Prognostische Implikationen

Nosokomialer Infektionen

Univ. Prof. Dr. A. Valentin, MBA

Kardinal Schwarzenberg Klinikum

Schwarzach i. Pongau

andreas.valentin@ks-klinikum.at

Zarb P, Euro Surveill 2012

28.1% ICU

20.000 pts, 66 hospitals, 23 countries

Verlauf einer kritischen Erkrankung

Grafik nach Cook D: Int Care Med, 2003

Nosokomiale Infektion

Prognostic Impact

Outcome: Hospital Mortality

Prognostic Impact

Previous health status

45%

ICU admission20%

Acute physiology

25%

NosocomialInfection ?

Outcome: Hospital Mortality

Attributable Mortality

Mortalitätsrisiko

Kritische Erkrankung

Mortalitätsrisiko

Nosokomiale Infektion

Gesamtes

Mortalitäts risiko

1-5 Year Hazard Ratio 1-10 Year Mortality Rate

Group HR (95% CI) Cohort (%) General population (%)

Severe sepsis/shock All Age <60

60-70 >70

Any comorbidity No Yes

4.5 (2.2.-9.1)

17.8 (13.4-23.8)

5.5 (3.6-8.5)

2.4 (1.3-4.4)

2.9 (1.7-3.8)

7.5 (3.6-15.5)

30.5 24.4 37.4 44.4

21.6 44.1

11.8 2.7 12.3 28.0

12.0 11.6

Critically ill, nonseptic All Age <60

60-70 >70

4.1 (2.6-6.5)

13.0 (6.8-25.1)

6.1 (3.0-12.2)

3.0 (1.3-6.8)

22.1 12.6 31.4 52.6

10.5 2.2 12.3 29.4

Cardiovascular surgery All Age <60

60-70 >70

1.2 (0.9-1.6) 2.2 (1.1-4.2)

1.4 (0.9-2.2)

0.9 (0.6-1.4)

15.9 5.9 15.0 25.9

14.8 4.1 12.5 26.3

Linder A, Crit Care Med 2014

Methodische Fragestellungen

• Definition Nosokomial

– (Bsp.VAP)

• Health aquired infection

(wann, wo?)

– Hospital acquired

– ICU acquired

• Lokalisation

– Blutstrom

– Lunge

– Urogenital

– Andere

• Quelle

– Katheter, Drains

– Tubus

– Übertragung

– ……….

• Outcome

– ICU

– Hospital

– Long-term

Klinischer

Verlauf vor

Nosokomialer

Infektion

• 44 Patienten mit NI

• 44 Pat. ohne NI

• 123 Variable für

Matching

• 96% Übereinstimmung

Girou E, Am J Respir Crit Care Med 1998

Methodik: gematchte Kontrollen

Garrouste-Orgeas M, Clin Infect Dis 2006

Nosokomiale Infektionen und Infektionen mit

multiresistenten Erregern – Häufigkeit und Sterblichkeit

Gastmeier P, Dtsch Med Wochenschr 2016

≈ 3%

Nosokomiale Infektionen und Mortalität

Assoziation ? Kausalität?

Daten aus EPIC Studie, JAMA 1995

Vincent JL, Lancet 2003

International study of the prevalence and outcomes of

infection in intensive care units

(EPIC II)

• 1265 ICUs

• 75 countries

• 13796 adult patients

• Antibiotics: 71%

• Infected: 51%

Not

infected

Infected

p

ICU Mortality 11% 25% <0.001

Hospital Mortality 15% 33% <0.001

OR 1 1.51 <0.001

Vincent JL, JAMA 2009

BLOODSTREAM INFECTION

Hospital-acquired

bloodstream infections

Barnett A.G, BMJ 2013

Clinical outcomes of health-care-associated infections and

antimicrobial resistance in patients admitted to European

intensive-care units

Lambert M, Lancet Infect Dis 2011

Bloodstream Infection

ICU-acquired

bloodstream

infection

• 10.041 pts

≥ 72h in ICU

• 5,7% with

at least

one ICU-BSI

• Overall increase

in 30 d

mortality risk

with ICU-BSI

was 40%

Adrie C, J Infect, 2017

Determinants of Outcome in Hospitalized Patients

with MRSA Bloodstream Infection

Variables Associated With

30-Day All-Cause Mortality

• Age

• Pleuropulmonary Infection

• Transfer to ICU

• Failure to receive appropriate

definitive antimicrobial therapy

Simor AE

Infect Control Hosp Epidemiol

2016

ICU acquired BSI

• 6339 ICU admissions (2 Australian hospitals)

• BSI after ≥ 72h in 5.2%

• Mortality with ICU-BSI: + 19%

• Absolute decrease in survival of 1% in the total population

Risk for ICU-BSI Hospital survival

Prowle JR, Crit Care 2011

ICU acquired BSI

Prowle JR, Crit Care 2011

Time-Dependency Overall Impact

PNEUMONIE

Clinical outcomes of health-care-associated infections and

antimicrobial resistance in patients admitted to European

intensive-care units

Lambert M, Lancet Infect Dis 2011

Pneumonia

COPD patients with ventilator-associated pneumonia

COPD

(n=397)

Without COPD

(n=1685)

VAP (%) 19.9 19.7 n.s.

