Device-associated infections in the intensive care units of Cyprus: results of the first national incidence study.

BACKGROUND: Surveillance of healthcare-associated infections (HCAIs) has become an integral part of infection control programs in several countries, especially in the intensive care unit (ICU) setting. In contrast, surveillance data on the epidemiology of ICU-acquired infections in Cyprus are limited. The aim of this study was to assess the risk of ICU-acquired infections and to identify areas for improvement in Cypriot hospitals by comparing observed incidence rates with international benchmarks and by specifying the microbiological and antibiotic resistance profiles of infecting organisms. MATERIALS AND METHODS: An active surveillance protocol was introduced in the ICUs of the four major public hospitals in Cyprus, based on the methodology of the US National Nosocomial Infections Surveillance system. RESULTS: During February to December 2007, 2,692 patients who were hospitalized in ICUs for a mean length of stay of 5 days acquired 214 infections for an overall incidence rate of 15.8 infections per 1,000 patient-days [95% confidence interval (CI): 13.8-18.1]. Bloodstream infections, pneumonias and urinary tract infections accounted for 80.4% of all infections; of these, 87.8% were device-related. Central line-associated bloodstream infection (CL-BSI) posed the greatest risk (18.6 cases per 1,000 central line-days; 95% CI 14.9-22.9), followed by ventilator-associated pneumonia (VAP) (6.4 cases per 1,000 ventilator-days; 95% CI 4.5-8.8) and catheter-associated urinary tract infection (2.8 cases per 1,000 urinary catheter-days; 95% CI 1.9-4.1). Most frequently isolated pathogens included Pseudomonas aeruginosa (21.6% of all isolates), coagulase-negative Staphylococcus (11.7%), Enterococcus spp. (11.3%) and Staphylococcus aureus (9.2%). Overall, 29.8% of P. aeruginosa isolates were imipenem-resistant and 68.2% of S. aureus were methicillin-resistant. The crude excess mortality rate associated with ICU-acquired infections was 33.2% (95% CI 24.9-41.9%) and the mean post-infection stay in the ICUs was 21.6 days (95% CI 17.0-26.2). CONCLUSION: In comparison to international benchmarks, the markedly high rate of CL-BSI, the high rate of VAP and the resistance patterns of major infecting pathogens identified in this study emphasize the need to improve current practices for appropriate use and management of invasive devices in Cypriot ICUs.

The dynamic relationship between antibiotic use and the incidence of vancomycin-resistant Enterococcus: time-series modelling of 7-year surveillance data in a tertiary-care hospital.

The role of antibiotics in the epidemiology of vancomycin-resistant Enterococcus (VRE) has been studied extensively, but controversies remain as to which, and to what extent, antibiotics facilitate the emergence and dissemination of VRE in hospitals. Aggregate data on the use of several antibiotic classes in terms of defined daily doses (DDD) per 100 patient-days (PD), and VRE incidence rates in terms of clinical isolates per 1000 PD, were evaluated during a 7-year period at a tertiary-care hospital. Time-series analysis (autoregressive integrated moving average (ARIMA) and transfer function models) was used to quantify the temporal effect of antibiotic use on VRE incidence and estimate effect-delays. The incidence rate of VRE observed in a specific bimester was found to be a function of its value during the preceding bimester and of prior changes in the volume of use of four antibiotic classes. In particular, an increase of one DDD/100 PD in the use of glycopeptides, fluoroquinolones, extended-spectrum cephalosporins and beta-lactam-beta-lactamase inhibitor combinations resulted, independently, in average changes of +0.024, +0.015, + 0.020 and -0.010 isolates per 1000 PD in the incidence of VRE, with average delays of 2, 4, 2 and 6 months, respectively, which explained 56% of the observed variation in VRE rates over time. Efforts to reduce VRE cross-transmission should be supplemented by targeted antibiotic control policies. The use of glycopeptides, broad-spectrum cephalosporins and fluoroquinolones in high amounts should be the targets of such policies. Penicillin-beta-lactamase inhibitor combinations might be suitable substitutes for extended-spectrum cephalosporins.

Emergence of vancomycin-resistant enterococci in a tertiary hospital in Crete, Greece: a cluster of cases and prevalence study on intestinal colonisation.

The aim of this study was to investigate the clinical and epidemiological characteristics of five consecutive cases of infection with vancomycin-resistant enterococci (VRE) and the prevalence of faecal carriage of VRE among patients admitted to a 700-bed university hospital where no VRE had been isolated previously. In a 2-month period, five consecutive patients infected with VRE were detected. Three VanB+ Enterococcus faecium isolates were obtained from three patients, while two VanA+ E. faecium isolates, one VanA+ Enterococcus faecalis isolate and one VanC1+ Enterococcus gallinarum isolate were obtained from the other two patients. Of 218 faecal specimens from all hospital wards, 41 (18.8%) were found to contain VRE. Forty-two isolates of VRE were obtained, comprising one (2%) E. faecalis, 11 (27%) E. faecium, 24 (57%) E. gallinarum and six (14%) Enterococcus casseliflavus/flavescens. Four isolates carried the vanA gene, eight carried vanB, 24 carried vanC1, and six carried vanC2/C3. Use of glycopeptides, the presence of central venous catheters and renal dialysis all correlated with VRE colonisation. The prevalence rates were among the highest reported in the literature.

Repeated multi-centre prevalence surveys of hospital-acquired infection in Greek hospitals. CICNet. Cretan Infection Control Network.

Three prevalence studies for the estimation of hospital-acquired infections (HAIs) were carried out in eight Greek hospitals on an annual basis during the years 1994-1996. The overall prevalence of HAI was 6.8, 5.5 and 5.9% for the three years, respectively. Among these, urinary tract infections ranged from 22.4 to 38.2%, lower respiratory tract infections ranged from 21.1 to 32.6%, surgical site infections ranged from 14.6 to 22.7% and bloodstream infections ranged from 9.0 to 13.2%. The prevalence of antibiotic usage among the hospitalized patients was found to be 49.3% in 1994, 47.3% in 1995 and 52.7% in 1996. Unjustified prescription of prophylactic usage was found to be the major component of these high percentages. Appropriate use of antibiotics for prophylaxis is one of the priorities of the current infection control programmes. The development of a nationwide network for the surveillance of HAIs in Greece is planned using the experience gained.