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Corso precongressuale: Le Infezioni Ospedaliere
Epidemiologia delle Infezioni
nelle Organizzazioni Sanitarie
Nicola Petrosillo
U.O.C. Infezioni Sistemiche e dell’Immunodepresso
Istituto Nazionale per le Malattie Infettive
“Lazzaro Spallanzani”, IRCCS-Roma
Infezioni correlate a organizzazioni
assistenziali (ICOS)
Infezioni acquisite
durante il ricovero
in ospedale
Infezioni acquisite
in ambulatorio
Infezioni acquisite
in day hospital,
day surgery
Infezioni in day care
UTI
BSI
PNE
SSI
OTH
Klevens RM et al. Public Health Reports 2007; 122: 160-6
Klevens RM et al. Public Health Reports 2007; 122: 160-6
Klevens RM et al. Public Health Reports 2007; 122: 160-6
Device-specific incidence rates/utilization ratio
U. ratio
X 1000 days
1
UTI
BSI
0,5
5
VAP
CVC
Urin cath
Ventilator
Edwards JR et al. Am J Infect Control 2007;35:290-301.
Main prevalence surveys on hospital
infections (HI) in Italy
Author/year
Setting
#pts
Moro (1983)
Tuscany(87)
Moro (1984)
130 Italian hospitals
26 hospitals
15 hospitals in Rome
36 wards of a hospital
3 hospitals in Chioggia
6 hospitals in Florence
34,577
5,564
5,695
623
435
684
3,073
888
11,343
Castelnuovo (98)
Mancarella (98)
Lazzeri (98)
Marena (98)
Pavia (1999)
Privitera (88)
1 teaching hosp in Pavia
4 hospitals in Catanzaro
259 Italian surgical wards
% prev.
6.8
5.1
5.5
5.8
5.5
7.2
6.4
1.7
5.0
Ippolito G, Nicastri E, Martini L, Petrosillo N. Infection 2003;31(S2):4-9
Main incidence studies on hospital
infections (HI) in Italy
Author (year)
Setting
# patients
Ippolito (1985)
71 Italian Intensive care units
6,589
29.5
Ortona (1985)
One teaching hospital
10,385
6.7
Greco (1987-89)
20 surgical wards
7,641
13,6
Scolfaro (1994)
One infectious pediatric unit
229
7.8
Pallavicini (1995-98)
One ICU in a teaching hospital
3,679
12.6
Scotton (1996-97)
One neurosurgical ICU
562
14.8
Petrosillo (1997-98)
19 Infectious Diseases Units
Valera (1998-99)
One pediatric cardiac surgery unit
Romagna Region (2001)
Hospitals in Emilia Romagna Regione
Di Palo (1980-82)
One surgical unit
Mosconi (1983-84)
23 ICUs
1,475
15.0 VAP
Ippolito (1985)
71 Italian ICUs
6,598
14.1 VAP
Moro (1991)
52 Italian ICUs
672
9.4 VAP
Moro (1991)
7 hospitals
607
9.3 CR-BSI
Alvarenz (1993-96)
One vascular surgical unit
806
1.8 SSI
Brusaferro (1996)
12 hospitals in Friuli Region
1,625
21.5 UTI
Petrosillo (1998-99)
17 Infectious Diseases units
1,379 HIV+
4.7 nosocomial BSI
4,330 HIV+
% incidence
6.3
104
30.8
6,158
4.7
991
3.8 SSI
Ippolito G, Nicastri E, Martini L, Petrosillo N. Infection 2003;31(S2):4-9
SSI – a European perspective of
incidence and economic burden
Costs of additional hospitalization days
associated with SSI
Source
Country
Cost per day Cost for
mean of 9.8
days
Netten & Curtis UK
409
4,008
Oostrenbrink
Netherlands
230
2,254
DKG
Germany
317
3,107
Pena
Spain
170
1,666
PMSI
France
412
4,038
Orsi
Italy
413
4,047
Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. 2004
ICOS
DIMENSIONI DEL PROBLEMA
 colpiscono circa il 5-10% dei pazienti
ricoverati
 rappresentano circa il 50% delle
complicanze ospedaliere
 casi annui: 450.000-700.000
 decessi annui: 4.500-7.500
 costo annuo:1 miliardo di euro
ICOS
INTERVENTI POSSIBILI
 quota prevenibile: 30-40%
 casi evitabili: 135.000-210.000
 decessi evitabili: 1.350-2.100
 costo evitabile: 300 milioni di euro
Quanto ci si lava le mani in Ospedale?
