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

Prevalence of hospital-acquired infection among patients with acute neurological conditions in the ICU

INTRODUCTION

Healthcare-associated infections (HAIs) are a significant cause of morbidity and mortality. HAIs become crucial in patients with neurological illnesses, as they need invasive procedures and extended care, prolonging the hospital stay in most cases. In this study, we report the type, microbial etiology, and outcome of patients with HAIs in a Neurology Intensive Care Unit setting.

METHODS

In this prospective study, 213 neurologically ill patients were recruited. Patient demographics, primary diagnosis, comorbidities, invasive interventions, device specific data, and length of hospital stay were recorded. Data collected for each episode of HAI included- site of infection, causative organisms, and susceptibility. Site specific infections were categorised as per CDC/NHSN definitions for HAIs.

RESULTS

The median age of patients was 60 years (range 15-88) and 66.70 % were male. HAIs were observed in 135 (63.38 %) patients. Majority of the patients had stroke (ischemic/haemorrhagic) [n = 142;66.66 %] followed by neuromuscular [n = 18; 8.45 %] and seizure disorder [n = 14; 6.57 %]. Most prevalent site of HAIs was urinary tract infections (UTI) (n = 80;37.55 %) followed by pneumonia (n = 74;34.74 %) and blood stream infections (n = 53;24.88 %). 209 patients (98.12 %) underwent urinary catheterization, 90 (42.3 %) required intubation and mechanical ventilation, and 70 (32.86 %) central venous catheterisations. Amongst various HAIs, commonly isolated bacterial pathogens in UTI were Escherichia coli [18/48;37.59 %], Enterococcus [10/48;20.83 %] while Candida species [35/40;87.50 %] was the most common amongst fungal pathogens. Causative organisms in Pneumonia were Klebsiella pneumoniae (27/104;25.96 %), Acinetobacter baumannii (n = 25/104;24.03 %), and Pseudomonas aeruginosa [14/104;13.46 %]. Among the blood stream infections, Staphylococcus species were the most common [39/161;24.22 %] followed by candida species [5/161;3.10 %]. Out of 55 patients who died, HAI was observed in 39 patients (70.90 %). Mean length of hospital stay was 17.56 ± 13.17 days. Presence of coronary artery disease, pulmonary site infection, low Glasgow Coma Scale, central venous catheterization, mechanical ventilation, abnormal chest x-ray, and multiple site infections were significantly associated with high mortality (p < 0.05).

CONCLUSION

In our study 63.38% of neurological patients had HAIs. The most common sites were urinary, pulmonary, and blood stream infections. Device associated infections were common and significantly associated with poor outcome. Considering the high incidence of HAIs early recognition and treatment of site-specific pathogens may improve the outcome in these patients.

Comprehensive analysis of the bacterial spectrum for enhanced clinical insight in microbial ureteral stent colonization, uncomplicated urinary tract infections and catheter-associated urinary tract infections: a principal component analysis-based literature review

PURPOSE

Controversies exist regarding the prevailing spectrum of microorganisms in microbial ureteral stent colonization (MUSC) and their clinical significance. The aim of this comprehensive review is to determine the predominant microbial spectrum in patients with an indwelling ureteral stent in comparison to catheter-associated urinary tract infections (CAUTI) and uncomplicated urinary tract infections (UTI).

METHODS

Google scholar, PubMed, Embase, Medline, and Cochrane literature databases were searched from inception to April 2022 to identify manuscripts on MUSC, uncomplicated UTI and CAUTI. A principal component analysis (PCA) was performed to identify patterns of the pathogen spectrum of the different groups.

RESULTS

We included 29 studies on MUSC, 28 studies on uncomplicated UTI and 23 CAUTI studies. The proportion of Staphylococci, Enterococci and Candida were significantly higher in MUSC and stent associated bacteriuria compared to their proportion in uncomplicated UTIs where E. coli dominates. By comparing MUSC, CAUTI and UTI with a PCA, the detected pathogen spectrum exhibited clearly distinguishable trends in the frequency of the main isolated pathogens influencing these three groups of urinary tract infections. With respect to MUSC and UTI, their 95% confidence interval ellipse only showed minimal overlap emphasizing that the spectrum of pathogens in the two groups is clearly distinct.

