European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008

Carl Suetens

Surveillance UnitEuropean Centre for Disease Prevention and Control

7th HIS International Conference, Liverpool, 10-13 October 2010

Standardized surveillance of Healthcare-Associated 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 unit-based)

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

Surgical Site Infection onlyIntensive care onlyBoth SSI and ICU

ICU or SSI pilotDoes not participate

NOISNOISSIROSIRO

RAISINRAISIN

ISC IIIISC III ENVINENVIN

ASRASR

SPIN-UTISPIN-UTIHELICSHELICS

KISSKISSNSIHNSIH

PREZIESPREZIESHPAHPA

SSHAIPSSHAIPHISCHISC INST HYGINST HYG

ANISANIS NNSRNNSR

NHSNHS

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

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SSI cumulative incidence by operation category and year, 2004-2008

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CABG CHOL COLO CSEC HPRO KPRO LAM

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Surveillance of SSI in hip prosthesis, 2004-2008

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In-hospital SSI Post-discharge SSI Unknown discharge date

Differences in post-discharge surveillance and type of SSI

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Cumulative incidence (% SSI) by country, HPRO, 2007

Organ/space Deep incisional

Superficial incisional SSI type unknown

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Cumulative incidence (% SSI) by country, post-discharge excluded, HPRO, 2007

Organ/space Deep incisional

Superficial incisional SSI type unknown

Post-discharge SSI included Post-discharge SSI excluded

AT DE ES FI FR HU IT LT NL NO PT UK Total

CABG 61.5 28.4 32.6 `21.1 40.9 30.4 91.3 NR1 29.2

CHOL 0 27.2 13.5 38.6 28.6 52.6 25.0 83.3 73.1 40.9 35.8

COLO 12.5 4.0 8.6 18.8 0 24.2 0 33.3 2.1 NR 11.9

CSEC 46.4 25.0 70.8 63.9 18.4 78.6 73.9 77.6 25.0 60.3 59.9

HPRO 47.6 22.5 20.0 28.1 59.8 10.5 16.7 0 67.7 71.2 50.0 21.9 35.4 KPRO 27.5 42.9 56.8 75.0 0 0 0 87.8 48.1 50.0

Percentage of SSI detected after discharge from the hospital by surgical procedure

EU reference tables, e.g. SSI incidence density in HPRO

NHSN risk indexNumber of hospitals

Number of pt-days

Number of in-hospital SSIs

In-hospital SSIs/1,000 pt-days

(95%CI) P10 P25 P50 P75 P90

All risk categories 484 701,645 440 0.63 (0.57-0.69) 0.0 0.0 0.0 0.9 2.0

Risk index 0 480 362,955 154 0.42 (0.36-0.50) 0.0 0.0 0.0 0.0 1.6

Risk index 1 477 249,199 203 0.81 (0.71-0.93) 0.0 0.0 0.0 0.0 2.5

Risk index 2-3 350 34,817 59 1.69 (1.29-2.19) 0.0 0.0 0.0 0.0 4.6

Risk index unknown 222 54,674 24 0.44 (0.28-0.65) 0.0 0.0 0.0 0.0 0.0

European surveillance of ICU-acquired infections 2000-2002: protocol

analysis, questionnaire, retrospective data analysis, meetings

Collaboration with ESICM

654 hospitals from 12 countries in 2008

2 levels: – Unit-based (minimal

data, trends) – Patient-based: risk

adjustment, Standardised Infection Ratio (Observed/Expected)

Ongoing surveillance

Pilot data received

Pilot ongoing/planned

No data

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Surveillance of ICU-acquired infections

Patient Counter

Case definition codeRelevant device in situ before onset*

Date of onset**

BSI: source of BSI***

Micro-organism 1

Micro-organism 2

Micro-organism 3

*** C-CVC, C-PER, C-ART, S-PUL, S-UTI, S-DIG, S-SSI, S-SST, S-OTH, UNK

HAI1: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4Staphylococcus aureus OXA GLYEnterococcus spp. AMP GLYEnterobacteriaceae AMC C3G ESBL CAR

AMC C3G ESBL CARP.aeruginosa PIP CAZ CAR COLAcinetobacter spp. CAR COL SUL

HAI2: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4Staphylococcus aureus OXA GLYEnterococcus spp. AMP GLYEnterobacteriaceae AMC C3G ESBL CAR

AMC C3G ESBL CARP.aeruginosa PIP CAZ CAR COLAcinetobacter spp. CAR COL SUL

HAI3: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4Staphylococcus aureus OXA GLYEnterococcus spp. AMP GLYEnterobacteriaceae AMC C3G ESBL CAR

AMC C3G ESBL CARP.aeruginosa PIP CAZ CAR COLAcinetobacter spp. CAR COL SULBold=minimal resistance data (as in PPS); SIR: S sensitive, I intermediate resistance, R resistant, U unknownAntibiotic codes: AMC: amoxicillin/clavulanate, AMP: ampicillin, C3G: cephalosporins of third generation(cefotaxim/cetriaxone/ceftazidim), CAR: carbapenems (imipenem/meropenem/doripenem), CAZ: ceftazidim, COL: colistin, GLY: glycopeptides (vancomycin, teicoplanin), OXA: oxacillin, SUL: SulbactamPIP: piperacillin/ticarcillin with or without enzyme inhibitorESBL: Extended Beta-Lactamase producing, Yes=R, No=S, U=Unknown

