Paolo Grossi

Clinica Malattie Infettive e TropicaliUniversità degli Studi dell’Insubria –

Ospedale di Circolo e Fondazione Macchi, Varese

Le infezioni nelle Unità di Terapia Intensiva:

è possibile ridurne l’incidenza?

2nd INFECTIVOLOGY TODAY"L’infettivologia del III millennio: NON solo AIDS"

PAESTUM 18-20 MAGGIO 2006

Studio INF-NOS 2002-04 Multicentrica Prevalenza di IN totale e per area

7,74,7

51,2

4,973,5

41,3

5 5,93,4

37,3

4,47,5

4,7

40,7

4,9

0

10

20

30

40

50

60

A'02 A'03 P'04 A'04

totale area chirurgica area critica area medica

Studi di prevalenza

% prevalenza

Prevalenza di pazienti con IN e durata degenza al momento dello studio

0

5

10

15

20

25

30

35

A'02 A'03 P'04 A'04

prevalenza %

DM infetti gg

DM non infetti gg

Tutto l’ospedale

Prevalenza di pazienti con IN e durata degenza al momento dello studio

0

5

10

15

20

25

30

35

40

45

A'02 A'03 P'04 A'04

prevalenza %

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Area critica

Principali patologie infettive in pazienti ricoverati in Terapia Intensiva

VENTILATOR ASSOCIATED PNEUMONIA (VAP)

BLOODSTREAM INFECTION (BSI)

URINARY TRACT INFECTION (UTI)

INTRA ABDOMINAL INFECTION (IAI)

Incidence rates and distribution of pathogens most Incidence rates and distribution of pathogens most commonly isolated from monomicrobial nosocomial commonly isolated from monomicrobial nosocomial

BSIs and associated crude mortality rates for all BSIs and associated crude mortality rates for all patients, patients in ICU, and patients in non-ICU patients, patients in ICU, and patients in non-ICU

wards.wards.

Hilmar Wisplinghoff, et al. CID 2004; 39:309–17

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.

Collateral Damage from Collateral Damage from Cephalosporins & QuinolonesCephalosporins & Quinolones

“…Neither third-generation cephalosporins nor quinolones appear suitable for sustained use in hospitals as “workhorse” antibiotic therapy….”

“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.”

Paterson DL. Clin Infect Dis 2004:38(Suppl 4):S341-S345

Am J Infect Control 2004;32:470-85.

National Nosocomial Infections Surveillance National Nosocomial Infections Surveillance (NNIS) System Report, data summary from (NNIS) System Report, data summary from

January 1992 through June 2004January 1992 through June 2004

Perugia, 11 maggio 2006

Staphylococcus aureus: invasive isolates resistant to methicillin (MRSA) in 2004

(European Antimicrobial Resistance Surveillance Scheme http://www.earss.rivm.nl)

Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in

2004.

(European Antimicrobial Resistance Surveillance Scheme http://www.earss.rivm.nl)

_____________________________________________

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) _____________________________________________

Enterobatteri produttori di ESBL

Luzzaro F. et eal. JCM, May 2006, p. 1659–1664

16,2%

16,5%

52,4%

Terapia Intensiva Neurochirurgia Cardiochirurgia Pediatria

Onco-Ematologia Chirurgia Medicina

Chirurgia

MedicinaICU

SORVEGLIANZA NAZIONALE 2003Pazienti ospedalizzati (n=504)

CATANIAVIM-1

PALERMOVIM-1

VIM-11

PESCARAIMP-13

VERONAVIM-1 VIM-2

IMP-2

TRIESTEVIM-1 VIM-2

MILANOVIM-1

VARESEVIM-1 VIM-2

IMP-2 IMP-12 IMP-13

PISAVIM-4

SIENAVIM-1

PAVIAVIM-1VIM-2

S. GIOVANNI ROTONDO

IMP-13

GENOVAVIM-1

NAPOLIVIM-1-like

IMP-13

AVELLINOVIM-like IMP-13

ROMAVIM-1 VIM-2

IMP-2 IMP-13

SASSARIVIM-1-like

CREMONAVIM-2-like

FOGGIAVIM-like

ATRIIMP-13

L’AQUILAVIM-4

PERUGIAIMP-like

TORINOVIM-1

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. aeruginosaP. putidaA. xylosoxydansAcinetobacter spp.

