Skip to main content Accessibility help

Incidence of and Risk Factors for Nosocomial Bloodstream Infections in Adults in the United States, 2003

  • Omar M. AL-Rawajfah (a1), Frank Stetzer (a2) and Jeanne Beauchamp Hewitt (a3) (a4)



Although many studies have examined nosocomial bloodstream infection (BSI), US national estimates of incidence and case-fatality rates have seldom been reported.


The purposes of this study were to generate US national estimates of the incidence and severity of nosocomial BSI and to identify risk factors for nosocomial BSI among adults hospitalized in the United States on the basis of a national probability sample.


This cross-sectional study used the US Nationwide Inpatient Sample for the year 2003 to estimate the incidence and case-fatality rate associated with nosocomial BSI in the total US population. Cases of nosocomial BSI were defined by using 1 or more International Classification of Diseases, 9th Revision, Clinical Modification codes in the secondary field(s) that corresponded to BSIs that occurred at least 48 hours after admission. The comparison group consisted of all patients without BSI codes in their NIS records. Weighted data were used to generate US national estimates of nosocomial BSIs. Logistic regression was used to identify independent risk factors for nosocomial BSI.


The US national estimated incidence of nosocomial BSI was 21.6 cases per 1,000 admissions, while the estimated case-fatality rate was 20.6%. Seven of the 10 leading causes of hospital admissions associated with nosocomial BSI were infection related. We estimate that 541,081 patients would have acquired a nosocomial BSI in 2003, and of these, 111,427 would have died. The final multivariate model consisted of the following risk factors: central venous catheter use (odds ratio [OR], 4.76), other infections (OR, 4.61), receipt of mechanical ventilation (OR, 4.97), trauma (OR, 1.98), hemodialysis (OR, 4.83), and malnutrition (OR, 2.50). The total maximum rescaled R2 was 0.22.


The Nationwide Inpatient Sample was useful for estimating national incidence and case-fatality rates, as well as examining independent predictors of nosocomial BSI.


