Surveillance of infections acquired in intensive care: usefulness in clinical practice

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.

Scoping review on diagnostic criteria and investigative approach in sepsis of unknown origin in critically ill patients

Background

Up to 11% of critically ill patients with sepsis have an unknown source, where the pathogen and site of infection are unclear. The aim of this scoping review is to document currently reported diagnostic criteria of sepsis of unknown origin (SUO) and identify the types and breadth of existing evidence supporting diagnostic processes to identify the infection source in critically ill patients with suspected SUO.

Methods

A literature search of Embase, MEDLINE and PubMed for published studies from 1910 to August 19, 2021 addressing the topic of SUO was performed. Study type, country of origin according to World Bank classification, diagnostic criteria of sepsis of unknown origin, and investigative approaches were extracted from the studies.

Results

From an initial 722 studies, 89 unique publications fulfilled the inclusion and exclusion criteria and were included for full text review. The most common publication type was case report/series 45/89 (51%). Only 10/89 (11%) of studies provided a diagnostic criteria of SUO, but a universally accepted diagnostic criterion was not identified. The included studies discussed 30/89 (34%) history, 23/89 (26%) examination, 57/89 (64%) imaging, microbiology 39/89 (44%), and special tests 32/89 (36%) as part of the diagnostic processes in patients with SUO.

Conclusions

Universally accepted diagnostic criteria for SUO was not found. Prospective studies on investigative processes in critically ill patients managed as SUO across different healthcare settings are needed to understand the epidemiology and inform the diagnostic criteria required to diagnose SUO.

The Use of Antibiotics for Ventilator-Associated Pneumonia in the MIMIC-IV Database

Purpose: By analyzing the clinical characteristics, etiological characteristics and commonly used antibiotics of patients with ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in the intensive care database. This study aims to provide guidance information for the clinical rational use of drugs for patients with VAP.

Method: Patients with VAP information were collected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, including their sociodemographic characteristics, vital signs, laboratory measurements, complications, microbiology, and antibiotic use. After data processing, the characteristics of the medications used by patients with VAP in ICUs were described using statistical graphs and tables, and experiences were summarized and the reasons were analyzed.

Results: This study included 2,068 patients with VAP. Forty-eight patient characteristics, including demographic indicators, vital signs, biochemical indicators, scores, and comorbidities, were compared between the survival and death groups of VAP patients. Cephalosporins and vancomycin were the most commonly used. Among them, fourth-generation cephalosporin (ForGC) combined with vancomycin was used the most, by 540 patients. First-generati49n cephalosporin (FirGC) combined with vancomycin was associated with the highest survival rate (86.7%). More than 55% of patients were infected with Gram-negative bacteria. However, patients with VAP had fewer resistant strains (<25%). FirGC or ForGC combined with vancomycin had many inflammation-related features that differed significantly from those in patients who did not receive medication.

Conclusion: Understanding antibiotic use, pathogenic bacteria compositions, and the drug resistance rates of patients with VAP can help prevent the occurrence of diseases, contain infections as soon as possible, and promote the recovery of patients.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units

BACKGROUND

Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection.

AIM

To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients.

DESIGN

A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion.

METHODS

The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable.

RESULTS

The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use.

CONCLUSION

Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort.

RELEVANCE TO CLINICAL PRACTICE

Effective oral care is integral to safe patient care in critical care.

Excess Mucin Impairs Subglottic Epithelial Host Defense in Mechanically Ventilated Patients

RATIONALE

Aspiration of infective subglottic secretions causes ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Mechanisms underlying subglottic colonization in critical illness have not been defined, limiting strategies for targeted prevention of VAP.

OBJECTIVES

To characterize subglottic host defense dysfunction in mechanically ventilated patients in the ICU; to determine whether subglottic mucin contributes to neutrophil phagocytic impairment and bacterial growth.

METHODS

Prospective subglottic sampling in mechanically ventilated patients (intubated for four or more days), and newly intubated control patients (intubated for less than 30 min); isolation and culture of primary subglottic epithelial cells from control patients; laboratory analysis of host innate immune defenses.

