Impacte d’una campanya de prevenció d’Infecció Nosocomial a una Unitat de Cures Intensives Pediàtriques. Utilitat d’un registre multicèntric d’infecció nosocomial

INTRODUCCIÓ: La infecció nosocomial (IN) a les Unitats de Cures Intensives Pediàtriques (UCIP) incrementa la morbimortalitat dels nens. En aquesta memòria de tesi doctoral es presenten dos estudis relacionats. El primer valora l’impacte d’ una campanya de prevenció d’IN a la UCIP, i el segon presenta un registre multicèntric d’IN a UCIP a Espanya. HIPÒTESIS: La campanya de prevenció d’IN a la UCIP podria disminuir les taxes d’IN i comportaria un descens de la morbimortalitat dels pacients. La creació d’un registre nacional multicèntric d’IN a les UCIPs permetria tenir informació sobre l’epidemiología de la infecció i el perfil de resistències. METODOLOGIA: El primer treball és un estudi prospectiu amb intervenció múltiple per reduir IN a la UCIP de l’hospital Sant Joan de Déu. Es dividí en tres períodes: Pre-intervenció (2006), intervenció (2007) en el que simplementaren els mesures i el període de seguiment a llarg plaç (2008). La intervenció radicava en tres accions principals: Crear un grup de Control d’ infecció, un programa educatiu d’higiene de mans i aplicar un paquet de mesures per reduir la IN. S’inclogueren nens ingressats a la UCIP t més de 24 hores. Es calcularen taxes de Bacterièmia relacionada con catèter (BRC), pneumònia associada a ventilació mecànica (NAVM) i infecció urinària associada a sondatge uretral (ITU-SU). El segon estudi és un estudi multicèntric prospectiu, observacional i descriptiu. El 2007 es creà el registre VINCIP (Vigilancia de Infección Nosocomial en Cuidados Intensivos Pediátricos). Es recolliren dades durant un mes (1-31 de març) per cada any d’estudi (2008-2012). No es van fer intervencions específiques durant aquest període com grup, però la majoria de les UCIPs implementen mesures per reduir la IN. Es recolliren taxes de BRC, NAVM i ITU-SU, microorganismes causants i patrons de resistències. RESULTATS: Primer estudi: S’inclogueren 851, 822 y 940 pacients, respectivament. Milloraren la taxa de BRC (8.1 a 6/1000-dies de catèter venós central CVC, p = 0.640), la de NAVM (28.3 a 10.6/1000 dies de ventilació mecànica, p = 0.005) i ITU-SU (23.3 a 5.8/1000 dies de sonda urinària, p < 0.001). Es va reduir l’estada hospitalària (18.56 vs 14,57 dies, p = 0,035) i la mortalitat (5,1% a 3,3%, p = 0.056). El model de regressió logística multivariable mostrà que la presència d’IN era factor independent de risc de mortalitat (OR 2.35 [95% IC, 1.02-5.55]; p = 0.046). Durant el seguiment a llarg plaç (en comparació amb el període pre-intervenció), les taxes van seguir millorant, BRC 4,6/1000 dies de CVC; NAVM, 9,1/1000 dies de ventilació mecànica i ITU-SU 5,2/1000 dies de sonda urinària (p = 0,205, p = 0.001 i p < 0.001 respectivament). Segon estudi. Ingressaren 3667 pacients. El nombre de pacients amb infecció nosocomial fou 90 (2.45%). La mitja de taxes dels 5 anys foren: BRC 3.8/1000 dies de CVC, NAVM 7.5/1000 dies de ventilació mecànica i ITU-SU 4.1/1000 dies de sonda urinària. Les taxes es reduiren homogèniament des de 2009 a 2012: BRC de 5.83 (95% CI 2.67- 11.07) a 0.49 (95% CI 0.0125- 2.76), p =0.0029; NAVM de 10.44 (95% CI 5.21-18.67) a 4.04 (95% CI 1.48-8.80), p= 0.0525; ITU-SU 7.10 (95% CI 3.067-13.999) a2.56 (95% CI 0.697-6.553), p= 0.0817; respectivament. Microorganismes: 63 de 99 (83.6%) bacteris gram-negatius (36.5% resistents), 19 (19.2%) bacteris gram-positius i 17 (17.2%) infeccions per Candida spp. CONCLUSIONS: Respecte al primer estudi, la campanya de prevenció d’IN va baixar globalment les taxes d’IN, l’estada hospitalària i la mortalitat. Els resultats es mantingueren en el període de seguimient a llarg plaç. Respecte al segon estudi presentat, els sistemes de vigilància local aporten informació per millorar les taxes d’infecció nosocomial, així com el patró de resistències.INTRODUCTION: Nosomial infections (NI) in the Pediatric Intensive care Unit (PICU) increases morbidity and mortality of patients. In this thesis we include two related articles. OBJECTIVES: - First study: To evaluate whether a quality improvement intervention could reduce NI in a PICU. - Second study: To report 5-years of NI surveillance data, as well as trends in infections by multidrug resistant organisms in Spanish PICU. METODOLOGY: - First article: Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up. The quality improvement intervention consisted of the creation of an infection control team, a program targeting hand hygiene, and quality practices focused on preventing NI. - Second article: multicentre, prospective, descriptive and observational study was conducted using the data from surveillance system for NI created in 2007 for Spanish PICU. Data were collected for one month, between 01 and 31 March, for every study year (2008–2012). RESULTS: - First study: We included 851, 822 and 940 patients. Compared with the preintervention period, in the intervention period, the rates of central line–associated bloodstream infection (CLABSI) decreased from 8.1to 6/1,000 central venous catheter-days (p = 0.640), ventilator associated pneumonia (VAP) decreased from 28.3 to 10.6/1,000 days of ventilation (p = 0.005), and catheter-associated urinary tract infection (CAUTI) decreased from 23.3 to 5.8/1,000 urinary catheter-days (p < 0.001). Furthermore, hospital length of stay decreased from 18.56 to 14.57 days (p = 0.035) and mortality decreased from 5.1% to 3.3% (p = 0.056). - Second study: A total of 3667 patients were admitted to the units during the study period. There were 90 (2.45%) patients with NI. The mean rates during the 5 years study were:CLABSI, 3.8/1000 central venous catheter-days, VAP 7.5/1000 endotracheal tube-days, and cathet CAUTI 4.1/1000 urinary catheter-days. All rates homogeneously decreased from 2009 to 2012. The microorganism analysis: 63 of the 99 isolated bacteria (63.6%) were Gramnegative bacteria (36.5% were resistant), 19 (19.2%) Gram-positive bacteria, and 17 (17.2%) were Candida spp. CONCLUSIONS: A multifaceted quality improvement intervention reduced nosocomial infections rates, hospital length of stay, and mortality in our PICU. The local surveillance systems provide information for dealing with nosocomial infection