16th ECCMID Nice, 2006

45th ICAACWashington,

2005

Resistenza ai carbapenemici in A. baumannii in Italia

Model for comprehensive surveillance and prevention of health care-associated adverse

events in the United States

Temporal Relationship between Prevalence of MRSA in One Hospital and Prevalence of MRSA in the Surrounding

Community: A Time Series Analysis

I. M. GOULD, et al. ICAAC 2004

Screening at patient

discharge should be tested

as new measure to control

Spread of MRSA in the

community

Proposed schematic to classify methicillin-resistant Staphylococcus aureus (MRSA) isolates as nosocomial or

community-onset strains among individuals with and individuals without health care–associated risk factors.

Salgado et al. CID 2003;36:131-139

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 (n=368, 92%) or infected (n=31, 8%) with MRSA.

• The prevalence of positive admissions was highest in sub-acute (5.7%) and chronic care wards (12.8%).

• MRSA carriers (n=355) were more likely to have one or several of the following risk factors (all p<.001): – older age– prior hospitalization– antibiotic exposure– invasive procedures – greater severity of underlying illness

D. PITTET, et al. ICAAC 2004

The Inanimate Environment Can Facilitate Transmission

~ 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.

X represents VRE culture positive sites

The spectrum of contaminant bacterial flora of patient’s files in ICU and surgical wards.

Panhotra Bodh R., et al, Am J Infect Control 2005;33:398-401

Origin of Nosocomial Infection Microorganisms:Origin of Nosocomial Infection Microorganisms: WaterWater

• Splash from sink drain, toilet flushing

• Faucet aerator, faucet, water lines

• Water from vase in surgical ward

Aeromonas, Acinetobacter,

Pseudomonas, Flavobacterium, Flavimonas,

Legionella, MycobacteriaTrautmann, 2005

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 2000;21:381–6.

Can we dosomething

else ?

Relationship between workload (modified TIS) and the number of trained nurses on day duty per week.

Dancer et al. Am J Infect Control 2006;34:10-7.

Relationship between workload (modified TIS) and the number of trained nurses on day duty per week.

Dancer et al. Am J Infect Control 2006;34:10-7.

Ospedale di Varese: procedure messe in atto per il controllo delle infezioni

nosocomiali

2001 Revisione dei protocolli terapeutici

2002 Adozione della richiesta motivata per l’utilizzo 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

0

20

40

60

80

100

2001

2002

2003

2004

2005

ICU Varese: percentuali di resistenza ai farmaciStaphylococcus aureus (2001-2005)

78,4

52,5

0

20

40

60

80

100

2001

2002

2003

2004

2005

ICU Varese: percentuali di resistenza ai farmaciEnterococcus faecium (2001-2005)

25

8

40

0

10

20

30

40

50

60

2001

2002

2003

2004

2005

ICU Varese: percentuali di resistenza ai farmaciPseudomonas aeruginosa (2001-2005)

21,8

33,738,5

24,7

0

10

20

30

40

50

60

2001

2002

2003

2004

2005

ICU Varese: percentuali di resistenza ai farmaciPseudomonas aeruginosa (2001-2005)

24,1

6,7

50,2 43,1

0

20

40

60

80

100

2001

2002

2003

2004

2005

ICU Varese: percentuali di resistenza ai farmaciEnterobacteriaceae (2001-2005)

24,6

14,820,4

Isolati di K. pneumoniae produttore di ESBLin Terapia intensiva (2001-2005)

0

10

20

30

40

50

60

70

80

2001 2002 2003 2004 2005

ESBL-positivi ESBL-negativi

N.

di is

ola

ti

25

38

1/20 2/19 3/15 1/17

Isolati di E. coli produttore di ESBLin Terapia intensiva (2001-2005)

0

10

20

30

40

50

60

70

80

2001 2002 2003 2004 2005

ESBL-positivi ESBL-negativi

N.

di is

ola

ti

1/34 1/52 1/34 2/515/43

Perugia, 11 maggio 2006

Il controllo delle resistenze batteriche si basa su attività di: sorveglianza, controllo e formazione

Sorveglianza da laboratorioMicrorganismi sentinella (P. aeruginosa MDR, A. baumannii MDR, MRSA, Enterobatteri produttori di ESBL, Enterococchi VRE)

Controllo delle resistenzeEpidemiologia delle resistenzeProfilassi antibiotica in chirurgia: protocolli e verifica applicativaPrescrizione motivata di molecole antibiotiche di classi selezionate Linee guida in patologie selezionate e nei trattamenti empiriciGestione dei CVC e dei dispositivi medico-chirurgiciProtocollo lavaggio maniMisure di isolamento (VRE, C. difficile)

Controllo del consumo da farmacia

FormazioneMigliorare la prescrizione di antibiotici con misure educativeElaborare e diffondere le direttive interne all'ospedale per le indicazioni più importanti

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