MEASUREMENTS AND MAIN RESULTS

Twenty-four patients in the ICU and 27 newly intubated control patients were studied. Subglottic ICU samples had significantly reduced microbiological diversity and contained potential respiratory pathogens. The subglottic microenvironment in the ICU was characterized by neutrophilic inflammation, significantly increased proinflammatory cytokines and neutrophil proteases, and altered physical properties of subglottic secretions, including accumulation of mucins. Subglottic mucin from ICU patients impaired the capacity of neutrophils to phagocytose and kill bacteria. Phagocytic impairment was reversible on treatment with a mucolytic agent. Subglottic mucus promoted growth and invasion of bacterial pathogens in a novel air-liquid interface model of primary human subglottic epithelium.

CONCLUSIONS

Mechanical ventilation in the ICU is characterized by substantial mucin secretion and neutrophilic inflammation. Mucin impairs neutrophil function and promotes bacterial growth. Mucolytic agents reverse mucin-mediated neutrophil dysfunction. Enhanced mucus disruption and removal has potential to augment preventive benefits of subglottic drainage.

Description of Clinical Characteristics of VAP Patients in MIMIC Database

Background: Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection of intensive-care units (ICUs). Accurate, timely diagnosis enables early VAP patients to receive appropriate therapies and reduce the occurrence of complication. However, so far clinical datas regarding the epidemiology and mortality of VAP are still limited. Medical Information Mart for Intensive Care (MIMIC) database is a free, open and public resource about ICU research database. MIMIC database is a free, open, public database that collects information on more than 40,000 ICU patients who are predominantly white people. Therefore, the purpose of the present study is to observe and describe the clinical characteristics of VAP patients in ICU from the MIMIC database.

Method: A total of 418 patients were enrolled in the study. General information, ventilator use information, microbiology information, antibiotic use information, and some nursing-related information were extracted to describe and analyze the clinical features of VAP patients.

Results: The results of the study showed that patients with one or three pathogens were the most. The main pathogens were YEAST (16.71%), STAPH AUREUS COAG+ (11.63%), Staphylococcus, COAGULASE NEGATIVE (8.68%), GRAM NEGATIVE ROD (S) (6.14%), and Pseudomonas aeruginosa (5.73%). Patients using 4 antibiotics were the most. The top five antibiotics in the largest proportion were synthetic antibacterials (24.66%), peptides (20.13%), cephalosporins (19.60%), penicillins (13.54%), and aminoglycosides (5.27%).

Conclusion: This study summarizes the common pathogens of VAP and the antibiotics commonly used in the treatment of VAP by describing the clinical information of 418 patients with VAP in the MIMIC database. In clinical treatment, we should pay attention to aseptic operation, develop appropriate antibacterial measures, closely monitor the pathogens of VAP infection, and use antibiotics in a timely manner to control the occurrence and development of VAP.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base

Selective digestive decontamination (SDD, topical antibiotic regimens applied to the respiratory tract) appears effective for preventing ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients. However, potential contextual effects of SDD on Staphylococcus aureus infections in the ICU remain unclear. The S. aureus ventilator associated pneumonia (S. aureus VAP), VAP overall and S. aureus bacteremia incidences within component (control and intervention) groups within 27 SDD studies were benchmarked against 115 observational groups. Component groups from 66 studies of various interventions other than SDD provided additional points of reference. In 27 SDD study control groups, the mean S. aureus VAP incidence is 9.6% (95% CI; 6.9–13.2) versus a benchmark derived from 115 observational groups being 4.8% (95% CI; 4.2–5.6). In nine SDD study control groups the mean S. aureus bacteremia incidence is 3.8% (95% CI; 2.1–5.7) versus a benchmark derived from 10 observational groups being 2.1% (95% CI; 1.1–4.1). The incidences of S. aureus VAP and S. aureus bacteremia within the control groups of SDD studies are each higher than literature derived benchmarks. Paradoxically, within the SDD intervention groups, the incidences of both S. aureus VAP and VAP overall are more similar to the benchmarks.

