Transcript Slide 1

European Surveillance of Surgical Site Infections
and ICU-acquired Infections, 2004-2008
Carl Suetens
Surveillance Unit
European Centre for Disease Prevention and Control
7th HIS International Conference, Liverpool, 10-13 October 2010
Standardized surveillance of HealthcareAssociated Infections in European hospitals
 Surveillance of Surgical Site
Infections (SSI)
 Surveillance of ICU-acquired
Infections (ICU)
 Point Prevalence Surveys as
alternative to hospital-wide
surveillance of all HAI types (PPS)
Standardisation of SSI & ICU surveillance
methods
Methodological differences between national protocols:
– Fair agreement in 2000 for SSI surveillance (7 countries),
similar to CDC/NNIS methodology
– Larger differences for surveillance of ICU-acquired
infections in 2000 (5 countries, 4 patient-based, 1 unitbased)
 Agree on common surveillance methodology and case
definitions: questionnaire (2000), meetings (2000-2002),
final protocols 2002-2003
 Work towards standardized interpretation of standard
methodology
 Develop indicators that take into account inter-country
differences in methodology and case-mix
Participation to HAI surveillance (HAI-Net),
status in 2010
SIRO
NOIS
HISC
SSHAIP
NHS HPA
INST HYG
PREZIES
NSIH
KISS
ANIS NNSR
RAISIN
ASR
HELICS
ISC III ENVIN
SPIN-UTI
Surgical Site Infection only
Intensive care only
ICU or SSI pilot
Both SSI and ICU
Does not participate
Surveillance of Surgical Site Infections: EU
methods vs CDC/NHSN
 Same as CDC/NHSN methodology, except:
– Hospital discharge date required
– Options: ICD9-CM codes, post-discharge date & status
– Selection of procedures: CABG, CHOL, COLO, CSEC,
HPRO, KPRO, LAM
 Indicators:
– % SSI within 30 d / 1 year
– % in-hospital SSI (post-discharge excluded)
– Incidence density: # in-hospital SSI/1000 patient-days:
• Adjustment for differences in post-discharge surveillance
• Adjustment for differences in post-operative length of stay
• Incidence density for Deep-Organ/Space infections only: adjustment for
differences in reporting superficial infections
– Stratification per NNIS risk index for all indicators
European surveillance of Surgical Site
Infections
 2000-2001: protocol analysis,
questionnaire, meetings
 6 countries in 2000 => 12
countries (15 networks), 1422
hospitals in 2008
600
100000
500
COLO
KPRO
CHOL
N of hospitals
CSEC
400
60000
300
40000
200
LAM
100
CABG
0
20000
0
AT
DE
ES
FI
FR
HU
IT
N. of hospitals
LT
NL
NO
PT
N of interventions
UK
N of interventions
80000
HPRO
CABG
CHOL
COLO
CSEC
HPRO
KPRO
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
Percentage of operations with SSI
SSI cumulative incidence by operation
category and year, 2004-2008
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
LAM
0
AT
BE
DE
ES
FI
In-hospital SSI
FR
HU
IT
Post-discharge SSI
LT
NL
NO
PL
Unknown discharge date
PT
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2004
2005
2006
2007
2004
2005
2006
2007
2008
2004
2005
2006
2007
2008
2005
2006
2005
2006
2007
2008
Percentage of operations with SSI
Surveillance of SSI in hip prosthesis, 2004-2008
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
UK
Differences in post-discharge surveillance
and type of SSI
4
P
2.5
P
2
1.5
75
90
75
1
50
50
1
2
N SSI/100 op. (%)
3
90
.5
25
25
10
0
0
10
UK-NI
UK-EN
LT
IT
FR
UK-SC
DE
AT
ES
UK-WA
PT
Organ/space
Superficial incisional
HU
FI
NO
UK-NI
NL
UK-SC
FR
Deep incisional
SSI type unknown
UK-EN
LT
IT
FI
Organ/space
Superficial incisional
Cumulative incidence (% SSI) by country, HPRO, 2007
