I Sessione:
Le infezioni nosocomiali: quale
gestione nelle strutture
residenziali assistite?
Epidemiologia e prevenzione
Paolo Durando
Dipartimento di Scienze della Salute
Scuola di Scienze Mediche e Farmaceutiche
IRCCS AOU San Martino-IST, Università degli Studi di Genova
Gruppo Tecnico Regionale per il Controllo delle Infezioni Correlate all’Assistenza
Società Italiana Multidisciplinare per la Prevenzione delle Infezioni nelle
Organizzazioni Sanitarie (SIMPIOS) – Sezione Liguria
HEALTH CARE-ASSOCIATED INFECTIONS
THE RESULT OF A DINAMIC INTERACTION
Host
Microrganisms
Environment
(setting, procedures,
HCWs behaviour)
Prevalenza di Infezioni Correlate all’Assistenza (ICA):
studi italiani pubblicati fra il 2000 e oggi
%
88 Ospedali
18667 Pazienti
arruolati
10 Ospedali
1315 Pazienti
arruolati
59 Ospedali 15 Ospedali
9467 Pazienti 2165 Pazienti
arruolati
arruolati
21 Ospedali
6352 Pazienti
arruolati
51 Ospedali
9609 Pazienti
arruolati
25 Ospedali 912 Pazienti
3176 Pazienti
arruolati
arruolati
1
Infection control and quality health care:
current challenges and future perspectives
, A/H1N1, MERS-CoV, Ebola…
Pittet D, AJIC 2005
Resistance in
Enterobacteriaceae:
impact and ability of
different β-lactamases
Livermore DM, K J Intern Med 2012
Cosgrove SE et al, Arch Int Med 2002
2
MultiDrug Resistance of Gram-Negative Bacilli (MDR-GNB):
an important clinical and public health issue
Emergence of resistance to multiple antimicrobial agents in pathogenic GNB has become a significant
public health threat, having a significant impact on morbidity, mortality (risk estimated nearly 2-3 times)
and on LOS and health-related costs.
The greater problem is for empirical theraphy, where growing resistance increases the risk that the
antimicrobial used will prove inactive: in particular, highly-resistant Gram-negative bacteria e.g.
multidrug-resistant carbapenemase-producing Klebsiella pneumoniae and Acinetobacter spp. can be
resistant to all currently available antimicrobial agents or remain susceptible only to older, potentially
more toxic agents like the polymyxins, leaving limited and suboptimal options for treatment.
Antibiotic treatment options for multidrug-resistant GNB are often very limited and finding an appropriate
drug is an increasing challenge since very few new antibiotics are expected to enter the market as the
older classes lose their efficacy
Testing and evaluation of antibiotic lead substances should identify epidemiologically frequent and
clinically relevant resistance mechanisms, as a basis for recommended hygiene measures in patient
care.
Magiorakos AP et al, Clin Microbiol Infect 2012; de Kraker ME et al, J Antimicrob Chemother 2011; ECDC 2011;
MMWR 2009; Roberts RR et al, Clin Infect Dis 2009; Falagas ME et al Clin Infect Dis 2008, Pitout JDD Lancet Infect Dis 2008
Antimicrobial resistance data from invasive isolates (blood and
cerebrospinal fluid) reported to EARS-Net by 29 EU/EEA countries in
2012 (data referring to 2011), and on trend analyses of EARSS/EARSNet data reported by the participating countries during the
period 2008 to 2011
Dramatic increase in Carbapenem-Resistant
Klebsiella Pneumoniae in Italy (I)
2009
2010
2011
2012
Klebsiella pneumoniae. Percentage (%) of invasive isolates with resistance
to carbapenems, by country, EU/EEA countries, 2009-2013.
2013
European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe.
Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). 2009-2013.
3
Dramatic increase in Carbapenem-Resistant
Klebsiella Pneumoniae in Italy (II)
Escherichia coli: trends of invasive isolates with combined resistance
(resistant to fluoroquinolones, third generation cephalosporins and
aminoglycosides), by country, EU/EEA countries, 2008–2011
The rise of carbapenem resistance in Europe:
just the tip of the iceberg?
A trend analysis showed increasing
trends for Greece, Cyprus, Hungary
and Italy (p < 0.01)
EARS-Net collects data on invasive
bacterial
isolates,
which
likely
correspond to a fraction of the total
number of infections.
