Criterios de aislamiento preventivo para la detección de portadores de bacterias multirresistentes en pacientes ingresados en la UCI: estudio multicéntrico dentro del programa Resistencia Zero / Preventive isolation criteria for multidrug-resistant bacteria detection in patients admitted to the ICU: Multicenter study within the Zero Resistance program

Objetivo: Conocer el rendimiento de los criterios de aislamiento preventivo del programa Resistencia Zero (RZ) e identificar los factores que pudieran mejorar su rendimiento. Diseño: Estudio de cohorte prospectivo y multicéntrico. Ámbito: Unidades de cuidados críticos que aplicaban el protocolo RZ, y que aceptaron la invitación al estudio. Pacientes o participantes: Pacientes a los que se les realizaron cultivos de vigilancia (nasal, faríngeo, axilar y rectal) y/o diagnósticos al ingreso en la UCI. Intervenciones: Análisis de los factores de riesgo (FR) RZ y otras variables del registro ENVIN. Se realizó un estudio univariable y multivariable con metodología de regresión logística binaria (significación con p<0,05). Se efectuó análisis de sensibilidad y especificidad para cada uno de los factores seleccionados. Variables de interés principales: Portador de bacteria multirresistente (BMR) al ingreso en la UCI, FR (antecedente de colonización/infección por BMR, ingreso hospitalario en los 3 meses previos, uso de antibiótico el mes previo, estar institucionalizado, diálisis y otras condiciones crónicas) y comorbilidades. Resultados: Participaron 2.252 pacientes de 9 UCI españolas. Fueron identificados BMR en 283 (12,6%). Ciento noventa y tres (68,2%) presentaban algún FR (OR: 4,6; IC 95%: 3,5-6,0). Todos los FR del programa RZ alcanzaron significación estadística (sensibilidad: 66%; especificidad: 79%), siendo el antecedente de BMR el factor con más peso. Inmunodepresión, tratamiento antibiótico al ingreso y sexo masculino son FR adicionales para BMR. Se aislaron BMR en 87 (31,8%) sin FR. (AU)

Objective: To verify the validity of a check list of risk factors (RF) proposed by the Spanish “Resistencia Zero” project (RZ) in the detection of multi-resistant bacteria (MRB), as well as to identify other possible RF for colonization and infection by MRB at intensive care (ICU) admission. Design: A prospective cohort study, conducted in 2016. Setting: Multicenter study, patients who needed admission to adult critical care units that applied the RZ protocol and accepted the invitation for the study. Patients or participants: Consecutive sample of patients admitted to ICU, who underwent surveillance (nasal, pharyngeal, axillary, and rectal) or clinical cultures. Interventions: Analysis of the RF of RZ project, in addition to other comorbidities, included in the ENVIN registry. A univariate and multivariate study was conducted, with binary logistic regression methodology (significance with P<.05). Sensitivity and specificity analyses were performed for each of the selected factors. Main variables of interest: Carrier of BMR at ICU admission, RF (previous MRB colonization/infection, hospital admission in the previous 3 months, antibiotic use in the past month, institutionalization, dialysis, and other chronic conditions) and comorbidities. Results: Two thousand two hundred and seventy patients were included from 9 Spanish ICUs. We identified BMR in 288 (12.6% of total patients admitted). One hundred and ninety-three (68.2%) had some RF (OD 4.6 -95% CI 3.5-6.0). All 6 RF from check list achieved statistical significance in the univariate analysis (sensitivity 66%, specificity 79%). Immunosuppression, antibiotic use at ICU admission and male gender were additional RF for BMR. BMR were isolated in 87 patients (31.8%) without RF. (AU)

Preventive isolation criteria for the detection of multidrug-resistant bacteria in patients admitted to the Intensive Care Unit: A multicenter study within the Zero Resistance program.

