National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009

Predictors and costs of surgical site infections in patients with endometrial cancer

OBJECTIVE

Technological advances in surgical management of endometrial cancer (EC) may allow for novel risk modification in surgical site infection (SSI).

METHODS

Perioperative variables were abstracted from EC cases surgically staged between January 1, 1999, and December 31, 2008. Primary outcome was SSI, as defined by American College of Surgeons National Surgical Quality Improvement Program. Counseling and global models were built to assess perioperative predictors of superficial incisional SSI and organ/space SSI. Thirty-day cost of SSI was calculated.

RESULTS

Among 1369 EC patients, 136 (9.9%) had SSI. In the counseling model, significant predictors of superficial incisional SSI were obesity, American Society of Anesthesiologists (ASA) score >2, preoperative anemia (hematocrit <36%), and laparotomy. In the global model, significant predictors of superficial incisional SSI were obesity, ASA score >2, smoking, laparotomy, and intraoperative transfusion. Counseling model predictors of organ/space SSI were older age, smoking, preoperative glucose >110 mg/dL, and prior methicillin-resistant Staphylococcus aureus (MRSA) infection. Global predictors of organ/space SSI were older age, smoking, vascular disease, prior MRSA infection, greater estimated blood loss, and lymphadenectomy or bowel resection. SSI resulted in a $5447 median increase in 30-day cost.

CONCLUSIONS

Our findings are useful to individualize preoperative risk counseling. Hyperglycemia and smoking are modifiable, and minimally invasive surgical approaches should be the preferred surgical route because they decrease SSI events. Judicious use of lymphadenectomy may decrease SSI. Thirty-day postoperative costs are considerably increased when SSI occurs.

Complications of peripherally inserted central venous catheter in Japanese neonatal intensive care units

BACKGROUND

The aim of this study was to investigate the incidence and risk factors of peripherally inserted central venous catheter (PICC)-related complications using a multicenter case survey.

METHOD

A prospective cohort study was carried out by 19 neonatal intensive care units (NICUs) in Japan from February 2005 to March 2007. A total of 975 case records were collected. PICC-related complications including pericardial effusion/cardiac tamponade pleural effusion/ascites, catheter removal difficulties, catheter-related bloodstream infection (CR-BSI), and symptomatic catheter-related thrombosis were collected from case record forms. As for precautions during insertion, institutions were classified into three groups: those with maximum barrier precautions; standard precautions; and no specific precautions.

RESULTS

PICC complications occurred in 27 cases (2.9%) among 946 PICC. The incidence was 1.6% for CR-BSI, and 0.1% for cardiac tamponade. CR-BSI rate per 1000 catheter-days was 1.1 with maximum barrier precautions at catheter insertion, 1.2 with standard precautions, and 1.8 with no specific precautions. Multiple logistic regression analysis showed that proximal placement (odds ratio [OR], 3.88; 95% confidence interval [CI]: 1.42-10.60, P = 0.008) and longer placement duration (OR, 1.35; 95%CI: 1.14-1.60, for each week, P = 0.0005) independently contributed to overall complications.

CONCLUSION

The incidence of cardiac tamponade was rare in this multicenter prospective study. Longer duration and proximal placement may be risk factors for PICC complications. In this cohort, the CR-BSI rate was low irrespective of the degree of barrier precautions at insertion.

Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings

BACKGROUND

Little data exist on the burden of device-associated health care-associated infection (DA-HAI) in China. This study examined the DA-HAI rate and evaluated its association with device use (DU), length of stay (LOS), and mortality in intensive care units (ICUs) in 4 Chinese hospitals.

METHODS

This was a prospective cohort surveillance study conducted in 7 ICUs in 4 hospitals. We applied International Nosocomial Control Consortium methods and Centers for Disease Control and Prevention (CDC)/National Health and Safety Network (NHSN) definitions to determine rates of central line-associated blood stream infection (CLABSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), DU, crude extra length of hospital stay (LOS), and mortality.

RESULTS

Between August 2008 and July 2010, there were a total of 2,631 admissions to the 7 ICUs in the study hospitals. The rate of VAP was 10.46/1,000 mechanical ventilator (MV)-days, the CLABSI rate was 7.66/1,000 central line (CL)-days, and the CAUTI rate was 1.29/1,000 urinary catheter (UC)-days. Pooled DU ratios were 0.43 for MV, 0.71 for CL, and 0.76 for UC. Crude extra LOS was 15 days for patients with CLABSI, 20.5 days for patients with VAP, and 27 days for patients with CAUTI. Crude extra mortality was 14% for patients with CLABSI, 22% for patients with VAP, and 43% for patients with CAUTI.

CONCLUSIONS

In the study ICUs, VAP and CLABSI rates were higher than CDC/NHSN's reported data, and LOS and mortality were increased. Compared with the CDC/NHSN and INICC data, the pooled DU ratio for MV was similar, and DU ratios for CL and UC use ratios were slightly higher.

Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial

BACKGROUND

Bacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children.

METHODS

In an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393).

FINDINGS

1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64-4·61) compared with standard practices (4·93 per 1000 days, 3·91-6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42-1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27-4·58) compared with standard practices (4·93 per 1000 days, 3·91-6·15; aIRR 0·64, 0·42-0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60-2·02).

INTERPRETATION

Critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated.

FUNDING

Sage Products, US National Institutes of Health.

Maintaining and sustaining the On the CUSP: stop BSI model in Hawaii

BACKGROUND

Hawaii joined the On the CUSP: Stop BSI national effort in the United States in 2009 (CUSP stands for Comprehensive Unit-based Safety Program). In the initial 18-month study evaluation, adult ICUs decreased central line-associated bloodstream infection (CLABSI) rates by 61%. The impact of a series of novel strategies/tools in reducing infections and sustaining the collaborative in ICUs and non-ICUs in Hawaii was assessed.

METHODS

This cohort collaborative consisted of 20 adult ICUs and 18 nonadult ICUs in 16 hospitals. Hawaii developed and implemented six tools between July 2010 and August 2011: a tool to investigate CLABSIs, a video to address cultural barriers, a standardized dressing change kit, a map of the cohort's journey, a 12-strategies leadership dashboard, and a geometric plot of consecutive infection-free days. The primary outcome measure was overall CLABSI rates (mean infections per 1,000 catheter-days).