Increasing reports of community cases
suggest
that
dissemination
of
carbapenem-resistant K. pneumoniae
has penetrated into the community.
Good surveillance and infection control
measures are urgently needed to
contain this spread.
Magiorakos et al.
Antimicrobial Res Infect Control 2013
4
The results highlight the emergence of carbapenemase-producing K. pneumoniae strains in
different hospitals and wards and the urgent need for infection control, antibiotic stewardship
programmes and utilization of a surveillance and prevention system
Univariate analysis of risk factors for in-hospital mortality among
91 patients infected by carbapenem-resistant Klebsiella
pneumoniae (CR-KP)
Results (II)
Multivariate analysis adjusted
for
appropriate
treatment,
combination
therapy
and
infectious-source
removal,
showed the following as
independent risk factors for
mortality:
Background
From January 2007 to May 2010, the five ICUs of the San Martino
University Hospital, Genoa, Italy, experienced sequential outbreaks of A.
baumannii infection.
Aims
(i)
to study the population structure of A. baumannii and identify the spread
of epidemic clones in the San Martino hospital;
(ii) to compare characterization data obtained using different molecular
approaches and evaluate their utility in molecular investigation;
(iii) to study the emergence of antimicrobial resistance.
5
Cases of infections caused by A. baumannii among ICUs and other wards by
the most frequently found genotypes of carbapenem-resistant A. baumannii
6 Epidemic clusters of A. baumannii
In ICUs, 27 (50.9%) and 26 (49.1%) patients were colonized and infected, respectively.
The mean age for colonized and infected patients was 68.5 and 56.2 years, respectively.
•
•
•
•
BSI: 53.8%
VAP: 19.2%
Complicated skin and soft tissue infections: 11.5%
meningitis or urinary tract infection: 7.7%
Among infected patients admitted in ICUs, the fatality rate was 33.3%.
Antimicrobial susceptibility patterns of Acinetobacter baumannii
isolates belonging to the most frequently found genotypes:
ST4, ST118, ST95
Most A. baumannii isolates were multidrug-resistant.
The majority of the strains typed were resistant to ampicillin-sulbactam,
piperacillin-tazobactam, broad spectrum cephems and fluoroquinolones, but
susceptible to colistin.
This pattern may have contributed to the rapid and successful spread.
6
Geographical
distribution of
Clostridium difficile
PCR ribotypes in
European countries
with more than
five typable isolates,
November, 2008
Rybotypes 018,
056, 027 are
usually associated
with complicated
disease outcome
7
 Con legge regionale n. 2/2011 è stata costituito
l'IRCCS AOU San Martino – IST di Genova, a
seguito dell'accorpamento dell’AOU San
Martino e dell'Istituto Scientifico Tumori. Il
nuovo Istituto è stato costituito dal 1°
settembre 2011, a seguito del riconoscimento
del carattere scientifico per la disciplina di
Oncologia, con conseguente estinzione dei due
pregressi enti.
 L'Istituto è costituito da 6 Dipartimenti ad
Attività Integrata:
 Dipartimento di Chirurgia generale,
specialistica e oncologica
 Dipartimento di Neuroscienze ed
Organi di senso
 Dipartimento di Medicina Interna
Generale e Specialistica
 Dipartimento di Emergenza ed
Accettazione
 Dipartimento
delle
Terapie
Oncologiche Integrate
 Dipartimento della Diagnostica, della
patologia e delle cure ad alta
complessità tecnologica





Ospedale di riferimento regionale per acuti
Numero di posti letto ordinari (anno 2013): circa 1200
Numero di ricoveri ordinari (anno 2013): circa 45.000
Numero di accessi totali (anno 2013): circa 90.000
Giornate di degenza (media 2011 – 2013): 473.810
HAI surveillance and control activities at
I.R.C.C.S. AOU San Martino – IST Genoa, Italy
 Laboratory surveillance of alert microrganisms for all hospital wards
 Point-prevalence surveys
 Carbapenemase-producing Enterobacteriacee (CPE)-BSI passive surveillance
 CPE-Colonization Screening in patients and hospital wards at higher risk
 Active surveillance of environmental cleaning and decontamination procedures
 Active surveillance of health-care workers adherence and compliance with HAI
prevention measures (i.e. hand hygiene, perioperative antimicrobial prophylaxis)
 Antimicrobial stewardship
IRCCS Azienda Ospedaliera Universitaria San Martino ‐ IST
Istituto Nazionale per la Ricerca sul Cancro
Largo Rosanna Benzi, 10 16132 GENOVA
SORVEGLIANZA DEI
MICRORGANISMI SENTINELLA
ANALISI DATI 2012-2013
Valutazione semestrale prevista nel 2014
8
FLUSSO INFORMATIVO
Nel momento in cui il Laboratorio referta un esame ed inserisce i dati nel
programma di Laboratorio, il dato viene rilevato dal sistema informatico
“Controllo infezioni ospedaliere” che, in automatico, invia una mail alla
Direzione Sanitaria e al Team ICA.
