Catheter-related Infections - Belgian epidemiological data
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(2) Catheter-Related Infections. Belgian Epidemiological Data Pierrette Melin Medical Microbiology University Hospital of Liege pm-chu lg 03.
(3) Introduction Major role of catheters in modern medecine Major cause of morbidity & mortality Multiple infectious complications Local site infections Systemic infections. bacteremia/fungemia, sepsis. Infective endocarditis Septic thrombo-phlebitis Other metastatic infections pm-chu lg 03.
(4) Incidence of catheter-related infections (CRI) Considerable variations by Catheter -related parameters. Type, site of insertion, duration in situ. Frequency of manipulations Patient-related parameters Hospital size, hospital service/unit. Major source of confusion. Inconsistent use of terms and definitions Lack of standard definitions. Diagnosis of CR-BSI problematic. pm-chu lg 03. (Blood Stream Infection). still.
(5) Catheter-related infections:. Examples of definitions. Catheter exit-site infection. Erythema or induration within 2 cm of the catheter exit site, in the absence of concommitant bloodstream infection Without concommitant purulence (CDC, 2002) In combination with a positive culture from the skin and/or pus at the insertion site (Polderman, 2002). Significant catheter colonization. Significant growth of a microorganism from the catheter tip, or subcutaneous segment of the catheter >15 CFU, « roll-plate » semiquantitative culture method >103 CFU, by quantitative culture method. pm-chu lg 03.
(6) Catheter-related infections:. Examples of definitions. CR-BSI. Clinical manifestations of infection and no apparent source except the catheter. in combination with. same organism (species and antibiogram) isolated from a (semi)quantitative culture of the catheter segment, and from a peripheral blood culture or from a paired « quantitative » blood culture (peripheral and catheter). Probable CR-BSI. In the absence of laboratory confirmation, normalisation of T° after removal of the implicated catheter (present for >48 h) from a patient with a BSI and without clear focus of infection at other site. pm-chu lg 03.
(7) Rate of CR-BSIs Number of CR-BSIs per 1,000 catheterdays (CDC 2002) More useful than. Number of CR-BSIs per 100 catheters Accounts for BSIs overtime - Adjusts risk for the No of days the catheter is in use. - Logistic problems to collect data ! pm-chu lg 03.
(8) US National Nosocomial Infection Surveillance System, January 1992-June 2001 Type of ICU. Coronary Cardiothoracic Medical Neurosurgical High risk nursery < 1,000 g 1,001-1,500 g 1,501-2,500 g 2,500 g. Etc.. pm-chu lg 03. CVC related BSI/1,000 cath days 4.5 2.9 5.9 4.7. 11.3 6.9 4.0 3.8. NNISS data to be used as benchmarks by individual hospitals for rate comparison (CDC).
(9) Type of catheter and rates of CR-BSIs based on 206 published prospective studies, M.K.Schinabeck, Clin Microbiol Newsletter 2003. Type of Catheter No.of CR-BSI /100 catheters Peripheral Venous C Arterial C Central Venous C non-tunneled tunneled Pulmonary artery C. 3.3 20.9 1.9. 2.3 1.2 5.5. Totally implantable C. 5.1. 0.2. pm-chu lg 03. 0.2 1.5. /1,000 cathdays 0.6 2.9.
(10) Type of catheter and rates of CRI (BSI, M.K.Schinabeck,. Clin Microbiol Newsletter 2003 and Local or BSI, CHU Lg). Type of Catheter Peripheral Venous C Arterial C Central Venous C non-tunneled tunneled. pm-chu lg 03. No.of CR-BSI /100 catheters 0.2 1.5 3.3 20.9. No.of CRI (Lg) /100 catheters 0.17 1.2 2.1.
(11) Belgian Data National Surveillance of Hospital Infections (NSIH) / ISP. Nosocomial Septicemia (> 48h postadmission). Cumulative data 1992-96 & 1998-June 2003 Year 2002 data Available denominators: . No. No.. of of. admissions patient-days. > 1 participation: 145 hospitals (80 % of Belgian H) > 3 participations: +/- 70 hospitals pm-chu lg 03.
(12) Data from CHU of Liège. Based on a retrospective review of laboratory results. . Period November 2002-October 2003 Culture of catheter if suspicion of CRI Colonized Catheters. Positive “Roll plate”culture with > 15 CFU No.= 525; Mean: 1,9 /Positive patient (1-17). Patients (No.= 95 episodes) with the same organism cultured concommittantly from blood and from catheter No denominator !! pm-chu lg 03.
(13) Type of catheter and rates of CR-BSIs 1992-2003 (& 2002), NSIH, ISP Belgium Type of Catheter. % of CR-BSI / Nosocomial BSI Probable Definite Total. Catheter-related. 8.9 (8.8). Central C Peripheral C Arterial C. 8.1 (7.2) 1.6 (1.4) 0.3 (0.3). Total No of Nosocomial BSI (septicemia > 48 h). pm-chu lg 03. 14.1 (12.9). 23.0 (21.7). (1.7/10,000 pt-days). 8.1 (10.6) 1.6 (1.4) 0.3 (0.3). 19.5 (18.5) 2.6 (2.6) 0.7 (0.7) 30570 (2705).
