Incidence and risk factors of device-associated infections and associated mortality at the intensive care in the Dutch surveillance system

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Katater İlişkili Üriner Sistem Enfeksiyonlarında Mortalite ile İlişkili Faktörlerin Değerlendirilmesi, 5 Yıllık Retrosepektif Çalışma

Amaç: Bu çalışmanın amacı, kateter ilişkili üriner sistem enfeksiyonlarında (Kİ-ÜSİ) mortalite ile epidemiyolojik faktörler, komorbid durumlar, antibiyotik direnci, ampirik antimikrobiyal tedavi ve laboratuvar parametreleri arasındaki ilişkiyi değerlendirmektir. Gereç ve yöntemler: Yoğun bakıma 1 Ocak 2015 ile 1 Ocak 2020 arasında kabul edilen 18 yaş ve üzeri hastalarda retrospektif bir kohort çalışması tasarlanmıştır. Birincil sonlanım noktası hastanın kabulünün ilk 28 günü içinde ölüm, ikincil son nokta ise 28 günden sonra sağkalımdı. p< 0.05 değeri anlamlı kabul edildi. Bulgular: Çalışmaya medyan yaşı 78, 198'i (%52,8) kadın olan toplam 375 hasta alındı. En sık saptanan mikroorganizmalar Escherichia coli (%50.9) ve Enterococcus faecalis (%16.8) idi. Gram negatif bakterilerin 3. kuşak sefalosporinlere, siprofloksasine ve meropenem'e direnci sırasıyla %41,3, %40 ve %8,6 saptandı. Gram pozitif bakterilerin %0,3'ünde vankomisin direnci tespit edildi. Mortalite oranı %58,1 idi. Artmış mortalite riski ile ilişkili faktörler ≥ 65 yaş, malignite varlığı, mekanik ventilasyon, APACHE II skoru ≥ 20 ve septik şok tanısıydı. Daha düşük ölüm riski ile ilişkili tek faktör kültürde E. coli'nin saptanmasıydı. Sonuç: Epidemiyolojik faktörlerin, eşlik eden hastalıkların, klinik skorlama sistemlerinin ve mikrobiyolojik sonuçların mortalite üzerine etkisi olduğu belirlendi. Bu çalışmanın sonuçları, kılavuzlarda yer alan enfeksiyon kontrol önlemleri ve tedavi önerileri ile birlikte değerlendirildiğinde, Kİ-ÜSİ'ye bağlı mortalitenin azaltılabileceğini düşünmekteyiz.

A scoping review of registry captured indicators for evaluating quality of critical care in ICU

BACKGROUND

Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation.

METHOD

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance.

RESULTS

The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).

CONCLUSIONS

Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.

Implementation of daily chlorhexidine bathing in intensive care units for reduction of central line-associated bloodstream infections

BACKGROUND

Daily chlorhexidine bathing has been associated with a reduction in central line-associated bloodstream infections (CLABSI). In the setting of an already established CLABSI surveillance system and an implemented CLABSI prevention bundle, we analysed the effect of daily chlorhexidine bathing in ICU patients on CLABSI incidence and its causative pathogens.

METHODS

This was a before-and-after study in intensive care units (ICUs) at a tertiary-care centre in Switzerland. Prospective surveillance of CLABSIs and their aetiologies was established. The intervention consisted of daily chlorhexidine bathing of ICU patients with a central venous catheter. A baseline period of 19 months was followed by an intervention period of 9 months.

FINDINGS

A total of 5008 patients were included. In the baseline period a mean CLABSI rate of 2.45/1000 catheter days (95% confidence interval (CI) 1.93-3.07) was observed, followed by 1.00/1000 catheter days (95% CI 0.55-1.67; P<0.001) in the intervention period. Introduction of chlorhexidine bathing was independently associated with a reduced risk of CLABSI (adjusted odds ratio 0.47, 95% CI 0.26-0.84, P=0.011). We did not observe a significant change in aetiology except for an increase of Serratia marcescens in the intervention period.

CONCLUSIONS

Introduction of daily chlorhexidine bathing resulted in a decline in CLABSI incidence on ICUs. Starting from a baseline CLABSI rate that can be considered standard in a high-income setting and several measures for CLABSI prevention implemented, chlorhexidine bathing proved helpful for a further reduction.

Central line-related bloodstream infections and microbiological study in an Egyptian Ministry of Health Hospital

BACKGROUND

Central line-associated bloodstream infections continue to be one of the most important health problems in ICU.

OBJECTIVES

To identify the central line-related bloodstream infections and their microbiological characteristics Specific objectives to the identify the incidence, predisposing factors of central line-related bloodstream Infections and study the antibiotic sensitivity patterns of the isolated organisms.

MATERIAL AND METHODS

Patients' demographic, clinical data, central venous catheter related data,and blood culture specimen collection data were collected utilizing a descriptive exploratory design from a purposive sample of 120 ICU patients underwent insertion central venous catheter.

RESULTS

out of 120 central line catheters sent for culture from patients immediately and seven days after insertion., 13(10.83%) were positive seven days after insertion. Of the 13 infection cases, 10 cases were Staphylococcus epidermis and the others were Staphylococcus aureus. In addition, most infected patients were overweight and obese, diabetic, had sub-clavian route, and their length of hospital stayed more than7 days.

CONCLUSION

10.83 % developed bacterial blood stream infection 7 days after insertion of central venous catheters, and most of bacterial isolates were Staphylococcus epidermis and were sensitive to Vancomycin and Amikain.

Management of peripheral venous catheters and implementation of guidelines in Germany: a national survey

BACKGROUND

Due to their frequent use, peripheral venous catheters (PVCs) are of importance in terms of catheter-related infections and their prevention. In 2017, revised national guidelines for the prevention of PVC-related infections were published in Germany.

AIM

To describe PVC handling practices and assess the implementation of national guidelines for the prevention of PVC-related infections in German acute care hospitals, 10 months after their release.

METHODS

An online survey on the management of PVCs in hospital wards was conducted. For this, 1191 acute care hospitals participating in the national surveillance system for healthcare-associated infections in Germany were invited to participate. Each hospital was asked to complete the survey for an intensive care unit (ICU), as well as a medical ward and a surgical ward. Participation in the survey was voluntary.

