Mercedes Palomar

Economic Impact of Candida Colonization and Candida Infection in the Critically Ill Patient

The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically ill patients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days to 73 medical-surgical ICUs in 70 Spanish hospitals between May 1998 and January 1999 were studied. From day 7 of ICU admission to ICU discharge, samples of tracheal aspirates, pharyngeal exudates, gastric aspirates and urine were collected every week for culture. Prolonged length of stay was associated with severity of illness, Candida colonization or infection, infection by other fungi, antifungal therapy, treatment with more than one antifungal agent, and toxicity associated with this therapy. Compared to non-colonized, non-infected patients (n=720), patients with Candida colonization (n=880) had an extended ICU stay of 6.2 days (OR, 1.69; 95%CI, 1.53–1.87; P<0.001) and an extended hospital stay of 8.6 days (OR, 1.27; 95%CI, 1.16–1.40; P<0.001). The corresponding figures for patients with Candida infection (n=105) were 12.7 days for ICU stay (OR, 2.13; 95%CI, 1.72–2.64; P<0.001) and 15.5 days for hospital stay (OR, 1.23; 95%CI, 0.99–1.52; P=0.060). Candida colonization resulted in an additional 8,000 EUR in direct costs and Candida infection almost 16,000 EUR. Both Candida colonization and Candida infection had an important economic impact in terms of cost increases due to longer stays in both the ICU and in the hospital.

Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience

Objective:Prevention of catheter-related bloodstream infection is a basic objective to optimize patient safety in the ICU. Building on the early success of a patient safety unit-based comprehensive intervention (the Keystone ICU project in Michigan), the Bacteremia Zero project aimed to assess its effectiveness after contextual adaptation at large-scale implementation in Spanish ICUs. Design:Prospective time series. Setting:A total of 192 ICUs throughout Spain. Patients:All patients admitted to the participating ICUs during the study period (baseline April 1 to June 30, 2008; intervention period from January 1, 2009, to June 30, 2010). Intervention:Engagement, education, execution, and evaluation were key program features. Main components of the intervention included a bundle of evidence-based clinical practices during insertion and maintenance of catheters and a unit-based safety program (including patient safety training and identification and analysis of errors through patient safety rounds) to improve the safety culture. Measurements and Main Results:The number of catheter-related bloodstream infections was expressed as median and interquartile range. Poisson distribution was used to calculate incidence rates and risk estimates. The participating ICUs accounted for 68% of all ICUs in Spain. Catheter-related bloodstream infection was reduced after 16–18 months of participation (median 3.07 vs 1.12 episodes per 1,000 catheter-days, p < 0.001). The adjusted incidence rate of bacteremia showed a 50% risk reduction (95% CI, 0.39–0.63) at the end of the follow-up period compared with baseline. The reduction was independent of hospital size and type. Conclusions:Results of the Bacteremia Zero project confirmed that the intervention significantly reduced catheter-related bloodstream infection after large-scale implementation in Spanish ICUs. This study suggests that the intervention can also be effective in different socioeconomic contexts even with decentralized health systems.

Risk factors for candidaemia in critically ill patients : a prospective surveillance study

Candidaemia is frequently a life‐threatening complication in patients admitted to the intensive care unit (ICU). To assess the risk factors for candidaemia in critically ill patients with prolonged ICU stay, a total of 1765 adult patients admitted for at least 7 days to 73 medical–surgical ICUs of 70 tertiary care hospitals in Spain participated in a prospective cohort study. Candidaemia was defined as recovery of Candida spp. from blood culture. Sixty‐eight episodes of candidaemia occurred in 63 patients, representing 35.7 episodes per 1000 ICU patients admitted, with an incidence rate of 1.5 episodes per 1000 days of ICU stay. Causative fungi were C. albicans in 57.1% of cases and non‐albicansCandida spp. in 42.9%. In the multivariate analysis, independent factors significantly associated with candidaemia were Candida colonisation (OR = 4.12, 95% CI: 1.82–9.33), total parenteral nutrition (OR = 3.89, 95% CI: 1.73–8.78), elective surgery (OR = 2.75, 95% CI: 1.17–6.45) and haemofiltration procedures (OR = 1.96, 95% CI: 1.06–3.62). In the ICU setting in Spain and in patients who have stayed in units for >7 days, more than half of cases of candidaemia were caused by C. albicans. Risk factors for candidaemia identified included Candida colonisation, elective surgery, total parenteral nutrition and haemodialysis.