(14) Distribution of microorganisms in « nosocomial » BSI (Belgium - USA) %. 70. NSIH 92-03. 60. Gram Positive. 50. NSIH 02 NNISS 92-99 (US). Gram Negative. 40 30. Yeast. 20 10. SA En te ro co cc i Ot he rG + Gr am ne g Ot he re n tb En te ro b. sp P.a er ug ino Ot sa he rN FG NB Ca nd i da. pm-chu lg 03. CN S. Gr am. po s. 0.
(15) Distribution of microorganisms in CR-BSI & Nosocomial BSI (Belgium) 80. % 70. NSIH noso BSI. Gram Positive. 60 50. NSIH 92-03 CRBSI NSIH 02 CRBSI. Gram Negative. 40 30. Yeast. 20 10. En te. SA. ro co cc i Ot he rG + Gr am ne g Ot he re En te ntb ro ba ct e rs P.a p er ug ino Ot sa he rN FG NB Ca nd ida. pm-chu lg 03. CN S. Gr am. po s. 0.
(16) Distribution of microorganisms in CR-BSI (Chu Lg & Belgium) 80. % 70. CHU Lg. Gram Positive. 60 50. NSIH 92-03 NSIH 02. Gram Negative. 40 30. Yeast. 20 10. En te. SA. ro co cc i Ot he rG + Gr am ne g Ot he re En ntb te ro ba ct e rs P.a p er ug ino Ot sa he rN FG NB Ca nd ida. pm-chu lg 03. CN S. Gr am. po s. 0.
(17) Colonized Catheter & Bloodstream Infection Quantitative or semiquantitative culture of a catheter segment. Positive Catheter. Risk Factor for BSI About 20- 30 % lead to CR-BSI confirmed by microbiology. Negative Catheter. Does not exclude a clinical CR-BSI. pm-chu lg 03.
(18) Microbial profile. Lg). Local I. (in %). of CRI. BSI. (colonized C.). (CHU. Other Cand C.albicans Candida NF GNB P.aeruginos Other Ente Enterobact Gram Nega Other Gram S.aureus S.epidermi Gram Posit. pm-chu lg-60 03. -50 -40 -30 -20 -10 0 0. 10. 20. 30. 40. 50. 60%.
(19) Risk factors for CRI Related to the patient . pm-chu lg 03. Age (< 1 or > 60) Distant infectious focus Neutropenia Immuno-suppressive therapy (except corticosteroids) Malignancy Previous or concommittant bacteremia Birth weight <1,500 g (neonates) Severity of underlying diseases Burns and extensive wounds.
(20) Risk factors for CRI. Related to the catheter and care Catheter types and materials Insertion site. Risk Femoral > jugular > subclavian vein // density of skin colonisation. Indwelling time . pm-chu lg 03. < 3 days, RF: +/- zero 3-7 days, RF © 3-5 % and > 7 days, RF © 5-10 %. Parenteral feeding Care and maintenance Dressing, etc..
(21) Risk factors for CRI. Related to hospital, unit Insertion procedure . pm-chu lg 03. Sub-optimal asepsis operator’s experience. Emergency Time from admission Intensive Care Unit.
(22) Type of colonized catheters per care unit (CHU Liège) %. 100% 80% 60% 40% 20%. pm-chu lg 03. ME DI CA L DI AL YS IS ME DI CA LI AB CU DO M. SU RG OT ER Y HE R SU RG ER Y GE NE RA LI CU BU RN IC U. 0%. Others Peripheric Central Arterial.
(23) Distribution of bacteria colonizing catheters per care unit (CHU Liège). 20. 20. 10. 10. 0. 0. SU. AB D. ME D pm-chu lg 03. RG SU RG GE N IC U BU RN IC U. 30. ME D. 30. RG SU RG GE N IC U BU RN IC U. 40. IC U. 40. DI A. 50. ME D. 50. SU. 60. Other G P.aeruginosaEnterobacter sp. IC U. 60. %. AB D. S.aureus Other G. ME D. %. 70. DI A. 70.
(24) Distribution of bacteria colonizing catheters per type of catheter (CHU Liège). S.aureusOther G 60. P.aeruginosaEnterobacter sp Other G. 60. %. %. 50. 0. 0. Pe. Ar te r pm-chu lg 03. er ic. 10. Pe rip h. 10. Ce ntr al. 20. te ria. 20. Ar. 30. rip he ric. 30. Ce nt ra l. 40. ial. 40. l. 50.
(25) Virulence of multi-resistant bacteria ???. S.aureus, MRSA and CRI. Type of infection S.aureus S.aureus S.aureus. bacteremia Positive catheters CR-BSI. (36 % of all SA bacteremia). % of MRSA 39,7 55 40,7 (CHU Lg). pm-chu lg 03.
(26) Conclusions RF for CRI. Great variability. Basic problems for accurate comparisons Local/systemic CRI. Clinical criteria/Microbiological results. Parameter to express rate of infections Diagnostic procedures Sub-optimal. Human and informatics resources. Illustration of pitfalls if no clear cut definitions and correct denominators Usefulness of retrospective or prospective analysis Quality improvement process. pm-chu lg 03.
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