Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study

Colonization and bloodstream infection with single- versus multi-lumen central venous catheters: a quantitative systematic review

There is a controversy as to whether the number of lumens in the central venous catheters may impact the incidence of catheter-related bloodstream infection. We performed a systematic search (MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies, any language, to April, 2003) for full reports on randomized comparisons of single-lumen and multi-lumen catheters. Trials had to report on dichotomous data of catheter colonization or bloodstream infection. Meta-analyses were performed using a fixed effect model. Data were expressed as odds ratio (OR) and number-needed-to-treat (NNT) with 95% confidence interval (CI). Five randomized trials (1987-1995) with data on 255 single-lumen and 275 multi-lumen catheters were analyzed. Average insertion times were 8 to 21 days with multi-lumen catheters and 9 to 24 days with single-lumen catheters. In 4 trials, 23 of 176 (13.1%) multi-lumen and 26 of 177 (14.7%) single-lumen catheters were colonized (OR, 0.92; 95% CI, 0.49-1.72). In 5 trials, bloodstream infection occurred with 23 of 275 (8.4%) multi-lumen and with 8 of 255 (3.1%) single-lumen catheters (OR, 2.58; 95% CI, 1.24-5.37; NNT, 19; 95% CI, 11-75). For every 20 single-lumen catheters inserted, one bloodstream infection will be avoided that would have occurred had multi-lumen catheters been used. The risk of catheter colonization is not decreased. Although these conclusions are based on limited data, single-lumen catheters should be used whenever feasible.

New method of classifying infections in critically ill patients

OBJECTIVE

To develop a systematic classification describing the contribution made by infection to the outcome from sepsis.

CONTEXT

The emergence of effective therapies for sepsis means that accurate methods of risk assessment are of increasing importance. Although there are well-validated instruments for describing risk factors in the host, the contribution made by the infection is less well served.

DESIGN AND METHODS

A systematic literature review of the English language literature published during the last 30 yrs of studies describing the outcome of infections, categorized by micro-organism and site of infection.

RESULTS

We surveyed 510 published articles including 55,854 clinical infections, and we generated specific risk codes for bacteremia, meningitis, pneumonia, skin and soft tissue infections, peritonitis, and urinary tract infections. Both the nature of the organisms and the site of infection have a significant impact on survival from sepsis, and there is a significant interaction between them.

CONCLUSION

We have described a novel approach to permit a better assessment of the contribution made by the infection to mortality in patients with sepsis or septic shock.

Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: a randomized controlled trial

OBJECTIVE

The aim of this study was to assess the efficacy of a disinfectable, needle-free connector in the prophylaxis of catheter-related bloodstream infection.

METHODS

A randomized controlled trial was performed in a polyvalent intensive care unit. Patients who needed multilumen central venous catheters were randomly assigned to a study or a control group. All catheters were inserted and manipulated according to the Centers for Disease Control and Prevention (CDC) recommendations. Study group patients were equipped with catheters with disinfectable, needle-free connectors whereas control group patients were equipped with catheters with 3-way stopcocks. Two peripheral blood cultures and a semiquantitative culture of the catheter tip were performed on removal of the catheter.

RESULTS

The study included 243 patients, with a total of 278 central venous catheters. The catheters' mean insertion duration was 9.9 days. Both groups were comparable regarding patient and catheter characteristics. Incidence rate of catheter-related bloodstream infection was 0.7 per 1000 days of catheter use in the study group, compared with 5.0 per 1000 days of catheter use in the control group (P=.03).

CONCLUSIONS

To add a disinfectable, needle-free connector to the CDC recommendations reduces the incidence of catheter-related bloodstream infection in critically ill patients with central venous catheters.

Benefits of minocycline and rifampin-impregnated central venous catheters

OBJECTIVE

To determine the efficacy of minocycline and rifampin-impregnated catheters compared to non-impregnated catheters in critically ill patients.

DESIGN

Prospective, randomized, double-blind, controlled, multicenter trial.

SETTING

Intensive care units of seven acute-care teaching hospitals in Spain. PATIENTS. Intensive care unit patients requiring triple-lumen central venous catheter for more than 3 days.

INTERVENTIONS

At catheter insertion, 228 patients were randomized to minocycline and rifampin-impregnated catheters and 237 to non-impregnated catheters. Skin, catheter tip, subcutaneous segment, hub cultures, peripheral blood and infusate cultures were performed at catheter withdrawal. The rate of colonization, catheter-related bloodstream infection (CRBSI) and catheter-related clinical infectious complications (purulence at the insertion site or CRBSI) were assessed.

MEASUREMENTS AND MAIN RESULTS

In the intention-to-treat analysis (primary analysis), the episodes per 1000 catheter days of clinical infectious complications decreased from 8.6 to 5.7 (RR =0.67, 95% CI 0.31-1.44), CRBSI from 5.9 to 3.1 (RR =0.53, 95% CI 0.2-1.44) and tip colonization from 24 to 10.4 (RR =0.43, 95% CI 0.26-0.73). Antimicrobial-impregnated catheters were associated with a significant decrease of coagulase-negative staphylococci colonization (RR =0.24, 95% CI 0.13-0.45) and a significant increase of Candida spp. colonization (RR =5.84, 95% CI 1.31-26.1).

CONCLUSIONS

The use of antimicrobial-impregnated catheters was associated with a significantly lower rate of coagulase-negative staphylococci colonization and a significant increase in Candida spp. colonization, although a decrease in CRBSI, increase in 30-day survival or reduced length of stay was not observed.