OBJECTIVE: To verify the validity of a checklist of risk factors (RFs) proposed by the Spanish "Zero Resistance" project (ZR) in the detection of multidrug-resistant bacteria (MRB), and to identify other possible RFs for colonization and infection by MRB on admission to the Intensive Care Unit (ICU). DESIGN: A prospective cohort study, conducted in 2016. SETTING: Multicenter study, patients requiring admission to adult ICUs that applied the ZR protocol and accepted the invitation for participating in the study. PATIENTS OR PARTICIPANTS: Consecutive sample of patients admitted to the ICU and who underwent surveillance (nasal, pharyngeal, axillary and rectal) or clinical cultures. INTERVENTIONS: Analysis of the RFs of the ZR project, in addition to other comorbidities, included in the ENVIN registry. A univariate and multivariate analysis was performed, with binary logistic regression methodology (significance considered for p < 0.05). Sensitivity and specificity analyses were performed for each of the selected factors. MAIN VARIABLES OF INTEREST: Carrier of MRB on admission to the ICU, RFs (previous MRB colonization/infection, hospital admission in the previous 3 months, antibiotic use in the past month, institutionalization, dialysis, and other chronic conditions) and comorbidities. RESULTS: A total of 2270 patients from 9 Spanish ICUs were included. We identified MRB in 288 (12.6% of the total patients admitted). In turn, 193 (68.2%) had some RF (OR 4.6, 95%CI: 3.5-6.0). All 6 RFs from the checklist reached statistical significance in the univariate analysis (sensitivity 66%, specificity 79%). Immunosuppression, antibiotic use on admission to the ICU and the male gender were additional RFs for MRB. MRB were isolated in 87 patients without RF (31.8%). CONCLUSIONS: Patients with at least one RF had an increased risk of being carriers of MRB. However, almost 32% of the MRB were isolated in patients without RFs. Other comorbidities such as immunosuppression, antibiotic use on admission to the ICU and the male gender could be considered as additional RFs.

A clinical evaluation of two central venous catheter stabilization systems.

BACKGROUND: Central venous catheters (CVCs) are commonly secured with sutures which are associated with microbial colonization and infection. We report a comparison of a suture-free system with standard sutures for securing short-term CVC in an international multicentre, prospective, randomized, non-blinded, observational feasibility study. Consented critical care patients who had a CVC inserted as part of their clinical management were randomized to receive either sutures or the suture-free system to secure their CVC. The main outcome measures were CVC migration (daily measurement of catheter movement) and unplanned catheter removals. RESULTS: The per cent of unplanned CVC removal in the two study groups was 2% (suture group 2 out of 86 patients) and 6% (suture-free group 5 out of 85 patients). Both securement methods were well tolerated in terms of skin irritation. The time and ease of application and removal of either securement systems were not rated significantly different. There was also no significant difference in CVC migration between the two securement systems in exploratory univariate and multivariate analyses. Overall, 42% (36 out of 86) of the CVC secured with sutures and 56% (48 out of 85) of the CVC secured with the suture-free securement system had CVC migration of ≥ 2 mm. CONCLUSIONS: The two securement systems performed similarly in terms of CVC migration and unplanned removal of CVC; however, the feasibility study was not powered to detect statistically significant differences in these two parameters. TRIAL REGISTRATION: ISRCTN, ISRCTN13939744. Registered 9 July 2015, http://www.isrctn.com/ISRCTN13939744 .

Quality of the aetiological diagnosis of ventilator-associated pneumonia in Spain in the opinion of intensive care specialists and microbiologists / Calidad del diagnóstico etiológico de la neumonía asociada a ventilación mecánica en España según la opinión de intensivistas y microbiólogos

