed by suppurative cholecystitis and cholangitis, pulmonary infection, and catheter-associated bloodstream infections (CABSIs). Pathogen of Candida , infection source of pulmonary infection, abdominal BSIs, intracranial infection, and enterogenic BSIs, underlying disease of cancers, hematologic malignancies, cerebrovascular disease, multiple traumas, pulmonary diseases, and digestive tract damage were the mortality risk factors in BSIs patients These four findings deserve to be widely applied clinically for preventing BSIs. 1. Introduction Sepsis is defined as life-threatening organ dysfunction resulting from a dysregulated host response to infection [ 1 ] . The 2021 International Guidelines for Management of Sepsis and Septic Shock recommend obtaining appropriate routine microbiologic cultures (including blood cultures) before initiating antimicrobial therapy [ 2 – 4 ] . While bloodstream infection (BSI) can cause sepsis, the Surviving Sepsis Campaign (SSC) guidelines emphasize that early identification and effective intervention significantly improve prognosis and reduce mortality [ 5 ] . Source control remains crucial for managing BSIs, involving drainage of abscesses (either open or percutaneous), debridement of infected tissue, restoration of normal anatomy, relief of obstructions, and preservation of physiological function [ 6 ] . Early identification of mortality risk factors is essential for successful BSI management. This study aims to investigate mortality risk factors related to pathogen characteristics, infection sources, and underlying disease burden to improve survival outcomes in BSI patients. 2. Materials and Methods 2.1 General materials We retrospectively analyzed 2 789 patient episodes confirmed by positive blood cultures, identified through our electronic medical record system. These cases were derived from 71,418 patients who underwent blood culture testing during hospitalization at a tertiary care hospital between 2013 and 2023. The study was approved by the 940 Hospital of Joint Logistics Support Force of People’s Liberation of the PLA Committee for Medical and Health Research Ethics, approval No.: [2023KYLL119]. The Ethics Committee waived the need for informed consent, as this was an observational study, the treatment of the patients was standard, and no samples were taken for the research.The study procedures complied with the ethical standards of the responsible institutional committee on human experimentation and adhered to the principles of the Helsink Declaration of 1975. 2.2 Blood Culture and Pathogenic Microbes This study included hospitalized patients with suspected bloodstream infections (BSIs) between January 2013 and January 2023. Blood cultures were collected using BacT/ALERT (bioMérieux, Durham, NC) or BD FA((Aerobic))/SN (Anaerobic) culture bottles and incubated in BacT/ALERT 3D or BD FX 400 automated systems for 7 days at the hospital's clinical microbiology laboratory.Upon positive detection, bottles underwent Gram staining and subculture. Laboratory personnel notified the primary clinical team of Gram stain results within 15 minutes of positivity. Species identification and antimicrobial susceptibility testing were performed using the VITEK 2 system (bioMérieux).A BSI episode was defined by microbial growth in blood culture plus clinical evidence of systemic infection. For common skin contaminants (coagulase-negative staphylococci, alpha-hemolytic streptococci), at least two identical isolates from separate venipunctures were required, leading to exclusion of 91 contaminated specimens and discuss with the clinician to confirm that the sample was contaminated. 2.3 Source of infection with BSIs We retrieved BSI patient data from the hospital's administrative system and obtained updated laboratory information through the Laboratory Information System (LIS). This comprehensive data collection ensured complete etiological documentation, even for patients discharged during the study period. Rule 1: Microbiological Confirmation (Highest Priority). A source is definitively confirmed if the same pathogen species with a fully compatible antimicrobial resistance profile is isolated from both the blood and a suspected focal site. Rule 2: Clinical & Radiological Correlation (Secondary Priority).If microbiological confirmation is absent, a source is designated as probable based on a clear invasive imaging finding (e.g., CT or ultrasound evidence of an abscess) from a site consistent with the patient's clinical signs, symptoms, and risk factors. Rule 3: Algorithm for Multiple Potential Sources. For patients with multiple culture-positive sites, the following comparative analysis is performed: the antimicrobial resistance profile of the bloodstream isolate is systematically compared to the profiles of isolates from all other sites. The focal site whose isolate's resistance profile is fully compatible with the bloodstream isolate's profile is assigned as the confirmed source. If no full compatibility exists, the source is designated as uncertain among the candidate sites. This rule ensures that in polymicrobial or complex scenarios, the source assignment is based on the most specific objective evidence available. Polymicrobial bloodstream infection was defined as the isolation of two or more distinct pathogenic organisms from different sets within 24–48 hours. 2.4 BSIs inpatient's underlying disease Underlying diseases—including cardio-cerebrovascular diseases, diabetes mellitus, chronic liver/kidney/respiratory diseases (e.g., COPD), malignancies, and hematologic disorders—were clinically diagnosed and systematically documented in the electronic medical record system using unique patient identifiers. Digestive tract damage is defined as structural or functional impairment of the gastrointestinal system. Enterogenic BSI refers to a Bloodstream Infection (BSI) that originates from the intestines or a gut source. Abdominal bloodstream infection (BSI) refers to a systemic infectious condition characterized by pathogenic microorganisms (e.g., bacteria, fungi) invading the circulation from an initial abdominal site, where they may establish and proliferate or release toxins. 2.5 Statistical treatment Statistical analyses were performed using SPSS(version 22.0, acknowledge the producer of SPSS) Categorical variables including age, gender, and ICU admission were analyzed using Pearson's χ² test. Statistical significance was defined as p < 0.05, with p < 0.01 indicating high significance. Multivariate regression identified the following independent predictors of mortality: pathogen, infection source and underlying disease. Kaplan-Meier survival curves were constructed with the time of first etiological diagnosis as the starting point, the survival analysis considered death within 360 days as the event of interest, with discharge from the hospital treated as a censoring event. In cases of in-hospital mortality, data were complete. Outcome data for surviving patients were collected by investigating their in-hospital outcomes alongside outpatient clinical records, missing data were omitted from the Kaplan-Meier analysis.Factors associated with in-hospital mortality were visualized using a forest plot (p < 0.01). The significance threshold was set at p < 0.05 for all analyses. 3. Results 3.1 General results and pathogen distribution with BSIs Between 2013 and 2023, bloodstream infections (BSIs) were diagnosed by positive blood cultures in 2 789 inpatients from a total of 71,418 admissions. The in-hospital mortality rate was 32.27%, corresponding to 156.5 deaths per 100,000 admissions(The hospital admits 70,000 patients annually). The BSI incidence was 485.07 per 100,000 admissions, the median age was 58(40.0–71.0), with a male-to-female ratio of 1.85.A total of 3,088 microbial strains representing 165 species were isolated, with polymicrobial infections accounting for 9.32% of cases. The distribution of pathogens was as follows: gram-negative bacilli (65.19%), gram-positive cocci (28.82%), fungi (2.67%), and anaerobic bacteria (2.61%), as detailed in Supplementary Table 1 . E.coli was the predominant pathogen (31.7%), followed by K.pneumoniae (12.2%), S. aureus (9.1%), E.faecium (3.9%), A. baumannii (3.7%), P.aeruginosa (3.7%), and S. epidermidis (3.6%). 3.2 Underlying diseases and infection source distribution with BSIs inpatients During the 2013 to 2023 period, a total of 2789 patients with underlying diseases and infection source distribution with BSIs are shown in Supplementary materials Table 2 . Cancer was the predominant underlying disease, present in 15.7% (434/2789) of patients, with a mortality rate of 46.9%. The most common malignancies included rectal cancer (2.2%), cholangiocarcinoma (2.1%), gastric cancer (1.8%), liver cancer (1.79%), and pancreatic cancer (1.4%). Infection sources in this group were: biliary tract (22.6%), enterogenic BSIs (17.3%), urinary tract (14.8%), pulmonary (11.9%), catheter-related (6.2%), abdominal (4.2%), and skin/soft tissue (2.1%).Hematologic malignancies constituted the second most common comorbidity (14.6%, 4 cases), with 45.6% mortality. Major subtypes included acute lymphoblastic leukemia (3.9%), acute non-lymphocytic leukemia (3.5%), acute myeloid leukemia (1.5%), and aplastic anemia (1.4%). Infection sources were: enterogenic BSIs (16.9%), pulmonary (14.6%), catheter-related (7.4%), urinary tract (4.9%), abdominal (2.5%), and biliary tract (2.4%). Notably, 169 cases (41.4%) had unidentified infection sources.Other significant comorbidities were uremia (6.1% prevalence, 16.2% mortality), primarily associated with catheter-related BSIs (64.1%); gallstone-related diseases with 18.1% mortality, predominantly linked to biliary infections (69.8%); and type 2 diabetes with 19.4% mortality, mainly associated with urinary tract (41.6%) and liver abscess-related BSIs (17.6%). 