Are Antimicrobial-Impregnated Catheters Effective? Don't Throw Out the Baby with the Bathwater

The antimicrobial-impregnated central venous catheter (CVC) has been the most intensively studied technology for the prevention of CVC-related bloodstream infections (BSIs) over the past 30 years. Although more than a dozen randomized trials have shown significant benefit, authors of an analysis published in a recent issue of Clinical Infectious Diseases have raised questions about the efficacy of antimicrobial-impregnated CVCs because of perceived defects in the experimental design of the studies and statistical analyses of the data. They have further argued that even if this technology might be effective in preventing CVC-related BSI, its cost-effectiveness is questionable. Although most of the studies scrutinized by the authors of this analysis indeed had shortcomings, we believe that their analysis unjustifiably downplays a large body of research that has demonstrated a consistent reduction in CVC-related BSI and a clear-cut cost-effectiveness associated with the use of antimicrobial-impregnated CVCs.

Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity

OBJECTIVE

To demonstrate the effectiveness of the Charlson weighted index of comorbidity (WIC) for controlling comorbidity in prospective studies focusing on mortality in patients with Staphylococcus aureus bacteremia (SAB).

DESIGN

Cohort study.

SETTING

Two tertiary-care, university-affiliated hospitals in France.

PATIENTS

One hundred sixty-six inpatients 18 years or older consecutively diagnosed with SAB from May 15, 2001, to May 15, 2002.

METHODS

Patients were prospectively assessed and cases were followed by the infectious diseases consult service at least 3 months after effective antibiotic therapy completion. The Charlson WIC was computed and dichotomized into scores of fewer than 3 points and 3 or more points. Bacteremia source, acute complication due to SAB acquisition in the ICU, and inappropriate empiric antibiotic therapy were recorded. The endpoint was death due to SAB and overall mortality.

RESULTS

In univariate analysis, the Charlson WIC was able to predict overall mortality and S. aureus-related death. The following variables were found to be independently predictive of mortality due to SAB using the Cox model: an acute complication due to S. aureus (OR, 8.9; CI95, 4 to 19.7; P < .001), a Charlson WIC score of 3 or more (OR, 3; CI95, 1.3 to 5.5; P = .006), and age (OR, 1.04; CI95, 1.009 to 1.07; P < .01).

CONCLUSIONS

Comorbidity contributes to death in patients with SAB. The Charlson WIC is a good predictor of mortality in this population and may be a useful instrument to control comorbidity in studies aiming to investigate risk factors for death due to bacteremia.

[Infectious complications related to non-tunneled central venous catheters in immunocompromised patients: prospective study about 210 cases]

OBJECTIVE

To evaluate infectious complications related to non-tunneled central venous catheter in immunocompromised patients, in a bone marrow unit.

METHODS

From July to April 2002, we inserted 210 non-tunneled central venous catheters in 139 immunocompromised patients (52 F/87 M). The mean age was 26 years (3-56 years). Our study included 33 children aged from 3 to 15 years, on whom 46 catheters were placed. The catheters were placed for the following indications: 145 catheters were used in subjects who received a bone marrow transplantation, 58 catheters were placed in subjects who received chemotherapy for acute leukemia and seven catheters were used in patients who received immunosuppressive therapy.

RESULTS

The mean duration of catheterization was 33 days (7-114 days). There were 3.1 catheter-related infections per 1000 catheter-days. Coagulase-negative Staphylococci were implicated in 64% of cases. We observed two pneumothorax (0.9%), one arterial puncture (0.4%) and two catheter-related thrombosis (0.9%).

CONCLUSION

Non-tunneled catheters in immunocompromised patients (adults and children) is a safe technique, and is an alternative to the Hickman catheters which are most widely used today in patients undergoing bone marrow transplantation.

Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine

The use of chlorhexidine gluconate solution for vascular catheter insertion site care reduces the risk of catheter-related bloodstream infection by one-half, compared with povidone iodine. Our objective was to evaluate the cost-effectiveness of chlorhexidine gluconate versus povidone iodine. We used data from randomized, controlled trials, meta-analyses, and epidemiologic studies to construct a decision analysis model. We estimated that use of chlorhexidine, rather than povidone, for central catheter site care resulted in a 1.6% decrease in the incidence of catheter-related bloodstream infection, a 0.23% decrease in the incidence of death, and savings of 113 dollars per catheter used. For peripheral catheter site care, the results were similar, although the differences were smaller. The results were found to be robust on multivariate sensitivity analyses. Use of chlorhexidine gluconate in place of the current standard solution for vascular catheter site care is a simple and cost-effective method of improving patient safety in the hospital setting.

Nosocomial infections in medical-surgical intensive care units in Argentina: attributable mortality and length of stay

BACKGROUND

Nosocomial infections are an important public health problem in many developing countries, particularly in the intensive care unit (ICU). Limited data exists on the incidence and burden of nosocomial infection in the ICU in Argentina.

METHODS

We performed baseline prospective nosocomial infection surveillance of all patients for 6 months in 3 medical-surgical ICUs (MS-ICUs) in Argentina (2 months in each ICU). Nosocomial infections were identified using the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance definitions. Overall and site-specific nosocomial infection rates, attributable mortality, and excess length of hospital stay were calculated.

