Article

High prevalence rate of multidrug resistance among nosocomial pathogens in the respiratory care center of a tertiary hospital

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Abstract

There is an increasing need for respiratory care centers (RCCs) for patients who require prolonged mechanical ventilation after intensive care unit (ICU) stay. Nosocomial infections occur at a high rate in ICUs, but there have been few studies of nosocomial infections in RCCs in Taiwan. The infection rates, sources, and pathogens of nosocomial infections in the RCC of a tertiary hospital were retrospectively analyzed from January 2001 to December 2002. Nosocomial infections were defined in accordance with the recommendations of the Centers for Disease Control in the United States. There were 398 nosocomial infections in 265 patients (1.5 episodes for each patient). The incidence density of nosocomial infection was 27.3%. The mean age +/- standard deviation of patients was 74.5 +/- 12.8 years. The mean duration of infection from the day of patient transfer to the RCC was 13 days (range, 2-78 days). Urinary tract infection was most common (53.8%), followed by bloodstream infection (31.2%), skin and soft tissue infection (6.0%), and lower respiratory tract infection (5.5%). 481 strains of microorganisms were isolated, 12.8% of which were Staphylococcus aureus (all methicillin-resistant), 11.1% were Klebsiella pneumoniae (69.1% of which were the extended spectrum beta-lactamase [ESBL] phenotype), and 10.6% were Escherichia coli (31.4% of which were the ESBL phenotype). The infection incidence density in the RCC was similar to previous findings for ICUs during the same period. However, there were differences in the distribution of sites and pathogens. Multiple drug resistance rates were high.

