Surveillance of Intensive Care Unit associated infection

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Surveillance of Intensive Care Unit associated
infection

• Training for the National Surveillance Programme
• Jane McNeish
• HPS

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Surveillance Training

• Overview of the surveillance program and
  epidemiology of ICUAI
• The Pilot Study
• Infection definitions and microbiology (according
  to the HELICS methodology)
• Reporting

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CollaborationSICSAG and HPS

• A methodology and data collection method was
  agreed
• Scottish Government funded the development of the
  HAI pages in Ward Watcher for this purpose.
• Ward Watcher has been developed to incorporate
  the collection of data required for ICUAI
  surveillance
• Pilot in 2005 tested the feasibility of both Ward
  Watcher and the Helics methods

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Why do ICU Surveillance?

• Healthcare associated infection is a challenge
• Scottish Prevalence study findings state that the
  prevalence of ICUAI is 27
• HAI is costly to the patient and the NHS
• Some infections (20-30) are preventable.
• ( Harbarth et al 2003)

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Why do ICU Surveillance?

• Measure of quality of care and patient safety
• Public and media are interested
• Political issue
• SPSP

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ICU Associated Infections

• Critically ill patient population
• Subject to invasive procedures
• More Antimicrobials are used
• Perception that
• There is a problem with infection in the ICU
• The ICU is hotbed for HAI and antibiotic
  resistant micro-organisms

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Scottish Prevalence Study (2007)
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Prevalence of device use in ICU
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ICU Acquired Infections - Epidemiology

• European Prevalence of Infection in Intensive
  Care (EPIC) study (1995)
• One day prevalence study
• 21 of patients investigated had an ICU acquired
  infection
• UK had an ICU acquired infection rate of 16
  (ranging from 9.7 to 31.6)
• Infections most frequently reported in
• the EPIC study were
• Pneumonias (46.9)
• Lower respiratory tract infections (17.9)
• Urinary tract infections (17.6)
• Bloodstream infections (12)

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CDC Congressional Testimony (March 2006)

• CDCs Role in Monitoring and Preventing
  Healthcare-Associated Infections
• During 1990-2004, rates of infections from
  medical devices decreased
• Bloodstream infections from central lines
  decreased by
• 54 in medical ICUs
• 43 in coronary ICUs
• 43 in surgical ICus
• 27 in paediatric ICUs
• Trends of ventilator-associated pneumonia rates
  were assessed through 2001 and substantially
  decreased from 31 to 58 among these same ICU
  types
• These data are derived from CDCs NNIS and NHSN
  systems

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Trends in ventilator-associated pneumonia (VAP)
rates for all 283 intensive care units
participating in the German nosocomial infection
surveillance system (KISS) from January 1999
through June 2003

• Infection Control and Hospital Epidemiology 28
  (3) 314-318.

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Purpose of Surveillance

• Surveillance is the ongoing systematic
  collection, analysis, and interpretation of
  health data essential to the planning,
  implementation, and evaluation of public health
  practice, closely integrated with the timely
  dissemination of these data to those who need to
  know. The final link of the surveillance chain is
  the application of these data to prevention and
  control.
• (Centers for Disease Control and Prevention 1988)

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Pilot Study

• In consultation with Consultants in Intensive
  Care Medicine, Microbiologists, and infection
  Control staff agreement was reached to carry out
  HIA surveillance in Scottish ICUs
• Scottish Surveillance of Healthcare Associated
  Infection Program (SSHAIP) team at HPS and
  Scottish Intensive Care Audit Group (SICSAG)
  collaboration
• Scottish Government funded the development of the
  HAI pages in Ward Watcher
• Pilot study carried out 2005 in 5 intensive Care
  Units

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Findings of Pilot Study

• Feasible to incorporate HAI surveillance within
  Ward Watcher.
• HELICS definitions for ICUAI are applicable in
  Scotland.
• Able to collect surveillance data for pneumonia,
  bloodstream infections and central venous
  catheter related infections
• Of 199 patients a total of 32 patients developed
  44 episodes of infection according to HELICS
  definitions for ICUAI.