FINDINGS

In total, 701 hospitals (response rate 59%) participated and provided data on 1449 wards (599 ICUs, 446 medical wards, 404 surgical wards). Approximately 43% of wards reported that they had implemented the new national guidelines where necessary. Structured surveillance for PVC-associated infections was established in only 21% of wards. While 94% of wards reported the inclusion of aspects of PVC handling in their general infection prevention education, questions on the training methods yielded diverse results. Approximately 59% of wards reported that they did not routinely use a combination of alcohol and a remanant disinfectant for skin disinfection before PVC insertion.

CONCLUSION

Generally, PVC management in Germany is well organized. However, potential for improvement was identified, particularly considering surveillance and implementation of selected national guidelines.

Using flexible methods to determine risk factors for ventilator-associated pneumonia in the Netherlands

Seven hospitals participated in the Dutch national surveillance for ventilator-associated pneumonia (VAP) and its risk factors. We analysed time-independent and time-dependent risk factors for VAP using the standard Cox regression and the flexible Weighted Cumulative Effects method (WCE) that evaluates both current and past exposures. The prospective surveillance of intensive care patients aged ≥16 years and ventilated ≥48 hours resulted in the inclusion of 940 primary ventilation periods, comprising 7872 ventilation days. The average VAP incidence density was 10.3/1000 ventilation days. Independent risk factors were age (16–40 years at increased risk: HR 2.42 95% confidence interval 1.07–5.50), COPD (HR 0.19 [0.04–0.78]), current sedation score (higher scores at increased risk), current selective oropharyngeal decontamination (HR 0.19 [0.04–0.91]), jet nebulizer (WCE, decreased risk), intravenous antibiotics for selective decontamination of the digestive tract (ivSDD, WCE, decreased risk), and intravenous antibiotics not for SDD (WCE, decreased risk). The protective effect of ivSDD was afforded for 24 days with a delay of 3 days. For some time-dependent variables, the WCE model was preferable over standard Cox proportional hazard regression. The WCE method can furthermore increase insight into the active time frame and possible delay herein of a time-dependent risk factor.

Infection of Small-Bore Tunneled Central Venous Catheters

OBJECTIVE. The purpose of this study is to evaluate the association of common clinical variables with small-bore tunneled central venous catheter (CVC) infection. MATERIALS AND METHODS. Retrospective data were collected from all small-bore (6-French) tunneled CVCs placed by the interventional radiology service between 2012 and 2015. Only patients who had a documented reason for tunneled CVC removal were included in the analysis to capture all events. Transfemoral, transhepatic, and translumbar placements were excluded to reduce cohort heterogeneity. Multiple clinical variables were collected from a review of the medical record. The t test and Fisher exact test were used for two-group comparisons for continuous variables and categoric variables, respectively. Logistic regression analyses were further used to identify variables that were associated with catheter infection. RESULTS. One hundred eighty-two patients (105 women [57.7%] and 77 men [42.3%]) with a mean (± SD) age of 49.7 ± 16 years were included. Thirty-two catheters (17.6%) were removed because of infection. Noninfected lines were removed at a mean of 39 (SD, 57.3) days, whereas infected lines were removed at a mean of 95.9 (SD, 113.4) days after placement (p < 0.001). There was a statistically significant difference in the number of tunneled CVCs removed for infection when the indication for tunneled CVC placement was the administration of IV antibiotics (p = 0.04). By multivariate analysis, only time to removal (p = 0.002; odds ratio, 0.992; 95% CI, 0.986-0.998) and a history of tunneled CVC (p = 0.01; odds ratio, 0.306; 95% CI, 0.121-0.772) were associated with catheter removal for infection. CONCLUSION. Time to catheter removal and history of tunneled CVC were associated with an increased risk of tunneled CVC removal because of infection.

A case series of anaphylaxis to chlorhexidine-impregnated central venous catheters in cardiac surgical patients

We report a case series of anaphylaxis to chlorhexidine-coated central venous catheters (CVCs) when used in cardiac surgical patients in our institution. Our experience, together with increasing reports of anaphylaxis to chlorhexidine-coated CVCs from other sources indicates that chlorhexidine-coated CVCs are not without additional risk. Attempts to lower rates of catheter-related bloodstream infection has led to the widespread adoption of chlorhexidine-coated CVCs in the perioperative and critical care setting, including for routine cardiac surgery. However, closer scrutiny indicates that there is lack of strong evidence demonstrating a meaningful reduction in rates of sepsis or serious morbidity, especially with CVC dwell times of less than seven days. Given the lack of clear benefit, we recommend non-coated CVCs for routine cardiac surgery, with even consideration for chlorhexidine-coated CVCs when specifically indicated for patients at high risk of CVC infection.

Hospital-Acquired Infections in Critically Ill Patients With Cancer

Hospital-acquired infections are a common and costly problem facing critically ill patients in the intensive care unit (ICU). Critically ill patients with cancer are a particularly vulnerable subpopulation who possesses additional, nonmodifiable risk factors for developing these infections and, in many cases, are at increased risk of death as a result. This review will describe the most common nosocomial infections patients with cancer acquire while in the ICU: ventilator-associated events, central line-associated bloodstream infection, catheter-associated urinary tract infections, and Clostridium difficile infection.

Epidemiology of device-associated infections in an intensive care unit of a teaching hospital in Nepal: A prospective surveillance study from a developing country

BACKGROUND

Device-associated health care-acquired infections (DA-HAIs) in intensive care unit patients are a major cause of morbidity, mortality, and increased health care costs.

METHODS

A prospective, structured clinicomicrobiological surveillance was carried out for 3 common DA-HAIs: ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) present in the patients of an intensive care unit of a teaching hospital in Nepal. DA-HAIs were identified using the Centers for Disease Control and Prevention definitions, and their rates were expressed as number of DA-HAIs per 1,000 device-days.

RESULTS

Overall incidence rate of DA-HAIs was 27.3 per 1,000 patient-days occurring in 37.1% of patients. The device utilization ratio for mechanical ventilation, central line catheter, and urinary catheter was 0.83, 0.63, and 0.78, respectively. The rates of VAP, CLABSI, and CAUTI were 21.40, 8.64, and 5.11 per 1,000 device-days, respectively. Acinetobacter spp (32.7%), Klebsiella spp (23.6%), Burkholderia cepacia complex (12.7%), and Escherichia coli (10.9%) were the common bacterial pathogens. Most of the bacterial isolates associated with DA-HAIs were found to be multidrug-resistant.

