Jean CARLET, M.D. Head of the Research and Safety Program The French National Authority for Health (HAS)

Transcription

1 ZERO VAP Dream, mystification, or reality? Jean CARLET, M.D. Head of the Research and Safety Program The French National Authority for Health (HAS)

2

3 National Prevalence surveys (95%) beds 99% of public hosp beds 75% of semi-private beds (PSPH) 9% of private hosp beds Faciliti ies (N) Year

4 6 5 SURVEILLANCE DES IN EN REANIMATION : SURVEILLANCE EN RESEAU Réseau réanimation du CCLIN Sud-Est, Inf. pulmonaire /1 j d'intubation 3 Médiane = 16, Services

5 ENQUETE DE PREVALENCE EN EUROPE ( ) Etudes anciennes non comparables 16,3 11,5 11,7 11,8 8,9 9 9,3 9,3 9,3 8 6,9 6,9 7,2 7,3 7,6 5,5 6,1 6,3 6,8 3,5 A lle m a gne 97 G rè ce 1 95 Tche chos l 84 N orv è ge 91 G rè ce 94 F ra nce 2 21* Ita lie 83 E spa gne 94 Tha ila nde 95 H ôpita l P ropre 9 F ra nce Es pa gne U K G rè ce 22 Lithua nie B e lgique 84 Suisse 98 Tha ila nde 89 D a ne m a rk Suè de

6 PREVALENCE OF NOSOCOMIAL INFECTIONS IN THE ICU Epic Study 1995 IMPORTANCE OF CASE MIX Italy = 4,25 Switzerland F = 3,25 Adjustment for LOS : I = 2,2 S 23,3 F = 1,7 S ,2 17,2 17,2 18,7 2 24,2 3,5 31,6 1 7,4 8,7 5 S w itz e r la n d D e n m a r k N e th e r la n d s U K L u x e m b u r g G e r m a n y B e lg iu m I r e la n d A u s tr ia P o r tu g a l F r a n c e G r è c e I ta lie

7 HELICS ICU SURVEILLANCE (C. SUETENS) ICU acquired pneumonia / 1 vent day Autriche Belgique Espagne Hollande Europe Portugual France Luxembourg

8 Impact of risk-adjustment on inter-country comparisons of ICU-acquired pneumonia indicators HELICS network PN cumulative incidence (%) Incidence density (/1 pt-days days) # PN (1st) / 1 pts 2% 15% 1% 5% % AT BE ES FR LU NO SK # PN / 1 pt-days AT BE ES FR LU NO SK Device-adjusted rate (IAP/ 1 int.days) Standardized infection ratio (O/E) # IAPs / 1 int-days AT BE ES FR LU NO SK O/E % (8RF) AT BE ES FR LU NO SK

9 Postoperative Pneumonia Risk Index Arozullah AM Ann Intern Med 21;135:

10 Prevention of VAP: Duration of mechanical ventilation Non invasive ventilation sedation modulation of gastric colonization Disinfection or sterilization of medical devices Oral decontamination semi-recumbent position subglottic aspiration Formation Surveillance SDD

11 EFFECT OF AN EDUCATION PROGRAM ON DECREASING CATHETER-RELATED RELATED BLOODSTREAM INFECTIONS IN THE SURGICAL ICU Coopersmith CM CCM 22, 3, beds ICU - 1 page self-study module for nurses - Posters all over the ICU - BSI went from 1,8/1 catheter days to 3,7/1 catheter days 66 % decrease (p <.1)

12 Reduction in VAP : Educationnal programs for HCP Ventilator associated pneumonia: Zack et al Critical Care Med 22

13 SDD + Céphalosporine IV Méta-analyse, D Amico et al, BMJ 1998 SDD seule

14 Colonization to infection June 17 Tracheal aspirates: P aeruginosa for 2 weeks June 22 BAL: 1^5 P aeruginosa 3 positive blood cultures

15 Quorum Sensing Exotoxines Signaux Bactéries

16 Arithromycin inhibits quorum sensing in P.aeruginosa Tateka et al AAC 21, 45, micro g of Azithro inhibit QS Partially restored by synthetic auto- inducers of quorum sensing Mechanism?

17 Virulence factors secretion types Type I: 1 step Type I and II secretion Type II: 2 steps (periplasm) Type III («TTSS»): Contact mediated Direct translocation = «bypass» Toxin Bacteria Type III Bacteria Host Cell Toxin Host Cell

18 Role of the TTSS proteins needle PcrV Pseudomonas ExoT ExoS ExoU Cytotoxicity Prevents internalization Immune response nucleus Host Cell Cytokines

19 Prevalence of TTSS proteins 71 strains from acute % expression infections PcrV ExoS ExoT ExoU Roy-Burman JID 21

20 P aeruginosa VAP: % strains 1 n= All death/relapse Recovery 4 2 Type III secretion ExoU secretion ExoS secretion ExoU ExoS ExoT PopB PopD Hauser Crit Care Med 22

21 Infections acquises en Réanimation Polyvalente de 1995 à 2 Hôpital Saint-Joseph - Paris SAPS2 et Omega en Points Gravité (SAPS 2) Infections acquises en Réa Poly Charge en soins (Omega) Infections jour-patients nd sem st sem nd sem st sem nd sem st sem nd sem st sem nd sem st sem 2

22 SURVEILLANCE DES IN EN REANIMATION : EVOLUTION DES TAUX Pneumopathies, Incidence (pour 1 j.) Réa 1 Réa 2 Réa 3

23 CONCLUSIONS VAP rates can be reduced The role of case mix is KEY. In patients staying for weeks, the risk will remain Definitions are determinant Some prevention measures are not Evidence based The role of antibiotics ( SDD, with or without systemic AB) is important, as well as the risk of resistance