e. velasco, l. c. santos thuler, c. a. marti

8/12/2019 . E. Velasco, L. C. Santos Thuler, C. a. Marti

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o s o c o m i a l i n f e c t i o n s in a n o n c o l o g yi n t e n s i v e c a r e u n i tE d u a r d o V e l a s co M DL u i z C l a u d i o S a n to s T h u l er M D M S cC a r l o s A l b e r t o d e S . M a r t i n s M DL e d a M a r i a d e C a s t r o D i a s R NV a n i a M a r i a d a S . e C . G o n ~ a l v e s R NRio de Janei ro Brazi l

Introduction Treatment of cancer has contribu ted to a growing number ofimmunocomp romised patients with life-threatening nosocomial infections (NI). Highmortality with considerable cost is observed when they are admitted to the intensive careunit (ICU). Few studies on infection control and surveillance have been undertaken in thispopulation group.Methods All patien ts treat ed a t a six-bed medical-surgical oncology ICU for >48 hours wereprospectively observed for the development of an NI a nd the influence of device u tilizationon infection rates. The analysis used the s tandard definitions of the National NosocomialInfect ion Surveillance System Intensive Care Unit surveillance component.Results From September 1993 through November 1995, 370 infections occurred in 623patients during 4034 patient-days, for an overall rate of 50.0 per 100 patients or 91.7 per1000 patient-days. Pneumo nia (28.9 ), urin ary tract infections (25.6 ), and bloodstreaminfections (24.1 ) were the main types of infection. The most common microorganismsisolated were Enterobac teriaceae (29.7 ), fungi (22.2 ), and Pseudomonas aeruginosa(13.2 ). The median device util ization ratios were 0.63, 0.83, and 0.86 for ventilator,indwelling urin ary catheter, and central venous catheter, respectively. The highest med iandevice-specific associated infection rate was 41.7 for ventilator. The med ian for the averagelength of stay was 8.8 days, and the average severity of illness score was 4.0. There was astrong positive correlation between the overall NI patient rate an d device utilization (r =0.56, p < 0.01), average severity of illness score (r = 0.54, p < 0.01), and average length ofstay (r = 0.67, p < 0.0l). No correl ations were statistically significant when pati ent-dayswere used in the denomina tor. Among the devices only the n umb er of central venouscatheter days was s ignificantly correlated with infections (r = 0.51, p = 0.01). The NIpatient -day rates were progressively higher the longer the pat ients stayed in the ICU.Conclusions The high rates reported in this s tudy may reflect a comb inat ion of severalfactors related to the unde rlying illness, neutrophil count, and exposure to invasiveprocedures. The adjusted infec tion rates described here provide specific surveillance datafor further inte rhospit al compari sons and also to assess the inf luence of invasive medicalinterventions, allowing the implementa tion of preventable measures to control infections.(AJIC Am J Infection Control 1997;26:458-462)

P r e v i o u s s t u d ie s h a v e e m p h a s i z e d t h e c o n s e -quenc e o f in f ec t ions as a r ea l t h r ea t t o immuno -suppr ess ed hos t s . 1~3 Aggres s ive an t in eop la s t i cc h e m o t h e r a p y h a s r e n d e r e d p a t i e n t s w i t h c a n c e rFrom the Infect ious Disease Service and Hospita l Infect ion Con-tro l Comm ittee, National Can cer Inst i tute, R io de Janeiro.Reprint requests: Eduardo Velasco, MD, Rua General Glicerio,486/1002, 22245-120, Rio de Janeiro, Brazi l .Co pyrigh t 1997 by the Association for Professionals in Infect ionControl and Epidemiology, Inc.0196-6553/97 5.00 + 0 17/46/76926

i m m u n o c o m p r o m i s e d a n d t h u s m o r e v u l n e r a b l eto in f ec t ions . Never the less , improv ement s in an -t i m i c r o b i a l a g e n t s a n d s u p p o r t i v e m e a s u r e s h a v el e n g t h e n e d s u r v i v a l a n d e v e n a t t a i n e d c u r e i nsome neop l as t i c d i seases , desp i t e the l if e - th r ea t -e n i n g i n f e c t i o u s c o m p l i c a t i o n s t h a t e v e n t u a l l y r e-q u i r e s o m e k i n d o f i n t e n s i v e c ar e s u p p o r t . S t u d i e sh a v e r e p o r t e d h i g h m o r t a l i t y a n d c o n s i d e r a b l ecos t f o r c r it i ca l ly i ll cance r pa t i e n t s a dmi t t ed tothe in t en s ive ca re un i t ( ICU) , 4,5 main l y beca use o fthe sever i ty of the und er ly i ng d i sease and th e ex -p o s u r e t o i n v a s i ve p r o c e d u r e s .