CONCLUSIONS

Incidence of DA-HAIs in the study intensive care unit was high compared with that of developed countries. Formulation and implementation of standard infection control protocols, active surveillance of DA-HAIs, and antimicrobial stewardship are urgently needed in our country.

Epidemiology, associated factors and outcomes of ICU-acquired infections caused by Gram-negative bacteria in critically ill patients: an observational, retrospective study

BACKGROUND

Gram-negative bacteria are increasingly responsible for nosocomial infections, including ICU-acquired infections. Due to high virulence, rate of multi-drug resistance and limited availability of new agents, these infections create cumbersome clinical burdens, making it important to reduce the risk of their occurrence. The aim of the study was to assess epidemiology-related factors and outcomes of Gram-negative, ICU-acquired infections in a cohort of medical-surgical patients.

METHODS

A retrospective survey was conducted on all patients admitted to a mixed ICU from January 2012 to December 2013. 'ICU-acquired infections' were defined as new infections acquired no less than 48 h after ICU admission. Diagnosis was made according to the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC/NHSN) criteria. Differences across patients who did and did not acquire a Gram-negative infection were tested regarding age, sex, body mass index, medical or surgical admission, cardiovascular comorbidities, chronic obstructive pulmonary disease, diabetes, end-stage renal failure, co-existing tumours and prophylactic anti-fungal treatment. Multivariate analysis was used to assess the independency of these associations. Finally, differences in ICU-mortality, ICU-length of stay and duration of mechanical ventilation were tested across patients with and without new, ICU-acquired, Gram-negative infections.

RESULTS

Of 494 patients admitted to the ICU, 46 (9.3 %) acquired an infection 48 or more hours after admittance. In 30/46 patients (65.2 %) the isolated bacterium was Gram-negative. Univariate analysis showed that clinical factors associated with new ICU-acquired Gram-negative infections were medical admission (p < 0.001, 95 % CI 0.59 - 0.29, OR = 0.13), chronic kidney disease (p = 0.018, 95 % CI 1.20 - 7.34, OR = 2.98) and prophylactic antifungal therapy (p < 0.001, 95 % CI 1.91 - 9.79, OR = 4.33). At multivariate analysis, only medical admission and prophylactic antifungal therapy were significantly associated with ICU-acquired Gram-negative infections. Higher ICU-length of stay and longer duration of mechanical ventilation were associated with these infections while ICU-mortality did not significantly differ.

CONCLUSIONS

ICU-acquired Gram-negative infections were common in a cohort of mixed medical-surgical patients. Only medical admission and anti-fungal prophylaxis were found to be independently associated with these infections; they were not found to have a significant effect on ICU-mortality.

Impact of Switching from an Open to a Closed Infusion System on Rates of Central Line–Associated Bloodstream Infection: A Meta-analysis of Time-Sequence Cohort Studies in 4 Countries

Background.

We report a meta-analysis of 4 identical time-series cohort studies of the impact of switching from use of open infusion containers (glass bottle, burette, or semirigid plastic bottle) to closed infusion containers (fully collapsible plastic containers) on central line-associated bloodstream infection (CLABSI) rates and all-cause intensive care unit (ICU) mortality in 15 adult ICUs in Argentina, Brazil, Italy, and Mexico.

Methods.

All ICUs used open infusion containers for 6–12 months, followed by switching to closed containers. Patient characteristics, adherence to infection control practices, CLABSI rates, and ICU mortality during the 2 periods were compared by χ2test for each country, and the results were combined using meta-analysis.

Results.

Similar numbers of patients participated in 2 periods (2,237 and 2,136). Patients in each period had comparable Average Severity of Illness Scores, risk factors for CLABSI, hand hygiene adherence, central line care, and mean duration of central line placement. CLABSI incidence dropped markedly in all 4 countries after switching from an open to a closed infusion container (pooled results, from 10.1 to 3.3 CLABSIs per 1,000 central line-days; relative risk [RR], 0.33 [95% confidence interval {CI}, 0.24-0.46];P<.001). All-cause ICU mortality also decreased significantiy, from 22.0 to 16.9 deaths per 100 patients (RR, 0.77 [95% CI, 0.68-0.87];P<.001).

Conclusions.

Switching from an open to a closed infusion container resulted in a striking reduction in the overall CLABSI incidence and all-cause ICU mortality. Data suggest that open infusion containers are associated with a greatiy increased risk of infusion-related bloodstream infection and increased ICU mortality that have been unrecognized. Furthermore, data suggest CLABSIs are associated with significant attributable mortality.

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.

Urinary tract infections in the critical care unit: A brief review

The use of indwelling catheters in the Critical Care Units (CCUs) has a major role in determining the incidence and the morbidity as well as mortality from hospital-acquired urinary tract infections (UTIs). Instituting evidence-based protocols can significantly reduce both the prevalence of indwelling catheterization as well as the incidence of hospital-acquired UTIs. The prevalence of catheter-associated urinary tract infections (CAUTIs) in the CCUs is directly linked to the widespread use of indwelling catheters in these settings. CAUTIs result in significant cost escalation for individual hospitals as well as the healthcare system as a whole. A UTI is an inflammatory response to colonization of the urinary tract, most commonly by bacteria or fungi. A UTI should be differentiated from the mere detection of bacteria in the urinary tract. This condition, referred to as asymptomatic bacteriuria, is common and does not require treatment, especially in the patient with an indwelling urinary catheter. A CAUTI occurs when a patient with an indwelling urinary catheter develops 2 or more signs or symptoms of a UTI such as hematuria, fever, suprapubic or flank pain, change in urine character, and altered mental status. CAUTI is classified as a complicated UTI. The current review highlights the important management issues in critical care patients having CAUTI. We performed a MEDLINE search using combinations of keywords such as urinary tract infection, critical care unit and indwelling urinary catheter. We reviewed the relevant publications with regard to CAUTI in patients in CCU.