Prognostic value of biomarkers after cardiopulmonary bypass in pediatrics: The prospective PANCAP study

Objective:To assess the usefulness of procalcitonin, pro-adrenomedullin and pro-atrial natriuretic peptide as predictors of need for mechanical ventilation and postoperative complications (need for inotropic support and bacterial infection) in critically ill pediatric patients after cardiopulmonary bypass. Design:A prospective, observational study Setting: Pediatric intensive care unit. Patients: Patients under 18 years old admitted after cardiopulmonary bypass. Measuraments and main results: Serum levels of procalcitonin, pro-adrenomedullin and pro-atrial natriuretic peptide were determined immediately after bypass and at 24-36 hours. Their values were correlated with the need for mechanical ventilation, inotropic support and bacterial infection. One hundred eleven patients were recruited. Septal defects (30.6%) and cardiac valve disease (17.1%) were the most frequent pathologies. 40.7% required mechanical ventilation, 94.6% inotropic support and 15.3% presented invasive bacterial infections. Pro-adrenomedullin and pro-atrial natriuretic peptide showed significant high values in patients needing mechanical ventilation. Cut-off values higher than 1.22 nmol/L and 215.3 pmol/L, respectively for each biomarker, may indicate need for mechanical ventilation with an AUC of 0.721 and 0.746 at admission and 0.738 and 0.753 at 24-36 hours, respectively but without statistical differences. Pro-adrenomedullin and procalcitonin showed statistically significant high values in patients with bacterial infections. Conclusions: After bypass, pro-adrenomedullin and pro-atrial natriuretic peptide are suitable biomarkers to predict the need for mechanical ventilation. Physicians should be alert if the values of these markers are high so as not to progress to early extubation. Procalcitonin is useful for predicting bacterial infection. This is a preliminary study and more clinical studies should be done to confirm the value of pro-adrenomedullin and pro-atrial natriuretic peptide as biomarkers after cardiopulmonary bypass

Pro-atrial natriuretic peptide and proadrenomedullin before cardiac surgery in children. Can we predict the future?

