Onset Of Nosocomial Infection Research Articles

Low incidence of multidrug-resistant bacteria and nosocomial infection due to a preventive multimodal nosocomial infection control: a 10-year single centre prospective cohort study in neurocritical care

BackgroundNosocomial infection (NI) control is an important issue in neurocritical care due to secondary brain damage and the increased morbidity and mortality of primary acute neurocritical care patients. The primary aim of this study was to determine incidence of nosocomial infections and multidrug-resistant bacteria and seek predictors of nosocomial infections in a preventive multimodal nosocomial infection protocol in the neurointensive care unit (NICU). The secondary aim focused on their impact on stay, mortality and cost in the NICU.MethodsA10-year, single-centre prospective observational cohort study was conducted on 3464 acute brain disease patients. There were 198 (5.7%) patients with nosocomial infection (wound 2.1%, respiratory 1.8%, urinary 1.0%, bloodstream 0.7% and other 0.1%); 67 (1.9%) with Extended spectrum beta-lactamase (ESBL); 52 (1.5%) with Methicillin-resistant Staphylococcus aureus (MRSA), nobody with Vancomycin-resistant enterococcus (VRE). The protocol included hygienic, epidemiological status and antibiotic policy. Univariate and multivarite logistic regression analysis was used for identifying predictors of nosocomial infection.ResultsFrom 198 NI patients, 153 had onset of NI during their NICU stay (4.4%; wound 1.0%, respiratory 1.7%, urinary 0.9%, bloodstream 0.6%, other 0.1%); ESBL in 31 (0.9%) patients, MRSA in 30 (0.9%) patients. Antibiotics in prophylaxis was given to 63.0% patients (59.2 % for operations), in therapy to 9.7% patients. Predictors of NI in multivariate logistic regression analysis were airways (OR 2.69, 95% CI 1.81-3.99, p<0.001), urine catheters (OR 2.77, 95% CI 1.00-7.70, p=0.050), NICU stay (OR 1.14, 95% CI 1.12-1.16, p<0.001), transfusions (OR 1.79, 95% CI 1.07-2.97, p=0.025) antibiotic prophylaxis (OR 0.50, 95% CI 0.34-0.74, p<0.001), wound complications (OR 2.30, 95% CI 1.33-3.97, p=0.003). NI patients had longer stay (p<0.001), higher mortality (p<0.001) and higher TISS sums (p<0.001) in the NICU.ConclusionsThe presented preventive multimodal nosocomial infection control management was efficient; it gave low rates of nosocomial infections (4.2%) and multidrug-resistant bacteria (ESBL 0.9%, MRSA 0.9% and no VRE). Strong predictors for onset of nosocomial infection were accesses such as airways and urine catheters, NICU stay, antibiotic prophylaxis, wound complications and transfusion. This study confirmed nosocomial infection is associated with worse outcome, higher cost and longer NICU stay.

Impact of functional status on the onset of nosocomial infections in an acute care for elders unit.

To assess the role of functional status as a risk factor for nosocomial infections in the elderly. Prospective study. Acute care for elders units of university hospital of Grenoble. All patients over 75 years old consecutively hospitalized between January and April 2007. The main judgement criteria was the rate of nosocomial infection during the hospital stay, defined according to the French technical comity against nosocomial infections. Other data included functional status at baseline and admission (Katz' ADL), usual risk factors for nosocomial infections, demographic and geriatric assessment data. The study included 223 patients. The mean age was 86.7±6.5 years. A nosocomial infection was diagnosed for 17.0% of the patients. In univariate analysis, the number of medicines, pressure sore, pneumonia diagnosis, illness severity, indwelling bladder catheter, IADL at baseline, and all disability parameters (ADL at baseline, ADL at admission, recent functional decline) were significantly associated with nosocomial infection (p<0.05). In multivariate analysis considering functional status at admission, indwelling bladder catheter (OR=4.43), severe disability at admission (OR=4.42) and illness severity (OR=2.68) were independently associated with nosocomial infection (p<0.05). In a second analysis considering functional status at baseline, only disability at baseline was independently associated with the onset of a nosocomial infection (OR=2.21). Our results suggest a significant impact of functional impairment on the incidence of nosocomial infections in hospitalized elderly population. Disability is a higher risk factor for nosocomial infections than the usual and well-known other parameters. Larger prospective studies are needed to examine the power of this relationship.

Impact of functional status on the onset of nosocomial infections in an acute care for elders unit

Objective To assess the role of functional status as a risk factor for nosocomial infections in the elderly.