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

INTRODUCCIÓN: Las guías para el diagnóstico microbiológico de la neumonía asociada a la ventilación mecánica (NAVM) son imprecisas. Este estudio describe la práctica clínica y las técnicas microbiológicas según la información proporcionada por intensivistas y microbiólogos de varias UCIs españolas, e identifica deficiencias y oportunidades de mejora. MÉTODOS: Se enviaron cuestionarios a 80 hospitales públicos españoles con servicios de cuidados intensivos y de microbiología, solicitando datos sobre el diagnóstico de la NAVM en el año anterior. RESULTADOS: Los 35 hospitales participantes (43,8%) abarcaron 673 camas de UCI con 32.020 admisiones y 173,820 estancias, y generaron 27.048 muestras del tracto respiratorio inferior. El 35% disponía de un servicio de microbiología 24/7. El 83% de las muestras fueron aspirados endotraqueales; el 47% de los Gram se informaron de inmediato y el 75% de las muestras se procesaron de manera semicuantitativa. Las técnicas moleculares y el antibiograma directo se realizaron en el 12% de los casos y en una institución, respectivamente. La respuesta media fue de 1,7 (DE 0,7) y 2,2 (SD 0,6) días para un cultivo negativo y uno positivo, respectivamente. La información directa estuvo disponible en el 65% de los hospitales. El 89% de los intensivistas consideraron muy útil la información microbiológica. En la mitad de la UCIs no había protocolos escritos de manejo de esta entidad. CONCLUSIONES: Intensivistas y microbiólogos coinciden en que las guías actuales para el diagnóstico de NAVM se podrían mejorar significativamente. También es necesario implementar las guías de manera más efectiva para mejorar la evolución de los pacientes

Quality of the aetiological diagnosis of ventilator-associated pneumonia in Spain in the opinion of intensive care specialists and microbiologists.

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.

Consumption of systemic antifungal agents among acute care hospitals in Catalonia (Spain), 2008-2013.

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.

Diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC) / Diagnóstico y el tratamiento de la bacteriemia y endocarditis por Staphylococcus aureus. Una guía de práctica clínica de la Sociedad Española de Microbiología Clínica y Enfermedades Infecciosas (SEIMC)

Both bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. The prognosis may darken not infrequently, especially in the presence of intracardiac devices or methicillin-resistance. Indeed, the optimization of the antimicrobial therapy is a key step in the outcome of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and - resistant isolates has led to the research of novel therapeutic schemes. Specifically, the interest raised in recent years on the new antimicrobials with activity against methicillin-resistant staphylococci has been also extended to infections caused by susceptible strains, which still carry the most important burden of infection. Recent clinical and experimental research has focused in the activity of new combinations of antimicrobials, their indication and role still being debatable. Also, the impact of an appropriate empirical antimicrobial treatment has acquired relevance in recent years. Finally, it is noteworthy the impact of the implementation of a systematic bundle of measures for improving the outcome. The aim of this clinical guideline is to provide an ensemble of recommendations in order to improve the treatment and prognosis of bacteremia and infective endocarditis caused by S. aureus, in accordance to the latest evidence published

Tanto la bacteriemia como la endocarditis infecciosa causada por Staphylococcus aureus son infecciones graves y frecuentes. El pronóstico puede verse ensombrecido por la presencia de dispositivos cardíacos o por la resistencia a meticilina. La optimización del tratamiento antimicrobiano es clave en los resultados. Las considerables tasas de fracaso terapéutico y la influencia de la susceptibilidad a vancomicina en el pronóstico, tanto de los episodios causados por cepas resistentes como sensibles a meticilina, ha conducido a la investigación de nuevos esquemas terapéuticos. Específicamente, el interés que en los últimos años han generado los nuevos antibióticos con actividad frente a cepas resistentes a meticilina se ha extendido a las cepas sensibles, que son aún responsables de la mayoría de los casos. Recientes estudios en el ámbito clínico y experimental se han centrado en la actividad de nuevas combinaciones, cuyo papel e indicación clínicas son aún objeto de debate. Por otro lado, la importancia de un tratamiento antibiótico empírico precoz y adecuado ha cobrado interés en los últimos años. Finalmente, cabe destacar el impacto que la instauración de un conjunto sistemático de medidas en el manejo de la bacteriemia estafilocócica tiene en el pronóstico global de la infección. Esta guía clínica reúne un conjunto de recomendaciones a la luz de la última evidencia científica, con el objeto de mejorar el tratamiento y pronóstico de la bacteriemia y endocarditis infecciosa causada por S. Aureus

