Nosocomial Infections in Solid Organ Transplant Recipients

Transcription

1 Nosocomial Infections in Solid Organ Transplant Recipients Focus On Prevention Through the Reduction of Alterable Risk Factors Gonzalo Bearman MD, MPH Assistant Professor of Medicine, Epidemiology and Community Health Associate Hospital Epidemiologist Virginia Commonwealth University

2 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

3 What this presentation will not cover: Opportunistic infections! Fungal, Viral, Parasitic Infections, Prion diseases Hospital associated or community outbreaks! Legionella Aspergillus, etc, etc, etc

4 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 3 rd party payors Weinstein RA. Emerg Infect Dis 1998;4: Jarvis WR. Emerg Infect Dis 2001;7:

5 Major Sites of Nosocomial Infections Urinary tract infection Surgical site infection Bloodstream infection Pneumonia (ventilator-associated)

6 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: Safdar N et al. Current Infect Dis Reports 2001;3:

7 Nosocomial Infections in the US Number of admissions (millions) Number of patient days (millions) Average length of stay (days) Number of nosocomial infections (millions) Incidence of nosocomial infections (per 1,000 patient-days) Burke JP. New Engl J Med 2003;348:

8 Attributable Costs of Nosocomial Infections Cost per Infection Wound infections Sternal wound infection Catheter-associated BSI Pneumonia Urinary tract infection $3,000 - $27,000 $20,000 - $80,000 $5,000 - $34,000 $10,000 - $29,000 $700 Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4 th ed. 2003:36.

9 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:

10 Nosocomial BSI in Solid Organ Transplant Recipients

11 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.

12 Bacteremia in transplant recipients Prospective analysis of 125 bacteremic episodes in 111 transplant recipients: Recipients: 18 heart transplants 26 Kidney transplants 80 liver transplants Wagener et al. AJIC 1992;20:

13 Bacteremia in transplant recipients 125 total episodes Early Onset (< 14 days) Late Onset (> 14 days) Proportion 32/125 93/125 (of episodes) (26%) (74%) Heart 18/ % (% of episodes) 80/ Liver 64% (% of episodes) 27/ Kidney 22% (% of episodes) Wagener et al. AJIC 1992;20:

14 Bacteremia in transplant recipients Kidney Transplant Liver Transplant Heart Transplant Aerobic Gram Negative Rods 48% of blood cultures: 49% of blood cultures: 39% of blood cultures: (48% of pathogens) E.coli, Klebesiella, Enterobacteriaciae P.aeruginosa Enterobacter sps E.Coli P.aeruginosa Gram Positive Organisms 50 % of blood cultures 50 % of blood cultures 50 % of blood cultures (50% of pathogens) S.epidermidis S.aureus S.epidermidis S.aureus S.epidermidis Fungi (6% of positive blood cultures) 0% of blood cultures 6% of Blood cultures: All Candida species 11% of blood cultures: All Candida species Polymicrobial (10% of positive blood cultures) 7% in Kidney transplants 11% of bacteremias 6% in heart transplants Wagener et al. AJIC 1992;20:

15 Bacteremia in transplant recipients Survival Community acquired 19/21 (90%) Nosocomial 78/104 (75%) Severity of illness Microbilogy Lower APACHE II Score E.coli S.aureus Enterobacteriaciae Higher APACHE II Score S.aureus P.aeruginosa Enterobacter sps S.epidermidis Wagener et al. AJIC 1992;20:

16 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

17 Comparative Risk of Bloodstream Infection in Organ Transplant Recipients Transplant Total patients Patients Infected Episodes Liver (28%) 20 Kidney (5%) 13 Heart or Heart/Lung 50 5 (10%) 7 Total (10%) 40 McClean et al. Infect Control Hosp Epi. Vol 15.No 9, September 1994

18 Comparative Risk of Bloodstream Infection in Organ Transplant Recipients Transplant Primary WND PN GI UTI (CVC) Liver Kidney Heart or Heart/Lung Total 11 (55%) 7 (54%) 6 (86%) 25 (60%) The majority of BSIs were Primary The majority of Primary BSIs were attributable to intravascular lines McClean et al. Infect Control Hosp Epi. Vol 15.No 9, September 1994

