Le infezioni nelle Unità di Terapia Intensiva:
è possibile ridurne l’incidenza?
Paolo Grossi
Clinica Malattie Infettive e Tropicali
Università degli Studi dell’Insubria –
Ospedale di Circolo e Fondazione Macchi, Varese
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
60
% prevalenza
51,2
50
41,3
37,3
40
40,7
30
20
10
7,7
4,7 4,9
0
totale
A'02
7
3,5
A'03
area chirurgica
5
5,9
3,4 4,4
7,5
4,7 4,9
P'04
A'04
area critica
Studi di prevalenza
area medica
Prevalenza di pazienti con IN e durata degenza al
momento dello studio
Tutto l’ospedale
35
30
25
20
15
10
5
0
A'02
A'03
P'04
A'04
prevalenza %
DM infetti gg
DM non infetti gg
Prevalenza di pazienti con IN e durata degenza al
momento dello studio
Area critica
45
40
35
30
25
20
15
10
5
0
A'02
A'03
P'04
A'04
prevalenza %
DM infetti gg
DM non infetti gg
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 commonly
isolated from monomicrobial nosocomial BSIs and associated
crude mortality rates for all patients, patients in ICU, and
patients in non-ICU 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
Cephalosporins & Quinolones
“Collateral damage’ is a term used to refer to ecological adverse
effects of antibiotic therapy; namely, the selection of drugresistant organisms and the unwanted development of
colonization or infection with multidrug-resistant organisms.”
“…Neither third-generation cephalosporins nor quinolones appear suitable for
sustained use in hospitals as “workhorse” antibiotic therapy….”
Paterson DL. Clin Infect Dis 2004:38(Suppl 4):S341-S345
National Nosocomial Infections Surveillance (NNIS)
System Report, data summary from January 1992
through June 2004
Am J Infect Control 2004;32:470-85.
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)
Enterobatteri produttori di ESBL
_____________________________________________
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)
_____________________________________________
Luzzaro F. et eal. JCM, May 2006, p. 1659–1664
SORVEGLIANZA NAZIONALE 2003
Pazienti ospedalizzati (n=504)
16,2%
Chirurgia
ICU
Medicina
16,5%
52,4%
Terapia Intensiva
Neurochirurgia
Cardiochirurgia
Onco-Ematologia
Chirurgia
Medicina
Pediatria
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.
VARESE
VIM-1 VIM-2
IMP-2 IMP-12 IMP-13
MILANO
VIM-1
VERONA
VIM-1 VIM-2
IMP-2
CREMONA
VIM-2-like
TORINO
VIM-1
P. aeruginosa
P. putida
A. xylosoxydans
Acinetobacter spp.
TRIESTE
VIM-1 VIM-2
PAVIA
VIM-1
VIM-2
SIENA
VIM-1
GENOVA
VIM-1
PERUGIA
IMP-like
ATRI
IMP-13
PISA
VIM-4
L’AQUILA
VIM-4
ROMA
VIM-1 VIM-2
IMP-2 IMP-13
SASSARI
VIM-1-like
PALERMO
VIM-1
VIM-11
PESCARA
IMP-13
S. GIOVANNI
ROTONDO
IMP-13
FOGGIA
VIM-like
NAPOLI
VIM-1-like
IMP-13
AVELLINO
VIM-like
IMP-13
45th ICAAC
Washington,
2005
CATANIA
VIM-1
16th ECCMID Nice, 2006
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
Screening at patient
discharge should be tested
as new measure to control
Spread of MRSA in the
community
I. M. GOULD, et al. ICAAC 2004
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
X represents VRE culture positive sites
~ 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.
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:
Water
• Splash from sink drain, toilet flushing
• Faucet aerator, faucet, water lines
• Water from vase in surgical ward
Trautmann, 2005
Aeromonas,
Acinetobacter,
Pseudomonas,
Flavobacterium,
Flavimonas,
Legionella,
Mycobacteria
Factors influencing adherence to handhygiene 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 do
something
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 medicochirurgici, 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
ICU Varese: percentuali di resistenza ai farmaci
Staphylococcus aureus (2001-2005)
100
78,4
80
52,5
2001
60
2002
2003
2004
40
2005
20
0
i
ci ll
i
n
Pe
na
a
ll in
i
c
a
Ox
C
ina
c
a
x
flo
o
r
ip
Er
it
i ci
m
o
r
na
Ge
in a
c
i
m
nta
ICU Varese: percentuali di resistenza ai farmaci
Enterococcus faecium (2001-2005)
100
80
2001
60
2002
40
2003
2004
40
25
20
8
0
Am
a
lin
l
i
pic
m
nta
e
G
HL
a
n
ici
i co
Te
n
pla
ina
nc
Va
o
a
ci n
i
m
2005
ICU Varese: percentuali di resistenza ai farmaci
Pseudomonas aeruginosa (2001-2005)
60
50
38,5
33,7
40
2001
24,7
30
2002
2003
21,8
2004
2005
20
10
0
e
Pi p
i lli
rac
na
azo
t
er a
p
i
P
C
im e
d
i
az
ef t
C
pim
e
f
e
e
ICU Varese: percentuali di resistenza ai farmaci
Pseudomonas aeruginosa (2001-2005)
60
50,2
43,1
50
40
2001
2002
24,1
30
2003
2004
20
2005
6,7
10
0
in
kac
i
Am
a
Cip
a
c in
a
lo x
f
o
r
m
ne
e
ip
Im
Me
m
ne
e
rop
ICU Varese: percentuali di resistenza ai farmaci
Enterobacteriaceae (2001-2005)
100
80
2001
60
2002
2003
40
24,6
20,4
14,8
20
0
a
l in
l
i
c
pi
Am
o
Am
av.
l
c
xi -
C
m
id i
z
a
ef t
e
Ge
in a
c
i
m
nta
C
ina
c
a
x
flo
o
r
ip
2004
2005
Isolati di K. pneumoniae produttore di ESBL
in Terapia intensiva (2001-2005)
80
70
60
N. di isolati
50
40
30
20
38
25
10
1/20
2/19
3/15
1/17
2002
2003
2004
2005
0
2001
ESBL-positivi
ESBL-negativi
Isolati di E. coli produttore di ESBL
in Terapia intensiva (2001-2005)
80
70
60
N. di isolati
50
40
30
20
5/43
1/34
1/52
1/34
2/51
2001
2002
2003
2004
2005
10
0
ESBL-positivi
ESBL-negativi
Perugia, 11 maggio 2006
Il controllo delle resistenze batteriche si basa su
attività di: sorveglianza, controllo e formazione
Sorveglianza da laboratorio
Microrganismi sentinella (P. aeruginosa MDR, A. baumannii MDR, MRSA,
Enterobatteri produttori di ESBL, Enterococchi VRE)
Controllo delle resistenze
Epidemiologia delle resistenze
Profilassi antibiotica in chirurgia: protocolli e verifica applicativa
Prescrizione motivata di molecole antibiotiche di classi selezionate
Linee guida in patologie selezionate e nei trattamenti empirici
Gestione dei CVC e dei dispositivi medico-chirurgici
Protocollo lavaggio mani
Misure di isolamento (VRE, C. difficile)
Controllo del consumo da farmacia
Formazione
Migliorare la prescrizione di antibiotici con misure educative
Elaborare e diffondere le direttive interne all'ospedale per le indicazioni più
importanti
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