Use of Nutrition to Prevent Stress‐induced Immunosuppression in the Pediatric Intensive Care Unit: A Clinical Trials Minefield

utrition measures intended to prevent stressinduced, immunosuppression-related morbidity in critically ill patients are receiving increased attention. Supplements such as glutamine, arginine, ω-3 fatty acids, antioxidants, zinc, and others have become candidates for such prophylaxis. Infections, especially sepsis, which occur all too commonly, are targets of these interventions. The mechanistic foundations on which these interventions are based are largely derived from studies of highly stressed animals and from cell cultures. These studies have provided a strong rationale for several treatments, especially glutamine supplementation. Furthermore, several single-center studies as well as meta-analyses of these studies in critically ill adults reveal a significant benefit of glutamine supplementation on mortality, length of stay, and infectious morbidity. Glutamine supplementation has become standard of care in certain populations. Randomized, multicenter clinical trials using glutamine as both nutrition replacement and pharmacologic intervention, independent of nutrition needs, are ongoing in adults. In this issue of the Journal of Parenteral and Enteral Nutrition (JPEN), Carcillo and colleagues 1 propose a multicenter randomized trial of glutamine, zinc, selenium, and parenteral metoclopramide, titled prevention of Critical Illness Stress-induced Immune Suppression (CRISIS) in the pediatric intensive care unit (PICU), and present the plan for this trial. The trial is designed to determine whether this intervention prolongs the time until onset of nosocomial infection or sepsis and secondarily decreases the rate of nosocomial infection or clinical sepsis per 100 PICU days; the trial also will determine the number of antibiotic-free days, the incidence of prolonged lymphopenia, and all-cause 28-day mortality.

Rationale and Design of the Pediatric Critical Illness Stress‐Induced Immune Suppression (CRISIS) Prevention Trial

Despite implementation of CDC recommendations and bundled interventions for preventing catheter-associated blood stream infection, ventilator-associated pneumonia, or urinary catheter-associated infections, nosocomial infections and sepsis remain a significant cause of morbidity and mortality in critically ill children. Recent studies suggest that acquired critical illness stress-induced immune suppression (CRISIS) plays a role in the development of nosocomial infection and sepsis. This condition can be related to inadequate zinc, selenium, and glutamine levels, as well as hypoprolactinemia, leading to stress-induced lymphopenia, a predominant T(H)2 monocyte/macrophage state, and subsequent immune suppression. Prolonged immune dysfunction increases the likelihood of nosocomial infections associated with invasive devices. Although strategies to prevent common complications of critical illness are routinely employed (eg, prophylaxis for gastrointestinal bleeding, thrombophlebitis), no prophylactic strategy is used to prevent stress-induced immune suppression. This is the authors' rationale for the pediatric CRISIS prevention trial (NCT00395161), designed as a randomized, double-blind, controlled clinical investigation to determine if daily enteral supplementation with zinc, selenium, and glutamine as well as parenteral metoclopramide (a dopamine 2 receptor antagonist that reverses hypoprolactinemia) prolongs the time until onset of nosocomial infection or sepsis in critically ill children compared to enteral supplementation with whey protein. If effective, this combined nutritional and pharmacologic approach may lessen the excess morbidity and mortality as well as resource utilization associated with nosocomial infections and sepsis in this population. The authors present the design and analytic plan for the CRISIS prevention trial.

Screening for Multidrug-Resistant Bacteria as a Predictive Test for Subsequent Onset of Nosocomial Infection

To investigate whether carriage of multidrug-resistant bacteria is a risk factor for nosocomial infection and whether detection of carriage is predictive of subsequent onset of nosocomial infection. In this observational cohort (study period, June 1998 through October 2002), nasal and rectal swab specimens from 412 consecutive patients admitted to the intensive care unit were tested for carriage of multidrug-resistant bacteria. Concomitantly, the bacteria responsible for any subsequent nosocomial infection, the date of infection, and some of the known clinical risk factors for nosocomial infection were noted. These factors were adjusted for potential confounders, using a Cox model stratified on the propensity score of multidrug-resistant bacteria carriage. The diagnostic characteristics of a carriage test, including the positive and negative diagnostic likelihood ratios, were calculated for all strata of the propensity score. Forty-two patients were carrying multidrug-resistant bacteria. Nosocomial infection occurred in 95 patients, of whom 16 (38%) were carriers, and 79 (83%) were noncarriers (P=.01). After adjustment for potential confounders, statistical analysis revealed that carriage remained a risk factor for nosocomial infection (relative risk, 2.08 [95% confidence interval {CI}, 1.13-3.81]). Receipt of antibiotic treatment at the time of intensive care unit admission was found to be protective against nosocomial infection. A positive result of test for detection of carriage seemed to be an efficient predictor of subsequent nosocomial infection (positive diagnostic likelihood ratio, 2.05 [95% CI, 1.15-3.66]), although a negative test result was not a predictor of subsequent nosocomial infection (negative likelihood ratio, 0.91 [95% CI, 0.73-1.11]). Carriage proved to be a risk factor for subsequent nosocomial infection. However, the carriage test was useful as a predictive tool only for patients with a positive test result.