RESULTS

A comparison of baseline data from 28 ICUs with 12-quarter (36-month) postimplementation data indicated that the CLABSI rate decreased across the entire state: overall, 1.57 to 0.29 infections/1,000 catheter-days; adult ICUs, 1.49 to 0.25 infections/1,000 catheter-days; nonadult ICUs, 2.54 to 0.33 infections/1,000 catheter-days, non-ICUs (N= 14), 4.52 to 0.25 infections/1,000 catheter-days, and PICU/NICU (N = 4), 2.05 to 0.53 infections/1,000 catheter-days. Days between CLABSIs in the adult ICUs statewide increased from a median of 5 days in 2009 to 70 days in 2011.

DISCUSSION

Hawaii successfully spread the program beyond adult ICUs and implemented a series of tools for maintenance and sustainment. Use of the tools shaped a culture around the continued belief that CLABSIs can be eradicated, and infections further reduced.

Using a criteria-based reminder to reduce use of indwelling urinary catheters and decrease urinary tract infections

BACKGROUND

Duration of indwelling urinary catheterization is an important risk factor for urinary tract infection.

OBJECTIVES

To determine whether a reminder approach reduces the use of urinary catheters and the incidence of catheter-associated urinary tract infections.

METHODS

A randomized control trial was performed in 2 respiratory intensive care units in a 2990-bed tertiary referral medical center. Patients who had urinary catheters in place for more than 2 days from April through November 2008 were randomly assigned to either the intervention group (use of a criteria-based reminder to remove the catheter) or the control group (no reminder).

RESULTS

A total of 278 patients were recruited. Utilization rate of indwelling urinary catheters was decreased by 22% in the intervention group compared with the control group (relative risk, 0.78; 95% CI, 0.76-0.80; P < .001). The intervention significantly shortened the median duration of catheterization (7 days vs 11 days for the control group; P < .001). The success rate for removing the catheters in the intervention group by day 7 was 88%. The reminder intervention reduced the incidence of catheter-associated infections by 48% (relative risk, 0.52; 95% CI, 0.32-0.86; P = .009) in the intervention group compared with the control group.

CONCLUSIONS

Use of a criteria-based reminder to remove indwelling urinary catheters can diminish the use of urinary catheterization and reduce the likelihood of catheter-associated urinary infections. This reminder approach can prevent catheter-associated urinary infections, and its use should be strongly considered as a way to enhance the safety of patients.

Biocompatibility analysis of an electrically-activated silver-based antibacterial surface system for medical device applications

The costs associated with the treatment of medical device and surgical site infections are a major cause of concern in the global healthcare system. To prevent transmission of such infections, a prophylactic surface system that provides protracted release of antibacterial silver ions using low intensity direct electric current (LIDC; 28 μA system current at 6 V) activation has been recently developed. To ensure the safety for future in vivo studies and potential clinical applications, this study assessed the biocompatibility of the LIDC-activated interdigitated silver electrodes-based surface system; in vitro toxicity to human epidermal keratinocytes, human dermal fibroblasts, and normal human osteoblasts, and antibacterial efficacy against Staphylococcus aureus and Escherichia coli was evaluated. The study concluded that the technological applications of the surface system for medical devices and surgical tools, which contact human tissues for less than 1.5 h, are expected to be self-sterilizing without causing toxicity in vivo.

Survey on hospital-acquired urinary tract infection in neurological intensive care unit

This study aimed to explore the causes, incidence, and risk factors of urinary tract infection patients in neurological intensive care unit (ICU). Patients (n = 916) admitted to the neurological ICU from January 2005 to December 2010 were retrospectively surveyed for urinary tract infections. There were 246 patients in neurological ICU who were diagnosed with hospital-acquired urinary tract infection during that period of time (26.9%). Forty-three cases were upper urinary tract infection, and 203 cases were lower urinary tract infection. The top three strains were Escherichia coli, Enterococcus faecalis, and Klebsiella pneumoniae. Older age (UTI rate, 22.6%), female patients (21.7%), hospital stay for more than 7 days (16.7%), diabetes (11.7%), and catheterization (21.1%) were the risk factors for hospital-acquired urinary tract infection. There is a high incidence of nosocomial urinary tract infection in the neurological intensive care unit. Active prevention program and surveillance need to be carried out in neurological ICU, especially in those with risk factors.

Infecções relacionadas à assistência a saúde baseada em critérios internacionais, realizada em unidade neonatal de cuidados progressivos de referência de Belo Horizonte, MG

OBJETIVO: Descrever a ocorrência de infecções relacionadas à assistência à saúde em uma unidade neonatal de serviço público de referência em Belo Horizonte, MG, baseando-se em critérios internacionais. MÉTODOS: Trata-se de estudo descritivo, realizado por busca ativa, na Unidade Neonatal de Cuidados Progressivos do Hospital das Clínicas da Universidade Federal de Minas Gerais (HC/UFMG), de 2008 a 2009. A notificação de infecções baseou-se nos critérios do National Healthcare Safety Network (NHSN). O banco de dados e análise foi realizado em programa interno do serviço. RESULTADOS: Foram notificados 325 episódios de infecção nos recém-nascidos, com densidade de incidência de 22,8/1.000 pacientes-dia e incidência proporcional geral de infecção de 36,7%. A sepse foi a principal infecção (62,5%) notificada. A densidade de incidência de infecções foi maior em neonatos com peso menor que 750g (42,4/1.000 pacientes-dia). Observou-se 18,15 episódios de Sepse Relacionada a Cateter/1.000 Cateter Venoso Central-dia e 19,29/1.000 episódios de Sepse Relacionada a Cateter Umbilical/1.000 Cateter umbilical-dia. Em 122 (37,5%) casos de infecção notificada houve isolamento de microorganismos, predominando Staphylococcus coagulase negativo e Staphylococcus aureus (51 casos). A mortalidade e letalidade foram 4,3% e 17,12%, respectivamente. CONCLUSÃO: A utilização de critérios padronizados para notificação de infecções é necessária para a construção de indicadores em neonatologia, que são escassos no país e ressaltam a necessidade de avaliação dos critérios nacionais propostos pela Agencia Nacional de Vigilância Sanitária (ANVISA).

Thickness of subcutaneous fat as a risk factor for infection in cervical spine fusion surgery

BACKGROUND

Surgical site infections increase the incidence of morbidity and mortality as well as health-care expenses. The cost of care increases threefold to fourfold as a consequence of surgical site infection after spinal surgery. The aim of the present study was to determine the role of subcutaneous fat thickness in the development of surgical site infection following cervical spine fusion surgery.