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... Further analysis of the distribution of ESBL-producing isolates in different ICUs showed that the most significant increase occurred in medical ICUs, with a peak prevalence rate of 35.9% in 2006 for E. coli (Shu et al., 2010). In a respiratory care center, one retrospective analysis in a tertiary care center from January 2001 to December 2002 reported that the ESBL phenotype was found in 31.4% of E. coli (Lee C. M. et al., 2009). In the respiratory care ward involving patients who required prolonged or long-term mechanical ventilation, Lin et al. reported that the prevalence of ESBLproducing isolates of E. coli was 39.5% (Lin et al., 2013). ...
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The unique nature of the intensive care unit (ICU) environment makes this part of the hospital a focus for the emergence and spread of many antimicrobial-resistant pathogens. There are ample opportunities for the cross-transmission of resistant bacteria from patient to patient, and patients are commonly exposed to broad-spectrum antimicrobial agents. Rates of resistance have increased for most pathogens associated with nosocomial infections among ICU patients, and rates are almost universally higher among ICU patients compared with non-ICU patients. There are many opportunities, however, to prevent the emergence and spread of these resistant pathogens through improved use of established infection control measures (i.e., patient isolation, hand washing, glove use, and appropriate gown use), and implementation of a systematic review of antimicrobial use.
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A one-year, prospective, two-observational cohort study was performed to evaluate the incidence and outcome in hospitalized patients (ICU and non-ICU) of nosocomial bacteraemia, and to assess its prognostic value in the ICU group. A group of 18 098 hospitalized patients and a group of 291 consecutive ICU patients were followed. Prognostic factors were determined using single and multivariable analyses. 109 (90 non-ICU and 19 ICU) patients developed 118 nosocomial bacteraemic episodes. The incidence of nosocomial bacteraemia was 6.0 per 1000 admissions (95% confidence interval (CI): 5-7%) and 65 per 1000 admissions in ICU patients (95% CI: 4.5-8.5%). Gram-positive and Gram-negative bacteria were 63/133 (47%) and 70/133 (53%) of the isolated micro-organisms respectively. Crude mortality rates were 41/109 (38%) with adverse outcome associated with mechanical ventilation (OR: 3.6; 95% CI: 1.4-9.2, P =0.01), neutropenia (OR: 7.7; 95% CI: 0.8-73.1;P =0.07) while gastro-intestinal surgery was associated with an improved outcome (OR: 0.4; 95% CI: 0.16-0.96;P =0.04). Of the 291 ICU patients, 19 acquired 22 episodes of nosocomial bacteraemia, and 18 were referred from the wards with documented nosocomial bacteraemia. Of these 37 bacteraemic patients, 17 (46%) died. When adjusting for predictors of death (SAPS II>/=40, cardiac and neurological failure), nosocomial bacteraemia markedly influence the outcome in ICU patients (OR: 3.4; 95% CI: 1.3-8.7;P =0.010). This study suggests that the outcome of nosocomial bacteraemia in hospitalized patients is poor in ventilated and neutropenic patients and that nosocomial bacteraemia per se influenced outcome in ICU patients.
Article
To determine the 1-day prevalence of community-acquired, hospital-acquired, or intensive care unit (ICU)-acquired infections in Mexican ICUs. To identify associated risk factors, predominant infecting organisms, and mortality rates. A 1-day point-prevalence study. A total of 254 adult ICUs in Mexico. Adult patients hospitalized in the participating ICUs. A total of 895 patients were studied, of whom 521 patients (58.2%) were infected. Community-acquired infection occurred in 214 patients (23.9%), non-ICU nosocomial infection occurred in 99 patients (11.1%), and 208 patients had at least one ICU-acquired infection (23.2%; 1.45 episodes/patient). The most frequently reported ICU-acquired infections were pneumonia (39.7%), urinary tract infections (20.5%), wound infection (13.3%), and bacteremia (7.3%). The mortality rate for the ICU-acquired infections after 6 wks of follow-up was 25.5%. Multivariate regression analysis showed the following risk factors for ICU-acquired infections: neurologic failure as a primary cause of admission (odds ratio [OR], 1.697; 95% confidence interval [CI], 1.001-2.839); length of stay in ICU (OR, 1.119; 95% CI, 1.091-1.151); number of therapeutic and/or diagnostic interventions during the preceding week (OR, 1.118; 95% CI, 1.016-1.231); peripherally administered infusion of hyperosmolar solutions (OR, 6.93; 95% CI, 2.452-21.661); sedative usage in the preceding week (OR, 1.751; 95% CI, 1.183-2.602); history of an emergency surgery in the preceding month (OR, 1.875; 95% CI, 1.251-2.813). The administration of antimicrobial treatment if there was an infection decreased the risk of death (OR, 0.406; 95% CI, 0.204-0.755). Evidence of a high frequency of nosocomial infections was found, and potential risk factors for acquiring infections and mortality were identified. Mortality rates according to the hierarchy of the systemic inflammatory response syndrome in Latin American ICUs are reported.
Article
To describe the epidemiology of nosocomial infections in combined medical-surgical (MS) intensive care units (ICUs) participating in the National Nosocomial Infection Surveillance (NNIS) System. Analysis of surveillance data on 498,998 patients with 1,554,070 patient-days, collected between 1992 and 1998 from 205 MS ICUs following the NNIS Intensive Care Unit protocol, representing 152 participating NNIS hospitals in the United States. Infections at three major sites represented 68% of all reported infections (nosocomial pneumonia, 31%; urinary tract infections (UTIs), 23%; and primary bloodstream infections (BSIs), 14%: 83% of episodes of nosocomial pneumonia were associated with mechanical ventilation, 97% of UTIs occurred in catheterized patients, and 87% of primary BSIs in patients with a central line. In patients with primary BSIs, coagulase-negative staphylococci (39%) were the most common pathogens reported; Staphylococcus aureus (12%) was as frequently reported as enterococci (11%). Coagulase-negative staphylococcal BSIs were increasingly reported over the 6 years, but no increase was seen in candidemia or enterococcal bacteremia. In patients with pneumonia, S. aureus (17%) was the most frequently reported isolate. Of reported isolates, 59% were gram-negative bacilli. In patients with UTIs, Escherichia coli (19%) was the most frequently reported isolate. Of reported isolates, 31% were fungi. In patients with surgical-site infections, Enterococcus (17%) was the single most frequently reported pathogen. Device-associated nosocomial infection rates for BSIs, pneumonia, and UTIs did not correlate with length of ICU stay, hospital bed size, number of beds in the ICU, or season. Combined MS ICUs in major teaching hospitals had higher device-associated infection rates compared to all other hospitals with combined medical-surgical units. Nosocomial infections in MS ICUs at the most frequent infection sites (bloodstream, urinary, and respiratory tract) almost always were associated with use of an invasive device. Device-associated infection rates were the best available comparative rates between combined MS ICUs, but the distribution of device-associated rates should be stratified by a hospital's major teaching affiliation status.
Article
Urinary catheters are associated with a number of complications, and nurses are ideally suited to minimize the associated risks by utilizing the available research in their practice • Urine tract infections caused by urine catheters are associated with increased mortality; however, urine catheter care is a nursing procedure, the importance of which is sometimes overlooked • This study reviews recommended guidelines on urine catheter care and current published literature on the subject • The aim of the study was to identify recommended practice and compare it with the current research and literature to conclude best practice • Conclusions made from this study are that existing guidelines correspond to the recommendations and findings in recent research and literature. However, more detailed guidelines and further research on how to prevent catheter‐associated urine tract infections and other complications may be of benefit
Health technology case study 28: intensive care units — clinical outcomes, costs and decision making. Congress, OTA-HCS-28
  • Ra Berenson
Berenson RA. Health technology case study 28: intensive care units — clinical outcomes, costs and decision making. Congress, OTA-HCS-28. Washington: Office of Technology Assessment; 1984.
The prevalence of nosocomial infection in intensive care (EPIC) study
  • Jl Vincent
  • Dj Bihari
  • Suter
  • Ha Bruining
  • J White
  • Nicolas-Chanoin
  • Mh
Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care (EPIC) study. JAMA. 1995;274:639-44.
Measuring efficiency of ventilator-dependent integrated respiratory care in Taiwan: an application of data envelopment analysis [thesis] Available from
  • Cc Chi
Chi CC. Measuring efficiency of ventilator-dependent integrated respiratory care in Taiwan: an application of data envelopment analysis [thesis]. Available from: http://fedetd.mis.nsysu.edu.tw/ FED-db/cgi-bin/FED-search/view_etd?identifier=oai:etd.lib.nsysu. edu.tw:etd-0715108-164020 [Article in Chinese.]