Nosocomial Bloodstream Infection and Clinical Sepsis



Võrreldes teiste samas piirkonnas olevate majutusasutustega on külastajad selle üle õnnelikumad. See on samuti hinnatud parima hinna ja kvaliteedi suhtega majutusasutuseks sihtkohas Mannebach! In our study population, exposure to central and arterial lines was similar in both groups of patients with BSIs, but the frequency and duration of the exposure were of greater importance than they were in the group of patients without BSIs.

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Surveillance definitions for primary BSI distinguish those that are microbiologically documented from those that are not. The latter is known as clinical sepsis, but information on its epidemiologic importance is limited.

We analyzed prospective on-site surveillance data of nosocomial infections in a medical intensive care unit. The overall BSI infection rate was Exposure to vascular devices was similar in patients with clinical sepsis and patients with microbiologically documented BSI.

We conclude that laboratory-based surveillance alone will underestimate the incidence of primary BSI and thus jeopardize benchmarking. Primary bloodstream infection BSI is a leading, infectious complication among critically ill patients 1. The impact on patient outcome is tremendous; BSI increases the mortality rate 6 , 7 , prolongs patient stay in an intensive care unit ICU and in the hospital 7 — 9 , and generates substantial extra costs 7 , 8.

For these reasons, surveillance and prevention of BSI are high priorities, and several interventions have proven to be effective 10 — Although surveillance of the former can be laboratory based, detection of clinical sepsis requires prospective on-site surveillance.

The surveillance strategy determines whether clinical sepsis will be detected, thus affecting the overall BSI incidence rate. Because prospective on-site surveillance requires more resources than laboratory-based surveillance, the choice of the surveillance strategy should be based on knowledge of the importance of clinical sepsis.

To our knowledge, clinical sepsis has never been investigated. This article describes the epidemiology of clinical sepsis in a medical ICU. The study took place in the bed medical ICU of a large teaching hospital in Geneva, Switzerland, from October to November The unit admits 1, patients per year; the mean length of stay is 4 days.

The surveillance strategy of nosocomial infection has been described previously Briefly, one infection control nurse visited the ICU daily 5 of 7days , gathered information from medical and nursing records, microbiologic and x-ray reports, and interviews with nurses and physicians in charge. Nosocomial infections were defined according to CDC criteria 17 , except that asymptomatic bacteriuria was not considered an infection Collected variables included all nosocomial infections, demographic characteristics, admission and discharge diagnoses, exposure to invasive devices and antibiotics, and ICU and hospital survival status.

Microbiologically documented BSI required one of the following: Clinical sepsis was diagnosed when the patient had either fever, hypotension, or oliguria, and all of the following: The surveillance strategy, definitions, and the discharge policy did not change over the study period. Patients were discharged from the ICU, according to specific guidelines designed for this unit, and compliance with these guidelines was checked daily by a senior staff member.

An ongoing intervention aiming to reduce catheter-related infection was begun in March Reports on the intervention and its effect have been published previously All primary BSI were considered in the first part of the analysis. Episodes of BSI that were not associated with a central line were identified. Infection rates were expressed as the total number of episodes per 1, ICU patient days, or the number of episodes associated with a central line per 1, central-line days.

The study population was then divided into three groups to describe the epidemiology of clinical sepsis. The first group included all patients who remained free of any ICU-acquired BSI; the second group comprised all patients whose first episode was a microbiologically documented BSI, and the third group included those whose first episode was clinical sepsis.

Only the first episode of BSI was considered. We then performed a subgroup analysis comparing patients with and without BSI but with at least a 5-day stay in the ICU. This analysis was conducted to exclude patients who died or were discharged quickly after ICU admission to ensure that patients without BSI were sufficiently exposed to the risk of acquiring nosocomial BSI. Exposure to invasive devices was estimated by the proportion of patients exposed to the device and the duration of the exposure.