Corresponding author

Faculty of Nursing, Al al-Bayt University, PO Box 130040, Mafraq, Jordan 25113 (


Hide All
1.Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
2.Freid, VM, Prager, K, MacKay, AP, Xia, H. Health, United States, 2003: Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics; 2003.
3.National Center for Health Statistics (NCHS). Data systems of the National Center for Health Statistics. NCHS document. Hyattsville, MD: NCHS, 1981:PHS82-1318.
4.Wisplinghoff, H, Bischoff, T, Tallent, SM, Seifert, H, Wenzel, RP, Edmond, MB. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004;39:309317.
5.Edmond, MB, Wallace, SE, McClish, DK, Pfaller, MA, Jones, RN, Wenzel, RP. Nosocomial bloodstream infections in United States hospitals: a three-year analysis. Clin Infect Dis 1999;29:239244.
6.Laupland, KB, Zygun, DA, Davies, HD, Church, DL, Louie, TJ, Doig, CJ. Population-based assessment of intensive care unit-acquired bloodstream infections in adults: incidence, risk factors, and associated mortality rate. Crit Care Med 2002;30:24622467.
7.Suljagic, V, Cobeljic, M, Jankovic, S, et al.Nosocomial bloodstream infections in ICU and non-ICU patients. Am J Infect Control 2005;33:333340.
8.Kim, PW, Perl, TM, Keelaghan, EF, et al.Risk of mortality with a bloodstream infection is higher in the less severely ill at admission. Am J Respir Crit Care Med 2005;171:616620.
9.Laupland, KB, Gregson, DB, Kirkpatrick, AW, et al.Bloodstream infection complicating trauma. Clin Invest Med 2004;27:253258.
10.Crabtree, TD, Pelletier, SJ, Gleason, TG, Pruett, TL, Sawyer, RG. Gender-dependent differences in outcome after the treatment of infection in hospitalized patients. JAMA 1999;282:21432148.
11.Laupland, KB, Gregson, DB, Zygun, DA, Doig, CJ, Mortis, G, Church, DL. Severe bloodstream infections: a population-based assessment. Crit Care Med 2004;32:992997.
12.Pittet, D, Davis, CS, Li, N, Wenzel, RP. Identifying the hospitalized patient at risk for nosocomial bloodstream infection: a population-based study. Proc Assoc Am Physicians 1997;109:5867.
13.Saint, S, Kaufman, SR, Rogers, MA, Baker, PD, Boyko, EJ, Lipsky, BA. Risk factors for nosocomial urinary tract–related bacteremia: a case-control study. Am J Infect Control 2006;34:401407.
14.Pittet, D, Thievent, B, Wenzel, RP, Li, N, Gurman, G, Suter, PM. Importance of pre-existing co-morbidities for prognosis of septicemia in critically ill patients. Intensive Care Med 1993;19:265272.
15.Leibovici, L, Paul, M, Weinberger, M, et al.Excess mortality in women with hospital-acquired bloodstream infection. Am J Med 2001;111:120125.
16.Munoz, P, Blanco, JR, Rodriguez-Creixems, M, Garcia, E, Delcan, JL, Bouza, E. Bloodstream infections after invasive nonsurgical cardiologic procedures. Arch Intern Med 2001;161:21102115.
17.Warren, DK, Zack, JE, Elward, AM, Cox, MJ, Fraser, VJ. Nosocomial primary bloodstream infections in intensive care unit patients in a non-teaching community medical center: a 21-month prospective study. Clin Infect Dis 2001;33:13291335.
18.Rojo, D, Pinedo, A, Clavijo, E, Garcia-Rodriguez, A, Garcia, V. Analysis of risk factors associated with nosocomial bacteraemias. J Hosp Infect 1999;42:135141.
19.Gross, PA, DeMauro, PJ, Van Antwerpen, C, Wallenstein, S, Chiang, S. Number of comorbidities as a predictor of nosocomial infection acquisition. Infect Control Hosp Epidemiol 1988;9:497500.
20.Jamulitrat, S, Meknavin, U, Thongpiyapoom, S. Factors affecting mortality outcome and risk of developing nosocomial bloodstream infection. Infect Control Hosp Epidemiol 1994;15:163170.
21.Laupland, KB, Kirkpatrick, AW, Church, DL, Ross, T, Gregson, DB. Intensive-care-unit-acquired bloodstream infections in a regional critically ill population. J Hosp Infect 2004;58:137145.
22.Samore, MH, Wessolossky, MA, Lewis, SM, Shubrooks, SJ JrKarchmer, AW. Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol 1997;79:873877.
23.Pittet, D. Nosocomial bloodstream infections. In: Wenzel, RP, ed. Prevention and Control of Nosocomial Infection. 3rd ed. Baltimore, MD: Williams and Wilkins; 1997:711769.