RESULTS

The overall nosocomial infection rate was 27% and 90 per 1000 patient-days. The most common site of infection was catheter-related bloodstream infection (32%), followed by ventilator-associated pneumonia (25%), and catheter-associated urinary tract infection (23%). The rate of central catheter-associated bloodstream infection in the MS-ICU was 44.61 per 1000 device-days, with an attributable mortality of 25%, and 12 attributable extra days of hospital stay. The urinary catheter-associated urinary tract infection rate in the MS-ICU was 22.55 per 1000 urinary catheter-days, with an attributable mortality of 5%, and 5 excess extra days of hospital stay. The ventilator-associated pneumonia rate in the MS-ICU was 50.87 per 1000 ventilator-days with an attributable mortality of 35%, and 10 attributable extra days of hospitalization.

CONCLUSION

Our study finds high rates of nosocomial infections in ICUs in Argentina, associated with a considerable attributable mortality and excess length of stay. Ongoing targeted surveillance and implementation of infection control strategies is necessary to control this growing problem.

A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study

Hub colonization and subsequent intraluminal progression due to frequent opening and manipulation of intravenous systems is the cause of many catheter-related infections (CRI). A prospective, comparative, randomized study was performed to assess a new closed-needleless hub device (CLAVE) compared with conventional open systems (COS). End-points were hub and skin colonization, catheter tip colonization, catheter-related bloodstream infection (CRBSI) and number of accidental needlesticks. All cultures were processed following standard semiquantitative microbiological techniques. The study involved patients who underwent heart surgery over an 11-month period in a post-surgical ICU. During the study period, 352 patients underwent major heart surgery and 1774 catheters were inserted. Overall, 865 catheters in 178 patients were allocated to the CLAVE system and 909 catheters in 174 patients to COS. The groups were similar regarding underlying conditions and risk factors for infection. Comparison of endpoint results in CLAVE and COS groups was as follows: incidence density per 1000 catheter-days of tip colonization: 59.2 versus 83.6 (P=0.003); of hub colonization: 7.56 versus 24.66 (P=0.0017); of skin colonization: 41.5 versus 58.9 (P=0.038); and of CRBSI 3.78 versus 5.89 (P=0.4). There was one accidental needlestick and one catheter-related prosthetic endocarditis in the COS group. Multivariate analysis showed that CLAVE use was an independent protective factor for tip colonization. CLAVE offered significant protection from catheter-tip and hub colonization.

Do antimicrobial-impregnated central venous catheters prevent catheter-related bloodstream infection?

Controversy surrounds the role of central venous catheters (CVCs) impregnated with antimicrobial agents in the prevention of catheter-related bloodstream infection (CRBSI). We reviewed the current literature to evaluate the efficacy of antimicrobial-impregnated CVCs for preventing CRBSI. Eleven randomized studies published in article form were identified that included a control group that received nonimpregnated CVCs. We evaluated study methodologies, inclusion of key patient characteristics, use of clinically relevant end points, and molecular-relatedness studies. Review of these 11 trials revealed several methodological flaws, including inconsistent definitions of CRBSI, failure to account for confounding variables, suboptimal statistical and epidemiological methods, and rare use of clinically relevant end points. This review also failed to demonstrate any significant clinical benefit associated with the use of antimicrobial-impregnated CVCs for the purpose of reducing CRBSI or improving patient outcomes. More rigorous studies are required to support or refute the hypothesis that antimicrobial-impregnated CVCs reduce the rate of or prevent CRBSI.

An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center

OBJECTIVE

To evaluate the effectiveness of an evidence-based intervention to prevent catheter-associated bloodstream infections among intensive care unit patients at a nonteaching, community hospital.

DESIGN

Nonrandomized pre/post observational trial.

SETTING

Two intensive care units at Missouri Baptist Medical Center, Saint Louis, MO.

PARTICIPANTS

Nurses and critical care physicians.

INTERVENTION

A ten-page, self-study module on the prevention of catheter-associated bloodstream infections, lectures, and posters given between July and September 1999.

MEASUREMENTS

The incidence of nosocomial catheter-associated bloodstream infection and patient demographics were measured for patients admitted between March 1998 and July 2000.

MAIN RESULTS

Thirty cases of catheter-associated bloodstream infections during 6110 catheter-days were noted in the preintervention period (4.9 cases/1000 catheter-days) vs. 11 cases during the 5210 catheter-days in the postintervention period (2.1 cases/1000 catheter-days). The relative risk for catheter-associated infection in the postintervention period was 0.43 (95% confidence interval, 0.22-0.84). Among catheterized patients, Acute Physiology and Chronic Health Evaluation II score (25.2 preintervention vs. 25.1 postintervention; p =.86), hemodialysis (91 of 647 [14%] patients vs. 69 of 541 [13%]; p =.70), and the mean number of catheter days per patient (9.1 vs. 9.6 days; p =.46) did not differ between the pre- and postintervention periods.

CONCLUSIONS

A focused, educational intervention among nurses and physicians in a nonteaching community hospital resulted in a significant, sustained reduction in the incidence of catheter-associated bloodstream infection.