Estudio Nacional de Vigilancia de Infección Nosocomial en Unidades de Cuidados Intensivos. Informe evolutivo de los años 2003-2005

Objetivo Describir las tasas nacionales de las infecciones adquiridas en Unidades de Cuidados Intensivos (UCI) relacionadas con dispositivos invasores durante 2003, 2004 y 2005, su etiologia y la evolucion de los marcadores de multirresistencia. Diseno Estudio prospectivo observacional. Ambito UCI u otras unidades donde ingresan pacientes criticos. Pacientes Un total de 21.608 pacientes ingresados durante mas de 24 horas en las UCI participantes. Principales variables de interes Infecciones relacionadas con dispositivos: neumonias relacionadas con ventilacion mecanica (N-VM), infecciones urinarias relacionadas con sonda uretral (IU-SU) y bacteriemias primarias (BP) y/o relacionadas con cateteres vasculares de riesgo (BCV). Resultados En 2.279 (10,5%) pacientes se han detectado 3.151 infecciones: 1.469 N-VM, 808 IU-SU y 874 BP/BCV. Las tasas de incidencia han oscilado desde 15,5 a 17,5 N-VM por 1.000 dias de ventilacion mecanica, 5,0 a 6,7 IU-SU por 1.000 dias de sonda uretral y 4,0 a 4,7 BP/BCV por 1.000 dias de cateter vascular. La etiologia predominante en las N-VM ha sido Staphylococcus aureus sensible a meticilina, Pseudomonas aeruginosa y Acinetobacter baumannii . Las IU-SU han estado originadas predominantemente por Escherichia coli, Candida albicans y Enterococcus faecalis . A. baumannii y E. coli han aumentado su resistencia a imipenem y ciprofloxacino o cefotaxima, respectivamente, en el ultimo ano controlado. Conclusiones Persisten tasas elevadas en todas las infecciones controladas, sin cambio en la etiologia y aumento de la resistencia de bacilos gramnegativos.

Factors related to hospital stay among patients with nosocomial infection acquired in the intensive care unit

OBJECTIVES To assess the influence of nosocomial infection on length of stay in the intensive care unit (ICU) and to determine the relative effect of other factors on extra length of hospitalization associated with nosocomial infection. DESIGN Prospective cohort multicenter study in the context of the ENVIN-UCI project. SETTING Medical or surgical ICUs of 49 different hospitals in Spain. METHODS All consecutive patients (N = 6,593) admitted to ICUs of the participating hospitals who stayed for more than 24 hours during a 3-month period (from January 15 to April 15, 1996) were included. Length of ICU stay was compared between patients with and without nosocomial infections. RESULTS Uninfected patients (N = 5,868) had a median stay in the ICU of 3 days, whereas the median for infected patients (N = 725) was 17 days (P < .001). The median for infected patients with one episode of nosocomial infection was 13 days. The greatest length of stay (40 days) was among patients admitted to the ICU because of medical diseases, with an infection acquired before admission to the ICU, and with the largest number of nosocomial infection episodes. In extended stays, nosocomial infection was significantly associated with length of hospitalization (day 21; odds ratio, 22.38; 95% confidence interval 16.6 to 30.4), whereas an effect of variables related to severity of illness on admission (Acute Physiology and Chronic Health Evaluation II score, urgent surgery, and infection prior to ICU admission) was not found. CONCLUSIONS The presence of nosocomial infection and the number of infection episodes were the variables with the strongest association with prolonged hospital stay among ICU patients.

Documento de consenso sobre el tratamiento de la bacteriemia y la endocarditis causada por Staphylococcus aureus resistente a la meticilina

Bacteremia and endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) are prevalent and clinically important. The rise in MRSA bacteremia and endocarditis is related with the increasing use of venous catheters and other vascular procedures. Glycopeptides have been the reference drugs for treating these infections. Unfortunately their activity is not completely satisfactory, particularly against MRSA strains with MICs > 1 microg/mL. The development of new antibiotics, such as linezolid and daptomycin, and the promise of future compounds (dalvabancin, ceftobiprole and telavancin) may change the expectatives in this field.The principal aim of this consensus document was to formulate several recommendations to improve the outcome of MRSA bacteremia and endocarditis, based on the latest reported scientific evidence. This document specifically analyzes the approach for three clinical situations: venous catheter-related bacteremia, persistent bacteremia, and infective endocarditis due to MRSA.