The epidemiology of bacteriuria and candiduria in critically ill patients

An observational study was conducted to describe the epidemiology of bacteriuria and candiduria in the intensive care unit (ICU), and the occurrence of blood stream infection (BSI) associated with ICU-acquired positive urine culture. Between 2006 and 2011, 444 episodes of either bacteriuria or candiduria defined by positive urine culture (microorganisms ⩾105 c.f.u./ml) occurred in 406 patients. Three hundred and seventy-seven (85%) were hospital-acquired including 221 which were ICU-acquired (6·4 ± 0·8 episodes/1000 ICU days). Escherichia coli was the most common bacteria of both community- and ICU-acquired bacteriuria/candiduria (49·2% and 29%, respectively). Candida spp. represented 55% (129/236) of pathogens responsible for ICU-acquired positive urine cultures. Patients with ICU-acquired candiduria had greater illness severity at ICU admission than those with ICU-acquired bacteriuria (APACHE III score 79 ± 25 vs. 66 ± 31, P = 0·0015). BSI associated with ICU-acquired positive urine culture occurred in 0·15/1000 ICU days and was more often due to Candida. In this study, Candida was the most common pathogen responsible for ICU-acquired positive urine cultures and illness severity was a risk factor for candiduria in the study population.

Impact of availability of guidelines and active surveillance in reducing the incidence of ventilator-associated pneumonia in Europe and worldwide

BACKGROUND

To analyse whether the availability of written standards for management of mechanically ventilated patients and/or the existence of a surveillance system for cases of ventilation-associated pneumonia (VAP) are positively associated with compliance with 6 well-established VAP prevention measures.

METHODS

Ecological study based on responses to an online-questionnaire completed by 1730 critical care physicians. Replies were received from 77 different countries, of which the majority, i.e. 1351, came from 36 European countries.

RESULTS

On a cross-country level, compliance with VAP prevention measures is higher in countries with a large number of prevention standards and/or VAP surveillance systems in place at ICU level., Likewise, implementation of standards and VAP surveillance systems has a significant impact on self-reported total compliance with VAP prevention measures (both p < 0.001). Moreover, predictions of overall prevention measure compliance show the effect size of the availability of written standards and existence of surveillance system. For instance, a female physician with 10 years of experience in critical care working in a 15-bed ICU in France has a predicted baseline level of VAP prevention measure compliance of 63 per cent. This baseline level increases by 9.5 percentage points (p < 0.001) if a written clinical VAP prevention standard is available in the ICU, and by another 4 percentage points (p < 0.001) if complemented by a VAP surveillance system.

CONCLUSIONS

The existence of written standards for management of mechanically ventilated patients in an ICU and the availability of VAP surveillance systems have shown to be positively associated with compliance with VAP prevention measures and should be fostered on a policy level.

Effect of aerosolized colistin as adjunctive treatment on the outcomes of microbiologically documented ventilator-associated pneumonia caused by colistin-only susceptible gram-negative bacteria

BACKGROUND

The increasing frequency of ventilator-associated pneumonia (VAP) caused by colistin-only susceptible (COS) gram-negative bacteria (GNB) is of great concern. Adjunctive aerosolized (AS) colistin can reportedly increase alveolar levels of the drug without increasing systemic toxicity. Good clinical results have been obtained in patients with cystic fibrosis, but conflicting data have been reported in patients with VAP.

METHODS

We conducted a retrospective, 1:1 matched case-control study to evaluate the efficacy and safety of AS plus IV colistin vs IV colistin alone in 208 patients in the ICU with VAP caused by COS Acinetobacter baumannii, Pseudomonas aeruginosa, or Klebsiella pneumoniae.

RESULTS

Compared with the IV colistin cohort, the AS-IV colistin cohort had a higher clinical cure rate (69.2% vs 54.8%, P = .03) and required fewer days of mechanical ventilation after VAP onset (8 days vs 12 days, P = .001). In the 166 patients with posttreatment cultures, eradication of the causative organism was also more common in the AS-IV colistin group (63.4% vs 50%, P = .08). No between-cohort differences were observed in all-cause ICU mortality, length of ICU stay after VAP onset, or rates of acute kidney injury (AKI) during colistin therapy. Independent predictors of clinical cure were trauma-related ICU admission (P = .01) and combined AS-IV colistin therapy (P = .009). Higher mean Simplified Acute Physiology Score II (P = .002) and Sequential Organ Failure Assessment (P = .05) scores, septic shock (P &lt; .001), and AKI onset during colistin treatment (P = .04) were independently associated with clinical failure.

CONCLUSIONS

Our results suggest that AS colistin might be a beneficial adjunct to IV colistin in the management of VAP caused by COS GNB.

Factors predicting prolonged empirical antifungal treatment in critically ill patients

Objective

To determine the incidence, risk factors, and impact on outcome of prolonged empirical antifungal treatment in ICU patients.

Methods

Retrospective observational study performed during a one-year period. Patients who stayed in the ICU >48 h, and received empirical antifungal treatment were included. Patients with confirmed invasive fungal disease were excluded. Prolonged antifungal treatment was defined as percentage of days in the ICU with antifungals > median percentage in the whole cohort of patients.

Results

Among the 560 patients hospitalized for >48 h, 153 (27%) patients received empirical antifungal treatment and were included in this study. Fluconazole was the most frequently used antifungal (46% of study patients). Median length of ICU stay was 19 days (IQR 8, 34), median duration of antifungal treatment was 8 days (IQR 3, 16), and median percentage of days in the ICU with antifungals was 48% (IQR 25, 80). Seventy-seven patients (50%) received prolonged empirical antifungal treatment. Chemotherapy (OR [95% CI] 2.6 [1.07-6.69], p = 0.034), and suspected infection at ICU admission (3.1 [1.05-9.48], p = 0.041) were independently associated with prolonged empirical antifungal treatment.

Duration of mechanical ventilation and ICU stay were significantly shorter in patients with prolonged empirical antifungal treatment compared with those with no prolonged empirical antifungal treatment. However, ICU mortality was similar in the two groups (46 versus 52%, p = 0.62).

Conclusion

Empirical antifungal treatment was prescribed in a large proportion of study patients. Chemotherapy, and suspicion of infection at ICU admission are independently associated with prolonged empirical antifungal treatment.

The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated

BACKGROUND

Ventilator-associated conditions (VACs) and infection-related ventilator-associated complications (iVACs) are the Centers for Disease Control and Prevention's new surveillance paradigms for patients who are mechanically ventilated. Little is known regarding the clinical impact and preventability of VACs and iVACs and their relationship to ventilator-associated pneumonia (VAP). We evaluated these using data from a large, multicenter, quality-improvement initiative.

