Search

To evaluate the relationship between antipseudomonal antibiotic consumption and each individual drug resistance rate in Pseudomonas aeruginosa strains causing ICU acquired invasive device-related infections (IDRI).A post hoc analysis was made of the data collected prospectively from the ENVIN-HELICS registry.Intensive Care Units participating in the ENVIN-UCI registry between the years 2007 and 2016 (3-month registry each year).Patients admitted for over 24h.Annual linear and nonlinear trends of resistance rates of P. aeruginosa strains identified in IDRI and days of treatment of each antipseudomonal antibiotic family per 1000 occupied ICU bed days (DOT) were calculated.A total of 15,095 episodes of IDRI were diagnosed in 11,652 patients (6.2% out of a total of 187,100). Pseudomonas aeruginosa was identified in 2095 (13.6%) of 15,432 pathogens causing IDRI. Resistance increased significantly over the study period for piperacillin-tazobactam (P0.001), imipenem (P=0.016), meropenem (P=0.004), ceftazidime (P=0.005) and cefepime (P=0.015), while variations in resistance rates for amikacin, ciprofloxacin, levofloxacin and colistin proved nonsignificant. A significant DOT decrease was observed for aminoglycosides (P0.001), cephalosporins (P0.001), quinolones (P0.001) and carbapenems (P0.001).No significant association was observed between consumption of each antipseudomonal antibiotic family and the respective resistance rates for P. aeruginosa strains identified in IDRI.

Epidemiology; Preventive medicine Epidemiologia, Medicina preventiva Epidemiología; Medicina preventiva Using categorical principal component analysis, we aimed to determine the relationship between health care-associated infections (HAIs) and diagnostic categories (DCs) in patients with acute heart disease using data collected in the Spanish prospective ENVIN-HELICS intensive care registry over a 10-year period (2005–2015). A total of 69,876 admissions were included, of which 5597 developed HAIs. Two 2-component CATPCA models were developed. In the first model, all cases were included; the first component was determined by the duration of the invasive devices, the ICU stay, the APACHE II score and the HAIs; the second component was determined by the type of admission (medical or surgical) and by the DCs. No clear association between DCs and HAIs was found. Cronbach’s alpha was 0.899, and the variance accounted for (VAF) was 52.5%. The second model included only admissions that developed HAIs; the first component was determined by the duration of the invasive devices and the ICU stay; the second component was determined by the inflammatory response, the mortality in the ICU and the HAIs. Cronbach’s alpha value was 0.855, and VAF was 46.9%. These findings highlight the role of exposure to invasive devices in the development of HAIS in patients with acute heart disease.

espanolObjetivo: conocer las dificultades en el cumplimiento de las recomendaciones segun la Care Bundle para prevenir las complicaciones asociadas a dispositivos de acceso vascular y valorar los factores asociados a las dificultades identificadas. Metodo: estudio transversal descriptivo. La poblacion de estudio fueron medicos y enfermeras del Hospital Universitario Arnau de Vilanova de Lleida (HUAV). Se administro un cuestionario pre y post-intervencion formativa, con un intervalo de cuatro meses. La formacion consistio en una sesion formativa de una hora de duracion dirigida a todos los profesionales del estudio sobre la importancia de aplicar las ocho recomendaciones mas relevantes de la Care Bundle. Se llevo a cabo un analisis descriptico y bivariante. Resultados: participaron 150 (31%) profesionales en la fase pre y 184 (38%) en la fase post-intervencion. Las dificultades mas prevalentes en ambas fases fueron: retirar los cateteres innecesarios (38 (25,3%) vs. 32 (17,4%)), el mantenimiento diario del cateter (47 (31,3%) vs. 48 (26,1%)), el manejo y/o acceso higienico al sistema circulatorio (44 (29,3) vs. 25 (13,6)) y recambiar los cateteres venosos perifericos segun protocolo (68 (45,6) vs. 73 (39,7)). Los factores asociados con dichas dificultades fueron principalmente ser enfermera (p Conclusiones: las dificultades mas prevalentes en el cumplimiento de las recomendaciones segun la Care Bundle fueron retirar los cateteres innecesarios, el mantenimiento diario de las vias centrales y/o perifericas, el manejo y/o acceso higienico al sistema circulatorio a traves del CVC o periferico, y el recambio de los cateteres venosos perifericos segun el protocolo. Los factores asociados a estas dificultades fueron la categoria profesional y la unidad donde se atiende al paciente. EnglishObjective: to understand the difficulties for implementing the recommendations according to the Care Bundle in order to prevent the complications associated with vascular access devices, and to assess those factors associated with the difficulties identified. Method: a descriptive transversal study, with a population formed by clinicians and nurses from the Hospital Universitario Arnau de Vilanova (HUAV) in Lleida. A pre-and-post training intervention questionnaire was applied, with a 4-month-interval. Training consisted in a 1-hour training session targeted to all professionals in the study, on the importance of implementing the eight most relevant recommendations in the Care Bundle. Descriptive and bivariate analysis was conducted. Results: the study included 150 (31%) professionals in the pre-intervention and 184 (38%) in the post-intervention stages. The most prevalent difficulties in both stages were: removing unnecessary catheters (38 (25.3%) vs. 32 (17.4%)), daily maintenance of catheters (47 (31.3%) vs. 48 (26.1%)), hygienic management and/or access to the circulatory system (44 (29.3) vs. 25 (13.6)) and replacing peripheral vein catheters according to protocol (68 (45.6) vs. 73 (39.7)). The factors associated with both difficulties were: mainly being a nurse (p Conclusions: the most prevalent difficulties for implementing the recommendations according to the Care Bundle were: removing unnecessary catheters, daily maintenance of central and/or peripheral IV lines, hygienic management and/or access to the circulatory system through central or peripheral venous catheter, and replacing peripheral vein catheters according to protocol. The factors associated with these difficulties were professional category and the unit where the patient is managed.

