Christelle Lizy

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients

Background:We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients. Methods:In a single-center, historical cohort study (1992–2006), we compared middle-aged (45–64 years; n = 524), old (65–74 years; n = 326), and very old ICU patients (≥75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay. Results:Although the total number of ICU admissions (patients aged ≥45 years) decreased by ∼10%, the number of very old patients increased by 33% between the periods 1992–1996 and 2002–2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992–1996) to 13.5% (1997–2001) and 17.4% (2002–2006) (p < 0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4‰ in middle-aged, 5.5‰ in old, and 4.6‰ in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0–1.5) and significant for very old age (hazard ratio, 1.8; 95% confidence interval, 1.4–2.4). Conclusion:Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

Risk factors and mortality for nosocomial bloodstream infections in elderly patients

OBJECTIVE To determine risk factors for nosocomial bloodstream infection (BSI) and associated mortality in geriatric patients in geriatric and internal medicine wards at a university hospital. METHODS Single-center retrospective (1992-2007), pairwise-matched (1:1-ratio) cohort study. Geriatric patients with nosocomial BSI were matched with controls without BSI on year of admission and length of hospitalization before onset of BSI. Demographic, microbiological, and clinical data are collected. RESULTS One-hundred forty-two BSI occurred in 129 patients. Predominant microorganisms were Escherichia coli (23.2%), coagulase-negative Staphylococci (19.4%), Pseudomonas aeruginosa (8.4%), Staphylococcus aureus (7.1%), Klebsiella pneumoniae (5.8%) and Candida spp. (5.8%). Matching was successful for 109 cases. Compared to matched control subjects, cases were more frequently female, suffered more frequently from arthrosis, angina pectoris and pressure ulcers, had worse Activities of Daily Living-scores, had more often an intravenous or bladder catheter, and were more often bedridden. Logistic regression demonstrated presence of an intravenous catheter (odds ratio [OR] 7.5, 95% confidence interval [CI] 2.5-22.9) and being bedridden (OR 2.9, 95% CI 1.6-5.3) as independent risk factors for BSI. In univariate analysis nosocomial BSI was associated with increased mortality (22.0% vs. 11.0%; P=0.029). After adjustment for confounding co-variates, however, nosocomial BSI was not associated with mortality (hazard ratio 1.3, 95% CI 0.6-2.6). Being bedridden and increasing age were independent risk factors for death. CONCLUSION Intravenous catheters and being bedridden are the main risk factors for nosocomial BSI. Although associated with higher mortality, this infectious complication seems not to be an independent risk factor for death in geriatric patients.

Estimating the length of hospitalization attributable to multidrug antibiotic resistance.

The topic of the economic impact of antibiotic resistance in Gram-negative nosocomial infection assessed in the article by Mauldin et al. (4) carries our particular interest (1, 5). One of the most important determinants of hospital costs is the length of stay (LOS). The median LOSs observed by Mauldin et al. for patients infected with susceptible and multidrug-resistant (MDR) Gram-negative bacteria were 30 days and 47 days, respectively (P < 0.0001). Accordingly, hospital costs were significantly higher in the latter group (median cost of

Nurses’ Sedation Practices During Weaning of Adults From Mechanical Ventilation in an Intensive Care Unit

178,359 versus

Bridging the knowledge–practice gap: a key issue in the prevention of healthcare-associated infections

106,293; P < 0.0001). As the authors themselves point out, this figure might be an overestimate, as the analysis lacked adjustment for LOS prior to the onset of infection, which is a well-known confounder in studies investigating the clinical and economic impact of MDR bacteria (2). Mauldin et al. did not consider LOS prior to infection because the exact date of infection is difficult to determine and because the infection-associated costs may increase even before the time of diagnosis. We respectfully disagree with the authors, as we believe these are insufficient reasons to exclude LOS prior to infection from the equation. First, difficulty in determining the onset of infection is a problem that is valid for patients infected with either susceptible or multidrug-resistant pathogens. Second, the onset of infection can be determined by initiation of empirical antimicrobial therapy, which is an important determinant of sepsis-related costs (6). Third, the difference in cost due to variability in determination of the onset of infection is outweighed by the magnitude of differences in the LOS prior to onset of infection for patients infected by susceptible and multidrug-resistant pathogens. This is illustrated in a study in which the LOSs of critically ill patients with bacteremia caused by susceptible (n = 208) and MDR (n = 120) Gram-negative bacilli were compared (3). The median total lengths of hospitalization in patients with bacteremia caused by MDR and susceptible bacteria were 60 days and 47 days (P = 0.007), respectively. Yet, this difference was nearly completely due to the difference in the LOS prior to the onset of bacteremia: 23 days and 11 days (P < 0.001), respectively. The LOSs after onset of bacteremia (calculated from the day of blood culture sampling) were not different: 35 days and 27 days (P = 0.333), respectively. These data illustrate that the confounding potential of LOS prior to infection cannot be disregarded in an analysis aiming to estimate the economic impact of infections caused by MDR pathogens.

