HAI-Net surveillance of HAIs in intensive care units (HAI-Net ICU): results and perspectives

Carl Suetens

Surveillance and Response Support Unit European Centre for Disease Prevention and Control

Healthcare-Associated Infections surveillance Network (HAI-Net)

Since 2000, as the HELICS project and then the IPSE project, both financed by grants from the European Commission (DG SANCO) to Claude Bernard University Lyon I, France

Coordinated by ECDC since July 2008

Coordination Committee (European experts) and contact points in participating countries

Modules:

Surgical site infections (SSIs): 16 countries HAIs in intensive care units: 15 countries Point prevalence survey (PPS): 30 countries HAI in long-term care facilities (LTCFs)

(HALT-2, outsourced), 24 countries C. difficile infections: pilot 14 countries

EU-wide CDI surveillance in 2016

Reports: Annual epidemiological reports 2007-2013;

PPS in acute care hospitals, 2011-2012; SSIs, 2008-2009, 2010-2011;

LTCFs (2010, 2013), ICU (in preparation); PPS interactive database

http://ecdc.europa.eu/en/activities/surveillance/HAI/Pages/default.aspx

HAI-Net ICU report 2008-2012

Number of years of participation, 2008-2012

Liechtenstein

Luxembourg

Malta

Non-visible countries

No participation

1 year

2 yrs

4 yrs

5 yrs

Not included

Participation 2008-2012

Patient-based data: 11 countries

Country - Data source N

of p

atie

nts

Media

n a

ge (y

ears)

Male

gender (%

)

ICU

morta

lity (%

)

Media

n S

APS II sco

re

Patie

nts fro

m co

mm

unity

(%)

Admission type (%)

Tra

um

a (%

)

Acu

te co

ronary

care

(%)

Impaire

d im

munity

(%)

Antib

iotics a

t adm

ission (%

)

Medica

l

Sch

edule

d su

rgery

Urg

ent su

rgery

Unknow

n (n

ot in

tota

l)

Austria 39 139 68 59.0 11.7 34 17.2 50.9 27.1 22 0.7 11.4 2.2 0.2 47.9

Belgium 17 178 72 59.8 10.9 31 35.7 60.8 28.6 10.6 0.5 6.5 24.4 6.1 41.8

Estonia 2 213 65 60.4 11.6 39 28.5 46.9 22.4 30.8 0.1 14.2 21.6 9.8 69.1

France 132 718 66 61.6 18.2 41 53.6 67.6 14.0 18.4 0.3 9.0 - 14.5 56.2

IT-GiViTI 52 339 69 58.8 16.6 37 20.9 50.5 23.1 26.4 0.0 14.1 - 1.4 -

IT-SPIN-UTI 5 853 70 61.4 18.1 35 23.9 51.2 31.4 17.3 0.9 4.0 13.5 3.9 60.1

Lithuania 11 488 63 56.8 16.2 30 26.6 51.7 28.7 19.5 0.4 7.9 18.8 11.5 25.8

Luxembourg 13 487 69 53.6 8.7 31 44.5 68.9 19.2 11.9 0.1 3.7 - 0.5 21.6

Portugal 17 470 66 63.5 17.6 44 34.5 61.9 11.8 26.3 0.0 13.8 - 12.1 51.8

Slovakia 1 372 62 62.2 22.6 51 34.8 63.1 10.4 26.5 0.8 24.4 17.3 15.8 82.2

Spain 127 733 65 65.1 13.5 30 49.9 68.3 18.7 13 1.5 7.2 20.1 8.2 21.4

UK-Scotland 21 304 62 56.4 16.0 43 26.1 59.3 14.6 26.1 11.6 7.9 4.9 4.9 76.3

UK-Wales 4 383 67 55.2 - - - - - - - - - - -

EU 446 677 66 61.4 15.3 36 40.7 62.7 18.9 18.4 2.1 9.1 14.8 8.4 41.0

Trend analysis 2008-2012 (pneumonia) Country - Data

source

2008 2009 2010 2011 2012 2008-2012 Trends,

2008–2012

Average

annual

change

2008–2012

p for trend

Croatia 19.9 - n.a.

IT-SPIN-UTI 15.1 12.4 18.2 14.9 18.1 0.99 n.s.

Belgium 16.5 17.6 12.2 13.5 15.1 -0.77 n.s.

France 13.5 13.7 13.4 13.9 13.7 0.05 n.s.

Estonia 7.5 3.2 23.0 18.1 10.6 2.10 <0.05

Austria 13.5 16.2 11.9 11.0 10.6 -1.07 n.s.

Lithuania 5.5 10.8 11.7 12.8 18.0 2.68 n.s.