METHODS

We performed a retrospective review of a consecutive cohort of 213 adult patients who underwent posterior cervical spine fusion between 2006 and 2008 at Duke University Medical Center. The horizontal distance from the lamina to the skin surface at the C5 level and the thickness of subcutaneous fat were measured, and the ratio of the fat thickness to the total distance at the surgical site was determined. Previously identified risk factors for the development of surgical site infection were also recorded.

RESULTS

Twenty-two of the 213 patients developed a postoperative infection. Obesity (body mass index ≥ 30 kg/m2) was not a significant risk factor for surgical site infection; the body mass index (and 95% confidence interval) was 29.4 ± 1.2 kg/m2 in the patients who developed a surgical site infection compared with 28.9 ± 0.94 kg/m2 in the patients without an infection. However, the thickness of subcutaneous fat and the ratio of the fat thickness to the lamina-to-skin distance were both significant risk factors for infection. The thickness of subcutaneous fat was 27.0 ± 2.5 mm in the patients who developed a surgical site infection group compared with 21.4 ± 0.88 mm in the patients without an infection (p = 0.042). The ratio of fat thickness to total thickness was 0.42 ± 0.019 in the patients who developed a surgical site infection compared with 0.35 ± 0.01 in the patients without an infection (p = 0.020). Multivariate analysis revealed this ratio to be an independent risk factor for developing a postoperative infection (odds ratio, 3.18; 95% confidence interval, 1.02 to 9.97).

CONCLUSIONS

The study demonstrated that the thickness of subcutaneous fat at the surgical site is a factor in the development of surgical site infection following cervical spine fusion and deserves assessment in the preoperative evaluation.

Rapid reduction of central line infections in hospitalized pediatric oncology patients through simple quality improvement methods

BACKGROUND

Pediatric hematology-oncology (PHO) patients are at significant risk for developing central line-associated bloodstream infections (CLA-BSIs) due to their prolonged dependence on such catheters. Effective strategies to eliminate these preventable infections are urgently needed. In this study, we investigated the implementation of bundled central line maintenance practices and their effect on hospital-acquired CLA-BSIs.

MATERIALS AND METHODS

CLA-BSI rates were analyzed within a single-institution's PHO unit between January 2005 and June 2011. In May 2008, a multidisciplinary quality improvement team developed techniques to improve the PHO unit's safety culture and implemented the use of catheter maintenance practices tailored to PHO patients. Data analysis was performed using time-series methods to evaluate the pre- and post-intervention effect of the practice changes.

RESULTS

The pre-intervention CLA-BSI incidence was 2.92 per 1,000-patient days (PD) and coagulase-negative Staphylococcus was the most prevalent pathogen (29%). In the post-intervention period, the CLA-BSI rate decreased substantially (45%) to 1.61 per 1,000-PD (P < 0.004). Early on, blood and marrow transplant (BMT) patients had a threefold higher CLA-BSI rate compared to non-BMT patients (P < 0.033). With additional infection control countermeasures added to the bundled practices, BMT patients experienced a larger CLA-BSI rate reduction such that BMT and non-BMT CLA-BSI rates were not significantly different post-intervention.

CONCLUSIONS

By adopting and effectively implementing uniform maintenance catheter care practices, learning multidisciplinary teamwork, and promoting a culture of patient safety, the CLA-BSI incidence in our study population was significantly reduced and maintained.

Simultaneous placement of multiple central lines increases central line-associated bloodstream infection rates

BACKGROUND

Surveillance for central line (CL)-associated bloodstream infections (CLABSIs) is generally advocated. However, the standard definition of this surveillance does not take into account the number of CLs in place and thus the possibility of increased infection risk with multiple CLs in place simultaneously. In this study, we tested the hypothesis that simultaneous placement of more than 1 CL is associated with an increased CLABSI rate.

METHODS

The number of CLs, CL-days, and CLABSIs and CLABSI rates with regard to the number of CLs in place simultaneously was documented in 2 intensive care units between 2001 and 2011. Standard CLABSI rates, as well as the rates for 1 CL and multiple CLs in place, were calculated.

RESULTS

The average CLABSI rate was significantly lower in patients with 1 CL in place compared with those with more than 1 CL in place (3.69 per 1,000 CL-days vs 13.09/1,000 CL-days; incidence rate ratio [IRR], 3.63; 95% confidence interval [CI], 2.61-5.05). Importantly, all differences from the standard rate (5.94/1,000 CL-days) were significant (1 CL vs standard: IRR, 0.61; 95% CI, 0.51-0.74; more than 1 CL vs standard: IRR, 2.23; 95% CI, 1.87-2.65; both P < .0001).

CONCLUSIONS

Our data show that the number of CLs in place had a strong influence on CLABSI rates. Thus, we advocate stratifying patients by the number of CLs in place to take this increased risk of infection into account during surveillance.

Laboratory-based surveillance of hospital-acquired catheter-related bloodstream infections in Catalonia. Results of the VINCat Program (2007-2010)

The VINCat Program is an institutional surveillance program for hospital-acquired infections developed in the healthcare institutions of Catalonia, Spain. The program includes the monitoring of various components of hospital-acquired infection, among which is catheter-related bloodstream infection (CRBSI). The aim of this study was to describe the frequency of CRBSI in hospitals participating in the VINCat Program over a period of 4 years (2007-2010). The monitoring of the CRBSI component is carried out continuously in all inpatient units by performing a daily assessment of all blood culture results issued by the Microbiology Laboratories. Precise definitions are used for CRBSI, and adjusted rates are expressed per 1,000 days of hospitalization, hospital size and type of catheter. The rates of CRBSI in catheters used for parenteral nutrition are adjusted and expressed per 1,000 days of device use. The aggregate data of the total period are shown in percentiles (10%, 25%, 50% or median, 75%, and 90%). From 2007 to 2010, a total of 2977 episodes of CRBSI were reported in 40 hospitals participating in the VINCat Program. The cumulative incidence of CRBSI has been 0.26 episodes per 1,000 days of hospitalization (CI95% 0.2 to 0.3). The overall incidence varied depending on hospital size: 0.36 ‰ for hospitals in Group I (>500 beds), 0.17 ‰ for Group II (200-500 beds), and 0.09 ‰ for Group III (<200 beds). 76% of the episodes were associated with central venous catheters (CVC), 19% of the episodes with peripheral venous catheters (PVC), and the remaining 5% with peripherally inserted CVCs (PICC). The most common organisms causing CRBSI were staphylococci, the group Klebsiella, Serratia and Enterobacter, Candida spp., and Pseudomonas aeruginosa. There are important differences in the etiology of CRBSI in relation to these variables. During the reporting period, a significant reduction (38.1%, CI95%, 29.0-46.0%) of CRBSI rates have been observed in Group I hospitals. CRBSI surveillance is an important element of the VINCat Program, offering to us the possibility of establishing standard values for this component and implementing intervention strategies for its reduction.

