Automated surveillance in French ICUs: is it feasible? Results from a survey in French ICUs participating in a surveillance network.

A survey was undertaken to evaluate the level of computerization in intensive care units (ICUs) within a French network dedicated to the surveillance of healthcare-associated infections, antimicrobial use (AMU) and antimicrobial resistance (AMR) in ICUs (REA-REZO). Ninety-eight ICUs responded, and patient records were computerized in 57%, antimicrobial prescriptions were computerized in 59% and AMR epidemiology was computerized in 72%. AMU and AMR feedback was provided to the ICU itself for 77% and 65% of ICUs, respectively, and feedback was provided to the national surveillance for 79% and 65% of ICUs, respectively. This study suggests that the level of computerization in ICUs requires further improvement.

Exogenous acquisition of Pseudomonas aeruginosa in intensive care units: a prospective multi-centre study (DYNAPYO study).

BACKGROUND: Pseudomonas aeruginosa remains one of the most common nosocomial pathogens in intensive care units (ICUs). Although exogenous acquisition has been widely documented in outbreaks, its importance is unclear in non-epidemic situations. AIM: To elucidate the role of exogenous origin of P. aeruginosa in ICU patients. METHODS: A chronological analysis of the acquisition of P. aeruginosa was performed using samples collected in 2009 in the DYNAPYO cohort study, during which patients and tap water were screened weekly. Molecular relatedness of P. aeruginosa isolates was investigated by pulsed-field gel electrophoresis. Exogenous acquisition was defined as identification of a P. aeruginosa pulsotype previously isolated from another patient or tap water in the ICU. FINDINGS: The DYNAPYO cohort included 1808 patients (10,402 samples) and 233 water taps (4946 samples). Typing of 1515 isolates from 373 patients and 375 isolates from 81 tap water samples identified 296 pulsotypes. Analysis showed exogenous acquisition in 170 (45.6%) of 373 patients. The pulsotype identified had previously been isolated from another patient and from a tap water sample for 86 and 29 patients, respectively. The results differed according to the ICU. CONCLUSION: Exogenous acquisition of P. aeruginosa could be prevented in half of patients. The overall findings of this survey support the need for studies on routes of transmission and risk assessment approach to better define how to control exogenous acquisition in ICUs.

Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017.

Infection is a risk for any intervention. In surgery, for example, pathogenic bacteria are found in more than 90% of operative wounds during closure. This exists whatever the surgical technique and whatever the environment (the laminar flow does not entirely eliminate this risk). These bacteria are few in number but can proliferate. They find in the operative wound a favourable environment (haematoma, ischaemia, modification of oxido-reduction potential...) and the intervention induces anomalies of the immune defences. In the case of the installation of foreign material, the risk is increased. The objective of antibiotic prophylaxis (ABP) is to prevent bacterial growth in order to reduce the risk of infection at the site of the intervention. The preoperative consultation represents a privileged moment to decide on the prescription of a ABP. It is possible to define the type of intervention planned, the associated risk of infection (and therefore the necessity or not of ABP), the time of prescription before surgery and any allergic antecedents which may modify the choice of the selected antibiotic molecule.

Antibiotic use and good practice in 314 French hospitals: The 2010 SPA2 prevalence study.

OBJECTIVES: We aimed to assess antibiotic prescriptions to identify potential targets for improvement. METHODS: We conducted a point prevalence survey (November 2010) of antibiotic use in 314 voluntary hospitals recruited by the French Infectious Diseases Society (SPILF) and the National Observatory for Epidemiology of Bacterial Resistance to Antimicrobials (ONERBA). Data were entered online, immediately analyzed and exported. RESULTS: The prevalence of antibiotic use was 19.5% (9059/46,446patients). A higher prevalence was observed in the infectious disease (58.4%), hematology (58%), and intensive care (48.7%) units. The three most frequently used antibiotic classes were aminopenicillins (23.8%), fluoroquinolones (17.9%), and 3rd-generation cephalosporins (16.7%). A monotherapy was prescribed to 64% of patients. The reasons for the antibiotic prescription were written in the medical records of 74% of patients and 62% were consistent with the local guidelines. CONCLUSION: Our results are similar to that of other studies. Various local targets for improvement have been identified to help hospitals define a better antibiotic stewardship.

Risk factors for Pseudomonas aeruginosa acquisition in intensive care units: a prospective multicentre study.

