nosocomial infections in solid organ transplant recipientsgbearman/adobe files/nosocomial infections...

Nosocomial Infections in Solid Organ Transplant Recipients

Focus On Prevention Through the Reduction of

Alterable Risk FactorsGonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University

Outline• Why are nosocomial infections important?• Nosocomial infections in transplants

– Data From VCU– Alterable risk factors and preventive measures

• BSI• Hospital acquired pneumonia• UTI

– Transplant specific antibiotic prophylaxis• Heart/Lung, Renal and Liver transplants

– Hand Hygiene• Importance of system level changes involving the

measurement and feedback of new technologies and NI process measures that minimize patient risk

What this presentation will not cover:

• Opportunistic infections!– Fungal, Viral, Parasitic Infections, Prion

diseases• Hospital associated or community

outbreaks!– Legionella– Aspergillus, etc, etc, etc

Nosocomial Infections• 5-10% of patients admitted to acute care

hospitals acquire infections– 2 million patients/year– ¼ of nosocomial infections occur in ICUs– 90,000 deaths/year– Attributable annual cost: $4.5 – $5.7 billion

• Cost is largely borne by the healthcare facility not 3rd party payors

Weinstein RA. Emerg Infect Dis 1998;4:416-420.Jarvis WR. Emerg Infect Dis 2001;7:170-173.

Major Sites of Nosocomial Infections

• Urinary tract infection• Surgical site infection• Bloodstream infection• Pneumonia (ventilator-associated)

Nosocomial Infections

• 70% are due to antibiotic-resistant organisms

• Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection

Burke JP. New Engl J Med 2003;348:651-656.Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

Nosocomial Infections in the US

9.8

1.9

5.3

190.0

35.9

1995

7.2Incidence of nosocomial infections(per 1,000 patient-days)

2.1Number of nosocomial infections (millions)

7.9Average length of stay (days)

299.0Number of patient days (millions)

37.7Number of admissions (millions)

1975

Burke JP. New Engl J Med 2003;348:651-656.

Attributable Costs of Nosocomial Infections

$700Urinary tract infection

$10,000 - $29,000Pneumonia

$5,000 - $34,000Catheter-associated BSI

$20,000 - $80,000Sternal wound infection

$3,000 - $27,000Wound infections

Cost per Infection

Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. 2003:36.

Shifting Vantage Points on Nosocomial Infections

Many infections are inevitable, although

some can be prevented

Each infection is potentially

preventable unless proven otherwise

Even in solid organ transplant recipients, many of the NI risk factors, pathogens and the preventive measures are

the same as for non-transplant recipients

Gerberding JL. Ann Intern Med 2002;137:665-670.

Nosocomial BSI in Solid Organ Transplant Recipients

Most infections during the first month after transplantation are related to surgical complications. These infections are similar to those occurring in general surgical patients.

Snydman, D. Clinical Infectious Diseases, 2001;33 (supplement):S5-S8.

Bacteremia in transplant recipients

• Prospective analysis of 125 bacteremicepisodes in 111 transplant recipients:– Recipients:

• 18 heart transplants• 26 Kidney transplants• 80 liver transplants

Wagener et al. AJIC 1992;20: 239-47


27/12522%

(% of episodes)

80/12564%

(% of episodes)

18/12514%

(% of episodes)

125 total episodes

270Kidney

5228Liver

144Heart

93/125(74%)

32/125(26%)

Proportion(of episodes)

Late Onset(> 14 days)

Early Onset(< 14 days)



6% in heart transplants

11% of bacteremias7% in Kidney transplants

Polymicrobial(10% of positive blood cultures)

11% of blood cultures:All Candida species

6% of Blood cultures:All Candida species

0% of blood culturesFungi

(6% of positive blood cultures)

50 % of blood culturesS.epidermidis

50 % of blood culturesS.aureusS.epidermidis

50 % of blood culturesS.epidermidisS.aureus

Gram Positive Organisms

(50% of pathogens)

39% of blood cultures:E.ColiP.aeruginosa

49% of blood cultures:P.aeruginosaEnterobacter sps

48% of blood cultures: E.coli, Klebesiella,Enterobacteriaciae

Aerobic Gram Negative Rods

(48% of pathogens)