4 5 8


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J I CV o l u m e 25 N u m b e r 6 V e l a s c o e t a l 5 9

Despite the importance of surveying high-riskpatients, few studies on infection control and sur-veillance have been und ert aken in this populationgr ou p. 3 ~-1 In developing countries the study ofnosocomial infection (NI) has not been as effec-tive as possible because of the lack of a uniformapproach for measuring quality of care. The ob-jective of this article is to report a 27-month st udyof nosocomial infection surveillance in an oncol-ogy ICU that is based on National NosocomialInfections Surveillance (NNIS) system methodsThese data might serve for comparative studieswith ot her oncology ICUs and also help to developa more efficient surveillance system, allowing fordetailed infection control measures for these

ihigh-risk patients.i

M T E R I L N D M E T H O D SiThe Cancer Hospital in Rio de Janeiro, Brazil, isa 206-bed refe+al teaching hospital for oncologicpatients with an average annual admission of ap-proxima tely 5800 patien ts, 130,000 outpat ien tconsultations, and 5000 annual surgical proce-dures. It is the main hospital of the NationalCancer Institute complex and has a very activetraining and teaching program The study was idone in the siX-bed medical-surgical ICU. All pa-tients treated ]in this unit for >48 hours wereprospectively Observed for the development of a

INI and the influence of device utilization (in-idwelling urinatT catheter [IUC] central venouscathe ter [CVC], and ventilator [VEN]) on infec-tion ratesThe data were collected from September 1993thro ugh Noverpber 1995, and the analysis usedthe protocol of the NNIS ICU component1~ andthe standard definitions of NI according to theI .Centers for D~lsease Control and Prevention22Patients were surveyed for NIs fr om the day of ad-mission until 48 hours after ICU discharge, if hos-pitalized, or ~ntil ICU discharge, if transferredfrom the hospital. ICU-related infections were de-fined as those [hat developed after a 48-hour stayin the unit and ]through the first 48 hours after dis-charge fro m th~ ICU. All infec tion rates, inc ludingpatient and patient-day and device- and non-de-vice-associated infections were calculated accord-ing to the forI~ulas as described in the NNIS sys-

1 2tern report ~The denom inator data collected Iwere the total num ber of patients at risk, the totalnumber of patient-days, the days of IUC, CVC,and VEN support per month.The three strategies used for compar ison of ICUinfection rates [considered the average severity-of-

illness score (ASIS), average length of stay (ALOS)in the ICU, and the device utilization (DU) ratio.The ASIS was defined according to the HospitalInfections Program, Centers for Disease Controland Prevention cr iteria 11 (i.e., patients received ascore of A through E depending on the degree ofillness whe n admit ted to the ICU). To calculate theASIS, points are ascribed to patients once a weekon the basis of the classification scheme. Onepoint is ascribed to postoperative patients requir-ing routine postoperative observation, 2 points tophysiologically stable patients requiring prophy-lactic overnight observation, 3 points for nursingand monitoring, 4 points for physiologically un-stable patients requiring intensive nursing andmedical care with the need for frequent reassess-ment and adjustment of therapy, and 5 points forphysiologically unstable patients wh o are in acoma or shock or who require cardiopulmonaryresuscitation or intensive medical and nursingcare with the need for f requent reassessment. Themonth ly ASIS for the unit is obtained by dividingthe total number of points ascribed to patients bythe total nu mbe r of patients in the ICU on the dayof weekly prevalence. The ALOS is a proxy for in-fection risk and is calculated with the numer atoras total patient-days added to the number of pre-vious days spent in the ICU by patients prese nt inthe ICU on the first day of the month and thenumb er of additional days patients present in theICU on the last day of this mon th will stay in theICU. The denominator is the number of patientsin the ICU on the first day of this month plus thenumber of patients admitted to the ICU duringthis month. 11 The DU of an ICU is one measure ofthe unit s invasive practice s and may serve as amar ker for the severity of illness of the patients inthe unit. The DU is calculated by dividing thenumb er of device-days by the numb er of patient-days. 11