Bacteriuria and Risk Factors for Bacteremia

Background Sedation and analgesia have an important impact on the outcome of patients treated with mechanical ventilation. International guidelines recommend use of sedation protocols to ensure best patient care. Objective To determine the sedation practice of intensive care nurses weaning adults from mechanical ventilation. Methods A cross‐sectional survey with a self‐administered questionnaire was used to determine sedation practices of Flemish critical care nurses during weaning. Consensus on content validity was achieved through a Delphi procedure among experts. Data were collected during the 32nd Annual Congress of the Flemish Society of Critical Care Nurses in Ghent, Belgium, December 2014. Results A total of 342 nurses were included in the study. Of these, 43.7% had a sedation protocol in their unit that was used by 61.8% of the respondents. Sedation protocols were more often available (P < .001) in academic hospitals (72%) than in general hospitals (41.5%). Sedatives were administered via continuous infusion with bolus doses if needed (81%). Level of sedation was assessed every 2 hours (56%), mostly via the Richmond Agitation‐Sedation Scale (59.1%). Daily interruption of sedation was used by 16.5% of respondents. The biggest barriers to daily interruption were patient comfort (49.4%) and fear of respiratory worsening (46.6%). Conclusions A considerable discrepancy exists between international recommendations and actual sedation practices. Standardization of sedation practices across different institutions on a regional and national level may improve the quality of care.

Replacement of Administration Sets Used to Administer Blood, Blood Products, or Lipid Emulsions for the Prevention of Central Line-Associated Bloodstream Infection

Healthcare-associated infections remain a serious threat in hospitalized patients (Blot, 2008). Because of their high degree of disease severity and the frequent use of invasive devices, especially patients admitted to intensive care units or those suffering from neutropenia are at risk for life-threatening infections such as pneumonia, bacteraemia or opportunistic infections such as invasive candidiasis or aspergillosis (Blot & Vandewoude, 2004; Blot, Koulenti et al., 2014; Blot, Vandewoude, Hoste, & Colardyn, 2003; Depuydt et al., 2006; Sousa, Ferrito, & Paiva, 2017; Vandewoude et al., 2004). To optimize adherence to infection prevention measures, guidelines have been developed. Unfortunately, simply publishing guidelines will not necessarily yield high compliance rates (Lambert et al., 2013; Valencia et al., 2016). Even stronger, multiple large-scaled, international studies demonstrated poor knowledge levels among intensive care nurses regarding essentials in infection prevention (Labeau, Vandijck, Claes, Van Aken, & Blot, 2007; Labeau et al., 2008; Labeau et al., 2016). While good knowledge does not guarantee adherence with recommendations, it seems evident that a lack of knowledge will significantly obstruct compliance. As such, an adequate knowledge level about recommendations is a reasonable starting point to tackle the problem of implementation. Therefore, educational initiatives are very often a first step and effective step in quality improvement initiatives (Blot, Bergs, Vogelaers, Blot, & Vandijck, 2014; Rello et al., 2013). In this regard, we read with interest the article by Tarakcioglu Celik and Korkmaz (2017). In their study, the authors evaluated knowledge of nurses regarding neutropenia and their practice regarding hand hygiene, preparation and administration of medication, and assessment of vital signs (Tarakcioglu Celik & Korkmaz, 2017). This study is an excellent example of the knowledge–practice gap, as good knowledge levels did not result in adequate practice, with overall low hand hygiene compliance and poor aseptic technique while preparing parenteral medication. While we still believe that in-depth education is needed, this new study stresses the necessity of a carefully planned implementation strategy once reasonable knowledge levels have been reached. Essentials for a well-balanced implementation strategy include (i) the identification and measurement of the problem (e.g., poor hand hygiene compliance), (ii) the development of an action plan in which all stakeholders are mentioned, (iii) the definition of clear and realistic objectives, (iv) the achievement of a consensus about the plan among all team members involved and (v) the