Epidemiology of surgical site infections after total hip and knee joint replacement during 2007-2009: a report from the VINCat Program

The VINCat Program is a system for epidemiological surveillance of healthcare-related infections in which the majority of Catalan hospitals participate. It has a specific module for surgical site infections (SSI) surveillance. Primary hip and knee arthroplasties are basic indicators of the program due to their high frequency and the important morbidity of SSI of these sites. Results are presented for surgical site infection (SSI) surveillance of primary hip and knee arthroplasties for the first three years of the VINCat Program. The program requires SSI surveillance to be performed in a standardized, prospective and continuous manner by an infection control team from the centers. With primary arthroplasties, as with all procedures involving implants, the surveillance is maintained for 1 year after the intervention. The VINCat Program uses the SSI definitions of the Centers for Disease Control (CDC) and patients are stratified by surgical risk, following the classification of the National Healthcare Safety Network (NHSN). During the period 2007-2009, 51 Catalan hospitals participated in the SSI surveillance of prosthetic orthopedic surgery. The overall SSI rate in the interventions for total primary hip prosthesis (7,804 procedures) was 3.0% (IC 95%: 2.6-3.4) and for total primary knee prosthesis (16,781 procedures) was 3.3% (IC95%: 3.0-3.6). During the period 2007-2009, the overall SSI rates for total primary hip and knee arthroplasty were higher than those published by some surveillance systems in our environment. There were significant differences in the infection rates by procedure and in those adjusted by risk among the different hospitals.

An evidence-based oral care protocol to decrease ventilator-associated pneumonia

The purpose of this study was to examine the impact of 0.12% chlorhexidine rinses and an oral care protocol on ventilator-associated pneumonia rates. A quasi-experimental preintervention-postintervention design was used. The sample included all patients admitted to critical care and on mechanical ventilation at any time during the study period. Data were collected 6 months before and 12 months after intervention. Ventilator-associated pneumonia rates were reduced from 4.3 to 1.86 per 1000 ventilator-days during the study period, with an estimated cost avoidance of $700,000 to $798,000.

A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*

OBJECTIVES

To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit.

DESIGN

We conducted a multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006.

SETTING

Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems.

INTERVENTIONS

A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication.

MEASUREMENTS AND RESULTS

We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates <1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to <1/1,000 central line days (a 69% reduction) at 12 months.

CONCLUSIONS

This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.

Extending total parenteral nutrition hang time in the neonatal intensive care unit: is it safe and cost effective?

AIM

To investigate the effects of prolonging hang time of total parenteral nutrition (TPN) fluid on central line-associated blood stream infection (CLABSI), TPN-related cost and nursing workload.

METHODS

A before-after observational study comparing the practice of hanging TPN bags for 48 h (6 February 2009-5 February 2010) versus 24 h (6 February 2008-5 February 2009) in a tertiary neonatal intensive care unit was conducted. The main outcome measures were CLABSI, TPN-related expenses and nursing workload.

RESULTS

One hundred thirty-six infants received 24-h TPN bags and 124 received 48-h TPN bags. Median (inter-quartile range) gestation (37 weeks (33,39) vs. 36 weeks (33,39)), mean (±standard deviation) admission weight of 2442 g (±101) versus 2476 g (±104) and TPN duration (9.7 days (±12.7) vs. 9.9 days (±13.4)) were similar (P > 0.05) between the 24- and 48-h TPN groups. There was no increase in CLABSI with longer hang time (0.8 vs. 0.4 per 1000 line days in the 24-h vs. 48-h group; P < 0.05). Annual cost saving using 48-h TPN was AUD 97,603.00. By using 48-h TPN, 68.3% of nurses indicated that their workload decreased and 80.5% indicated that time spent changing TPN reduced.

CONCLUSION

Extending TPN hang time from 24 to 48 h did not alter CLABSI rate and was associated with a reduced TPN-related cost and perceived nursing workload. Larger randomised controlled trials are needed to more clearly delineate these effects.

Incidence of catheter-associated bloodstream infection after introduction of minocycline and rifampin antimicrobial-coated catheters in a pediatric burn population

The Centers for Disease Control and Prevention guidelines for prevention of intravascular catheter-related infections suggest that antimicrobial-coated catheters can decrease the risk of developing catheter-related bloodstream infection in a variety of adult patient populations. There are limited data on their efficacy in the pediatric population, particularly among children with burn injuries. A study was conducted at Shriners Hospitals for Children®, Boston, to determine whether minocycline/rifampin (MR)-coated catheters could decrease the incidence of catheter-associated bloodstream infection (CABSI) in a pediatric burn population. A historical control group included all patients with double- or triple-lumen catheters inserted in the 18-month period from January 2006 to June 2007. The study group included all patients with MR antimicrobial double- or triple-lumen catheters inserted in the subsequent 18-month period, July 2007 to December 2008. Data collected included name, age, date of burn/injury, date of admission, percent TBSA area burn injury or other diagnosis, catheter site (subclavian, internal jugular, or femoral), method of insertion (new percutaneous stick or guidewire), type of catheter (double or triple lumen), date inserted, duration of catheter placement (days), and positive blood cultures recovered while the central venous catheter was in place. CABSI was defined using the Centers for Disease Control and Prevention definition of laboratory-confirmed bloodstream infection. There were a total of 66 patients with 252 catheters (1780 catheter days) in the control group and 75 patients with 263 catheters (1633 catheter days) in the study group. Age, percent burn injury, catheter site, and method of insertion were not statistically different between the two groups. The percentage of infected catheters and the rate of infection were significantly different for the two groups, with the MR antimicrobial catheters only half as likely to become infected. In a subset of these patients with catheters in place for more than 4 days, the percentage of infected catheters and rate of infection were also significantly different with results similar to those in the entire group. MR antimicrobial-coated catheters significantly reduced the incidence of CABSI in this pediatric burn population compared with noncoated catheters.

