National Surveillance of Infections acquired in Intensive Care Units

National Surveillance of Infections acquired in Intensive Care Units Annual Report 2015 Public Health & Surveillance Healthcare-associated infections and Antimicrobial resistance Juliette Wytsmanstraat 14 1050 Brussel België http://www.wiv-isp.be http://www.wiv-isp.be/nsih

Author: Karl Mertens Unit Healthcare-associated infections and Antimicrobial resistance September 2017 Brussels, Belgium T 02 642 57 95 E-mail: karl.mertens@wiv-isp.be This project was financed by Acknowledgements: The author wishes to thank all participating hospitals for their efforts to provide data 2

Introduction This report summarizes the results of the National Surveillance of ICU-acquired Infections for the year 2015. This surveillance is established in 1997 and since then organized by the Scientific Institute for Public Health to monitor incidence of ICUacquired infections in Belgium. The current surveillance protocol (ref 1) relies on inclusion criteria and case definitions laid out by the European Centre for Disease Prevention and Control. Annual reference data for the year 2015 are available in separately published statistical reports infection indicators and risk factor indicators 2015 (Refs 2-3). This report presents and discusses main indicators for incidence and intrinsic risk factors of ICU-acquired infection for 2015 as well as trends for the last four years. Both aggregated means (obtained from multi-centric hospital data) are presented, as well as the relevant percentiles of the distribution of means of individual hospitals or units. Participation In 2015, 11 hospitals collected and submitted surveillance data (Table 1). This concerned 13 units, which participated for 30 three-month periods. This surveillance includes patients with ICU-admission during surveillance periods of three consecutive months and ICU stay of at least three days. For 2015, this totaled 2 968 patients and corresponding 23 940 patient days [2 (Table 1)]. The participation to this surveillance seems stable in comparison with recent years, with 12 hospitals that submitted data in 2013 and 2014. In 2015, a majority of surveillance data was collected through the so-called patientbased registration option (67% of all three-month periods), with data on all followed patients irrespective of acquiring an infection being encoded. Hospitals opting for unit-based registration, in which only data is encoded of patients who acquired infection, remain a minority. Optional data on catheter follow-up and on antimicrobial use was encoded in 40% and 56% of trimesters respectively. In 2015, all hospitals included pneumonia and bloodstream infections in the infection types followed for this surveillance, while half of hospitals included urinary tract infections and catheterrelated infections. 3

Table 1: National surveillance of ICU*-acquired infections: participation indicators 2012-2015 Indicator Year 2012 2013 2014 2015 # %* # % # % # % Hospital years* 14 12 12 11 hospitals Unit quarters 38 31 37 30 ICUs Unit-based registration (level 1) 10 26 11 35 10 27 10 33 ICUs Patient-based registration (level 2) 28 74 20 65 27 73 20 67 ICUs CVC* utilization (level 2b) 5 13 5 16 14 38 12 40 ICUs Antibiotic utilization (level 2c) 16 42 10 32 20 54 14 47 ICUs Follow-up of pneumonia 38 100 31 100 37 100 30 100 ICUs Follow-up of bloodstream infection 37 97 31 100 37 100 30 100 ICUs Follow-up of urinary tract infection 20 53 12 39 22 59 15 50 ICUs Follow-up of catheter-related infection 12 32 8 26 19 51 15 50 ICUs ICU=Intensive Care Units; Hospital years=number of hospitals with at least one tree-month participation period; CVC=Central Vascular Catheter; %=proportion of Unit quarters Main indicators on infection incidence and risk factors The average length of stay in ICU of followed patients in 2015 was 7.9 ICU days (Table 2a). Use of invasive intubation and of central vascular catheter in ICU was 443 intubation days and 738 catheter days per 1000 patient days, respectively. Intubation use was the highest in the last four years, while CVC use was the lowest in the last four years. On average, 4.2% of followed patients acquired Pneumonia in 2015 (Table 2). This marks almost a 50% decrease of this indicator over the last 4 years. The incidence density of ICU acquired pneumonia was 6.7 episodes per 1000 patient days, a similar result as 2014 but still the lowest of the last 4 years. The incidence density of Intubation-associated Pneumonia (IAP) with presence of invasive intubation in the 2 days preceding infection - was 8.5 IAPS per 1000 intubation days, marking a substantial 60% decrease as compared to the result of 2012. Looking at the median of hospital incidences, the incidences for Pneumonia and IAPs still remain the lowest of the last 4 years (Ref 2, Table 3), confirming the earlier observed decrease in annual incidences. Note that the difference between the database mean and the median of a particular indicator might be due to a single hospital contributing an extreme outlying result. Figure 1 (left panel) shows long term trends of ICU-acquired and Intubationassociated Pneumonia (IAP). Particularly the incidence of IAP follows a historical decreasing trend since the start of the surveillance in 1997, with the 2015 IAP rate of 8.5 being only 30% of the 1997 IAP rate of 27. It should be noted that this decrease occurs in the presence of an increasing trend of intubation use (Fig 1 right panel) On average, 1.6% of followed patients acquired a Bloodstream infection (BSI) in ICU in 2015 (Table 2). The incidence density of BSI in 2015 was 2.2 episodes per 4