3.3 Infection source and pathogenic distribution with BSIs Urinary tract infections(UTI) represented the most common infection source (17.0%), followed by suppurative cholecystitis/cholangitis (12.7%), pulmonary infections (11.9%), catheter-associated BSIs (11.0%), enterogenic BSIs (7.9%), abdominal infections (7.2%), and skin/soft tissue infections (5.0%).Among 475 UTI-associated BSI cases, mortality was 18.5%, with E.coli (65.5%), K. pneumoniae (8.2%), E. faecium (3.4%), and S.aureus (3.2%) as the predominant pathogens. These cases were frequently complicated by diabetes and urological disorders (Fig. 1 ).Mortality rates varied significantly by infection source: suppurative cholecystitis/cholangitis (n = 354, 24.0% mortality) was primarily associated with E. coli (49.4%) and K. pneumoniae (18.9%); pulmonary sources (n = 332) demonstrated the highest mortality (51.6%), mainly attributed to K. pneumoniae (22.9%) and S. aureus (17.6%); catheter-associated BSIs (n = 306, 29.4% mortality) were dominated by S. epidermidis (23.4%) and S. aureus (18.8%); enterogenic BSIs (n = 220, 45.0% mortality) were chiefly caused by E. coli (34.5%) and anaerobic bacteria (16.1%); abdominal sources (n = 201, 50.25% mortality) predominantly involved E. coli (34.3%) and K. pneumoniae (13.6%); and skin/soft tissue infections (n = 139, 30.2% mortality) were mainly due to S. aureu s (36.7%) and E. coli (11.9%).Notably, 302 cases (10.8%) had unidentified infection sources, among which hematologic malignancies were the predominant underlying condition (54%). 3.4 Mortality risk factors and Multivariate regression survival analysis for BSIs Multivariate regression analysis identified several significant mortality risk factors for bloodstream infections (BSIs) (Table 1 ). Carbapenem-resistant K.pneumoniae (CRKP, p < 0.001) and carbapenem-resistant P.aeruginosa (CRPA, p = 0.002), age ≥ 60 years (OR 1.2, 95% CI 1.0-1.4, p = 0.013) and methicillin-resistant S.aureus (MRSA) (OR 1.8, 95% CI 1.1–2.9, p = 0.031) infection demonstrated significant mortality associations. Multivariate regression analysis further confirmed independent mortality predictors (Fig. 2 and Table 2 ). Significant pathogen-related factors included polymicrobial infection (OR 2.3, 95% CI 1.6–3.3), A.baumannii (OR 2.9, 95% CI 1.7-5.0), and Candida spp. (OR 6.6, 95% CI 3.5–12.3). High-risk infection sources comprised pulmonary (OR 2.1, 95% CI 1.6–2.8), abdominal (OR 1.9, 95% CI 1.4–2.7),and intracranial (OR 2.7, 95% CI 1.4–5.3). Significant comorbidities included solid cancers (OR 2.4, 95% CI 1.9–3.2), hematologic malignancies (OR 2.5, 95% CI 1.89–3.3), cerebrovascular disease (OR 2.4, 95% CI 1.6=-3.5).Kaplan-Meier survival analysis revealed a 28-day survival rate of 0.64 ± 0.01 and a 90-day survival rate of 0.33 ± 0.02, with a median survival time of 52 days (IQR 46–58) (Fig. 3 and Table 3 ). Table 1 Baseline demographics by survival status in BSIs patients (cases, %) Demographics and clinical characteristics Total(n = 2789) Non-survivor(n = 903) Survivor(n = 1886) p -value Age, years 58(40–71) 58(45–72) 56(43–69) 0.029 Age 0.013 >=60 1248(45%) 435(34%) 813(66%) < 60 1542(55%) 469(30%) 1073(70%) Sex 0.274 Male 1804(65%) 609(34%) 1195(66%) Female 975(35%) 293(30%) 582(70%) ICU Admission < 0.001 Yes 247(9%) 130(52%) 117(48%) No 2526(91%) 768(30%) 1758(70%) E.coli 0.068 ESBL+ 583(62%) 160(27%) 423(73%) ESBL- 350(38%) 94(29%) 286(71%) MRSA 0.031 Yes 88(35%) 32(36%) 55(64%) No 162(65%) 44(27%) 118(73%) CRPA 0.002 Yes 12(11%) 8(67%) 4(33%) No 94(89%) 29(31%) 65(69%) CRKP < 0.001 Yes 11(5%) 7(64%) 5(36%) No 236(95%) 76(32%) 160(68%) CRAB 0.650 Yes 74(85%) 39(53%) 35(47%) No 13(15%) 6(46%) 7(54%) Cancer 438(16%) 201(46%) 238(54%) < 0.001 Hematologic malignancies 387(14%) 179(46%) 208(54%) < 0.001 Uremia 164(6%) 27(16%) 137(86%) 0.014 Diabetes 132(5%) 27(20%) 105(80%) 0.198 Cirrhosis 108(4%) 33(31%) 75(69%) 0.317 Cerebrovascular disease 154(6%) 70(45%) 84(55%) < 0.001 Severe acute pancreatitis 75(3%) 21(28%) 54(72%) 0.696 Trauma 181(7%) 70(39%) 111(61%) 0.001 Autoimmunity disease 64(2%) 20(31%) 44(69%) 0.377 Prostatic hyperplasia 67(2%) 5(7%) 62(93%) 0.002 Digestive tract damage 68(2%) 29(43%) 39(57%) 0.004 Note: Median [IQR] or n [%] by outcome group) and indicate that p-values are from univariate tests (Mann–Whitney U, χ², or Fisher’s exact, as appropriate; age > = 60, sex, ICU admission, E.coli(ESBL+),MRSA,CRPA,CRKP,CRAB,cancer,hematologic malignancies, uremia,diabetes, cerebrovascular disease, severe acute pancreatitis, trauma, autoimmunity disease, prostatic hyperplasia, digestive tract damage are multivariate regression as appropriate. CRKP:Carbapenem-resistant Klebsiella pneumoniae CRKP:Carbapenem-resistant Klebsiella pneumoniae; CRPA:carbapenem-resistant Pseudomonas aeruginosa; MRSA:methicillin-resistant Staphylococcus aureus; CRAB :Carbapenem-resistant Acinetobacter baumannii. Table 2 Mortality (n/N, %) by pathogen and infection source in patients(cases) Pathogen and infection source Total(n/2789) Non-survivor(n = 903) Survivor(n = 1886) p -value Polymicrobial 332(11.9%) 152(46%) 180(54%) < 0.001 E.coli 862(30.9%) 247(29%) 615(71%) 0.662 S.aureus 241(8.6%) 74(31%) 168(69%) 0.642 K.pneumoniae 328(11.8%) 105(30%) 223(70%) 0.230 P.aeruginosa 85(3.0%) 27(32%) 58(68%) 0.426 Acinetobacter baumannii 77(2.8%) 40(53%) 37(47%) < 0.001 Candida 62(2.2%) 44(71%) 18(29%) < 0.001 CONs 129(4.6%) 30(23%) 99(77%) 0.427 B.melitensis 73(2.6%) 3(4%) 70(96%) < 0.001 Enterococcus spp. 81(2.9%) 39(48%) 43(52%) 0.001 Salmonella group 22(0.8%) 8(36%) 14(64%) 0.362 Str. pneumoniae 40(1.4%) 18(45.0) 23(55%) 0.026 Anaerobe 58(2.1%) 17(29%) 41(71%) 0.744 Streptococcus group 122(4.4%) 31(25%) 91(75%) 0.730 E.cloacae 68(2.4%) 14(21%) 54(79%) 0.283 Infection source UTIs BISs 474(17.0%) 90(19%) 384(81%) < 0.001 Pulmonary infection 332(11.9%) 169(51%) 163(49%) < 0.001 Abdominal BISs 201(7.2%) 98(49%) 103(51%) < 0.001 Suppurativecholecystitis and cholangitis 355(12.7) 84(24%) 271(76%) 0.002 CA-BSIs 290(10.4%) 80(28%) 210(72%) 0.106 Infectious endocarditis 87(3.1%) 25(29%) 53(71%) 0.422 Intracranial infection 40(1.4%) 23(58%) 17(42%) 0.003 SSTIs 148(5.3%) 50(34%) 98(66%) 0.879 Liver abscess 96(3.4%) 21(22%) 75(78%) 0.031 Enterogenic BISs 215(7.7%) 96(45%) 120(55%) 0.005 Bone and Joint Infection (BJI) 61(2.2%) 6(10%) 55(90%) 0.001 Data are median (IQR) or n (%). p values were calculated by Multivariate regression. Table 3 Survival Analysis of the Study Cohort (n = 2789 patients) Time Point Survival Rate (Mean ± SD) Number at risk 3 days 0.90 ± 0.01 275 7 days 0.85 ± 0.01 416 28 days 0.64 ± 0.01 735 90 days 0.33 ± 0.02 857 4. Discussions Among 2789 inpatients with bloodstream infections (BSIs) confirmed by positive blood cultures, the in-hospital mortality was 32.3%, corresponding to a mortality rate of 156.5 per 100,000 admissions. The BSI incidence rate was 485.1 per 100,000 admissions, which exceeds reported global benchmarks—mortality rates were higher than those documented in the United States (28.6%) and globally (26.7%) [ 7 ] , while the incidence rate also surpassed the global average of 189 per 100,000 person-years [ 8 ] . Our analysis of 3,088 BSI isolates identified 165 distinct species, with polymicrobial infections accounting for 9.3% of cases. The diversity of BSI pathogens underscores the importance of obtaining blood cultures and thorough pathogen identification to guide appropriate antimicrobial therapy. E.coli was the predominant pathogen (31.7%), consistent with previous reports identifying it as the most common BSI agent (28.3%) [ 9 ] . K. pneumoniae represented the second most frequent species (12.2%), aligning with published literature [ 3 ] . S.aureus ranked as the third most prevalent pathogen, with methicillin-resistant S. aureus (MRSA) which accounted for 35.10% of S. aureus isolates, highlighting the substantial burden of MRSA bacteremia in hospital settings. Malignancies represented the most prevalent underlying condition among BSI patients and were associated with high mortality (46.9%). Specific cancer types included rectal cancer, and cholangiocarcinoma. This finding aligns with established literature reporting cancer-associated BSI mortality rates of 48%-62% [ 10 ] . Furthermore, Mirouse et al [ 11 ] found that early RBC transfusion in septic hematological malignancy patients significantly increased mortality, supporting a conservative transfusion strategy. Enhanced management of BSIs during neutropenic episodes may potentially reduce mortality in cancer treatment regimens. Chronic kidney disease, including uremia, constituted the third most common comorbidity (6.1% of BSI patients). Nephrology patients have a high incidence of BSI, particularly patients undergoing haemodialysis. [ 12 ] . Gallstone-related diseases and cholecystitis represented the fourth predominant underlying condition, with a mortality rate of 18.1%. Suppurative cholecystitis and cholangitis served as the primary infection sources (69.8%), typically characterized by biliary tract obstruction, inflammation, and pyogenic infection. Optimal management requires appropriate antibiotic therapy combined with prompt surgical biliary decompression [ 13 ] . Type 2 diabetes mellitus was associated with a BSI mortality rate of 19.40%. The most frequent infection sources in this population were urinary tract infections and liver abscesses, which may be attributable to impaired glycemic control and dysregulated immune responses that compromise host defense mechanisms. Urinary tract infections represented the most common source of BSIs (17.0%), with E.coli as the predominant pathogen (65.5%). This finding is consistent with multinational surveillance data indicating that nosocomial UTI-related sepsis accounts for 12%-30% of cases [ 14 ] . Suppurative cholecystitis and cholangitis constituted the second most frequent infection source, though BSIs from these origins are rarely documented in literature. The predominant pathogens— E. coli , K. pneumoniae , and E.faecium —reflect the intestinal flora typically involved in biliary tract infections [ 15 ] . Pulmonary infections represented the third most common BSI source in our study, contrasting with reports identifying them as the primary source [ 2 , 5 ] . The relatively lower incidence may be attributed to the lower bacterial colony-forming units (CFU) typically present in pulmonary infections compared to urinary or biliary sources. Catheter-associated bloodstream infections (CABSIs) accounted for 11.0% of BSIs, aligning with Rosenthal et al.'s six-year study reporting incidence rates of 2.7 per 1000 peripheral venous catheter-days [ 16 ] . The pathogen distribution— S.epidermidis , S. aureus , other coagulase-negative staphylococci , Acinetobacter baumannii , and Candida spp. —corresponds with our findings. In the multivariate regression icreased Odds of mortality were associated with ICU admission, solid cancer….. etc. Multivariate regression analysis identified several significant