Length of stay is one of the key determinants for the risk of nosocomial infections. The distribution of this at-risk time is heavily skewed and depends on discharge or death. This study applied landmark competing risk prediction models to account for a large proportion of short-stay patients and a small proportion of long-stay patients.

Introduction Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies. Methods Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year. Results Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs. Conclusions Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.

Objective:To study the impact of duration of mechanical ventilation, hospitalization and multiple ventilation episodes on the development of pneumonia while accounting for extubation as a competing event.Design:A multicenter data base from a Spanish surveillance network was used to conduct a retrospective analysis of prospectively collected intensive care patients followed from admission to discharge.Setting:Spanish intensive care units (ICUs).Patients:Mechanically ventilated adult patients from 158 ICUs with 45,486 admissions, 48,705 ventilation episodes, and 314,196 ventilator days.Methods:Competing-risk models were applied to account for extubation plus 48 hours as a competing event for acquiring ventilator-associated pneumonia (VAP).Results:Time in the ICU before mechanical ventilation was associated with an increased VAP hazard rate and with longer intubation time. This indirect prolongation of intubation increased the cumulative risk to eventually acquire VAP. For instance, comparing 3–4 versus 0 days, the adjusted VAP hazard ratio was 1.40 (95% confidence interval [CI], 1.19–1.64) and the adjusted extubation hazard ratio was 0.64 (95% CI, 0.61–0.68), which leads to an adjusted VAP subdistribution hazard ratio (sHR) of 2.13 (95% CI, 1.83–2.50). Similarly, due to prolonged intubation, multiple ventilation episodes increase the risk for VAP; the adjusted sHR is 1.52 (95% CI, 1.35–1.72) for the second episode compared to the first episode, and the adjusted sHR is 1.54 (95% CI, 1.03–2.30) for the third episode compared to the first episode. The Kaplan-Meier method produced an upward biased estimated cumulative risk for VAP.Conclusions:A competing-risk analysis is necessary to receive unbiased risk estimates and to quantify the indirect effect of intubation time on the cumulative VAP risk. Our findings may guide physicians to improve medical decisions related to the harms and benefits of the duration of ventilation.

Analysing the determinants and consequences of hospital-acquired infections involves the evaluation of large cohorts. Infected patients in the cohort are often rare for specific pathogens, because most of the patients admitted to the hospital are discharged or die without such an infection. Death and discharge are competing events to acquiring an infection, because these individuals are no longer at risk of getting a hospital-acquired infection. Therefore, the data is best analysed with an extended survival model – the extended illness-death model. A common problem in cohort studies is the costly collection of covariate values. In order to provide efficient use of data from infected as well as uninfected patients, we propose a tailored case-cohort approach for the extended illness-death model. The basic idea of the case-cohort design is to only use a random sample of the full cohort, referred to as subcohort, and all cases, namely the infected patients. Thus, covariate values are only obtained for a small part of the full cohort. The method is based on existing and established methods and is used to perform regression analysis in adapted Cox proportional hazards models. We propose estimation of all cause-specific cumulative hazards and transition probabilities in an extended illness-death model based on case-cohort sampling. As an example, we apply the methodology to infection with a specific pathogen using a large cohort from Spanish hospital data. The obtained results of the case-cohort design are compared with the results in the full cohort to investigate the performance of the proposed method. Copyright © 2016 John Wiley & Sons, Ltd.

Objective: To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level. Design: Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study. Setting: Spanish ICU. Patients: Patients admitted for over 24 h. Interventions: None. Variables: Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period-was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel-and multivariate models were used for the analysis of mortality and were performed. in each stratum of severity level. Results: The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients >79 years (11.2% vs. 12.7%, P

ObjectiveCompeting risks are a necessary consideration when analyzing risk factors for nosocomial infections (NIs). In this article, we identify additional information that a competing risks analysis provides in a hospital setting. Furthermore, we improve on established methods for nested case-control designs to acquire this information.MethodsUsing data from 2 Spanish intensive care units and model simulations, we show how controls selected by time-dynamic sampling for NI can be weighted to perform risk-factor analysis for death or discharge without infection. This extension not only enables hazard rate analysis for the competing risk, it also enables prediction analysis for NI.ResultsThe estimates acquired from the extension were in good agreement with the results from the full (real and simulated) cohort dataset. The reduced dataset results averted any false interpretation common in a competing-risks setting.ConclusionsUsing additional information that is routinely collected in a hospital setting, a nested case-control design can be successfully adapted to avoid a competing risks bias. Furthermore, this adapted method can be used to reanalyze past nested case-control studies to enhance their findings.

Background Beta-lactam anti-infective levels after standard dosing have been shown to be subtherapeutic when renal clearance is augmented. Objective To determine if piperacillin and meropenem are found to be in their therapeutic range in infected critically ill patients when administered by continuous intravenous infusion (CII) assisted by a therapeutic drug monitoring (TDM) report issued by the pharmacy service. Methods This prospective non-controlled intervention study evaluated septic patients in an intensive care unit. Patients received a loading dose of meropenem or piperacillin-tazobactam and the antibiotics were afterwards administered by CII. Blood concentrations were determined by high-performance liquid chromatography assays. The adequacy of β-lactam therapy in the cohort subjected to intervention was assessed by determining whether plasma levels during CII were >4 times the informed minimum inhibitory concentration during the first 96 hours of treatment. Results A total of 124 patients were subject to TDM during antibiotic treatment but, for the analysis of the fulfilment of pharmacodynamic requirements, data from 31/124 (25%) were excluded. Of the whole cohort of treatment courses, 57/93 (61.3%) reached the target level. Plasma levels were adequate in 41/70 (58.6%) and 16/23 (69.6%) of the patients treated with piperacillin-tazobactam and meropenem, respectively. Globally, recommendations based on TDM results were followed in 35/93 (37.6%) of the treatment courses. Conclusions The results of the study show that, in critically ill patients with sepsis, there is a significant proportion of treatment courses where target levels are not reached even if the antibiotics are administered by CII and TDM support is provided by the pharmacy service. This TDM support should be offered on a real-time basis to be really useful.

