Corso precongressuale: Le Infezioni Ospedaliere

Epidemiologia delle Infezioni nelle Organizzazioni Sanitarie

Nicola PetrosilloU.O.C. Infezioni Sistemiche e dell’Immunodepresso

Istituto Nazionale per le Malattie Infettive“Lazzaro Spallanzani”, IRCCS-Roma

Infezioni correlate a organizzazioni assistenziali (ICOS)

Infezioni acquisite durante il ricovero in ospedale

Infezioni acquisitein day hospital,day surgery

Infezioni acquisitein ambulatorio

Infezioni in day care

Klevens RM et al. Public Health Reports 2007; 122: 160-6

UTI

BSI

PNE

SSI

OTH

Klevens RM et al. Public Health Reports 2007; 122: 160-6

Klevens RM et al. Public Health Reports 2007; 122: 160-6

Device-specific incidence rates/utilization ratio

Edwards JR et al. Am J Infect Control 2007;35:290-301.

X 1000 days

CVC

U. ratio

Urin cath Ventilator

1

0,5

BSI

5

UTI

VAP

Main prevalence surveys on hospital infections (HI) in Italy

Ippolito G, Nicastri E, Martini L, Petrosillo N. Infection 2003;31(S2):4-9

Author/year Setting #pts % prev.

Moro (1983) 130 Italian hospitals 34,577 6.8Tuscany(87) 26 hospitals 5,564 5.1Moro (1984) 15 hospitals in Rome 5,695 5.5Castelnuovo (98) 36 wards of a hospital 623 5.8Mancarella (98) 3 hospitals in Chioggia 435 5.5Lazzeri (98) 6 hospitals in Florence 684 7.2Marena (98) 1 teaching hosp in Pavia 3,073 6.4Pavia (1999) 4 hospitals in Catanzaro 888 1.7Privitera (88) 259 Italian surgical wards 11,343 5.0

Main incidence studies on hospital infections (HI) in Italy

Ippolito G, Nicastri E, Martini L, Petrosillo N. Infection 2003;31(S2):4-9

Author (year) Setting # patients % incidenceIppolito (1985) 71 Italian Intensive care units 6,589 29.5

Ortona (1985) One teaching hospital 10,385 6.7

Greco (1987-89) 20 surgical wards 7,641 13,6

Scolfaro (1994) One infectious pediatric unit 229 7.8

Pallavicini (1995-98) One ICU in a teaching hospital 3,679 12.6

Scotton (1996-97) One neurosurgical ICU 562 14.8

Petrosillo (1997-98) 19 Infectious Diseases Units 4,330 HIV+ 6.3

Valera (1998-99) One pediatric cardiac surgery unit 104 30.8

Romagna Region (2001) Hospitals in Emilia Romagna Regione 6,158 4.7

Di Palo (1980-82) One surgical unit 991 3.8 SSI

Mosconi (1983-84) 23 ICUs 1,475 15.0 VAP

Ippolito (1985) 71 Italian ICUs 6,598 14.1 VAP

Moro (1991) 52 Italian ICUs 672 9.4 VAP

Moro (1991) 7 hospitals 607 9.3 CR-BSI

Alvarenz (1993-96) One vascular surgical unit 806 1.8 SSI

Brusaferro (1996) 12 hospitals in Friuli Region 1,625 21.5 UTI

Petrosillo (1998-99) 17 Infectious Diseases units 1,379 HIV+ 4.7 nosocomial BSI

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. 2004

Source Country Cost per day

Cost for mean of 9.8 days

Netten & Curtis

UK 409 4,008

Oostrenbrink Netherlands 230 2,254

DKG Germany 317 3,107

Pena Spain 170 1,666

PMSI France 412 4,038

Orsi Italy 413 4,047

Costs of additional hospitalization days associated with SSI

ICOSDIMENSIONI DEL PROBLEMA

colpiscono circa il 5-10% dei pazienti ricoverati rappresentano circa il 50% delle complicanze ospedaliere

casi annui: 450.000-700.000

decessi annui: 4.500-7.500

costo annuo:1 miliardo di euro

ICOSINTERVENTI POSSIBILI

quota prevenibile: 30-40%

costo evitabile: 300 milioni di euro

decessi evitabili: 1.350-2.100

casi evitabili: 135.000-210.000

Quanto ci si lava le mani in Ospedale?Quanto ci si lava le mani in Ospedale?