19 Comparative Risk of Bloodstream Infection in Organ Transplant Recipients Organism Liver Kidney Heart Total Gram Positive aerobes S.aureus 13 (62%) 7 (47%) 6 (75%) 26 (59%) S.epidermidis Gram negative aerobes E.coli, Klebesiella, Enterobacteriaciae 5 (24%) 5 (33%) 2 (25%) 12 (27%) P.aeruginosa Other Candida Bacteriodes 3 (14%) 3 (20%) 0 6 (13%) Total McClean et al. Infect Control Hosp Epi. Vol 15.No 9, September 1994

20 Nosocomial Bloodstream Infections, Rank Pathogen Percent 1 Coagulase-negative Staph 31.3% 2 S. aureus 20.2% 3 Enterococci 9.4% 4 Candida spp 9.0% 5 E. coli 5.6% 6 Klebsiella spp 4.8% 7 Pseudomonas aeruginosa 4.3% 8 Enterobacter spp 3.9% N= 20, Serratia spp Acinetobacter spp 1.7% 1.3% Edmond M. SCOPE Project.

21 Preventive Measures for Nosocomial BSI

22 The risk factors interact in a dynamic fashion El Host The CVC is the greatest risk factor for Nosocomial BSI The CVC: Subclavian, Femoral and IJ sites The intensity of the Catheter Manipulation As the host cannot be altered, preventive measures are focused on risk factor modification of catheter use, duration, placement and manipulation

23 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

24 Nosocomial Bloodstream Infections 12-25% attributable mortality Risk for bloodstream infection: BSI per 1,000 catheter/days Subclavian or internal jugular CVC Hickman/Broviac (cuffed, tunneled) PICC Catheter type and expected duration of use should be taken into consideration

25 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

26 Putting BSI preventive strategies into practice.

27 Eliminating catheter-related bloodstream infections in the intensive care unit Purpose: Method: To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs) 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 Oct;32(10):

28 Eliminating catheter-related bloodstream infections in the intensive care unit Interventions Staff Education all physicians or physician extenders who insert central catheters were required to complete a Webbased training module and successfully complete a ten-question test before they were allowed to insert a central venous catheter. hand hygiene Example Creation of a catheter insertion cart central catheter insertion cart that contains the equipment and supplies needed reduced the number of steps required for compliance Pronovost et al. Crit Care Med Oct;32(10):

29 Eliminating catheter-related bloodstream infections in the intensive care unit Promotion of daily Catheter Removal 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 Evidence based checklist CVC insertion and for BSI risk reduction 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 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 Pronovost et al. Crit Care Med Oct;32(10):

30 Eliminating catheter-related bloodstream infections in the intensive care unit Pronovost et al. Crit Care Med Oct;32(10):

31 Eliminating catheter-related bloodstream infections in the intensive care unit 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 Pronovost et al. Crit Care Med Oct;32(10):

32 Eliminating catheter-related bloodstream infections in the intensive care unit BSI Rate 1 st quarter BSI Rate 4th quarter January April Study ICU 11.3/1,000 catheter days 0/1,000 catheter days 0.54/1,000 catheter days No crbsi over 9 month s Control ICU 5.7/1,000 catheter days 1.6/1,000 catheter days 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. Pronovost et al. Crit Care Med Oct;32(10):

33 Hospital Acquired Pneumonia in Solid Organ Transplant Recipients

34 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, Enterobacter spp)

35 Hospital Acquired Pneumonia Infections after Liver Transplantation Bacterial Pneumonia N=15 Hospital Acquired N=10 Community Acquired N=5 Pathophysiology 7 (70%) where ventilator associated 3 aspiration 2 aspiration Nosocomial Organisms (episodes) S.aureus (1) P. Aeruginosa (4) Enterobacter cloacae (2) Acinetobacter (2) E.coli (1) Kusne et al. Medicine, Vol 67, No.2,

36 Hospital Acquired Pneumonia Risk Factors for Nosocomial Pneumonia Risk Factor Gastric aspiration Intubation Decreased consciousness Thoracic or abdominal surgery Approx. Magnitude of Increased Risk Alterable Non- Chronic Lung Disease Age> Alterable

37 Prevention of VAP Semirecumbent position of ventilated patients (head of bed at 45 ) is the most effective measure for decreasing bronchoaspiration

38 Prevention of Nosocomial Pneumonia Head of bed elevation at degrees This Intervention is : Easy Simple cheap Semi-elevated position prevents bronchoaspiration

39 Nosocomial Pneumonia in Lung Transplantation Transplant Type Organisms Prophylaxis Lung Transplant Heart/Lung Transplant (anastamotic colonization) S.aureus P.aeruginosa B.Cepacia GNR IDSA(A-III) Rec. CF Patients: Culture specific (targeted therapy) for 2 weeks post transplant or until purulent secretions disappear Soave R. Clinical Infectious Diseases, 2001;33 (supplement):s26-31