Executive summary of the diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC) / Executive summary del diagnóstico y el tratamiento de la bacteriemia y endocarditis por Staphylococcus aureus. Una guía de práctica clínica de la Sociedad Española de Microbiología Clínica y Enfermedades Infecciosas (SEIMC)

Bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. Optimization of treatment is fundamental in the prognosis of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates have led to research on novel therapeutic schemes. The interest in the new antimicrobials with activity against methicillin-resistant staphylococci has been extended to susceptible strains, which still carry the most important burden of infection. New combinations of antimicrobials have been investigated in experimental and clinical studies, but their role is still being debated. Also, the appropriateness of the initial empirical therapy has acquired relevance in recent years. The aim of this guideline is to update the 2009 guidelines and to provide an ensemble of recommendations in order to improve the treatment of staphylococcal bacteremia and infective endocarditis, in accordance with the latest published evidence

La bacteriemia y la endocarditis infecciosa causadas por Staphylococcus aureus son enfermedades frecuentes y graves. El tratamiento antibiótico es clave en el éxito terapéutico. El reciente descubrimiento de la relación entre la susceptibilidad a vancomicina y el pronóstico de estas infecciones, tanto cuando en cepas resistentes como sensibles a meticilina, ha llevado a la investigación de nuevos tratamientos. El interés por los nuevos antibióticos con actividad frente a cepas resistentes a meticilina se ha extendido a las cepas sensibles, aún responsables de la mayor parte de infecciones. Estudios clínicos y experimentales han evaluado la eficacia de nuevas combinaciones de antimicrobianos, si bien su indicación no ha sido aún establecida. También la necesidad de un tratamiento inicial empírico correcto ha cobrado relevancia. El objetivo de este documento es actualizar el documento de consenso del 2009 y obtener un conjunto de recomendaciones para mejorar el tratamiento de la bacteriemia y endocarditis estafilocócicas, de acuerdo a la última evidencia científica publicada

Diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC).

Both bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. The prognosis may darken not infrequently, especially in the presence of intracardiac devices or methicillin-resistance. Indeed, the optimization of the antimicrobial therapy is a key step in the outcome of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates has led to the research of novel therapeutic schemes. Specifically, the interest raised in recent years on the new antimicrobials with activity against methicillin-resistant staphylococci has been also extended to infections caused by susceptible strains, which still carry the most important burden of infection. Recent clinical and experimental research has focused in the activity of new combinations of antimicrobials, their indication and role still being debatable. Also, the impact of an appropriate empirical antimicrobial treatment has acquired relevance in recent years. Finally, it is noteworthy the impact of the implementation of a systematic bundle of measures for improving the outcome. The aim of this clinical guideline is to provide an ensemble of recommendations in order to improve the treatment and prognosis of bacteremia and infective endocarditis caused by S. aureus, in accordance to the latest evidence published.

Executive summary of the diagnosis and treatment of bacteremia and endocarditis due to Staphylococcus aureus. A clinical guideline from the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC).

Bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. Optimization of treatment is fundamental in the prognosis of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates have led to research on novel therapeutic schemes. The interest in the new antimicrobials with activity against methicillin-resistant staphylococci has been extended to susceptible strains, which still carry the most important burden of infection. New combinations of antimicrobials have been investigated in experimental and clinical studies, but their role is still being debated. Also, the appropriateness of the initial empirical therapy has acquired relevance in recent years. The aim of this guideline is to update the 2009 guidelines and to provide an ensemble of recommendations in order to improve the treatment of staphylococcal bacteremia and infective endocarditis, in accordance with the latest published evidence.