Effects of rapid detection of bloodstream infections on length of hospitalization and hospital charges

Current automated continuous-monitoring blood culture systems afford more rapid detection of bacteremia and fungemia than is possible with non-instrument-based manual methods. Use of these systems has not been studied objectively with respect to impact on patient outcomes, including hospital charges and length of hospitalization. We conducted a prospective, two-center study in which the time from the obtainment of the initial positive blood culture until the Gram stain was called was evaluated for 917 cases of bloodstream infection. Factors showing univariate associations with a shorter time to notification included higher body temperature and respiratory rate and higher percentage of immature neutrophils. Multiple linear regression models determined that the primary predictors of both increased microbiology laboratory and total hospital charges for patients with bloodstream infection were nonmicrobiologic and included length of stay and host factors such as the admitting service and underlying illness score. Significant microbiologic predictors of increased charges included the number of blood cultures obtained, nosocomial acquisition, and polymicrobial bloodstream infections. Accelerated failure time regression analysis demonstrated that microbiologic factors, including time until notification, organism group, and nosocomial acquisition, were independently associated with length of hospitalization after bacteremia, as were the factors of admitting service, gender, and age. Our data suggest that an increased time to notification of bloodstream infection is independently associated with increased length of stay. We conclude that the time to notification is an obvious target for efforts to shorten length of stay. The newest generation of automated continuous-monitoring blood culture systems, which shorten the time required to obtain a positive result, should impact length of hospitalization.

Nosocomial infections in adult intensive-care units

Nosocomial infections affect about 30% of patients in intensive-care units and are associated with substantial morbidity and mortality. Several risk factors have been identified, including the use of catheters and other invasive equipment, and certain groups of patients-eg, those with trauma or burns-are recognised as being more susceptible to nosocomial infection than others. Awareness of these factors and adherence to simple preventive measures, such as adequate hand hygiene, can limit the burden of disease. Management of nosocomial infection relies on adequate and appropriate antibiotic therapy, which should be selected after discussion with infectious-disease specialists and adapted as microbiological data become available.

[Surveillance of nosocomial infections in intensive care units. Current data and interpretations]

The German nosocomial infections surveillance system KISS was established in 1996 using a surveillance protocol based on the National Nosocomial Infections Surveillance (NNIS) System. Meanwhile data from a total of 274 intensive care units (ICU) are available, among them 134 interdisciplinary, 71 surgical, 55 medical, 9 neurosurgical and 5 paediatric ICUs. The data comprise about 6,966 surveillance months with more than 500,000 intensive care patients and more than 1.8 million patient days. A total of 6,888 cases of pneumonia and 2,357 cases of central venous catheter (CVC) associated primary bloodstream infections (BSI) were recorded. Ventilator associated pneumonia rates and CVC associated primary BSI rates are presented, stratified according to the type of the ICU and affiliation to a university, a teaching hospital or another type of hospital. The most frequent pathogens associated with ventilator associated pneumonia were S. aureus (24.1%), followed by P. aeruginosa (16.8%) and Klebsiella spp. (12.1%). In the case of CVC associated primary BSI coagulase negative staphylococci dominated (30.9%) followed by S. aureus (15.4%) and Enterococci spp. (11.6%). A remarkable increase of Methicillin Resistant Staphylococcus aureus (MRSA) infections was observed during the period from 1997 to 2002. 19.2% of S. aureus associated pneumonia cases and 25.5% of S. aureus associated primary BSI were due to MRSA. KISS data are useful benchmarks for internal quality management, however a careful interpretation is necessary to stimulate infection control efforts.

Influence of the critically ill state on host-pathogen interactions within the intestine: gut-derived sepsis redefined

Severe and prolonged states of catabolic stress have been shown to have profound effects on the intestinal tract microflora and intestinal function. Gut-derived sepsis is a term used to describe a state of systemic inflammation with organ dysfunction after severe catabolic stress hypothesized to be initiated and perpetuated by the intestinal tract microflora. Popular notions of the mechanism of this process have suggested that stress promotes the translocation of intestinal bacteria or their toxins into the systemic compartment resulting in the release of proinflammatory cytokines which participate in the systemic inflammatory response syndrome. This review is an attempt to redefine the mechanism of gut-derived sepsis by focusing on molecular events that result from host-pathogen interactions within the intestinal tract itself. This evidence-based review posits that gut-derived bacteremia, even with potent nosocomial pathogens, is an event of low proinflammatory potential and, itself, is an insufficient stimulus for the systemic inflammatory response and organ failure state typically seen after severe and prolonged catabolic stress. Mechanisms of this apparent paradox are discussed.

Which antimicrobial impregnated central venous catheter should we use? Modeling the costs and outcomes of antimicrobial catheter use

BACKGROUND

Catheter-related bloodstream infections are costly and associated with substantial morbidity and mortality. Trials suggest that central venous catheters impregnated with minocycline/rifampin, although more expensive, are clinically superior to chlorhexidine/silver sulfadiazine impregnated catheters. It remains unclear whether minocycline/rifampin catheters are cost-effective for all high-risk patients or only those requiring longer-term catheterization.

METHODS

We developed a series of decision models with patient-level clinical trial data to determine whether minocycline/rifampin catheters are cost-effective for patients requiring various durations of catheterization. We calculated incremental cost-effectiveness ratios for patients catheterized for durations ranging from 1 to 25 days.

RESULTS

The data were too sparse to estimate cost-effectiveness for patients catheterized less than 8 days. The probability that minocycline/rifampin catheters were cost-effective compared with chlorhexidine/silver sulfadiazine catheters in patients catheterized for 8 days was 91%. The probability that the minocycline/rifampin catheters in patients catheterized 13 days or longer resulted in cost savings was more than 95%.

CONCLUSIONS

Our analysis suggests that central venous catheters coated with minocycline/rifampin are cost-effective for patients catheterized for at least 1 week and lead to overall cost savings when patients are catheterized for 2 weeks or longer. Policies for the use of antimicrobial catheters in high-risk patients should reflect patients' expected duration of catheterization.