Contemporaneamente il referto è leggibile presso l’U.O. di interesse su
LaboWeb.
L’U.O. Igiene ed Epidemiologia Ospedaliera invia, via fax, il modulo “SCHEDA DI SEGNALAZIONE DI
ISOLAMENTO DI MICRORGANISMO SENTINELLA” MODAZHEP_0044 all’U.O. di pertinenza. In tale
modulo è riportato:
Indicazione della U.O. (Padiglione, CdC, fax)
• Data, nome del paziente, microrganismo isolato, sede di isolamento
• Indicazioni delle precauzioni da contatto
• Consulenza infettivologo
• Data e firma di chi segnala
• Data e firma del ricevente.
Il fax datato e firmato dal ricevente, dovrà essere inserito dal Medico di reparto nella cartella clinica del
paziente.
L’U.O. provvede ad attuare le misure specifiche previste dalle procedure:
- LGAZHEP_0002 “RACCOMANDAZIONI PER LE MISURE DI ISOLAMENTO IN OSPEDALE”
- IOAZHEP_0044 “GESTIONE E SORVEGLIANZA PAZIENTI COLONIZZATI/INFETTI DA MICRORGANISMI
SENTINELLA”
Primi Isolamenti dei Principali
Microrganismi Alert
*
608
* Trattandosi di un patogeno endemico la sorveglianza è stata sospesa a marzo
2013
9
Studio di prevalenza delle infezioni correlate all’assistenza
all’interno dell’I.R.C.C.S. S. Martino – IST
Gennaio - Febbraio 2014
Complessivamente sono stati inclusi nello studio 956 pazienti ricoverati in 74 reparti ospedalieri
afferenti a 5 Dipartimenti ad Attività Integrata.
34,4%
63,9%
Percentuale di pazienti
1,7%
Anni
10
Percentuale di pazienti
Percentuale di pazienti
Analisi multivariata: principali ICA (overall e per singola
localizzazione) e valutazione dei fattori di rischio associati
Durando P et al., J Hosp Infect 2009
11
Durata della
degenza
(giorni)
Totale
IRCCS
(n=956)
MED
(n=556)
SUR
(n=236)
RHB
(n=50)
ICU
(n=43)
PSY
(n=30)
GO
(n=27)
PED
(n=14)
Media
12,9
12,1
10,3
27,9
29,0
11,8
3,2
5,9
Mediana
7
8
6
22
20
7
3
4
IQR
3-16
4 – 15,5
2 - 12
10 - 38
10 - 39
2 - 13
1-6
2–7
Range
0-139
1 - 129
0 - 139
1 - 102
2 - 103
0 - 133
0-7
0 - 17
HAI prevalence and key results
(European PPS)
2011/12
IRCCS 2014
AOU San
Martino
Europe 2007
DIPME
DIPEA
DIPOE
DIPCR
DIPNS
TOT IRCCS
Italy
N° of pts
314
156
120
209
157
956
14784
231459
N° of pts with
HAI
40
34
27
36
11
148
938
13829
72
17,2
(12,4 – 23,0)
7,0
(3,6 – 12,2)
15,5
(13,3 – 18,0)
6,3
(5,4 – 7,4)
6,0
(5,7 – 6,3)
7,9
HAI
Prevalence %
(IC95%)
12,7
21,8
22,5
(9,4 – 17,0) (15,6 – 29,1) (15,4 – 31,0)
912
N° of HAIs
44
41
29
42
11
167
1068
15000
84
N° of HAIs
per infected pt
1,10
1,21
1,07
1,17
1,0
1,13
1,14
1,08
1,17
N° of HAIs
with microrg.