We separately investigated peripheral, arterial, and central vascular lines. Among patients with BSI, the duration of the exposure to the vascular line was censored at onset of the first episode of BSI. Continuous variables were summarized by means or medians and compared with the Student t-test or a nonparametric test, when appropriate.

Categorical variables were compared by using chi-square or the Fisher exact test. All statistical analyses were conducted with Stata 7. Median age was The main admission diagnoses were infectious The leading sites were the lungs pneumonia, We detected nine episodes of secondary BSI, six secondary to a urinary tract infection, two to a lower respiratory tract infection, and one to a skin and soft tissue infection.

Of episodes of BSI, 33 Four episodes three of clinical sepsis and one of microbiologically confirmed BSI were not associated with a central line. Exposure to systemic antimicrobial drugs before blood culture was Among the 33 episodes of microbiologically confirmed BSI, 4 were polymicrobial.

Table 1 displays BSI infection rates per 1, patient days and central-line days. The overall rate of BSI was These BSIs occurred in 91 patients; 73 patients had a single episode, 14 had two, and 4 had three episodes. The first episode was microbiologically documented for 28 patients and diagnosed as clinical sepsis for Selected characteristics of patients with and without BSI are displayed in Table 2. Patients without BSI tended to be older; the distribution of admission diagnosis was similar in both groups, but intoxication was more prevalent in patients without BSI, although the difference was not statistically significant.

Illness appeared more severe in patients with BSI, as estimated by a higher number of discharge diagnoses, a longer ICU length of stay, and a higher mortality rate. The picture remained the same. The occurrence of pneumonia, urinary tract infection, and other infections was similar in patients with microbiologically documented BSI and clinical sepsis, but less frequent in patients without BSI.

However, catheter exit-site infection was more frequent in patients with clinical sepsis Figure. The results of exposure to invasive devices are shown in Table 3. Exposure to vascular lines was censored at the time of the first episode of BSI.

Exposure to central lines and arterial lines was similar in patients with a microbiologically documented episode of BSI and in those with clinical sepsis but much lower in patients without BSI. Three episodes of primary BSI occurred in patients without a central line in place before onset of infection. Similarly, exposure to urinary catheter and mechanical ventilation was lower in patients without BSI. The hospital mortality rates among patients without BSI, with a microbiologically confirmed BSI, and with clinical sepsis were We also found that a minority of BSI were microbiologically documented and that ignoring clinical sepsis has a large impact on the BSI infection rate.

To our knowledge, this is the first report that provides a detailed epidemiologic description of clinical sepsis. Whether clinical sepsis represents a primary BSI or whether it is a systemic reaction accompanying an unrecognized infection at another site or a noninfectious systemic inflammatory response are valid concerns 1 , 20 — The definition is not specific because it requires, among other criteria, only one of three clinical signs fever, hypotension, or oliguria.

Also, this condition mandates antimicrobial therapy prescribed by the physician for suspected sepsis. Thus, we decided to use unmodified definitions, elaborated by CDC and widely used because they are still considered the standard operational definitions for surveillance of nosocomial infections.

An epidemiologic description of patients without BSI, with microbiologically documented BSI, and with clinical sepsis provides valuable information. In our study population, exposure to central and arterial lines was similar in both groups of patients with BSIs, but the frequency and duration of the exposure were of greater importance than they were in the group of patients without BSIs. The longer exposure to vascular devices does not reflect the impact of BSI because exposure was censored at time of BSI.

Consequently, the most powerful risk factor for clinical sepsis is the same as that for microbiologically documented BSI.

Second, during the same study period we implemented an intervention targeted at vascular-access care to reduce the incidence of catheter-related BSIs Please Sign Up below to be the first to know when tickets are available and on sale. Very Cheap Prices -. Remember — quality costs! Scammers use promises as: A really bad situation which you buy tickets and a day before the match you get a call that there are no tickets for you or you get a different category usually a lower one.

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