Discord among performance measures for central line-associated bloodstream infection

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures.

OBJECTIVE

Evaluate consistency and reasons for discordance among chart review and claims-based CLABSI events.

METHODS

We conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). All events had full-text medical record reviews and were identified as concordant or discordant with the other metric.

RESULTS

In the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source.

CONCLUSION

Substantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.

Health care-associated infections in the neonatal intensive care unit: barriers to continued success

Health care-associated infections often result in significant morbidity and mortality to affected patients and substantial financial cost to an overburdened health care system. Local, statewide, and national efforts have been conducted to eradicate central line-associated infections, ventilator-associated pneumonia, and urinary tract infections from inpatient and outpatient facilities. In the neonatal intensive care unit population, significant improvements have been made in many areas, but have been hindered in others by a lack of population-specific definitions, data, and guidelines for prevention and management. Therefore, more concerted efforts are needed in these areas for continued progress to occur.

Endotracheal tube: friend or foe? Bacteria, the endotracheal tube, and the impact of colonization and infection

The microbiology of the endotracheal tube culture plays a role in diagnosing a variety of diseases in the newborn intensive care unit, including subglottic stenosis, bronchopulmonary dysplasia, and ventilator-associated pneumonia. Bacterial production of a biofilm that coats the endotracheal tube acts as a reservoir for infection, prevents eradication, and may play a role in the development of subglottic stenosis. The diagnosis of ventilator-associated pneumonia is limited by the CDC definition as well as currently available diagnostic methods. Biomarkers could aid in differentiating colonization from infection, but are not available to most clinicians. The etiology of ventilator-associated pneumonia is often polymicrobial. Failure to differentiate colonization from infection results in unnecessary prescription of antibiotics, which could contribute to antimicrobial resistance. Measures to prevent ventilator-associated pneumonia have been described, primarily in the adult population.

Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit

BACKGROUND

A major risk factor for the development of bloodstream infection is the presence of a central venous catheter (CVC), especially in immunocompromised patients. CVC hub contamination is a risk factor for central line-associated bloodstream infection (CLABSI).

METHODS

This observational before-after trial in a tertiary care hospital's oncology unit included adult patients with a CVC. During the intervention period, the practice of central line hub care was changed from cleaning with alcohol wipes to using alcohol-impregnated port protectors. To accommodate the protectors, the needless hubs were changed to a neutral pressure connector. The intervention period (January-July 2010) was compared with a historical control (January-December 2009).

RESULTS

A total of 3,005 central line-days and 1 CLABSI (a rate of 0.3 infections/1,000 central line-days) were documented during the intervention period, compared with 6,851 central line-days and 16 CLABSIs (2.3 infections/1,000 central line-days) during the control period (relative risk, 0.14; 95% confidence interval [CI], 0.02-1.07; P = .03). The rate of contaminated blood cultures (CBCs) from central lines was 2.5% (17 of 692) during the control period, but only 0.2% (1 of 470) during the intervention period (relative risk, 0.09; 95% CI, 0.01-0.65; P = .002).

CONCLUSIONS

The implementation of alcohol-impregnated port protectors and needleless neutral pressure connectors significantly reduced the rates of CLABSIs and CBCs in our oncology patient population.

Decreasing ventilator-associated pneumonia in the intensive care unit: a sustainable comprehensive quality improvement program

An intensive care unit implemented an oral care bundle to decrease ventilator-associated pneumonia (VAP). A retrospective analysis comparing like time periods revealed the VAP rate per 1,000 ventilator-days dropped significantly from 10.5 to 0 (P = .016). The oral care bundle remains in place as of end of May 2011 and has proven to be a sustainable method for VAP prevention.

The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia

BACKGROUND

Ventilator-associated pneumonia (VAP) prevention is an important patient safety initiative. We describe the impact of a multidisciplinary surveillance program on VAP rates in a tertiary medical-surgical-trauma intensive care unit (ICU).

METHODS

An epidemiologic surveillance program was established in 2003 as a joint project between ICU and Infection Prevention and Control Department to regularly report VAP rates to guide evidence-based VAP preventive strategies. VAP cases were diagnosed according to predefined criteria and prospectively recorded by a research physician. VAP microbiology, risk factors, and outcomes were noted.

RESULTS

Of 2,812 ventilated patients, 433 (15.4%) developed VAP corresponding to 15.9 episodes per 1,000 ventilator-days. The rate decreased from 19.1 in 2003 to 6.3 per 1,000 ventilator-days in 2009. On multivariate analysis, VAP was associated with accidental extubation (hazard ratio [HR], 4.11; 95% confidence interval [CI]: 1.93-8.73), trauma versus medical diagnosis (HR, 2.59; 95% CI: 2.07-3.23), chronic obstructive pulmonary disease (HR, 1.55; 95% CI: 1.08-2.22), and neuromuscular blockade (HR, 1.39; 95% CI: 1.07-1.81). The most common isolated pathogens were Gram-negative organisms. VAP patients had longer mechanical ventilation duration, ICU and hospital length of stay, but similar ICU and hospital mortality compared with non-VAP patients.

CONCLUSION

The study showed a reduction in VAP rates with active surveillance, reporting and evidence-based preventive strategies and identified several modifiable risk factors, which should be the focus of additional interventions.

Reduction of surgical site infections in low transverse cesarean section at a university hospital

BACKGROUND

We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS).

METHODS

An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings.

RESULTS

Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P = .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period.

CONCLUSION

A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS.

Risk of parenteral nutrition in neonates--an overview

Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.

The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis

BACKGROUND

Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.

OBJECTIVE

A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.

DATA SOURCES

MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google).

STUDY SELECTION

Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.

DATA EXTRACTION

Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data.

DATA SYNTHESIS

Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.

CONCLUSIONS

Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.

International nosocomial infection control consortium findings of device-associated infections rate in an intensive care unit of a lebanese university hospital

OBJECTIVES

To determine the rates of device-associated healthcare-associated infections (DA-HAI), microbiological profile, bacterial resistance, length of stay (LOS), excess mortality and hand hygiene compliance in one intensive care unit (ICU) of a hospital member of the International Infection Control Consortium (INICC) in Beirut, Lebanon.