Nosocomial Infection Surveillance in a Surgical Intensive Care Unit in Spain, 1996-2000: A Time-Trend Analysis

Objective.

To establish the occurrence, distribution, and secular time trend of nosocomial infections (NIs) in a surgical intensive care unit (ICU).

Design and Setting.

Follow-up study in a teaching hospital in Spain.

Methods.

In May 1995 we established an nosocomial infection surveillance system in our surgical ICU. We collected information daily for all patients who were in the ICU for at least 48 hours (546 patients from 1996 through 2000). We used the Centers for Disease Control and Prevention definitions and criteria for infections. Monthly, we determined the site-specific incidence densities of NIs, the rates of medical device use, and the Poisson probability distribution, which determined whether the case count equalled the number of expected cases (the mean number of cases during the previous year, with extreme values excluded). We compared yearly and monthly infection rates by Poisson regression, using site-specific NIs as a dependent variable and year and month as dummy variables. We tested annual trends with an alternative Poisson regression model fitting a single linear trend.

Results.

The average rate of catheter-associated urinary tract infections was 8.4 per 1000 catheter-days; that of ventilator-associated pneumonia, 21 per 1000 ventilator-days; and that of central line–associated bloodstream infections, 30 per 1000 central line–days. The rate of urinary tract infections did not change over the study period, but there was a trend toward decreases in the rates of central line–associated bloodstream infections and ventilator-associated pneumonia.

Conclusion.

An NI surveillance and control program contributed to a progressive decrease in NI rates.

Automated surveillance for ventilator-associated events

BACKGROUND

The US Centers for Disease Control and Prevention has implemented a new, multitiered definition for ventilator-associated events (VAEs) to replace their former definition of ventilator-associated pneumonia (VAP). We hypothesized that the new definition could be implemented in an automated, efficient, and reliable manner using the electronic health record and that the new definition would identify different patients than those identified under the previous definition.

METHODS

We conducted a retrospective cohort analysis using an automated algorithm to analyze all patients admitted to the ICU at a single urban, tertiary-care hospital from 2008 to 2013.

RESULTS

We identified 26,466 consecutive admissions to the ICU, 10,998 (42%) of whom were mechanically ventilated and 675 (3%) of whom were identified as having any VAE. Any VAE was associated with an adjusted increased risk of death (OR, 1.91; 95% CI, 1.53-2.37; P < .0001). The automated algorithm was reliable (sensitivity of 93.5%, 95% CI, 77.2%-98.8%; specificity of 100%, 95% CI, 98.8%-100% vs a human abstractor). Comparison of patients with a VAE and with the former VAP definition yielded little agreement (κ = 0.06).

CONCLUSIONS

A fully automated method of identifying VAEs is efficient and reliable within a single institution. Although VAEs are strongly associated with worse patient outcomes, additional research is required to evaluate whether and which interventions can successfully prevent VAEs.

Conversion of Prevalence Survey Data on Nosocomial Infections to Incidence Estimates: A Simplified Tool for Surveillance?

We calculated the incidence of nosocomial infection in 2 intensive care units (ICUs) on the basis of prevalence data recorded from 1997 through 2002 and compared these estimates to cumulative incidences measured in the 2 ICUs during the same period to investigate the feasibility and the reliability of converting prevalence data to incidence estimates. Decreases in the calculated and measured incidences over time in the ICUs were found to be statistically significantly related.

Topical antibiotics as a major contextual hazard toward bacteremia within selective digestive decontamination studies: a meta-analysis

BACKGROUND

Among methods for preventing pneumonia and possibly also bacteremia in intensive care unit (ICU) patients, Selective Digestive Decontamination (SDD) appears most effective within randomized concurrent controlled trials (RCCT's) although more recent trials have been cluster randomized. However, of the SDD components, whether protocolized parenteral antibiotic prophylaxis (PPAP) is required, and whether the topical antibiotic actually presents a contextual hazard, remain unresolved. The objective here is to compare the bacteremia rates and patterns of isolates in SDD-RCCT's versus the broader evidence base.