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Since 2005

• Refinements were required to Ward Watcher
• To streamline the data collection
• To ensure data could be accessed locally for
  immediate local reporting
• To simplify data transfer to SICSAG
• ICUs using Ward Watcher require
• the updated version

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Infection definitions and microbiology

• Data definitions for ICU acquired infection
• Detailed knowledge of
  definitions NOT required
• Ward Watcher will diagnose
  infections based on
• the data entered for signs, symptoms
  and laboratory
• findings
• For reference, the definitions are
  detailed in the protocol
• Definitions comply with the HELICS protocol
• Infections definitions are for surveillance
  purposes and should not influence clinical
  decision making

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Applying the definitions

• Microbiology
• Work with microbiologists locally to determine
  which tests apply to your unit
• They should help with interpretation of criteria
  and any local issues
• HPS will support staff with any queries and help
  to resolve any difficulties with interpretation

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Infection Definitions Pneumonia

• Based on CDC definitions
• Pneumonia can be diagnosed at five levels
  (PN1-PN5)
• Signs and symptoms and microbiology
• PN1 PN2 require both signs and symptoms of
  pneumonia and quantitative lab confirmation from
  Lower Respiratory Tract (LRT) specimen
• PN3 requires signs and symptoms of pneumonia
  and alternative microbiology methods
• PN4 require signs and symptoms of pneumonia
  with positive sputum culture or non quantitative
  LRT culture
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• PN5 require signs and symptoms of pneumonia
  with no positive micro- organism
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Infection Definitions Blood Stream Infections
(BSI-A and BSI-B)

• BSI-A
• 1 positive blood culture for a recognised
  pathogen
• or
• Patient has at least one of the following signs
  and symptoms fever (gt38C.) chills, or
  hypotension
• and
• Two positive blood cultures for a common skin
  contaminant (from 2 separate blood samples drawn
  within 48hrs).
• Skin contaminants
• Coagulase-neg staphylococci
• Micrococcus sp.
• Propionibacterium acnes
• Bacillus sp.
• Corynebacterium sp.

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Infection Definitions Blood Stream Infections
(BSI-A and BSI-B)

• BSI-B
• Patient has at least one of the following signs
  or symptoms fever (gt38C.), chills, or
  hypotension.
• And either
• 1 positive blood culture with a skin contaminant
  in patient with an intravascular line in place
  and in whom the physician instituted appropriate
  antimicrobial therapy.
• Or
• positive blood Antigen test
• Haemophilus influenzae
• Streptococcus pneumoniae
• Neisseria meningitidis
• Group B Strepyococcus

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CVC Related Infection

• Three CRIs
• Local CVC-related infection
• General CVC-related infection
• CVC related BSI

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CRI1 Local CVC-related infection(no positive
blood culture)

• Quantitative CVC tip culture 103 CFU/ml
• or
• Semiquantitative tip CVC culture gt15 CFU
• and
• Pus and/or inflammation at the insertion site or
  tunnel

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CRI2General CVC-related infection(no positive
blood culture)

• Quantitative CVC tip culture 103 CFU/ml
• or
• Semi-quantitative tip CVC culture gt15 CFU
• and
• Clinical signs (fever gt38C. chills, or
  hypotension) improve within 48hrs after catheter
  removal

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CRI3 CVC-related BSIBSI occurring 48hrs before
or after catheter removal

• and
• Positive culture with the same micro-organism of
  EITHER
• Quantitative CVC tip culture 10³ CFU/ml or
  semi-quantitative CVC tip culture gt15 CFU
• Quantitative blood culture ratio CVC blood
  sample/peripheral blood sample gt5
• Differential delay of positivity of blood
  culture CVC blood sample culture positive 2 hrs
  or less before peripheral blood culture (blood
  samples drawn at the same time)
• Positive culture with the same micro-organism
  from pus from insertion

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Reporting

• Data will be sent from SICSAG to HPS only with
  written permission from the unit
• HPS will receive 2 downloads from SICSAG per year
• Data will be checked and an annual report will be
  produced
• Data will be sent to HELICS for inclusion in
  Europe wide report
• HPS will encourage and support staff to feedback
  their data locally with the aim of reducing
  infection rates- increase the success of the
  surveillance programme

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Any Questions?