To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators. Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance. Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p

Resumen La epidemiologia de las infecciones por Clostridium difficile (ICD) en pacientes criticos es escasa y centrada en estudios limitados en tiempo y/o en brotes epidemicos. Objetivo Describir las caracteristicas y los factores de riesgo de pacientes criticos ingresados en UCI con ICD, asi como los tratamientos utilizados para su control. Material y metodo Analisis retrospectivo de pacientes incluidos en el registro ENVIN-UCI con ICD en el ano 2012. Los pacientes se han seguido hasta 72 h despues de su alta de UCI. Se ha cumplimentado un cuaderno de recogida de datos, en el que se incluyen variables demograficas, factores de riesgo relacionados con Clostridium difficile, tratamiento y evolucion. Los aislamientos se han clasificado por su origen en comunitarios, nosocomiales extra-UCI y nosocomiales intra-UCI en funcion del dia de aislamiento. Se presentan las tasas por episodios por 10.000 dias de estancia en UCI. Se describe la mortalidad global intra-UCI y hospitalaria. Resultados Se han detectado 68 episodios de ICD en 33 (19,1%) UCI de las 173 participantes en el registro (2,1 episodios por 10.000 dias de estancia-UCI). En 45 (66,2%) casos eran hombres, con edad media de 63,4 (16,4) anos, APACHE II al ingreso de 19,9 (7,4) y enfermedad de base medica 44 (64,7%). En 62 (91,2%) ocasiones presentaron mas de 3 deposiciones liquidas/dia y en 40 (58,8%) se asocio con sepsis severa o shock septico. En 13 (19,1%) ocasiones fue de origen comunitario, en 13 (19,1%) de origen nosocomial extra-UCI y en 42 (61,8%) de origen intra-UCI. Factores de riesgo: edad > 64 anos 39 (57,4%), ingreso previo hospital (3 meses) 32 (45,6%), antimicrobianos (7 dias previos) 57 (83,8%), nutricion enteral 23 (33,8%) e inhibidores H2 39 (57,4%). Siguieron tratamiento inicial combinado 18 (26,5%) casos y se ha utilizado metronidazol en 60 (88,2%) y vancomicina en 31 (45,6%) casos. Hubo mortalidad global intra-UCI en 17 (25,0%) casos y hospitalaria de 19 (27,9%). Conclusiones La tasa de ICD en pacientes ingresados en UCI es baja y afecta a pacientes con elevada gravedad y mortalidad. La presencia de ICD es un marcador de mal pronostico.

Data on the epidemiology of infections caused by Clostridium difficile (CDI) in critically ill patients are scarce and center on studies with a limited time framework and/or epidemic outbreaks. Objective To describe the characteristics and risk factors of critically ill patients admitted to the ICU with CDI, as well as the treatments used for the control of such infections. Materials and methods A retrospective study was made of patients included in the ENVIN-ICU registry with CDI in 2012. Patients were followed up to 72 h after discharge from the ICU. A case report form was used to record the following data: demographic variables, risk factors related to CDI, treatment and outcome. Infections were classified as community-acquired, nosocomial out-ICU and nosocomial in-ICU, according to the day on which Clostridium difficile isolates were obtained. Infection rates as episodes per 10,000 days of ICU stay are presented. The global in-ICU and hospital mortality rates were calculated. Results Sixty-eight episodes of CDI in 33 out of a total of 173 ICUs participating in the registry were recorded (19.1%) (2.1 episodes per 10,000 days of ICU stay). Forty-five patients were men (66.2%), with a mean (SD) age of 63.4 (16.4) years, a mean APACHE II score on ICU admission of 19.9 (7.4), and an underlying medical condition in 44 (64.7%). Sixty-two patients (91.2%) presented more than 3 liquid depositions/day, 40 (58.8%) in association with severe sepsis or septic shock. Community-acquired infection occurred in 13 patients (19.1%), nosocomial out-ICU infection in 13 (19.1%), and in-ICU infection in 42 (61.8%). Risk factors included age > 64 years in 39 cases (57.4%), previous hospital admission (3 months) in 32 (45.6%), use of antimicrobials (previous 7 days) in 57 (83.8%), enteral nutrition in 23 (33.8%), and the use of H2 inhibitors in 39 (57.4%). Initial combined treatment was administered to 18 patients (26.5%). Metronidazole was used in 60 (88.2%) and vancomycin in 31 (45.6%). The in-ICU mortality rate was 25.0% (n = 17), with a hospital mortality 27.9% (n = 19). Conclusions The rate of ICD in ICU patients is low, the infection affects severely ill patients, and is associated with high mortality. The presence of CDI is a marker of poor prognosis.

Resumen El proyecto nacional Bacteriemia Zero (BZ) consiste en la aplicacion simultanea de un paquete de medidas para la prevencion de bacteriemias relacionadas con cateteres venosos centrales (B- CVC ) en los pacientes criticos y en el desarrollo de un plan integral en seguridad. El objetivo es presentar los resultados de la aplicacion del proyecto BZ en las unidades de cuidados intensivos (UCI) de la comunidad autonoma de Catalunya. Se han incluido todos los pacientes ingresados en las UCI participantes de Catalunya en el registro ENVIN-HELICS desde enero de 2009 hasta junio de 2010. Han aportado informacion 36 UCI (92,3%) de las 39 posibles. Se han diagnosticado 281 episodios de B-CVC (tasa global de 2,53 episodios por 1.000 dias de CVC). Las tasas han variado significativamente entre las UCI que han participado mas o menos de 12 meses en el proyecto (2,17 frente a 4,27 episodios por 1.000 dias de CVC, respectivamente; p La aplicacion del proyecto BZ en Catalunya ha disminuido la tasa de las B-CVC en las UCI de esta comunidad en mas del 40%, mejorando el objetivo inicial de 4 episodios por 1.000 dias de CVC.