1000 patient days, and the incidence density of CVC-associated Bloodstream infection (CAB) with presence of a CVC in the 2 days preceding the infection was 2.1 episodes per 1000 CVC days. For all three indicators, these results marked very slight increases compared to 2014. The incidence of primary BSI having declared origin catheter or unknown - was 1.3 episodes per 1000 patient days, while the incidence of CVC-associated primary bloodstream infections was 1.4 episodes per 1000 CVC days. While this was the lowest four-year result for these two indicators when looking at database means, this was not the case when relying on the median of hospital incidences (Ref 3, Table 4), making a clear trend of annual incidence inconclusive. Table 5 shows results on selected risk factors for infection as collected through registration option 2 patient-based registration. In 2015, the average Simplified acute physiology score II score was 40.4. The average age was 67.1 years. About 62% of ICU admissions of followed patients were due to medical reasons. Forty percent of followed patients were female. Table 2: National surveillance of ICU-acquired infections: Infection indicators 2012-2015 (database means) Indicator Year 2012 2013 2014 2015 Patient days (mean) 7,5 7,3 7,6 7,9 days in ICU Intubation days 309 439 427 443 /1000 patient days CVC days 793 782 794 738 /1000 patient days Patients with ICU-acquired pneumonia 8,1 6,0 4,5 4,2 /100 admissions ICU-acquired pneumonia 13,4 9,9 6,7 6,7 /1000 patient days Intubation-associated pneumonia 20,7 15,2 12,0 8,5 /1000 intubation days Patients with ICU-acquired bloodstream infection Unit 2,0 1,9 1,3 1,6 /100 admissions ICU-acquired bloodstream infection 3,2 3,4 1,9 2,2 /1000 patient days CVC-associated bloodstream infection 2,9 3,9 2,0 2,1 /1000 CVC days Primary bloodstream infection 1,9 2,5 1,4 1,3 /1000 patient days Catheter-associated primary bloodstream infection ICU=Intensive Care Units; CVC=Central vascular catheter 2,0 2,8 1,5 1,4 /1000 CVC days 5

