A multicentre analysis of catheter-related infection based on a hierarchical model.

PURPOSE: To decrease intensive care unit (ICU)-acquired catheter-related infections (CRI), it is essential that healthcare workers receive training and that quality improvement programmes are in place. The aim of our study was to evaluate risk factors for catheter colonisation and infection, focussing specifically on local care bundles. METHODS: Data were collected prospectively in 51 ICUs [7,188 patients, 8,626 central venous catheters (CVCs)] during two 6-month periods in 2007 and 2008, using a standardized questionnaire on catheter insertion, care and removal. Colonisation and CRI incidence were 6.1 and 2.2/1,000 CVC-days, respectively. A hierarchical mixed logistic model was used to identify risk factors for CRI and colonisation. RESULTS: Written CVC protocols were available in 46 (90 %) ICUs and were strictly followed in 38 ICUs. Factors significantly associated with CRI fell into three overall categories: (1) patient-related factors-immunosuppression [odds ratio (OR) 1.42, p = 0.02], medical diagnosis at admission (OR 1.64, p = 0.03) and trauma patient (OR 2.54, p < 0.001); (2) catheter-related factors-catheter rank (OR 1.7, p < 0.0001, non-subclavian catheter (OR 2.1, p < 0.001) and longer time with the catheter (p < 10(-4)); (3) centre-related factors-quantitative tip culture method (OR 2.55, p = 0.005) and alcohol-based povidone-iodine [OR 0.68, 95 % confidence interval (CI) 0.49-0.96] or alcohol-based chlorhexidine preparations (OR 0.69, 95 % CI 0.34-1.39) as compared to an aqueous povidone-iodine preparation (p < 0.001). CONCLUSIONS: We identified several risk factors for CRI that are amenable to improvement (preference for the subclavian route and use of an antiseptic solution containing alcohol). However, several patient-related factors were also found, and the use of quantitative catheter culture methods increased culture sensitivity, thereby increasing the CRI rate. Case-mix issues and the culture method should be taken into account when assessing the risk of CRI across centres.

Study of prone positioning to reduce ventilator-associated pneumonia in hypoxaemic patients.

The aim of the present study was to examine whether prone positioning (PP) affects ventilator associated-pneumonia (VAP) and mortality in patients with acute lung injury/adult respiratory distress syndrome. 2,409 prospectively included patients were admitted over 9 yrs (2000-2008) to 12 French intensive care units (ICUs) (OUTCOMEREA). The patients required invasive mechanical ventilation (MV) and had arterial oxygen tension/inspiratory oxygen fraction ratios <300 during the first 48 h. Controls were matched to PP patients on the PP propensity score (+/-10%), MV duration longer than that in PP patients before the first turn prone, and centre. VAP incidence was similar in the PP and control groups (24 versus 13 episodes.1,000 patient-days MV(-1) respectively, p = 0.14). After adjustment, PP did not decrease VAP occurrence (HR 1.64 (95% CI 0.70-3.84); p = 0.25) but significantly delayed hospital mortality (HR 0.56 (95% CI 0.39-0.79); p = 0.001), without decreasing 28-day mortality (37% in both groups). Post hoc analyses indicated that PP did not protect against VAP but, when used for >1 day, might decrease mortality and benefit the sickest patients (Simplified Acute Physiology Score >50). In ICU patients with hypoxaemic acute respiratory failure, PP had no effect on the risk of VAP. PP delayed mortality without decreasing 28-day mortality. PP >1 day might decrease mortality, particularly in the sickest patients.