[Empirical antimicrobial therapy in ICU admitted patients. Influence of microbiological confirmation on the length of treatment]. / Influencia de la confirmación microbiológica en la duración y adaptación del tratamiento antimicrobiano empírico de los pacientes ingresados en UCI.

Introduction. Most patients admitted to the Intensive Care Units (ICU) receive antimicrobial treatment. A proper therapeutic strategy may be useful in decreasing inappropriate empirical antibiotic treatments. When the infection is not microbiologically confirmed, the antimicrobial streamlining may be difficult. Nevertheless, there is scant information about the influence of the microbiological confirmation of the infections on empirical antimicrobial treatment duration. Method. Post-hoc analysis of prospective data (ENVIN-UCI register) and observational study of patients admitted (> 24 hours) in a medico-surgical ICU, through the three-months annual surveillance interval for a period of ten years, receiving antimicrobial treatment for treating an infection. Demographic, infection and microbiological data were collected as well as empirical antimicrobial treatment and causes of adaptation. The main goal was to establish the influence of microbiological confirmation on empirical antimicrobial treatment duration. Results. During the study period 1,526 patients were included, 1,260 infections were diagnosed and an empirical antibiotic treatment was started in 1,754 cases. Infections were microbiologically confirmed in 1,073 (62.2%) of the empirical antibiotic treatment. In 593 (55.3%) cases, the antimicrobial treatment was considered appropriate. The main cause of treatment adaptation in the microbiologically confirmed infections was streamlining (39%). The microbiological confirmation of the infection was not associated with significantly shorter empirical antibiotic treatments (6.6 ± 5.2 VS. 6.8 ± 4.5 days). Conclusion. The microbiological confirmation of infections in patients admitted to UCI was associated with a higher reduction of antimicrobial spectrum, although had no effect on the length of empirical antimicrobial therapy.

Influencia de la confirmación microbiológica en la duración y adaptación del tratamiento antimicrobiano empírico de los pacientes ingresados en UCI / Empirical antimicrobial therapy in ICU admitted patients. Influence of microbiological confirmation on the length of treatment

Introducción. Un elevado porcentaje de pacientes que ingresan en las Unidades de Cuidados intensivos (UCI) reciben tratamiento antimicrobiano. Inicialmente, éste ha de ser empírico, en espera de la confirmación microbiológica. Sin embargo, la adaptación y la duración del tratamiento empírico inicial son dificultosas en los casos en los que no se existe confirmación microbiológica de la infección. Además, existe escasa información sobre la influencia de la confirmación microbiológica en la duración y adaptación del tratamiento empírico. Método. Estudio post-hoc de datos prospectivos (registro ENVIN-UCI), observacional de pacientes ingresados (> 24 horas), en una UCI médico-quirúrgica durante los cortes de 3 meses anuales de 2001 a 2011, y que recibieron tratamiento antimicrobiano para el tratamiento de una infección. Se recogieron datos demográficos, de las infecciones, de la microbiología, del tratamiento antimicrobiano empírico y de las causas de adaptación del mismo, con el objetivo de determinar la influencia de la información microbiológica en la duración y adaptación del tratamiento empírico inicial. Resultados. Durante el periodo de estudio se incluyeron 1.516 pacientes y 1.260 infecciones que condicionaron 1.754 indicaciones de tratamiento empírico. En 1.073 (62,2%) de las indicaciones realizadas como tratamiento empírico se obtuvo confirmación microbiológica de la infección. En 593 (55,3%) casos los antibióticos prescritos se consideraron adecuados. La principal causa de adaptación del tratamiento en las infecciones con confirmación microbiológica fue la reducción de espectro (39%). La confirmación microbiológica no se asoció a diferencias significativas en la duración del tratamiento antimicrobiano en su indicación empírica (6,6 ± 5,2 vs. 6,8 ± 4,5 días). Conclusión. La confirmación microbiológica de las infecciones en pacientes ingresados en UCI permitió la reducción del espectro aunque no modificó de forma significativa la duración del tratamiento antimicrobiano en las indicaciones realizadas como tratamiento empírico (AU)

