Post on 22-Jan-2016
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Paolo Grossi
Clinica Malattie Infettive e TropicaliUniversità degli Studi dell’Insubria –
Ospedale di Circolo e Fondazione Macchi, Varese
Le infezioni nelle Unità di Terapia Intensiva:
è possibile ridurne l’incidenza?
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
7,74,7
51,2
4,973,5
41,3
5 5,93,4
37,3
4,47,5
4,7
40,7
4,9
0
10
20
30
40
50
60
A'02 A'03 P'04 A'04
totale area chirurgica area critica area medica
Studi di prevalenza
% prevalenza
Prevalenza di pazienti con IN e durata degenza al momento dello studio
0
5
10
15
20
25
30
35
A'02 A'03 P'04 A'04
prevalenza %
DM infetti gg
DM non infetti gg
Tutto l’ospedale
Prevalenza di pazienti con IN e durata degenza al momento dello studio
0
5
10
15
20
25
30
35
40
45
A'02 A'03 P'04 A'04
prevalenza %
DM infetti gg
DM non infetti gg
Area critica
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 Incidence rates and distribution of pathogens most commonly isolated from monomicrobial nosocomial commonly isolated from monomicrobial nosocomial
BSIs and associated crude mortality rates for all BSIs and associated crude mortality rates for all patients, patients in ICU, and patients in non-ICU patients, patients in ICU, and patients in non-ICU
wards.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 Collateral Damage from Cephalosporins & QuinolonesCephalosporins & Quinolones
“…Neither third-generation cephalosporins nor quinolones appear suitable for sustained use in hospitals as “workhorse” antibiotic therapy….”
“Collateral damage’ is a term used to refer to ecological adverse effects of antibiotic therapy; namely, the selection of drug-resistant organisms and the unwanted development of colonization or infection with multidrug-resistant organisms.”
Paterson DL. Clin Infect Dis 2004:38(Suppl 4):S341-S345
Am J Infect Control 2004;32:470-85.
National Nosocomial Infections Surveillance National Nosocomial Infections Surveillance (NNIS) System Report, data summary from (NNIS) System Report, data summary from
January 1992 through June 2004January 1992 through June 2004
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)
_____________________________________________
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) _____________________________________________
Enterobatteri produttori di ESBL
Luzzaro F. et eal. JCM, May 2006, p. 1659–1664
16,2%
16,5%
52,4%
Terapia Intensiva Neurochirurgia Cardiochirurgia Pediatria
Onco-Ematologia Chirurgia Medicina
Chirurgia
MedicinaICU
SORVEGLIANZA NAZIONALE 2003Pazienti ospedalizzati (n=504)
CATANIAVIM-1
PALERMOVIM-1
VIM-11
PESCARAIMP-13
VERONAVIM-1 VIM-2
IMP-2
TRIESTEVIM-1 VIM-2
MILANOVIM-1
VARESEVIM-1 VIM-2
IMP-2 IMP-12 IMP-13
PISAVIM-4
SIENAVIM-1
PAVIAVIM-1VIM-2
S. GIOVANNI ROTONDO
IMP-13
GENOVAVIM-1
NAPOLIVIM-1-like
IMP-13
AVELLINOVIM-like IMP-13
ROMAVIM-1 VIM-2
IMP-2 IMP-13
SASSARIVIM-1-like
CREMONAVIM-2-like
FOGGIAVIM-like
ATRIIMP-13
L’AQUILAVIM-4
PERUGIAIMP-like
TORINOVIM-1
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.
P. aeruginosaP. putidaA. xylosoxydansAcinetobacter spp.
16th ECCMID Nice, 2006
45th ICAACWashington,
2005
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
I. M. GOULD, et al. ICAAC 2004
Screening at patient
discharge should be tested
as new measure to control
Spread of MRSA in the
community
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
~ 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.
X represents VRE culture positive sites
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:Origin of Nosocomial Infection Microorganisms: WaterWater
• Splash from sink drain, toilet flushing
• Faucet aerator, faucet, water lines
• Water from vase in surgical ward
Aeromonas, Acinetobacter,
Pseudomonas, Flavobacterium, Flavimonas,
Legionella, MycobacteriaTrautmann, 2005
Factors influencing adherence to hand-hygiene 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 dosomething
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 medico-chirurgici, 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
0
20
40
60
80
100
2001
2002
2003
2004
2005
ICU Varese: percentuali di resistenza ai farmaciStaphylococcus aureus (2001-2005)
78,4
52,5
0
20
40
60
80
100
2001
2002
2003
2004
2005
ICU Varese: percentuali di resistenza ai farmaciEnterococcus faecium (2001-2005)
25
8
40
0
10
20
30
40
50
60
2001
2002
2003
2004
2005
ICU Varese: percentuali di resistenza ai farmaciPseudomonas aeruginosa (2001-2005)
21,8
33,738,5
24,7
0
10
20
30
40
50
60
2001
2002
2003
2004
2005
ICU Varese: percentuali di resistenza ai farmaciPseudomonas aeruginosa (2001-2005)
24,1
6,7
50,2 43,1
0
20
40
60
80
100
2001
2002
2003
2004
2005
ICU Varese: percentuali di resistenza ai farmaciEnterobacteriaceae (2001-2005)
24,6
14,820,4
Isolati di K. pneumoniae produttore di ESBLin Terapia intensiva (2001-2005)
0
10
20
30
40
50
60
70
80
2001 2002 2003 2004 2005
ESBL-positivi ESBL-negativi
N.
di is
ola
ti
25
38
1/20 2/19 3/15 1/17
Isolati di E. coli produttore di ESBLin Terapia intensiva (2001-2005)
0
10
20
30
40
50
60
70
80
2001 2002 2003 2004 2005
ESBL-positivi ESBL-negativi
N.
di is
ola
ti
1/34 1/52 1/34 2/515/43
Perugia, 11 maggio 2006
Il controllo delle resistenze batteriche si basa su attività di: sorveglianza, controllo e formazione
Sorveglianza da laboratorioMicrorganismi sentinella (P. aeruginosa MDR, A. baumannii MDR, MRSA, Enterobatteri produttori di ESBL, Enterococchi VRE)
Controllo delle resistenzeEpidemiologia delle resistenzeProfilassi antibiotica in chirurgia: protocolli e verifica applicativaPrescrizione motivata di molecole antibiotiche di classi selezionate Linee guida in patologie selezionate e nei trattamenti empiriciGestione dei CVC e dei dispositivi medico-chirurgiciProtocollo lavaggio maniMisure di isolamento (VRE, C. difficile)
Controllo del consumo da farmacia
FormazioneMigliorare la prescrizione di antibiotici con misure educativeElaborare e diffondere le direttive interne all'ospedale per le indicazioni più importanti
Infectious Diseases Expert Resources
Infectious Diseases Specialists
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Surgical InfectionExperts
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