To reduce the confounding influence of patientICU stay or device exposure on the infection rate,we evaluated the correlation between overall NIrate (patient or patient-days) and average lengthof patient stay or device-days utilization In addi-tion, we also compared the device-associated in-fection rates for pneumonia, bloodstream infec-tions, an d ur inar y tract infectionsR E S U L T S

During the 27-month period 370 infections oc-curred in 623 new patient admissions over 4034patient-days. The medians of the overall NI patientand pat ient-day rates were 50.0 infections per 100


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A J I C4 6 V e l a s c o e t al De ce mb e r 1 9 9 7

1

8

6

4

2

15

1

5

2

F i g . 1 A . Num ber o f IUC-assoc ia ted u r inary t rac t in fec -t ions and IUC -days cor re lat ion coef f ic ient r = 0.17,p > 0.05).

8

_z4

Dom 2

15

1

5

16

F i g , 1 B , Number o f CVC-assoc ia ted b loods t ream in fec -t ions and C VC -days cor re lat ion coef f ic ient r =0.62,p < 0.001).

14

12

1

8

6

4

2

2

F i g 1 . Number o f cases o f VEN-assoc ia ted pneumo-nia and VE N-days cor re lat ion coef f ic ient r = 0.36,p > 0,05).

T a b l e 1 . Dev ice-spec i f i c u t il i za t ion med ian ra t ios anddev ice-a ssoc ia ted in fect ion ra tes

Range MedianC V C u t i l i z a t i o n r a t i o *V E N u t i l iz a t i o n r a t i o *U r i n a r y c a t h e t e r u t i l i z a t i o n r a t i o *C V C - a s s o c i a t e d B S l r a t e rV E N - a s s o c i a t e d P N E U r a t e rU r i n a r y c a t h e t e r - a s s o c i a t e d U T I r at e1 -

0 . 6 6 - 1 , 0 2 0 . 8 60 . 3 1 - 0 . 8 1 0 . 6 30 . 5 9 - 0 . 9 9 0 . 8 3

7 . 5 - 5 8 , 8 2 5 , 61 5 . 4 - 8 2 . 4 4 1 . 7

7 . 9 - 8 0 . 6 2 7 . 5BSI Bloodstream infection; PNEU pneumonia ; UTI urinary tract infection.*No. o f device-days/No, o f pa t ien t-days.? No. o f speci f ic device -asso cia ted in fections/No, o f devic e-d ays )x 1000,

T a b l e 2 , Correlat ion between NI and overal l DU rat io,ASIS and ALOS

Correlationcoefficient p Value

D U a n d N I p a t i e n t r a t e * 0 . 5 6D U a n d N I p a t i e n t - d a y r at e1 - 0 , 3 3A S l S a n d N I p a t i e n t r a t e * 0 . 5 4A S l S a n d N I p a t i e n t - d a y r a t e r 0 . 3 9A L O S a n d N I p a t i e n t r a t e* 0 . 6 7A L O S a n d N I p a t i e n t - d a y r a t e r 0 , 2 2

< 0 . 0 1> 0 . 0 5< 0 , 0 1> 0 , 0 5< 0 . 0 1> 0 . 0 5

*NI patient rate = No , of infections/No, of patients) x 100.1-NI pa t ien t-da y ra te = No. o f in fect ions/No, p a t ien t-da ys)x 1000.

p a t i e n t s ( r a n g e 1 3 .2 t o 1 0 0 ) a n d 9 1 . 7 i n f e c t i o n s p e r1 0 00 p a t i e n t - d a y s ( r a n g e 3 5 . 7 to 1 4 3. 8) . P n e u m o -n i a ( 2 8 .9 ) , u r i n a r y t r a c t i n f e c t i o n s ( 2 5 .6 ) , a n db l o o d s t r e a m i n f e c t i o n s (2 4 . 1 ) w e r e t h e m a j o r r e -p o r t e d i n f e ct io n s . I s o l a te d m i c r o o r g a n i s m s w e r eE n t e r o b a c t e r i a c e a e ( 2 9 .7 ) , f u n g i ( 2 2. 2 ) , Pseudomonas aeruginosa ( 1 3. 2 ) , o t h e r g r a m - n e g a t i v eb a c i l l i ( 1 3 ) , Staphylococcus aureus ( 5 . 3 ) , a n do t h e r g r a m - p o s i t i v e c o c c i ( 1 6. 6 ) .