Una valutazione di 34 studi pubblicati
sulla adesione al lavaggio delle mani tra
gli operatori sanitari ha riscontrato che
questa adesione varia dal 5% al 81%
Adesione al lavaggio delle mani da parte
degli operatori sanitari
34
31
28
25
22
19
16
13
10
7
4
90
80
70
60
50
40
30
20
10
0
1
Il valore medio è solo
del 40%
Adesione Percentuale
Media
Studi
Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002, Vol.51
Pittet D et al. Int J Infect Dis 2006; 10: 419-24
Core element of hand transmission.
Contestualization of the risk
Sax H et al. J Hosp Infect 2007; 67:9-21
Sax H et al. J Hosp Infect 2007; 67:9-21
Sax H et al. J Hosp Infect 2007; 67:9-21
Healthcare-associated infections: main issues
• Pathogenicity of microorganisms
• Risk factors
• Immunosuppression
• Cross contamination
• Antibiotic pressure and resistance
• Emerging organisms
• Relevance of clones in HAI epidemics
• Strategies
-search and destroy
-developing a culture of safety
- WHO campaign
• Social aspects of HAI
- antibiotic use
- medico-economic aspects
- non-traditional forces to change HAI prevention
Infezioni post-operatorie in Italia
Petrosillo N et al BMC Infect Dis 2008; 7;8:34.
4665 interventi in 48 chirurgie
316 infezioni (6,8 per 100 interventi)
0,8%
5,4%
0,5%
SSI
BSI
LRTI
Circa la
metà dopo
la dimissione
Klevens RM et al. JAMA 2007; 298:1763-71
The risk of infection in LTCFs
Recent prevalence and incidence infection studies in LTCFs
Author, year, place
Mongardi, 2003, Italy
Eriksen, 2004, Norway
Stevenson, 2005, US
Type of
study
Prevalence
N° of facilities (n°
of residents)
49
(1926)
Infection
rate
9,6
(weighed)
Prevalence
(4 surveys,
2002-2003)
Incidence
203-300
(11465-17174)
6,6-7,6
17
(472019 residentdays)
1
(34793 residentdays)
4
(21503 residentdays)
3,64
Engelhart, 2005,
Germany
Incidence
Brusaferro, 2006, Italy
Incidence
Rate by
infection site§
UTI 1,5
LRTI 2,9
URTI 1,5
Skin 3,1
Conjuntivitis
1,7
GI 0,4
UTI 3-3-3,8
LRTI 1,2-1,6
SSI 0,3-0,5
Skin 1,5-2,0
RTI 1,75
Skin 1,10
UTI 0,60
GI 0,16
6,0
RTI 2,2
Skin 1,2
UTI 1,0
GI 1,2
11,8
LRTI 2,5
Skin 2,7
UTI 3,2
GI 1,2
Conjuntivitis
1,2
§ UTI = Urinary Tract Infections; LRTI = Lower Respiratory Tract Infections; URTI = Upper Respiratory Tract Infections; GI = Gastrointestinal
infections
4 LTCFs in NE Italy
859 pts. (79.3 ± 11 years)
The risk of infection in LTCFs
In nursing homes, the prevalence of antibiotic resistance
Gould CV et al ICHE
2006; 27: 920-25
(45 LTCFs, 2002-2003)
90
80
70
60
50
40
30
20
10
0
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Red columns:
frequency higher
than the 90°
percentile reported
by NNIS in medical
ICUs
% resistant
is extremely high
Hematogenous complications in 42/342 (13%) pts with S. aureus CR-BSI
Fowler VG Jr et al. Clin Infect Dis 2005;40:695-703
Staphylococcus aureus Endocarditis. A Consequence of
Medical Progress
•Prospective observational cohort study set in 39 medical centers in 16 countries.