(%)
26 (59,1)
20 (48,8)
6 (20,7)
22 (52,4)
7 (63,6)
81 (48,5)
652 (61,0)
8114 (54,1)
70 (83,3)
Total N° of
reported
microrg.
35
28
8
28
7
106
841
10076
107
Totale IRCCS
N. microrganismi
%
Microrganismi totali
106
106
Staphylococcus aureus
16
15,1
Escherichia coli
13
12,3
Staphylococci coagulasi-negativi
13
12,3
Enterococcus spp
11
10,4
Klebsiella pneumoniae
11
10,4
Pseudomonas aeruginosa
9
8,5
Candida spp
9
8,5
Clostridium difficile
7
6,6
Proteus spp
6
5,7
Enterobateriacee spp
5
4,7
Morganella spp
2
1,9
Serratia marcescens
2
MRSA: 87,5%
3GC-R: 30,8%
CAR-R: 0
VRE: 18,2%
3GC-R: 90,9%
CAR-R: 63,6
,
CAR-R: 44,4%
1,9
Corynebacterium spp
1
0,9
Bacilli Gram Positivi non spec.
1
0,9
12
HAIs with onset during current
hospitalization in ICUs
IRCCS 2014
UA1D1
N HAIs
TOT
UA1D
UA1D2
Rel %
N HAIs
Rel %
N HAIs
HAND1
Rel %
TOT
HAND
HAND4
N HAIs
Rel %
N HAIs
Rel %
TOT
ICU
N HAIs
Rel %
N HAIs
Rel %
3,6
Day of HAI onset
Day 1 – 2
0
-
0
-
0
-
1
16,7
0
-
1
6,7
1
Day 3 - 4
2
18,2
0
-
2
15,4
0
-
0
-
0
-
2
7,1
Day 5 – 7
2
18,2
0
-
2
15,4
0
-
1
11,1
1
6,7
3
10,7
Day 8 - 14
1
9,1
0
-
1
7,7
2
33,3
2
22,2
4
26,6
5
17,9
Day 15 - 21
2
18,2
0
-
2
15,4
1
16,7
2
22,2
3
20
5
17,9
> Day 21
4
16,4
2
100
6
46,2
2
33,3
4
44,5
6
40
12
42,9
Patients with positive culture for carpapenem-resistant
Klebsiella pneumoniae (any site, only first isolate) at I.R.C.C.S.
San Martino – IST Genoa, Italy (years 2008-2013)
June 2012: mandatory screening
13
Mortalità per tutte le cause a 30 giorni: analisi univariata
N Pazienti/totale (%)
Sopravvissuti (n=298) Deceduti (n=164)
OR
CI95%
P-value
103/291 (35,40%)
0,99
0,67 - 1,47
0,95
8/41 (19,51%)
3/32 (9,38%)
16/56 (28,57%)
41/112 (36,61%)
67/156 (42,95%)
29/65 (44,62%)
ref
0,43
1,65
2,38
3,11
3,32
0,10 - 1,76
0,63 - 4,33
1,01 - 5,64
1,35 - 7,16
1,33 - 8,29
0,24
0,31
0,05
0,008
0,01
Mortalità per
51/134 (38,06%)
1,16 tutte
0,77le
- 1,77
60/149cause
(40,27%)in pazienti
1,35
0,91
- 2,03
affetti
81/244 (33,20%)
0,81CRKP
0,55-1,18
da BSI da
0,46
0,14
0,27
Caratteristiche demografiche
Sesso (M/F)
188/291 (64,60%)
Età
40<
33/41 (80,49%)
40-49
29/32 (90,63%)
50-59
40/56 (71,43%)
60-69
71/112 (63,39%)
70-79
89/156 (57,05%)
≥80
36/65 (55,38%)
Condizioni di comorbosità
Mortalità
per tutte
le
Neoplasia
83/134
(61,94%)
Infezioni
89/149 (59,73%)
cause in pazienti
affetti
Intervento chirurgico
(66,80%)
da BSI 163/244
da CSKP
Charlson comorbidity index
a 30 giorni
26,21%
0
18/22
(81,82%)
1-2
30/35 (85,71%)
3
32/37 (86,49%)
4
41/63 (65,08%)
≥5
177/305 (58,03%)
Pattern di resistenza
Resistenza ai carbapenemi
191/317 (60,25%)
Area specialistica di
insorgenza
ICU
142/237 (59,92%)
MED
84/138 (60,87%)
RHB
18/22 (81,82%)
SUR
58/69 (84,06%)
a 30 giorni
4/22 (18,18%)
ref39,75%
5/35 (14,29%)
0,75
0,18 - 3,16
5/37 (13,51%)
0,70
0,17 - 3,0
22/63 (34,92%)
2,41
0,73 - 8,02
128/305 (41,97%)
3,25
1,08 - 9,85
0,70
0,63
0,15
0,04
126/317 (39,75%)
1,86
1,2-2,86
0,005
95/237 (40,08%)