24.Ryan, T, Mc Carthy, JF, Rady, MY, et al.Early bloodstream infection after cardiopulmonary bypass: frequency rate, risk factors, and implications. Crit Care Med 1997;25:20092014.
25.Jensen, AG, Wachmann, CH, Poulsen, KB, et al.Risk factors for hospital-acquired Staphylococcus aureus bacteremia. Arch Intern Med 1999;159:14371444.
26.Pawar, M, Mehta, Y, Kapoor, P, Sharma, J, Gupta, A, Trehan, N. Central venous catheter-related blood stream infections: incidence, risk factors, outcome, and associated pathogens. J Cardiothorac Vase Anesth 2004;18:304308.
27.Siegman-Igra, Y, Jacobi, E, Lang, R, Schwartz, D, Carmeli, Y. Unexpected hospital-acquired bacteraemia in patients at low risk of bloodstream infection: the role of a heparin drip. J Hosp Infect 2005;60:122128.
28.Robert, J, Fridkin, SK, Blumberg, HM, et al.The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infect Control Hosp Epidemiol 2000;21:1217.
29.Rubinson, L, Diette, GB, Song, X, Brower, RG, Krishnan, JA. Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit. Crit Care Med 2004;32:350357.
30.Yoshida, T, Tsushima, K, Tsuchiya, A, et al.Risk factors for hospital-acquired bacteremia. Intern Med 2005;44:11571162.
31.Warren, DK, Quadir, WW, Hollenbeak, CS, Elward, AM, Cox, MJ, Fraser, VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Crit Care Med 2006;34:20842089.
32.Shorr, AF, Jackson, WL, Kelly, KM, Fu, M, Kollef, MH. Transfusion practice and blood stream infections in critically ill patients. Chest 2005;127:17221728.
33.Alonso-Echanove, J, Edwards, JR, Richards, MJ, et al.Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infect Control Hosp Epidemiol 2003;24:916925.
34.Fridkin, SK, Pear, SM, Williamson, TH, Galgiani, JN, Jarvis, WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996;17:150158.
35.Rodriguez, C, Munoz, P, Rodriguez-Creixems, M, Yanez, JF, Palomo, J, Bouza, E. Bloodstream infections among heart transplant recipients. Transplantation 2006;81:384391.
36.Agency for Healthcare Research and Quality. HCUP nationwide inpatient sample: design of the HCUP nationwide inpatient sample, 2003. Rockville, MD: Agency for Healthcare Research and Quality, 2005.
37.Agency for Healthcare Research and Quality. Introduction to the HCUP nationwide inpatient sample (NIS), 2003. Rockville, MD: Agency for Healthcare Research and Quality; 2005.
38.Centers for Disease Control and Prevention. CDC definitions for nosocomial infections. Am J Infect Control 1989;17:4243.
39.O'Grady, NP, Alexander, M, Dellinger, EP, et al.Guidelines for the prevention of intravascular catheter-related infections: Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10):129.
40.Shorr, AF, Tabak, YP, Killian, AD, Gupta, V, Liu, LZ, Kollef, MH. Healthcare-associated bloodstream infection: a distinct entity? insights from a large U.S. database. Crit Care Med 2006;34:25882595.
41.Edgeworth, JD, Treacher, DF, Eykyn, SJ. A 25-year study of nosocomial bacteremia in an adult intensive care unit. Crit Care Med 1999;27:14211428.
42.ICD.9.CM. International Classification of Diseases, 9th Revision. Clinical Modification. Hyattsville, MD: National Center for Health Statistics; 2002. Available at: Accessed November, 2006.
43.Swanson, K, Hyatt, K. ICD.9.CM. International Classification of Diseases, 9th Revision. Clinical Modification. Vols. 1, 2, 3; 6th ed. Los Angeles, CA: Practice Management Information Corporation; 2002.
44.Braun, L, Riedel, AA, Cooper, LM. Severe sepsis in managed care: analysis of incidence, one-year mortality, and associated costs of care. J Manag Care Pharm 2004;10:521530.
45.Williams, MD, Braun, LA, Cooper, LM, et al.Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care. Crit Care 2004;8:R291R298.
46.Diekema, DJ, Beekmann, SE, Chapin, KC, Morel, KA, Munson, E, Doern, GV. Epidemiology and outcome of nosocomial and community-onset bloodstream infection. J Clin Microbiol 2003;41:36553660.
47.Dombrovskiy, VY, Martin, AA, Sunderram, J, Paz, HL. Facing the challenge: decreasing case fatality rates in severe sepsis despite increasing hospitalizations. Crit Care Med 2005;33:25552562.
48.Gordis, L. Epidemiology. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2004.