Una valutazione di Una valutazione di 34 studi34 studi pubblicati pubblicati sulla adesione al lavaggio delle mani tra sulla adesione al lavaggio delle mani tra gli operatori sanitari ha riscontrato che gli operatori sanitari ha riscontrato che questa adesione varia dal questa adesione varia dal 5% al 81%5% al 81%

Il valore medio è solo Il valore medio è solo del 40%del 40%

Adesione al lavaggio delle mani da parte Adesione al lavaggio delle mani da parte degli operatori sanitaridegli operatori sanitari

MediaMedia

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1 4 7 10 13 16 19 22 25 28 31 34

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Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002, Vol.51Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002, Vol.51

Pittet D et al. Int J Infect Dis 2006; 10: 419-24

Core element of hand transmission.Contestualization of the risk

Sax H et al. J Hosp Infect 2007; 67:9-21

Sax H et al. J Hosp Infect 2007; 67:9-21

Sax H et al. J Hosp Infect 2007; 67:9-21

Healthcare-associated infections: main issues

• Pathogenicity of microorganisms• Risk factors• Immunosuppression• Cross contamination• Antibiotic pressure and resistance• Emerging organisms• Relevance of clones in HAI epidemics• Strategies -search and destroy -developing a culture of safety - WHO campaign• Social aspects of HAI - antibiotic use - medico-economic aspects - non-traditional forces to change HAI prevention

Infezioni post-operatorie in ItaliaPetrosillo N et al BMC Infect Dis 2008; 7;8:34.

4665 interventi in 48 chirurgie

316 infezioni (6,8 per 100 interventi)

SSI

BSI

LRTI5,4%

0,8% 0,5%

Circa la metà dopola dimissione

Klevens RM et al. JAMA 2007; 298:1763-71

Recent prevalence and incidence infection studies in LTCFs Author, year, place Type of

study N° of facilities (n°

of residents) I nfection

rate

Rate by infection site§

Mongardi, 2003, I taly Prevalence 49 (1926)

9,6 (weighed)

UTI 1,5 LRTI 2,9 URTI 1,5 Skin 3,1 Conjuntivitis 1,7 GI 0,4

Eriksen, 2004, Norway Prevalence (4 surveys, 2002-2003)

203-300 (11465-17174)

6,6-7,6 UTI 3-3-3,8 LRTI 1,2-1,6 SSI 0,3-0,5 Skin 1,5-2,0

Stevenson, 2005, US I ncidence 17 (472019 resident-

days)

3,64 RTI 1,75 Skin 1,10 UTI 0,60 GI 0,16

Engelhart, 2005, Germany

I ncidence 1 (34793 resident-

days)

6,0 RTI 2,2 Skin 1,2 UTI 1,0 GI 1,2

Brusaferro, 2006, I taly I ncidence 4 (21503 resident-

days)

11,8 LRTI 2,5 Skin 2,7 UTI 3,2 GI 1,2 Conjuntivitis 1,2

§ UTI = Urinary Tract Infections; LRTI = Lower Respiratory Tract Infections; URTI = Upper Respiratory Tract Infections; GI = Gastrointestinal

infections

The risk of infection in LTCFs

4 LTCFs in NE Italy

859 pts. (79.3 ± 11 years)

In nursing homes, the prevalence of antibiotic resistance

is extremely high

0102030405060708090

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VRE

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Red columns: frequency higher than the 90° percentile reported by NNIS in medical ICUs

Gould CV et al ICHE 2006; 27: 920-25(45 LTCFs, 2002-2003)

The risk of infection in LTCFs

Hematogenous complications in 42/342 (13%) pts with S. aureus CR-BSI

Fowler VG Jr et al. Clin Infect Dis 2005;40:695-703

Staphylococcus aureus Endocarditis. A Consequence of Medical Progress

•Prospective observational cohort study set in 39 medical centers in 16 countries. •1779 patients with definite IE as defined by Duke criteria (International Collaboration on Endocarditis-Prospective Cohort Study) from June 2000 to December 2003.