Introduction and objective: Pro-atrial natriuretic peptide (proANP) and pro-adrenomedullin (proADM) levels increase in acute heart failure and sepsis. After cardiac surgery, children may require increased support in the intensive care unit and may develop complications. The aim of this study was to evaluate the utility of proANP and proADM values, determined prior to cardiac surgery, for predicting the need for increased respiratory or inotropic support during the post-operative period. Methods: This was a prospective study in children. Biomarkers were analyzed before surgery using a single blood test. The primary endpoints were the need for greater respiratory and/or inotropic support during the post-operative period. Secondary endpoints were the relationship between these biomarkers and complications after surgery. Results: One hundred thirteen patients were included. ProANP and proADM were higher in children who required greater respiratory and inotropic support, especially proANP; for increased respiratory support, 578.9 vs. 106.6 pmol/L (p = 0.004), and for increased inotropic support, 1938 vs. 110.4 pmol/L (p = 0.002). ProANP had a greater AUC than proADM for predicting increased respiratory support after surgery: 0.791 vs. 0.724. A possible cut-off point for proANP could be ≥ 325 pmol/L (sensitivity = 66.7% and specificity = 88.8%). In the multivariate analysis, the logarithmic transformation of proANP was independently associated with the need for increased respiratory support (OR = 3.575). Patients who presented a poor outcome after cardiac surgery also had higher biomarker values (proADM, p = 0.013; proANP, p = 0.001). Conclusions: Elevated proANP before cardiac surgery may identify which children will need more respiratory and inotropic support during the post-operative period

Trends in mortality in septic patients according to the different organ failure during 15 years

Background The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality. Methods A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes. Results Of 11.916.974 discharges from all acute-care hospitals during the study period (2005-2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (p < 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (p < 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (p < 0.0001). Conclusions The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant

Procalcitonin to stop antibiotics after cardiovascular surgery in a pediatric intensive care unit-The PROSACAB study.

Introduction and objective: Children admitted to the pediatric intensive care unit after cardiovascular surgery usually require treatment with antibiotics due to suspicion of infection. The aim of this study was to assess the effectiveness of procalcitonin in decreasing the duration of antibiotic treatment in children after cardiovascular surgery. Methods: Prospective, interventional study carried out in a pediatric intensive care unit. Included patients under 18 years old admitted after cardiopulmonary bypass. Two groups were compared, depending on the implementation of the PCT-guided protocol to stop or de-escalate the antibiotic treatment (Group 1, 2011-2013 and group 2, 2014-2018). This new protocol was based on the decrease of the PCT value by 20% or 50% with respect to the maximum value of PCT. Primary endpoints were mortality, stewardship indication, duration of antibiotic treatment, and antibiotic-free days. Results: 886 patients were recruited. There were 226 suspicions of infection (25.5%), and they were confirmed in 38 cases (16.8%). The global rate of infections was 4.3%. 102 patients received broad-spectrum antibiotic (4.7±1.7 days in group 1, 3.9±1 days in group 2 with p = 0.160). The rate of de-escalation was higher in group 2 (30/62, 48.4%) than in group 1 (24/92, 26.1%) with p = 0.004. A reduction of 1.1 days of antibiotic treatment (group 1, 7.7±2.2 and group 2, 6.7±2.2, with p = 0.005) and 2 more antibiotic free-days free in PICU in group 2 were observed (p = 0.001), without adverse outcomes. Conclusions: Procalcitonin-guided protocol for stewardship after cardiac surgery seems to be safe and useful to decrease the antibiotic exposure. This protocol could help to reduce the duration of broad-spectrum antibiotics and the duration of antibiotics in total, without developing complications or adverse effects

Additional file 1 of Trends in mortality in septic patients according to the different organ failure during 15 years

Additional file 1. ICD‑9‑MC codes used to identify infectious process, site of infection, acute organ dysfunction and procedures used in intensive care unit