Prognostische Implikationen
Nosokomialer Infektionen
Univ. Prof. Dr. A. Valentin, MBA
Kardinal Schwarzenberg Klinikum
Schwarzach i. Pongau
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?
Top Related