BACKGROUND: Pseudomonas aeruginosa is a major nosocomial pathogen in intensive care units (ICUs); however, endogenous versus exogenous origin of contamination remains unclear. AIM: To identify individual and environmental ICU risk factors for P. aeruginosa acquisition. METHODS: A five-month prospective multicentric study was performed in ten French ICUs. Adult patients hospitalized in ICU for ≥ 24 h were included and screened for P. aeruginosa colonization on admission, weekly and before discharge. P. aeruginosa acquisition was defined by a subsequent colonization or infection if screening swabs on admission were negative. Water samples were obtained weekly on water taps of the ICUs. Data on patient characteristics, invasive devices exposure, antimicrobial therapy, P. aeruginosa water and patient colonization pressures, and ICU characteristics were collected. Hazard ratios (HRs) were estimated using multivariate Cox model. FINDINGS: Among the 1314 patients without P. aeruginosa on admission, 201 (15%) acquired P. aeruginosa during their ICU stay. Individual characteristics significantly associated with P. aeruginosa acquisition were history of previous P. aeruginosa infection or colonization, cumulative duration of mechanical ventilation and cumulative days of antibiotics not active against P. aeruginosa. Environmental risk factors for P. aeruginosa acquisition were cumulative daily ward 'nine equivalents of nursing manpower use score' (NEMS) [hazard ratio (HR): 1.47 for ≥ 30 points; 95% confidence interval (CI): 1.06-2.03] and contaminated tap water in patient's room (HR: 1.76; CI: 1.09-2.84). CONCLUSION: Individual risk factors and environmental factors for which intervention is possible were identified for P. aeruginosa acquisition.

Vascular catheter-related infection claims to health insurance company: often preventable.

Using the main French health insurance company database over a 10-year period, the preventability of catheter-related infections of patients who claimed compensation after prosecution was reviewed by a panel expert. They occurred in 71 patients with few co-morbidities or risk factors for nosocomial infection and were mainly related to the use of a peripheral vascular catheter (42 cases) and due to Staphylococcus aureus (51 cases). Forty-two infections were considered to be preventable. Infections due to peripheral venous catheters were significantly more often preventable than those due to central ones (p < 0.05). We conclude that catheter-related infections perceived by patients and the justice system as not related to unforeseeable medical complications are mainly peripheral catheter infections due to S. aureus and might be an appropriate target for new preventive strategies.

An attempt to validate the modification of the American-European consensus definition of acute lung injury/acute respiratory distress syndrome by the Berlin definition in a university hospital.

PURPOSE: The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition. METHODS: We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO2/FiO2 <300 mmHg regardless of the positive end-expiratory pressure (PEEP) level, and acute onset of new or increased bilateral infiltrates or opacities on chest X-ray were screened from ICU admission up to discharge. Patients with cardiogenic pulmonary edema were excluded. Patients were further classified into specific categories by using the American-European Consensus Conference and the Berlin definition criteria. The complete data set was measured at the time of inclusion. Patient outcome was measured at day 28 after inclusion. RESULTS: During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP ≥ 5 cmH2O and 20 (7.2 %) had PaO2/FiO2 ratio ≤200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P > 0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P < 0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P < 0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28. CONCLUSIONS: The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO2/FiO2 at study entry was independently associated with mortality.

[Organization of mechanical ventilation in French Intensive care units]. / Organisation de la ventilation artificielle dans les unités de réanimation en France.

OBJECTIVES: To clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents. STUDY DESIGN: Declarative survey. METHODS: Between September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions. RESULTS: Among the 62 participating ICUs, a median of 15 ventilators/ICU (range 1-50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU. CONCLUSIONS: This first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement.

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.

Point prevalence survey of antibiotic use in French hospitals in 2009.

