Colonization with methicillin-resistant Staphylococcus aureus in ICU patients: morbidity, mortality, and glycopeptide use.

peer reviewed[en] OBJECTIVE: To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization on the occurrence of S. aureus infections (methicillin-resistant and methicillin-susceptible), the use of glycopeptides, and outcome among intensive care unit (CU) patients. DESIGN: Prospective observational cohort survey. SETTING: A medical-surgical ICU with 10 single-bed rooms in a 460-bed, tertiary-care, university-affiliated hospital. PATIENTS: A total of 1,044 ICU patients were followed for the detection of MRSA colonization from July 1, 1995, to July, 1 1998. METHODS: MRSA colonization was detected using nasal samples in all patients plus wound samples in surgical patients within 48 hours of admission or within the first 48 hours of ICU stay and weekly thereafter. MRSA infections were defined using Centers for Disease Control and Prevention standard definitions, except for ventilator-associated pneumonia and catheter-related infections, which were defined by quantitative distal culture samples. RESULTS: One thousand forty-four patients (70% medical patients) were included in the analysis. Mean age was 61+/-18 years; mean Simplified Acute Physiologic Score (SAPS) II was 36.4+/-20; and median ICU stay was 4 (range, 1-193) days. Two hundred thirty-one patients (22%) died in the ICU. Fifty-four patients (5.1%) were colonized with MRSA on admission, and 52 (4.9%) of 1,044 acquired MRSA colonization in the ICU. Thirty-five patients developed a total of 42 S. aureus infections (32 MRSA, 10 methicillin-susceptible). After factors associated with the development of an S. aureus infection were adjusted for in a multivariate Cox model (SAPS II >36: hazard ratio [HR], 1.64; P=.09; male gender: HR, 2.2; P=.05), MRSA colonization increased the risk of S. aureus infection (HR, 3.84; P=.0003). MRSA colonization did not influence ICU mortality (HR, 1.01; P=.94). Glycopeptides were used in 11.4% of the patients (119/1,044) for a median duration of 5 days. For patients with no colonization, MRSA colonization on admission, and ICU-acquired MRSA colonization, respectively, glycopeptide use per 1,000 hospital days was 37.7, 235.2, and 118.3 days. MRSA colonization per se increased by 3.3-fold the use of glycopeptides in MRSA-colonized patients, even when an MRSA infection was not demonstrated, compared to non-colonized patients. CONCLUSIONS: In our unit, MRSA colonization greatly increased the risk of S. aureus infection and of glycopeptide use in colonized and non-colonized patients, without influencing ICU mortality. MRSA colonization influenced glycopeptide use even if an MRSA infection was not demonstrated; thus, an MRSA control program is warranted to decrease vancomycin use and to limit glycopeptide resistance in gram-positive cocci

A continuous quality-improvement program reduces nosocomial infection rates in the ICU.

OBJECTIVE: To assess the impact of a continuous quality-improvement program on nosocomial infection rates. DESIGN AND SETTING: Prospective single-center study in the medical-surgical ICU of a tertiary care center. PATIENTS. We admitted 1764 patients during the 5-year study period (1995-2000); 55% were mechanically ventilated and 21% died. Mean SAPS II was 37+/-21 points and mean length of ICU stay was 9.7+/-16.1 days. INTERVENTIONS: Implementation of an infection control program based on international recommendations. The program was updated regularly according to infection and colonization rates and reports in the literature. MEASUREMENTS AND RESULTS: Prospective surveillance showed the following rates per 1000 procedure days: ventilator-associated pneumonia (VAP) 8.7, urinary tract infection (UTI) 17.2, central venous catheter (CVC) colonization 6.1, and CVC-related bacteremia and 2.0; arterial catheter colonization did not occur. In the 5 years following implementation of the infection control program there was a significant decline in the rate per patient days of UTI, CVC colonization, and CVC-related bacteremia but not VAP. Between the first and second 2.5-year periods the time to infection increased significantly for UTI and CVC-related colonization. CONCLUSIONS: A continuous quality-improvement program based on surveillance of nosocomial infections in a nonselected medical-surgical ICU population was associated with sustained decreases in UTI and CVC-related infections

Ten-year decrease of acquired methicillin-resistant Staphylococcus aureus (MRSA) bacteremia at a single institution: the result of a multifaceted program combining cross-transmission prevention and antimicrobial stewardship.

peer reviewedUNLABELLED: BACKGROUND: In France, the proportion of MRSA has been over 25% since 2000. Prevention of hospital-acquired (HA) MRSA spread is based on isolation precautions and antibiotic stewardship. At our institution, before 2000, the Infection Disease and the Infection Control teams had failed to reduce HA-MRSA rates. OBJECTIVES AND METHODS: We implemented a multifaceted hospital-wide prevention program and measured the effects on HA-MRSA colonization and bacteremia rates between 2000 and 2009. From 2000 to 2003, active screening and decontamination of ICU patients, hospital wide alcohol based hand rubs (ABHR) use, control of specific classes of antibiotics, compliance audits, and feed-backs to the care providers were successively implemented. The efficacy of the program was assessed by HA-MRSA colonized and bacteremic patient rates per 1000 patient-days in patients hospitalized for more than twenty-four hours. RESULTS: Compliance with the isolation practices increased between 2000 and 2009. Consumption of ABHR increased from 6.8 L to 27.5 L per 1000 patient-days. The use of antibiotic Defined Daily Doses (DDD) per 1000 patient-days decreased by 31%. HA-MRSA colonization decreased by 84% from 1.09 to 0.17 per 1000 patient-days and HA-MRSA bacteremia by 93%, from 0.15 to 0.01 per 1000 patient-days (p < 10-7 for each rate). CONCLUSIONS: In an area highly endemic for MRSA, a multifaceted prevention program allows for sustainable reduction in HA-MRSA bacteremia rates

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II

International audienceRATIONALE: Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention. OBJECTIVES: We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality. METHODS: We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales. MEASUREMENTS AND MAIN RESULTS: Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039). CONCLUSIONS: The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results