METHODS

Bacteremia incidence proportion data were extracted from component (control and intervention) groups decanted from studies investigating antibiotic (SDD) or non-antibiotic methods of VAP prevention and summarized using random effects meta-analysis of study and group level data. A reference category of groups derived from purely observational studies without any prevention method under study provided a benchmark incidence.

RESULTS

Within SDD RCCTs, the mean bacteremia incidence among concurrent component groups not exposed to PPAP (27 control; 17.1%; 13.1-22.1% and 12 intervention groups; 16.2%; 9.1-27.3%) is double that of the benchmark bacteremia incidence derived from 39 benchmark groups (8.3; 6.8-10.2%) and also 20 control groups from studies of non-antibiotic methods (7.1%; 4.8 - 10.5). There is a selective increase in coagulase negative staphylococci (CNS) but not in Pseudomonas aeruginosa among bacteremia isolates within control groups of SDD-RCCT's versus benchmark groups with data available.

CONCLUSIONS

The topical antibiotic component of SDD presents a major contextual hazard toward bacteremia against which the PPAP component partially mitigates.

A Prevalence Survey of Intravascular Catheter use in a General Hospital

Purpose

Survey of intravascular catheter management is an essential step in the control and prevention of catheter-related infection. In recent years, most surveillance studies only included catheters from intensive care units (ICUs). Data regarding the level of care and adherence to international guidelines in a whole general institution are scarce. Our objective was to evaluate the care situation of intravascular catheters in our adult units of a General Hospital.

Methods

We surveyed adults hospitalized in non-psychiatric/maternity wards. In a week, a nurse visited all the adult hospitalized patients. Data were registered in a protocol that included variables, such as no. of catheters, location of catheter, type of catheter, date of placement and the need of an indication of each catheter in the visit day.

Results

We included in the study a total of 753 adult patients. Of them, 653 (86.7%) had one or more inserted catheters at the moment of the study visit (total: 797 catheters). Of all the catheters, 144 (18.0%) were central venous catheters and 653 (81.9%) were peripheral lines. The hospitalization units where the patients were admitted were ICU, 52 (6.9%); and non-ICU, 601 (92.0%). There were 183 (22.9%) catheters with no need to remain in place in the day of the study. Overall, we found 464 (71.0%) patients with one or more opportunities for catheter care improvement.

Conclusions

A rapid survey of the care situation of intravascular catheters is feasible and easy to do with our methodology. The data show great opportunity for improvement, mainly in the non-ICU areas.

When policy gets it right: variability in u.s. Hospitals' diagnosis of ventilator-associated pneumonia*

OBJECTIVE

The Centers for Disease Control has recently proposed a major change in how ventilator-associated pneumonia is defined. This has profound implications for public reporting, reimbursement, and accountability measures for ICUs. We sought to provide evidence for or against this change by quantifying limitations of the national definition of ventilator-associated pneumonia that was in place until January 2013, particularly with regard to comparisons between, and ranking of, hospitals and ICUs.

DESIGN

A prospective survey of a nationally representative group of 43 hospitals, randomly selected from the American Hospital Association Guide (2009). Subjects classified six standardized vignettes of possible cases of ventilator-associated pneumonia as pneumonia or no pneumonia.

SUBJECTS

Individuals responsible for ventilator-associated pneumonia surveillance at 43 U.S. hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured the proportion of standardized cases classified as ventilator-associated pneumonia. Of 138 hospitals consented, 61 partially completed the survey and 43 fully completed the survey (response rate 44% and 31%, respectively). Agreement among hospitals about classification of cases as ventilator-associated pneumonia/not ventilator-associated pneumonia was nearly random (Fleiss κ 0.13). Some hospitals rated 0% of cases as having pneumonia; others classified 100% as having pneumonia (median, 50%; interquartile range, 33-66%). Although region of the country did not predict case assignment, respondents who described their region as "rural" were more likely to judge a case to be pneumonia than respondents elsewhere (relative risk, 1.25, Kruskal-Wallis chi-square, p = 0.03).