CONCLUSIONS

The frequency of detection of Staphylococci, Enterococci and Candida is more common in MUSC as compared to UTI. Thus, patients with indwelling ureteral stents should undergo an antimicrobial prophylaxis targeting this microbial spectrum in case of further surgery.

Implementation of systematic safety checklists in a neurocritical care unit: a quality improvement study

BACKGROUND AND OBJECTIVES

Structured and systematised checklists have been shown to prevent complications and improve patient care. We evaluated the implementation of systematic safety checklists in our neurocritical care unit (NCCU) and assessed its effect on patient outcomes.

DESIGN/METHODS

This quality improvement project followed a Plan-Do-Study-Act (PDSA) methodology. A checklist for medication reconciliation, thromboembolic prophylaxis, glycaemic control, daily spontaneous awakening, breathing trial, diet, catheter/lines duration monitoring and antibiotics de-escalation was implemented during daily patient rounds. Main outcomes included the rate of new infections, mortality and NCCU-length of stay (LOS). Intervened patients were compared with historical controls after propensity score and Euclidean distance matching to balance baseline covariates.

RESULTS

After several PDSA iterations, we applied checklists to 411 patients; the overall average age was 61.34 (17.39). The main reason for admission included tumour resection (31.39%), ischaemic stroke (26.76%) and intracerebral haemorrhage (10.95%); the mean Sequential Organ Failure Assessment (SOFA) score was 2.58 (2.68). At the end of the study, the checklist compliance rate throughout the full NCCU stays reached 97.11%. After controlling for SOFA score, age, sex and primary admitting diagnosis, the implementation of systematic checklists significantly correlated with a reduced LOS (ß=-0.15, 95% CI -0.24 to -0.06), reduced rate of any new infections (OR 0.59, 95% CI 0.40 to 0.87) and reduced urinary tract infections (UTIs) (OR 0.23, 95% CI 0.09 to 0.55). Propensity score and Euclidean distance matching yielded 382 and 338 pairs with excellent covariate balance. After matching, outcomes remained significant.

DISCUSSION

The implementation of safety checklists in the NCCU proved feasible, easy to incorporate into the NCCU workflow, and a helpful tool to improve adherence to practice guidelines and quality of care measurements. Furthermore, our intervention resulted in a reduced NCCU-LOS, rate of new infections and rate of UTIs compared with propensity score and Euclidean distance matched historical controls.

Analysis of the Risk Factors for Nosocomial Bacterial Infection in Patients with COVID-19 in a Tertiary Hospital

Background

Infection surveillance and risk factor analysis are among the most important prerequisites for the prevention and treatment of nosocomial bacteria infections, which are the demands for both infected and non-infected patients.

Purpose

To explore the risk factors for nosocomial bacterial infection of patients with COVID-19, and further to provide a theoretical basis for scientific prevention and control of nosocomial bacterial infection.

Methods

Between 10 January 2020 and 9 March 2020, we collected data of 212 patients with COVID-19 and then explored the influence of age, gender, length of stay, use of ventilator, urinary catheterization, central venous catheterization, white blood cell (WBC) count and procalcitonin on the nosocomial bacterial infection of patients with COVID-19 by a retrospective study.

Results

There were 212 confirmed cases of COVID-19, of which 31 cases had nosocomial bacterial infections, with an incidence of 14.62%. The most common types of nosocomial bacterial infections were lower respiratory tract (12 cases, 38.71%), which was the most frequent site, followed by urinary tract (10 cases, 32.26%), blood stream (7 cases, 22.58%), upper respiratory tract (1 case, 3.23%) and gastrointestinal tract infection (1 case, 3.23%). The incidence of nosocomial bacterial infection was significantly correlated with age, arteriovenous catheterization, urinary catheterization, WBC count and procalcitonin. Moreover, multivariate analysis confirmed that WBC (OR 8.38, 95% CI 1.07 to 65.55), procalcitonin (OR 4.92, 95% CI 1.39 to 17.33) and urinary catheterization (OR 25.38, 95% CI 5.09 to 126.53) were independent risk factors for the nosocomial bacterial infection of patients with COVID-19.