OBJECTIVES: To evaluate the feasibility of a point prevalence survey for monitoring antibiotic use in a voluntary sample of French hospitals. METHODS: Demographic and medical data were collected for all inpatients. Additional characteristics regarding antimicrobial treatment, type of infection and microbiological results were collected only for patients receiving antimicrobials. RESULTS: Among 3964 patients in 38 hospitals, 343 (8.7%) received antimicrobial prophylaxis and 1276 (32.2%) antimicrobial therapy. The duration of surgical antimicrobial prophylaxis was >1 day in 41 out of 200 (21%) of the cases. Among patients with antimicrobial therapy, 959 (75.2%) received ß-lactams (including 34.8% penicillins with ß-lactam inhibitors, 22.1% third-generation cephalosporins and 7.8% carbapenems) and 301 (23.6%) received fluoroquinolones (50% orally). A total of 518 (40.6%) patients were treated with more than one drug and 345 (27.2%) were treated for >7 days. Patients treated for hospital-acquired infections (39.2%) were more likely to receive combinations (47.6% versus 34.4%, P < 0.01), carbapenems (14.4% versus 2.6%, P < 0.01), glycopeptides (14.4% versus 3.7%, P < 0.01) and antifungals (17% versus 5.3%, P < 0.01) for a longer duration (7.8 versus 6 days, P < 0.01). Fifty-six patients (4.4%) were treated for >7 days and did not have any microbiological sample drawn. The time allocated for the survey represented 18.3-25.0 h for 100 patients. CONCLUSIONS: The data provide directions for further interventions, such as better use of diagnostic tools, decreasing the treatment duration and the use of combinations. In addition, the survey shows that, although cumbersome, it is feasible to improve the representativeness of national data in European surveys.

[Reversing ICU-acquired immunosuppression: an innovative biomarker-guided therapeutic strategy for decreasing sepsis mortality and nosocomial infection rate]. / Biomarqueurs et thérapeutiques individualisées dans la prise en charge de l'immunosuppression acquise en réanimation.

Septic syndromes (systemic inflammatory response associated with infection) remain a major although largely under-recognized health care problem and represent the first cause of mortality in intensive care units. Regarding immune response, it is now agreed that sepsis induces an anti-inflammatory process, acting as a negative feedback. This inhibitory mechanism becomes deleterious as nearly all immune functions are rapidly compromised. The magnitude and persistence over time of this immunosuppression is correlated with nosocomial infections and mortality. Decreased HLA-DR expression on monocytes/increased percentage of regulatory T cells are biomarkers identifying patients at risk who could benefit from immunotherapy. This review attempts to integrate these new facts into an up-to-date account of sepsis pathophysiology.

Automated detection of nosocomial infections: evaluation of different strategies in an intensive care unit 2000-2006.

The aim of this study was to evaluate seven different strategies for the automated detection of nosocomial infections (NIs) in an intensive care unit (ICU) by using different hospital information systems: microbiology database, antibiotic prescriptions, medico-administrative database, and textual hospital discharge summaries. The study involved 1,499 patients admitted to an ICU of the University Hospital of Lyon (France) between 2000 and 2006. The data were extracted from the microbiology laboratory information system, the clinical information system on the ward and the medico-administrative database. Different algorithms and strategies were developed, using these data sources individually or in combination. The performances of each strategy were assessed by comparing the results with the ward data collected as a national standardised surveillance protocol, adapted from the National Nosocomial Infections Surveillance system as the gold standard. From 1,499 patients, 282 NIs were reported. The strategy with the best sensitivity for detecting these infections using an automated method was the combination of antibiotic prescription or microbiology, with a sensitivity of 99.3% [95% confidence interval (CI): 98.2-100] and a specificity of 56.8% (95% CI: 54.0-59.6). Automated methods of NI detection represent an alternative to traditional monitoring methods. Further study involving more ICUs should be performed before national recommendations can be established.

[Severe and acute pancreatitis admitted in intensive care: a prospective epidemiological multiple centre study using CClin network database]. / Épidémiologie, pronostic et complications infectieuses nosocomiales des pancréatites aiguës graves en réanimation: étude prospective multicentrique à partir de la base de données CClin Sud-Est.

OBJECTIVES: To describe the demographic characteristics, incidence of extra-abdominal hospital-acquired infections and outcome of patients admitted to intensive care unit (ICU) with severe acute pancreatitis. STUDY DESIGN: A retrospective, observational multiple center (65 centers) analysis of prospectively acquired data. PATIENTS AND METHODS: During 2 years, all consecutive admitted patients to ICU for severe acute pancreatitis in the centers participating in the nosocomial infections surveillance network CClin Sud-Est were included. Patients whose ICU stay was less than 48 hours were not included. Demographic characteristics, extra-abdominal hospital-acquired infections and clinical course were described. RESULTS: During the study period, 510 patients were included which represented 2 % of patients with a length of stay longer than 48 hours in the 65 participating ICUs. The global attack rate of extra-abdominal hospital-acquired infections (pneumonia, bacteremia, urinary tract or central venous catheter infection) was 23 % in overall patients and it was 33 % in the 294 mechanically ventilated patients. ICU mortality was 20 % in overall patients and it was 34 % in mechanically ventilated patients. CONCLUSION: Severe acute pancreatitis represents 2 % of ICU stay longer than 48 hours. Its clinical course is frequently complicated by hospital-acquired infections and is associated with an high ICU mortality rate. This epidemiological observational study may be used for calculating sample size for future multicenter interventional therapeutic studies.