54/138 (39,13%)
4/22 (18,18%)
11/69 (15,94%)
3,43
3,31
1,20
ref
1,71 - 6,89
1,59 - 6,88
0,34 - 4,25
0,0005
0,001
0,78
 Stimare l’incidenza delle infezioni da Clostridium difficile acquisite
durante il ricovero presso l’IRCCS San Martino – IST di Genova
 Stimare la mortalità da tutte le cause nei 30 giorni successivi
all’infezione da Clostridium difficile
 Descrivere le caratteristiche demografiche e cliniche dei pazienti con
infezione da Clostridium difficile acquisite durante il ricovero presso
l’IRCCS San Martino – IST di Genova
 Descrivere i fattori di rischio correlati alla mortalità da tutte le cause
nei 30 giorni successivi all’infezione da Clostridium difficile
 Studio retrospettivo basato sulla definizione di caso del National
Health Safety Network (NHSN) di Laboratory Identified Event (LabID
Event):
« A case of CDI is defined as a positive laboratory test result (non
duplicative) for C. difficile toxin A and/or B, or a toxin-producing C.
difficile organism detected by culture or other laboratory means
performed on a stool sample»
 Incident (new case) CDI Assay: Any
LabID Event from a specimen
obtained >8 weeks after the most
recent LabID Event (or with no
previous LabID Event documented)
for that patient.
 Recurrent CDI Assay: Any LabID
Event from a specimen obtained >2
weeks and ≤8 weeks after the most
recent LabID Event for that patient.
14
 Sulla base delle tempistiche della diagnosi di CDI e della storia clinica
del paziente, le CDI sono state ulteriormente categorizzate come
prescritto dal NHSN
Community-Onset
(CO):
CDI
identified as an outpatient or an
inpatient ≤3 days after admission
to the facility (i.e., before or on
days 1, 2, or 3 of admission).
Community-Onset Healthcare Facility–
Associated (CO-HCFA): Community onset
Healthcare Facility–Onset (HO):
CDI identified from a patient who was
discharged from the facility ≤4 weeks prior to
current date of stool specimen collection
CDI identified >3 days after admission
to the facility (i.e., on or after day 4)
3282 stool specimens tested
(from April 2010 to August 2014)
450 positive specimens (13,7%)
Correction for duplicate positivites
and CDI recurrences
374 patients
Excluded 26 community onset or
community onset healthcare facility
associated CDI patients
348 patients
2010A
2011
2012
2013
2014B
Ai
Bi
Totale
Test
Totale positivi
Nuovi casi totali
(>56 giorni)
Recidive
(≤56; >14 giorni)
Duplicati
(< 14 giorni)
Healthcare Facility onset
HO-CDI (nuovi casi)
277
442
678
1122
813
24 (8,7%)
38 (8,6%)
82 (12,1%)
164 (14,6%)
142 (17,5%)
21
35
75
134
109
2
1
6
15
11
1
2
1
15
22
19
32
74
127
96
dati iniziano dal 1/4/2010
dati arrivano fino al 31/8/2014
Facility-Onset (HO): CDI identified > 3 days after admission to the facility (or after day 4)
C Healthcare
Hospital Onset – Clostridium difficile Infection (HO-CDI) incidence at
I.R.C.C.S. San Martino – IST Genoa, 2010 – 2014
2010
N°
2011
Hosp.