mortality risk factors for BSIs, including ICU admission, hematologic malignancies, solid cancers, candidemia, carbapenem-resistant K.pneumoniae (CRKP), carbapenem-resistant P.aeruginosa (CRPA), and polymicrobial infection, all showing highly significant differences compared to controls (p < 0.01). Additionally, age ≥ 60 years (OR 1.2, 95% CI 1.0-1.4, p = 0.013) and methicillin-resistant Staphylococcus aureus (MRSA) (OR 1.8, 95% CI 1.1–2.9, p = 0.031) infection demonstrated significant mortality associations.These findings align with established literature [ 17 – 18 ] confirming that drug-resistant BSIs (CRPA, CRKP, MRSA, and candidemia) are associated with increased mortality. Furthermore, BSIs occurring during the first year following hematopoietic stem cell transplantation (HSCT) demonstrate particularly high mortality rates [ 19 ] .Our Kaplan-Meier survival analysis revealed a 28-day survival rate of 0.636 ± 0.014 for BSI patients, Higher than reported in the literature, the overall BSIs mortality rate of BSIs was 21.5% [ 20 ] . Multiple logistic regression analysis confirmed several factors significantly associated with decreased survival (all p < 0.01): pathogens including Candida species; infection sources comprising pulmonary, abdominal, intracranial, and enterogenic BSIs; and underlying conditions including cancers, hematologic malignancies, cerebrovascular disease, multiple trauma, pulmonary diseases, and digestive tract damage (all OR > 1.00). Limitations First, this is a retrospective design as our study. Second we did not capture time-to-appropriate antimicrobial therapy or time to source control, which are known determinants of survival in BSIs; therefore, residual confounding by treatment timeliness cannot be excluded. Third, this was a single-center study at a tertiary hospital, which may limit external generalizability. Fourth, the infection-source assignment relied on a predefined algorithm integrating cultures, imaging, and clinical judgment; misclassification of source-especially in polymicrobial or immunocompromised hosts-remains possible. Fifith, although we reported key organisms, detailed antimicrobial resistance phenotypes (e.g., ESBL, carbapenemase class, MICs) were not analyzed across all pathogens, precluding resistance-adjusted estimates. Finally, the retrospective design is susceptible to information bias and unmeasured confounding despite multivariable adjustment. Abbreviations BSIs: bloodstream infections BD: Becton Dickinson LIS: Laboratory Information System COPD: Chronic Obstructive Pulmonary Disease K. pneumoniae :Klebsiella pneumoniae S.aureus: Staphylococcus aureus E.coli: Escherichia coli P.aeruginosa : Pseudomonas aeruginosa S.epidermidis: Staphylococcus epidermidis CRKP:Carbapenem-resistant Klebsiella pneumoniae CRPA:carbapenem-resistant Pseudomonas aeruginosa MRSA:methicillin-resistant Staphylococcus aureus CRAB :Carbapenem-resistant Acinetobacter baumannii UTI:Urinary tract infections CFU:colony-forming units CABSIs:Catheter-associated bloodstream infections HSCT:hematopoietic stem cell transplantation OR: Odds Ratio Declarations Ethics approval and consent to participate: The study was approved by the 940 Hospital of Joint Logistics Support Force of People’s Liberation of the PLA Committee for Medical and Health Research Ethics. The Ethics Committee waived the need for informed consent, as this was an observational study, the treatment of the patients was standard, and no samples were taken for the research. Clinical Trial: There are no clinical trials available Consent for publication : All authors agree to publish articles in the journal Availability of data and material: The datasets generated and analyzed during this study are not publicly available to protect patient confidentiality. De-identified data are available from the corresponding author upon reasonable request, subject to approval by the ethics committee of [The Ethics Committee of the 940th Hospital of the Joint Logistics Support Force] (Approval No.: [2023KYLL119]; Date:2023-03-16) and compliance with institutional data protection policies. Competing interests: The authors declare that they have no competing interests. Funding: Project supported by the Key Program of Gansu Joint Research Fund（Grant No. 25JRRA1183）;Project supported by the Gansu Provincial Science and Technology Major Project (Grant No. 24ZDCA004) Authors' contributions - Feng Qiangsheng conceived the study and participated in the design, data collection, statistical analysis, data interpretation, and manuscript drafting. Song Yuejuan participated in the design, statistical analysis, data interpretation, and drafting of the manuscript. Yuan xing participated in statistical analysis and data interpretation the manuscript.Ha XiaoQin participated in the design, statistical analysis, data interpretation, and drafting of the manuscript. All the authors read and approved the final manuscript. Acknowledgements: We would like to thank our competent technicians for their diligent and accurate work in the data collection process. We would also like to thank the staff at the Microbiology Laboratory, the 940th Hospital of Joint Logistics Support Force of People’s Liberation, for consecutively including cases and sending registration forms to physicians treating the patients at the wards. References Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for sepsis and Septic Shock (sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287. PMID: 26903338; PMCID: PMC4968574.. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for the management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247. doi 10.1007/s00134-021-06506-y. Epub 2021 Oct 2. PMID: 34599691; PMCID: PMC8486643. Karen C. Carroll, Michael A. Pfaller. Manual of clinical microbiology［M］.12th ed.Washington: ASM，2019: 234－246． Pien BC, Sundaram P, Raoof N, et al. 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Ann Intensive Care. 2017 Dec;7(1):62. doi: 10.1186/s13613-017-0292-3. Epub 2017 Jun 12. PMID: 28608137; PMCID: PMC5468360. Rojas L, Muñoz P, Kestler M, Arroyo D, Guembe M, Rodríguez-Créixems M, Verde E, Bouza E. Bloodstream infections in patients with kidney disease: risk factors for poor outcome and mortality. J Hosp Infect. 2013 Nov;85(3):196-205. doi: 10.1016/j.jhin.2013.07.009. Epub 2013 Aug 31. PMID: 24001997. Chock E, Wolfe BM, Matolo NM. Acute suppurative cholangitis. Surg Clin North Am. 1981 Aug;61(4):885-92. doi: 10.1016/s0039-6109(16)42486-2. PMID: 7025298. Bonkat G, Cai T, Veeratterapillay R, et al. Management of Urosepsis in 2018. Eur Urol Focus. 2019 Jan;5(1):5-9. doi: 10.1016/j.euf.2018.11.003. Epub 2018 Nov 15. PMID: 30448051. Mizutani S, Torisu S, Kaneko Y, et al. Retrospective analysis of canine gallbladder contents in biliary sludge and gallbladder mucoceles. J Vet Med Sci. 2017 Feb 28;79(2):366-374. doi: 10.1292/jvms.16-0562. Epub 2016 Dec 17. PMID: 27990011; PMCID: PMC5326943. Rosenthal VD, Bat-Erdene I, Gupta D, et al. Six-year study on peripheral venous catheter-associated BSI rates in 262 ICUs in eight countries of South-East Asia: International Nosocomial Infection Control Consortium findings. J Vasc Access. 2021 Jan;22(1):34-41. doi: 10.1177/1129729820917259. Epub 2020 May 14. PMID: 32406328. Hassoun-Kheir N, Guedes M, Ngo Nsoga MT, et al. A systematic review on the excess health risk of antibiotic-resistant bloodstream infections for six key pathogens in Europe. Clin Microbiol Infect. 2024 Mar;30 Suppl 1:S14-S25. doi: 10.1016/j.cmi.2023.09.001. Epub 2023 Oct 4. PMID: 37802750. Pezzani MD, Arieti F, Rajendran NB, et al.Frequency of bloodstream infections caused by six key antibiotic-resistant pathogens for prioritization of research and discovery of new therapies in Europe: a systematic review. Clin Microbiol Infect. 2024 Mar;30 Suppl 1:S4-S13. doi: 10.1016/j.cmi.2023.10.019. Epub 2023 Nov 15. PMID: 38007387. Mikulska M, Del Bono V, Bruzzi P, et al. Mortality after bloodstream infections in allogeneic haematopoietic stem cell transplant (HSCT) recipients. Infection. 2012 Jun;40(3):271-8. doi: 10.1007/s15010-011-0229-y. Epub 2011 Dec 21. PMID: 22187340. Amanati A, Sajedianfard S, Khajeh S, Ghasempour S, Mehrangiz S, Nematolahi S, Shahhosein Z. Bloodstream infections in adult patients with malignancy, epidemiology, microbiology, and risk factors associated with mortality and multi-drug resistance. BMC Infect Dis. 2021 Jul 2;21(1):636. doi: 10.1186/s12879-021-06243-z. PMID: 34215207; PMCID: PMC8254331. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterialstable12.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 14 Apr, 2026 Reviews received at journal 18 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviews received at journal 26 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 15 Jan, 2026 Editor assigned by journal 24 Dec, 2025 Submission checks completed at journal 24 Dec, 2025 First submitted to journal 22 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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11:20:04","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116968,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8426546/v1/25ccf6e3cfc41c8d540308ec.html"},{"id":100676248,"identity":"af55a6fc-44a4-4f3a-840a-78a61a60c5bd","added_by":"auto","created_at":"2026-01-20 11:17:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":294415,"visible":true,"origin":"","legend":"\u003cp\u003eUTIs was the first infection source accounting for 17.0%, followed by suppurative cholecystitis and cholangitis, pulmonary infection, CABSIs, enterogenic BSIs, abdominal infection, and skin and soft tissue infections (SSTIs) accounted for 12.7%,11.9%,11.0%,7.9%,7.2%, and 5.0% respectively.