0

50

100

150

200

250

HC-ass CA non-IVDU CA IVDU

558S.AureusIE

Fowler VG, Jr et al. JAMA 2005; 293:3012-21

Ventricular Assist DeviceVentricular assist device-related infections occur in

18–59% of patients after implantation

Infection can involve any aspect of the device:

the surgical site

the driveline

the device pocket

the pump itself

(More than half infections include multiple sites)

Complications:

bloodstream infection

Relapsing bacteraemia

Sepsis

Device-associated endocarditis

Rarely: mediastinitis, peritonitis, pseudoaneursysm Lancet Infect Dis 2006

Ventricular Assist DeviceTiming of ventricular assist device-related infections:

Most infections occur between 2 weeks and 2 months of implantation

Only 5–10% of patients developed infections beyond 3 months

Microbiology:

Staphylococcus aureus and epidemidis (24-56%)

Enterococci

Gram-negative bacilli (eg, Pseudomonas aeruginosa, Enterobacter, Klebsiella)

Fungi (Candida)

Outcome:

Serious device-related infection, such as endocarditis, is associated with up to

50% mortality

Device infection is significantly associated with decreased survival after

transplantationLancet Infect Dis 2006

Keene A et al. Infect Control Hosp Epidemiol 2005;26:622-28

24% of colonized patients developed S. aureus infection versus 2% of noncolonized patients (p<0.01)

Pan A et al. Infect Control Hosp Epidemiol 2005;26:127-133

J Hosp Infect. 2007;67:308-15

Infection in Solid-Organ Transplant Recipients

Fishman JA. N Engl J Med 2007; 357: 2601-14

Nusair A et al. Infect Control Hosp Epidemiol 2008; 29: 424-29

Nusair A et al. Infect Control Hosp Epidemiol 2008; 29: 424-29

Transplantation Proceedings 2008; 40, 1986–1988

Mattner F et al. J Heart Lung Transplant 2007; 26: 241-9

Mattner F et al. J heart Lung Transplant 2007; 26: 241-9

Michalak G et al. Transplantation Proceedings 2005; 37, 3560–3563

From 1988 to 2004, 51 patients underwent SPKT

CMV

Bacterial

Fungal

systemic 13pulmonary 13urinary tract 15intestinal 8wound 23 (45%)

SSI and transplant

Patients who develop SSI are - twice as likely to die, - 60% more likely to be in the intensive care unit,- and 5 times more likely to be readmitted to the hospital after discharge.

This manifested also in longer hospital stays and higher hospitalization costs.

Kirkland KB et al.. Inf Control Hosp Epidemiol 1999;20:725-730

Clostridium difficile associated colitis (CDAD) and transplant

•The reported incidence of CDAD varies from 3.5% in adult kidney recipients to 31% in lung transplants.

•This variability may be due to differences in - the type of organ transplantation,- diagnostic methods, - Immunosuppressive regimen, - time after transplantation, - follow-up period- and other population characteristics.

Gunderson CC et al. Transpl Infect Dis 2008: 10: 245–251

•Between November 1990 and November 2005, 202 consecutive patients underwent 208 lung transplantation procedures.

•Fifteen of 208 lung recipients developed 23 episodes of CDC with a median follow-up period of 2.7 years (range, 0-13.6)

•The annual incidence of CDC in lung transplant recipients was 2.1%.

•All patients with confirmed disease had at least 1 of the following 3 risk factors: -recent antibiotic use, -recent hospitalization, or -augmentation of steroid dosage.

Gunderson CC et al. Transpl Infect Dis 2008: 10: 245–251