CABG
ES
61.5 28.4 32.6
UK-WA
NO
FI
FR
HU
IT
LT
NL
NO
`21.1
40.9 30.4
91.3
27.2 13.5
38.6
28.6 52.6 25.0 83.3
73.1
4.0
CHOL
0
COLO
12.5
8.6
18.8
CSEC
46.4 25.0 70.8
63.9
18.4 78.6
HPRO
KPRO
47.6 22.5 20.0 28.1 59.8
27.5 42.9 56.8 75.0
10.5 16.7
0
0
0
24.2
0
0
0
33.3
PT
UK
1
NR
29.2
35.8
40.9
2.1
Total
NR
11.9
73.9
77.6
25.0 60.3
59.9
67.7
87.8
71.2
50.0 21.9
48.1
35.4
50.0
HU
ES
Deep incisional
SSI type unknown
Post-discharge SSI excluded
Percentage of SSI detected after discharge from the hospital by surgical procedure
DE
NL
PT
Cumulative incidence (% SSI) by country, post-discharge excluded, HPRO, 2007
Post-discharge SSI included
AT
AT
DE
EU reference tables, e.g. SSI incidence
density in HPRO
NHSN risk index
All risk categories
Risk index 0
Risk index 1
Risk index 2-3
Risk index unknown
Number
of inNumber of Number of hospital
hospitals pt-days
SSIs
484
480
477
350
222
701,645
362,955
249,199
34,817
54,674
440
154
203
59
24
In-hospital
SSIs/1,000 pt-days
(95%CI)
P10
0.63 (0.57-0.69) 0.0
0.42 (0.36-0.50) 0.0
0.81 (0.71-0.93) 0.0
1.69 (1.29-2.19) 0.0
0.44 (0.28-0.65) 0.0
P25
0.0
0.0
0.0
0.0
0.0
P50
0.0
0.0
0.0
0.0
0.0
P75
0.9
0.0
0.0
0.0
0.0
P90
2.0
1.6
2.5
4.6
0.0
European surveillance of ICU-acquired
infections
 2000-2002: protocol analysis,
questionnaire, retrospective data
analysis, meetings
 Collaboration with ESICM
Ongoing surveillance
 654 hospitals from 12 countries
in 2008
Pilot ongoing/planned
400
600
800
1000
1200
No data
0
200
Rank(VAPs/1000 int.days)
 2 levels:
– Unit-based (minimal data,
trends)
– Patient-based: risk
adjustment, Standardised
Infection Ratio
(Observed/Expected)
Pilot data received
0
200
400
600
Rank(O/E)
800
1000
1200
Surveillance of ICU-acquired infections
Patient-based surveillance in the ICU
Methodology of EU surveillance of ICU-acquired
infections
0
10
20
30
 Patients staying less than 3 days in the ICU excluded from
denominators (different from US-NHSN/DE-KISS)
AT
BE
DE
ES
FR
IT
LT
Length of stay in the ICU (days) by country
LU
PT
SK
UK
Methodology of EU surveillance of ICUacquired infections
 Case definitions differ from CDC/NHSN definitions:
– Bloodstream Infections: include secondary BSI
– Pneumonia:
• based on CDC PNU definition, not identical
• Intubator-Associated (IAP) vs Ventilator-Associated (VAP)
 Definition of “nosocomial” or “ICU-acquired”: >48 h, in practice > Day 2,
instead of “not present or in incubation at admission”
 ECDC outsourced Concordance study of HAI case definitions CDC/NHSN
vs. IPSE/HELICS (2009-2010, P. Gastmeier et al):
 Quantify difference in case classification (concordance) => kappa
 Results show excellent concordance (kappa>=0.99) for PN
and
primary BSI
HELICS case definition of pneumonia
(2003) – also in ECDC PPS protocol
X-ray(s) + clinical symptoms (t°/wbc +
sput./ronchi…)
 PN1: protected sample + quantitative culture (104
CFU/ml BAL/103 PB,DPA)
 PN2: non-protected sample (ETA) + quantitative
culture (106 CFU/ml)
 PN3: alternative microbiological criteria
 PN4: sputum bacteriology or non-quantitative ETA
 PN5: no microbiological criterion
0
20
40
60
80
100
Differences in diagnostic practices of
ICU-acquired pneumonia, 2008
AT
BE
PN1
DE
ES
PN2
FR
IT
LT
PN3
LU
PT
PN4
SK
UK
PN5
0
20
40
60
80
100
Date of onset pneumonia
AT
BE
DE
D3-4
ES
FR
HR
D5-6
IT
LT
LU
PT
D7-13
Day of onset pneumonia in the ICU, by country, 2007
RO
SK
UK
>=D14
Micro-organisms isolated in ICU-acquired
infections, 2004-2008
Pneumonia
Bloodstream infections
Coag.-neg.
staphylococci
Enterococcus
spp.