T h e n u m b e r o f I U C d a y s, C V C d a y s , a n d V E Nd a y s o b s e r v e d d u r i n g t h e s t u d y w a s 3 3 1 2 , 3 5 0 7,a n d 2 4 9 6 d a y s , r e s p e c ti v e ly . T a b le 1 s h o w s t h a t t h em e d i a n D U r a ti o s r a n g e d f r o m 0 . 6 3 fo r V E N t o0 . 8 6 f o r C V C , w h e r e a s t h e h i g h e s t m e d i a n d e v i c e -s p e c i f i c a s s o c i a t e d i n f e c t i o n r a t e w a s 4 1 . 7 f o r V E N .

T h e A L O S r a n g e d f r o m 4 .8 t o 2 0 .4 d a y s ( m e d i a n8 .8 ), w h e r e a s t h e A S I S o f p a t i e n t s r a n g e d f r o m 3 .3t o 4 . 5 ( m e d i a n 4 . 0 ) . T a b l e 2 d e m o n s t r a t e s t h es t r o n g p o s i t i v e c o r r e l a t i o n b e t w e e n t h e o v e r a l l N Ip a t i e n t r a t e a n d D U ( r -= 0 . 5 6 , p < 0 .0 1 ) , A SI S ( r =0 . 5 4 , p < 0 . 0 1 ) , a n d A L O S ( r = 0 . 6 7 , p < 0 .0 1 ) , b u ta r e d u c e d a n d n o n s i g n i f i c a n t c o r r e l a t i o n w e r e n o -t ic e d w h e n p a t i e n t- d a y s w a s u s e d i n t h e d e n o m i -n a t o r ( r = 0 . 3 9 a n d 0 . 2 2 , r e s p e c t i v e l y ) . W h e n w ea n a l y z e d h i g h - r i s k d e v i c e s s e p a r a t e l y ( F i gs . 1 A t o1 C ), a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n w a s


4/5

J I CV o l u m e 2 5 , N u m b e r 6 V e l a s c o e t a l 4 6

a c h i ev e d b e t w e e n t h e n u m b e r o f C V C - da y s a n da s s o c i a t e d i n f e c t i o n s ( r = 0 . 5 1 , p = 0 . 0 1 ) . F i g . 2s h o w s a g r a d u a l a n d p r o g r e s s i v e l y i n c r e a s i n gt r e n d i n t h e N I s d e s p i t e t h e h i g h r a t e s o f o c c u r -r e n c e a t a l l s t r a t a o f p a t i e n t s t ay .D I S C U S S I O N

N I s a re a n i m p o r t a n t c a u s e o f m o r b i d i t y a n dm o r t a l i t y i n c f i n c e r p a t i e n t s a d m i t t e d t o t h e I C U . 13M a n y f a c to r s i n c r e a s e t h e r i sk o f i n f e c t io u s c o m -p l i c a ti o n s a n d c o n s e q u e n t l y a f fe c t t h e i n f e c t i o nr a t e s a n d t h e ~ r o g n o s i s o f th i s g r o u p o f h i g h - r i s kp a t i e n t s . 14,1~ M o r e r e c e n t l y , s e v e r a l s u r v e i l l a n c es t u d ie s b a s e d o n t h e N N I S s y s t e m m e t h o d s h a v er e p o r t e d N I r a t e s i n I C U s . 16-19 H o w e v e r , a n o n c o l -o g y IC U w o u l d b e e x p e c t e d t o h a v e a g r o u p o f c r it -i c aU y i ll i m m U n o s u p p r e s s e d p a t i e n t s a t h i g h e r i n -t r i n s i c ~" "n d e x t r i n s i c ri s k s f o r in f e c t i o n s w i t h l o n g e rs t a y t h a n w o u l d a n I C U w i t h o u t s u c h p a t i e n ts .T h e s e r i s k f a c t o r s c e r t a i n l y a f f e c t t h e v a l i d i t y o fo v e ra l l i n f e c t i o n r a t e c o m p a r i s o n s a m o n g d i f f e re n tI C U t y p es . A p r e c e d i n g s t u d y f r o m t h e C e n t e r s f o rD i s e as e C o n t r b l a n d P r e v e n t i o n a n d t h e N N I S s y s-t e m h a s a l r e a d y e m p h a s i z e d t h a t d a t a f r o m c e r t a i nt y p e s o f IC U g s h o u l d b e a n a l y z e d s e p a r a t e l y b e -c a u s e o f d i ff e { e n t i n f e c t i o n r a t e d i s t r i b u t i o n s J 7