The global impact of drug resistance

Measuring the impact of drug resistance is an important step in understanding the scope of the problem and formulating policies to limit the emergence and spread of resistant organisms. Studies have focused on measuring the increased costs, morbidity, and mortality in patients with infections due to resistant versus susceptible organisms. These have generally found that resistance worsens outcomes. By focusing only on infected patients, however, they may understate the impact of resistance. It is important to recognize that resistance also affects the treatment of individuals with nonresistant organisms. In areas with high rates of resistance, physicians and governments have changed empiric therapy for malaria, tuberculosis, acute respiratory infections, and other diseases, increasing overall treatment costs. In some instances, these costs may exceed those attributable to treatment failure.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device–Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e., education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

The pediatrician and medical care of the child with cancer

The child's pediatrician is an important resource for families regarding a host of issues such as infections, complications and side effects of chemotherapy, school issues, and psychosocial stressors that are common in families of children with life-threatening illness. This article provides guidance for caring for children with malignancies in the primary care setting.

Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disease Control and Prevention, U.S

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device-Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Calibration and discrimination by daily Logistic Organ Dysfunction scoring comparatively with daily Sequential Organ Failure Assessment scoring for predicting hospital mortality in critically ill patients

OBJECTIVE

The Logistic Organ Dysfunction (LOD) score has been proved effective in evaluating severity during the first day in an intensive care unit but has not been evaluated later. To evaluate attributable mortality related to nosocomial events, organ dysfunction scores that remain accurate throughout the intensive care unit stay are needed. The objective of this study was to evaluate how accurately daily LOD scoring predicts mortality comparatively with daily Sequential Organ Failure Assessment (SOFA) scoring.

DESIGN

Prospective multicenter study.

SETTING

Six intensive care units in France.

PATIENTS

A total of 1685 patients with intensive care unit stays longer than 48 hrs were included in this study (511 hospital deaths). Median age was 66 yrs, and median Simplified Acute Physiology Score II at admission was 38. For each patient, a senior physician recorded the variables needed to compute organ dysfunction scores daily throughout the intensive care unit stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

SOFA and LOD scores were computed daily during the first 7 days. Calibration was evaluated based on goodness-of-fit by the Hosmer-Lemeshow chi-square statistic (lower chi-square values and higher values indicate better fit) and discrimination based on the receiver operating characteristics (ROC) area under the curve (AUC; a ROC-AUC of 1 indicates faultless discrimination and a ROC-AUC of 0.5 indicates the effects of chance alone). Because calibration of both scores was poor at all time points ( p<.001), customization was performed using the total score (model 1) or separate introduction of each dysfunction (model 2). The performance of customized LOD and SOFA scores on a given day in predicting mortality was assessed in those patients who spent at least one more calendar day in the intensive care unit. The original LOD and SOFA scores had satisfactory ROC-AUC values (0.720 to 0.766). Internal consistency of both scores was acceptable ( p< 10(-4) for each organ dysfunction). After customization, the original scores calibrated well between days 1 and 7. Discrimination by both scores was better with model 2 (AUC-ROC, 0.729-0.784).

CONCLUSION

Daily LOD and SOFA scores showed good accuracy and internal consistency, and they could be used to adjust severity for events occurring in the intensive care unit.

Catheter infection risk related to the distance between insertion site and burned area

A prospective observational study of central venous catheters (CVC) was carried out in order to determine if a CVC inserted near an open burn wound increases catheter infection risk in burned patients. The study was carried out during a 12-month period (1998-1999) at the Benaim Foundation's Burn Unit in Buenos Aires (C.E.P.A.Q.). Eighty-three CVCs were inserted in 20 burned patients during the study period. Twenty-six catheters were inserted near an open wound (NOW) and 57 far from an open wound (FOW). NOW CVCs were considered when 25 cm2 surrounding the catheter's insertion site overlapped the wound. Colonization rates were 84% (22/26 CVCs) in those inserted NOW and 47% (27/57 CVCs) in FOW (P = 0.001). Colonization relative risk of NOW-CVCs was 1.79 (95% confidence interval, 1.3-2.46). Bacteremia rates were 27% (7/26 CVCs) in CVCs inserted NOW and 6% (3/57 CVCs) in FOW (P = 0.004). Bacteremic risk of NOW-CVCs was 5.12 (95% confidence interval, 1.44-18.22). Colonization rates were higher and sooner in NOW-CVCs than in FOW-CVCs. We suggest that insertion of catheters near an open burn wound should be avoided and, if inevitable, should not be left in place for period exceeding 3 days.