40 Nosocomial UTI

41 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

42 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:

43 The principal risk factor is duration if urinary catheterization Table 3. Risk factors for catheter-associated urinary tract infection, based on prospective studies and use of multivariable statistical modeling. Factor Relative risk Prolonged catheterization >6 days Female gender Catheter insertion outside operating room Urology service Other active sites of infection Diabetes Malnutrition Azotemia (creatinine >2.0 mg/dl Ureteral stent Monitoring of urine output Drainage tube below level of bladder and above collection bag Dennis G. Maki* and Paul A. Tambyah, Emerging Infectious Diseases, 2001

44 Prevention of Nosocomial UTIs Avoid catheter when possible & discontinue ASAP Aseptic insertion by trained HCWspreferably in OR Maintain closed system of drainage Ensure dependent drainage Minimize manipulation of the system Silver coated catheters

45 Nosocomial UTI: Silver Impregnated Urinary Catheters

46 Nosocomial UTI: Silver Impregnated Urinary Catheters Dennis G. Maki* and Paul A. Tambyah, Emerging Infectious Diseases, 2001

47 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 1 st 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

48 UTI in Kidney Transplantation Transplant Type Incidence Organisms Prophylaxis/Treatment IDSA-Recommendations Kidney Transplantation - Early infections associated with pyelonephritis and urospepsis 5%-36 % Majority within the first 3 months Enterbacteriaciae Enterococci S.aureus P.aeruginosa Salmonella 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) Soave R. Clinical Infectious Diseases, 2001;33 (supplement):s26-31

49 Special Concerns: Liver Transplantation Transplant Type Infections Organisms Prophylaxis/treatment Liver Transplantation Intrahepatic and extrahepatic abscesses Cholangitis Peritonitis SSI BSI Enterbacteriaciae Enterococci VRE S.aureus Anaerobes Candida 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) Badger et al, Transplant Proceedings. 1991;23: Smith SD et al, Transplantation. 1993;55:1306-9

50 30%-40% of all Nosocomial Infections are Attributed to Cross Transmission

51 The inanimate environment is a reservoir of pathogens X represents a positive Enterococcus culture The pathogens are ubiquitous ~ 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.

52 The inanimate environment is a reservoir of pathogens 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: Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:

53 The inanimate environment is a reservoir of pathogens 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: Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:

54 The inanimate environment is a reservoir of pathogens 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: Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:

55 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

56 Alcohol based hand hygiene Quick solutions Easy to use Very effective antisepsis due to bactericidal properties of alcohol

57 Impact of alcohol based hand sanitizers at VCU: can this improve hand hygiene?

58 Study Algorithm Incremental Increase in Alcohol Dispensers Hand Hygiene Educational Program Implemented Direct Observation of Hand Hygiene Arch Intern Med. 2000;160:

59 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:

60 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

61 How are we improving compliance with IC recommendations for your patients in the ICU?

62 Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance. Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1,2, Gonzalo Bearman MD, MPH 1,2 Divisions of Infectious Diseases 1 and Quality Health Care 2 Department of Internal Medicine Virginia Commonwealth University School of Medicine Richmond, VA, USA Conferencia anual de SHEA, Los Angeles, California

63 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 Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1,2, Gonzalo Bearman MD, MPH 1,2

64 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 Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1,2, Gonzalo Bearman MD, MPH 1,2

65 Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance. MRICU STICU Process Measure Baseline Q Q3 (2004) Q4 (2004) Q1 (2005) P value* Baseli ne Q Q3 (2004 Q4 (2004) Q1 (2005) P value* HH % 14/44 31/91 33/91 50/ /38 42/80 40/80 49/ Opp (32%) (37%) (36%) (46%) (50%) (53%) (50%) (49%) HOB % Opp 28/51 (55%) 320/333 (96%) 450/45 4 (99%) 551/556 (99%) < /43 (47%) 229/30 7 (75%) 389/48 8 (79%) 275/36 1 (76%) <0.001 Fem. CVC % of Days 195/1093 (18%) 130/769 (16%) 80/879 (9.1%) 51/951 (5.4% < /110 9 (8.4%) 49/970 (5.1%) 14/107 7 (1.3%) 26/920 (2.8%) 0.01 Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1,2, Gonzalo Bearman MD, MPH 1,2

66 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 Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1,2, Gonzalo Bearman MD, MPH 1,2

67 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

68 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