days
Incide
nce (x
1000
pd)
N°
2012
Hosp.
days
Incide
nce (x
1000
pd)
N°
2013
Hosp.
days
Incide
nce (x
1000
pd)
N°
2014
Hosp.
days
Incide
nce (x
1000
pd)
N°
Hosp.
days
Incide
nce (x
1000
pd)
19
351450
0,05
32
485309
0,07
74
475438
0,16
127
460683
0,28
96
298006
0,32
9
187399
0,05
24
250474
0,10
54
240704
0,22
53
223616
0,24
59
152190
0,39
SUR
3
93908
0,03
1
130901
0,01
1
123733
0,01
5
117828
0,04
6
73923
0,08
ICU
3
12613
0,24
0
18521
0,00
3
16451
0,18
4
14940
0,27
1
10387
0,10
RHB
4
17669
0,23
7
33423
0,21
15
45487
0,33
65
62927
1,03
30
34347
0,87
+3 Standard Deviation
+2 Standard Deviation
+1 Standard Deviation
giu-14
ago-14
apr-14
ott-13
dic-13
feb-14
giu-13
apr-13
ago-13
ott-12
dic-12
feb-13
giu-12
apr-12
ago-12
ott-11
dic-11
feb-12
giu-11
apr-11
ago-11
ott-10
dic-10
feb-11
giu-10
Mean
apr-10
0,65
0,6
0,55
0,5
0,45
0,4
0,35
0,3
0,25
0,2
0,15
0,1
0,05
0
ago-10
per 1000 patient days
Tot IRCCS
MED
15
80
72,7
70
p value = 0,0005
60
50
%
40
29,4
30
18,7
17,7
20
10
0
Area medica
Area chirurgica
Area terapia intensiva
Area riabilitativa e
lungo-degenza
It is not antibiotic resistance
genes that kill people, it is
bacteria…
A steady stream of new antibiotics aimed at MDR Gram-negative bacteria
would be welcome, but this alone might make a relatively modest impact
on clinical outcomes.
Much more effective would be innovative approaches to reducing the
likelihood of colonization and subsequent infection, thereby reducing both
the need to use antibiotics at all and the constant pressure leading to
multiple antibiotic resistance.
Such strategies are likely to be more effective in the long term than
relying on a pipeline of antibiotics that will only ever have a limited
lifespan.
Cohen J, Antimicrob Chemother 2013
Strategie per il controllo delle infezioni
 Misure generali
 Sorveglianza
 Precauzioni standard
 Misure aggiuntive (isolamento, ecc.)
 Antibiotico profilassi e terapia
 Misure specifiche (Immunoprofilassi)
 Specificamente dirette contro:





Infezioni del Tratto Urinario
Infezioni del Sito Chirurgico
Infezioni Respiratorie (es., VAPs)
Sepsi (es., CR-BSIs)
……
16
Strategies to preventi HAIs
in the hospital setting (I)
Ongoing epidemiological and lab-based surveillance (i.e.,
prevalence surveys, alert-microrganism periodic reports,
etc.)
Health-care personnel education and direct observation
on proper hand hygiene following the WHO multimodal
strategy (i.e., posters in wards, leaflets for parents,
alcohol-based hand rub at points of care)
Strategies to preventi HAIs
in the hospital setting (II)
Health-care personnel education and direct observation
on appropriate management of colonized/infected patients
(i.e., strenghtening isolation measures, cohorting, etc.)