Antimicrobial activity of a novel catheter lock solution

Intravascular catheter-associated bloodstream infections significantly increase rates of morbidity and hospital costs. Microbial colonization and development of biofilms, which are known to be recalcitrant to antibiotic therapy, often lead to the loss of otherwise patent vascular access systems. We evaluated a new taurolidine- and citrate-based catheter lock solution (Neutrolin; Biolink Corporation, Norwell, Mass.) for its activity against planktonic microbes, antimicrobial activity in a catheter model, and biofilm eradication activity. In studies of planktonic microbes, after 24 h of contact, 675 mg of taurolidine-citrate solution per liter caused > 99% reductions in the initial counts of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Entercoccus faecalis. A solution of 13,500 mg/liter was cidal for Candida albicans. Ports and attached catheters inoculated with 50 to 600 CFU of these bloodstream isolates per ml were locked with heparin or the taurolidine-citrate solution. After 72 h, there was no growth in the taurolidine-citrate-treated devices but the heparin-treated devices exhibited growth in the range of 6 x 10(2) to 5 x 10(6) CFU/ml. Biofilms were developed on silicone disks in modified Robbins devices with broth containing 6% serum (initial counts, 10(6) to 10(8) CFU/cm(2)). The axenic biofilms were treated for 24 h with taurolidine-citrate or heparin. Taurolidine-citrate exposure resulted in a median reduction of 4.8 logs, whereas heparin treatment resulted in a median reduction of 1.7 logs (P < 0.01). No significant differences in the effects of the two treatments against P. aeruginosa and C. albicans were observed. These findings suggest that taurolidine-citrate is a promising combination agent for the prevention and treatment of intravascular catheter-related infections.

Overview of catheter-related infections with special emphasis on prevention based on educational programs

Intra-vascular access is an unavoidable tool in sophisticated modern medical practice, and catheter-related infection remains a leading cause of nosocomial infections, particularly in intensive care units where it is associated with significant patient morbidity, mortality, and additional hospital costs. The incidence of catheter-related bloodstream infection ranges from 2 to 14 episodes per 1000 catheter-days. On average, microbiologically documented, device-related bloodstream infections complicate the use of a central venous line in three to five per 100 cases. But this represents only the visible part of the iceberg and most episodes of clinical sepsis are nowadays considered to be catheter-related. We briefly review the pathophysiology of these infections, highlighting the importance of the skin insertion site and the intravenous line hub as principal sources of colonization and infection. Principles of therapy are briefly addressed. A large proportion of these infections are preventable and this has been the objective of creating precise guidelines. It was recently suggested that the situation may evolve with the introduction of antibiotic/antiseptic-coated devices, whose impact on the epidemiology of antibiotic resistance remains to be determined. Recently, educational programs and/or a global preventive strategy based on the strict application of specific preventive measures and careful control of all factors associated with infection proved to be even more effective than coated devices in reducing rates of infection. Practical aspects regarding educational approaches will help clinicians to adapt and incorporate educational programs into clinical practice.

Hospital-acquired, laboratory-confirmed bloodstream infection: increased hospital stay and direct costs

OBJECTIVES

To determine increased hospital stay and direct costs attributable to hospital-acquired, laboratory-confirmed bloodstream infection (BSI), and to evaluate the matching variable length of stay (LOS).

DESIGN

Retrospective (historical) cohort study with 1:2 matching in intensive care units and surgical wards.

SETTING

A 2,000-bed university hospital in Rome, Italy.

PATIENTS

All patients admitted between January 1994 and June 1995 who had hospital-acquired, laboratory-confirmed BSI were considered cases; all others were eligible as controls.

METHODS

Two controls (A and B) were selected per case in a stepwise fashion. Controls in group A were selected according to the following six criteria: ward, gender, age, diagnosis, central venous catheter, and LOS equal to the interval from admission to infection in a matched case +/- 20% (LOS +/- 20%). Controls in group B were selected according to the first five criteria, but excluded LOS +/- 20%.

RESULTS

One hundred five of 108 patients were each matched with two controls. The matching appropriateness score was greater than 90%. With the use of controls in groups A and B, the case-fatality rates attributable to hospital-acquired, laboratory-confirmed BSI were 35.2% and 40.9%, respectively; the estimated risk ratios for death were 2.60 and 3.52 (P = .0001), respectively. The increased hospital stay per case attributable to hospital-acquired, laboratory-confirmed BSI was 19.1 (mean) and 13.0 (median) days for matched pairs in control group A and 19.9 (mean) and 15.0 (median) days for matched pairs in control group B. With controls in group A, the cost of increased hospital stay per patient attributable to hospital-acquired, laboratory-confirmed BSI was Euro 15,413. The additional cost per patient due to treatment was Euro 943, making the overall direct cost Euro 16,356 per case.

CONCLUSIONS

This study should make it possible to estimate the cost of hospital-acquired, laboratory-confirmed BSI in most hospitals after adjusting for incidence rate. It also confirmed the use of LOS +/- 20% as a matching variable to limit overestimation of increased hospital stay. To our knowledge, this is among the first such studies in Europe.

Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit

OBJECTIVE

The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections.

DESIGN

Pre- and postintervention observational study.

SETTING

Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital.

PATIENTS

A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000.

INTERVENTIONS

A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU.

MEASUREMENTS AND MAIN RESULTS

Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between $185,000 and $2.808 million.

CONCLUSIONS

A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization.

Infection control in the ICU

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Preventing vascular catheter-related infections: current controversies

Prevention of vascular catheter-related infection remains an important priority. This review focuses on salient controversies regarding optimal preventive methods. Intensity of surveillance for nosocomial infections was the single most important predictor of prevention in the Study of the Efficacy of Nosocomial Infection Control (SENIC). Used suboptimally by most hospitals in the SENIC study, surveillance is probably conducted even less today. There has been one randomized trial of the optimal method of aseptic insertion for central venous catheters and none comparing the 2 most frequently used sites. Scheduled replacement did not prevent infection in multiple randomized trials but, according to a recent survey, was still being used frequently. Chlorhexidine preparation of skin before and during catheterization has significantly reduced colonization of catheters in multiple randomized trials and should be used. Impregnation of catheter and/or hub surfaces with antiseptics raises less concern about fostering the development of antibiotic resistance than does the use of antibiotics for this purpose.