METHODS

We retrospectively applied definitions for VAC and iVAC to data from a prospective time series study in which VAP clinical practice guidelines were implemented in 11 North American ICUs. Each ICU enrolled 30 consecutive patients mechanically ventilated &gt; 48 h during each of four study periods. Data on clinical outcomes and concordance with prevention recommendations were collected. VAC, iVAC, and VAP rates over time, the agreement (κ statistic) between definitions, associated morbidity/mortality, and independent risk factors for each were determined.

RESULTS

Of 1,320 patients, 139 (10.5%) developed a VAC, 65 (4.9%) developed an iVAC, and 148 (11.2%) developed VAP. The agreement between VAP and VAC was 0.18, and between VAP and iVAC it was 0.19. Patients who developed a VAC or iVAC had significantly more ventilator days, hospital days, and antibiotic days and higher hospital mortality than patients who had neither of these conditions. Increased concordance with VAP prevention guidelines during the study was associated with decreased VAP and VAC rates but no change in iVAC rates.

CONCLUSIONS

VACs and iVACs are associated with significant morbidity and mortality. Although the agreement between VAC, iVAC, and VAP is poor, a higher adoption of measures to prevent VAP was associated with lower VAP and VAC rates.

Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions

PURPOSE

Persistent low-level hypotension represents a barrier to discharging patients from the intensive care unit (ICU). Midodrine may be an effective adjunct to wean intravenous (IV) vasopressors and permit ICU discharge. We tested the hypothesis that midodrine, given to patients on IV vasopressors who otherwise met ICU discharge criteria, increased the magnitude of change in IV vasopressor rate.

MATERIALS AND METHODS

This was a prospective, observational study in 20 adult surgical ICU patients who met ICU discharge criteria except for an IV vasopressor requirement. We compared the change in phenylephrine equivalent rates during the day before midodrine to the change in phenylephrine equivalent rates after midodrine initiation and analyzed changes in total body fluid balance, heart rate, mean arterial pressure, and white blood cell count during this period.

RESULTS

Patients received 41.0±33.4 μg/min of phenylephrine equivalents and the change in IV vasopressor rate (slope) decreased significantly from -0.62 μg/min per hour of phenylephrine equivalents before midodrine to -2.20 μg/min per hour following the initiation of midodrine treatment (P=.012). Change in total body fluid balance, heart rate, mean arterial pressure, and white blood cell count did not correlate with change in IV vasopressor rate.

CONCLUSION

Midodrine treatment was associated with an increase in the magnitude of decline of the IV vasopressor rate. Oral midodrine may facilitate liberation of surgical ICU patients from an IV vasopressor infusion, and this may affect discharge readiness of patients from the ICU.

Comparison of non-intensive care unit (ICU) versus ICU rates of catheter-associated urinary tract infection in community hospitals

We describe and compare the epidemiology of catheter-associated urinary tract infection (CAUTI) occurring in non-intensive care unit (ICU) versus ICU wards in a network of community hospitals over a 2-year period. Overall, 72% of cases of CAUTI occurred in non-ICU patients, which indicates that this population is an important target for dedicated surveillance and prevention efforts.

Infections acquired in intensive care units: results of national surveillance in Belgium, 1997-2010

BACKGROUND AND AIM

To describe the methodology and output of the Belgian surveillance for infections acquired in intensive care units (ICUs) between 1997 and 2010.

METHODS

Since 1997, ICUs in acute care hospitals in Belgium have been encouraged by federal law to participate in a national multi-centre prospective observational surveillance programme. A protocol and software tool for data collection was developed, and the case definitions and methodology follow those of the European Centre for Disease Prevention and Control.

FINDINGS

For 2010, 18 hospitals provided data on 59 observation quarters, 6478 ICU patients and 52,593 ICU patient-days. The mean incidence rates of ICU-acquired pneumonia and intubation-associated pneumonia were 13 per 1000 patient-days and 12 per 1000 intubation-days, respectively. The mean incidence rates of ICU-acquired bloodstream infections, central vascular catheter (CVC)-associated bloodstream infections and CVC-associated primary bloodstream infections were 3.2 per 1000 patient-days, 2.6 per 1000 catheter-days and 2.3 per 1000 catheter-days, respectively. Between 1997 and 2010, stable trends in ICU-acquired pneumonia and bloodstream infections were observed, together with decreasing trends for intubation-associated pneumonia and CVC-associated bloodstream infections, and a stable trend for CVC-associated primary bloodstream infections.

CONCLUSIONS

In Belgium, national surveillance of ICU-acquired infections allows acute care hospitals to track the incidence of infections at local level, enabling comparison with national and European reference data. Between 1997 and 2010, the incidence of ICU-acquired infections increased and the incidence of device-associated infections decreased.

Life expectancy of brain impaired, chronically ventilated children

We present a 5-year survival profile of 42 children and adolescents between 1 to 21 years of age in an immobile minimally conscious state, chronically dependent on supportive ventilation. Data were collected from a 22-bed pediatric unit dedicated to this unique population, within a 350-bed geriatric hospital, between May 2006 and May 2011. The practice of ventilating children even in minimally conscious state stems from the unique cultural, religious, and ethnic background of the population in Israel. The 5-year survival probability was 48% (52% probability of death within 5 years, 26.5% within 2 years). No significant difference was found in the survival profile of patients admitted following hypoxic accidents (20 children) and those admitted with other problems such as genetic/metabolic diseases or brain anomalies (22). The mortality rate of male patients was higher than that of female patients, but the difference was not statistically significant. No difference in 5-year mortality rates was found between children of different ethnic backgrounds.