"Zero-VAP" is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units (ICU) consisting of a bundle of ventilator-associated pneumonia (VAP) prevention measures.An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses, the project is supported by the Spanish Ministry of Health, and participation is voluntary. In addition to guidelines for VAP prevention, the "Zero-VAP" Project incorporates an integral patient safety program and continuous online validation of the application of the bundle. For the latter, VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program "ENVIN-HELICS" database, which provides continuous information about local, regional and national VAP incidence rates. Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation. A total of 35 preventive measures were initially selected. A task force of experts used the Grading of Recommendations, Assessment, Development and Evaluation Working Group methodology to generate a list of 7 basic "mandatory" recommendations (education and training in airway management, strict hand hygiene for airway management, cuff pressure control, oral hygiene with chlorhexidine, semi-recumbent positioning, promoting measures that safely avoid or reduce time on ventilator, and discouraging scheduled changes of ventilator circuits, humidifiers and endotracheal tubes) and 3 additional "highly recommended" measures (selective decontamination of the digestive tract, aspiration of subglottic secretions, and a short course of iv antibiotic).We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project. Compared to conventional guideline documents, the associated safety assurance program, the online data recording and compliance control systems, as well as the existence of a pre-defined objective are the distinct features of "Zero VAP".

Background.More than 10% of patients admitted to intensive care units (ICUs) experience a severe, healthcare-associated infection, such as ventilator-associated pneumonia (VAP) or bloodstream infection (BSI). What could be a public health target for prevention is hotly debated, because properly adjusting for intrinsic risk factors in the patient population is difficult. We aimed to estimate the proportion of ICU-acquired VAP and BSI cases that are amenable to prevention in routine conditions.Methods.We analyzed routine data collected prospectively according to the European standard protocol for patient-based surveillance of healthcare-acquired infections in ICUs. We computed the number of infections to be expected if, after adjustment for case mix, the infection incidence in ICUs with higher infection rates could be reduced to that of the top-tenth-percentile-ranked ICU. Computations came from model-based simulation of individual patient profiles over time in the ICU. The preventable proportion was computed as the number of observed cases minus the number of expected cases divided by the number of observed cases.Results.Data for 78,222 patients admitted for more than 2 days to 525 ICUs in 6 European countries from 2005 to 2008 were available for analysis. We calculated that 52% of VAP and 69% of BSI was preventable.Conclusions.Our pragmatic, if highly conservative, estimates quantify the potential for prevention of VAP and BSI in routine conditions, assuming that variation in infection incidence between ICUs can be eliminated with improved quality of care, apart from variation attributable to differential case mix.

Resumen Objetivo Analizar las infecciones en Pacientes criticos postOperados de Cirugia Cardiaca (POCC). Ambito Unidades de cuidados intensivos (UCI). Diseno Estudio observacional, prospectivo y multicentrico. Pacientes Se incluyeron los pacientes POCC incluidos en el registro ENVIN-HELICS entre los anos 2005-2011. Variables de interes principal Neumonias relacionadas con ventilacion mecanica (N-VM), infecciones urinarias relacionadas con sonda uretral (IU-SU), bacteriemias primarias y/o relacionadas con cateteres vasculares (BP-BCV) y bacteriemias secundarias (BS). Resultados De los 97.692 pacientes registrados 9.089 (9,3%) fueron POCC. En 440 (4,8%) POCC se identificaron una o mas de las infecciones controladas. La densidad de infeccion fue de 9,94 episodios de N-VM por 1.000 dias de VM; 3,4 episodios de IU-SU por 1.000 dias de SU, 3,10 episodios de BP-BCV por 1.000 dias de CVC; y 1,84 episodios de BS por 1.000 dias de estancia en UCI. Los factores de riesgo estadisticamente significativos fueron estancia en UCI (OR 1,18; IC95% 1,16-1,20), APACHE II al ingreso en UCI (OR 1,05; IC95% 1,03-1,07), cirugia urgente (OR 1,67; IC95% 1,13-2,47), tratamiento antibiotico previo (OR 1,38; IC95% 1,04- 1,83), colonizacion previa de Pseudomonas aeruginosa (OR 18,25; IC95% 3,74-89,06) o enterobacterias productoras de betalactamasas de espectro extendido (OR 16,97; IC95% 5,4-53,2). La mortalidad intra-UCI fue del 4,1%; del 32,2% en aquellos que desarrollaron una o mas infecciones y del 2,9% en los pacientes sin infeccion (p Conclusiones El 9,3% de los pacientes incluidos en el registro fueron POCC. La mortalidad global de los POCC es baja pero aumenta significativamente en aquellos que desarrollaron una o mas infecciones.