Portugal 13.9 13.0 10.4 10.0 10.2 -1.05 <0.05

EU 13.6 13.1 10.7 10.8 10.2 -1.03 <0.001

Slovakia 19.0 11.1 7.5 7.3 12.3 -1.74 <0.001

Romania 5.9 11.5 - n.a.

Spain 14.6 11.6 11.2 9.4 7.4 -1.64 <0.001

IT-GiViTI 7.2 7.4 7.8 0.28 n.s.

Sweden 5.6 - n.a.

UK-Scotland 9.3 13.0 5.6 5.4 3.4 -1.94 <0.001

Luxembourg 6.8 3.4 3.9 4.9 3.9 -0.42 n.s.

PN diagnosis and Origin of BSI

40%

26%

34%

Catheter

Unknown

Secondary BSI

BSI origin

47%

20%

14%6%

5%

10%

Pulmonary Digestive tract

Urinary tract Surgical site

Skin/soft tissue Other

Primary infection in secondary BSI

Origin of bloodstream infections

0 25 50 75 100

Percentage of pneumonia

Estonia

Luxembourg

Belgium

Slovakia

Lithuania

Portugal

Austria

UK-Scotland

Romania

IT-SPIN-UTI

IT-GiViTI

Spain

Croatia

France

PN1 PN2 PN3 PN4 PN5

Diagnostic categories of pneumonia

Attributable mortality analysis

One approach: matched case cohort using propensity score matching

More statistical approaches in future (multi-state, marginal structural models, cox regression + time-dependent co-variates…)

Pneumonia

No Yes

Number of patients 20 686 20 686

Median age (years) 66 65

Gender (% male) 70.1 71.0

Median propensity score 183 183

Median intubation days before onset* 8 8

Median length of stay (days) before onset* 11 9

Median SAPS II score 47 46

Trauma patient (%) 15.2 16.0

Impaired immunity (%) 13.4 12.5

Admission type:

Medical (%) 65.0 65.2

Scheduled surgery (%) 10.2 10.3

Urgent surgery (%) 24.1 24.0

ICU mortality 29.3 32.8

attributable mortality: 3.5% (95% CI 2.6-4.4%)

Pneumonia

Bloodstream infection

No Yes

Number of patients 12 294 12 294

Median age (years) 66 65

Gender (% male) 67.8 68.3

Median propensity score 158 158

Median CVC days before onset* 12 11

Median intubation days before onset* 10 10.5

Median length of stay (days) before onset* 14 13

Median SAPS II score 45 46

Trauma patient (%) 13.2 13.1

Impaired immunity (%) 13.9 14

Admission type:

Medical (%) 64.2 63.6

Scheduled surgery (%) 10.5 11.1

Urgent surgery (%) 24.3 24.7

ICU mortality 29.5 34.6

Bloodstream infections

attributable mortality: 5.1% (95% CI 4.0-6.2%)

Changes to the ICU protocol

Request of European Commission:

– Structure and process indicators of HAI prevention

– HAI mortality data

Process for identification of prevention indicators:

– Meeting HAI-Net ICU Network, Oct 2013

– Smaller expert meeting, February 2014

– HAI-Net Coordination Committee, May 2014

– Teleconferences HAI-Net ICU expert group

– Consultation of Infection Section of ESICM (Oct 2014)

http://ec.europa.eu/health/patient_safety/healthcare_associated_infections/index_en.htm

Council Recommendation of 9 June 2009 on patient safety, including the prevention and control of healthcare associated infections (2009/C 151/01)

ECDC PPS in acute care hospitals, 2011-2012: structure and process indicators

Infection prevention and control indicators in 2011-2012: single bed rooms, alcohol hand rub consumption

Mapping leads to action: e.g. measures to improve AHR data availability in UK-Scotland

Percentage of beds in single rooms Alcohol hand rub consumption

*Poor data representativeness; Source: ECDC PPS, 2011-2012. Report available from http://www.ecdc.europa.eu/en/publications/Publications/healthcare-associated-infections-antimicrobial-use-PPS.pdf

ECDC PPS in acute care hospitals, 2011-2012: structure and process indicators

Two indicators of infection prevention and control staffing

Mapping leads to action: e.g. Czech Republic: National HAI Reference Centre (2012), new IPC guidance (2013)

IPC nurses (FTE/250 beds) IPC doctors (FTE/250 beds)

Infection prevention and control indicators: objectives Increase awareness for HAI/AMR prevention through

surveillance/repeated PPS

Add local value to surveillance by inter-hospital comparison and follow-up of key preventive measures (=> increase participation to surveillance networks?)