Conclusion

Understanding the risk factors for nosocomial bacterial infection of patients with COVID-19 and strengthening the monitoring of various susceptible factors are helpful to control the occurrence of nosocomial bacterial infection in the COVID-19 isolation wards.

Device Utilization Ratios in Infection Prevention: Process or Outcome Measure?

PURPOSE OF REVIEW

The purpose of this review is to describe the role of device utilization as a component of surveillance for healthcare-associated infections and describe its potential role as a measurement of healthcare quality.

RECENT FINDINGS

Device utilization, while primarily a process-based measure in the prevention of device-associated infections can also serve as an important outcome in the evaluation of an infection prevention program. Device utilization can be an important and resource-efficient measurement when coupled with measurements of risk-adjusted infection rates. The measurement of the device utilization ratio can provide insight into the risk of device-associated harms, including non-infectious harms, which would not be captured with currently used infection-based surveillance metrics. Further study and validation of standardized, risk-adjusted device utilization measurements is an important area for future exploration.

Healthcare Burden and Costs Associated with Urinary Tract Infections in Type 2 Diabetes Mellitus Patients: An Analysis Based on a Large Sample of 456,586 German Patients

OBJECTIVES

We examined the real-world treatment of urinary tract infections (UTIs) in a type 2 diabetes mellitus (T2DM) population, evaluated UTI-related healthcare resource use and direct treatment costs, and assessed factors that may predict UTI-related costs.

METHODS

We analyzed an anonymized dataset from a regional German healthcare fund (2010-2012). UTI-associated resource use was described by the number of UTI-associated outpatient visits, the number and length of UTI-related acute hospital visits, and the number of UTI-related antibiotics prescriptions. UTI-related direct treatment costs were studied both based on these resource use numbers and, additionally, based on a comparison of all-cause annual healthcare costs of T2DM-patients who were or were not affected by a UTI. To identify factors that might predict direct treatment costs related to UTI treatment, we conducted generalized linear regression model analyses (based on gamma distribution) using sociodemographic and clinical characteristics of observed patients as available in the database as independent variables.

RESULTS

A total of 456,586 T2DM-patients were included with a mean age of 73.8, a percentage of 56.3 female patients, and a mean Charlson comorbidity index of 7.3. In our database, we observed 48,337 UTI events. The direct mean resource-based costs were €315.90 per UTI event. Older age, higher comorbidity status, at least one previous non-UTI infection, and poorer renal function were associated with higher costs, while female gender and at least one previous UTI event were associated with lower costs. In the all-cause cost analysis, healthcare costs per patient year were €3,916 higher in the UTI group than in the non-UTI group.

CONCLUSION

Our study confirms that UTI is a common complication in patients with T2DM. Patients with T2DM who have had previous infections, who are older, and who are male, as well as patients who have more comorbidities or severe renal insufficiency, face above-average UTI treatment costs. These patient groups, therefore, should receive special attention in the real-world treatment of T2DM, which should include a regular screening of UTI risk.

Predictors of Infective Outcomes Following Hip Fracture: A Cohort Study

Objectives: This study sought to assess the value of differing pre-operative measures in prediction of post-operative non-surgical site infection (NSSI) and length of hospital stay following hip fracture surgery. Methods: All patients admitted during a one year period with a hip fracture to our department were included in the study (n=207). Primary outcome measures were ten independent risk factors correlated to the development of non-surgical site infection following surgery for hip fracture. Secondary outcome measures were duration of hospital stay and inpatient mortality. Results: The patients who had severe cognitive impairment had a 71.0% risk of developing non-surgical site infection. Patients who had multiple medical co-morbidities also had increased risk of developing non-surgical site infection at 59.1%. Patients who developed NSSI on average stayed in hospital 13.1 days longer than patients who did not (31.6 vs. 18.5, p < .001). Conclusions: This study demonstrates the importance of reducing post-operative infection in hip fracture patients in view of reducing morbidity, mortality and cost. These patients can be stratified by risk factors and interventions can be employed in view of reducing inpatient post-operative infection rates in this cohort.