Figure 1: Long-term evolution of ICU-acquired Pneumonia (Left) and Invasive device use in ICU (Right), as measured by the National surveillance of ICU-acquired infections (BE). ICU=Intensive Care Unit; PN=Pneumonia; CVC= Central vascular catheter Table 5: National surveillance of ICU-acquired infections 2012-2015: risk factor indicators indicator Year 2012 2013 2014 2015 SAPS* II score (mean) 34,3 35,0 35,3 40,4 Age (mean) 68,1 67,6 64,7 67,1 years medical admission 74,7 69,0 61,4 61,8 % patients Female 41,0 40,3 39,2 40,1 % patients ICU=Intensive care unit; SAPS=Simplified acute physiology score Declared microorganisms Table 4 shows the distribution of most frequent microorganisms in episodes of ICUacquired Pneumonia. Most frequent in 2015 were Pneumonia due to Escherichia coli (14.4%), Pseudomonas aeruginosa (13.9%) and Staphylococcus aureus (13.3%). The top three of frequent microorganisms is unchanged during the last four years. In 6

2015, the most frequently reported microorganisms in BSI episodes were Enterococcus faecium, Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa (all 11%, Table 5). Due to sparse data, results on antimicrobial resistance will not be discussed. Table 4: National surveillance of ICU-acquired infections: reported micro-organisms for Pneumonia episodes 2012-2015 (database mean/top 10) Rank Year 2012 2013 2014 2015 Code % Code % Code % Code % 1 PSEAER 12,6 ESCCOL 16,0 ESCCOL 16,5 ESCCOL 14,4 2 ESCCOL 10,2 PSEAER 12,1 PSEAER 12,9 PSEAER 13,9 3 STAAUR 7,8 STAAUR 10,1 STAAUR 9,8 STAAUR 13,3 4 STANSP 7,5 KLEPNE 4,6 KLEPNE 8,0 ENBCLO 7,8 5 STEMAL 7,3 MOGSPP 3,9 ENBCLO 7,1 KLEPNE 7,2 6 ENBCLO 5,8 ENBCLO 3,9 HAEINF 5,8 HAEINF 4,4 7 KLEPNE 4,0 CANALB 3,6 KLEOXY 4,5 SERMAR 3,9 8 ENBAER 3,8 STEMAL 3,3 ENBAER 4,0 KLEOXY 3,3 9 SERMAR 3,5 ASPFUM 3,3 PRTMIR 4,0 STEMAL 2,8 10 PSEOTH 3,3 HAEINF 2,9 STRPNE 3,6 STERI 2,8 STERI=Sterile examination; ASPFUM=Aspergillus fumigatus; CANALB=Candida albicans; ENBAER=Enterobacter aerogenes; ENBCLO=Enterobacter cloacae; ESCCOL=Escherichia coli; HAEINF=Haemophilus influenzae; KLEOXY=Klebsiella oxytoca; KLEPNE=Klebsiella pneumoniae; MOGSPP=Morganella species; PRTMIR=Proteus mirabilis; PSEAER=Pseudomonas aeruginosa; PSEOTH=Pseudomonadaceae family, other; SERMAR=Serratia marcescens; STAAUR=Staphylococcus aureus; STANSP=Staphylococcus sp., not specified; STEMAL=Stenotrophomonas maltophilia; STRPNE=Streptococcus pneumoniae 7