and of invasive medical devices (i.e., adoption of care
bundles for the prevention of central line infections, SSIs
and VAP)
Controlled use of antimicrobials (annual reporting and
production of local recommendations on antimicrobial
treatment and surgical prophylaxis)
In neonatal units, use of human milk and involvment of
parents in children’ care
RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS IN ALL HEALTHCARE SETTINGS
51
Healthcare Infection Control Practices Advisory Committee (HICPAC)
17
RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS IN ALL HEALTHCARE SETTINGS
Healthcare Infection Control Practices Advisory Committee (HICPAC)
52
Impatto della promozione dell’igiene delle mani
 Negli ultimi 30 anni, oltre 20 studi hanno dimostrato l’efficacia nel ridurre le ICPA
Increase of
hand hygiene
compliance
Year Hospital setting
Follow-up
Reference
1989 Adult ICU
From 14% to 73%
(before pt contact)
HCAI rates: from 33% to 10%
6 years
Conly et al
2000 Hospital-wide
From 48% to 66%
HCAI prevalence: from 16.9% to 9.5%
8 years
Pittet et al
From 43% to 80%
HCAI incidence: from 15.1 to 10.7/1000 patient-days
2 years
2004 NICU
2005 Adult ICUs
Reduction of HCAI rates
From 23.1% to 64.5% HCAI incidence: from 47.5 to 27.9/1000 patient-days 21 months
2005 Hospital-wide
From 62% to 81%
Significant reduction in rotavirus infections
2007 Neonatal unit
From 42% to 55%
HCAI incidence: overall from 11 to 8.2
infections/1000 patient-days) and in very low birth
weight neonates from 15.5 to 8.8 infections /1000
patient-days
2007 Neurosurgery
NA
2008 1) 6 pilot health-care
facilities
2) all public health-care
facilities in Victoria (Aus)
2008 NICU
Won et al
Rosenthal
et al
4 years
Zerr et al
27 months
Pessoa-Silva
et al
2 years
Thu et al
1) from 21% to 48%
2) from 20% to 53%
MRSA bacteraemia:
1) from 0.05 to 0.02/100 patient-discharges per
month; 2) from 0.03 to 0.01/100 patient-discharges
per month
SSI rates: from 8.3% to 3.8%
1) 2 years
2) 1 year
Grayson et al
NA
HCAI incidence: from 4.1 to 1.2/1000 patient-days
18 months
Capretti et al
Compliance per l’igiene delle mani
in diverse strutture sanitarie
Author
Year
Sector
Compliance
Preston
1981
General Wards
ICU
16%
30%
Albert
1981
ICU
ICU
41%
28%
1983
Hospital-wide
45%
1987
Neonatal ICU
30
1990
ICU
32
Larson
Donowitz
Graham
Dubbert
Pettinger
Larson
Doebbeling
<40%
ICU
81
1991
Surgical ICU
51
1992
1990
Neonatal Unit
29
ICU
40
Zimakoff
1993
ICU
40
Meengs
1994
1992
Emergency Room
32
Pittet
1999
Hospital-wide
48
Pittet and Boyce. Lancet Infectious Diseases 2001
18
Descending Order of Resistance
to Germicidal Chemicals
Activity Levels of
Selected Liquid
Germicides
19
20
21
2013
Early recognition of CDI
Antimicrobial stewardship
Hand hygiene
Healthcare personnel education
Implementation of Contact Precautions for CDI
pts.
Patient education
Administrative support
Environmental controls
22
Ambulatorio Prevenzione Malattie Trasmissibili,
Vaccinazioni e Sperimentazioni Cliniche
Dipartimento di Scienze della Salute
Scuola di Scienze Mediche e Farmaceutiche
Università degli Studi di Genova
IRCCS AOU San Martino-IST di Genova
H-030-014 Study
“Efficacy, Immunogenicity, and Safety
Study of Clostridium difficile Toxoid
Vaccine in Subjects at Risk for
C. difficile Infection”
Noi operatori sanitari seguiamo le linee guida
e raccomandazioni internazionali e nazionali
per la prevenzione del rischio infettivo nei
nostri reparti?
23
We can do better tha this!
Durando P et al, AJIC 2012
“….intervention in infection control should be education-based, processbased and system-based.”
“ ….only a multidsciplinary team can cope successfully with the
challenges of modern infection control and epidemiology.”
Pittet D. AJIC, 2005
“ Today ’ s
infection
control
professionals should not only
continue to recognize, explain,
and act but also demonstrate
their administrators the costeffectiveness of infection control
plans !!”
I.F. Semmelweis
F. Nightingale
24
Società scientifiche e
gruppi di lavoro sulle
infezioni correlate
all’assistenza
Gruppo Italiano di Studio di Igiene
Ospedaliera (GISIO)
http://www.societaitalianaigiene.org/
Società Italiana Multidisciplinare
per la Prevenzione delle Infezioni
nelle Organizzazioni Sanitarie
http://www.simpios.it/
GRAZIE!!!
25