[Use of the French medico-administrative database (PMSI) to detect nosocomial infections in the University hospital of Lyon]. / Intérêt de l'utilisation des données du Programme médicalisé des systèmes d'information (PMSI) pour la surveillance des infections nosocomiales aux Hospices Civils de Lyon.

BACKGROUND: Surveillance is an effective element in the fight against nosocomial infections, but the monitoring methods are often cumbersome and time consuming. The detection of infection in computerized databases is a means to alleviate the workload of health care teams. The objective of this study was to evaluate the performance of using discharge summaries in medico-administrative databases (PMSI) for the identification of nosocomial infections in surgery, intensive care and obstetrics. METHODS: The retrospective assessment study included patients who were hospitalized in general surgery, intensive care and obstetrics at different periods of time in 2006 and 2007 depending on the wards. Patients were monitored according to standard protocols which are coordinated at the regional level by the Southeast coordinating centre (CCLIN). The performance of identifying cases of nosocomial infection from discharge diagnoses coded by using the International Classification of Diseases (tenth revision) was evaluated by a study of sensitivity, specificity, positive and negative predictive values with their 95% confidence intervals. RESULTS: Using a limited number of diagnostic codes, the sensitivity and specificity were, respectively, 26.3% (95% CI 13.2-42.1) and 99.5% (95% 98.8-100.0) for the identification of surgical site infections. By expanding the number of diagnostic codes, the sensitivity and specificity were 78.9% (95% CI 65.8-92.1) and 65.7% (95% CI 61.0-70.3). The sensitivity and specificity for case identification of nosocomial infections in intensive care were 48.8% (95% CI 42.6-55.0) and 78.4% (95% CI 76.1-80.1), and were 42.9% (95% CI 25.0-60.7) and 87.3% (95% CI 85.2-89.3) for identification of postpartum infections. CONCLUSION: The PMSI is not a sufficiently efficient method in terms of sensitivity to be used in surveillance of nosocomial infections. A reassessment of the PMSI must be considered, with changes in coding of comorbidity that occurred in 2009.

Experience of European intensive care physicians with infections due to antibiotic-resistant bacteria, 2009.

A survey was performed among European intensive care physicians to obtain information about their perception and experience with selected antibiotic-resistant bacteria. Seventy-eight out of 95 (82%) participants considered having to deal with infections due to antibiotic-resistant bacteria in the intensive care unit where they work was a major or significant problem. Methicillin-resistant Staphylococcus aureus (MRSA) and third-generation cephalosporin-resistant Enterobacteriaceae were the most frequently reported antibiotic-resistant bacteria with 69 (73%) and 67 (71%) participants reporting having treated at least one patient with such an infection during the preceding six months, respectively. Antibiotic-resistant Gram-negative bacteria, including carbapenem-resistant Enterobacteriaceae, were more frequently reported than any selected antibiotic-resistant Gram-positive bacteria, with the exception of MRSA. Fifty (53%) participants declared having treated at least one patient infected with a bacterium totally or almost totally resistant to available antibiotics during the past six months, with 8 participants having treated more than 10 such patients and 13 having treated from 3 to 10 such patients.

[Septic shock: from recommendations to bedside]. / Choc septique: des recommandations à la pratique.

Management of septic shock requires complex and multiple diagnostic as well as therapeutic procedures in a limited time-frame. This issue is a major source of medical errors. The author presents a critical analysis of tools (guidelines, clinical path, algorithm, check-lists) to help physicians for the management of patients with septic shock.

[Necrotizing bacterial skin and software tissue infection with muscular involvement revealing of cancer of the colon]. / Dermohypodermite bactérienne nécrosante (DHBN) avec atteinte musculaire à Clostridium septicum révélatrice d'un cancer du côlon.

We report the case of a 38-year-old woman with a necrotizing bacterial skin and soft tissue infection with muscular involvement. The clinical picture was similar to a gaseous gangrene of the right lower limb with a septic shock and multiple organ failure, without predisposing factor such as trauma, and necessitating a hip amputation. The primary site of the disease was a perforated colic adenocarcinoma with peritoneal and retroperitoneal infection. The association of necrotizing skin and soft tissue infection with muscular involvement due to Clostridium septicum to a neoplasma is classical and in front of such an infection a neoplasma should be researched.