Table 5: National surveillance of ICU-acquired infections: reported micro-organisms for Bloodstream infection episodes 2012-2015 (database mean/top 10) Rank Year 2012 2013 2014 2015 Code % Code % Code % Code % 1 STAOTH 18,9 STAOTH 27,7 ESCCOL 14,3 ESCCOL 11,1 2 PSEAER 14,7 ENCFAE 14,9 STAAUR 12,2 PSEAER 11,1 3 ENCFAE 9,5 ENBCLO 6,4 CANALB 8,2 ENCFAI 11,1 4 CANALB 7,4 ESCCOL 6,4 STANSP 8,2 STAAUR 11,1 5 ENBCLO 6,3 STANSP 5,3 STAHAE 6,1 KLEPNE 9,3 6 KLEPNE 5,3 PSEAER 4,3 ENCFAE 6,1 ENCFAE 9,3 7 CANGLA 5,3 CANGLA 3,2 STAOTH 6,1 CANALB 5,6 8 STAAUR 4,2 CANALB 3,2 SERMAR 6,1 ENBCLO 5,6 9 STANSP 4,2 STAAUR 3,2 ENCFAI 6,1 KLEOXY 5,6 10 SERMAR 3,2 STAEPI 2,1 PSEAER 4,1 CANGLA 3,7 CANALB=Candida albicans; CANGLA=Candida glabrata; ENBCLO=Enterobacter cloacae; ENCFAE=Enterococcus faecalis; ENCFAI=Enterococcus faecium; ESCCOL=Escherichia coli; KLEOXY=Klebsiella oxytoca; KLEPNE=Klebsiella pneumoniae; PSEAER=Pseudomonas aeruginosa; SERMAR=Serratia marcescens; STAAUR= Staphylococcus aureus; STAEPI=Staphylococcus epidermidis; STAHAE=Staphylococcus haemolyticus; STANSP=Staphylococcus sp., not specified ; STAOTH=Other coagulase-negative Stafylococci (cns). 8

Conclusions The annual upload of the national surveillance database to the TESSy system of ECDC allows comparison of results with other EU networks following the ECDC study protocol and case definitions. Based on the latest available report on incidence of ICU-acquired Infections, BE results for 2015 rank lower than the EU mean of 7.7 ICU-acquired Pneumonia and 3.0 ICU-acquired Bloodstream infections per 1000 patient days (Ref 5). The low participation to the NSIH-ICU surveillance in the last couple of years needs extra attention. The reasons for this are multiple. First, collecting data for this surveillance is only optional under current Federal law (Ref 6), and will normally come second with respect to the mandatory participation of national NSIH-AMR and - SEP surveillances under this law. Second, as far as collecting data on ICU-acquired Bloodstream infection is concerned, double reporting exists with the national SEP surveillance on Bloodstream infections hospital-wide. The participation to this surveillance will normally be prioritized given its mandatory status. Furthermore, single reporting of Pneumonia will ask for more efforts as compared to reporting Bloodstream infection, given the case definition of the former being based on both clinical and laboratory criteria. Because the low number of participating ICUs makes extrapolation of results to a national context problematic, the following simplifications were already implemented in the last years: possibility to collect data using the unit-based registration option; the possibility to choose one infection type and one ICU for registration; the possibility to avoid re-registration by creating surveillance data directly from existing electronic sources within the hospital. The following additions to enhance participation are currently planned: migration to the new healthdata.be platform which should allow improved electronic registration forms and integrated electronic data upload; addition of a module on structure and process parameters for the prevention of infection. References 1 Study protocol: Surveillance of Infections acquired in Intensive Care Units; Protocol HELICS Belgium, Scientific Institute of Public Health, National Surveillance of Hospital Infections. Brussels, Belgium. April 2017 Addendum. Available on http://www.nsih.be 2 Surveillance of ICU-acquired Infections - National feedback reports on infection indicators - Years 2012-2015. Scientific Institute of Public Health, National Surveillance of Hospital Infections (NSIH program). Available on http://www.nsih.be 3 Surveillance of ICU-acquired Infections - National feedback reports on risk factor indicators - Years 2012-2015. Scientific Institute of Public Health, National Surveillance of Hospital Infections (NSIH program). Available on http://www.nsih.be 9

4 European surveillance of Healthcare-Associated Infections in Intensive Care Units HAI-ICU protocol v1.01 Standard and Light. European Centre for Disease Prevention and Control. Available on http://www.ecdc.europa.eu 5 European Centre for Disease Prevention and Control. The European Surveillance System Report Incidence Density of ICU-acquired Infections, in All Units, Reporting Year 2015. Stockholm: ECDC; 2017. 6 Belgisch staatsblad (2015). Royal decision of Januari 8 2015 modifying the royal decision of April 25th 2002 concerning the fixation and liquidation of the budget of financial means of hospitals. 10