Introduction. Most patients admitted to the Intensive Care Units (ICU) receive antimicrobial treatment. A proper therapeutic strategy may be useful in decreasing inappropriate empirical antibiotic treatments. When the infection is not microbiologically confirmed, the antimicrobial streamlining may be difficult. Nevertheless, there is scant information about the influence of the microbiological confirmation of the infections on empirical antimicrobial treatment duration. Method. Post-hoc analysis of prospective data (ENVIN-UCI register) and observational study of patients admitted (> 24 hours) in a medico-surgical ICU, through the three-months annual surveillance interval for a period of ten years, receiving antimicrobial treatment for treating an infection. Demographic, infection and microbiological data were collected as well as empirical antimicrobial treatment and causes of adaptation. The main goal was to establish the influence of microbiological confirmation on empirical antimicrobial treatment duration. Results. During the study period 1,526 patients were included, 1,260 infections were diagnosed and an empirical antibiotic treatment was started in 1,754 cases. Infections were microbiologically confirmed in 1,073 (62.2%) of the empirical antibiotic treatment. In 593 (55.3%) cases, the antimicrobial treatment was considered appropriate. The main cause of treatment adaptation in the microbiologically confirmed infections was streamlining (39%). The microbiological confirmation of the infection was not associated with significantly shorter empirical antibiotic treatments (6.6 ± 5.2 VS. 6.8 ± 4.5 days). Conclusion. The microbiological confirmation of infections in patients admitted to UCI was associated with a higher reduction of antimicrobial spectrum, although had no effect on the length of empirical antimicrobial therapy (AU)

[Results of the implementation of the Bacteremia Zero project in Catalonia, Spain]. / Resultados de la aplicación del proyecto Bacteriemia Zero en Catalunya.

The nationwide Bacteremia Zero (BZ) Project consists in the simultaneous implementation of measures to prevent central venous catheter-related bacteremia (CVC-B) in critically ill patients and in the development of an integral safety plan. The objective is to present the results obtained after the implementation of the BZ project in the ICUs of the Autonomous Community of Catalonia, Spain. All patients admitted to ICUs in Catalonia participating in the ENVIN-HELICS registry between January 2009 and June 2010 were included. Information was provided by 36 (92.3%) of the total possible 39 ICUs. A total of 281 episodes of CVC-B were diagnosed (overall rate of 2.53 episodes per 1000 days of CVC). The rates have varied significantly between ICUs that participated in the project for more or less than 12 months (2.17 vs. 4.27 episodes per 1000 days of CVC, respectively; p<.0001). The implementation of the BZ Project in Catalonia has been associated with a decrease greater than 40% in the CVC-B rates in the ICUs of this community, which is much higher than the initial objective of 4 episodes per 1000 days of CVC).

Resultados de la aplicación del proyecto Bacteriemia Zero en Catalunya / Results of the implementation of the Bacteremia Zero project in Catalonia, Spain

El proyecto nacional Bacteriemia Zero (BZ) consiste en la aplicación simultánea de un paquete de medidas para la prevención de bacteriemias relacionadas con catéteres venosos centrales (B-CVC) en los pacientes críticos y en el desarrollo de un plan integral en seguridad. El objetivo es presentar los resultados de la aplicación del proyecto BZ en las unidades de cuidados intensivos (UCI) de la comunidad autónoma de Catalunya. Se han incluido todos los pacientes ingresados en las UCI participantes de Catalunya en el registro ENVINHELICS desde enero de 2009 hasta junio de 2010. Han aportado información 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 días de CVC). Las tasas han variado significativamente entre las UCI que han participado más o menos de 12 meses en el proyecto (2,17 frente a 4,27 episodios por 1.000 días de CVC, respectivamente; p < 0,0001). La aplicación del proyecto BZ en Catalunya ha disminuido la tasa de las B-CVC en las UCI de esta comunidad en más del 40%, mejorando el objetivo inicial de 4 episodios por 1.000 días de CVC (AU)

