1. Le infezioni in UTIC sono davvero un
problema? In che cifre ci muoviamo?
Dr Vincenzo Galati
INMI L. Spallanzani

2. EVOLUZIONE DELLA CASISTICA DELLE UTIC
Motivo del ricovero in
Motivo del ricovero in
UTIC negli anni ’90
UTIC negli anni ‘60
(studio EARISA)
50
100
37,5
75
25
50
12,5
25
0
0 IMA A. inst. CHF Aritmie A. Stabile
IMA

3. UTILIZZO RISORSE IN UTIC (2006-2009)
50
45
40
35
30
25
20
15
10
5
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ap
bg
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is
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Dati UTIC - Ravenna 2006-2009

4. OSPEDALE PER INTENSITA’ DI CURA:
LIVELLI DI CURA
 livello 1, unificato, comprende la terapia
intensiva e subintensiva;
 livello 2, articolato almeno per area funzionale,
comprende il ricovero ordinario e il ricovero a
ciclo breve che presuppone la permanenza di
almeno una notte in ospedale (week surgery,
one day surgery);
 livello 3, unificato, è invece dedicato alla cura
delle post-acuzie o low care.

5. OSPEDALE PER INTENSITA’ DI CURA
 Il livello di cura richiesto dal caso consegue ad
una valutazione di instabilità clinica (associata a
determinate alterazioni di parametri fisiologici) e
di complessità assistenziale (medica e
infermieristica)
 Il livello di cura assegnato è definito dalla
tecnologia disponibile, dalle competenze
presenti e dal tipo, quantità e qualità del
personale assegnato

6.  Mechanical respirators (including CPAP delivery systems to
use with face mask): one machine for two beds
 intra-aortic balloon pump: one consol every three beds up
to the first six patients
 haemodyalisis haemofiltration machine: should be
available (probably more cost effective if supplied by
nephrology department)

7. I° censimento infermieristico nazionale delle UTIC
Complessità assistenziale

8. Fattori di rischio per HAI – Multi Drug resistant Organisms
(MDRO)
N Engl J Med 362;19 may 13, 2010

9. Fattori di rischio per Multi-Drug
Resistant Organisms (MDRO)
• Pregresso trattamento antibiotico
• Durata del ricovero > 5 giorni
• Presenza di invasive devices
• Gravi comorbidità
• Pregresso ricovero in lungodegenza
Tejal N. Gandhi, et al. Crit Care Med 2010 Vol. 38, No. 8 (Suppl.)

10. INFEZIONI NOSOCOMIALI
Dimensione del problema
•Ogni anno >2 milioni di persone negli Stati Uniti presentano
un’infezione nosocomiale
5-35% dei pazienti ricoverati in ICU
polmoniti associate a ventilazione (VAP),
infezioni del torrente circolatorio associate a catetere,
infezioni del sito chirurgico
infezioni associate a catetere urinario
rappresentano >80% delle infezioni nosocomiali.
P. Eggimann,D.Pittet. Infection control in the ICU: CHEST 2001.

11. CDC/NHSN SURVEILLANCE DEFINITION OF
HEALTH CARE–ASSOCIATED INFECTION
(HAI)
CDC defines an Health-care Associated Infection (HAI) as a
localized or systemic condition resulting from an adverse
reaction to the presence of an infectious agent(s) or its
toxin(s).
toxin(s)
There must be no evidence that the infection was present
or incubating at the time of admission to the acute care
setting.
setting
HAIs may be caused by infectious agents from endogenous or
exogenous sources.
 Endogenous sources are body sites, such as the skin, nose,
mouth, gastrointestinal (GI) tract, or vagina that are normally
inhabited by microorganisms.
 Exogenous sources are those external to the patient, such
as patient care personnel, visitors, patient care equipment,
medical devices, or the health care environment.

12. HAI: ITALIA
STIMA DIMENSIONI DEL PROBLEMA
 colpiscono circa il 5-10% dei pazienti
ricoverati
 rappresentano circa il 50% delle
complicanze ospedaliere
 casi annui: 450.000-700.000
 decessi annui: 4.500-7.000
 costo annuo:1 miliardo di euro

13. HAI - ITALIA
INTERVENTI POSSIBILI
quota prevenibile: 30-40%
casi evitabili: 135.000-210.000
decessi evitabili: 1.350-2.100
costo evitabile: 300 milioni di euro

14. Studio EPIC- Europa occidentale - 1995
Studio di prevalenza (1417 ICU osservate per un periodo
di 24 ore; 10038 pazienti)
 44.8% presentavano un’infezione (31% infezione acquisita
in ospedale; 20.6% infezione acquisita in ICU), di cui:
 polmonite 46.9%
 altra infezione delle basse vie respiratorie 17.8%
 infezione delle vie urinarie 17.6%
 infezione del torrente circolatorio12%
Vincent JL, JAMA 1995