Management of Antimicrobial Use in the Intensive Care Unit

Critically ill patients admitted to the intensive care unit (ICU) are frequently treated with antimicrobials. The appropriate and judicious use of antimicrobial treatment in the ICU setting is a constant clinical challenge for healthcare staff due to the appearance and spread of new multiresistant pathogens and the need to update knowledge of factors involved in the selection of multiresistance and in the patient’s clinical response. In order to optimize the efficacy of empirical antibacterial treatments and to reduce the selection of multiresistant pathogens, different strategies have been advocated, including de-escalation therapy and pre-emptive therapy as well as measurement of pharmacokinetic and pharmacodynamic (pK/pD) parameters for proper dosing adjustment. Although the theoretical arguments of all these strategies are very attractive, evidence of their effectiveness is scarce. The identification of the concentrationdependent and time-dependent activity pattern of antimicrobials allow the classification of drugs into three groups, each group with its own pK/pD characteristics, which are the basis for the identification of new forms of administration of antimicrobials to optimize their efficacy (single dose, loading dose, continuous infusion) and to decrease toxicity. The appearance of new multiresistant pathogens, such as imipenem-resistant Pseudomonas aeruginosa and/or Acinetobacter baumannii, carbapenem-resistant Gram-negative bacteria harbouring carbapenemases, and vancomycin-resistant Enterococcus spp., has determined the use of new antibacterials, the reintroduction of other drugs that have been removed in the past due to toxicity or the use of combinations with in vitro synergy. Finally, pharmacoeconomic aspects should be considered for the choice of appropriate antimicrobials in the care of critically ill patients.

Estudio nacional de vigilancia de infección nosocomial en unidades de cuidados intensivos. Informe del año 2000

Objetivo Identificar las tasas nacionales de las infecciones hospitalarias adquiridas en Unidades de Cuidados Intensivos (UCI) relacionadas con instrumentalizacion, correspondientes al ano 2002, asi como conocer sus etiologias y la evolucion de las resistencias de aquellos microorganismos mas prevalentes. Diseno Estudio de serie de casos, observacional y prospectivo. Ambito 85 UCI, servicios o unidades de Cuidados Intensivos u otras unidades en donde se ingresan pacientes criticos, pertenecientes a 80 hospitales distintos. Pacientes y metodos Se han incluido de forma continuada los pacientes ingresados durante mas de 24 horas en las UCI participantes, que fueron seguidos hasta su alta de UCI o hasta un maximo de 30 dias. Las infecciones objeto de vigilancia han sido: neumonias relacionadas con ventilacion mecanica (N-VM), infecciones urinarias relacionadas con sonda uretral (IU-SU), bacteriemias primarias (BP) y relacionadas con cateteres vasculares (B-CVC) y bacteriemias secundarias. Resultados Se han incluido 6.868 pacientes. En 684 (10%) pacientes se han detectado 1.019 infecciones, 445 N-VM (43,7%), 229 IU-SU (22,5%), 100 BP (9,8%), 135 B-CVC (13,2%) y 110 bacteriemias secundarias (10,8%). Las densidades de incidencia en relacion con los dias de exposicion al factor de riesgo han sido 18,0 N-VM por 1.000 dias de ventilacion mecanica, 6,0 IU-SU por 1.000 dias de sonda uretral y 4,5 BP-CVC por 1.000 dias de cateter venoso central. La etiologia predominante en las N-VM precoces ha sido Staphylococcus aureus sensible a meticilina y Haemophilus influenzae y en las N-VM tardias Pseudomonas aeruginosa y Acinetobacter baumannii. Las IU-SU han estado originadas predominantemente por Escherichia coli y Enterococcus faecalis y las BP-CVC por Staphylococcus epidermidis y Staphylococcus coagulasa negativo. Entre los marcadores de resistencia destacan por su frecuencia: P. aeruginosa resistente a imipenem-cilastatina (34,7%) y a ceftazidima (29,5%), S. aureus resistente a meticilina (35,3%), A. baumannii resistente a imipenem (33,9%) y E. coli resistente a ciprofloxacino (20,0%). No se ha detectado ninguna cepa de Enterococcus spp. o de Staphylococcus aureus resistente a vancomicina. Conclusiones Se han identificado, para el ano 2002, las tasas nacionales de las infecciones nosocomiales relacionadas con ventilacion mecanica, sonda uretral y cateter venoso central, asi como los agentes patogenos que predominan en cada una de ellas y el estado de los marcadores de multirresistencia.

Infecciones nosocomiales por Staphylococcus aureus en pacientes críticos en unidades de cuidados intensivos

Fundamento y objetivo: Investigar la frecuencia de infecciones nosocomiales por Staphylococcus aureus en pacientes criticos ingresados en unidades de cuidados intensivos (UCI) de Espana y describir las caracteristicas y la evolucion de aquellos en quienes se han aislado. Pacientes y metodo: Se ha realizado un estudio prospectivo, observacional y multicentrico, en el que se ha incluido a los pacientes ingresados en las UCI de los hospitales participantes en el Estudio Nacional de Vigilancia de Infeccion Nosocomial (ENVIN) durante 1 o 2 meses desde el ano 1997 hasta 2003. Los pacientes se clasificaron como infectados por S. aureus, infectados por otros microorganismos y sin infecciones nosocomiales. Resultados: De 34.914 pacientes controlados 3.450 (9,9%) adquirieron 5.599 infecciones nosocomiales durante su estancia en la UCI (16,0 infecciones por cada 100 pacientes). En 682 (19,8%) de los pacientes con infecciones se identificaron 775 infecciones en las que uno de los microorganismos responsables era S. aureus (incidencia acumulada: 2,2 episodios de infeccion por S. aureus por 100 pacientes). Se observo un predominio de S. aureus en las neumonias relacionadas con ventilacion mecanica (21,4%) y en las bacteriemias relacionadas con cateteres (13,0%). Las variables que se asociaron de forma individual con la aparicion de infeccion por S. aureus fueron el sexo masculino (odds ratio [OR] = 1,25; intervalo de confianza [IC] del 95%, 1,03-1,52) y los procesos de base traumatica (OR = 1,72; IC del 95%, 1,26-2,35), mientras que la mayor edad fue un factor protector (OR = 0,90; IC del 95%, 0,84-0,96). La mortalidad de los pacientes con infeccion por S. aureus fue significativamente superior a la de los pacientes con infecciones por otros microorganismos y, a su vez, la de ambas fue superior a la de los pacientes sin infecciones (el 34,5, el 30,3 y el 10,7%, respectivamente). En 208 (30,5%) pacientes las infecciones fueron debidas a S. aureus resistentes a meticilina, las cuales aumentaron de forma significativa a lo largo de los anos analizados (p = 0,001). La mortalidad de los pacientes con infecciones producidas por S. aureus resistente a meticilina fue del 35,1%, y la de las producidas por S. aureus sensibles a meticilina del 34,2% (p = NS). Conclusiones: S. aureus esta presente en el 19,8% de los pacientes con infecciones adquiridas en las UCI, principalmente en neumonias relacionadas con ventilacion mecanica. La mortalidad de los pacientes con infecciones por S. aureus ha sido superior a la de los pacientes con infecciones por otros microorganismos y a la de pacientes sin infecciones. Por el contrario, no se han identificado diferencias en la evolucion de los pacientes con infecciones por S. aureus sensibles o resistentes a meticilina.

Prevention of ventilator-associated pneumonia in intensive care units: an international online survey

BackgroundOn average 7% of patients admitted to intensive-care units (ICUs) suffer from a potentially preventable ventilator-associated pneumonia (VAP). Our objective was to survey attitudes and practices of ICUs doctors in the field of VAP prevention.MethodsA questionnaire was made available online in 6 languages from April, 1st to September 1st, 2012 and disseminated through international and national ICU societies. We investigated reported practices as regards (1) established clinical guidelines for VAP prevention, and (2) measurement of process and outcomes, under the assumption “if you cannot measure it, you cannot improve it”; as well as attitudes towards the implementation of a measurement system. Weighted estimations for Europe were computed based on countries for which at least 10 completed replies were available, using total country population as a weight. Data from other countries were pooled together. Detailed country-specific results are presented in an online additional file.ResultsA total of 1730 replies were received from 77 countries; 1281 from 16 countries were used to compute weighted European estimates, as follows: care for intubated patients, combined with a measure of compliance to this guideline at least once a year, was reported by 57% of the respondents (95% CI: 54–60) for hand hygiene, 28% (95% CI: 24–33) for systematic daily interruption of sedation and weaning protocol, and 27% (95%: 23–30) for oral care with chlorhexidine. Only 20% (95% CI: 17–22) were able to provide an estimation of outcome data (VAP rate) in their ICU, still 93% (95% CI: 91–94) agreed that “Monitoring of VAP-related measures stimulates quality improvement”. Results for 449 respondents from 61 countries not included in the European estimates are broadly comparable.ConclusionsThis study shows a low compliance with VAP prevention practices, as reported by ICU doctors in Europe and elsewhere, and identifies priorities for improvement.