european surveillance of surgical site infections and icu-acquired infections, 2004-2008 carl...
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European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008
Carl Suetens
Surveillance UnitEuropean Centre for Disease Prevention and Control
7th HIS International Conference, Liverpool, 10-13 October 2010
Standardized surveillance of Healthcare-Associated Infections in European hospitals Surveillance of Surgical Site
Infections (SSI)
Surveillance of ICU-acquired Infections (ICU)
Point Prevalence Surveys as alternative to hospital-wide surveillance of all HAI types (PPS)
Standardisation of SSI & ICU surveillance methods
Methodological differences between national protocols:
– Fair agreement in 2000 for SSI surveillance (7 countries), similar to CDC/NNIS methodology
– Larger differences for surveillance of ICU-acquired infections in 2000 (5 countries, 4 patient-based, 1 unit-based)
Agree on common surveillance methodology and case definitions: questionnaire (2000), meetings (2000-2002), final protocols 2002-2003
Work towards standardized interpretation of standard methodology
Develop indicators that take into account inter-country differences in methodology and case-mix
Participation to HAI surveillance (HAI-Net), status in 2010
Surgical Site Infection onlyIntensive care onlyBoth SSI and ICU
ICU or SSI pilotDoes not participate
NOISNOISSIROSIRO
RAISINRAISIN
ISC IIIISC III ENVINENVIN
ASRASR
SPIN-UTISPIN-UTIHELICSHELICS
KISSKISSNSIHNSIH
PREZIESPREZIESHPAHPA
SSHAIPSSHAIPHISCHISC INST HYGINST HYG
ANISANIS NNSRNNSR
NHSNHS
Surveillance of Surgical Site Infections: EU methods vs CDC/NHSN Same as CDC/NHSN methodology, except:
– Hospital discharge date required– Options: ICD9-CM codes, post-discharge date &
status– Selection of procedures: CABG, CHOL, COLO, CSEC,
HPRO, KPRO, LAM Indicators:
– % SSI within 30 d / 1 year – % in-hospital SSI (post-discharge excluded)– Incidence density: # in-hospital SSI/1000 patient-
days: • Adjustment for differences in post-discharge surveillance• Adjustment for differences in post-operative length of stay• Incidence density for Deep-Organ/Space infections only:
adjustment for differences in reporting superficial infections– Stratification per NNIS risk index for all indicators
European surveillance of Surgical Site Infections 2000-2001: protocol analysis,
questionnaire, meetings
6 countries in 2000 => 12 countries (15 networks), 1422 hospitals in 2008
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AT DE ES FI FR HU IT LT NL NO PT UK
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N. of hospitals N of interventions
CABGCHOL
COLO
CSEC
HPRO
KPRO
LAM
SSI cumulative incidence by operation category and year, 2004-2008
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CABG CHOL COLO CSEC HPRO KPRO LAM
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Surveillance of SSI in hip prosthesis, 2004-2008
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AT BE DE ES FI FR HU IT LT NL NO PL PT UK
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SI
In-hospital SSI Post-discharge SSI Unknown discharge date
Differences in post-discharge surveillance and type of SSI
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UK-ENFR
ITDE
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ATPT
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Cumulative incidence (% SSI) by country, HPRO, 2007
Organ/space Deep incisional
Superficial incisional SSI type unknown
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SI/1
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UK-ENFI
ITDE
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NLNO
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HU
Cumulative incidence (% SSI) by country, post-discharge excluded, HPRO, 2007
Organ/space Deep incisional
Superficial incisional SSI type unknown
Post-discharge SSI included Post-discharge SSI excluded
AT DE ES FI FR HU IT LT NL NO PT UK Total
CABG 61.5 28.4 32.6 `21.1 40.9 30.4 91.3 NR1 29.2
CHOL 0 27.2 13.5 38.6 28.6 52.6 25.0 83.3 73.1 40.9 35.8
COLO 12.5 4.0 8.6 18.8 0 24.2 0 33.3 2.1 NR 11.9
CSEC 46.4 25.0 70.8 63.9 18.4 78.6 73.9 77.6 25.0 60.3 59.9
HPRO 47.6 22.5 20.0 28.1 59.8 10.5 16.7 0 67.7 71.2 50.0 21.9 35.4 KPRO 27.5 42.9 56.8 75.0 0 0 0 87.8 48.1 50.0
Percentage of SSI detected after discharge from the hospital by surgical procedure
EU reference tables, e.g. SSI incidence density in HPRO
NHSN risk indexNumber of hospitals
Number of pt-days
Number of in-hospital SSIs
In-hospital SSIs/1,000 pt-days
(95%CI) P10 P25 P50 P75 P90
All risk categories 484 701,645 440 0.63 (0.57-0.69) 0.0 0.0 0.0 0.9 2.0
Risk index 0 480 362,955 154 0.42 (0.36-0.50) 0.0 0.0 0.0 0.0 1.6
