To the Editor—We read with great interest the article by Dantes et alReference Dantes, Rock and Milstone ¹ on the preventability of hospital-onset bacteremias (HOBs) and the use of this metric as a quality outcome measure. In 2017, we also reported a retrospective analysis of the impact of quality improvement efforts on overall intensive care unit (ICU) HOBs over the course of 10 years at an academic medical center, during a period when the institution developed a virtual critical care department that utilized telemedicine technology and concurrently developed, implemented, and iteratively adapted multiple clinical practice guidelines across the ICUs of an academic medical center.Reference Civitarese, Ruggieri and Walz ^{2 –} Reference Lilly, Cody and Zhao ⁴

In our study, which examined a total of 835 bacteremias across 7 ICUs, we observed a progressive and sustained 82.8% decrease in total annual bloodstream infections (BSIs), including an 85.0% decrease in primary BSIs and 81.4% decrease in secondary BSIs.Reference Civitarese, Ruggieri and Walz ² Our analysis by pathogen also detected significant decreases in BSI rates for all pathogens, particularly highest for non–S. aureus staphylococci (0.300-fold per year) and Staphylococcus aureus(0.191-fold). Decreases in BSI rates were significant across all ICUs, with the exception of the cardiac surgery and coronary care unit. Potential confounders of decreased number of blood cultures drawn, length of ICU stay, APACHE IV scores, glucose levels, vital status, and number of stays were controlled for during regression analysis, and our results remained highly significant following this adjustment.

Thus, our findings indicate that institutions can prevent and markedly reduce the incidence of HOBs, at least in the ICU setting. Moreover, BSIs represent a relatively objective end point where the primary identified limitations have been concerns with appropriate identification of blood culture contaminants and infections that arise from mucosal barrier injury.Reference Freeman, Chen, Sexton and Anderson ^{5 ,} Reference Steinberg and Coffin ⁶ This focus contrasts with other hospital-acquired infection metrics such as catheter associated urinary tract infections, ventilator associated events, Clostridioides difficile infection, and central-line associated bloodstream infections, where multiple definition issues have been identified that can lead to both inaccurate estimations of infection rates and can potentially promote efforts to “game the system.”Reference Madden, Weinstein and Sifri ^{7 ,} Reference Lilly, Landry and Sood ⁸