CONCLUSIONS

In this nationally representative study of hospitals, assignment of ventilator-associated pneumonia is extremely variable, enough to render comparisons between hospitals worthless, even when standardized cases eliminate variability in clinical data abstraction. The magnitude of this variability highlights the limitations of using poorly performing surveillance definitions as methods of hospital evaluation and comparison, and our study provides very strong support for moving to a more objective definition of ventilator-associated complications.

Antibiotic resistance in the intensive care unit setting

Antibiotic resistance is an important factor influencing clinical outcome for patients in intensive care units. It is also associated with increased healthcare costs resulting from prolonged patient stays. The problem of antibiotic resistance is particularly acute in intensive care units because they house seriously ill patients who are predisposed to infection, as a result of which, antibiotic use is extremely common. Strategies for controlling resistance in intensive care units have focused on attempting to reduce unnecessary antibiotic use, while at the same time ensuring adequate antibiotic cover is provided. The formulation of policies for the effective use of antibiotics in individual intensive care units requires a multidisciplinary approach, entailing regular epidemiological surveillance, together with input from critical care specialists, infectious disease specialists and pharmacists.

Subglottic secretion drainage for preventing ventilator associated pneumonia: a meta-analysis

BACKGROUND

Ventilator associated pneumonia (VAP) in the intensive care unit (ICU) has been shown to be associated with significant morbidity and mortality.(1-3) It has been reported to affect between 9 and 27% of intubated patients receiving mechanical ventilation.(4-6) OBJECTIVE: A meta-analysis was undertaken to combine information from published studies of the effect of subglottic drainage of secretions on the incidence of ventilated associated pneumonia in adult ICU patients.

DATA SOURCES

Studies were identified by searching MEDLINE (1966 to January 2011), EMBASE (1980-2011), and CINAHL (1982 to January 2011).

REVIEW METHODS

Randomized trials of subglottic drainage of secretions compared to usual care in adult mechanically ventilated ICU patients were included in the meta-analysis.

RESULTS

Subglottic drainage of secretions was estimated to reduced the risk of VAP by 48% (fixed-effect relative risk (RR)=0.52, 95% confidence interval (CI), 0.42-0.65). When comparing subglottic drainage and control groups, the summary relative risk for ICU mortality was 1.05 (95% CI, 0.86-1.28) and for hospital mortality was 0.96 (95% CI, 0.81-1.12). Overall subglottic drainage effect on days of mechanical ventilation was -1.04 days (95% CI, -2.79-0.71).

CONCLUSION

This meta-analysis of published randomized control trials shows that almost one-half of cases of VAP may be prevented with the use of specialized endotracheal tubes designed to drain subglottic secretions. Time on mechanical ventilation may be reduced and time to development of VAP may be increased, but no reduction in ICU or hospital mortality has been observed in published trials.

Exploiting amyloid: how and why bacteria use cross-β fibrils

Many bacteria produce protein fibrils that are structurally analogous to those associated with protein misfolding diseases such as Alzheimer's disease. However, unlike fibrils associated with disease, bacterial amyloids have beneficial functions including conferring stability to biofilms, regulating development or imparting virulence. In the present review, we consider what makes amyloid fibrils so suitable for these roles and discuss recent developments in the study of bacterial amyloids, in particular the chaplins from Streptomyces coelicolor. We also consider the broader impact of the study of bacterial amyloids on our understanding of infection and disease and on developments in nanotechnology.

Active training and surveillance: 2 good friends to reduce urinary catheterization rate

BACKGROUND

Because catheter-associated urinary tract infections (CAUTI) represent the most frequent health care-associated infection (HAI), we implemented an educational intervention on urinary catheter use to reduce the CAUTI rate.