Heart Transplant

Liver Transplant

Kidney Transplant



S.aureusP.aeruginosaEnterobacter spsS.epidermidis

E.coliS.aureusEnterobacteriaciae

Microbilogy

Higher APACHE II Score

Lower APACHE II ScoreSeverity of

illness

78/104(75%)

19/21(90%)

Survival

NosocomialCommunity acquired


Comparative Risk of Bloodstream Infection in Organ Transplant Recipients

• Purpose:– Determine the relative rates of BSI in solid

organ transplant recipients• Method

– Data collected on 277 consecutive patients over a 33 month period in a Canadian, Tertiary Care Medical Center

McClean et al. Infect Control Hosp Epi. Vol 15.No 9, September 1994


4028 (10%)275Total

75 (10%)50Heart or Heart/Lung

139 (5%)175Kidney

2014 (28%)50Liver

EpisodesPatients Infected

Total patientsTransplant



Total

Heart or Heart/Lung

Kidney

Liver

Transplant

543425 (60%)

01006 (86%)

41107 (54%)

122411 (55%)

UTIGIPNWNDPrimary(CVC)

•The majority of BSIs were Primary

•The majority of Primary BSIs were attributable to intravascular lines



4481521Total

6 (13%)03 (20%)3 (14%)OtherCandidaBacteriodes

12 (27%)2 (25%)5 (33%)5 (24%)Gram negative aerobesE.coli, Klebesiella,EnterobacteriaciaeP.aeruginosa

26 (59%)6 (75%)7 (47%)13 (62%)Gram Positive aerobesS.aureusS.epidermidis

TotalHeartKidneyLiverOrganism


Nosocomial Bloodstream Infections, 1995-2002

1.3%Acinetobacter spp10

1.7%Serratia spp93.9%Enterobacter spp84.3%Pseudomonas aeruginosa74.8%Klebsiella spp65.6%E. coli59.0%Candida spp49.4%Enterococci3

20.2%S. aureus231.3%Coagulase-negative Staph1

PercentPathogenRank

N= 20,978

Edmond M. SCOPE Project.

Preventive Measures for Nosocomial BSI

The CVC: Subclavian, Femoral and IJ sites

The intensity of the Catheter Manipulation

El Host

The CVC is the greatest risk

factor for Nosocomial BSI

As the host cannot be altered, preventive measures are focused on risk factor modification of catheter use, duration, placement and manipulation

The risk factors interact in a

dynamic fashion

Risk Factors for Nosocomial BSIs

• Heavy skin colonization at the insertion site

• Internal jugular or femoral vein sites• Duration of placement• Contamination of the catheter hub

Nosocomial Bloodstream Infections

• 12-25% attributable mortality• Risk for bloodstream infection:

0.2 - 2.2PICC

1Hickman/Broviac (cuffed, tunneled)

5-7Subclavian or internal jugular CVC

BSI per 1,000 catheter/days

Catheter type and expected duration of use should be taken into consideration

Prevention of Nosocomial BSIs

• Limit duration of use of intravascular catheters– No advantage to changing catheters routinely

• Maximal barrier precautions for insertion– Sterile gloves, gown, mask, cap, full-size drape– Moderately strong supporting evidence

• Chlorhexidine prep for catheter insertion– Significantly decreases catheter colonization; less

clear evidence for BSI– Disadvantages: possibility of skin sensitivity to

chlorhexidine, potential for chlorhexidine resistance

Putting BSI preventive strategies into practice….

Eliminating catheter-related bloodstream infections in the intensive care unit

– Purpose:– To determine whether a multifaceted systems

intervention would eliminate catheter-related bloodstream infections (CR-BSIs)

– Method:– Prospective cohort study in a surgical intensive

care unit (ICU) with a concurrent control ICU.

–Patients:– All patients with a central venous catheter in the

ICU

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.