\u003cstrong\u003e \u003c/strong\u003eBSIs infection source and pathogen. The 475 cases of UTIs pathogen were \u003cem\u003eE.coli, K.pneumoniae, Enterococcus faecium, and S. aureus\u003c/em\u003e, etc.. The 354 cases were suppurative cholecystitis and cholangitis pathogen were \u003cem\u003eE.coli, K.pneumoniae, Enterococcus faecium, \u003c/em\u003eand\u003cem\u003e Streptococcus spp,\u003c/em\u003e etc.. The 332 cases were pulmonary pathogen were \u003cem\u003eK.pneumoniae, S. aureus, E.coli, Ps. aeruginosa, Str. Pneumoniae, \u003c/em\u003eand\u003cem\u003e Acinetobacter baumannii\u003c/em\u003e,et al. The 306 cases where CABSI pathogens were \u003cem\u003eS. epidermidis\u003c/em\u003e, \u003cem\u003eS. aureus\u003c/em\u003e, other \u003cem\u003eCoagulase-negative staphylococci\u003c/em\u003e,\u003cem\u003e Acinetobacter baumannii, \u003c/em\u003eand\u003cem\u003e Candida spp\u003c/em\u003e. etc. The 220 cases where enterogenic source pathogens were \u003cem\u003eE.coli, Anaerobic bacteria, \u003c/em\u003eand\u003cem\u003e Salmonella group\u003c/em\u003e accounting for 34.5%,16.1%, and 8.8% respectively. The 201 cases where abdominal source pathogens were \u003cem\u003eE.coli, K. pneumoniae, Enterococcus faecium, Acinetobacter baumannii, Candida spp., Anaerobic bacteria,\u003c/em\u003e etc. The 139 cases where SSTIs pathogen were \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eE.coli, \u003c/em\u003eand, \u003cem\u003ePs. aeruginosa\u003c/em\u003e. etc. There were 302 cases (10.8%) that were unknown sources of infection, and 54% was hematologic malignancy.\u003c/p\u003e","description":"","filename":"FIG.1.png","url":"https://assets-eu.researchsquare.com/files/rs-8426546/v1/9a39698e44fa592ad9ee6c3f.png"},{"id":100676564,"identity":"f9892b02-c46e-4a50-be53-c7c4adbc2641","added_by":"auto","created_at":"2026-01-20 11:20:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":459584,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariate regression survival analysis in BSIs patients. The mortality factor of pathogen were Polymicrobial infection(OR 2.267, 95%CI 1.561–3.291, p\u0026lt;0.001), \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e(OR 2.902, 95%CI 1.690-4.983, p\u0026lt;0.001), \u003cem\u003eCandida\u003c/em\u003e(OR 6.561, 95%CI 3.505-12.284, p\u0026lt;0.001), \u003cem\u003eEnterococcus spp\u003c/em\u003e (OR 2.372, 95%CI 1.394-4.038, p=0.001), \u003cem\u003eStr. pneumoniae \u003c/em\u003e(OR 2.196, 95%CI 1.098-4.393, p=0.026). The mortality factor of Infection source were pulmonary infection (OR 2.105, 95%CI 11.583-2.801, p\u0026lt;0.001), Abdominal BSIs (OR 1.932, 95%CI 1.383-2.699, p\u0026lt;0.001), Intracranial infection (OR 2.733, 95%CI 1.421-5.257, p=0.003), and Enterogenic BSIs (OR 1.728, 95%CI 1.304-2.291, p=0.005). The mortality factor of underlying disease were of Cancers (OR 2.424, 95%CI 1.850-3.177, p\u0026lt;0.001), Hematologic malignancies (OR 2.459, 95%CI 1.861-3.250, p\u0026lt;0.001), Cerebrovascular disease(OR 2.387, 95%CI 1.645-3.463, p\u0026lt;0.001), multiple trauma(OR 1.804, 95%CI 1.263-2.576, p=0.001), and Digestive tract damage(OR 2.130, 95%CI 1.268-3.577, p=0.004).\u003c/p\u003e","description":"","filename":"FIG.2.png","url":"https://assets-eu.researchsquare.com/files/rs-8426546/v1/3b0a7be59207d0eb5eb1d91b.png"},{"id":100676096,"identity":"585b5f2a-b8ef-4d96-a7c6-65138865753d","added_by":"auto","created_at":"2026-01-20 11:16:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":35289,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meie survival curve for BSIs show the 28 days survival rate was 0.64 ± 0.01, and the 90 days survival rate was 0.33 ± 0.02 days. Interquartile range (IQR)52 days (46,58) (95% CI).\u003c/p\u003e","description":"","filename":"FiG.3.png","url":"https://assets-eu.researchsquare.com/files/rs-8426546/v1/f664f0f2c9dc359994b82bcc.png"},{"id":100797943,"identity":"825ad692-b255-4174-9f5a-79fcab17dae4","added_by":"auto","created_at":"2026-01-21 13:51:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1801259,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8426546/v1/d35b60ae-1e0e-4ed5-b144-e85f37423f5b.pdf"},{"id":100676571,"identity":"3ae989ea-2997-4eef-8617-71be7d78d36f","added_by":"auto","created_at":"2026-01-20 11:20:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34631,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterialstable12.docx","url":"https://assets-eu.researchsquare.com/files/rs-8426546/v1/63398d9477fa7ac59a83b86f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of Mortality in Bloodstream Infections: Pathogens, Infection Sources, and Comorbidities","fulltext":[{"header":"Highlights","content":"\u003col\u003e\n \u003cli\u003eWe found BSIs 28d survival rate were 0.630\u0026nbsp;\u0026plusmn;\u0026nbsp;0.014 days.\u003c/li\u003e\n \u003cli\u003eWe found\u0026nbsp;cancers were the frequently underlying disease with\u0026nbsp;BSIs,\u0026nbsp;followed by\u0026nbsp;hematologic malignancy, uremia, gallstones and cholecystitis, and type 2 diabetes.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWe also found that the first infection source with BSIs was UTIs, followed by suppurative cholecystitis and cholangitis, pulmonary infection, and catheter-associated bloodstream infections (CABSIs).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePathogen of \u003cem\u003eCandida\u003c/em\u003e, infection source of pulmonary infection, abdominal BSIs, intracranial infection, and enterogenic BSIs, underlying disease of cancers, hematologic malignancies, cerebrovascular disease, multiple traumas, pulmonary diseases, and digestive tract damage were the\u0026nbsp;mortality risk factors in BSIs patients\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese four findings deserve to be widely applied clinically for preventing BSIs.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eSepsis is defined as life-threatening organ dysfunction resulting from a dysregulated host response to infection \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The 2021 International Guidelines for Management of Sepsis and Septic Shock recommend obtaining appropriate routine microbiologic cultures (including blood cultures) before initiating antimicrobial therapy \u003csup\u003e[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. While bloodstream infection (BSI) can cause sepsis, the Surviving Sepsis Campaign (SSC) guidelines emphasize that early identification and effective intervention significantly improve prognosis and reduce mortality \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Source control remains crucial for managing BSIs, involving drainage of abscesses (either open or percutaneous), debridement of infected tissue, restoration of normal anatomy, relief of obstructions, and preservation of physiological function \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Early identification of mortality risk factors is essential for successful BSI management. This study aims to investigate mortality risk factors related to pathogen characteristics, infection sources, and underlying disease burden to improve survival outcomes in BSI patients.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 General materials\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed 2 789 patient episodes confirmed by positive blood cultures, identified through our electronic medical record system. These cases were derived from 71,418 patients who underwent blood culture testing during hospitalization at a tertiary care hospital between 2013 and 2023. The study was approved by the 940 Hospital of Joint Logistics Support Force of People\u0026rsquo;s Liberation of the PLA Committee for Medical and Health Research Ethics, approval No.: [2023KYLL119]. The Ethics Committee waived the need for informed consent, as this was an observational study, the treatment of the patients was standard, and no samples were taken for the research.The study procedures complied with the ethical standards of the responsible institutional committee on human experimentation and adhered to the principles of the Helsink Declaration of 1975.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Blood Culture and Pathogenic Microbes\u003c/h2\u003e \u003cp\u003eThis study included hospitalized patients with suspected bloodstream infections (BSIs) between January 2013 and January 2023. Blood cultures were collected using BacT/ALERT (bioM\u0026eacute;rieux, Durham, NC) or BD FA((Aerobic))/SN (Anaerobic) culture bottles and incubated in BacT/ALERT 3D or BD FX 400 automated systems for 7 days at the hospital's clinical microbiology laboratory.Upon positive detection, bottles underwent Gram staining and subculture. Laboratory personnel notified the primary clinical team of Gram stain results within 15 minutes of positivity. Species identification and antimicrobial susceptibility testing were performed using the VITEK 2 system (bioM\u0026eacute;rieux).A BSI episode was defined by microbial growth in blood culture plus clinical evidence of systemic infection. For common skin contaminants (coagulase-negative staphylococci, alpha-hemolytic streptococci), at least two identical isolates from separate venipunctures were required, leading to exclusion of 91 contaminated specimens and discuss with the clinician to confirm that the sample was contaminated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Source of infection with BSIs\u003c/h2\u003e \u003cp\u003eWe retrieved BSI patient data from the hospital's administrative system and obtained updated laboratory information through the Laboratory Information System (LIS). This comprehensive data collection ensured complete etiological documentation, even for patients discharged during the study period. Rule 1: Microbiological Confirmation (Highest Priority). A source is definitively confirmed if the same pathogen species with a fully compatible antimicrobial resistance profile is isolated from both the blood and a suspected focal site. Rule 2: Clinical \u0026amp; Radiological Correlation (Secondary Priority).If microbiological confirmation is absent, a source is designated as probable based on a clear invasive imaging finding (e.g., CT or ultrasound evidence of an abscess) from a site consistent with the patient's clinical signs, symptoms, and risk factors. Rule 3: Algorithm for Multiple Potential Sources. For patients with multiple culture-positive sites, the following comparative analysis is performed: the antimicrobial resistance profile of the bloodstream isolate is systematically compared to the profiles of isolates from all other sites. The focal site whose isolate's resistance profile is fully compatible with the bloodstream isolate's profile is assigned as the confirmed source. If no full compatibility exists, the source is designated as uncertain among the candidate sites. This rule ensures that in polymicrobial or complex scenarios, the source assignment is based on the most specific objective evidence available. Polymicrobial bloodstream infection was defined as the isolation of two or more distinct pathogenic organisms from different sets within 24\u0026ndash;48 hours.