Council of Europe: 1974 recomendación de realizar estudios sobre la situación de la IN en Europa

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2 Council of Europe: 1974 recomendación de realizar estudios sobre la situación de la IN en Europa Estudios sobre la situación de la IN en Europa: - DANOP - WHO.CARE - ESICM encuestas - EURO.NIS - EPIC Mostraron la necesidad de armonizar las políticas de control de la infección en Europa

3 Council of Europe The main objectives of the European HAI surveillance are: -to analyse inter-country differences, -to work towards comparable surveillance methods, -to draw up European reference tables for inter-hospital comparisons of risk-adjusted HAI rates, -to contribute to the extension of HAI surveillance in the European Union (EU) -to follow up and report on long-term trends in HAI rates in the EU and within Member States, as well as trends in the occurrence of different healthcare-associated pathogens, including trends of antimicrobial resistance markers.

4 The Hospitals in Europe Link for Infection Control through Surveillance (HELICS) network was created in 2000 in the context of Decision 2119/98/EC, as a network for the surveillance of Health Care Associated Infections (HAIs) and funded by the European Commission s Directorate- General for Health and Consumers (DG SANCO)

5 Country Belgium France (SE) Netherlands Spain Germany US Network NSIH-ICU REA-SE PREZIES-ICU ENVIN-UCI KISS-ICU NNIS (CDC) Type of surveillance Patient, date of admission Patient, date of discharge Patient, date of admission Patient, date of admission Unit based, 5 ICU types Unit based, 11 ICU types Incl. patients >48h ICU (>24) >48h ICU >48h ICU >24h ICU All All Period incl data n patients patient-days mean LOS (days) P50 SAPS II P50 APACHE II Definition of device-day <24 h use <24 h use >=24h <24 h use <24 h use <24 h use Central line days 3 cath=1 day 3 cath=1 day 3 cath=3 days 3 cath=3 days 3 cath=1 day 3 cath=1 day ventilation-days/1000 pd central line days/1000 pd urinary cath. days/1000 pd Definition of "icu-acquired" infection infection date > 2 days (48h) after admission infection date > 2 days (48h) after admission not present at admission not in incubation at admission not in incubation at admission not in incubation at admission Definition of "deviceassociated" infection >=1 day device before infection >=1 day device before infection clinician decides >=24h device in 48h bef. inf. >=24h device in 48h bef. inf. >=24h device in 48h bef. inf. Infection episodes in indicator first infection only first infection only all episodes all episodes all episodes all episodes Definition of Pneumonia large, clinical + bacteriological bacteriological BAL/PB CDC + definite BAL/PB CDC CDC CDC # VAP/100 admissions 5.1% 9.1% 14.0% 6.5% 1.6% # VAP/1000 ventilation days # C-BSI/100 admissions 1.3% 0.8% 2.2% 1.1% 0.5% # C-BSI/1000 central line d # UTI/100 admissions 8.6% 6.7% 3.1% 1.1% UTI rate/1000 ur. catheter d

6 History of HAI surveillance in the EU HELICS (Hospitals in Europe Link for infection control through surveillance) = collaboration of national/regional surveillance networks (PH institutes, Univ...) First collaboration in , funding discontinued : Helics IP I (EC DG- Sanco funded project): standardization of surveillance methods for SSI and ICU-acquired infections (protocols), retrospective data analysis : Helics IP II: prospective surveillance /2008: Continued Helics surveillance support as one of workpackages of IPSE (Improving Patient Safety in Europe) From 1/7/2008: transition HCAI surveillance coordination to ECDC Stockholm IPSE

7 Elaboración de un nuevo protocolo estandarizado para toda Europa

8 History of HAI surveillance in the EU HELICS (Hospitals in Europe Link for infection control through surveillance) = collaboration of national/regional surveillance networks (PH institutes, Univ...) First collaboration in , funding discontinued : Helics IP I (EC DG- Sanco funded project): standardization of surveillance methods for SSI and ICU-acquired infections (protocols), retrospective data analysis : Helics IP II: prospective surveillance /2008: Continued Helics surveillance support as one of workpackages of IPSE (Improving Patient Safety in Europe) From 1/7/2008: transition HCAI surveillance coordination to ECDC Stockholm IPSE

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10 History of HAI surveillance in the EU

11 Surveillance methodology Standard and light protocol The ECDC HAI-Net ICU protocol is based on - and very similar to - the HELICS-ICU protocol from which it adopted HAI case definitions, data collection and reporting procedures for ICUs participating in the national/regional surveillance of infections acquired in ICUs across Europe. As for other surveillance modules of HAI-Net, there are two versions of the protocol for surveillance of HAI in intensive care units as part of HAI-Net ICU: -a patient-based ( standard ) protocol -a unit-based ( light ) protocol. In patient-based surveillance, denominator data include risk factors for risk adjusted inter-hospital comparisons and are collected for each patient, infected or not. In unit-based surveillance, aggregated denominator data are collected for the entire ICU.