•central catheter insertion cart that contains the equipment and supplies needed• reduced the number of steps required for compliance

Creation of a catheter insertion cart

•all physicians or physician extenders who insert central catheters were required to complete a Web-based training module and successfully complete a ten-question test before they were allowed to insert a central venous catheter. hand hygiene

Staff Education

ExampleInterventions



Procedure aborted if they observed a violation in compliance with the evidence-based guidelines.The nurse paged the SICU attending physician if the resident/operator violated the procedure

Nurses empowered to stop the catheter insertion procedure if a violation of the guidelines occurred

•Hand hygiene prior to procedure•chlorhexidine skin preparation•Full-barrier precautions during central venous catheter insertion•Subclavian vein placement as the preferred site, maintaining a sterile field while inserting the catheter•Use of antiseptic impregnated catheter

Evidence based checklist CVC insertion and for BSI

risk reduction

•Asked daily during patient rounds whether any catheters or tubes could be removed. •This was added it to the rounding form, called the daily goals form, which is used to develop daily care plans for patients in our SICU

Promotion of daily Catheter Removal



• Results:– During the first month nursing completed

the checklist for 38 procedures:• eight (24%) for new central venous access,• 30 (79%) for catheter exchanges over a wire, • three (8%) were emergent.

– nursing intervention was required in 32% (12/38) of central venous catheter insertions



1.6/1,000 catheter days


Control ICU


No crBSI over 9 month s

0/1,000 catheter days


Study ICU

January 2003-April 2004

BSI Rate 4th quarter2002

BSI Rate 1st

quarter1998

Multifaceted, comprehensive program requiring CVC insertion education, with safety checks for proper hand hygiene, aseptic insertion procedure and operator

responsibility can result in reduction of nosocomial BSI in an ICU setting.


Hospital Acquired Pneumonia in Solid Organ Transplant

Recipients

Nosocomial Pneumonia (non-transplant)

• Cumulative incidence = 1-3% per day of intubation

• Early onset (first 3-4 days of mechanical ventilation)– Antibiotic sensitive, community organisms

(S. pneumoniae, H. influenzae, S. aureus)• Late onset

– Antibiotic resistant, nosocomial organisms (MRSA, Ps. aeruginosa, Acinetobacter spp, Enterobacterspp)

Hospital Acquired PneumoniaInfections after Liver Transplantation

2 aspirationCommunity Acquired

N=5

S.aureus (1)P. Aeruginosa (4)Enterobacter cloacae (2)Acinetobacter (2)E.coli (1)

7 (70%) where ventilator associated3 aspiration

Hospital Acquired

N=10

Nosocomial Organisms(episodes)

PathophysiologyBacterial Pneumonia

N=15

Kusne et al. Medicine, Vol 67, No.2, 132-153. 1988

Hospital Acquired Pneumonia

4.7Thoracic or abdominal

surgery

2.3Age>70

3.7Chronic Lung Disease

5.8Decreased consciousness

6.7Intubation

10.6Gastric aspiration

Risk Factors for Nosocomial Pneumonia

Approx. Magnitude of Increased Risk

Risk Factor

Alterable

Non-Alterable

Prevention of VAP

• Semirecumbent position of ventilated patients (head of bed at 45°) is the most

effective measure for decreasing bronchoaspiration

Prevention of Nosocomial Pneumonia

Head of bed elevation at 30-45 degrees

This Intervention is :

•Easy

•Simple

•cheap

Semi-elevated position prevents bronchoaspiration

Nosocomial Pneumonia in Lung Transplantation

IDSA(A-III) Rec.CF Patients:Culture specific (targeted therapy) for 2 weeks post transplant or until purulent secretions disappear

S.aureusP.aeruginosaB.CepaciaGNR

Lung TransplantHeart/Lung Transplant(anastamotic colonization)

ProphylaxisOrganismsTransplant Type

Soave R. Clinical Infectious Diseases, 2001;33 (supplement):S26-31

Nosocomial UTI

Nosocomial Urinary Tract Infections

• Most common hospital-acquired infection (40% of all nosocomial infections)– 1 million cases of nosocomial UTI per year in the US

• Of nosocomial infections, lowest mortality & cost

• >80% associated with urinary catheter

Nosocomial Urinary Tract Infections

• 25% of hospitalized patients will have a urinary catheter for part of their stay