Nosocomial primary bloodstream infections in intensive care unit patients in a nonteaching community medical center: a 21-month prospective study

All patients admitted to the medical and surgical intensive care units of a 500-bed nonteaching suburban hospital were followed prospectively for the occurrence of nosocomial primary bloodstream infections for 21 months. The incidence of primary bloodstream infection was 38 (1%) of 3163 patients; among patients with central venous catheters, it was 34 (4%) of 920 patients, or 4.0 infections per 1000 catheter-days. Ventilator-associated pneumonia, congestive heart failure, and each intravascular catheter inserted were independently associated with the development of a nosocomial primary bloodstream infection. Among infected patients, the crude mortality rate was 53%, and these patients had longer stays in intensive care units and the hospital than did uninfected patients. Bloodstream infection, however, was not an independent risk factor for death. The incidence, risk factors, and serious outcomes of bloodstream infections in a nonteaching community hospital were similar to those seen in tertiary-care teaching hospitals.

Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients

We studied a cohort of 2201 patients hospitalized in 15 French intensive care units (ICUs) for > or = 48 h during a 4-mo period to assess the incidence and outcomes of primary and definite catheter-related bloodstream (CRB) or secondary nosocomial bloodstream infection (NBSI). Variables associated with ICU death and duration of stay were determined by logistic regression, and attributable mortality and length of stay (LOS) from a nested matched case-control (96 pairs) study, stratified on the source of bacteremia. Bacteremia occurred in 5% (95% CI 4.1-6%) of patients with > or = 48 h ICU stay. Primary, CRB, and secondary NBSI accounted for 29%, 26%, and 45% of the 111 episodes, respectively. NBSI was associated with a markedly increased risk of death (OR = 4.6; 95% CI 2.9-7.1) and an attributable mortality of 35% (95% CI, 28%-47%). In the case-control study, the excess mortality was 20% (p = 0.03) in patients with primary bacteremia and CRB, and 55% (p < 0.001) for secondary bacteremia; in patients with CRB only, the excess mortality was 11.5%. The median excess ICU LOS in survivors of NBSI was 9.5 d, and was similar, irrespective of its source. The risk of mortality associated with primary and catheter-related bacteremia appears much lower than that of secondary bacteremia, but is sizable, and the excess LOS incurred by the various categories of bacteremia is comparable. Differentiating catheter-related bacteremia from both primary and other secondary bacteremia appears warranted in studies conducted in critically ill patients.

[Catheter-related infection in intensive care. Physiopathology, diagnosis, treatment and prevention]

PURPOSE

To review the mechanisms, diagnosis, treatment and prophylaxis of catheter-related sepsis in intensive care unit patients.

DATA SOURCES

A Medline research of the English- or French-language reports published between 1966 and 2000 and a manual research of references of relevant papers.

STUDY SELECTION

Experimental, clinical and basic research studies related to catheter-related sepsis.

DATA EXTRACTION

Data in selected articles were reviewed, and relevant clinical information was extracted.

DATA SYNTHESIS

Infection remains the major complication related to catheter insertion. No bacteriological exam or systematic catheter change is required in the absence of infection suspicion. In the intensive care unit, and without septic shock, the surveillance of skin cultures at the catheter insertion site or the time to positivity of hub-blood versus peripheral-blood culture determination may reduce the number of unnecessary removed catheters. Catheter change over a guidewire is not recommended because of the risk of dissemination of infection. When the catheter is removed, a quantitative culture is warranted. The treatment of catheter-related sepsis is based on catheter removal. The use of antibiotics is limited to some organisms or when the infection is complicated. The persistence of fever and positive blood cultures 72 h after catheter removal require to look for dissemination of infection or septic thrombophlebitis, especially if S. aureus or Candida are incriminated. The treatment of infection without catheter removal is not recommended in the intensive care unit because of a high risk of treatment failure. Compliance with catheter care guidelines and continuing quality improvement programs are the two major procedures in reducing catheter infection.

CONCLUSIONS

Improved understanding of the pathophysiology of catheter-related sepsis has led to improved prevention. Compliance with catheter care guidelines and continuing quality improvement programs are majors procedures to reduce the risk of catheter infection.

Variation in nosocomial infection prevalence according to patient care setting:a hospital-wide survey

A study was performed to estimate the prevalence of nosocomial infections (NI) and assess differences between medical care settings in one hospital complex. A seven-day period-prevalence survey was conducted in May 1998 in a large primary and tertiary healthcare centre in Geneva, Switzerland, that included all patients in acute, sub-acute and chronic care settings. Variables included demography, exposure to invasive devices and antibiotics, surgical history, and patients' localization. Overall prevalence of NI was 11.3% (acute, 8.4%; sub-acute, 11.4%; chronic care setting, 16.4%) in the 1928 patients studied, and ranged from 0% in ophthalmology to 23% in critical care units. Odds of infection in sub-acute and chronic care settings were significantly higher than in the acute care setting even after adjustment for case-mix [OR, 2.59; 95% confidence interval (CI(95)) 1.53-4.41; and OR, 2.34; Cl(95)1.38-3.95, respectively]. As a distinct group, patients in the geriatric location (belonging to the sub-acute care setting) showed a significant proportion of urinary (39%) and respiratory (21%) tract infections, contrasting with a relatively low exposure to urinary catheters (6.1%) and orotracheal intubation (0%). In conclusion, sub-acute and chronic care settings are associated with high infection prevalence even after case-mix adjustment. Prevalence studies are an easy surveillance tool that can be exploited further by analysing data according to hospital care settings to identify high-risk areas.