The nationwide Bacteremia Zero (BZ) Project consists in the simultaneous implementation of measures to prevent central venous catheter-related bacteremia (CVC-B) in critically ill patients and in the development of an integral safety plan. The objective is to present the results obtained after the implementation of the BZ project in the ICUs of the Autonomous Community of Catalonia, Spain. All patients admitted to ICUs in Catalonia participating in the ENVIN-HELICS registry between January 2009 and June 2010 were included. Information was provided by 36 (92.3%) of the total possible 39 ICUs. A total of 281 episodes of CVC-B were diagnosed (overall rate of 2.53 episodes per 1000 days of CVC). The rates have varied significantly between ICUs that participated in the project for more or less than 12 months (2.17 vs. 4.27 episodes per 1000 days of CVC, respectively; p<.0001). The implementation of the BZ Project in Catalonia has been associated with a decrease greater than 40% in the CVC-B rates in the ICUs of this community, which is much higher than the initial objective of 4 episodes per 1000 days of CVC) (AU)

Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data.

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.

Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience.

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 effectiveness after contextual adaptation at large-scale implementation in Spanish ICUs. DESIGN: Prospective time series. SETTING: A total of 192 ICUs throughout Spain. PATIENTS: All patients admitted to the participating ICUs during the study period (baseline April 1 to June 30, 2008; intervention period from January 1, 2009, to June 30, 2010). INTERVENTION: Engagement, education, execution, and evaluation were key program features. Main components of the intervention included a bundle of evidence-based clinical practices during insertion and maintenance of catheters and a unit-based safety program (including patient safety training and identification and analysis of errors through patient safety rounds) to improve the safety culture. MEASUREMENTS AND MAIN RESULTS: The number of catheter-related bloodstream infections was expressed as median and interquartile range. Poisson distribution was used to calculate incidence rates and risk estimates. The participating ICUs accounted for 68% of all ICUs in Spain. Catheter-related bloodstream infection was reduced after 16-18 months of participation (median 3.07 vs 1.12 episodes per 1,000 catheter-days, p<0.001). The adjusted incidence rate of bacteremia showed a 50% risk reduction (95% CI, 0.39-0.63) at the end of the follow-up period compared with baseline. The reduction was independent of hospital size and type. CONCLUSIONS: Results of the Bacteremia Zero project confirmed that the intervention significantly reduced catheter-related bloodstream infection after large-scale implementation in Spanish ICUs. This study suggests that the intervention can also be effective in different socioeconomic contexts even with decentralized health systems.

Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients.

PURPOSE: To analyze the impact of primary and catheterrelated bloodstream infections (PBSI/CRBSI) on morbidity and mortality. METHODS: A matched case-control study (1:4) was carried out on a Spanish epidemiological database of critically ill patients (ENVIN-HELICS). To determine the risk of death in patients with PBSI/CRBSI a matched Cox proportional hazard regression analysis was performed. RESULTS: Out of the 74,585 registered patients, those with at least one episode of monomicrobial PBSI/CRBSI were selected and paired with patients without PBSI/CRBSI for demographic and diagnostic criteria and seriousness of their condition on admission to the Intensive Care Unit (ICU). for mortality analysis, 1,879 patients with PBSI/CRBSI were paired with 7,516 controls. The crude death rate in the ICU was 28.1% among the cases and 18.7% among the controls. Attributable mortality 9.4% (HR:1.20; 95% confidence interval: 1.07-1.34; p<0.001). Risk of death varied according to the source of infection, aetiology, moment of onset of bloodstream infection and severity on admission to the ICU. The median stay in the ICU of patients who survived PBSI/CRBSI was 13 days longer than the controls, also varying according to aetiology, moment of onset of bloodstream infection and severity on admission. CONCLUSIONS: Acquisition of PBSI/CRBSI in critically ill patients significantly increases mortality and length of ICU stay, which justifies prevention efforts.