12 Indicators generated by the different levels of the protocol for the surveillance of NI infections in the ICU Level 1 Unit-based component (patient-days + ICU characteristics) Continuous surveillance Level 2 Patient-based component (NI Risk score, device-days) Min 3 months #NI/1000 pt-days Site specific incidence rates Pathogen-specific incidence rates Stratification by ICU type Deviceadjusted infection rates Standarized infection ratio Stratification by patient type

13 Inclusion criteria Patients staying less than 3 days in the ICU are excluded in both protocol versions. One record per infection is collected together with antimicrobial resistance markers for isolated microorganisms. Infections occurring after 48 hours in the ICU are considered as ICU-acquired. The minimal requirement for HAI-Net surveillance of ICU-acquired infections is to include bloodstream infection or pneumonia. Urinary tract infections (UTI) and catheter-related infections (CRI) may be added optionally

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18 2004: 544 ICUs (8 countries) 2008: 896 ICUs (13 countries) 2012: 1249 ICUs (15 countries)

19 Country / Data source Number of ICUs N of ICU years N of ICU patients N of ICU patient days Austria P Belgium P/U Croatia U Czech Republic U Estonia P/U France P Germany , U Italy P IT-SPIN-UTI P IT-GiViTI P Lithuania P Luxembourg P Malta U Portugal P Romania U Slovakia P/U Spain P Sweden U United Kingdom P UK-Scotland P UK-Wales P Total , P/U Total w/o DE , P/U Protocol

20 Evolution of selected case-mix indicators in ICUs participating at least 3 years from 2008 to 2012 (n=528 ICUs).

21 Characteristics of ICU patients in countries providing patient-based data, : invasive device use Country - data source % Intubation Device days/100 patient days Central vascular catheter % Device days/100 patient days Urinary catheter % Device days/100 patient days Parenteral nutrition % Device days/100 patient days Austria Belgium Estonia France IT-GiViTI IT-SPIN-UTI Lithuania Luxembourg Portugal Slovakia Spain UK-Scotland UK-Wales EU (a) (a) EU database mean (patient-based data only); - no data (not included in surveillance protocol)

22 Characteristics of ICU patients in countries providing patient-based data, : invasive device use INTUB CVC UC TPN Aust Belg Eston France IT-Gi IT-Spin Lith Luxem Port Slov Spain UK-Scot UK-Wales EU (a) EU database mean (patient-based data only); - no data (not included in surveillance protocol)

23 Cumulative incidence, incidence density and device-associated BSI rate by country, patient-based and unit-based surveillance combined,

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26 Time from ICU admission to onset of bloodstream infection by country/network, (n= BSI episodes)

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29 BSI

30 ICU-acquired pneumonia

31 Diagnostic category of ICU-acquired pneumonia by country-network, (n= pneumonia episodes) France Croatia Spain IT-GiViTI IT-SPIN-UTI Romania UK-Scotland Austria Portugal Lithuania Slovakia Belgium Luxembourg Estonia Percentage of pneumonia PN1 PN2 PN3 PN4 PN5

32 Time from ICU admission to onset of pneumonia by country/network, (n= pneumonia episodes)

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34 Relative frequency (%) of the ten most frequently isolated microorganisms in ICU-acquired Pn by country-network, (n= isolates) Country - Data source N of isolates Pseudomonas aeruginos S aureus E coli Austria Belgium Croatia Estonia France Germany IT-GiViTI* IT-SPIN-UTI Lithuania Luxembourg Portugal Romania Slovakia Spain Sweden UK-Scotland Klebsiella spp. Candida spp. Enterobacter spp. Acinetobacter spp. S maltophilia Enterococcus spp. Serratia spp.