Objective To analyze postoperative infections in critically ill patients undergoing heart surgery. Setting Intensive care units (ICUs). Design An observational, prospective, multicenter study was carried out. Patients Patients in the postoperative period of heart surgery admitted to the ICU and included in the ENVIN-HELICS registry between 2005 and 2011. Main outcome variables Mechanical ventilation associated pneumonia (MVP), urinary catheter-related infection (UCI), primary bacteremia (PB), PB related to vascular catheters (PB-VC) and secondary bacteremia. Results Of a total of 97,692 patients included in the study, 9089 (9.3%) had undergone heart surgery. In 440 patients (4.8%), one or more infections were recorded. Infection rates were 9.94 episodes of MVP per 1000 days of mechanical ventilation, 3.4 episodes of UCI per 1000 days of urinary catheterization, 3.10 episodes of BP-VC per 1000 days of central venous catheter, and 1.84 episodes of secondary bacteremia per 1000 days of ICU stay. Statistically significant risk factors for infection were ICU stay (odds ratio [OR] 1.18, 95%CI 1.16–1.20), APACHE II upon admission to the ICU (OR 1.05, 95%CI 1.03–1.07), emergency surgery (OR 1.67, 95%CI 1.13–2.47), previous antibiotic treatment (OR 1.38, 95%CI 1.04–1.83), and previous colonization by Pseudomonas aeruginosa (OR 18.25, 95%CI 3.74–89.06) or extended spectrum beta-lactamase producing enterobacteria (OR 16.97, 95%CI 5.4–53.2). The overall ICU mortality rate was 4.1% (32.2% in patients who developed one or more infections and 2.9% in uninfected patients) (p Conclusions Of the patients included in the ENVIN-HELICS registry, 9.3% were postoperative heart surgery patients. The overall mortality was low but increased significantly in patients who developed one or more infection episodes.

Objective:Prevention of catheter-related bloodstream infection is a basic objective to optimize patient safety in the ICU. Building on the early success of a patient safety unit-based comprehensive intervention (the Keystone ICU project in Michigan), the Bacteremia Zero project aimed to assess its e

Objective To describe trends in national catheter-related urinary tract infection (CRUTI) rates, as well as etiologies and multiresistance markers. Design An observational, prospective, multicenter voluntary participation study was conducted from 1 April to 30 June in the period between 2005 and 2010. Setting Intensive Care Units (ICUs) that participated in the ENVIN-ICU registry during the study period. Patients We included all patients admitted to the participating ICUs and patients with urinary catheter placement for more than 24 h (78,863 patients). Intervention Patient monitoring was continued until discharge from the ICU or up to 60 days. Variables of interest CRUTIs were defined according to the CDC system, and frequency is expressed as incidence density (ID) in relation to the number of urinary catheter-patients days. Results A total of 2329 patients (2.95%) developed one or more CRUTI. The ID decreased from 6.69 to 4.18 episodes per 1000 days of urinary catheter between 2005 and 2010 ( p Escherichia coli strains (37.1%) increased, as well as imipenem-resistant (36.4%) and ciprofloxacin-resistant (37.1%) strains of Pseudomonas aeruginosa . Conclusions A decrease was observed in CRUTI rates, maintaining the same etiological distribution and showing increased resistances in gramnegative pathogens, especially E. coli and P. aeruginosa.

Predicting methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs) avoids inappropriate antimicrobial empirical treatment and enhances infection control. We describe risk factors for colonisation/infection related to MRSA (MRSA-C/I) in critically ill patients once in the ICU and on ICU admission, and search for an easy-to-use predictive model for MRSA colonisation/infection on ICU admission. This multicentre cohort study included 69,894 patients admitted consecutively (stay24h) in April-June in the five-year period 2006-2010 from 147 Spanish ICUs participating in the National Surveillance Study of Nosocomial Infections in ICUs (ENVIN-HELICS). Data from all patients included were used to identify risk factors for MRSA-C/I during ICU stays, from admission to discharge, using uni- and multivariable analysis (Poisson regression) to check that the sample to be used to develop the predictive models was representative of standard critical care population. To identify risk factors for MRSA-C/I on ICU admission and to develop prediction models, multivariable logistic regression analysis were then performed only on those admitted in 2010 (n=16950, 2/3 for analysis and 1/3 for subsequent validation). We found that, in the period 2006-2010, 1046 patients were MRSA-C/I. Independent risk factors for MRSA-C/I in ICU were: age65, trauma or medical patient, high APACHE-II score, admitted from a long-term care facility, urinary catheter, previous antibiotic treatment and skin-soft tissue or post-surgical superficial skin infections. Colonisation with several different MDRs significantly increased the risk of MRSA-C/I. Risk factors on ICU admission were: male gender, trauma critical patient, urgent surgery, admitted from other ICUs, hospital ward or long-term facility, immunosuppression and skin-soft tissue infection. Although the best model to identify carriers of MRSA had a good discrimination (AUC-ROC, 0.77; 95% CI, 0.72-0.82), sensitivity was 67% and specificity 76.5%. Including more complex variables did not improve prediction capability. Our conclusion is that clinical-demographic risk factors for colonisation/infection related to MRSA should not be used to accurately identify patients who would benefit from empirical anti-MRSA treatment or from specific preventive measures. Independent risk factors for MRSA colonisation/infection during ICU stay and on ICU admission are described. The latter should be considered in future studies for MRSA prediction.

In nested case-control studies, incidence density sampling is the time-dependent matching procedure to approximate hazard ratios. The cumulative incidence function can also be estimated if information from the full cohort is used. In the presence of competing events, however, the cumulative incidence function depends on the hazard of the disease of interest and on the competing events hazard. Using hospital-acquired infection as an example (full cohort), we propose a sampling method for nested case-control studies to estimate subdistribution hazard ratios. With further information on the full cohort, the cumulative incidence function for the event of interest can then be estimated as well.

Analysing the determinants and consequences of hospital-acquired infections involves the evaluation of large cohorts. Infected patients in the cohort are often rare for specific pathogens, because most of the patients admitted to the hospital are discharged or die without such an infection. Death and discharge are competing events to acquiring an infection, because these individuals are no longer at risk of getting a hospital-acquired infection. Therefore, the data is best analysed with an extended survival model - the extended illness-death model. A common problem in cohort studies is the costly collection of covariate values. In order to provide efficient use of data from infected as well as uninfected patients, we propose a tailored case-cohort approach for the extended illness-death model. The basic idea of the case-cohort design is to only use a random sample of the full cohort, referred to as subcohort, and all cases, namely the infected patients. Thus, covariate values are only obtained for a small part of the full cohort. The method is based on existing and established methods and is used to perform regression analysis in adapted Cox proportional hazards models. We propose estimation of all cause-specific cumulative hazards and transition probabilities in an extended illness-death model based on case-cohort sampling. As an example, we apply the methodology to infection with a specific pathogen using a large cohort from Spanish hospital data. The obtained results of the case-cohort design are compared with the results in the full cohort to investigate the performance of the proposed method. Copyright © 2016 John WileySons, Ltd.