MATERIALS AND METHODS

An open label, prospective cohort, active DA-HAI surveillance study was conducted on adults admitted to a tertiary-care ICU in Lebanon from November 2007 to March 2010. The protocol and methodology implemented were developed by INICC. Data collection was performed in the participating ICUs. Data uploading and analyses were conducted at INICC headquarters on proprietary software. DA-HAI rates were recorded by applying the definitions of the National Healthcare Safety Network (NHSN) at the US Centers for Disease Control and Prevention (CDC). We analyzed the DA-HAI, mechanical ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CAUTI) rates, microorganism profile, excess LOS, excess mortality, and hand hygiene compliance.

RESULTS

A total of 666 patients hospitalized for 5,506 days acquired 65 DA-HAIs, an overall rate of 9.8% [(95% confidence interval (CI) 7.6-12.3], and 11.8 (95% CI 9.1-15.0) DA-HAIs per 1000 ICU-days. The CLA-BSI rate was 5.2 (95% CI 2.8-8.7) per 1000 catheter-days; the VAP rate was 8.1 (95% CI 5.5-11.7) per 1000 ventilator-days; and the CAUTI rate was 4.1 (95% CI 2.6-6.2) per 1000 catheter-days. LOS of patients was 7.3 days for those without DA-HAI, 13.8 days for those with CLA-BSI, 18.8 days for those with VAP. Excess mortality was 40.9% [relative risk (RR) 3.14; P 0.004] for CLA-BSI. Mortality of VAP and CAUTI was not significantly different from patients without DA-HAI. Escherichia coli was the most common isolated microorganism. Overall hand hygiene compliance was 84.9% (95% CI 82.3-87.3).

CONCLUSIONS

DA-HAI rates, bacterial resistance, LOS and mortality were moderately high, below INICC overall data and above CDC-NHSN data. Infection control programs including surveillance and antibiotic policies are essential and continue to be a priority in Lebanon.

Beyond the central line-associated bloodstream infection bundle: the value of the clinical nurse specialist in continuing evidence-based practice changes

PURPOSE

The purpose of this project was to demonstrate the value of clinical nurse specialist (CNS)-led efforts to optimize patient outcomes through continued monitoring and management of a previously implemented evidence-based practice project.

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) significantly impact patient morbidity/mortality and cost of care. In 2006, the critical care unit (CCU) of the Portland VA Medical Center implemented national recommendations for the prevention of CLABSIs through use of the Institute of Healthcare Improvement Central Line Bundle. This practice change was led by the CCU and infection control CNSs, and compliance in the completion of bundle items has remained consistently high (>90%). Although the CCU has maintained CLABSI rates below the national benchmark, it experienced a 4-month period of increased incidence in late 2008.

DESCRIPTION

Clinical nurse specialists in CCU and infection control organized a "Hot Team" of nurses from multiple departments throughout the hospital to evaluate processes/data related to the recent increase in infections. Using national guidelines, the team focused on interdisciplinary implementation of strategies beyond the Central Line Bundle components. Consideration of cost and workflow patterns was critical to decision making.

OUTCOME

Infection rates in CCU decreased from a high of 1.5 per 1000 line days down to 0 in June 2011, with the last CLABSI occurring in May 2010.

CONCLUSION

The formation and efforts of a CNS-led team of nurses has been successful in decreasing infection rates through implementation of multiple innovative strategies.

IMPLICATIONS

Clinical nurse specialist surveillance, management, and leadership following project implementation are valuable strategies for continued optimal patient outcomes.

National practice patterns in preoperative and postoperative antibiotic prophylaxis in breast procedures requiring drains: survey of the American Society of Breast Surgeons

BACKGROUND

To assess national practice patterns regarding use of perioperative antibiotics by surgeons performing breast operations requiring drainage tubes.

METHODS

The members of the American Society of Breast Surgeons (ASBrS) were surveyed regarding use of perioperative antibiotics for breast operations requiring drains, with or without immediate tissue expander or implant reconstruction.

RESULTS

Of 2,857 ASBrS members contacted, 917 (32 %) responded; all self-identified as surgeons. Of 905 evaluable respondents, most described themselves as general surgeons (46 %) or breast surgeons (46 %). For cases in which drains are anticipated, most respondents (86 %) reported routine use of preoperative prophylactic antibiotics, with 99 % selecting cephalosporins. Use of antibiotic >24 h postoperatively varied by whether or not reconstruction was performed. In nonreconstruction cases, the majority (76 %) reported "never/almost never" prescribing antibiotics beyond the 24-h postoperative period, but 16 % reported "always/almost always." In reconstruction cases, the majority (58 %) reported routine antibiotic use beyond 24 h, and the primary driver of the decision to use antibiotics was reported to be the plastic surgeon (83 %). Among those reporting use at >24 h, the duration recommended for nonreconstruction cases was "up to 1 week" in 38 % and "until drains removed" in 39 %; this was similar for reconstruction cases.

CONCLUSIONS

Cephalosporins are utilized uniformly as preoperative antibiotic prophylaxis in breast operations requiring drains. However, use of postoperative antibiotic prophylaxis is strongly dependent on the presence of immediate breast reconstruction. Consensus is lacking on the role of postoperative antibiotic prophylaxis in breast operations utilizing drains.

Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units

BACKGROUND

Little is known about whether recommended strategies to prevent catheter-associated urinary tract infection (CAUTI) are being implemented in intensive care units (ICU) in the United States.

OBJECTIVES

Our objectives were to describe the presence of and adherence to CAUTI prevention policies in ICUs, to identify variations in policies based on organizational characteristics, and to determine whether a relationship exists between prevention policies and CAUTI incidence rates.

METHODS

Four hundred forty-one hospitals that participate in the National Healthcare Safety Network were surveyed in spring 2008.

RESULTS

Two hundred fifty hospitals provided information for 415 ICUs (response rate, 57%). A small proportion of ICUs surveyed had policies supporting bladder ultrasound (26%, n = 106), condom catheters (20%, n = 82), catheter removal reminders (12%, n = 51), or nurse-initiated catheter discontinuation (10%, n = 39). ICUs in hospitals with ≥ 500 beds were half as likely as those in smaller hospitals to have adopted at least 1 CAUTI prevention policy (odds ratio, 0.52; 95% confidence interval: 0.33-0.86), and ICUs in hospitals where the infection control director reported always having access to key decision makers for planning were more than twice as likely as those with less access to have adopted a policy (odds ratio, 2.41; 95% confidence interval: 1.56-3.72).

CONCLUSION

Little attention is currently placed on CAUTI prevention in ICUs in the United States. Further research is needed to elucidate relationships between adherence to CAUTI prevention recommendations and CAUTI incidence rates.