Reanimación y prevención de las infecciones nosocomiales

Los servicios de reanimación deben organizar de forma minuciosa la prevención de infecciones en sus enfermos, ya que éstos suelen estar inmunodeprimidos, están sometidos a múltiples procedimientos invasivos realizados por un personal sanitario variado, a menudo en situaciones de urgencia y a cualquier hora del día o de la noche. Las principales infecciones que hay que tratar de prevenir son las neumonías bacterianas adquiridas asociadas a ventilación mecánica (NAVM), las infecciones relacionadas con catéteres intravasculares y las infecciones urinarias asociadas al sondeo vesical. La incidencia de estas infecciones ha disminuido en la mayoría de los servicios que realizan un control cifrado, sobre todo gracias a la implantación de programas de mejora de la calidad. Las técnicas de prevención son múltiples y deben aplicarse simultáneamente. Incluyen medidas globales, como las modalidades de prevención de la transmisión cruzada (higiene de las manos, sobre todo) o de uso de antibióticos, concebidas para reducir la presión de selección de bacterias resistentes a éstos, así como medidas específicas relativas a la colocación y uso de cada uno de los dispositivos invasivos. Numerosas técnicas han demostrado su eficacia en estudios de buen nivel metodológico (higiene de las manos, apósitos para catéteres, etc.), mientras que otras siguen siendo objeto de controversias, por lo que las recomendaciones nacionales e internacionales se actualizan regularmente de acuerdo con los nuevos datos científicos. Estas medidas, implantadas de manera razonada en el marco de programas de mejora de la calidad, permiten obtener tasas muy bajas de infecciones relacionadas con el uso de catéteres vasculares y resultados menos satisfactorios con las NAVM, que justifican la necesidad de proseguir la investigación en este campo.

Rianimazione e prevenzione delle infezioni nosocomiali

I servizi di rianimazione devono organizzare la prevenzione delle infezioni nei loro pazienti in modo minuzioso, in quanto i pazienti sono spesso immunodepressi e subiscono gesti invasivi molteplici, realizzati da personale differente, spesso in situazioni di urgenza e a qualsiasi ora del giorno o della notte. Le principali infezioni che bisogna tentare di prevenire sono le polmoniti batteriche acquisite sotto ventilazione meccanica (PAVM), le infezioni su cateteri intravascolari e le infezioni urinarie su catetere vescicale. L’incidenza di queste infezioni è diminuita nella maggior parte dei servizi che ne effettuano un monitoraggio su base numerica, in particolare nel quadro di programmi di miglioramento della qualità. Le tecniche di prevenzione sono molteplici e devono essere applicate simultaneamente. Esse riguardano delle misure globali, come le modalità di prevenzione della trasmissione crociata (igiene delle mani, in particolare) o di utilizzo degli antibiotici nella prospettiva di ridurre la pressione di selezione di batteri resistenti agli antibiotici, così come delle misure specifiche relative al posizionamento e all’utilizzo di ciascuno dei dispositivi invasivi. Numerose tecniche si sono dimostrate efficaci in studi di buon livello metodologico (igiene delle mani, medicazioni dei cateteri, ecc.) mentre altre sono ancora oggetto di controversie, portando a raccomandazioni nazionali e internazionali regolarmente aggiornate in funzione dei nuovi dati scientifici. Queste misure, implementate in modo ragionato nel quadro di programmi di miglioramento della qualità, consentono di ottenere dei tassi molto bassi per quanto riguarda le infezioni dei cateteri vascolari e dei risultati meno buoni per le PAVM, illustrando la necessità di proseguire la ricerca in questo settore.

Empiric antibiotic, mechanical ventilation, and central venous catheter duration as potential factors mediating the effect of a checklist prompting intervention on mortality: an exploratory analysis

Background

Checklists are clinical decision support tools that improve process of care and patient outcomes. We previously demonstrated that prompting critical care physicians to address issues on a daily rounding checklist that were being overlooked reduced utilization of empiric antibiotics and mechanical ventilation, and reduced risk-adjusted mortality and length of stay. We sought to examine the degree to which these process of care improvements explained the observed difference in hospital mortality between the group that received prompting and an unprompted control group.

Methods

In the medical intensive care unit (MICU) of a tertiary care hospital, we conducted face-to-face prompting of critical care physicians if processes of care on a checklist were being overlooked. A control MICU team used the checklist without prompting. We performed exploratory analyses of the mediating effect of empiric antibiotic, mechanical ventilation, and central venous catheter (CVC)duration on risk-adjusted mortality.

Results

One hundred forty prompted group and 125 control group patients were included. One hundred eighty-three patients were exposed to at least one day of empiric antibiotics during MICU admission. Hospital mortality increased as empiric antibiotic duration increased (P<0.001). Prompting was associated with shorter empiric antibiotic duration and lower risk-adjusted mortality in patients receiving empiric antibiotics (OR 0.41, 95% CI 0.18-0.92, P=0.032). When empiric antibiotic duration was added to mortality models, the adjusted OR for the intervention was attenuated from 0.41 to 0.50, suggesting that shorter duration of empiric antibiotics explained 15.2% of the overall benefit of prompting. Evaluation of mechanical ventilation was limited by study size. Accounting for CVC duration changed the intervention effect slightly.

Conclusions

In this analysis, some improvement in mortality associated with prompting was explained by shorter empiric antibiotic duration. However, most of the mortality benefit of prompting was unexplained.

Intra-abdominal pressure measurement using the FoleyManometer does not increase the risk for urinary tract infection in critically ill patients

OBJECTIVE

The aim of this study was to determine whether intra-abdominal pressure (IAP) monitoring using the FoleyManometer (Holtech Medical, Charlottenlund, Denmark) increases the risk of urinary tract infection (UTI).

DESIGN

A retrospective database review was conducted.

SETTING

The study was conducted in the 12-bed medical intensive care unit of ZNA Stuivenberg Hospital (Antwerp, Belgium), a tertiary hospital.

PATIENTS

There were 5,890 patients admitted to the medical intensive care unit of which 1,097 patients underwent intrabladder pressure (IBP) monitoring as estimate for IAP.

INTERVENTIONS

Crude and adjusted UTI rates were compared among patients undergoing IAP measurements with three different intrabladder methods: a modified homemade technique, a FoleyManometer with 35 ml reservoir, and a FoleyManometer low volume (FoleyManometerLV) with less than 10 ml priming volume.

MEASUREMENTS AND RESULTS

Four consecutive time periods of 24 months were defined and compared with regard to IAP measurement: period 1 (2000-2001), during which IAP monitoring was not used routinely (which serves as a control group), was compared with period 2 (2002-2003), using a modified homemade technique; period 3 (2004-2005), introducing the FoleyManometer; and finally period 4 (2006-2007), in which the FoleyManometerLV was introduced. The incidence of IBP measurements increased from 1.4% in period 1 to 45.4% in period 4 (p < 0.001). At the same time, the Simplified Acute Physiology Score (version 2) (SAPS-II) increased significantly from 24.4 ± 21.5 to 34.9 ± 18.7 (p < 0.001) together with the percentage of ventilated patients from 18.6% to 40.7% (p < 0.001). In total, 1,097 patients had IAP measurements via the bladder. The UTI rates were adjusted for disease severity by multiplying each crude rate with the ratio of control versus study patient SAPS-II probability of mortality. Crude and adjusted UTI rates per 1,000 catheter days (CD) were on average 16.1 and 12.8/1,000 CD, respectively, and were not significantly different between the four time periods.