Three-year survey of bacteremia and fungemia in a pediatric intensive care unit

BACKGROUND

Knowledge of the pattern of blood stream infection (BSI) in patients in intensive care units (ICUs) can help determine antibiotic prescribing policy and infection control procedures. However, there have been few pediatric-based studies.

METHODS

Surveillance of BSI in a pediatric ICU for 3 years, amounting to 131 episodes of significant bacteremia and fungemia.

RESULTS

The incidence of BSI was 39.0 per 1,000 admissions (10.6 per 1,000 bed days). Eighty-four (64.1%) episodes were ICU-acquired, and 27 (20.6%) were community-acquired. Gram-positive, Gram-negative and anaerobic bacteria accounted for 62.2, 30.8 and 1.4%, respectively, of the 143 microorganisms isolated, 5.6% were yeasts. Neisseria meningitidis was the most common species in community-acquired infections, and staphylococci predominated in hospital-acquired episodes. Eighty-seven percent of patients had significant underlying disease, including 60.3% with congenitally acquired conditions. Intravascular devices were the most common source of infection, accounting for 41.2% of all episodes. The crude mortality in children with BSI was 26.5%, compared with 8.1% in those without BSI.

CONCLUSIONS

The pattern of BSI in ICUs is partly determined by the type of patient treated. However, some observations are generally applicable, notably the increasing importance of antibiotic-resistant bacteria that are often of low virulence and device-associated. Our experience suggests that universal use of broad spectrum empiric antibiotics to cover these pathogens (which risks further promoting antibiotic resistance) may not improve patient outcome. Our study provides a basis for other pediatric ICUs to evaluate their rates and outcomes of BSI.

The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients

OBJECTIVE

To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients.

DESIGN

Three strategies were used to estimate the mortality attributable to bleeding in two multicentre databases. The first method matched patients who bled with those who did not (matched cohort), using duration of ICU stay prior to the bleed, each of six domains of the Multiple Organ Dysfunction Score (MODS) measured 3 days prior to the bleed, APACHE II score, age, admitting diagnosis, and duration of mechanical ventilation. The second approach employed Cox proportional hazards regression to match bleeding and non-bleeding patients (model-based matched cohort). The third method, instead of matching, derived estimates based on regression modelling using the entire population (regression method). Three parallel analyses were conducted for the length of ICU stay attributable to clinically important bleeding.

SETTING

Sixteen Canadian university-affiliated ICUs.

PATIENTS

A total of 1666 critically ill patients receiving mechanical ventilation for at least 48 hours.

MEASUREMENTS

We prospectively collected data on patient demographics, APACHE II score, admitting diagnosis, daily MODS, clinically important bleeding, length of ICU stay, and mortality. Independent adjudicators determined the occurrence of clinically important gastrointestinal bleeding, defined as overt bleeding in association with haemodynamic compromise or blood transfusion.

RESULTS

Of 1666 patients, 59 developed clinically important gastrointestinal bleeding. The mean APACHE II score was 22.9 +/- 8.6 among bleeding patients and 23.3 +/- 7.7 among non-bleeding patients. The risk of death was increased in patients with bleeding using all three analytic approaches (matched cohort method: relative risk [RR]= 2.9, 95% confidence interval (CI)= 1.6-5.5; model-based matched cohort method: RR = 1.8, 95% CI = 1.1-2.9; and the regression method: RR = 4.1, 95% CI = 2.6-6.5). However, this was not significant for the adjusted regression method (RR = 1.0, 95% CI = 0.6-1.7). The median length of ICU stay attributable to clinically important bleeding for these three methods, respectively, was 3.8 days (95% CI = -0.01 to 7.6 days), 6.7 days (95% CI = 2.7-10.7 days), and 7.9 days (95% CI = 1.4-14.4 days).

CONCLUSIONS

Clinically important upper gastrointestinal bleeding has an important attributable morbidity and mortality, associated with a RR of death of 1-4 and an excess length of ICU stay of approximately 4-8 days.

Evaluation of outcome of intravenous catheter-related infections in critically ill patients

Fifty-seven patients developed an episode of catheter-related infection (CRI) in the bloodstream during their stay in the intensive care unit (cases) and were prospectively observed to establish the attributable mortality, increase in length of stay, and excess costs. Costs were estimated by multiplying the number of excess days of stay by the reimbursement provided. The outcomes for these cases were compared with those for matched control subjects without CRI. Eight cases were excluded as no control was found. Of the 49 cases, 31 were coagulase-negative staphylococci (CNS). The level of severity was similar for both groups (APACHE II 15.5 +/- 7. 2 versus 15.2 +/- 7.3). There were no significant differences (p > 0. 20) in the mortality observed in the hospital for the cases (22.4%, 95% confidence interval [CI] 0.3% to 34.9%) and the control subjects (34.7%, 95% CI 21.2% to 40.1%). Among the survivors, the hospital stay was increased by 19.6 d (95% CI -1.1; 40.4). This represents an added cost of 3,124 Euros per episode of CRI among the survivors. In conclusion, our cohort study failed to show a difference in attributable mortality due to CRI in intensive care unit patients. Nevertheless, these infections lead to an increase in hospital stay of approximately 20 d. Each episode of CRI represents an additional cost of more than 3,000 Euros.