Introduction: There are limited data about the use of antifungal agents (AF) in critically ill patients and treatment trends since the inclusion of the new generation AF. The use of these agents may have a significant influence on the development of new resistances. Methods: Observational prospective study of the systemic use of AF in patients admitted to Spanish intensive care units (ICU) participating in the ENVIN-HELICS register, from 2006 to 2010. The annual

The aim of the study was to assess the evolution of antibiotic consumption in acute care hospitals in Catalonia (population 7.5 million), according to hospital size and department, during the period 2007-2009. The methodology used for monitoring antibiotic consumption was the ATC/DDD system, and the unit of measurement was DDD/100 occupied bed-days (DDD/100 OBD). Hospitals were stratified according to size: I) large university hospitals (with more than 500 beds); II) medium-sized hospitals (between 200 and 500 beds); and III) small hospitals (fewer than 200 beds). The consumption was also analyzed and stratified according to department: medical, surgical and intensive care unit (ICU). Specific training in data management on antibiotic consumption was given to all participant hospitals before the implementation of the program. The mean antibiotic (J01) consumption, calculated in DDD/100 OBD, increased although without statistical significance (p=0.640): 74.68 (2007), 75.13 (2008) and 78.04 (2009). The values of the medians expressed in DDD/100 OBD in group I were 83.27 (in 2007), 82.16 (2008) and 86.93 (2009), in group II 72.60 (2007), 70.78 (2008) and 75.17 (2009) and in group III 65.66 (2007), 69.32 (2008) and 72.39 (2009). Antibiotic consumption was higher in large hospitals than in medium-sized or small hospitals. Catalan hospitals recorded an increase of 4.49% from 2007 to 2009, especially due to the rising use of carbapenems, cephalosporins, monobactams and the other antibiotic groups.

Infections occurring among outpatients having recent contact with the health-care system have been recently classified as health-care-associated infections to distinguish them from hospital- and community-acquired infections. Patients with bloodstream infections (BSIs) were studied to assess health-care-associated infections at admission in the ICU.This work was a multicenter, prospective, observational study of all adult patients with BSI at ICU admission at 27 Spanish hospitals and one Argentine hospital. Cases of BSI were classified as community-acquired BSI (CAB), health-care-associated BSI (HCAB), or hospital-acquired BSI (HAB), and their characteristics were compared.Of 726 BSIs, 343 (47.2%) were CABs, 252 (34.7%) were HABs, and 131 (18.0%) were HCABs. Potentially antibiotic-resistant pathogens were more frequently isolated in HABs (34.8%) and HCABs (27.6%) than in CABs (10.3%) (P.001). Logistic regression analysis revealed that HABs (OR, 4.6; 95% CI, 2.9-7.3), HCABs (OR, 3.1; 95% CI, 1.8-5.4), and BSIs of unknown origin (OR, 1.7; 95% CI, 1.0-2.8) were independently associated with the isolation of potentially antibiotic-resistant pathogens. The incidence of inappropriate treatment was significantly higher in HABs (OR, 3.4; 95% CI, 2.1-5.3) and in HCABs (OR, 1.8; 95% CI, 1.0-3.2) than in CABs.One in five BSIs diagnosed at ICU admission is health-care-associated. The incidence of potentially drug-resistant pathogens in HCABs is more similar to that of HABs, and they should be treated as such until culture data are available.

Inappropriate empirical antibiotic therapy for severe infections in the intensive care unit is a modifiable prognostic factor that has a great effect on patient outcome and health care resources. Inappropriate treatment is usually associated with microorganisms resistant to the common antibiotics, which must be empirically targeted when risk factors are present. Previous antibiotic exposure, prolonged length of hospital stay, admission category, local susceptibilities, colonization pressure, and the presence of invasive devices increase the likelihood of infection by resistant pathogens. Consideration of issues beyond in vitro susceptibility, such as antibiotic physicochemistry, tissue penetration, and pharmacokinetic/pharmacodynamic-driven dosing, is mandatory for the optimization of antibiotic use.

Purpose To explore the impact of length-biased sampling on the evaluation of risk factors of nosocomial infections (NIs) in point-prevalence studies. Methods We used cohort data with full information including the exact date of the NI and mimicked an artificial 1-day prevalence study by picking a sample from this cohort study. Based on the cohort data, we studied the underlying multistate model which accounts for NI as an intermediate and discharge/death as competing events. Simple formulas are derived to display relationships between risk, hazard, and prevalence odds ratios. Results Due to length-biased sampling, long stay and thus sicker patients are more likely to be sampled. In addition, patients with NIs usually stay longer in hospital. We explored mechanisms that are—due to the design—hidden in prevalence data. In our example, we showed that prevalence odds ratios were usually less pronounced than risk odds ratios but more pronounced than hazard ratios. Conclusions Thus, to avoid misinterpretation, knowledge of the mechanisms from the underlying multistate model is essential for the interpretation of risk factors derived from point-prevalence data.