MO-Code

European Surveillance of ICU-acquired infectionsInfection and AMR form, standard (ICU2)

MO-Code

MO-Code

___ / ___ / ______

*relevant device use (intubation for PN, CVC for BSI, urinary catheter for UTI) in 48 hours before onset of infection (even intermittent use), 7 days for UTI **Only for infections not present/active at admission

MO-code MO-code MO-code

HAI 1 HAI 2 HAI 3

O Yes O No O Unknown

O Yes O No O Unknown

Target antimicrobial resistance data in ICU-acquired infections

O Yes O No O Unknown

___ / ___ / ______ ___ / ___ / ______

ICU-acquired infections

Patient-based surveillance in the ICU

European Surveillance of ICU-acquired infectionsPatient-based risk factor form (ICU1)

Hospital code Date of admission in hospital: ___ / ___ / _______

ICU code (abbr name) Patient Counter

Patient data

Age in years: ____ yrs Gender: M F UNK Date of admission in ICU: ___ / ___ / _______

Date of ICU discharge ___ / ___ / _______ Outcome at ICU discharge: Alive Dead UNK

Origin of the patient O Ward this/oth hosp O Other ICU O Community O LTCF O Other O UNK

SAPS II score: Apache II score:

Type of admission: O medical O scheduled surgical O unscheduled surgical O UNK

Trauma: O Yes O No O UNK Impaired immunity: O Yes O No O UNK

Antimicrobial treatment +/- 48 Hrs around admission : O Yes O No O UNK

Acute coronary care: O Yes O No O UNK

Surgery site (within last 30 days before admission, incl. day of admission) O UNK O No SurgeryO coronary O other cardiac O other thoracic O other vascular O abdominal O neurosurgery O other site

Exposure to invasive devices in the ICU

Central vascular catheter in ICU: O Yes O No O Unk

If Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______

Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______

Intubation in ICU: O Yes O No O UnkIf Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______

Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______

Urinary catheter in ICU: O Yes O No O UnkIf Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______

Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______

Parenteral nutrition in ICU: O Yes O No O Unk (optional)If Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______

Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______

Patient received antimicrobial(s) during ICU stay O Yes O No O Unkown

Antimicrobial (generic or brand name) or ATC5 Indication

Indication: P: prophylaxis E: empiric treatment M: documented treatment S: SDD (Selective Digestive Decontamination)

Start Date End Date

Methodology of EU surveillance of ICU-acquired infections

Patients staying less than 3 days in the ICU excluded from denominators (different from US-NHSN/DE-KISS)

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Length of stay in the ICU (days) by country

Methodology of EU surveillance of ICU-acquired 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 protocolX-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

Differences in diagnostic practices of ICU-acquired pneumonia, 2008

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Date of onset pneumonia

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Day of onset pneumonia in the ICU, by country, 2007

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Micro-organisms isolated in ICU-acquired infections, 2004-2008

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Enterococcus spp.

Stenotrophomonasspp.

Haemophilus spp.

Acinetobacter spp.

Enterobacter spp.

Candida spp.

Klebsiella spp.

E. coli

S. aureus

P. aeruginosa

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Candida spp.

Klebsiella spp.

E. coli

P. aeruginosa

S. aureus

Enterococcusspp.

Coag.-neg.staphylococci

2008 2007 2004-2006

Pneumonia Bloodstream infections

EU reference tables, e.g. device-adjusted ICU-acquired pneumonia ratesCountry N of ICUs Mean P10 P25 P50 P75 P90

AT 37 6.2 0 0 4 11.8 16.1BE 17 17 0 0.5 9.3 30.7 49.7ES 111 20 2.3 8.9 15.6 26.9 41FR 165 15.6 4 7.5 14.2 20.8 29.1IT 27 18.6 0 2.2 6.1 19.1 68.8LT 9 14.3 0 1.6 8.2 11 45.8LU 8 6.7 0 3.8 6.5 9.6 14PT 6 11.5 3.4 5.6 10.2 17.9 21.4SK 5 20.7 0 0 14.6 42.3 46.8Total 385 16 0 6.1 12.8 20.8 35

Support to HAI surveillance : on-site HAI surveillance workshops

HAI surveillance workshop, Sofia, Nov 2009

Hungarian HELICSwin, Budapest workshop, June 2009

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

EU HAI surveillance integrated in TESSy

TESSy = “The European Surveillance System” = ECDC’s online database, upload and reporting system for all communicable diseases under surveillance

Integration of all dedicated surveillance networks

October (4-8/10): HAI TESSy training for national surveillance coordinators and data managers

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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)

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)

SSI ICU PPS HALTSTANDARD (patient-based) X X X X

LIGHT (unit-based) X X X X

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| info@ecdc.europa.eu