Tight glycemic control versus standard care after pediatric cardiac surgery

BACKGROUND

In some studies, tight glycemic control with insulin improved outcomes in adults undergoing cardiac surgery, but these benefits are unproven in critically ill children at risk for hyperinsulinemic hypoglycemia. We tested the hypothesis that tight glycemic control reduces morbidity after pediatric cardiac surgery.

METHODS

In this two-center, prospective, randomized trial, we enrolled 980 children, 0 to 36 months of age, undergoing surgery with cardiopulmonary bypass. Patients were randomly assigned to either tight glycemic control (with the use of an insulin-dosing algorithm targeting a blood glucose level of 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) or standard care in the cardiac intensive care unit (ICU). Continuous glucose monitoring was used to guide the frequency of blood glucose measurement and to detect impending hypoglycemia. The primary outcome was the rate of health care-associated infections in the cardiac ICU. Secondary outcomes included mortality, length of stay, organ failure, and hypoglycemia.

RESULTS

A total of 444 of the 490 children assigned to tight glycemic control (91%) received insulin versus 9 of 490 children assigned to standard care (2%). Although normoglycemia was achieved earlier with tight glycemic control than with standard care (6 hours vs. 16 hours, P<0.001) and was maintained for a greater proportion of the critical illness period (50% vs. 33%, P<0.001), tight glycemic control was not associated with a significantly decreased rate of health care-associated infections (8.6 vs. 9.9 per 1000 patient-days, P=0.67). Secondary outcomes did not differ significantly between groups, and tight glycemic control did not benefit high-risk subgroups. Only 3% of the patients assigned to tight glycemic control had severe hypoglycemia (blood glucose <40 mg per deciliter [2.2 mmol per liter]).

CONCLUSIONS

Tight glycemic control can be achieved with a low hypoglycemia rate after cardiac surgery in children, but it does not significantly change the infection rate, mortality, length of stay, or measures of organ failure, as compared with standard care. (Funded by the National Heart, Lung, and Blood Institute and others; SPECS ClinicalTrials.gov number, NCT00443599.).

Surveillance on secular trends of incidence and mortality for device-associated infection in the intensive care unit setting at a tertiary medical center in Taiwan, 2000-2008: a retrospective observational study

Background

Device–associated infection (DAI) plays an important part in nosocomial infection. Active surveillance and infection control are needed to disclose the specific situation in each hospital and to cope with this problem effectively. We examined the rates of DAI by antimicrobial-resistant pathogens, and 30–day and in–hospital mortality in the intensive care unit (ICU).

Methods

Prospective surveillance was conducted in a mixed medical and surgical ICU at a major teaching hospital from 2000 through 2008. Trend analysis was performed and logistic regression was used to assess prognostic factors of mortality.

Results

The overall rate of DAIs was 3.03 episodes per 1000 device–days. The most common DAI type was catheter–associated urinary tract infection (3.76 per 1000 urinary catheter–days). There was a decrease in DAI rates in 2005 and rates of ventilator–associated pneumonia (VAP, 3.18 per 1000 ventilator–days) have remained low since then (p < 0.001). The crude rates of 30–day (33.6%) and in–hospital (52.3%) mortality, as well as infection by antibiotic-resistant VAP pathogens also decreased. The most common antimicrobial-resistant pathogens were methicillin–resistant Staphylococcus aureus (94.9%) and imipenem–resistant Acinetobacter baumannii (p < 0.001), which also increased at the most rapid rate. The rate of antimicrobial resistance among Enterobacteriaceae also increased significantly (p < 0.05). After controlling for potentially confounding factors, the DAI was an independent prognostic factor for both 30–day mortality (OR 2.51, 95% confidence interval [CI] 1.99–3.17, p = 0.001) and in–hospital mortality (OR 3.61, 95% CI 2.10–3.25, p < 0.001).

Conclusions

The decrease in the rate of DAI and infection by resistant bacteria on the impact of severe acute respiratory syndrome can be attributed to active infection control and improved adherence after 2003.

2012 Young Investigator Award winner: The distribution of body mass as a significant risk factor for lumbar spinal fusion postoperative infections

STUDY DESIGN

A retrospective review.

OBJECTIVE

The purpose of this study was to determine the role in body habitus and weight distribution on developing a surgical site infection (SSI).

SUMMARY OF BACKGROUND DATA

SSI after lumbar spine surgery remains a significant cause of morbidity. The literature demonstrates an increased risk of postoperative infections associated with obesity, diabetes, and multilevel surgeries.

METHODS

A retrospective review was performed on a consecutive cohort of 298 adult patients who underwent lumbar spine fusion surgeries between 2006 and 2008 at the Duke University Medical Center. Previously identified risk factors (i.e., number of levels, diabetes, body mass index [BMI]) were collected, as well as the horizontal distance from the lamina to the skin surface (measured at L4) and thickness of subcutaneous fat at the surgical site.

RESULTS

Among the 298 patients, 24 (8%) had postoperative infections. Of the previously identified risk factors, number of levels (P = 0.0078) was found to be significantly associated with infections, whereas BMI (P = 0.16) and diabetes (P = 0.13) were found not to be statistically significant. Obesity (BMI ≥30) (P = 0.025), skin to lamina distance (P = 0.046), and thickness of the subcutaneous fat (P = 0.035) were found to be significant risk factors for SSI.

CONCLUSION

Our findings suggest that in obese patients, the distribution of body mass is more predictive of SSI than the absolute BMI and deserves attention in preoperative evaluation.

Changes in the pattern of hospital intravenous antimicrobial use in Saudi Arabia, 2006-2008

BACKGROUND AND OBJECTIVE

Hospitals should measure antimicrobial use based on the WHO's recommended metric, the defined daily dose (DDD). There is no data on antimicrobial usage based on DDD in Saudi Arabia. Thus, this study evaluates the trend in antimicrobial consumption based on this concept.

DESIGN AND SETTING

Observational study in a general hospital in Saudi Arabia from 2006-2008.

METHODS

We analyzed the use of intravenous systemic antibacterial agents (group J01 of the Anatomical Therapeutic Chemical [ATC] classification and the classes of this group) that were administered to hospitalized patients by reviewing the data obtained from the pharmacy records. Antimicrobial consumption was calculated as the number of DDD per 100 bed-days.