The prevalence of hospital-acquired Methicillin-resistant Staphylococcus aureus (MRSA) infections shows a huge variety across Europe. Some countries reported a reduction in MRSA frequency, while in others countries increasing MRSA rates have been observed. To reduce the spread of MRSA in the healthcare setting, a sufficient MRSA management is essential. In order to reflect the MRSA management across Europe, MRSA prevention policies were surveyed in ten countries. The survey was performed by questionnaires in European intensive care units (ICUs) and surgical departments (SDs) in 2004. Questionnaires asked for availability of bedside alcohol hand-disinfection, isolation precautions, decolonization and screening methods. The study was embedded in the Hospital in Europe Link for Infection Control through Surveillance (HELICS) Project, a European collaboration of national surveillance networks. HELICS was initiated in order to harmonize the national surveillance activities in the individual countries. Therefore, HELICS participants developed surveillance modules for nosocomial infections in ICUs and for surgical site infections (SSI). The coordination of this surveillance has now been transferred to the European Centre for Disease Prevention and Control (ECDC). A total of 526 ICUs and 223 SDs from ten countries sent data on organisational characteristics and policies, demonstrating wide variations in care. Substantial variation existed in availability of bedside alcohol hand-disinfection, which was much higher in participating ICUs rather than in SDs (86 vs. 59%). Surveillance cultures of contact patients were obtained in approximately three-fourths of all SDs (72%) and ICUs (75%). Countries with decreasing MRSA proportions showed especially strict implementation of various prevention measures. The data obtained regarding MRSA prevention measures should stimulate infection control professionals to pursue further initiatives. Particularly, the vigorous MRSA management in countries with decreasing MRSA proportions should encourage hospitals to implement preventive measures in order to reduce the spread of MRSA.

Bacteremia and endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) are prevalent and clinically important. The rise in MRSA bacteremia and endocarditis is related with the increasing use of venous catheters and other vascular procedures. Glycopeptides have been the reference drugs for treating these infections. Unfortunately their activity is not completely satisfactory, particularly against MRSA strains with MICs > 1 microg/mL. The development of new antibiotics, such as linezolid and daptomycin, and the promise of future compounds (dalvabancin, ceftobiprole and telavancin) may change the expectatives in this field.The principal aim of this consensus document was to formulate several recommendations to improve the outcome of MRSA bacteremia and endocarditis, based on the latest reported scientific evidence. This document specifically analyzes the approach for three clinical situations: venous catheter-related bacteremia, persistent bacteremia, and infective endocarditis due to MRSA.

This study was performed to evaluate associations between organisational characteristics, routine practices and the incidence densities of central venous catheter-associated bloodstream infections (CVC-BSI rates) in European intensive care units (ICUs) as part of the HELICS project (Hospitals in Europe Link for Infection Control through Surveillance). Questionnaires were sent to ICUs participating in the national nosocomial infection surveillance networks in 2004. The national networks were asked for the CVC-BSI rates of the ICUs participating for the time period 2003--2004. Univariate and multivariate risk factor analyses were performed to identify which practices had the greatest impact on CVC-BSI rates. A total of 526 ICUs from 10 countries sent data on organisational characteristics and practices, demonstrating wide variation in care. CVC-BSI rates were also provided for 288 ICUs from five countries. This made it possible to include 1383444 patient days, 969897 CVC days and 1935 CVC-BSI cases in the analysis. Adjusted logistic regression analysis showed that the categorical variables of country [odds ratio (OR) varying per country from OR: 2.3; 95% confidence interval (CI): 0.5-10.2; to OR: 12.8; 95% CI: 4.4-37.5; in reference to the country with the lowest CVC-BSI rates] and type of hospital 'university' (OR: 2.08; 95% CI: 1.02-4.25) were independent risk factors for high CVC-BSI rates. Substantial variation existed in CVC-BSI prevention activities, surveillance methods and estimated CVC-BSI rates among the European countries. Differences in cultural, social and legal perspectives as well as differences between healthcare systems are crucial in explaining these differences.

Los indicadores de infeccion nosocomial (IN) son una expresion de la calidad asistencial asi como de la seguridad de los pacientes durante su estancia en el hospital. La cuantificacion de los indicadores de infeccion se realiza mediante la aplicacion de sistemas y/o programas de vigilancia. Los sistemas actuales de vigilancia de IN se basan tanto en estudios de prevalencia como de incidencia. En Espana se realiza desde el ano 1990 el estudio de prevalencia EPINE, promovido por la Sociedad Espanola de Medicina Preventiva, Salud Publica e Higiene, que ha desarrollado 25 indicadores relacionados con IN en el conjunto de pacientes hospitalizados. Asimismo, desde el ano 1994, se realiza el estudio de incidencia ENVIN-HELICS promovido por el Grupo de Trabajo de Enfermedades Infecciosas de la Sociedad Espanola de Medicina Intensiva, Critica y Unidades Coronarias que ha desarrollado 9 indicadores relacionados con infeccion adquirida en unidades de cuidados intensivos (UCI) en pacientes criticos. La participacion en ambos sistemas de vigilancia es voluntaria y ha crecido de forma progresiva ano tras ano. Los dos sistemas de vigilancia ofrecen resultados de diferentes realidades en el entorno de la IN son complementarios entre si y han contribuido a crear una formacion y una sensibilizacion del personal sanitario ante la IN y la seguridad del paciente. Este articulo muestra los indicadores correspondientes al ano 2007 obtenidos por ambos programas, asi como los estandares de referencia.