METHODS

The intervention was focused on correct management of catheterized patients. To assess the participants' knowledge, pre- and post-tests were performed. An active CAUTI surveillance program took place in a 900-bed teaching hospital in central Italy before and after the educational intervention. CAUTI definition, catheterization rate, and CAUTI rate were expressed according to the Centers for Disease and Prevention/National Healthcare Safety Network definitions. The level of significance was set at P ≤ .05.

RESULTS

Two hundred ninety-six health care workers attended the educational intervention; the analysis of the pre- and post-tests highlighted a statistically significant improvement (P < .05). Before the intervention, mean catheterization rate was 18.5% (95% confidence interval [CI]:18.1-18.9); 46 cases of CAUTI were detected, with an incidence rate of 6.6/1,000 catheter-days (95% CI: 4.8-8.8). After the intervention, mean catheterization rate was 9.2% (95% CI: 8.9-9.5); 19 cases of CAUTI were detected, with an incidence rate of 5.8/1,000 catheter-days (95% CI: 3.5-9.0).

CONCLUSION

Through an active educational update and thanks to the implementation of a surveillance system, a successful reduction of catheterization rate was achieved. More efforts are needed to preserve this goal and to improve the CAUTI rate also.

Nosocomial infections and risk factors in the intensive care unit of a teaching and research hospital: a prospective cohort study

Background

To evaluate the incidence, risk factors and etiology of nosocomial infections (NIs) in the intensive care unit (ICU) of our hospital in order to improve our infection control policies.

Material/Methods

A 1-year prospective cohort study of nosocomial infection (NI) surveillance was conducted in our ICU in 2008.

Results

Out of 1134 patients hospitalized in the ICU for a period of 6257 days, 115 patients acquired a total of 135 NIs distributed as follows: 36.3% bacteremia, 30.4% ventilator-associated pneumonia (VAP), 18.5% catheter-associated urinary tract infection, 7.4% central-line infection, 5.9% cutaneous infection, and 1.3% meningitis. The incidence rate of NI was 21.6 in 1000 patient-days, and the rate of NI was 25.6%. Length of ICU stay, central venous catheterisation, mechanical ventilation and tracheostomy were statistically significant risk factors for NI. Of all NI, 112 (83%) were microbiologically-confirmed and 68.8% of the isolates were Gram-negative, 27.6% were Gram-positive, and 3.6% were fungi. 23 (17%) were clinically-defined infections. The most frequently isolated organism was P. aeruginosa (25%), followed by S. aureus (21.4%), E. coli (18.7%) and A. baumannii (16.9%).

Conclusions

The bloodstream was the most common site and Gram-negatives were the most commonly reported causes of ICU infections.

Errors in Administrative-Reported Ventilator-Associated Pneumonia Rates: Are Never Events Really So?

Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients’ medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients ( P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.

Evaluation of nosocomial infections and risk factors in critically ill patients

Background

Nosocomial infections are one of the most serious complications in intensive care unit patients because they lead to high morbidity, mortality, length of stay and cost. The aim of this study was to determine the nosocomial infections, risk factors, pathogens and the antimicrobial susceptibilities of them in intensive care unit of a university hospital.

Material/Methods

The patients were observed prospectively by the unit-directed active surveillance method based on patient and the laboratory.

Results

20.1% of the patients developed a total of 40 intensive care unit-acquired infections for a total of 988 patient-days. The infection sites were the lower respiratory tract, urinary tract, bloodstream, wound, and the central nervous system. The respiratory deficiency, diabetes mellitus, usage of steroid and antibiotics were found as the risk factors. The most common pathogens were Enterobacteriaceae, Staphylococcus aureus, Candida species. No vancomycin resistance was determined in Gram positive bacteria. Imipenem and meropenem were found to be the most effective antibiotics to Enterobacteriaceae.

