| Abstract |
Background: Infections related to healthcare facilities, or Hospital Acquired Infections (HAIs), are the cause of great concern worldwide in all health care units. They are associated with prolonged hospital stay, increased mortality, high hospital costs, increase of multidrug resistant microorganisms and their spreading. Patients hospitalized in ICUs are at high risk for developing HAIs due to their underlying serious illness, the frequent use of catheters and invasive devices, immunosuppression, the frequent interventions they undergo to, and also because of the administration of multiple antibiotics, the already increased drug resistance and the spread of multidrug-resistant microorganisms in ICUs.
Objective: The aim of the study is the surveillance of HAIs in the ICU of Venizeleio Hospital, by identifying the pathogens associated with them, the frequency of their occurrence and the recording of microbial resistance. In addition, the recording of administrated antibiotics and the duration of administration, and the association of HAIs with mortality and patients length of stay.
Methods: The surveillance at the ICU of Venizeleio General Hospital of Heraklion lasted 6 months (01/10/2019 - 31/03/2020). The protocol followed was the HAI-Net ICU protocol, version 2.2 of the European Center for Disease Prevention and Control. The data was recorded on the online platform Helics Win.Net. The criterion for admitting patients to the study was their hospitalization in the ICU for at least 48 hours. The data were extracted from the patients’ medical files, the aMedWeb hospital’s electronic system, the imaging tests (X-rays, CT scans) through the EVORAD system and the hospital’s microbiological laboratory (for cultures and antibiotics). Patients demographics, date of admission and discharge, cause of admission, and APACHE II clinical severity score were recorded. The relationship between the occurrence of HAIs and the patients length of stay in the ICU as well as the use of interventional devices (central venous catheters, (intra) tracheal tubes, urinary catheters), were also recorded. The device-related blood stream infections, pneumonias and urinary tract infections were recorded. Finally, we recoded the administered antibiotics , the isolated pathogens and their drug resistance.
Results: During the period of surveillance at the ICU of Venizeleio Hospital, 150 patients were admitted, 96 of whom met the criteria for admission to the study. 55 (57.3%) were men and 41 (42.7%) were women. The average age was 64.1 (± 17.7) years. The cause of admission was pathological or surgical at 76% and 24%, respectively, with 15.6% of cases concerning trauma and 15.6% of patients being immunosuppressed. The average APACHE II score was 22.4 (± 8.4). The average length of stay of patients in the ICU was 11.1 (± 8.5) days. Patients mortality in the ICU was 32.3%. 97.9% of patients received antimicrobial therapy during their stay at the ICU, 65% were intubated, 78% had CVC and 79% had a urine catheter. The mortality was higher in patients with confirmed HAIs (55.6% vs 26.9%, p = 0.026), in older patients (mean age 69.5 vs 61.3, p = 0.025) and in those with higher APACHE score (27 vs 20.3, p <0.001) . The total length of stay of patients in the ICU was higher in those with HAIs (average length of stay 22.1 vs 8.5 days, p <0.001).
18 (18.7%) of the 96 patients in the study had at least one HAI. A total of 28 episodes of HAIs were recorded. 3 patients had 2 HAIs and 2 patients had 3 HAIs. The total incidence of HAIs was 18.8 per 1000 patient-days. 3 patients (12%) had BSI, 5 (20%) had CRI, 15 (60%) had device-related pneumonias, and 2 (8%) patients had catheter-related urinary tract infections.
During the present study, 23 pathogens were isolated, 2 of which were Candida species. 71.5% of pathogens were Gram-negative. Staphylococcus species were isolated in 6 cases of HAIs. Enterobacteriae were found in 5 HAIs. Pseudomonas aeruginosa was isolated in 3 pneumonias and Acinetobacter baumanii in 7 HAIs.
Staphylococcus species were 100% resistant to Oxacillin. Enterobacteriae were 60% resistant to Amox / clavulanic acid, 3rd generation cephalosporins and carbapenems. Pseudomonas aeruginosa was 100% resistant to Piperacillin-tazobactam and Ceftazidime. Acinetobacter baumanii was 100% resistant to Ceftazidime and Carbapenemes, and 30% to Colistin. 2 of Acinetobacter baumanii were PDR species, accounting for 9.5% of all isolated pathogens.
97.9% of patients admitted to the study received antibiotics. In the majority of patients, antimicrobial therapy was administered empirically (p <0.001). 14.2% were treated with carbapenems and glycopeptides (68% teicoplanin). Cephalosporins were administered in 13.6% of cases. In fact, 85.4% , of the cephalosporins were 3rd generation and 14.6% were 5th generation. 13.1% of patients received clindamycin and 10.2% a combination of penicillin and β-lactamase inhibitor. In percentages below 10%, fluoroquinolones (8%) were administered, mainly levofloxacin, colistin (7.4%), tetracyclines, linezolid, and antifungals (4%). A total of 352 antimicrobial agents were administered, corresponding to 2799 Days Of Treatment (DOT) and 2104 DOT / 1000 patient-days. Consequently, each patient received an average of 2 antibiotics per day.
Conclusion: HAIs in the ICU of Venizeleio Hospital had high incidence rates, especially the device-related ones, and were associated with higher mortality and prolonged hospital stay. Increased antibiotic use and high antimicrobial resistance highlight the urgent need to introduce systems and strategies for monitoring, recording and preventing HAIs in ICUs, which, together with the rational use of antibiotics, will lead to a significant HAIs elimination.
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