O u r r e s ul t s i s h o w e d a m u c h h i g h e r p a t i e n t - d a yr a t e ( 9 1 .7 i n f e c t i o n s p e r 1 0 0 0 p a t i e n t - d a y s ) a n di n v a s i v e d e v i + e s e x p o s u r e ( T a b l e 2 ) t h a n d i d t h ep r e v i o u s l y p f u b l is h e d r e p o r t o f N I r a t e s i n an o n o n c o l o g y ] a d ul t a n d p e d i a t r i c I C U . 17 W e a l s of a i le d to f i n d a s t r o n g c o r r e l a t i o n b e t w e e n t h eo v e r a l l p a t i e m - r a t e s a n d D U r a t i o s ( F i g . 1 ) , e x c e p tf o r il o o d s t r e a m i n f e c t i o n s a n d C V C e x p o s u r e ( r =0 . 5 1 ) , u n l i k e ~ h e a b o v e s t u d y .

T h e A L O S W a s a l so n o t s t r o n g l y a s s o c i a t e d w i t hN I s w h e n w d c o n t r o l le d f o r th e c o n f o u n d i n g i n -f l u e n c e o f l e n g t h o f s t a y b y u s i n g p a t i e n t - d a y s a st h e d e n o m i n a t o r ( r = 0 . 22 ) . H o w e v e r , s tr a t i f i c a -t i o n o f le n g t ~ o f p a t i e n t s t a y s h o w e d t h a t N I p a -t i e n t - d a y r at ~ s t e n d e d t o b e p r o g r e s s i v e ly h i g h e rt h e l o n g e r t h ~ p a t i e n t s s t a y e d i n t h e I C U .

[ O u r h ] g h - r a te o u t h e r r e s u l ts m a y r e f l e ct a c o m -b i n a t i o n o f s ~ v e r a l f a c t o r s r e l a t e d t o t h e s e v e r i t yo f t h e u n d e r l y i n g i l ln e s s, t h e n e u t r o p h i l c o u n t , i n -v a s i v e p r o c e d u r e s , u s e o f d e v ic e s , a n d i n f e c t i o n st h a t u su a l l y O c cu r i n i m m u n o c o m p r o m i s e d c a n-c e r p a t ie n t s . A d j u s t e d i n f e c t i o n r a t e s i n a n o n c o l -o g y I C U p r o v i d e s p e c if i c s u r v e i ll a n c e d a t a f o rm o r e p r e c i s ~ i n t e r h o s p i t a l c o m p o n e n t c o m p a r -i s o n s . T h e y a l s o h e l p a s s e s s t h e i n f l u e n c e o f i n v a -s iv e m e d i c a l l in t e r v e n ti o n s o n t h e s e h i g h - r i s k p a -t ie n ts , a l l o w i n g f o r t h e i m p l e m e n t a t i o n o fp r e v e n t i v e m ~ e a s u r e s t o c o n t r o l i n f e c t i o n s .

1 2 0

1I L l

ZoI - -oLIJLI .Z. 1

ooot/oz

8 0

6 0

4 0

2 0

, ~ . ~ ~ , . ~ ~F i g . 2 . A L O S a t l O S a n d c o r r e s p o n d i n g N I p a t i e n t a n dpa t i en t days ra t es . S t ra t i fi ca t ion acc o rd i ng t o qua r t ii es .