Conclusions

Hospital infection rate in intensive care unit is not very high. The diabetes mellitus, length of stay, usage of steroids, urinary catheter and central venous catheter were determined as the risk factors by the final logistic regression analysis. These data, which were collected from a newly established intensive care unit of a university hospital, are important in order to predict the infections and the antimicrobial resistance profile that will develop in the future.

Nosocomial Infection in an Intensive Care Unit in a Brazilian University Hospital

This prospective study aimed to determine the nosocomial infection (NI) incidence in an Intensive Care Unit (ICU), its association with clinical characteristics and occurrence sites. It was carried out among 1.886 patients admitted in an ICU of a University Hospital, from August 2005 to January 2008. Data analysis was done using Fisher’s test and Relative Risk (RR). There were 383 NIs (20.3%). The infections were in the urinary tract (n=144; 37.6%), pneumonia (n=98; 25.6%), sepsis (n=58; 15.1%), surgical site (n=54; 14.1%) and others (n=29; 7.7%). Hospitalization average was 19.3 days for patients with NI and 20.2 days for those with colonization by resistant microorganisms. The mortality was 39.5% among patients with NI (RR: 4.4; 3.4-5.6). The NI was associated with patients originated from other units of the institution/emergency unit, more than 4 days of hospitalization, community infection, colonized by resistant microorganisms, using invasive procedures and deaths resulting from NI.

Nosocomial infections and risk factors in intensive care unit of a university hospital in Turkey

The aim of this study was to determine the types nosocomial infections (NIs) and the risk factors for NIs in the central intensive care unit (ICU) of Trakya University Hospital. The patients admitted to the ICU were observed prospectively by the unit-directed active surveillance method based on patient and the laboratory over a 9-month-period. The samples of urine, blood, sputum or tracheal aspirate were taken from the patients on the first and the third days of their hospitalization in ICU; the patients were cultured routinely. Other samples were taken and cultured if there was suspicion of an infection. Infections were considered as ICU-associated if they developed after 48 hours of hospitalization in the unit and 5 days after discharge from the unit if the patients had been sent to a different ward in the hospital. The rate of NIs in 135 patients assigned was found to be 68%. The most common infection sites were lower respiratory tract, urinary tract, bloodstream, catheter site and surgical wound. Hospitalization in ICU for more than 6 days and colonization was found to be the main risk factor for NIs. Prolonged mechanical ventilation and tracheostomy, as well as frequently changed nasogastric catheterization, were found to be risk factors for lower respiratory tract infections. For bloodstream infections, both prolonged insertion of and frequent change of arterial catheters, and for urinary tract infections, female gender, period and repeating of urinary catheterization were risk factors. A high prevalence rate of nosocomial infections was found in this study. Invasive device use and duration of use continue to greatly influence the development of nosocomial infection in ICU. Important factors to prevent nosocomial infections are to avoid long hospitalization and unnecessary device application. Control and prevention strategies based on continuing education of healthcare workers will decrease the nosocomial infections in the intensive care unit.

Ventilator-associated pneumonia in adults in developing countries: a systematic review

BACKGROUND

Ventilator-associated pneumonia (VAP) is a leading cause of death in hospitalized patients, but there has been no systematic analysis of the incidence, microbiology, and outcome of VAP in developing countries or of the interventions most applicable in that setting.

METHODS

We reviewed MEDLINE (January 1966-April 2007) and bibliographies of the retrieved articles for all observational or interventional studies that examined the incidence, microbiology, outcome, and prevention of VAP in ventilated adults in developing countries. We evaluated the rates of VAP using the National Healthcare Safety Network (NHSN) definitions and the impact of VAP on the intensive care unit (ICU) length of stay (LOS) and mortality, and the impact of interventions used to reduce VAP rates.

RESULTS

The rates of VAP varied from 10 to 41.7 per 1000 ventilator-days and were generally higher than NHSN benchmark rates. Gram-negative bacilli were the most common pathogens (41-92%), followed by Gram-positive cocci (6-58%). VAP was associated with a crude mortality that ranged from 16% to 94% and with increased ICU LOS. Only a small number of VAP intervention studies were performed; these found that staff education programs, implementation of hand hygiene, and VAP prevention practice guidelines, and/or implementation of sedation protocol were associated with a significant reduction in VAP rates. Only one interventional study was a randomized controlled trial comparing two technologies, the rest were sequential observational. This study compared a heat and moisture exchanger (HME) to a heated humidifying system (HHS) and found no difference in VAP rates.

