Transcript Nosoref: a French survey of nosocomial infections

Nosoref:
a French survey of
nosocomial infections (NI)
surveillance in intensive
care units (ICU)
F L’Hériteau1, C Alberti2, G Troché3, P Moine4,
Y Cohen5, JF Timsit6 and the Outcomerea group
1Unité
d’hygiène, Hôpital Bichat, Paris, 2Biostatistics, Hôpital Debré, Paris, 3ICU, Hôpital Mignot, Versailles,
4ICU, Hôpital Lariboisière, Paris, 5ICU, Hôpital Avicenne, Bobigny, 6ICU, Hôpital Bichat, Paris, France
Introduction
• Nosocomial infections (NI) prevention and control is mandatory in
intensive care units (ICU) in France;
• Surveillance and investigative methods differ from one ICU to another;
• Accordingly, comparison of results indicators between ICUs may be
difficult or inaccurate;
• Better understanding differences between the methods used by various
ICUs for NI surveillance is important in order to compare them
• We performed a national survey of these methods
Material and methods
•
A questionnaire focusing on methods of NI surveillance in ICU was prepared by the working group,
tested in 20 ICU and revised by an expert committee (C Brun-Buisson, J Carlet, A Le Pape). This was
sent to all ICU in France and sent a second time to non responders. Finally, a random sample of non
responders was interviewed by phone.
•
Objectives of the study:
–
–
to describe the different methods used in French ICUs for NI surveillance and prevention;
to identify factors which could explain the differences between ICU.
•
The following data were collected:
- structure factors factors: type of center (secondary or tertiary care), type of ICU (medical, surgical,
polyvalent, other); geographic location; number of beds and ventilators;
- staff factors: number of physicians (senior and junior); number of nurses (day and night) and
staff/bed ratio
- equipment factors: microbiology lab in the hospital; computerization of microbiology lab data.
•
Correspondence analysis was performed to try to identify the factors defining different categories of
ICU.
Results (1)
Written response
n (%)
147 (58%)
Oral response
n (%)
82 (61%)
Medical ICU
36 (14%)
10 (7%)
Surgical ICU
40 (16%)
14 (10%)
Others ICU
28 (11%)
29 (22%)
Polyvalent ICU
p
0.008
Written response
Oral response
p
Beds
11 [8-15]
10 [8-12]
0.08
Ventilators
10 [8-14]
9 [6-12]
0.07
475 [335-650]
500 [382.5-755]
0.03
Sen. phys./bed* 0.31 [0.22-0.42]
0.27 [0.18-0.38]
0.03
Nurses/bed
(day)
Nurses/bed
(night)
0.58 [0.5-0.68]
0.56 [0.5-0.67]
0.65
0.42 [0.33-0.5]
0.40 [0.33-0.5]
0.59
Median |q1-q3]
Admissions/y.*
*p<0.05
[q1-q3]: interquartile interval
Median [q1-q3]
• 252 ICU responded to the written
questionnaire (44%); 142 (47% of
non responders) were interviewed
by phone
• Specialized Medical and surgical
ICU staff completed the
questionnaire more frequently than
others
• ICUs interviewed by phone had
more admissions and a lower
medical staff/ bed ratio than ICU
who returned the questionnaire
Results (2)
• NI are systematically mentioned in medical discharge reports in 72% of ICU
Recording data on invasive procedures
• Prospective recording of proportion of patients undergoing invasive procedures
(Mechanical ventilation [MV], central venous catheter [CVC], urinary catheter [UC]) is
the best way to accurately estimate the incidence of NI.
• The proportion of ICU recording data on invasive procedures is shown below.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
92%
86%
81%
76%
59% 62%
Written
Oral
% pts under MV
% pts with CVC
% pts with UC
Results (3)
Surveillance of invasive procedures (written responders)
Proportion of ICU recording % of patients undergoing invasive procedures
100%
% according to type of ICU
P<0.05
P<0.05
80%
• Less surveillance of MV and CVC in
surgical ICUs
60%
40%
20%
0%
%MV
surgical
%CVC
medical
polyvalent
% UC
other
• % of patients under invasive procedures is more frequently monitored when
microbiology lab is in the hospital (93% of ICU) than where it is not:
– 93% vs 69% (p=0.006) for MV;
– 83% vs 41% (p=0.0002) for CVC;
– 61% vs 24% (p=0.004) for UC.
• The median [interquartile interval] nurses/ bed ratio of ICU recording % of patients
with UC is higher 0.44 [0.35-0.5] than for ICU who do not 0.37 [0.33-0.5] (p=0.01).
Comparisons of other staff factors are not statistically significant.
Results (4)
Central venous catheter (CVC) infections surveillance
Central venous catheter infection surveillance (written responders)
60%
48%
50%
% of ICU
• 34% of ICU remove CVC at admission
55%
40%
34%
30%
• 55% of ICU remove CVC at discharge
20%
10%
0%
CVC removal at
admission
CVC removal at
discharge
Systematic CVC
culture in case of
death
Type of CVC culture (written responders)
• 48% of ICU systematically culture CVC
sample in deceased patients
180
160
156
n ICU
140
120
100
• Quantitative technique (Brun Buisson)
is widely used in French ICU
80
60
40
36
28
20
2
0
Brun Buisson
Maki
qualitative
Sherez
Results (5)
Diagnosis of ventilator-associated pneumonia (VAP)
(written responses)
Proportion of ICU using the diagnostic procedure
for VAP
40%
42%
42%
42%
27%
30%
26%
15%
4%
ali
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PT
C
n
bl i
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L
BA
i
in
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r
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C
bru
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L
BA
L-D
A
B
le
p
am
s
o
n
% ICU (often or always)
Qualit trach aspi: qualitative tracheal aspiration; quantt trach aspi: quantitative tracheal aspiration; PTC: plugged telescopic catheter; BAL:
broncho-alveolar lavage; fibro-PTC: PTC under fibroscopy; brush: protected specimen brush; BAL-D: direct examination of BAL
Results (6)
Nosocomial urinary tract infections (UTI)
diagnosis and surveillance
• 35% of ICU perform systematic
periodic urine cultures for
catheterized patients
• 67% of ICU include candiduria in
the evaluation for UTI
40
35
30
25
20
15
10
5
0
yes
no
if positive dipstick
Systematic periodical urine culture are performed
in catheterized patients
% of ICU
• 30% of ICU perform systematic
urine culture at admission
% of ICU
urine culture is performed at admission
70
60
50
40
30
20
10
0
yes
no
Results (7)
Multiresistant bacteria (MRB) carriage screening
• Screening for MRB carriers at admission:
77% of ICU in written responders
55% of ICU in oral responders
•
•
•
Screening at admission is more frequent in
teaching hospitals,than in non teaching (83% vs.
73% ; p=0.055).
Screening during stay is more frequent in teaching
hospital than in non teaching (78% vs. 59%,
p=0.05).
Screening at admission or during ICU stay is
more frequent when the microbiology lab is located
in the the hospital (80% and 69% respectively), than
when it is not (36% and 20% respectively);
(p<0.0001 for both)
MRB screening at admission (see below) and during
ICU stay (data not shown) is less frequent in Northern
and Western region than in others.
MBR carriage screening at admission according to region
% of ICU
• Screening for MRB carriers during ICU stay:
67% of ICU in written responders
48% of ICU in oral responders
100
90
80
70
60
50
40
30
20
10
0
71
87%
Paris
25
North
31
39
57
17
West
East
Southeast
Southwest
Results (8)
MRB carriage screening and labeling
Screening for specific MRB
Labeling of specific MRB carriers
MRSA
MRSA
ESBL
ESBL
Acinetobacter
imip-R Pa
149
imip-R Pa
146
163
150
Others
10%
20%
30%
40%
50%
% of ICU
At admission
60%
70%
99
87
C difficile
0%
•
•
cefta-R Pa
E. case
ticar-R Pa
68
47
49
34
47
134
Acinetobacter
cefta-R Pa
•
191
ticar-R Pa
E. case
7
10
196
112
24
0
50
100
yes
150
no
200
250
n ICU
During stay
Methicillin resistant Staphylococcus aureus (MRSA) and expanded spectrum beta-lactamase
producing Enterobacteriaceae (ESBL) are the MRB most frequently looked for.
Similarly, carriage these MRB are the most frequently labeled in ICU.
Screening for or labeling of carriers are less frequent for cephalosporinase hyperproducing
Enterobacteriaceae (E case), or Pseudomonas aeruginosa resistant to ticarcillin (ticar-R Pa),
ceftazidime (cefta-R Pa) or imipenem (imip-R Pa)
Multiple Correspondence analysis (MCA) (1)
Note: MCA enables the identification of the core variables which are the
principal factors describing any particular point of interest. These factors can
then be used as the essential points to document in order to categorize ICUs.
•
MCA indicated that 50 % of the structure parameters variance was explained by 3 dimensions
that included the following variables:
– dimension1
– dimension 2
– dimension 3
•
university vs. non university hospital
ratio number of ventilators/ number of beds > or < 1
ratio number of senior physicians/ beds > or < 1/3
76% of the VAP diagnosis parameters variance was explained by 3 dimensions including:
– dimension 1
– dimension 2
– dimension 3
ICU do (or do not) perform qualitative aspiration
ICU do (or do not) use plugged telescopic catheter
ICU do (or do not) initiate antibiotic therapy before results
Multiple Correspondence analysis (MCA) (2)
•
75% of the CVC-related infection diagnosis parameters variance was explained by 3 dimensions
including:
– dimension 1
– dimension 2
– dimension 3
•
74% of the nosocomial UTI surveillance parameters variance was explained by 2 dimensions
including:
– dimension 1
– dimension 2
•
local signs are (or are not) recorded at CVC removal
ICU do (or do not) record % of patients undergoing CVC
CVC are systematically (or not) removed at admission
ICU do (or do not) monitor % of patients with urinary catheter
periodic urine cultures are (or are not) performed in patients with urinary catheter
75% of the MRB surveillance parameters variance was explained by 3 dimensions including:
– dimension 1
– dimension 2
– dimension 3
screening for ESBL and Acinetobacter carriage at admission and during stay
labeling of ESBL and MRSA carriers
screening for MRSA carriage during stay and at admission
Conclusion
• Procedures for surveillance and diagnosis of NI differ from one ICU to another. MRB
policies also differ between ICUs.
• Using multivariate descriptive methods, the way the surveillance is organized is
resumed by:
– Structure: type of hospital; ventilator/bed ratio; senior physicians/bed ratio
– VAP diagnosis procedures: qualitative aspiration; plugged telescopic catheter; antibiotic therapy
initiated before microbiology results
– CVC-related infection diagnosis: local signs recorded at CVC removal; % of patients undergoing
CVC recorded; CVC systematically removed at admission
– Nosocomial UTI surveillance: % of patients with urinary catheter monitored; perodic urine cultures
in catheterized patients
– MRB surveillance: screening for ESBL and Acinetobacter carriage; labeling of MRSA carriage;
screening for MRSA carriage
• These factors must be taken into account when comparing ICUs on the basis of the
results of NI surveillance.
Contacts:
• François L’Hériteau: [email protected]
• For more data about Nosoref and The Outcomerea Group:
http://www.outcomerea.org