Inter-country comparison and follow-up of implementation of key preventive measures in EU/EEA countries

Follow-up of implementation of ECDC guidance and Council Recommendation 2009/C 151/01

At the longer term: linking evolution of prevention indicators with outcome indicators trends

Indicators: criteria

Should measure:

- Capacity/Preparedness

AND

- Behaviour/Practices

Evidence-based

Feasible

Valid & reproducible

Sufficient variability

Allow change over time

Limited number, best selection for EU-level surveillance

Infection Prevention and Control

Surveillance process

Antimicrobial Stewardship

Hospital denominator data

Common indicators for ARHAI surveillance networks

EARS-Net

HAI-Net

Lab001

Lab002

ESAC-Net

Hospital-based

antimicrobial

consumption

PPS

ICU

SSI

CDI

Hosp12

Hosp34

Hosp56

Hosp78

Standardised

hospital

codes

Specific

indicators

Hospital indicators

and denominator data (1 record per hospital and per

surveillande period/ year)

HAI-Net ICU structure and process indicators

1-2 weeks data collection & aggregated reporting per year/surveillance period, Unit based (aggregated), at least 30 opportunities per indicator

Current proposal:

– Hand hygiene: alcohol handrub consumption (L/1000 pt days) in ICU

– ICU staffing: registered nurses and nurse aides

– Antimicrobial stewardship: systematic review of AM after 48-72 hrs

– IAP prevention: cuff pressure control, oral decontamination, patient position

– CR-BSI prevention: CVC maintenance – dressing observation and/or clinical surveillance of insertion site (chart review)

Time frame HAI-Net ICU indicators/ evaluation of practices

Forms: hospital/ICU data 1/2

Hospital data

Hospital Code Year:

Hospital Type: O primary O secondary O tertiary O specialised

ICU characteristics

ICU Id

ICU size Number of beds in the ICU

ICU specialty

Percentage of intubated patients in year (true or estimated %): %

HAI types included in surveillance: O Pneumonia (PN) O Bloodstream Infections (BSI)

O Urinary tract infections (UTI) O Catheter-related infections (CRI1+2+3)

ICU indicators and denominators (one sheet per surveillance period)

Start date

N of

admissions

N of patient-

days

N of

admissions

N of patient-

days

Recommended minimal surveillance period = 3 months, maximum 1 year; add one form for each period

O Mixed O Medical O Surgical O Coronary O Burns O Neurosurgical

O Pediatric O Neonatal O Other O Unknown

Surveillance Period Patients staying >2 days All Patients

European Surveillance of ICU-acquired infections

Hospital / ICU form (standard & light protocol)

Hospital size

(n of beds)

Unique identif ier for each intensive care unit w ithin an hospital

End date

STRUCTURE AND PROCESS INDICATORS

Alcohol hand rub consumption during the previous year: Litres

Number of patient days (all) in the previous year patient days

ICU staffing

Number of hours of nurses present in the ICU in 7 days nurse hours

Number of hours of nurses' aides present in the ICU in 7 days nurse hours

Number of patient days in these 7 days patient days

Practice evaluation: Start date __ / __ / _____ End date __ / __ / _____

N of files /

observations

N

compliance

Intubation: Position of the patient not supine (observation)

CVC: Catheter site dressing is not damp, loose or visibly soiled

(observation)

Antimicrobial stewardship: Review antimicrobial therapy after 48-

72 hours (chart review)

Intubation: Endotracheal cuff pressure controlled and/or corrected

at least twice a day (chart review)

Intubation: Oral decontamination using oral antiseptics at least

twice a day (chart review)

Forms: hospital/ICU data 2/2

STRUCTURE AND PROCESS INDICATORS

Alcohol hand rub consumption during the previous year: Litres

Number of patient days (all) in the previous year patient days

ICU staffing

Number of hours of nurses present in the ICU in 7 days nurse hours

Number of hours of nurses' aides present in the ICU in 7 days nurse hours

Number of patient days in these 7 days patient days

Practice evaluation: Start date __ / __ / _____ End date __ / __ / _____

N of files /

observations

N

compliance

Intubation: Position of the patient not supine (observation)

CVC: Catheter site dressing is not damp, loose or visibly soiled

(observation)

Antimicrobial stewardship: Review antimicrobial therapy after 48-

72 hours (chart review)

Intubation: Endotracheal cuff pressure controlled and/or corrected

at least twice a day (chart review)

Intubation: Oral decontamination using oral antiseptics at least

twice a day (chart review)

HAI-Net ICU other protocol changes: attributable mortality HAI-related mortality, direct measurement of relationship of HAI to

death:

– Measured at HAI data level (Light and Standard protocol)

– In addition to statistical approach for countries with patient-based (standard protocol) data

– Proposal: for each patient with HAI, record outcome:

No death in ICU Death in ICU, HAI definitely contributed to death Death in ICU, HAI possibly contributed to death Death in ICU, no relationship to HAI Death in ICU, relationship to HAI unknown/ not verified

Methodology:

– Algorithm/cause analysis in ICU by clinician(s) and/or ICP?