To assess the risk factors associated with CR-BSI development in critically ill patients with non-tunneled, non-cuffed central venous catheters (CVC) and the prognosis of the episodes of CR-BSI. Design and setting; prospective, observational, multicenter study in nine Spanish Hospitals. All subjects admitted to the participating ICUs from October 2004 to June 2005 with a CVC. None. Overall, 1,366 patients were enrolled and 2,101 catheters were analyzed. Sixty-six episodes of CR-BSI were diagnosed. The incidence of CR-BSI was significantly higher in CVC compared with peripherically inserted central venous catheters (PICVC) without significant differences among the three locations of CVC. In the multivariate analysis, duration of catheterization and change over a guidewire were the independent variables associated with the development of CR-BSI whereas the use of a PICVC was a protective factor. Excluding PICVC, 1,598 conventional CVC were analyzed. In this subset, duration of catheterization, tracheostomy and change over a guidewire were independent risk factors for CR-BSI. A multivariate analysis of predictors for mortality among 66 patients with CRSI showed that early removal of the catheter was a protective factor and APACHE II score at the admission was a strong determinant of in-hospital mortality. Peripherically inserted central venous catheters is associated with a lower incidence of CR-BSI in critically ill patients. Exchange over a guidewire of CVC and duration of catheterization are strong contributors to CR-BSI. Our results reinforce the importance of early catheter removal in critically ill patients with CR-BSI.

The incidence of invasive mycoses following solid organ transplant (SOT) ranges from 5 to 42% depending on the organ transplanted. Despite the increasing impact of viral infections in SOT, fungal infections still have a main role in transplant recipients. In fact, they remain a common cause of morbidity and mortality in the early and late post-transplant periods. Aspergillus spp. and Candida spp. account for most IFI, but recent epidemiological and clinical studies suggest the emergence of mycelia fungi other than Aspergillus as well as resistant strains of Candida in these patients. Due to the difficulty in making a definitive diagnosis, the treatment is sometimes delayed or is not prescribed (post-mortem diagnosis). Serological and molecular detection of Aspergillus antigens or fungal DNA, in blood and/or BAL samples, may improve the diagnosis of pulmonary aspergillosis, but in SOT the sensitivity is variable and more studies are needed. Another pendent issue is antifungal prophylaxis in SOT recipients; it is unknown which is the best agent or the time duration, and in which receptors must be applied. Treatment combining AmB preparations, newer antifungal drugs, early surgical resection of infected tissue and discontinuation or modulation of immunosuppressive treatment can to be necessary in selected patients and in certain occasions, and all of them may improve prognosis of IFI. However, there are two main handicaps in the management of FI in transplant recipients: firstly, to establish an early diagnosis, secondly, delays in applying early treatment with antifungal drugs. Development of new early diagnostic tools more precise and well-designed multicenter evaluations of diagnostic methods and therapeutic regimens available at present are the important work in the next 3-5 years. This review highlights changing spectrum of invasive fungal infections, risk factors, antifungal prophylaxis, and treatment following SOT.

OBJECTIVES: We provide a case-cohort approach and show that a full competing risk analysis is feasible even in a reduced data set. Competing events for hospital-acquired infections are death or discharge from the hospital because they preclude the observation of such infections. STUDY DESIGN AND SETTING: Using surveillance data of 6,568 patient admissions (full cohort) from two Spanish intensive care units, we propose a case-cohort approach which uses only data from a random sample of the full cohort and all infected patients (the cases). We combine established methodology to study following measures: event-specific as well as subdistribution hazard ratios for all three events (infection, death, and discharge), cumulative hazards as well as incidence functions by risk factor, and also for all three events. RESULTS: Compared with the values from the full cohort, all measures are well approximated with the case-cohort design. For the event of interest (infection), event-specific and subdistribution hazards can be estimated with the full efficiency of the case-cohort design. So, standard errors are only slightly increased, whereas the precision of estimated hazards of the competing events is inflated according to the size of the subcohort. CONCLUSION: The case-cohort design provides an appropriate sampling design for studying hospital-acquired infections in a reduced data set. Potential effects of risk factors on the competing events (death and discharge) can be evaluated. This study was funded by the German Research Foundation (Deutsche Forschungsgemeinschaft) (grant no WO 1746/1-2). M.W. received funding from Deutsche Forschungsgemeinschaft.

Severe sepsis and septic shock are common causes of death in intensive care units (ICU). The incidence of sepsis has been increasing over the past two decades, and is expected to continue rising during the next few years. Despite the fact that we know much about the complex pathophysiologic alterations that occur in severe sepsis and septic shock, patients with sepsis remain at a high risk of death. However, in the last few years, new treatment strategies have significantly improved patient outcome. This article reviews nine major studies published during 2004 and 2005: two deal with incidence rates, distribution of pathogens and trends in antibiotic resistance among ICU patients with sepsis; two discuss selected aspects of antibiotic therapy, the usefulness of combination therapy for sepsis in immunocompetent patients and the impact of empirical treatment in Pseudomonas aeruginosa bloodstream infections; two consider the usefulness of risk assessment in the management of sepsis and the importance of dynamic clinical evolution of critically ill patients with infection. The remaining three studies analyze adjunctive therapy in severe sepsis: the effect of an intensive glucose-management protocol on the outcome of critically ill patients; the evaluation of relative adrenal insufficiency and the variability of cortisol plasma concentrations over a 24-hour period; and the use of Drotrecogin alfa (Activated) for adults with severe sepsis and a low risk of death.

Objective To know the patterns and consumption trends (2008-2013) of antifungal agents for systemic use in 52 acute care hospitals affiliated to VINCat Program in Catalonia (Spain). Methods Consumption was calculated in defined daily doses (DDD)/100 patient-days and analyzed according to hospital size and complexity and clinical departments. Results Antifungal consumption was higher in intensive care units (ICU) (14.79) than in medical (3.08) and surgical departments (1.19). Fluconazole was the most consumed agent in all type of hospitals and departments. Overall antifungal consumption increased by 20.5%during the study period (p = 0.066); a significant upward trend was observed in the consumption of both azoles and echinocandins. In ICUs, antifungal consumption increased by 12.4% (p = 0.019). Conclusions The study showed a sustained increase in the overall consumption of systemic antifungals in a large number of acute care hospitals of different characteristics in Catalonia. In ICUs there was a trend towards the substitution of older agents by the new ones.