Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Nosocomial Infections
Distribution by site of infection
Other: C. difficile
Bloodstream Lung
Urinary Tract
Surgical Site
hDressings
CHG impregnated dressings
hPatients
CHG bathing (source control)
CA-BSI Hand hygiene Daily CVC review rate Optimal insertion site MSB for insertion 2% CHG for skin prep CHG bathing
Time
h complexity, redundancy
Line placement kits/carts, checklists
hApply newer approaches as needed hCHG dressings, bathing hMove prevention out of the ICU hLine placement and care teams
hOne third with VAP have no autopsy evidence hOne fourth without VAP have autopsy evidence hAspects of definition are subjective hConditions with similar clinical findings:
hatelectasis, pulmonary edema, thromboembolic dz, ARDS, alveolar hemorrhage, hypersensitivity pneumonitis, pulmonary contusion, combinations of disorders (e.g. BSI + pulmonary edema)
Klompas M. JAMA 2007;297:1583.
Subjectivity and inaccuracy in the VAP definition allow hospitals to undertake practices that will markedly decrease their VAP rates and yet do little or nothing to improve patient outcomes.
Klompas M, Platt R. Ann Intern Med 2007;147:803-805. Klompas M. Thorax 2009;64:463-65
Pathogenesis of VAP
hEntry of pathogens into lower respiratory tract colonization infection hLeakage/aspiration around ET tube Biofilm adherent to ET tube hInhalation of contaminated aerosols hDirect inoculation hHematogenous spread hInfection often multifocal hSampling issues?
Niederman, Craven, et al. Am J Resp Crit Care Med 2005;171:388-416.
Clostridium difficile
hAnaerobic, sporeforming bacillus hGram-positive hPresent in soil and environment hHospitals are major reservoirs
Main Host Defenses against CDAD hIntact microbiota of colon hHumoral immune response Events leading to CDAD: hAntimicrobial use hC. difficile exposure/carriage h? Defect in humoral immunity
hGreat geographic variability in rates of BI/NAP1 hAccounts for 61% of CDAD isolates from recent multicenter sample of acute care CDAD in Chicago
Black SR et al. Infect Control Hosp Epidemiol 2011;32(9):897-902
Transmission
hTransmitted via fecal-oral route hSpread via healthcare workers hands and contaminated environments hHand Hygiene hAlcohol-based hand cleaners do not eliminate spores. hMust wash hands with soap and water
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf http://www.cdc.gov/ncidod/dhqp/HAI_shea_idsa.html
hData suggest infection rates differ by site: FEMORAL > IJ > SUBCLAVIAN
Merrer, et al. JAMA 2001;286: 700-707. Mermel, et al. Am J Med 1991;91:197-205.
Educational program for catheter insertion Increase maximal barrier use 44% 65% Decrease CA-BSI 4.5 2.9 per 1000 pt days
Sherertz R, et al. Ann Intern Med 2000;132:641
Metanalysis: 7 studies of CHG versus P-I Pooled RR 0.5 (0.3-0.9), favored CHG
Ann Int Med 2002;136:792-801.
hMinocycline/rifampin: hSeveral randomized trials demonstrate reduction in CA-BSI compared with placebo
Raad I, et al. Ann Int Med 1997;128:267-74 Darouiche R, et al. NEJM 1999;340:1-8 Chatzinikolaou I, et al. Am J Med 2003;115:352-57. Hanna H, et al. J Clin Onc 2004;22:3163-71 Darouiche R, et al. Ann Surg 2005;242:192-200.
One of three RCTs demonstrated significant in VAP Overall trend favors semirecumbent position Patients should not be completely supine. Alexiou, et al. J Crit Care 2009;24:515-522
(1) Labeau, et al. Lancet ID 2011;11:845 (2) Kola et al. J Hosp Inf 2007;66:207.
Preventing VAP:
Antmicrobial (silver) coated ET tubes
h2003 pts randomized hAmong those intubated > 24 hrs: h4.8 vs. 7.5% microconfirmed VAP, p=0.03 hNo diff in vent days, LOS, mortality, MD suspicion of VAP hReducing VAP, or reducing colonizers?
Ventilator Associated Pneumonia: Risk Factors (partial list) hMechanical ventilation hRecumbent position hIncreased gastric pH aspiration hEnteral feeding h level of consciousness hAdvanced age hMale sex hPre-existing pulmonary disease
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm Niederman et al. Am J Resp Crit Care Med 2005;171:388-416.
hOnly four studies met inclusion criteria hAll had methodologic problems
All were before-after study designs Little information re diagnostic approach before and after Selection/publication bias, confounding? Resar et al. Jt Comm J Qual Pt Saf 2005;31:243. Berriel-Cass et al. Jt Comm J Qual Pt Saf 2006;32:612. Youngquist et al. Jt Comm J Qual Pt Saf 2007;33:219. Unahalekhaka et al. Jt Comm J Qual Pt Saf 2007;33:387.
hIs the bundle cost-effective? Which aspects are most important? Should new elements be added?
hRCT in 12 Italian ICUs, N = 600 adults hEarly trach (6-8 d) vs. late (13-15 d) hVAP: 14% early vs. 21% late (p=0.07) h risk for VAP (HR, 0.66 [0.42-1.04], remaining on vent (HR, 0.7 [0.56-0.87]), remaining in ICU (HR, 0.7 [0.55-0.97]), h Mortality risk, but NS (HR, 0.8)
Terragni, et al. JAMA 2010;303:1483
hInterpret clinical signs as strictly as possible hInterpret CXRs as strictly as possible hRequire consensus between 2 or more IPs hSeek intensivist endorsement before accepting case hRequire BAL for diagnosis hSet quantitative growth thresholds for diagnosis hTransfer patients who require prolonged ventilation hExpand surveillance to include uncomplicated postop patients
Am J Infect Cont 2011, Sept 22 (Epub ahead of print)