CONCLUSIONS

Intrabladder pressure monitoring as estimate for IAP either via a closed transducer technique or the closed FoleyManometer technique seems safe and does not alter the risk of UTI in critically ill patients.

Incidence of bacteremia at the time of ICU admission and its impact on outcome

CONTEXT

Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome.

METHODS

Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score.

STATISTICAL ANALYSIS

Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality.

RESULTS

Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100).

CONCLUSIONS

Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.

The role of fluoroquinolones in the management of urinary tract infections in areas with high rates of fluoroquinolone-resistant uropathogens

Fluoroquinolones have been recommended as the drugs of choice for the empirical treatment of uncomplicated and complicated urinary tract infections (UTIs) caused by trimethoprim-sulfamethoxazole-resistant uropathogens. However, because of the increased use of both oral and parenteral fluoroquinolones for other kinds of infections, increasing rates of resistance to fluoroquinolones among the most common uropathogens have challenged this recommendation, particularly in the Asia-Pacific region. The current interpretative criteria for the in vitro susceptibility of uropathogens to some fluoroquinolones, such as levofloxacin and ciprofloxacin, are set according to their therapeutic efficacy for bloodstream infections, and are not specific to UTIs. Fluoroquinolones exhibit concentration-dependent antibacterial activity, high renal excretion, and relatively early and prolonged urinary bactericidal titers. Whether or not current interpretative criteria for the in vitro susceptibility of uropathogens to fluoroquinolones predict clinical failure in treating UTIs is still controversial. The Clinical and Laboratory Standards Institute (CLSI) has established UTI-specific breakpoints for resistance to a few fluoroquinolones. However, the application of high-dose fluoroquinolone therapy for the treatment of mild to moderate UTIs caused by isolates with higher minimum inhibitory concentrations (MICs) of several fluoroquinolones needs to be re-validated based on more relevant clinical studies, prudent pharmacokinetic/pharmacodynamic (PK/PD) considerations, and thorough study of the mutant prevention concentration of fluoroquinolones in the treatment of UTI.

Incidence of bacteremia at the time of ICU admission and its impact on outcome

CONTEXT

Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome.

METHODS

Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score.

STATISTICAL ANALYSIS

Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality.

RESULTS

Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100).

CONCLUSIONS

Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.

Low serum citrulline concentration correlates with catheter-related bloodstream infections in children with intestinal failure

BACKGROUND

Serum citrulline concentration is used as a biomarker of enterocyte mass and enteral tolerance, and low serum concentrations are correlated with bacteremia in immunosuppressed adults undergoing hematopoietic stem cell transplant. The authors sought to determine if citrulline was associated with the development of catheter-related bloodstream infections (CRBSIs) in children with intestinal failure.

METHODS

Data were reviewed from 66 children treated in a multidisciplinary intestinal rehabilitation program, who had serum concentration citrulline measured between January 2007 and August 2009. All patients had a diagnosis of intestinal failure requiring parenteral nutrition (PN) support. Exclusion criteria included central venous catheter in situ <30 days, creatinine clearance <20 mL/minute, or a history of organ transplant/immunosuppression.

RESULTS

A total of 15 patients were excluded because of the above criteria. In this cohort of 51 patients, 26 (51%) developed CRBSIs. Both groups were similar in terms of gestational age, diagnosis, nutrition status, and biochemical liver function tests. The mean (± standard deviation [SD]) minimum serum citrulline concentration was significantly lower in patients who developed CRBSIs (6.7 ± 4.6 µmol/L) than in those who did not (11.3 ± 6.4 µmol/L, P = .004). Multivariate logistic regression analysis identified lower minimum serum citrulline concentration and longer central venous catheter duration as independently associated with CRBSI (P = .003 and P = .038, respectively).

CONCLUSIONS

Low serum citrulline concentration and longer central venous catheter time are independently associated with CRBSI in children with intestinal failure. Serum citrulline concentration may be a useful biomarker to identify patients with intestinal failure who are at high risk of developing a CRBSI.

Risk factors and mortality for nosocomial bloodstream infections in elderly patients

OBJECTIVE

To determine risk factors for nosocomial bloodstream infection (BSI) and associated mortality in geriatric patients in geriatric and internal medicine wards at a university hospital.

METHODS

Single-center retrospective (1992-2007), pairwise-matched (1:1-ratio) cohort study. Geriatric patients with nosocomial BSI were matched with controls without BSI on year of admission and length of hospitalization before onset of BSI. Demographic, microbiological, and clinical data are collected.

RESULTS

One-hundred forty-two BSI occurred in 129 patients. Predominant microorganisms were Escherichia coli (23.2%), coagulase-negative Staphylococci (19.4%), Pseudomonas aeruginosa (8.4%), Staphylococcus aureus (7.1%), Klebsiella pneumoniae (5.8%) and Candida spp. (5.8%). Matching was successful for 109 cases. Compared to matched control subjects, cases were more frequently female, suffered more frequently from arthrosis, angina pectoris and pressure ulcers, had worse Activities of Daily Living-scores, had more often an intravenous or bladder catheter, and were more often bedridden. Logistic regression demonstrated presence of an intravenous catheter (odds ratio [OR] 7.5, 95% confidence interval [CI] 2.5-22.9) and being bedridden (OR 2.9, 95% CI 1.6-5.3) as independent risk factors for BSI. In univariate analysis nosocomial BSI was associated with increased mortality (22.0% vs. 11.0%; P=0.029). After adjustment for confounding co-variates, however, nosocomial BSI was not associated with mortality (hazard ratio 1.3, 95% CI 0.6-2.6). Being bedridden and increasing age were independent risk factors for death.

CONCLUSION

Intravenous catheters and being bedridden are the main risk factors for nosocomial BSI. Although associated with higher mortality, this infectious complication seems not to be an independent risk factor for death in geriatric patients.