– Consider: expected death on ICU admission/SAPS II score/McCabe score, other causes of death, active (complication of) HAI at time of death, antimicrobial resistance, appropriateness of treatment

HAI-Net ICU other protocol changes

Removal variables standard protocol (too many missing data):

– date of hospital admission

– coronary care

– previous surgery site

– parenteral nutrition

Change APACHE II in “Other severity score type” (APACHE II, SAPS III, McCabe, MPM …) and “Other severity score value”

Antimicrobial resistance data:

- request to change markers from ‘non-susceptible’ to ‘resistant’ (no change for ICU protocol – S/I/R/U collected)

- colistin (+tigecycline?) for Enterobacteriaceae, remove ESBL (only keep C3G), remove AMC?

- add PDR (pandrug-resistance)? (no PDR – possible PDR – confirmed PDR – Unknown)

Forms: patients/HAIs European Surveillance of ICU-acquired infections

Patient-based risk factor form (standard protocol)

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: Other severity score name*:

Other severity score value:

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*Other severity score name: APACHE II, APACHE III, APACHE IV, SAPS 3, MPM II, MPM III, McCabe score

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 Unk

If Yes: Start Date 1 : ___ / ___ / _______ End Date 1: ___ / ___ / _______

Start Date 2 : ___ / ___ / _______ End Date 2: ___ / ___ / _______

Urinary catheter in ICU: O Yes O No O Unk

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

Patient had at least one ICU-acquired infection included in surveillance O Yes O No O Unknown

(if yes, fill out HAI form)

Indication: P: prophylaxis E: empiric treatment M: documented treatment S: SDD (Selective Digestive

Decontamination)

Start Date End Date

Patient Counter

Case definition code

Relevant device in

situ before onset*

Date of onset

BSI: source of BSI***

Micro-organism 1

Micro-organism 2

Micro-organism 3

Patient ICU outcome: O discharged alive O death, HAI definitely contributed to death

O death, HAI possibly contributed to death O death, no relation to HAI O death, relationship to HAI unknown

HAI1: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4

Staphylococcus aureus OXA GLY

Enterococcus spp. AMP GLY

Enterobacteriaceae AMC C3G ESBL CAR

AMC C3G ESBL CAR

P.aeruginosa PIP CAZ CAR COL

Acinetobacter spp. CAR COL SUL

HAI2: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4

Staphylococcus aureus OXA GLY

Enterococcus spp. AMP GLY

Enterobacteriaceae AMC C3G ESBL CAR

AMC C3G ESBL CAR

P.aeruginosa PIP CAZ CAR COL

Acinetobacter spp. CAR COL SUL

HAI3: AB1 SIR1 AB2 SIR2 AB3 SIR3 AB4 SIR4

Staphylococcus aureus OXA GLY

Enterococcus spp. AMP GLY

Enterobacteriaceae AMC C3G ESBL CAR

AMC C3G ESBL CAR

P.aeruginosa PIP CAZ CAR COL

Acinetobacter spp. CAR COL SUL

Bold=minimal resistance data (as in PPS); SIR: S sensitive, I intermediate resistance, R resistant, U unknow n

Antibiotic 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: Sulbactam; PIP: piperacillin/ticarcillin w ith or w ithout

enzyme inhibitor; ESBL: Extended Beta-Lactamase producing, Yes=R, No=S, U=Unknow n

MO-Code

European Surveillance of ICU-acquired infections

HAI and AMR form, standard protocol

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; ** C-CVC, C-PER, C-ART, S-PUL, S-UTI, S-DIG, S-SSI, S-SST, S-OTH, UNK

MO-code MO-code MO-code

___ / ___ / ______

ICU-acquired infections

O Yes O No

O Unknown

___ / ___ / ______ ___ / ___ / ______

O Yes O No

O Unknown

O Yes O No

O Unknown

Target antimicrobial resistance data in ICU-acquired infections

HAI 1 HAI 2 HAI 3

Perspectives for integration of prevention indicators in EU surveillance

Pilot indicators for prevention of ICU-acquired infections

Pilot: 20 countries, min 1 hospital per country

Discussion at meeting of ECDC ARHAI networks, Stockholm, 11-13 February

Gradual implementation in national surveillance protocols

HelicsWin.Net software + new ICU protocols available 5/5/2015

Website: http://antibiotic.ecdc.europa.eu Facebook: EAAD.EU Twitter: @EAAD_EU (#EAAD)

18 November 2015