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 BSIs inpatient's underlying disease\u003c/h2\u003e \u003cp\u003eUnderlying diseases\u0026mdash;including cardio-cerebrovascular diseases, diabetes mellitus, chronic liver/kidney/respiratory diseases (e.g., COPD), malignancies, and hematologic disorders\u0026mdash;were clinically diagnosed and systematically documented in the electronic medical record system using unique patient identifiers. Digestive tract damage is defined as structural or functional impairment of the gastrointestinal system. Enterogenic BSI refers to a Bloodstream Infection (BSI) that originates from the intestines or a gut source. Abdominal bloodstream infection (BSI) refers to a systemic infectious condition characterized by pathogenic microorganisms (e.g., bacteria, fungi) invading the circulation from an initial abdominal site, where they may establish and proliferate or release toxins.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical treatment\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS(version 22.0, acknowledge the producer of SPSS) Categorical variables including age, gender, and ICU admission were analyzed using Pearson's χ\u0026sup2; test. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 indicating high significance. Multivariate regression identified the following independent predictors of mortality: pathogen, infection source and underlying disease. Kaplan-Meier survival curves were constructed with the time of first etiological diagnosis as the starting point, the survival analysis considered death within 360 days as the event of interest, with discharge from the hospital treated as a censoring event. In cases of in-hospital mortality, data were complete. Outcome data for surviving patients were collected by investigating their in-hospital outcomes alongside outpatient clinical records, missing data were omitted from the Kaplan-Meier analysis.Factors associated with in-hospital mortality were visualized using a forest plot (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The significance threshold was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 General results and pathogen distribution with BSIs\u003c/h2\u003e \u003cp\u003eBetween 2013 and 2023, bloodstream infections (BSIs) were diagnosed by positive blood cultures in 2 789 inpatients from a total of 71,418 admissions. The in-hospital mortality rate was 32.27%, corresponding to 156.5 deaths per 100,000 admissions(The hospital admits 70,000 patients annually). The BSI incidence was 485.07 per 100,000 admissions, the median age was 58(40.0\u0026ndash;71.0), with a male-to-female ratio of 1.85.A total of 3,088 microbial strains representing 165 species were isolated, with polymicrobial infections accounting for 9.32% of cases. The distribution of pathogens was as follows: gram-negative bacilli (65.19%), gram-positive cocci (28.82%), fungi (2.67%), and anaerobic bacteria (2.61%), as detailed in \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e. \u003cem\u003eE.coli\u003c/em\u003e was the predominant pathogen (31.7%), followed by \u003cem\u003eK.pneumoniae\u003c/em\u003e (12.2%), \u003cem\u003eS. aureus\u003c/em\u003e (9.1%), \u003cem\u003eE.faecium\u003c/em\u003e (3.9%), \u003cem\u003eA. baumannii\u003c/em\u003e (3.7%), \u003cem\u003eP.aeruginosa\u003c/em\u003e (3.7%), and \u003cem\u003eS. epidermidis\u003c/em\u003e (3.6%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Underlying diseases and infection source distribution with BSIs inpatients\u003c/h2\u003e \u003cp\u003eDuring the 2013 to 2023 period, a total of 2789 patients with underlying diseases and infection source distribution with BSIs are shown in \u003cb\u003eSupplementary materials Table\u0026nbsp;2\u003c/b\u003e. Cancer was the predominant underlying disease, present in 15.7% (434/2789) of patients, with a mortality rate of 46.9%. The most common malignancies included rectal cancer (2.2%), cholangiocarcinoma (2.1%), gastric cancer (1.8%), liver cancer (1.79%), and pancreatic cancer (1.4%). Infection sources in this group were: biliary tract (22.6%), enterogenic BSIs (17.3%), urinary tract (14.8%), pulmonary (11.9%), catheter-related (6.2%), abdominal (4.2%), and skin/soft tissue (2.1%).Hematologic malignancies constituted the second most common comorbidity (14.6%, 4 cases), with 45.6% mortality. Major subtypes included acute lymphoblastic leukemia (3.9%), acute non-lymphocytic leukemia (3.5%), acute myeloid leukemia (1.5%), and aplastic anemia (1.4%). Infection sources were: enterogenic BSIs (16.9%), pulmonary (14.6%), catheter-related (7.4%), urinary tract (4.9%), abdominal (2.5%), and biliary tract (2.4%). Notably, 169 cases (41.4%) had unidentified infection sources.Other significant comorbidities were uremia (6.1% prevalence, 16.2% mortality), primarily associated with catheter-related BSIs (64.1%); gallstone-related diseases with 18.1% mortality, predominantly linked to biliary infections (69.8%); and type 2 diabetes with 19.4% mortality, mainly associated with urinary tract (41.6%) and liver abscess-related BSIs (17.6%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Infection source and pathogenic distribution with BSIs\u003c/h2\u003e \u003cp\u003eUrinary tract infections(UTI) represented the most common infection source (17.0%), followed by suppurative cholecystitis/cholangitis (12.7%), pulmonary infections (11.9%), catheter-associated BSIs (11.0%), enterogenic BSIs (7.9%), abdominal infections (7.2%), and skin/soft tissue infections (5.0%).Among 475 UTI-associated BSI cases, mortality was 18.5%, with \u003cem\u003eE.coli\u003c/em\u003e (65.5%), \u003cem\u003eK. pneumoniae\u003c/em\u003e (8.2%), \u003cem\u003eE. faecium\u003c/em\u003e (3.4%), and \u003cem\u003eS.aureus\u003c/em\u003e (3.2%) as the predominant pathogens. These cases were frequently complicated by diabetes and urological disorders (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).Mortality rates varied significantly by infection source: suppurative cholecystitis/cholangitis (n\u0026thinsp;=\u0026thinsp;354, 24.0% mortality) was primarily associated with \u003cem\u003eE. coli\u003c/em\u003e (49.4%) and \u003cem\u003eK. pneumoniae\u003c/em\u003e (18.9%); pulmonary sources (n\u0026thinsp;=\u0026thinsp;332) demonstrated the highest mortality (51.6%), mainly attributed to \u003cem\u003eK. pneumoniae\u003c/em\u003e (22.9%) and \u003cem\u003eS. aureus\u003c/em\u003e (17.6%); catheter-associated BSIs (n\u0026thinsp;=\u0026thinsp;306, 29.4% mortality) were dominated by \u003cem\u003eS. epidermidis\u003c/em\u003e (23.4%) and \u003cem\u003eS. aureus\u003c/em\u003e (18.8%); enterogenic BSIs (n\u0026thinsp;=\u0026thinsp;220, 45.0% mortality) were chiefly caused by \u003cem\u003eE. coli\u003c/em\u003e (34.5%) and anaerobic bacteria (16.1%); abdominal sources (n\u0026thinsp;=\u0026thinsp;201, 50.25% mortality) predominantly involved \u003cem\u003eE. coli\u003c/em\u003e (34.3%) and \u003cem\u003eK. pneumoniae\u003c/em\u003e (13.6%); and skin/soft tissue infections (n\u0026thinsp;=\u0026thinsp;139, 30.2% mortality) were mainly due to \u003cem\u003eS. aureu\u003c/em\u003es (36.7%) and \u003cem\u003eE. coli\u003c/em\u003e (11.9%).Notably, 302 cases (10.8%) had unidentified infection sources, among which hematologic malignancies were the predominant underlying condition (54%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Mortality risk factors and Multivariate regression survival analysis for BSIs\u003c/h2\u003e \u003cp\u003eMultivariate regression analysis identified several significant mortality risk factors for bloodstream infections (BSIs) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Carbapenem-resistant \u003cem\u003eK.pneumoniae\u003c/em\u003e (CRKP, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and carbapenem-resistant \u003cem\u003eP.aeruginosa\u003c/em\u003e (CRPA, p\u0026thinsp;=\u0026thinsp;0.002), age\u0026thinsp;\u0026ge;\u0026thinsp;60 years (OR 1.2, 95% CI 1.0-1.4, p\u0026thinsp;=\u0026thinsp;0.013) and methicillin-resistant \u003cem\u003eS.aureus\u003c/em\u003e (MRSA) (OR 1.8, 95% CI 1.1\u0026ndash;2.9, p\u0026thinsp;=\u0026thinsp;0.031) infection demonstrated significant mortality associations. Multivariate regression analysis further confirmed independent mortality predictors (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003eand\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Significant pathogen-related factors included polymicrobial infection (OR 2.3, 95% CI 1.6\u0026ndash;3.3), \u003cem\u003eA.baumannii\u003c/em\u003e (OR 2.9, 95% CI 1.7-5.0), and \u003cem\u003eCandida spp.\u003c/em\u003e (OR 6.6, 95% CI 3.5\u0026ndash;12.3). High-risk infection sources comprised pulmonary (OR 2.1, 95% CI 1.6\u0026ndash;2.8), abdominal (OR 1.9, 95% CI 1.4\u0026ndash;2.7),and intracranial (OR 2.7, 95% CI 1.4\u0026ndash;5.3). Significant comorbidities included solid cancers (OR 2.4, 95% CI 1.9\u0026ndash;3.2), hematologic malignancies (OR 2.5, 95% CI 1.89\u0026ndash;3.3), cerebrovascular disease (OR 2.4, 95% CI 1.6=-3.5).Kaplan-Meier survival analysis revealed a 28-day survival rate of 0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01 and a 90-day survival rate of 0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02, with a median survival time of 52 days (IQR 46\u0026ndash;58) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003eand\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographics by survival status in BSIs patients (cases, %)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics and clinical characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal(n\u0026thinsp;=\u0026thinsp;2789)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-survivor(n\u0026thinsp;=\u0026thinsp;903)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurvivor(n\u0026thinsp;=\u0026thinsp;1886)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58(40\u0026ndash;71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58(45\u0026ndash;72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56(43\u0026ndash;69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1248(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e435(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e813(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1542(55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e469(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1073(70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1804(65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e609(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1195(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e975(35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e293(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e582(70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU Admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e247(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130(52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117(48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2526(91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e768(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1758(70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE.coli\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESBL+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e583(62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160(27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e423(73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESBL-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e350(38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e286(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88(35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55(64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162(65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e118(73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRPA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94(89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65(69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRKP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236(95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76(32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160(68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRAB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.650\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74(85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e438(16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e201(46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e238(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematologic malignancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e387(14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e179(46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e208(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUremia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e137(86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132(5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105(80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75(69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84(55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere acute pancreatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54(72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70(39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111(61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutoimmunity disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44(69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.377\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstatic hyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62(93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigestive tract damage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39(57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: Median [IQR] or n [%] by outcome group) and indicate that p-values are from univariate tests (Mann\u0026ndash;Whitney U, χ\u0026sup2;, or Fisher\u0026rsquo;s exact, as appropriate; age\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;60, sex, ICU admission, E.coli(ESBL+),MRSA,CRPA,CRKP,CRAB,cancer,hematologic malignancies, uremia,diabetes, cerebrovascular disease, severe acute pancreatitis, trauma, autoimmunity disease, prostatic hyperplasia, digestive tract damage are multivariate regression as appropriate. CRKP:Carbapenem-resistant \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e CRKP:Carbapenem-resistant \u003cem\u003eKlebsiella pneumoniae;\u003c/em\u003eCRPA:carbapenem-resistant \u003cem\u003ePseudomonas aeruginosa;\u003c/em\u003eMRSA:methicillin-resistant \u003cem\u003eStaphylococcus aureus;\u003c/em\u003e CRAB :Carbapenem-resistant \u003cem\u003eAcinetobacter baumannii.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMortality (n/N, %) by pathogen and infection source in patients(cases)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathogen and infection source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal(n/2789)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-survivor(n\u0026thinsp;=\u0026thinsp;903)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurvivor(n\u0026thinsp;=\u0026thinsp;1886)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolymicrobial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e332(11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e152(46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e180(54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e862(30.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e247(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e615(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eS.aureus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e241(8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168(69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eK.pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e328(11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e223(70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP.aeruginosa\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85(3.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58(68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAcinetobacter baumannii\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77(2.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37(47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCandida\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62(2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCONs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129(4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99(77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.427\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eB.melitensis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73(2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70(96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus spp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81(2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43(52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSalmonella group\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22(0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStr. pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40(1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23(55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAnaerobe\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58(2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStreptococcus group\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122(4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91(75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eE.cloacae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68(2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54(79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfection source\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUTIs BISs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e474(17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90(19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e384(81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e332(11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169(51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e163(49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal BISs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e201(7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98(49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103(51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuppurativecholecystitis and cholangitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e355(12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e271(76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA-BSIs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e290(10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e210(72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfectious endocarditis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87(3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40(1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSTIs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148(5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e96(3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75(78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnterogenic BISs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e215(7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120(55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone and Joint Infection (BJI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61(2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55(90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are median (IQR) or n (%). p values were calculated by Multivariate regression.