49.Houchens, R, Elixhauser, A. Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances, 2001. HCUP Method Series Report 2003-02. Rockville, MD: US Agency for Healthcare Research and Quality; 2005. Available at: Accessed June 2006.
50.Wisplinghoff, H, Seifert, H, Tallent, SM, Bischoff, T, Wenzel, RP, Edmond, MB. Nosocomial bloodstream infections in pediatric patients in United States hospitals: epidemiology, clinical features and susceptibilities. Pediatr Infect Dis J 2003;22:686691.
51.Stevenson, KB, Khan, Y, Dickman, J, et al.Administrative coding data, compared with CDC/NHSN criteria, are poor indicators of health care-associated infections. Am J Infect Control 2008;36:155164.
52.Pittet, D, Wenzel, RP. Nosocomial bloodstream infections: secular trends in rates, mortality, and contribution to total hospital deaths. Arch Intern Med 1995;155:11771184.
53.Orsi, GB, Di Stefano, L, Noah, N. Hospital-acquired, laboratory-confirmed bloodstream infection: increased hospital stay and direct costs. Infect Control Hosp Epidemiol 2002;23:190197.
54.Sohn, AH, Garrett, DO, Sinkowitz-Cochran, RL, et al.Prevalence of nosocomial infections in neonatal intensive care unit patients: results from the first national point-prevalence survey. J Pediatr 2001;139:821827.
55.Grohskopf, LA, Sinkowitz-Cochran, RL, Garrett, DO, et al.A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States. J Pediatr 2002;140:432438.
56.Sax, H, Pittet, D. Interhospital differences in nosocomial infection rates: importance of case-mix adjustment. Arch Intern Med 2002;162:24372442.
57.Banerjee, SN, Emori, TG, Culver, DH, et al.Secular trends in nosocomial primary bloodstream infections in the United States, 1980–1989. National Nosocomial Infections Surveillance System. Am J Med 1991;91(Suppl 3B):86S89S.
58.Garrouste-Orgeas, M, Chevret, S, Mainardi, JL, Timsit, JF, Misset, B, Carlet, J. A one-year prospective study of nosocomial bacteraemia in ICU and non-ICU patients and its impact on patient outcome. J Hosp Infect 2000;44:206213.
59.Martin, GS, Mannino, DM, Eaton, S, Moss, M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:15461554.
60.Taylor, G, Gravel, D, Johnston, L, Embil, J, Holton, D, Paton, S. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. Am J Infect Control 2004;32:155160.
61.Blot, SI, Depuydt, P, Annemans, L, et al.Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections. Clin Infect Dis 2005;41:15911598.
62.Pittet, D, Li, N, Woolson, RF, Wenzel, RP. Microbiological factors influencing the outcome of nosocomial bloodstream infections: a 6-year validated, population-based model. Clin Infect Dis 1997;24:10681078.
63.Eggimann, P, Harbarth, S, Constantin, MN, Touveneau, S, Chevrolet, JC, Pittet, D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000;355:18641868.
64.Sherertz, RJ, Ely, EW, Westbrook, DM, et al.Education of physicians-intraining can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132:641648.
65.El-Masri, MM, Hammad, TA, McLeskey, SW, Joshi, M, Korniewicz, DM. Predictors of nosocomial bloodstream infections among critically ill adult trauma patients. Infect Control Hosp Epidemiol 2004;25:656663.
66.Brun-Buisson, C. The epidemiology of the systemic inflammatory response. Intensive Care Med 2000;26(Suppl 1):S64S74.
67.Moss, M. Epidemiology of sepsis: race, sex, and chronic alcohol abuse. Clin Infect Dis 2005;41(Suppl 7):S490S497.
68.Gastmeier, P, Geffers, C, Schwab, F, Fitzner, J, Obladen, M, Ruden, H. Development of a surveillance system for nosocomial infections: the component for neonatal intensive care units in Germany. J Hosp Infect 2004;57:126131.
69.Mermel, LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132:391402.
70.Mermel, LA, Farr, BM, Sherertz, RJ, et al.Guidelines for the management of intravascular catheter-related infections. J Intraven Nurs 2001;24:180205.

Incidence of and Risk Factors for Nosocomial Bloodstream Infections in Adults in the United States, 2003

  • Omar M. AL-Rawajfah (a1), Frank Stetzer (a2) and Jeanne Beauchamp Hewitt (a3) (a4)


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed