Sonia Labeau

Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis

BACKGROUND We did a systematic review and random effects meta-analysis of randomised trials to assess the effect of oral care with chlorhexidine or povidone-iodine on the prevalence of ventilator-associated pneumonia versus oral care without these antiseptics in adults. METHODS Studies were identified through PubMed, CINAHL, Web of Science, CENTRAL, and complementary manual searches. Eligible studies were randomised trials of mechanically ventilated adult patients receiving oral care with chlorhexidine or povidone-iodine. Relative risks (RR) and 95% CIs were calculated with the Mantel-Haenszel model and heterogeneity was assessed with the I(2) test. FINDINGS 14 studies were included (2481 patients), 12 investigating the effect of chlorhexidine (2341 patients) and two of povidone-iodine (140 patients). Overall, antiseptic use resulted in a significant risk reduction of ventilator-associated pneumonia (RR 0.67; 95% CI 0.50-0.88; p=0.004). Chlorhexidine application was shown to be effective (RR 0.72; 95% CI 0.55-0.94; p=0.02), whereas the effect resulting from povidone-iodine remains unclear (RR 0.39; 95% CI 0.11-1.36; p=0.14). Heterogeneity was moderate (I(2)=29%; p=0.16) for the trials using chlorhexidine and high (I(2)=67%; p=0.08) for those assessing povidone-iodine use. Favourable effects were more pronounced in subgroup analyses for 2% chlorhexidine (RR 0.53, 95% CI 0.31-0.91), and in cardiosurgical studies (RR 0.41, 95% CI 0.17-0.98). INTERPRETATION This analysis showed a beneficial effect of oral antiseptic use in prevention of ventilator-associated pneumonia. Clinicians should take these findings into account when providing oral care to intubated patients. FUNDING None.

Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units

BACKGROUND Although hand hygiene is the most effective measure for preventing cross-infection, overall compliance is poor among health care workers. OBJECTIVES To identify and describe predictors and determinants of noncompliance with hand hygiene prescriptions in intensive care unit nurses by means of a questionnaire. METHODS A questionnaire based on a behavioral theory model was filled out by 148 nurses working on a 40-bed intensive care unit in a university hospital. Subjects were asked to fill out the 56-item questionnaire twice within a 2- to 6-week period. During this period, no interventions to enforce hand hygiene occurred on the unit. RESULTS Response rate for the test was 73% (108/148); response rate for the retest was 53% (57/108). The mean self-reported compliance rate was 84%. Factor analysis revealed 8 elementary factors potentially associated with compliance. Internal consistency of the scales was acceptable. Intraclass correlation was low (<0.60) for 2 subscales but acceptable (>0.60) for 6 subscales. A low self-efficacy was independently associated with noncompliance (beta = .379; P = .001). After exclusion of this variable, a negative attitude toward time-related barriers was associated with noncompliance (beta = -.147; P < .001). CONCLUSIONS Neither having good theoretical knowledge of hand hygiene guidelines nor social influence or moral perceptions had any predictive value relative to hand hygiene practice. A valid questionnaire to identify predictors and determinants of noncompliance with hand hygiene has been designed. Nurses reporting a poor self-efficacy or a poor attitude toward time-related barriers appear to be less compliant.

Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses.

Objective:To determine European intensive care unit (ICU) nurses’ knowledge of guidelines for preventing central venous catheter-related infection from the Centers for Disease Control and Prevention. Design:Multicountry survey (October 2006-March 2007). Setting:Twenty-two European countries. Participants:ICU nurses. Measurements and Main Results:Using a validated multiple-choice test, knowledge of ten recommendations for central venous catheter-related infection prevention was evaluated (one point per question) and assessed in relation to participants’ gender, ICU experience, number of ICU beds, and acquisition of a specialized ICU qualification. We collected 3405 questionnaires (70.9% response rate); mean test score was 44.4%. Fifty-six percent knew that central venous catheters should be replaced on indication only, and 74% knew this also concerns replacement over a guidewire. Replacing pressure transducers and tubing every 4 days, and using coated devices in patients requiring a central venous catheter >5 days in settings with high infection rates only were recognized as recommended by 53% and 31%, respectively. Central venous catheters dressings in general are known to be changed on indication and at least once weekly by 43%, and 26% recognized that both polyurethane and gauze dressings are recommended. Only 14% checked 2% aqueous chlorhexidine as the recommended disinfection solution; 30% knew antibiotic ointments are not recommended because they trigger resistance. Replacing administration sets within 24 hrs after administering lipid emulsions was recognized as recommended by 90%, but only 26% knew sets should be replaced every 96 hrs when administering neither lipid emulsions nor blood products. Professional seniority and number of ICU beds showed to be independently associated with better test scores. Conclusions:Opportunities exist to optimize knowledge of central venous catheter-related infection prevention among European ICU nurses. We recommend including central venous catheter-related infection prevention guidelines in educational curricula and continuing refresher education programs.

Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses

As part of a needs analysis preceding the development of an e-learning platform on infection prevention, European intensive care unit (ICU) nurses were subjected to a knowledge test on evidence-based guidelines for preventing ventilator-associated pneumonia (VAP). A validated multiple-choice questionnaire was distributed to 22 European countries between October 2006 and March 2007. Demographics included nationality, gender, ICU experience, number of ICU beds and acquisition of a specialised degree in intensive care. We collected 3329 questionnaires (response rate 69.1%). The average score was 45.1%. Fifty-five percent of respondents knew that the oral route is recommended for intubation; 35% knew that ventilator circuits should be changed for each new patient; 38% knew that heat and moisture exchangers were the recommended humidifier type, but only 21% knew that these should be changed once weekly; closed suctioning systems were recommended by 46%, and 18% knew that these must be changed for each new patient only; 51% and 57%, respectively, recognised that subglottic drainage and kinetic beds reduce VAP incidence. Most (85%) knew that semi-recumbent positioning prevents VAP. Professional seniority and number of ICU beds were shown to be independently associated with better test scores. Further research may determine whether low scores are related to a lack of knowledge, deficiencies in training, differences in what is regarded as good practice, and/or a lack of consistent policy.

Daily cost of antimicrobial therapy in patients with Intensive Care Unit-acquired, laboratory-confirmed bloodstream infection

This study analysed daily antimicrobial costs of Intensive Care Unit (ICU)-acquired, laboratory-confirmed bloodstream infection (BSI) per patient admitted to the ICU of a university hospital, based on prospectively collected data over a 4-year period (2003-2006). Costs were calculated based on the price of the agent(s) initiated on the first day of appropriate treatment and according to: (i) focus of infection; (ii) pathogen; and (iii) antimicrobial agent. The study included 310 adult patients who developed 446 BSI episodes. Mean overall daily antimicrobial cost was euro114.25. Daily antimicrobial cost was most expensive for BSIs with unknown focus (euro137.70), followed by catheter-related (euro122.73), pulmonary (euro112.80), abdominal (euro98.00), wound (euro89.21), urinary (euro87.85) and other inciting focuses (euro81.59). Coagulase-negative staphylococci were the most prevalent pathogens isolated. Treatment of BSIs caused by Candida spp. was the most costly. The daily antimicrobial costs per infected patient with multidrug-resistant BSI was ca. 50% higher compared with those without (euro165.09 vs. euro82.67; P<0.001). Among the total of 852 prescriptions, beta-lactam antibiotics accounted for approximately one-third of the overall daily cost of antimicrobial agents. The antibiotic cost associated with ICU-acquired, laboratory-confirmed BSI is significant and should be reduced by implementing infection control measures and preventive strategies.

Value of lower respiratory tract surveillance cultures to predict bacterial pathogens in ventilator-associated pneumonia: systematic review and diagnostic test accuracy meta-analysis

PurposeIn ventilator-associated pneumonia (VAP), early appropriate antimicrobial therapy may be hampered by involvement of multidrug-resistant (MDR) pathogens.MethodsA systematic review and diagnostic test accuracy meta-analysis were performed to analyse whether lower respiratory tract surveillance cultures accurately predict the causative pathogens of subsequent VAP in adult patients. Selection and assessment of eligibility were performed by three investigators by mutual consideration. Of the 525 studies retrieved, 14 were eligible for inclusion (all in English; published since 1994), accounting for 791 VAP episodes. The following data were collected: study and population characteristics; in- and exclusion criteria; diagnostic criteria for VAP; microbiological workup of surveillance and diagnostic VAP cultures. Sub-analyses were conducted for VAP caused by Staphylococcus aureus, Pseudomonas spp., and Acinetobacter spp., MDR microorganisms, frequency of sampling, and consideration of all versus the most recent surveillance cultures.ResultsThe meta-analysis showed a high accuracy of surveillance cultures, with pooled sensitivities up to 0.75 and specificities up to 0.92 in culture-positive VAP. The area under the curve (AUC) of the hierarchical summary receiver-operating characteristic curve demonstrates moderate accuracy (AUC: 0.90) in predicting multidrug resistance. A sampling frequency of >2/week (sensitivity 0.79; specificity 0.96) and consideration of only the most recent surveillance culture (sensitivity 0.78; specificity 0.96) are associated with a higher accuracy of prediction.ConclusionsThis study provides evidence for the benefit of surveillance cultures in predicting MDR bacterial pathogens in VAP. However, clinical and statistical heterogeneity, limited samples sizes, and bias remain important limitations of this meta-analysis.

An evaluation of family-centered care services and organization of visiting policies in Belgian intensive care units: a multicenter survey.

BACKGROUND Admission in an intensive care unit (ICU) is a major cause of psychologic stress for the patient and the entire family, and liberalization of visitation has been shown to have a beneficial impact. However, despite the data available, practice has not changed much to incorporate these findings. OBJECTIVE This study aimed to evaluate the visiting policies of Belgian ICUs. METHODS A descriptive multicenter questionnaire survey was prospectively conducted. RESULTS Fifty-seven ICUs completed the questionnaire (75.0%). All (100%) reported restricted visiting-hour policies, and limited numbers of visitors. Mean total daily visiting time was 69+/-33 minutes. The type of visitors was restricted to only immediate relatives in 11 ICUs (19.3%). Children were not allowed in 5 ICUs (8.8%), and 46 ICUs (80.7%) fixed an age limit for visiting. Thirty ICUs (52.6%) were providing families with information in a special room in addition to the waiting room, whereas 6 (10.5%) reported having no waiting room available, and 9 ICUs (15.8%) provided an information leaflet. A structured first family meeting at time of admission was organized in 42 ICUs (73.7%). A final family meeting at ICU discharge was planned in only 16 centers (28.1%). CONCLUSION Participating ICUs homogeneously reported restricted visiting policies regarding visiting hours and type and number of visitors. According to the evidence available, providing a plea for more liberal visitation, these results may be a first step toward reorganization of visiting policies in Belgian ICUs.

Nursing considerations to complement the Surviving Sepsis Campaign guidelines

Objectives:To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. Design:Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. Methods:We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. Results:Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. Conclusion:Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.

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.

The role of nurses working in emergency and critical care environments in the prevention of intravascular catheter-related bloodstream infections.

Intravascular catheter-related infections are a major problem in healthcare. This review provides up-to-date guidance of evidence-based recommendations for the prevention of intravascular catheter-related infections with special focus on strategies relevant for nurses working in emergency and critical care environments or practitioners responsible for surveillance and control of infections. The review concludes by providing a range of approaches advocated for: (i) translating guidelines to the needs and expectations of emergency and critical care nurses, and (ii) increasing the chance of successful implementation and compliance with these recommendations.