35 Trends of microorganism groups isolated in ICU-acquired pneumonia in a cohort of 913 ICUs with at least 3 participations from

36 ICU-acquired pneumonia

37 Cumulative incidence, incidence density and device-associated urinary tract infection rate, Country Data source N of patients with UTI (a) Cumulati ve incidence (UTI %) N of UTI episodes N of UTI episodes per 1000 patient days N of CAUTI episodes (b) N CAUTIs/1000 UC days (c) Mean (d) Median (IQR) (e) Austria ( ) Belgium ( ) Croatia Estonia ( ) France ( ) IT-GiViTI IT-SPIN-UTI ( ) Lithuania ( ) Luxembourg ( ) Portugal ( ) Romania Slovakia ( ) Spain ( ) Total ( )

38 Relative frequency (%) of the ten most frequently isolated microorganisms in ICU-acquired UTI, (n= isolates) Country - Data source Number of isolates Escherichia coli Candida spp. Enterococcus spp. Pseudomonas aeruginosa Klebsiella spp. Enterobacter spp. Proteus spp. Coagulasenegative staphylococci Citrobacter spp. Acinetobacter spp. Austria Belgium Estonia France Germany IT-SPIN-UTI Lithuania Luxembourg Portugal Romania Slovakia Spain EU

39 Trends of microorganism groups isolated in ICU-acquired UTI in a cohort of 756 ICUs with at least 3 participations from

40 Antimicrobial resistance in ICU-acquired infections Methicillin-R S. aureus Vancomycin-NS Enterococci 3GC-NS Enterobacteriaceae Carbapenem-NS Pseudomonas spp. Carbapenem-NS Acinetobacter spp. Country/ data source N tested % R N tested % NS N tested % NS N tested % NS N tested Austria Belgium Estonia France IT-GiViTI IT-SPIN-UTI Lithuania Luxembourg Malta Portugal Romania Slovakia Spain Sweden UK-Scotland EU Infection type Bloodstream % NS

41 Antimicrobial resistance in ICU-acquired infections Methicillin-R S. aureus Vancomycin-NS Enterococci 3GC-NS Enterobacteriace ae Carbapenem-NS Pseudomonas spp. Carbapenem-NS Acinetobacter spp. N tested % R N tested % NS N test % NS N tested % NS N tested % NS EU Infection type Bloodstream Pneumonia Urinary tract p value <0.001 <0.001 < n.s. Year, cohort ICUs only p for trend <0.001 n.s. <0.001 n.s. n.s.

42 Antimicrobial resistance in ICU-acquired infections Methicillin-R S. aureus Vancomycin-NS Enterococci 3GC-NS Enterobacteriace ae Carbapenem-NS Pseudomonas spp. Carbapenem-NS Acinetobacter spp. N tested % R N tested % NS N test % NS N tested % NS N tested % NS EU Infection type Bloodstream Pneumonia Urinary tract p value <0.001 <0.001 < n.s. Year, cohort ICUs only p for trend <0.001 n.s. <0.001 n.s. n.s.

43 Antimicrobial resistance in ICU-acquired infections Methicillin-R S. aureus Vancomycin-NS Enterococci 3GC-NS Enterobacteriace ae Carbapenem-NS Pseudomonas spp. Carbapenem-NS Acinetobacter spp. N tested % R N tested % NS N test % NS N tested % NS N tested % NS EU Infection type Bloodstream Pneumonia Urinary tract p value <0.001 <0.001 < n.s. Year, cohort ICUs only p for trend <0.001 n.s. <0.001 n.s. n.s.

44 Antimicrobial resistance in ICU-acquired infections Methicillin-R S. aureus Vancomycin-NS Enterococci 3GC-NS Enterobacteriace ae Carbapenem-NS Pseudomonas spp. Carbapenem-NS Acinetobacter spp. N tested % R N tested % NS N test % NS N tested % NS N tested % NS EU Infection type Bloodstream Pneumonia Urinary tract p value <0.001 <0.001 < n.s. Year, cohort ICUs only p for trend <0.001 n.s. <0.001 n.s. n.s.

45 Antimicrobial resistance in ICU-acquired infections % % MRSA VRE TGCR-Ent CR-P aer CR-Acin 0 MRSA VRE TGCR-Ent CR-P aer CR-Acin BSI Pn UT Belgium, Estonia, Italy SPIN-UTI, Lithuania Malta, Portugal, Slovakia and Spain, more detailed resistance data: Klebsiella spp. isolates non-susceptible to CBP increased from 1.4% in 2008 to 10.0% in 2012 (p<0.001). Colistin-R was reported in 3.4 % of A. baumannii (n=39/1 135), 2.3 % of P. aeruginosa (n=43/1 864) and 38.9 % of S maltophilia isolates (n=65/167).

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47 Contribución española en el diseño del programa oficial de vigilancia europeo desde su inicio. Contribución con datos del nivel 2, (ENVIN completo), con el número de pacientes más elevado tras Francia. Se remiten los pacientes registrados durante todo el año. Para mejor comparabilidad de nuestros datos oficiales (informe anual ENVIN), seria necesario adaptar los indicadores españoles a los criterios europeos, que solo incluyen pacientes con estancia de superior a 48 horas

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