[Urinary tract colonization and infection in critically ill patients]

Urinary tract infections (UTIs) account for 20-50% of all hospital-acquired infections occurring in the intensive care unit (ICU). In some reports UTI was found to be more frequent than hospital-acquired pneumonia and intravascular device bacteremia, with a greater incidence in developing countries. The risk factors associated with the appearance of UTI include the severity of illness at the time of admission to the ICU, female status, prolonged urinary catheterization or a longer ICU stay and poor urinary catheter management - mainly disconnection of the closed system. about the present study offers data on the epidemiology of UTI in the ICU, the identified risk factors, etiology, diagnosis, impact upon morbidity and mortality, and the measures to prevent its appearance.

Reducing catheter-associated urinary tract infection in the critical care unit

Changes in reimbursement policies have focused attention on the use of indwelling catheters in the critical care unit as well as their role in hospital-acquired urinary tract infections. Implementation of an evidence-based prevention program can significantly reduce both the prevalence of indwelling catheterization and the incidence of hospital-acquired catheter-associated urinary tract infection. This article describes the epidemiology and pathophysiology of catheter-associated urinary tract infection, and outlines essential elements of an evidence-based prevention program for the critical care unit.

Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit

OBJECTIVE

Identification of catheter-related bloodstream infection (CR-BSI) risk factors and determination of whether intervention related to identified risk factors would reduce CR-BSI rates.

DESIGN

Prospective, observational, interventional and interrupted time-series study.

SETTING

Pediatric Intensive Care Unit (PICU) in a university hospital.

METHODS

During a 7-year period, 609 central venous catheters (CVC) were placed in 389 patients. CR-BSI risk factors were determined by multivariate analysis during two periods (January 2000-November 2002 and January 2003-April 2007). An intervention to reduce identified risk factors was performed after the first period. CR-BSI rates per 1,000 catheters-days were compared during the two periods.

RESULTS

The CR-BSI rate was 11.94 [(95% CI 7.94-15.94)/1,000 catheter-days during the first period]. Weight [OR 0.96 (0.91-0.99)], parenteral nutrition (PN) [OR 3.38 (1.40-8.19)] and indwelling time (IT) [OR 1.08 (1.02-1.14)] were CR-BSI risk factors. Practice changes aimed at reducing PN and IT were introduced. PN decreased from 49.8% [95% CI (49.7-49.9)] to 26.7% [(95% CI 26.6-26.8)] (p < 0.001), and IT dropped from 9.92 (95% CI 9.09-10.75) to 8.13 (95% CI 7.47-8.79) days (p < 0.001). The CR-BSI rate was reduced to 3.05 (95% CI 0.93-5.17)/1,000 catheter-days. During the last period, PN and IT were no longer CR-BSI risk factors. Type of catheterisation (guide wire exchange) [OR 6.66 (1.40-31.7)] was the only CR-BSI risk factor.

CONCLUSIONS

PN and IT were independent CR-BSI risk factors during the first period. An intervention focused on PN and IT reduction resulted in a sustained decrease of CR-BSI rates in our PICU.

Diagnosis, management and prevention of ventilator-associated pneumonia: an update

Ventilator-associated pneumonia (VAP) affects 10-20% of mechanically ventilated patients and is associated with increased morbidity and mortality and high costs. Early diagnosis is crucial for rapid appropriate antimicrobial therapy to be instituted, but debate remains as to the optimal diagnostic strategy. Noninvasive clinical-based diagnosis is rapid but may not be as accurate as invasive techniques. Increased use of biomarkers and advances in genomics and proteomics may help speed up diagnosis. Management of VAP relies principally on appropriate antimicrobial therapy, which should be selected according to individual patient factors, such as previous antibacterial therapy and length of hospitalization or mechanical ventilation, and local infection and resistance patterns. In addition, once bacterial culture and sensitivity results are available, broad-spectrum therapy should be de-escalated to provide a more specific, narrower-spectrum cover. Optimum duration of antibacterial therapy is difficult to define and should be tailored to clinical response. Biomarker levels may be useful to monitor response to therapy. With the high morbidity and mortality, prevention of VAP is important and several strategies have been shown to reduce the rates of VAP in mechanically ventilated patients, including using noninvasive ventilation where possible, and semi-recumbent positioning. Other potentially beneficial preventive techniques include subglottal suctioning, oral decontamination strategies and antimicrobial-coated endotracheal tubes, although further study is needed to confirm the cost effectiveness of these strategies.

Bladder pressure measurements are an independent predictor of urinary tract infection in trauma patients

PURPOSE

To determine the risk factors for urinary tract infections (UTIs) specific to trauma patients in order to assist in the development of infection control protocols.

METHODS

Data were collected prospectively from January 2003 until December 2005 by an epidemiology nurse and combined with registry data from our Level 1 trauma center. The trauma patients admitted to the Surgery and Trauma Intensive Care Unit (STICU)(n = 938) who did and did not have UTIs were compared for demographics, Injury Severity Score (ISS), and epidemiologic data, including use of Foley catheters and bladder pressure measurements (BPMs). An open system was used for the measurements in which the catheter was disconnected from the bag to instill 50 mL of saline into the bladder, and an 18-gauge needle was inserted into the catheter to measure the pressure.

RESULTS

A total of 50 patients had no Foley catheter or UTIs. Among the 836 patients with catheters but no BPMs, there were 36 UTIs (4.31%), whereas the 52 patients with catheters and BPMs had 12 UTIs (23.08%)(p < 0.0001). Patients with UTIs were more severely injured older females (mean age 40.1 ± 18.6 years with no UTI vs. 48.5 ± 20.8 with UTIs; p = 0.0083; percent female 26.4 no UTI vs. 45.8 UTI; p = 0.007; ISS 19.3 ± 11.3 no UTI vs. 26.2 ± 11.6; p < 0.0001). Using logistic regression, BPM was an independent predictor of UTI, with infection being seven times more likely in the patients having the measurements (odds ratio [OR] 6.99; 95% confidence-interval [CI] 3.087-15.827). Along with age (OR 1.039; CI 1.024-1.054) and ISS (OR 1.081; CI 1.056-1.106), having BPMs was an independent predictor of death (OR 2.475; CI 1.191-6.328).

CONCLUSION

This is the first study that demonstrates a greater risk of UTI with BPM using the open technique independent of patient gender or degree of injury. Given these findings and a previous trial demonstrating no difference in UTI rates with a closed circuit for BPM, our institution has incorporated a closed circuit technique into its infection control protocol.