Oral Care, Ventilator-Associated Pneumonia, and Counting Cultures

Bacteremia We read with interest the research article by Conway et al1 on risk factors for bacteremia in critically ill patients with bacteriuria. By means of a matched cohort study, these investigators found bacteremia to be associated with male sex, an immunosuppressed status, a urinary tract procedure, and continued bladder catheterization after the onset of bacteriuria. The link between catheter-associated bacteriuria and subsequent systemic infections cannot be disregarded. A substantial proportion (13%21%) of secondary gram-negative bacteremias originate from primary urinary tract infections.2-6 This observation is important because catheter-associated urinary tract infection is a very common infectious complication in intensive care units.7-9 Unlike previous researchers, Conway et al found enterococcal bacteriuria to be protective for bacteremia, compared with other pathogens. This observation stresses the ongoing debate about the pathogenic significance of enterococci as is the case in peritonitis.10,11 Probably enterococci can be considered opportunistic pathogens, meaning that the immune system of the host, rather than the invasive potential of the pathogen, predefines the risk of systemic infection with these microorganisms. Furthermore, the authors found no relationship between multidrug resistance and risk of bacteremia. This finding is not really surprising. The virulence of bacteria is more closely related to particular strains than to its antimicrobial susceptibility patterns. Of course, in some cases high-level resistance can join extreme virulence, as has been described for a strain causing community-acquired Staphylococcus aureus infection.12 Finally, we wonder why the authors did not include candiduria in their analysis. Within the context of multisite Candida colonization, candiduria as such is well recognized as a particular risk factor for invasive candidiasis and candidemia.13,14

Morbidity and Mortality of Bloodstream Infections in Patients With Severe Burn Injury

To the Editor—Given our particular interest in the field of evidence-based guidelines for infection prevention, 1-3 we were delighted to welcome the publication of the journal’s October 2008 Supplement 1, which contained a compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Indeed, in addition to supplying the healthcare worker with a very useful and excellent update of the existing recommendations, this compendium provides enlightening information regarding implementation strategies and performance measures for internal and external reporting. The paper’s executive summary states that the updated recommendations are not meant to supplant the existing, more-detailed guideline documents but aim to provide practical guidance. 4 Nevertheless, while reading the guidelines for the prevention of central line–associated bloodstream infections, 5 some questions arose. Therefore, we gratefully take this opportunity to address these questions, which concern the management of intravenous administration sets, and we thank the authors in advance for their interest and clarification. The article by Marschall et al. 5 recommends replacement

Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2009, Volume 18, No. 6 507 Oral Care, Ventilator-Associated Pneumonia, and Counting Cultures There are plenty of opportunities for improvement in the field of health care–associated infection prevention. As a consequence, continuous educational efforts focused on cost-effective evidencebased strategies remain essential. This is also true for oral hygiene practice. A study by Grap et al revealed that the primary tools for performing oral care were sponge toothettes, although these are ineffective for removing dental plaque. Also, oral care practices are generally poorly documented in patient’s files. According to a European survey in 59 intensive care units (ICUs), 93% of nurses perceived oral hygiene in mechanically ventilated patients to be of high priority. However, 68% of nurses find cleaning the oral cavity in such patients difficult, 40% find it unpleasant, and 73% indicated they need better supplies and equipment. Clearly, the importance of oral hygiene to prevent ventilator-associated pneumonia should continuously be stressed by means of quality and/or research projects. Therefore, we were particularly interested in the article by Pedreira et al regarding oral care in intubated and mechanically ventilated pediatric patients. In a randomized controlled trial, these investigators compared the oropharyngeal microbiological profile between patients who received oral care with use of chlorhexidine 0.12% (n = 27) and a control group (n = 29). In both groups, strict toothbrushing was carried out. Oropharyngeal secretions were collected on days 0, 2, and 4, and at discharge, and were cultured for qualitative microbiological identification. The 2 groups did not differ significantly in the colonization of potentially pathogenic flora. These negative results are in contrast with other data that stress the added value of proper oral care and chlorhexidine as an antiseptic agent. An important concept in the pathogenesis of pneumonia is the strong relationship between the bacterial inoculum and the hazard of infection. In other words, whereas chlorhexidine oral washes failed to significantly reduce the number of colonizations by pathogenic microorganisms, it might have been successful in decreasing the bacterial load (lower bacterial counts with an identical number of isolates detected). In the study by Pedreira et al, oropharyngeal samples were collected, transported, and incubated in a strict standardized way. However, a qualitative culturing technique was used that indicates only the presence of microorganisms (colonization or not). We assume it must have been possible to report bacterial inoculums if quantitative cultures were used. In this way the study results may have turned out positive, even if one considers the small sample size. CHRISTELLE LIZY, RN, CCRN, NELE BRUSSELAERS, MD, SONIA LABEAU, RN, MNSC, DOMINIQUE VANDIJCK, RN, CCRN, MSC, PHD, DAVID DE WANDEL, RN, MSC, DIRK VOGELAERS, MD, PHD, STIJN BLOT, RN, CCRN, MNSC, PHD Ghent, Belgium