P. aeruginosa
S. aureus
E. coli
S. aureus
Klebsiella spp.
P. aeruginosa
Candida spp.
E. coli
Enterobacter spp.
Klebsiella spp.
Acinetobacter spp.
Candida spp.
Stenotrophomonas
spp.
Enterobacter
spp.
Acinetobacter
spp.
Enterococcus spp.
Serratia spp.
Haemophilus spp.
0
0.05
2008
0.1
2007
0.15
2004-2006
0.2
2008
2007
0.0% 10.0
%
2004-2006
20.0
%
30.0
%
40.0
%
EU reference tables, e.g. device-adjusted
ICU-acquired pneumonia rates
Country
AT
BE
ES
FR
IT
LT
LU
PT
SK
Total
N of ICUs
37
17
111
165
27
9
8
6
5
385
Mean
6.2
17
20
15.6
18.6
14.3
6.7
11.5
20.7
16
P10
0
0
2.3
4
0
0
0
3.4
0
0
P25
0
0.5
8.9
7.5
2.2
1.6
3.8
5.6
0
6.1
P50
4
9.3
15.6
14.2
6.1
8.2
6.5
10.2
14.6
12.8
P75
11.8
30.7
26.9
20.8
19.1
11
9.6
17.9
42.3
20.8
P90
16.1
49.7
41
29.1
68.8
45.8
14
21.4
46.8
35
Support to HAI surveillance : on-site HAI
surveillance workshops
 Technical support visit to help
set up HAI surveillance
networks (4 in 2010)
 2 x ½ day workshop
 Intensive Care (ICU), Surgical
Site Infections (SSI) or both
 Typically 20 participants from
hospitals
 Including case studies of HAI
case definitions and computer
exercises (HELICSwin)
 + support to national
coordination team &
installation of software tools
HAI surveillance workshop, Sofia, Nov 2009
Hungarian HELICSwin, Budapest workshop, June 2009
EU HAI surveillance integrated in TESSy
Pre-TESSY
MS
 TESSy = “The European Surveillance
System” = ECDC’s online database,
upload and reporting system for all
communicable diseases under
surveillance
DSN
MS
DSN
MS
MS
DSN
MS
DSN
MS
DSN
MS
DSN
MS
DSN
MS
DSN
MS
DSN
MS
Country
National institute
Country
Disease expert
Country
General public
Country
Country
Country
Country
Country
Country
Country
Country
Country
Country
TESSy
Data access
 October (4-8/10): HAI TESSy training
for national surveillance coordinators
and data managers
DSN
MS
Data upload and access
 Integration of all dedicated
surveillance networks
DSN
MS
AF member
MB member
…
…
…
…
…
Data users
HAI surveillance: ICU & SSI now integrated
in ECDC’s TESSy system
From IPSE to HAI-Net: What has changed?
 Naming conventions:
– Healthcare-Associated Infections: HAI instead of HCAI
– IPSE => HAI-Net
– Unit-based protocols: “level 1” => “light”
– Patient-based protocols: “level 2” => “standard” (full)
STANDARD
(patient-based)
LIGHT
(unit-based)
SSI
ICU
PPS
HALT
X
X
X
X
X
X
X
X
 Changes agreed at HAI surveillance Annual Meeting:
– SSI: “Light” version, coverage, post-discharge method
– ICU: Some variables/options dropped, AMR target list
– New minimal AMR marker set (PPS)
Conclusions
 Standardized surveillance of surgical site infections and ICU-acquired
infections: based on HELICS/IPSE network, now continued by ECDC
 27+ countries = 27+ opinions, but large majority in favour of agreeing
on single method
 Need for extension of surveillance, but setting up HAI surveillance
networks requires important resources (hospitals, national coordination)
 training of trainers and on-site training
 translation of protocols
 free software tools, multilingual
 Standardized methods/definitions  standardized surveillance practices!
 From January 2011: ECDC HAI surveillance website + interactive data
analysis
Thank you to all national surveillance
networks and participating hospitals!
www.ecdc.europa.eu| [email protected]