•1779 patients with definite IE as defined by Duke criteria (International
Collaboration on Endocarditis-Prospective Cohort Study) from June 2000 to December
2003.
250
200
558
S.Aureus
IE
150
100
50
0
HC-ass
CA non-IVDU
CA IVDU
Fowler VG, Jr et al. JAMA 2005; 293:3012-21
Ventricular Assist Device
Ventricular assist device-related infections occur in
18–59% of patients after implantation
Infection can involve any aspect of the device:
the surgical site
the driveline
the device pocket
the pump itself
(More than half infections include multiple sites)
Complications:
bloodstream infection
Relapsing bacteraemia
Sepsis
Device-associated endocarditis
Rarely: mediastinitis, peritonitis, pseudoaneursysm
Lancet Infect Dis 2006
Ventricular Assist Device
Timing of ventricular assist device-related infections:
Most infections occur between 2 weeks and 2 months of implantation
Only 5–10% of patients developed infections beyond 3 months
Microbiology:
Staphylococcus aureus and epidemidis (24-56%)
Enterococci
Gram-negative bacilli (eg, Pseudomonas aeruginosa, Enterobacter, Klebsiella)
Fungi (Candida)
Outcome:
Serious device-related infection, such as endocarditis, is associated with up to
50% mortality
Device infection is significantly associated with decreased survival after
transplantation
Lancet Infect Dis 2006
24% of colonized patients developed S.
aureus infection versus 2% of
noncolonized patients (p<0.01)
Keene A et al. Infect Control Hosp Epidemiol 2005;26:622
Pan A et al. Infect Control Hosp Epidemiol 2005;26:127-133
J Hosp Infect. 2007;67:308-15
Infection in Solid-Organ Transplant Recipients
Fishman JA. N Engl J Med 2007; 357: 2601-14
Nusair A et al. Infect Control Hosp Epidemiol 2008; 29: 424-29
Nusair A et al. Infect Control Hosp Epidemiol 2008; 29: 424-29
Transplantation Proceedings 2008; 40, 1986–1988
Mattner F et al. J Heart Lung Transplant 2007; 26: 241-9
Mattner F et al. J heart Lung Transplant 2007; 26: 241-9
From 1988 to 2004, 51 patients underwent SPKT
systemic 13
pulmonary 13
urinary tract 15
intestinal 8
wound 23 (45%)
CMV
Bacterial
Fungal
Michalak G et al. Transplantation Proceedings 2005; 37, 3560–3563
SSI and transplant
Patients who develop SSI are
- twice as likely to die,
- 60% more likely to be in the intensive care unit,
- and 5 times more likely to be readmitted to the
hospital after discharge.
This manifested also in longer hospital stays and higher
hospitalization costs.
Kirkland KB et al.. Inf Control Hosp Epidemiol 1999;20:725-730
Clostridium difficile associated colitis
(CDAD) and transplant
•The reported incidence of CDAD varies from 3.5% in
adult kidney recipients to 31% in lung transplants.
•This variability may be due to differences in
- the type of organ transplantation,
- diagnostic methods,
- Immunosuppressive regimen,
- time after transplantation,
- follow-up period
- and other population characteristics.
•Between November 1990 and November 2005, 202 consecutive
patients underwent 208 lung transplantation procedures.
•Fifteen of 208 lung recipients developed 23 episodes of CDC
with a median follow-up period of 2.7 years (range,
0-13.6)
•The annual incidence of CDC in lung transplant recipients was
2.1%.
•All patients with confirmed disease had at least 1 of the following
3 risk factors:
-recent antibiotic use,
-recent hospitalization, or
-augmentation of steroid dosage.
Gunderson CC et al. Transpl Infect Dis 2008: 10: 245–251
Gunderson CC et al. Transpl Infect Dis 2008: 10: 245–251