SAPS II (points; median) 45 46 n.s.

ICU mortality (%) 34.5 37.4 n.s.

a secondary analysis of the European (EU)-VAP/ CAP database

Koulenti D, Eur J Clin Microbiol Infect Dis 2015

ICU acquired pneumonia:

monomicrobial vs. polymicrobial

• 441 consecutive pts with ICUAP

• 58% microbiological confirmation

• 16% polymicrobial pneumonia

Ferrer M, Crit Care 2015

UROGENITALTRAKT

Catheter-associated urinary tract infetion

Chant C, Crit Care Med 2011

SPEZIFISCHE FRAGESTELLUNGEN

EUROBACT Study

ICU patients with hospital aquired fungemia

• Fungemia in 8.3%

of HA-BSI

• Fungemia already at

ICU admission: 23%

• 28 day mortality:

– Fungemia 41%

– Bacteremia 35%

Paiva JA, Crit Care 2016

Association of nosocomial infections with delayed cerebral

ischemia in aneurysmal subarachnoid hemorrhage

Foreman PM, J Neurosurg 2016

Colonization and infection with ESBL-producing

Enterobacteriaceae (ESBL-PE) in ICU patients

• ESBL-PE infections increased

– carbapenem consumption

– LOS

– day 28 mortality

Barbier F, J Antimicrob Chemotherap 2016

• ESBL-PE carriage increased

– carbapenem consumption

– LOS

ICU aquired infections and age

Without ICU

aquired

infection

With ICU

aquired

infection

Age

<80

Age

≥80

Age

<80

Age

≥80

ICU mortality (%) 21 33 52 68

HR for death 1.0 1.0 2.5 2.1

Maillet JM, J Hosp Infect 2014

1410 pts with ICU stay >3 days

Age: 18.9% ≥ 80 years

WAS BEDEUTET DAS ALLES ?

Admission Diagnosis

Sepsis

Admission Diagnosis

Non-Infectious

Van Vught L.A., JAMA 2016

Long-Term Mortality After Pneumonia in Cardiac

Surgery Patients: A Propensity-Matched Analysis

Patient group

1 Year

survival

%

5 year

survival

%

Pneumonia

n=32 83 62

p=0.03 Matched control

n=64 98 81

Rest of cohort

n=2628 98 91

Surgery n(%)

CABG 1162 (42)

Valve repair 884 (32)

Valve repair + CABG 487 (18)

Other 217 (8)

Type of surgery n(%)

Scheduled 2523 (92)

Unscheduled 227 (8)

Risk of long-term mortality

associated with pneumonia

HR 3.96 (95% CI, 1.41-11.14)

Ibanez J, J Intensive Care Med

From Sepsis to Chronic Critical Illness Mira J.C., Crit Care Med 2017

Marchioni A, Eur J Clin Invest 2015

Burden of Six Healthcare-Associated Infections on European Population Health:

- Years of life lost due to premature mortality (YLL) - Years lived with disability (YLD)

Cassini A, PLoS Med 2016

Incidence of microbiologically diagnosed

pneumonias in 34 Austrian ICUs

Burgmann H, Int Care Med 2010

Median 10.1 (5.7-18.2) per 100 pts

Bacterial cross transmissions

and nosocomial infection rates

4.6 cross transmissions/1000 patient days

Kola A

Crit Care Med

2010

Device-associated infection rates ranged

from 0.9 to 9.6 per 1000 device-days

• German KISS (2005-2009

• 800 Hospitals, 586 ICUs

Geffers C, Dtsch Ärzteblatt 2011

A. Valentin 10/2004

Risk as probability of an

unfavourable outcome

Intrinsic Risk

• Premorbidity & Age

• Current Diagnosis

• Severity of Illness

Extrinsic Risk

• Treatment decisions

• Process of care

• Infection Prevention

• ………………

Hugonnet S, Crit Care Med 2007

The effect of workload on infection risk

in critically ill patients

The daily proportion

of infected pts

is correlated with

nurse to patient ratio

of days 2-4 prior

Noso-komiale

Infektion

• Mortalitätsrisiko (ICU, KH) • Risiko Chronic Critical Illness • Langzeitprognose?