• Incidence of nosocomial UTI is ~5% per catheterized day

• Virtually all patients develop bacteriuria by 30 days of catheterization– Of these: 3% will develop bacteremia

Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

The principal risk factor is duration if urinary catheterization

1.9Drainage tube below level of bladder and above collection bag

2.0Monitoring of urine output2.5Ureteral stent

2.1-2.6Azotemia (creatinine >2.0 mg/dL2.4Malnutrition

2.2-2.3Diabetes2.3-2.4 Other active sites of infection2.0-4.0Urology service2.0-5.3Catheter insertion outside operating room2.5-3.7Female gender5.1-6.8Prolonged catheterization >6 days

Relative riskFactor

Table 3. Risk factors for catheter-associated urinary tract infection, based on prospective studies and use of multivariable statistical modeling.

Dennis G. Maki* and Paul A. Tambyah, Emerging Infectious Diseases, 2001

Prevention of Nosocomial UTIs

• Avoid catheter when possible & discontinue ASAP

• Aseptic insertion by trained HCWs-preferably in OR

• Maintain closed system of drainage• Ensure dependent drainage• Minimize manipulation of the system• Silver coated catheters

Nosocomial UTI:Silver Impregnated Urinary Catheters

Nosocomial UTI:Silver Impregnated Urinary Catheters

Dennis G. Maki* and Paul A. Tambyah, Emerging Infectious Diseases, 2001

Nosocomial Urinary Tract Infections:Silver Alloy Catheters• Advantages:

– Most studies have demonstrated a significant decrease in incidence of UTI

– Insertion, care no different than for 1st generation catheter• Disadvantage:

– Cost • Supporting evidence: reasonably strong (high

strength of evidence for impact & effectiveness at low cost & complexity)

• Primary goal should still remain avoiding the use of catheters when possible & discontinuing as soon as possible

UTI in Kidney Transplantation

5%-36 %Majority within the first 3 months

Incidence

IDSA-Recommendations•Treatment of asymptomatic UTI and surveillance urine culture (BII) recommendation

–Prolonged prophylaxis reduces rates of UTI/Bacteremia but no impact on patient and graft survival

•TMP/Sulfa or Ciprofloxacin

•Salmonelluria- 6 weeks of Rx (BII)• Asymptomatic Candiduria Rx recommended (A-II)

EnterbacteriaciaeEnterococciS.aureusP.aeruginosaSalmonella

Kidney Transplantation- Early infections associated with pyelonephritis and urospepsis

Prophylaxis/TreatmentOrganismsTransplant Type

Soave R. Clinical Infectious Diseases, 2001;33 (supplement):S26-31

Special Concerns: Liver Transplantation

•Intrahepaticand extrahepatic abscesses•Cholangitis•Peritonitis•SSI•BSI

Infections

Selective Bowel Decontamination (SBD)•Non-absorbable/topical antibiotics

–Decreased bacterial infections in 2 randomized, controlled trials OLT recipients

•Antibiotic prophylaxis warranted before/after each post transplant cholangiogram , liver biopsy (IDSA A1)

EnterbacteriaciaeEnterococciVRES.aureusAnaerobesCandida

LiverTransplantation

Prophylaxis/treatmentOrganismsTransplant Type

Badger et al, Transplant Proceedings. 1991;23:1460-1

Smith SD et al, Transplantation. 1993;55:1306-9

30%-40% of all Nosocomial Infections are Attributed to

Cross Transmission

The inanimate environment is a reservoir of pathogens

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcusculture

The pathogens are ubiquitous


Recovery of MRSA, VRE, C.diff CNS and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869


Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

Transfer of VRE via HCW Hands

16 transfers (10.6%) occurred in 151 opportunities.

•13 transfers occurred in rooms of unconscious patients who were unable to spontaneously touch their immediate environment

Duckro et al. Archive of Int Med. Vol.165,2005

Alcohol based hand hygiene solutionsQuick Easy to use

Very effective antisepsis due to bactericidal properties of alcohol

Impact of alcohol based hand sanitizers at VCU: can this

improve hand hygiene?