R E F E R E N C E S1. Schimpff SC. Infections in the cancer patient-diagnosis,prevention, and treatment. In: Mandell GL, Bennett JE,Dolin R, editors. Principles and practice of infectious dis-eases. 4th e dition. New Y ork: Churchill Living stone; 1995.p. 2666-75.2. Young LS. Nosocomial infections in the immunocom pro-mised adult. Am J Med 1981;70:398-404.3. Velasco ED, M artins CA, Vidal E, et al. Infec96es em pa-cientes neu trop~nicos. R ev Bras C ancer 1986;32:195-204.4. Jonhnso n MH, G ordon PW, Fitzgerald E Stratification ofprognosis in granulocytopenic patients with hem atologicmalignan cies using the APACHE I severity of illness score.Crit C are Med 1986;14:693-7.5. Schapira DV, Studnicki J, Bradhum DD, WolffE Jarret A.Intensive care, survival, and expense of treating criticallyill cancer patie nts. JAM A 1993;269:783-6.6. Robinson GN, Tegtmeier BR, Zaia JA, et al. Brief report:nosocomial infections rates in a cancer treatm ent center.Infect Control 1986;5:289-94.7. Rotstein C, Cummings M, Nicolau AL, et al. Nosocomialinfection rates at an oncology center. Infect Control HospEp idem iol .1989;9:13 9.8. Aguiar N, Bermudez LE, Vidal E, et al. Controle das in-

fec~6es hospitalares no Instituto Nacional de C fincer, M.Saude. Rev Bras Cancer 1982;29:7-20.


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9. Bermudez LE, Vidal E, Velasco E, et al. Controle de in-fec~go hospitalar: experi~ncia de dois anos. Rev BrasCancer 1984;30:6-13.10. Velasco EV, Mar tins CAS, Vidal E, Carva lho AD,Gaglianone TC. Infec96es nosocomiais em um hospitaloncoldgico. Rev Paul Med 1990;108:61-70.11. Emor i TG, Culver DH, Hor an TC, Jarvis WR, et al.National nosocomial infections surveillance system(NNIS): description of surveillance methods. AJIC Am JInfect Control 1991;19:19-35.12. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM.CDC definitions for nosoc omial infections, 1988. AJIC AmJ Infect Control 1988;16:128-40.13. Bone RC. Concepts in emergency and critical care: inten-sive care, survival, and expense of treating critically ill can-cer patien ts. JAMA 1993;269:783-6.14. Schuster DE Marion JM. Precedents for meaningful recoveryduring treatment in a medical intensive care unit: outcome in pa-tients with hematologic malignancy. Am J Med 1983;75:402-8.15. Lloy d-Th omas AR, Wright I, Li ste r TA, Hinds CJ.

Prognosis of patients receiving intensive care for life

threatening medical complications of haematological ma-lignancy. BMJ 1988;296:1025-9.16. Hospital Infecti ons Program, Natio nal Cen ter for In-fectious Disease, Centers for Disease Control and Pre-vention, Public Health Service, U.S. Department ofHealth and Human Services. National Nosocomial In-fections Surveillance (NNIS) semiannual report, May1995: a report from the National Nosocomial Infec-tions Surveillance (NNIS) System. Am J Infect Control1995;23:377-85.17. Jarvis WR, Edwards JR, Culver DH, Hughes JM, Ho ran T,Emori TG, et al. Nosocomial infection rates in adult andpediatric intensive care units in the United States. Am JMed 1991;91(suppl 3B):185S-91S.18. Gaynes RP, Martone WJ, Culver DH, et al. Comparison ofrates of nosocomial infections in neonatal intensive careunit s in the United States. Am J Med 1991;91(suppl 3B):192S-6S.19. Josephson A, Karanfil L, Alonso H, Watson A, Blight J.Risk-specific nosocomial infection rates. Am J Med1991;91(suppl 3B):131S-7S.

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S u b s c r i p t i o n s m u s t b e i n f o r c e t o q u a l if y B o u n d v o l u m e s a r e n o t a v a i l a b l e i n p l a c eo f a r eg u l a r j o u r n a l s u b s c r i p t i o n

e. velasco, l. c. santos thuler, c. a. marti

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