CONCLUSIONS

Based on the existing literature, the rate of VAP in developing countries is higher than NHSN benchmark rates and is associated with a significant impact on patient outcome. Only a few studies reported successful interventions to reduce VAP. There is a clear need for additional epidemiologic studies to better understand the scope of the problem. Additionally, more work needs to be done on strategies to prevent VAP, probably with emphasis on practical, low-cost, low technology, easily implemented measures.

The comparison of susceptibility patterns of Gram-negative invasive and non-invasive pathogens in Estonian hospitals

A total of 560 invasive and 1062 non-invasive isolates were collected. The antimicrobial susceptibility of invasive versus non-invasive Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae isolates were evaluated using the E-tests. The equal domination of Gram-negative among both invasive and non-invasive pathogens was estimated in our study if contaminants were excluded. The emergence trend of Gram-positive microbes especially of coagulase negative staphylococci may be proved only after application of exclusive algorithms. Due to similar susceptibility, the data of non-invasive Gram-negative pathogens can be useful to predict resistance of invasive ones. Also, the surveillance of invasive pathogens provides useful information about the general susceptibility of pathogens.

Antibiotic prophylaxis of early onset pneumonia in critically ill comatose patients. A randomized study

OBJECTIVE

To evaluate if a 3-day ampicillin-sulbactam prophylaxis can reduce the occurrence of early-onset pneumonia (EOP) in comatose mechanically-ventilated patients.

DESIGN

This was a single-centre, prospective, randomised, open study.

SETTING

A 10-bed general-neurological ICU in a 2,000-bed university hospital.

PATIENTS AND PARTICIPANTS

Comatose mechanically-ventilated patients with traumatic, surgical or medical brain injury.

INTERVENTIONS

Patients were randomized to either ampicillin-sulbactam prophylaxis (3 g every 6 h for 3 days) plus standard treatment or standard treatment alone.

MEASUREMENTS AND RESULTS

Main outcome was the occurrence of EOP. Secondary outcome measures were occurrence of late-onset pneumonia, percentage of non-pulmonary infections and of emerging multiresistant bacteria, duration of mechanical ventilation and of ICU stay and ICU mortality. Interim analysis at 1 year demonstrated a statistically significant reduction of EOP in the ampicillin-sulbactam group, and the study was interrupted. Overall, 39.5% of the patients developed EOP, 57.9% in the standard treatment group and 21.0% in the ampicillin-sulbactam group (chi-square 5.3971; P =0.022). Relative risk reduction of EOP in patients receiving ampicillin-sulbactam prophylaxis was 64%; the number of patients to be treated to avoid one episode of EOP was three. No differences in other outcome parameters were found; however, the small sample size precluded a definite analysis.

CONCLUSIONS

Antibiotic prophylaxis with ampicillin-sulbactam significantly reduced the occurrence of EOP in critically ill comatose mechanically ventilated patients. This result should encourage a large multicenter trial to demonstrate whether ampicillin-sulbactam prophylaxis reduces patient mortality, and whether antibiotic resistance is increased in patients receiving prophylaxis.

Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia

The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia (VAP). A prospective, randomized, controlled trial was performed in a medical intensive care unit (MICU) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were randomized to receive endotracheal suction with either closed catheters (closed suction group; N-41) or single-use catheters (open suction group; N=37). Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization. There was no difference between the groups in terms of the frequency of development of VAP, mortality in the MICU, length of MICU stay and duration of mechanical ventilation. Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized (P=0.14). The colonization rates by Acinetobacter spp. and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group (P<0.01 and P=0.04, respectively). In conclusion, closed endotracheal suction resulted in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction.