Paolo Grossi

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Le infezioni nelle Unità di Terapia Intensiva è
possibile ridurne lincidenza?

• Paolo Grossi
• Clinica Malattie Infettive e Tropicali
• Università degli Studi dellInsubria
• Ospedale di Circolo e Fondazione Macchi, Varese

2nd INFECTIVOLOGY TODAY "Linfettivologia del III
millennio NON solo AIDS" PAESTUM 18-20 MAGGIO
2006
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Studio INF-NOS 2002-04 Multicentrica Prevalenza
di IN totale e per area
prevalenza
Studi di prevalenza
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Prevalenza di pazienti con IN e durata degenza al
momento dello studio
Tutto lospedale
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Prevalenza di pazienti con IN e durata degenza al
momento dello studio
Area critica
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Principali patologie infettive in pazienti
ricoverati in Terapia Intensiva
VENTILATOR ASSOCIATED PNEUMONIA
(VAP) BLOODSTREAM INFECTION (BSI) URINARY TRACT
INFECTION (UTI) INTRA ABDOMINAL INFECTION (IAI)
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Incidence rates and distribution of pathogens
most commonly isolated from monomicrobial
nosocomial BSIs and associated crude mortality
rates for all patients, patients in ICU, and
patients in non-ICU wards.
Hilmar Wisplinghoff, et al. CID 2004 3930917
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Infections in ICU

• Intensive care units can be considered as
  factories for creating, disseminating and
  amplifying resistance to antibiotics, for many
  reasons
• importation of resistant microorganisms at
  admission,
• selection of resistant strains with an extensive
  use of broad spectrum antibiotics,
• cross-transmission of resistant strains via the
  hands or the environment.

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Collateral Damage from Cephalosporins
Quinolones
Collateral damage is a term used to refer
to ecological adverse effects of antibiotic
therapy namely, the selection of drug-resistant
organisms and the unwanted development of
colonization or infection with multidrug-resistant
organisms.
Neither third-generation cephalosporins nor
quinolones appear suitable for sustained use in
hospitals as workhorse antibiotic therapy.
Paterson DL. Clin Infect Dis 200438(Suppl
4)S341-S345
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National Nosocomial Infections Surveillance
(NNIS) System Report, data summary from January
1992 through June 2004
Am J Infect Control 200432470-85.
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Perugia, 11 maggio 2006
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Staphylococcus aureus invasive isolates
resistant to methicillin (MRSA) in 2004
(European Antimicrobial Resistance Surveillance
Scheme http//www.earss.rivm.nl)
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Enterococcus faecium proportion of invasive
isolates resistant to vancomycin in 2004.
(European Antimicrobial Resistance Surveillance
Scheme http//www.earss.rivm.nl)
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Enterobatteri produttori di ESBL
_____________________________________________
Pazienti Isolati ESBL
No. No. ()
_____________________________________________
Ricoverati (1999) 8.015 509 (6,3)
Ricoverati (2003) 6.850 504 (7,4)
Ambulatoriali (2003) 2.226 79 (3,5)
_____________________________________________

Luzzaro F. et eal. JCM, May 2006, p. 16591664
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SORVEGLIANZA NAZIONALE 2003 Pazienti
ospedalizzati (n504)
Chirurgia
ICU
Medicina
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The Italian map of MBL producer has been updated
on the basis of this nationwide
survey. MBL-producing P. aeruginosa are present
over the whole national territory, though the
impact of MBL producers remains relatively
low. VIM producers are more prevalent than IMP
producers. Production of MBL in other GNNFs and
Enterobacteriaceae is limited to occasional
isolates.
P. aeruginosa P. putida A. xylosoxydans Acinetobac
ter spp.
45th ICAAC Washington, 2005
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Resistenza ai carbapenemici in A. baumannii in
Italia
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Model for comprehensive surveillance and
prevention of health care-associated adverse
events in the United States
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Temporal Relationship between Prevalence of MRSA
in One Hospital and Prevalence of MRSA in the
Surrounding Community A Time Series Analysis
Screening at patient discharge should be
tested as new measure to control Spread of MRSA
in the community
I. M. GOULD, et al. ICAAC 2004
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Proposed schematic to classify methicillin-resista
nt Staphylococcus aureus (MRSA) isolates as
nosocomial or community-onset strains among
individuals with and individuals without health
careassociated risk factors.
Salgado et al. CID 200336131-139
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Evaluating the Probability of MRSA Carriage at
Admission to a Large University Hospital with
Endemic MRSA

• Screening was performed by nasal and inguinal
  swabs within 24 hours of admission, and included
  other sites when clinically indicated.
• From January through August 2003, 90
  (12,072/13,440) of all admissions were screened.
  Overall, 399 admissions (prevalence, 3.3) were
  found colonized (n368, 92) or infected (n31,
  8) with MRSA.
• The prevalence of positive admissions was highest
  in sub-acute (5.7) and chronic care wards
  (12.8).
• MRSA carriers (n355) were more likely to have
  one or several of the following risk factors (all
  plt.001)
• older age
• prior hospitalization
• antibiotic exposure
• invasive procedures
• greater severity of underlying illness