Risk index 1 477 249,199 203 0.81 (0.71-0.93) 0.0 0.0 0.0 0.0 2.5
Risk index 2-3 350 34,817 59 1.69 (1.29-2.19) 0.0 0.0 0.0 0.0 4.6
Risk index unknown 222 54,674 24 0.44 (0.28-0.65) 0.0 0.0 0.0 0.0 0.0
European surveillance of ICU-acquired infections 2000-2002: protocol
analysis, questionnaire, retrospective data analysis, meetings
Collaboration with ESICM
654 hospitals from 12 countries in 2008
2 levels: – Unit-based (minimal
data, trends) – Patient-based: risk
adjustment, Standardised Infection Ratio (Observed/Expected)
Ongoing surveillance
Pilot data received
Pilot ongoing/planned
No data
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Surveillance of ICU-acquired infections
Patient Counter
Case definition codeRelevant device in situ before onset*
Date of onset**
BSI: source of BSI***
Micro-organism 1
Micro-organism 2
Micro-organism 3
*** C-CVC, C-PER, C-ART, S-PUL, S-UTI, S-DIG, S-SSI, S-SST, S-OTH, UNK
HAI1: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4Staphylococcus aureus OXA GLYEnterococcus spp. AMP GLYEnterobacteriaceae AMC C3G ESBL CAR
AMC C3G ESBL CARP.aeruginosa PIP CAZ CAR COLAcinetobacter spp. CAR COL SUL
HAI2: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4Staphylococcus aureus OXA GLYEnterococcus spp. AMP GLYEnterobacteriaceae AMC C3G ESBL CAR
AMC C3G ESBL CARP.aeruginosa PIP CAZ CAR COLAcinetobacter spp. CAR COL SUL
HAI3: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4Staphylococcus aureus OXA GLYEnterococcus spp. AMP GLYEnterobacteriaceae AMC C3G ESBL CAR
AMC C3G ESBL CARP.aeruginosa PIP CAZ CAR COLAcinetobacter spp. CAR COL SULBold=minimal resistance data (as in PPS); SIR: S sensitive, I intermediate resistance, R resistant, U unknownAntibiotic codes: AMC: amoxicillin/clavulanate, AMP: ampicillin, C3G: cephalosporins of third generation(cefotaxim/cetriaxone/ceftazidim), CAR: carbapenems (imipenem/meropenem/doripenem), CAZ: ceftazidim, COL: colistin, GLY: glycopeptides (vancomycin, teicoplanin), OXA: oxacillin, SUL: SulbactamPIP: piperacillin/ticarcillin with or without enzyme inhibitorESBL: Extended Beta-Lactamase producing, Yes=R, No=S, U=Unknown
MO-Code
European Surveillance of ICU-acquired infectionsInfection and AMR form, standard (ICU2)
MO-Code
MO-Code
___ / ___ / ______
*relevant device use (intubation for PN, CVC for BSI, urinary catheter for UTI) in 48 hours before onset of infection (even intermittent use), 7 days for UTI **Only for infections not present/active at admission
MO-code MO-code MO-code
HAI 1 HAI 2 HAI 3
O Yes O No O Unknown
O Yes O No O Unknown
Target antimicrobial resistance data in ICU-acquired infections
O Yes O No O Unknown
___ / ___ / ______ ___ / ___ / ______
ICU-acquired infections
Patient-based surveillance in the ICU
European Surveillance of ICU-acquired infectionsPatient-based risk factor form (ICU1)
Hospital code Date of admission in hospital: ___ / ___ / _______
ICU code (abbr name) Patient Counter
Patient data
Age in years: ____ yrs Gender: M F UNK Date of admission in ICU: ___ / ___ / _______
Date of ICU discharge ___ / ___ / _______ Outcome at ICU discharge: Alive Dead UNK
Origin of the patient O Ward this/oth hosp O Other ICU O Community O LTCF O Other O UNK
SAPS II score: Apache II score:
Type of admission: O medical O scheduled surgical O unscheduled surgical O UNK
Trauma: O Yes O No O UNK Impaired immunity: O Yes O No O UNK
Antimicrobial treatment +/- 48 Hrs around admission : O Yes O No O UNK
Acute coronary care: O Yes O No O UNK
Surgery site (within last 30 days before admission, incl. day of admission) O UNK O No SurgeryO coronary O other cardiac O other thoracic O other vascular O abdominal O neurosurgery O other site
Exposure to invasive devices in the ICU
Central vascular catheter in ICU: O Yes O No O Unk
If Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______
Intubation in ICU: O Yes O No O UnkIf Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______
Urinary catheter in ICU: O Yes O No O UnkIf Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______
Parenteral nutrition in ICU: O Yes O No O Unk (optional)If Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______
Patient received antimicrobial(s) during ICU stay O Yes O No O Unkown
Antimicrobial (generic or brand name) or ATC5 Indication
Indication: P: prophylaxis E: empiric treatment M: documented treatment S: SDD (Selective Digestive Decontamination)
Start Date End Date
Methodology of EU surveillance of ICU-acquired infections
Patients staying less than 3 days in the ICU excluded from denominators (different from US-NHSN/DE-KISS)
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AT BE DE ES FR IT LT LU PT SK UK
Length of stay in the ICU (days) by country
Methodology of EU surveillance of ICU-acquired infections Case definitions differ from CDC/NHSN definitions:
– Bloodstream Infections: include secondary BSI
– Pneumonia:
• based on CDC PNU definition, not identical• Intubator-Associated (IAP) vs Ventilator-Associated (VAP)
Definition of “nosocomial” or “ICU-acquired”: >48 h, in practice > Day 2, instead of “not present or in incubation at admission”
ECDC outsourced Concordance study of HAI case definitions CDC/NHSN vs. IPSE/HELICS (2009-2010, P. Gastmeier et al): Quantify difference in case classification (concordance) =>
kappa Results show excellent concordance (kappa>=0.99) for PN
and primary BSI
HELICS case definition of pneumonia(2003) – also in ECDC PPS protocolX-ray(s) + clinical symptoms (t°/wbc +
sput./ronchi…)
PN1: protected sample + quantitative culture (104 CFU/ml BAL/103 PB,DPA)
PN2: non-protected sample (ETA) + quantitative culture (106 CFU/ml)
PN3: alternative microbiological criteria
PN4: sputum bacteriology or non-quantitative ETA
PN5: no microbiological criterion
Differences in diagnostic practices of ICU-acquired pneumonia, 2008
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AT BE DE ES FR IT LT LU PT SK UK
PN1 PN2 PN3 PN4 PN5
Date of onset pneumonia
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AT BE DE ES FR HR IT LT LU PT RO SK UK
Day of onset pneumonia in the ICU, by country, 2007
D3-4 D5-6 D7-13 >=D14
Micro-organisms isolated in ICU-acquired infections, 2004-2008
0 0.05 0.1 0.15 0.2
Enterococcus spp.
Stenotrophomonasspp.
Haemophilus spp.
Acinetobacter spp.
Enterobacter spp.
Candida spp.
Klebsiella spp.
E. coli
S. aureus
P. aeruginosa
2008 2007 2004-2006
0.0% 10.0%
20.0%
30.0%
40.0%
Serratia spp.
Acinetobacterspp.
Enterobacterspp.
Candida spp.
Klebsiella spp.
E. coli
P. aeruginosa
S. aureus
Enterococcusspp.
Coag.-neg.staphylococci
2008 2007 2004-2006
Pneumonia Bloodstream infections
EU reference tables, e.g. device-adjusted ICU-acquired pneumonia ratesCountry N of ICUs Mean P10 P25 P50 P75 P90
AT 37 6.2 0 0 4 11.8 16.1BE 17 17 0 0.5 9.3 30.7 49.7ES 111 20 2.3 8.9 15.6 26.9 41FR 165 15.6 4 7.5 14.2 20.8 29.1IT 27 18.6 0 2.2 6.1 19.1 68.8LT 9 14.3 0 1.6 8.2 11 45.8LU 8 6.7 0 3.8 6.5 9.6 14PT 6 11.5 3.4 5.6 10.2 17.9 21.4SK 5 20.7 0 0 14.6 42.3 46.8Total 385 16 0 6.1 12.8 20.8 35
Support to HAI surveillance : on-site HAI surveillance workshops
HAI surveillance workshop, Sofia, Nov 2009
Hungarian HELICSwin, Budapest workshop, June 2009
Technical support visit to help set up HAI surveillance networks (4 in 2010)
2 x ½ day workshop Intensive Care (ICU),
Surgical Site Infections (SSI) or both
Typically 20 participants from hospitals
Including case studies of HAI case definitions and computer exercises (HELICSwin)
+ support to national coordination team & installation of software tools
EU HAI surveillance integrated in TESSy
TESSy = “The European Surveillance System” = ECDC’s online database, upload and reporting system for all communicable diseases under surveillance
Integration of all dedicated surveillance networks
October (4-8/10): HAI TESSy training for national surveillance coordinators and data managers
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Pre-TESSY
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Disease expert
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AF member
MB member
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TESSy
Dat
a up
load
and
acc
ess
Data access
Data users
HAI surveillance: ICU & SSI now integrated in ECDC’s TESSy system
From IPSE to HAI-Net: What has changed? Naming conventions:
– Healthcare-Associated Infections: HAI instead of HCAI– IPSE => HAI-Net– Unit-based protocols: “level 1” => “light”– Patient-based protocols: “level 2” => “standard” (full)
Changes agreed at HAI surveillance Annual Meeting:– SSI: “Light” version, coverage, post-discharge method– ICU: Some variables/options dropped, AMR target list– New minimal AMR marker set (PPS)
SSI ICU PPS HALTSTANDARD (patient-based) X X X X
LIGHT (unit-based) X X X X
Conclusions
Standardized surveillance of surgical site infections and ICU-acquired infections: based on HELICS/IPSE network, now continued by ECDC
27+ countries = 27+ opinions, but large majority in favour of agreeing on single method
Need for extension of surveillance, but setting up HAI surveillance networks requires important resources (hospitals, national coordination)
training of trainers and on-site training
translation of protocols
free software tools, multilingual
Standardized methods/definitions standardized surveillance practices!
From January 2011: ECDC HAI surveillance website + interactive data analysis
Thank you to all national surveillance networks and participating hospitals!
www.ecdc.europa.eu| [email protected]