The Impact of Frailty Syndrome on Endogenous Endophthalmitis Development and Outcomes: A Population-Level Analysis

Purpose

To characterize the impact of frailty syndrome on endogenous endophthalmitis (EE) development and clinical outcomes among septicemic patients.

Design

Population-level retrospective cohort study

Subjects

Hospital inpatients aged ≥ 18 years within the National Inpatient Sample (NIS, years 2002-2014) diagnosed with bacterial septicemia

Methods

Septicemic patients were classified as frail or non-frail using the previously validated Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator, and diagnosis of endogenous endophthalmitis was abstracted from ICD-9 codes. We used multivariable logistic regression to generate odds ratios (OR) for rates of EE development and in-hospital mortality based on frailty status. We also examined the association between frailty and blood-culture-proven organism class, inpatient length of stay, and total charges billed to insurance.

Main Outcome Measures

Incidence of EE among septicemic patients; Rates of EE development among frail and non-frail patients; blood-culture-proven microbe type, length of inpatient stay, and total charges billed to insurance as a function of frailty status

Results

9293 of 18,470,658 (0.05%) inpatients with bacteremia developed EE, 2102 (22.6%) of whom had at least 1 frailty-defining feature (predominantly malnutrition, 68%). The odds of developing EE were 16.7% higher for frail patients (OR 1.167, 95% CI [1.108-1.229]), controlling for age, gender, race, concomitant HIV/AIDS, pyogenic liver abscess, infectious endocarditis, cirrhosis, and diabetes with chronic complications. Frail EE patients had a 27.9% increased odds of in-hospital death, independent of age, gender, race, and Elixhauser comorbidity score [OR 1.279, 95% CI 1.056-1.549]. Higher rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (14.3% versus 10.9%, P=0.000016), gram-negative bacteremia (7.5% versus 4.9%, P=0.000003), and concomitant candidemia (10.4% versus 7.0%, P<0.000001) were associated with frailty. Hospital stays were significantly longer (median 14 days, IQR 19 days, P<0.00001) and total charges billed to insurance were significantly greater (median $96,398, IQR $154,682, P<0.00001) among frail EE patients.

Conclusions

Frailty syndrome independently associates with the development of endogenous endophthalmitis in the setting of bacterial septicemia; Frailty-associated EE may occur in patients with malnutrition and particular bacterial subtypes, and predisposes to higher rates of in-hospital death and healthcare resource usage

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