15. PREVALENZA DI ICPA NELLE UTI (EPIC 1992)
35
30
25
20
%
15
10
5
0
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tria elgi Eir a nci ani re ci Ita li urg an d ga ll agn vez i z zer UK
A us B Fr er m G mb Ol orto Sp S Svi
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u ss P
L
High variability of the prevalence of ICU-acquired infections among countries, from a
minimum of 9.7% in Switzerland to a maximum of 31.6% in Italy
Vincent JL, JAMA 1995

16. EPIC II
Infection and related sepsis:
• leading cause of death in
noncardiac ICUs
• mortality rates reach 60%
• account for approximately 40%
of total ICU expenditures
JAMA, December 2, 2009—Vol 302, No. 21

17. Studio EPIC II
 13 796 adult patients
 7087 (51%) classified as infected on the day of
the study
 71% were receiving antibiotics (as prophylaxis
or treatment).
 16% of the infected patients treated with
antifungal agents
JAMA, December 2, 2009—Vol 302, No. 21

18. Studio EPIC II
Caratteristiche dei
pazienti arruolati
JAMA, December 2, 2009—Vol 302, No. 21

19. Studio EPIC II
Infected patients had:
• more comorbid conditions
• higher SAPS II
• higher SOFA scores on admission
JAMA, December 2, 2009—Vol 302, No. 21

20. EPIC II: most common site of infection
JAMA, December 2, 2009, Vol 302, No. 21

21. EPIC II: most common site of infection
• lungs 64%
• abdomen 20%
• bloodstream 15%
• renal tract/genitourinary system 14%
JAMA, December 2, 2009—Vol 302, No. 21

22. EPIC II
JAMA, December 2, 2009—Vol 302, No. 21

23. Studio EPIC II
Variabili correlate
con la mortalità in
ospedale

24. Design: Prospective observational cohort study on the French
OUTCOMEREA multicenter database
Setting: Twelve medical or surgical ICUs
Patients: Unselected patients hospitalized for ≥ 48 hrs enrolled
between 1997 and 2003. 3,611 patients included
Objective: to measure the incidence of previously defined AEs
and nosocomial infections in a large ICU population and to
evaluate the impact of these events on mortality.

27. Most common AEs
 Nosocomial pneumonia (11.8%)
 Urinary tract infections (9%)
 Bloodstream infections (6.7%)
 Extubation (7.1%)
 Cardiac arrest (5.7%)

30. Adjusting for both disease severity and the possible
occurrence of multiple AEs in individual patients, we
found that AEs independently associated with death
included:
 three nosocomial infections (BSI, nosocomial
pneumonia, and organ/space or deep incisional SSI)
and
 two iatrogenic events (pneumothorax and
gastrointestinal bleeding).

31. Review of the available data to estimate the clinical
outcomes and costs associated with CRBSIs during
intensive care unit (ICU)stays in four European countries
(France, Germany, Italy and the UK).

33. Italy
National surveillance network developed by the GIVITI (Gruppo Italiano
per la Valutazione degli Interventi in Terapia Intensiva) started in 2005.
 CRBSI rate was estimated at 2.0 per 1000 catheter days (95%
CI: 1.9e2.2) in 2007 with an
 average duration of implantation of 8.6 days based on 37 239
patients recruited in 124 ICUs.10
 490 000 CVCs and arterial catheters are implanted every year
in ICUs (Ethicon market research).
 estimate of 8500 CRBSIs per year.
 estimated annual cost related to CRBSIs in ICU: 81.6 €
Million

34.  Surveillance study on device-associated health care-associated infections (DA-
HAIs) within intensive care units (ICUs) collected by hospitals participating in
the International Nosocomial Infection Control Consortium (INICC) from
January 2004 through December 2009 in 422 intensive care units (ICUs) of 36
countries in Latin America, Asia, Africa, and Europe.
 Prospective data from 313,008 patients hospitalized in the consortium’s ICUs
for an aggregate of 2,194,897 ICU bed-days.

35. Data on device-associated
health care-associated
infections (DA-HAIs) :
Central line-associated
primary BSIs (CLABSIs)
 catheter-associated urinary
tract infections (CAUTIs)
 ventilator-associated
pneumonia (VAP)

42. Conclusion:
The rate of device use in the INICC ICUs is similar to or
even lower than that reported in US ICUs by the
NNIS/NHSN system;
 DA-HAI rates identified in INICC ICUs are significantly
higher than the published US rates
 The antimicrobial resistance rates found in INICC ICUs
for methicillin-resistant Staphylococcus aureus (MRSA)
isolates, enterobacteria resistant to ceftazidime (ESBL),
and Pseudomonas aeruginosa as resistant to
fluoroquinolones were significantly higher than those
reported in NHSN ICUs
 HAIs, particularly DA-HAI in ICU patients in limited-
resources countries, pose a grave and often concealed
risk to patient safety.