Epidemiology of urinary tract infections in type 2 diabetes mellitus patients: An analysis based on a large sample of 456,586 German T2DM patients

INTRODUCTION

This analysis was conducted to investigate urinary tract infection (UTI) incidence among Type 2 Diabetes mellitus (T2DM) patients in Germany in a real-world setting and to identify risk factors associated with UTI incidence/recurrence.

METHODS

Our cohort study was conducted based on an anonymized dataset from a regional German sickness fund (2010-2012). A UTI event was mainly identified through observed outpatient/inpatient UTI diagnoses. We reported the number of UTI events per 1000 patient-years. Furthermore, the proportion of patients affected by ≥1 and ≥2 UTI events in the observational period was separately reported. Finally, three multivariate Cox regression analyses were conducted to identify factors that may be associated with UTI event risk or recurrent UTI event risk.

RESULTS

A total of 456,586 T2DM-prevalent patients were identified (mean age 72.8years, 56.1% female, mean Charlson Comorbidity Index (CCI) of 7.3). Overall, the UTI event rate was 87.3 events per 1000 patient-years (111.8/55.8 per 1000 patient-years for women/men (p<0.001)). The highest UTI event rates were observed for those aged >89years. After 730days after first observed T2DM diagnosis, the proportion of women/men still UTI-event-free was 80.9%/90.2% (p<0.001). Most important factors associated with UTI risk in our three models were older age (Hazard Ratio (HR)=1.56-1.70 for >79years), female gender (HR=1.38-1.57), UTIs in the previous two years (HR=2.77-5.94), number of comorbidities as measured by the CCI (HR=1.32-1.52 for CCI>6) and at least one cystoscopy in the previous year (HR=2.06-5.48). Furthermore, high HbA1c values in the previous year (HR=1.29-1.4 referring to HbA1c>9.5%) and a poor kidney function (HR=1.11-1.211 referring to glomerular filtration rate (GFR)<60ml/min) increased the UTI event risk.

DISCUSSION

Our study confirms that UTI event risk is high in T2DM patients. Older female patients having experienced previous UTIs face an above-average UTI risk, especially if these risk factors are associated with poor glycemic control and poor kidney function.

Nosocomial infections in patients with spontaneous intracerebral hemorrhage

BACKGROUND

Nosocomial infections are frequent complications in patients with intracerebral hemorrhage.

OBJECTIVES

To determine the prevalence, risk factors, and outcomes of nosocomial infections in patients with intracerebral hemorrhage.

METHODS

Prospectively collected data on patients with spontaneous intracerebral hemorrhage between January 2009 and June 2012 were retrospectively reviewed. Patients who had nosocomial infection during the hospital stay were compared with patients who did not. Poor outcome was defined as death or discharge to a long-term nursing facility.

RESULTS

At least 1 nosocomial infection developed in 26% of 202 patients with intracerebral hemorrhage. The most common infections were pneumonia (18%), urinary tract infection (12%), meningitis or ventriculitis (3%), and bacteremia (1%). On univariate analysis, independent predictors of nosocomial infection were intraventricular hemorrhage, hydrocephalus, low score on the Glasgow Coma Scale at admission, hyperglycemia at admission, and treatment with mechanical ventilation. On multivariate regression analysis, the only significant predictor of nosocomial infection was intraventricular hemorrhage (odds ratio, 5.4; 95% CI, 1.2-11.4; P = .02). Patients with nosocomial infection were more likely than those without to require a percutaneous gastrostomy tube (odds ratio, 33.1, 95% CI, 23.3-604.4; P < .001) and to have a longer stay in the intensive care unit or hospital without a significant increase in mortality. Patients with nosocomial pneumonia were also more likely to have a poor outcome (P < .001).

CONCLUSION

Pneumonia was the most common infection among patients with intracerebral hemorrhage.