RESULTS

Of the total parenteral antibiotics, ciprofloxacin was the most commonly used intravenous antibiotic (67.6%), followed by ceftriaxone (6%), cefazolin (5%), and imipenem-enzyme inhibitor (4.3%). The DDD per 100 patient-days usage of intravenous antimicrobial agents was as follows: J01MA02 ciprofloxacin (parenteral) 82.643, J01DD04 ceftriaxone 7.447, J01DB02 cefazolin 6.166, J01DH51 imipenem-enzyme inhibitor 5.234, J01MA12 levofloxacin 3.188, and J01XA01 vancomycin 2.97. Intravenous ciprofloxacin usage increased from 3.55 to 82.643 DDD/100 patient days.

CONCLUSION

The study showed that the most commonly used intravenous systemic antimicrobial agent was ciprofloxacin. Thus, strategies are needed to specifically target these agents for prescribing improvement.

Impact of surgical site infections after open and laparoscopic colon and rectal surgeries on postoperative resource consumption

PURPOSE

To estimate the impact of surgical site infection (SSI) on postoperative resource consumption for colon and rectal open and laparoscopic surgeries after accounting for infection depth and patient characteristics, and to compare these estimates among institutions.

METHODS

We collected administrative and SSI-related data from eight Japanese hospitals, and used generalized linear models to estimate excess postoperative length of stay (LOS) and charges attributable to SSI. Covariates included wound class, American Society of Anesthesiologists (ASA) score, operation time, emergency, colostomy, trauma, implant, and comorbidities.

RESULTS

We examined 1,108 colon surgery (CS) and 477 rectal surgery (RS) patients. For open surgery, the postoperative LOS in non-SSI patients was 13.5 (CS) and 15.9 days (RS). Compared with non-SSI patients, the postoperative LOS increased by 4.5 (CS) and 2.8 days (RS) for superficial SSI, 6.8 (CS) and 8.5 days (RS) for deep SSI, and 7.8 and 9.5 days for space/organ SSI. For laparoscopic surgery, the postoperative LOS was 9.8 (CS) and 14.6 days (RS). SSI was significantly associated with increased postoperative LOS for superficial SSI [by 4.8 (CS) and 3.6 days (RS)], deep SSI [by 10.3 (CS) and 23.9 days (RS)], and space/organ SSI [by 8.9 days (RS)]. The postoperative LOS among hospitals was 3.8-10.4 days (CS) and 1.3-12.2 days (RS). Postoperative SSI-attributable charges ranged from $386 to $2,873, depending on organ, procedure, and infection depth.

CONCLUSION

This study quantified the impact of SSIs on resource consumption and confirmed significant cost variations among hospitals. These variations could not be explained by patient characteristics or infection type.

Ventilator-associated pneumonia rates at major trauma centers compared with a national benchmark: a multi-institutional study of the AAST

BACKGROUND

Ventilator-associated pneumonia (VAP) rates reported by the National Healthcare Safety Network (NHSN) are used as a benchmark and quality measure, yet different rates are reported from many trauma centers. This multi-institutional study was undertaken to elucidate VAP rates at major trauma centers.

METHODS

VAP rate/1,000 ventilator days, diagnostic methods, institutional, and aggregate patient data were collected retrospectively from a convenience sample of trauma centers for 2008 and 2009 and analyzed with descriptive statistics.

RESULTS

At 47 participating Level I and II centers, the pooled mean VAP rate was 17.2 versus 8.1 for NHSN (2006-2008). Hospitals' rates were highly variable (range, 1.8-57.6), with 72.3% being above NHSN's mean. Rates differed based on who determined the rate (trauma service, 27.5; infection control or quality or epidemiology, 11.9; or collaborative effort, 19.9) and the frequency with which VAP was excluded based on aspiration or diagnosis before hospital day 5. In 2008 and 2009, blunt trauma patients had higher VAP rates (17.3 and 17.6, respectively) than penetrating patients (11.0 and 10.9, respectively). More centers used a clinical diagnostic strategy (57%) than a bacteriologic strategy (43%). Patients with VAP had a mean Injury Severity Score of 28.7, mean Intensive Care Unit length of stay of 20.8 days, and a 12.2% mortality rate. 50.5% of VAP patients had a traumatic brain injury.

CONCLUSIONS

VAP rates at major trauma centers are markedly higher than those reported by NHSN and vary significantly among centers. Available data are insufficient to set benchmarks, because it is questionable whether any one data set is truly representative of most trauma centers. Application of a single benchmark to all centers may be inappropriate, and reliable diagnostic and reporting standards are needed. Prospective analysis of a larger data set is warranted, with attention to injury severity, risk factors specific to trauma patients, diagnostic method used, VAP definitions and exclusions, and reporting guidelines.

LEVEL OF EVIDENCE

III, prognostic study.

Device-associated nosocomial infection rates in intensive care units at Cairo University hospitals: first step toward initiating surveillance programs in a resource-limited country

BACKGROUND

Device associated infections (DAIs) have major impact on patient morbidity and mortality.

METHODS

This study involved active prospective surveillance to measure the incidence of DAIs, evaluate microbiological profiles, and investigate excessive mortality in intensive care units (ICUs) in 3 hospitals of Cairo University applying the US Centers for Disease Control and Prevention's National Healthcare Safety Network case definitions for ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central-line associated bloodstream infection (CLABSI). Data were collected between March 2009 and May 2010.

RESULTS

A total of 1,101 patients were hospitalized for a total of 10,869 days, had 4,734 device-days, and acquired 97 DAIs, with an overall rate of 20.5/1,000 ICU days. VAP was the most commonly identified infection (88.7%); followed by CLABSI (8.2%) and CAUTI (3.1%). Excess mortality was 48% (relative risk, 1.9; P < .001) for CAUTI, 12.9% (relative risk, 1.2; 95% confidence interval, 1.1-1.4; P < .05) for VAP, and 45.7% for CLABSI. Acinetobacter baumannii was the most frequently isolated pathogen (36.1%), followed by Klebsiella pneumoniae (29.2%) and Pseudomonas aeruginosa (22.2%). High antimicrobial resistance was identified, with 85% of A baumannii isolates resistant to ciprofloxacin and imipenem, 76% of K pneumoniae isolates were extended-spectrum β-lactamase producers, and 56.3% P aeruginosa isolates resistant to imipenem (56.3%).

CONCLUSION

High rates of DAI and antimicrobial resistance require strengthening infection control, instituting surveillance systems, and implementing evidence-based preventive strategies.