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvival Analysis of the Study Cohort (n\u0026thinsp;=\u0026thinsp;2789 patients)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvival Rate (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber at risk\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussions","content":"\u003cp\u003eAmong 2789 inpatients with bloodstream infections (BSIs) confirmed by positive blood cultures, the in-hospital mortality was 32.3%, corresponding to a mortality rate of 156.5 per 100,000 admissions. The BSI incidence rate was 485.1 per 100,000 admissions, which exceeds reported global benchmarks\u0026mdash;mortality rates were higher than those documented in the United States (28.6%) and globally (26.7%) \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, while the incidence rate also surpassed the global average of 189 per 100,000 person-years \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur analysis of 3,088 BSI isolates identified 165 distinct species, with polymicrobial infections accounting for 9.3% of cases. The diversity of BSI pathogens underscores the importance of obtaining blood cultures and thorough pathogen identification to guide appropriate antimicrobial therapy. \u003cem\u003eE.coli\u003c/em\u003e was the predominant pathogen (31.7%), consistent with previous reports identifying it as the most common BSI agent (28.3%) \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. \u003cem\u003eK. pneumoniae\u003c/em\u003e represented the second most frequent species (12.2%), aligning with published literature \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. \u003cem\u003eS.aureus\u003c/em\u003e ranked as the third most prevalent pathogen, with methicillin-resistant \u003cem\u003eS. aureus\u003c/em\u003e (MRSA) which accounted for 35.10% of S. aureus isolates, highlighting the substantial burden of MRSA bacteremia in hospital settings.\u003c/p\u003e \u003cp\u003eMalignancies represented the most prevalent underlying condition among BSI patients and were associated with high mortality (46.9%). Specific cancer types included rectal cancer, and cholangiocarcinoma. This finding aligns with established literature reporting cancer-associated BSI mortality rates of 48%-62% \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Furthermore, Mirouse et al \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e found that early RBC transfusion in septic hematological malignancy patients significantly increased mortality, supporting a conservative transfusion strategy. Enhanced management of BSIs during neutropenic episodes may potentially reduce mortality in cancer treatment regimens. Chronic kidney disease, including uremia, constituted the third most common comorbidity (6.1% of BSI patients). Nephrology patients have a high incidence of BSI, particularly patients undergoing haemodialysis. \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Gallstone-related diseases and cholecystitis represented the fourth predominant underlying condition, with a mortality rate of 18.1%. Suppurative cholecystitis and cholangitis served as the primary infection sources (69.8%), typically characterized by biliary tract obstruction, inflammation, and pyogenic infection. Optimal management requires appropriate antibiotic therapy combined with prompt surgical biliary decompression \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Type 2 diabetes mellitus was associated with a BSI mortality rate of 19.40%. The most frequent infection sources in this population were urinary tract infections and liver abscesses, which may be attributable to impaired glycemic control and dysregulated immune responses that compromise host defense mechanisms.\u003c/p\u003e \u003cp\u003eUrinary tract infections represented the most common source of BSIs (17.0%), with \u003cem\u003eE.coli\u003c/em\u003e as the predominant pathogen (65.5%). This finding is consistent with multinational surveillance data indicating that nosocomial UTI-related sepsis accounts for 12%-30% of cases \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Suppurative cholecystitis and cholangitis constituted the second most frequent infection source, though BSIs from these origins are rarely documented in literature. The predominant pathogens\u0026mdash;\u003cem\u003eE. coli\u003c/em\u003e, \u003cem\u003eK. pneumoniae\u003c/em\u003e, and \u003cem\u003eE.faecium\u003c/em\u003e\u0026mdash;reflect the intestinal flora typically involved in biliary tract infections \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Pulmonary infections represented the third most common BSI source in our study, contrasting with reports identifying them as the primary source \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. The relatively lower incidence may be attributed to the lower bacterial colony-forming units (CFU) typically present in pulmonary infections compared to urinary or biliary sources. Catheter-associated bloodstream infections (CABSIs) accounted for 11.0% of BSIs, aligning with Rosenthal et al.'s six-year study reporting incidence rates of 2.7 per 1000 peripheral venous catheter-days \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. The pathogen distribution\u0026mdash;\u003cem\u003eS.epidermidis\u003c/em\u003e, \u003cem\u003eS. aureus\u003c/em\u003e, other \u003cem\u003ecoagulase-negative staphylococci\u003c/em\u003e, \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e, and \u003cem\u003eCandida spp.\u003c/em\u003e\u0026mdash;corresponds with our findings.\u003c/p\u003e \u003cp\u003eIn the multivariate regression icreased Odds of mortality were associated with ICU admission, solid cancer\u0026hellip;.. etc. Multivariate regression analysis identified several significant mortality risk factors for BSIs, including ICU admission, hematologic malignancies, solid cancers, candidemia, carbapenem-resistant \u003cem\u003eK.pneumoniae\u003c/em\u003e (CRKP), carbapenem-resistant \u003cem\u003eP.aeruginosa\u003c/em\u003e (CRPA), and polymicrobial infection, all showing highly significant differences compared to controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Additionally, age\u0026thinsp;\u0026ge;\u0026thinsp;60 years (OR 1.2, 95% CI 1.0-1.4, p\u0026thinsp;=\u0026thinsp;0.013) and methicillin-resistant Staphylococcus aureus (MRSA) (OR 1.8, 95% CI 1.1\u0026ndash;2.9, p\u0026thinsp;=\u0026thinsp;0.031) infection demonstrated significant mortality associations.These findings align with established literature \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e confirming that drug-resistant BSIs (CRPA, CRKP, MRSA, and candidemia) are associated with increased mortality. Furthermore, BSIs occurring during the first year following hematopoietic stem cell transplantation (HSCT) demonstrate particularly high mortality rates \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.Our Kaplan-Meier survival analysis revealed a 28-day survival rate of 0.636\u0026thinsp;\u0026plusmn;\u0026thinsp;0.014 for BSI patients, Higher than reported in the literature, the overall BSIs mortality rate of BSIs was 21.5% \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Multiple logistic regression analysis confirmed several factors significantly associated with decreased survival (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.01): pathogens including \u003cem\u003eCandida\u003c/em\u003e species; infection sources comprising pulmonary, abdominal, intracranial, and enterogenic BSIs; and underlying conditions including cancers, hematologic malignancies, cerebrovascular disease, multiple trauma, pulmonary diseases, and digestive tract damage (all OR\u0026thinsp;\u0026gt;\u0026thinsp;1.00).\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFirst, this is a retrospective design as our study. Second we did not capture time-to-appropriate antimicrobial therapy or time to source control, which are known determinants of survival in BSIs; therefore, residual confounding by treatment timeliness cannot be excluded. Third, this was a single-center study at a tertiary hospital, which may limit external generalizability. Fourth, the infection-source assignment relied on a predefined algorithm integrating cultures, imaging, and clinical judgment; misclassification of source-especially in polymicrobial or immunocompromised hosts-remains possible. Fifith, although we reported key organisms, detailed antimicrobial resistance phenotypes (e.g., ESBL, carbapenemase class, MICs) were not analyzed across all pathogens, precluding resistance-adjusted estimates. Finally, the retrospective design is susceptible to information bias and unmeasured confounding despite multivariable adjustment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBSIs: bloodstream infections\u003c/p\u003e\n\u003cp\u003eBD: Becton Dickinson\u003c/p\u003e\n\u003cp\u003eLIS: Laboratory Information System\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOPD: Chronic Obstructive Pulmonary Disease\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eK. pneumoniae :Klebsiella pneumoniae\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eS.aureus: Staphylococcus aureus\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eE.coli: Escherichia coli\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP.aeruginosa : Pseudomonas aeruginosa\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eS.epidermidis: Staphylococcus epidermidis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCRKP:Carbapenem-resistant \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCRPA:carbapenem-resistant \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMRSA:methicillin-resistant \u003cem\u003eStaphylococcus aureus\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCRAB\u003cem\u003e\u0026nbsp;\u003c/em\u003e:Carbapenem-resistant\u003cem\u003e\u0026nbsp;Acinetobacter baumannii\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUTI:Urinary tract infections\u003c/p\u003e\n\u003cp\u003eCFU:colony-forming units\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCABSIs:Catheter-associated bloodstream infections\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHSCT:hematopoietic stem cell transplantation\u003c/p\u003e\n\u003cp\u003eOR: Odds Ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study was approved by the 940 Hospital of Joint Logistics Support Force of People\u0026rsquo;s Liberation of the PLA Committee for Medical and Health Research Ethics. The Ethics Committee waived the need for informed consent, as this was an observational study, the treatment of the patients was standard, and no samples were taken for the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial:\u003c/strong\u003e \u003cstrong\u003eThere are no clinical trials available\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: All authors agree to publish articles in the journal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e The datasets generated and analyzed during this study are not publicly available to protect patient confidentiality. De-identified data are available from the corresponding author upon reasonable request, subject to approval by the ethics committee of [The Ethics Committee of the 940th Hospital of the Joint Logistics Support Force] (Approval No.: [2023KYLL119]; Date:2023-03-16) and compliance with institutional data protection policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eProject supported by the Key Program of Gansu Joint Research Fund（Grant No. 25JRRA1183）;Project supported by the Gansu Provincial Science and Technology Major Project (Grant No. 24ZDCA004)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions -\u003c/strong\u003e Feng Qiangsheng conceived the study and participated in the design, data collection, statistical analysis, data interpretation, and manuscript drafting. Song Yuejuan participated in the design, statistical analysis, data interpretation, and drafting of the manuscript. Yuan xing participated in statistical analysis and data interpretation the manuscript.Ha XiaoQin participated in the design, statistical analysis, data interpretation, and drafting of the manuscript. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We would like to thank our competent technicians for their diligent and accurate work in the data collection process. We would also like to thank the staff at the Microbiology Laboratory, the 940th Hospital of Joint Logistics Support Force of People\u0026rsquo;s Liberation, for consecutively including cases and sending registration forms to physicians treating the patients at the wards.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSinger M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for sepsis and Septic Shock (sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287. PMID: 26903338; PMCID: PMC4968574..\u003c/li\u003e\n\u003cli\u003eEvans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for the management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247. doi 10.1007/s00134-021-06506-y. Epub 2021 Oct 2. PMID: 34599691; PMCID: PMC8486643.\u003c/li\u003e\n\u003cli\u003eKaren C. Carroll, Michael A. Pfaller. Manual of clinical microbiology［M］.12th ed.Washington: ASM，2019: 234－246．\u003c/li\u003e\n\u003cli\u003ePien BC, Sundaram P, Raoof N, et al. The clinical and prognostic importance of positive blood cultures in adults[J]. Am J Med ,2010,123:819\u0026ndash;828.\u003c/li\u003e\n\u003cli\u003eR. P. Dellinger, J. M. Carlet, H.Masur, et al., Surviving sepsis Campaign guidelines for management of severe BSIs and septic shock Critical[J].CareMedicine.2004,32(3): 858\u0026ndash;873.\u003c/li\u003e\n\u003cli\u003eDe Waele JJ, Girardis M, Martin-Loeches I. Source control in the management of sepsis and septic shock. Intensive Care Med. 2022 Dec;48(12):1799-1802. doi: 10.1007/s00134-022-06852-5. Epub 2022 Sep 14. PMID: 36102944.\u003c/li\u003e\n\u003cli\u003eBaron Ej, Miller JM, Weinstein MP, et al.A Guide toUtilization of the Mirobiology Laboratorty for Diagnosie of Infections Disease:2013 Recommendations by the Infections Disease Society of America(IDSA) and the American Society for Microbiology(ASM) [J].Clin Infect Dis,2013,33(24):3020-3021.\u003c/li\u003e\n\u003cli\u003eRudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study [J]. Lancet, 2020, 395(10219):200-211.\u003c/li\u003e\n\u003cli\u003eBuetti Niccol\u0026ograve;,Marschall Jonas,Atkinson Andrew et al. National Bloodstream Infection Surveillance in Switzerland 2008-2014: Different Patterns and Trends for University and Community Hospitals.[J] ., 2016, 37(9): 1060-7.\u003c/li\u003e\n\u003cli\u003eNazer L, Lopez-Olivo MA, Cuenca JA, Awad W, Brown AR, Abusara A, Sirimaturos M, Hicklen RS, Nates JL. All-cause mortality in cancer patients treated for sepsis in intensive care units: a systematic review and meta-analysis. Support Care Cancer. 2022 Dec;30(12):10099-10109. doi: 10.1007/s00520-022-07392-w. Epub 2022 Oct 10. PMID: 36214879; PMCID: PMC9549043.\u003c/li\u003e\n\u003cli\u003eMirouse A, Resche-Rigon M, Lemiale V, Mokart D, Kouatchet A, Mayaux J, Vincent F, Nyunga M, Bruneel F, Rabbat A, Lebert C, Perez P, Renault A, Meert AP, Benoit D, Hamidfar R, Jourdain M, Darmon M, Azoulay E, P\u0026egrave;ne F; Groupe de Recherche sur la R\u0026eacute;animation Respiratoire en Onco-H\u0026eacute;matologie (Grrr-OH). Red blood cell transfusion in the resuscitation of septic patients with hematological malignancies. Ann Intensive Care. 2017 Dec;7(1):62. doi: 10.1186/s13613-017-0292-3. Epub 2017 Jun 12. PMID: 28608137; PMCID: PMC5468360.\u003c/li\u003e\n\u003cli\u003eRojas L, Mu\u0026ntilde;oz P, Kestler M, Arroyo D, Guembe M, Rodr\u0026iacute;guez-Cr\u0026eacute;ixems M, Verde E, Bouza E. Bloodstream infections in patients with kidney disease: risk factors for poor outcome and mortality. J Hosp Infect. 2013 Nov;85(3):196-205. doi: 10.1016/j.jhin.2013.07.009. Epub 2013 Aug 31. PMID: 24001997.\u003c/li\u003e\n\u003cli\u003eChock E, Wolfe BM, Matolo NM. Acute suppurative cholangitis. Surg Clin North Am. 1981 Aug;61(4):885-92. doi: 10.1016/s0039-6109(16)42486-2. PMID: 7025298.\u003c/li\u003e\n\u003cli\u003eBonkat G, Cai T, Veeratterapillay R, et al. Management of Urosepsis in 2018. Eur Urol Focus. 2019 Jan;5(1):5-9. doi: 10.1016/j.euf.2018.11.003. Epub 2018 Nov 15. PMID: 30448051.\u003c/li\u003e\n\u003cli\u003eMizutani S, Torisu S, Kaneko Y, et al. Retrospective analysis of canine gallbladder contents in biliary sludge and gallbladder mucoceles. J Vet Med Sci. 2017 Feb 28;79(2):366-374. doi: 10.1292/jvms.16-0562. Epub 2016 Dec 17. PMID: 27990011; PMCID: PMC5326943.\u003c/li\u003e\n\u003cli\u003eRosenthal VD, Bat-Erdene I, Gupta D, et al. Six-year study on peripheral venous catheter-associated BSI rates in 262 ICUs in eight countries of South-East Asia: International Nosocomial Infection Control Consortium findings. J Vasc Access. 2021 Jan;22(1):34-41. doi: 10.1177/1129729820917259. Epub 2020 May 14. PMID: 32406328.\u003c/li\u003e\n\u003cli\u003eHassoun-Kheir N, Guedes M, Ngo Nsoga MT, et al. A systematic review on the excess health risk of antibiotic-resistant bloodstream infections for six key pathogens in Europe. Clin Microbiol Infect. 2024 Mar;30 Suppl 1:S14-S25. doi: 10.1016/j.cmi.2023.09.001. Epub 2023 Oct 4. PMID: 37802750.\u003c/li\u003e\n\u003cli\u003ePezzani MD, Arieti F, Rajendran NB, et al.Frequency of bloodstream infections caused by six key antibiotic-resistant pathogens for prioritization of research and discovery of new therapies in Europe: a systematic review. Clin Microbiol Infect. 2024 Mar;30 Suppl 1:S4-S13. doi: 10.1016/j.cmi.2023.10.019. Epub 2023 Nov 15. PMID: 38007387.\u003c/li\u003e\n\u003cli\u003eMikulska M, Del Bono V, Bruzzi P, et al. Mortality after bloodstream infections in allogeneic haematopoietic stem cell transplant (HSCT) recipients. Infection. 2012 Jun;40(3):271-8. doi: 10.1007/s15010-011-0229-y. Epub 2011 Dec 21. PMID: 22187340.\u003c/li\u003e\n\u003cli\u003eAmanati A, Sajedianfard S, Khajeh S, Ghasempour S, Mehrangiz S, Nematolahi S, Shahhosein Z. Bloodstream infections in adult patients with malignancy, epidemiology, microbiology, and risk factors associated with mortality and multi-drug resistance. BMC Infect Dis. 2021 Jul 2;21(1):636. doi: 10.1186/s12879-021-06243-z. PMID: 34215207; PMCID: PMC8254331.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"BSIs, Underlying diseases, Infection source, Mortality, Risk factors","lastPublishedDoi":"10.21203/rs.3.rs-8426546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8426546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective \u003c/strong\u003eTo identify risk factors influencing mortality in critically ill patients with bloodstream infections (BSIs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eWe analyzed 2789 BSI patients diagnosed by positive blood culture between 2013 and 2023. Multivariate regression analysis was employed to assess the impact of pathogen type, underlying diseases, and infection sources on mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eOverall in-hospital death was 32.3%in BSIs. Predominant pathogens were \u003cem\u003eEscherichia coli\u003c/em\u003e (31.7%), and\u003cem\u003e Klebsiella pneumoniae\u003c/em\u003e (14.3%). Common comorbidities included cancer (15.6%), and hematologic malignancies (14.5%). Primary infection sources were urinary tract (17.0%) and biliary tract (12.7%). Significant mortality predictors were: polymicrobial infection (OR 2.3, 95% CI 1.7-4.0), \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e (OR 2.9, 95% CI 1.7-5.0), \u003cem\u003eCandida spp.\u003c/em\u003e (OR 6.7, 95% CI 3.5-12.9), \u003cem\u003eEnterococcus spp.\u003c/em\u003e (OR 2.4, 95% CI 1.4-4.0), \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e (OR 2.2, 95% CI 1.1-4.43); pulmonary (OR 2.1, 95% CI 1.6-2.8), abdominal (OR 1.9, 95% CI 1.4-2.7), intracranial (OR 2.7, 95% CI 1.4-5.3), and enterogenic BSIs (OR 1.7, 95% CI 1.3-2.3); solid tumors (OR 2.4, 95% CI 1.9-3.18), hematologic malignancies (OR 2.5, 95% CI 1.9-3.2), cerebrovascular disease (OR 2.4, 95% CI 1.6-3.5), multiple trauma (OR 1.8, 95% CI 1.3-2.6), and digestive tract damage (OR 2.1, 95% CI 1.3-3.6). All reported associations were statistically significant (p\u0026lt;0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eIn this cohort, BSIs due to \u003cem\u003eCandida\u003c/em\u003e, pulmonary or abdominal sources, and in patients with cancers or hematologic malignancies were associated with higher mortality predictors of death.\u003c/p\u003e","manuscriptTitle":"Predictors of Mortality in Bloodstream Infections: Pathogens, Infection Sources, and Comorbidities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 09:43:58","doi":"10.21203/rs.3.rs-8426546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-14T06:54:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T04:26:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-03-10T08:52:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T07:51:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258824520845961947982760518160459736477","date":"2026-01-21T02:12:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-15T18:23:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-24T14:08:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-24T14:06:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2025-12-22T15:18:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d5406e98-db58-48e3-a899-9b623fa3a19d","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T06:10:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 09:43:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8426546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8426546","identity":"rs-8426546","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}