D. PITTET, et al. ICAAC 2004
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The Inanimate Environment Can Facilitate
Transmission
X represents VRE culture positive sites
Contaminated surfaces increase
cross-transmission Abstract The Risk of Hand
and Glove Contamination after Contact with a VRE
() Patient Environment. Hayden M, ICAAC, 2001,
Chicago, IL.
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The spectrum of contaminant bacterial flora of
patients files in ICU and surgical wards.
Panhotra Bodh R., et al, Am J Infect Control
200533398-401
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Origin of Nosocomial Infection Microorganisms
Water

• Splash from sink drain, toilet flushing
• Faucet aerator, faucet, water lines
• Water from vase in surgical ward

• Aeromonas,
• Acinetobacter, Pseudomonas, Flavobacterium,
  Flavimonas,
• Legionella,
• Mycobacteria

Trautmann, 2005
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Factors influencing adherence to hand-hygiene
practices

• Observed risk factors for poor adherence to
  recommended hand-hygiene practices
• Physician status (rather than a nurse)
• Nursing assistant status (rather than a nurse)
• Male sex
• Working in an intensive-care unit
• Working during the week (versus the weekend)
• Wearing gowns/gloves
• Automated sink
• Activities with high risk of cross-transmission
• High number of opportunities for hand hygiene per
  hour of patient care

Adapted from Pittet D. Infect Control Hosp
Epidemiol 2000213816.
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Can we do something else ?
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Relationship between workload (modified TIS) and
the number of trained nurses on day duty per week.
Dancer et al. Am J Infect Control 20063410-7.
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Total workload, MRSA acquisition weeks, number of
nurses on day duty, and hygiene assessment over a
5-month period on the ICU
Dancer et al. Am J Infect Control 20063410-7.
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Relationship between workload (modified TIS) and
the number of trained nurses on day duty per week.
Dancer et al. Am J Infect Control 20063410-7.
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Ospedale di Varese procedure messe in atto per
il controllo delle infezioni nosocomiali

• 2001 Revisione dei protocolli terapeutici
• 2002 Adozione della richiesta motivata per
  lutilizzo di alcuni antibiotici ad ampio
  spettro (associata ad attività di formazione)
• 2003 Elaborazione e diffusione di direttive
  interne all'ospedale per le indicazioni più
  importanti (gestione di CVC e dispositivi
  medico- chirurgici, emocolture)
• 2004 Revisione dei protocolli per la profilassi
  delle infezioni delle ferite chirurgiche
• 2005 Adozione di un nuovo protocollo per la
  disinfezione delle mani
• 2006 Informatizzazione della richiesta motivata
  di antibiotici

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ICU Varese percentuali di resistenza ai
farmaci Staphylococcus aureus (2001-2005)
78,4
52,5
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ICU Varese percentuali di resistenza ai
farmaci Enterococcus faecium (2001-2005)
40
25
8
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ICU Varese percentuali di resistenza ai
farmaci Pseudomonas aeruginosa (2001-2005)
38,5
33,7
24,7
21,8
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ICU Varese percentuali di resistenza ai
farmaci Pseudomonas aeruginosa (2001-2005)
50,2
43,1
24,1
6,7
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ICU Varese percentuali di resistenza ai
farmaci Enterobacteriaceae (2001-2005)
24,6
20,4
14,8
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Isolati di K. pneumoniae produttore di ESBL in
Terapia intensiva (2001-2005)
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Isolati di E. coli produttore di ESBL in Terapia
intensiva (2001-2005)
Perugia, 11 maggio 2006
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Il controllo delle resistenze batteriche si basa
su attività di sorveglianza, controllo e
formazione

• Sorveglianza da laboratorio
• Microrganismi sentinella (P. aeruginosa MDR, A.
  baumannii MDR, MRSA, Enterobatteri produttori di
  ESBL, Enterococchi VRE)
• Controllo delle resistenze
• Epidemiologia delle resistenze
• Profilassi antibiotica in chirurgia protocolli e
  verifica applicativa
• Prescrizione motivata di molecole antibiotiche di
  classi selezionate
• Linee guida in patologie selezionate e nei
  trattamenti empirici
• Gestione dei CVC e dei dispositivi
  medico-chirurgici
• Protocollo lavaggio mani
• Misure di isolamento (VRE, C. difficile)
• Controllo del consumo da farmacia
• Formazione
• Migliorare la prescrizione di antibiotici con
  misure educative
• Elaborare e diffondere le direttive interne
  all'ospedale per le indicazioni più importanti

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