Study Algorithm

Hand Hygiene Educational Program Implemented

Direct Observation of Hand Hygiene

Incremental Increase in Alcohol Dispensers

Arch Intern Med. 2000;160:1017-1021.

Results

Hand hygiene practice can be improved with education and greater accessibility of alcohol hand sanitizers

•Improvement in Hand Hygiene Compliance

Arch Intern Med. 2000;160:1017-1021.

Hand Hygiene

• Single most important method to limit cross transmission of nosocomial pathogens

• Multiple opportunities exist for HCW hand contamination– Direct patient care– Inanimate environment

• Alcohol based hand sanitizers are ubiquitous– USE THEM BEFORE AND AFTER PATIENT

CARE ACTIVITIES

How are we improving compliance with IC

recommendations for your patients in the ICU?

Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance.

Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2, Gonzalo Bearman MD, MPH1,2

Divisions of Infectious Diseases1 and Quality Health Care2

Department of Internal Medicine

Virginia Commonwealth University School of Medicine

Richmond, VA, USA Conferencia anual de SHEA, Los Angeles, California

-Measurement and feedback of infection control process

measures in the intensive care unit: impact on compliance.

• To measure selected infection control process measures

• To feedback the results of process indicator measurement to ICU leadership

• To assess the impact of feedback on compliance with infection control process measures


Measurement and feedback of infection control process measures in the intensive care unit: impact

on compliance.

• Selected Infection Control Process Measures:– Hand Hygiene– Femoral Catheter use as proportion of CVC days– Proportion of Head of bed (HOB) elevations in medical

(MRICU) and Surgical (STICU) Intensive Care Units• All Data Collected by ICPs

– Baseline data- April-June 2004– Follow up- 3rd, 4th quarters of 2004, 1st quarter 2005– Baseline and follow up data presented to ICU nurses

and Physician staff• Differences in proportions analyzed for

significance by Chi-Square Method


Measurement and feedback of infection control process measures in the intensive

care unit: impact on compliance.

0.0126/920(2.8%)

14/1077

(1.3%)

49/970(5.1%)

93/1109

(8.4%)

<0.00151/951(5.4%

80/879(9.1%)

130/769(16%)

195/1093(18%)

Fem. CVC% of Days

<0.001275/361

(76%)

389/488

(79%)

229/307

(75%)

20/43(47%)

<0.001551/556(99%)

450/454

(99%)

320/333(96%)

28/51(55%)

HOB %Opp

0.91649/100(49%)

40/80(50%)

42/80(53%)

19/38(50%)

0.10150/108(46%)

33/91(36%)

31/91(37%)

14/44(32%)

HH % Opp

P value*

Q1(2005)

Q4(2004)

Q3(2004

BaselineQ2-

2004P

value*Q1

(2005)Q4

(2004)Q3

(2004)BaselineQ2-2004

STICUMRICU

Process Measure


Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance.

• Feedback of process measures:• lowered the use of femoral catheters• Improved the proportion of elevated HOBs in

both ICUs• There was no significant improvement in hand

hygiene.• System level changes such as catheter

placement and HOB elevation appears to be impacted by feedback whereas individual level practices such as hand hygiene were not affected


Conclusion• Much like other critically ill patients, solid organ

transplant recipients are prone to nosocomial infections.

• Even in solid organ transplant recipients, the NI risk factors, pathogens and the preventive measures are the same as for non-transplant recipients

• The major nosocomial infections are:– BSI– Hospital acquired pneumonia– Hospital acquired UTI

• The principal NI pathogens are bacterial and represent colonizing or nosocomial pathogens– S.aureus– Enterococci- VRE– Enterobacteriaciae– P.aeruginosa

Conclusion• Risk reduction strategies are well defined in the

literature– Lack of adherence to IC measures is recognized as

important in the pathogenesis of NIs• System level changes involving the measurement

and feedback of adherence to IC measures are needed to implement risk reduction strategies consistently– BSI: comprehensive catheter use/care– VAP: HOB elevation– UTI: catheter insertion, care and silver impregnated

catheters– Hand Hygiene- alcohol based sanitizers

• Selective antibiotic prophylaxis may be warranted in certain cases involving:

• Lung transplants, Liver Transplants, Kidney Transplants

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