Impact of an Infection Control Program in an Intensive Care Unit in France

To evaluate the impact of an infection control program in an intensive care unit (ICU). Prospective before-after study. Two 6-month study periods were compared; between these periods, an infection control program based on isolation was implemented. Polyvalent ICU of Montpellier Teaching Hospital.Patients. Any patient who was hospitalized in the ICU for >48 hours and was discharged during 1 of the 2 periods. The main patient-related variables were sex, age at admission, type of patient (surgical, medical, or trauma), Simplified Acute Physiology Score II, length of ICU stay, need for intubation, duration of exposure to invasive devices, onset of nosocomial infection and pathogens responsible, and death. We compared the 2 study periods with respect to the incidence of 4 nosocomial infections (pneumonia, urinary tract infection, bacteremia, and catheter-associated infection), the frequency of infection with the main multidrug-resistant pathogens, and patient survival. Patients in periods 1 and 2 were similar with regard to sex, age, physiology score, and exposure to invasive devices. The rates of infection with multidrug-resistant pathogens were significantly lower during period 2 than during period 1 (infection rate: 28.1% of patients in period 1 and 9.6% of patients in period 2 [P = .01]; pneumonia rate: 32.6% of patients in period 1 and 4.2% of patients in period 2 [P = .008]). The mortality rate among patients with nosocomial pneumonia was 38.2% in period 1 and 4.3% in period 2 (P = .009). After implementation of an infection control program, the rate of infection with multidrug-resistant pathogens decreased, as did the mortality rate among patients with nosocomial pneumonia.

Physiopathologie du sepsis sévère

Regarding the definition. Severe sepsis associates an explosive inflammatory reaction and organ failure. It is secondary to bacterial, fungal or viral infection. It can be at the origin of acute circulatory failure (state of septic shock). Response of the organism to infection. The presence of certain components of the membrane of pathogenic agents induces the release of various mediators in cascade, notably cytokines. Toll-like receptors (10 cloned in humans) intervene in the detection of microbes and in the inherent and subsequently adaptive immune response. Immune paralysis. The release of pro-inflammatory mediators characterizes the initial phase of sepsis. Persistence of the latter provokes acquired immunodepression, related to an anti-inflammatory profile, and hence to a delayed decrease in hypersensitivity, an incapacity to cope with the infection and the onset of nosocomial infections. The role of the mediators. During sepsis, the cytokines are predominantly pro-inflammatory (TNF-alpha and notably IL-1beta) whereas others, produced concomitantly or subsequently, are predominantly anti-inflammatory (IL-10 in particular). In fact, the majority of the cytokines have multiple and intrinsic effects, they mediate immune defense but also pathological manifestations. Many other mediators intervene: coagulation or complement systems, contact system, breakdown products of the phospholipid membrane, arachidonic acid metabolites, free radicals and nitrous oxide. Endocrine and metabolic dysregulations. The concept of relative adrenal insufficiency and peripheral syndrome of resistance to glycocorticosteroids have led to hormone replacement therapy during septic shock. Acute insulin resistance has also been described. The role of the endothelium and coagulation. The endothelium plays a key part in the onset of vascular insufficiency during sepsis due to abnormalities in vasomotricity and thrombomodulation. The anticoagulant regulating system is perturbed; there is a decrease in protein C with inactivation of its active form, which has pro-fibrinolytic properties, and a decrease in antithrombin III. Regarding myocardial dysfunction During septic shock there is often severe left ventricular systolic dysfunction, sometimes also involving the right ventricle, largely under-diagnosed despite its severe prognosis, and associated with reduced or even collapsed heart rate.

Association between severity of illness and mortality from nosocomial infection

Background: For the years 1987 through 1992, a study was undertaken to analyze nosocomial infection mortality data and to stratify risk according to severity of underlying illness to compare with published data from the Centers for Disease Control and Prevention. Methods: Nosocomial infections that contributed to or caused death were identified. In addition, during 1990 through 1992, severity of illness was determined as the subjective estimate of the risk of death or lack of risk of death during the current hospital admission before the onset of the nosocomial infection. These groups were named + SIC and − SIC, respectively. Results: It was determined that the data from death certificates in cases of known nosocomial infection were not sufficient to determine whether nosocomial infection contributed to or caused death. There was a 24% increase in cases of nosocomial infection contributing to or causing death when a physician reviewed deaths in patients with nosocomial infections who did not have a diagnosis of nosocomial infection listed on the death certificate. The rates for nosocomial infections contributing to or causing death are as follows: nosocomial pneumonia, 20%; and bloodstream infections, 19%. In patients who died and had severity of illness determination, there was a statistically significant difference in the rates of nosocomial infections contributing to or causing death between −SIC and +SIC groups for both nosocomial pneumonia and bloodstream infections. The rates for bloodstream infections were as follows: −SIC, 5%; and +SIC, 21%. For nosocomial pneumonia, the rates were as follows: −SIC, 13%; and + SIC, 23%. Conclusion: In published reports from the Centers for Disease Control and Prevention, a rate of 13% is given for nosocomial pneumonia and bloodstream infections contributing to or causing death; however, there is no stratification for severity of illness in these reports. The presence of life-threatening illness before the onset of nosocomial pneumonia or bloodstream infection accounts for most deaths among our patients. For valid comparisons, mortality outcome data for nosocomial infections should be stratified for risk according to severity of underlying illness.