Infections following major heart surgery in European intensive care units: there is room for improvement (ESGNI 007 Study)

doi:10.1016/j.jhin.2006.03.007

Journal of Hospital Infection

Volume 63, Issue 4, August 2006, Pages 399-405

https://doi.org/10.1016/j.jhin.2006.03.007 Get rights and content

Summary

Patients undergoing major heart surgery (MHS) may be at increased risk for nosocomial infections. To assess the incidence and type of infections in MHS patients in European intensive care units (ICUs) and their quality of care, a questionnaire was sent to a selection of MHS ICUs in Europe. Seventeen hospitals from seven European countries participated. Overall, 53% of the ICUs received patients only for MHS and the other 47% were mixed. During the study period, 11 915 patients underwent MHS and 1181 (9.9%) developed one or more nosocomial infections. Ventilator-associated pneumonia (VAP) was the most common infection [median 3.8%; interquartile range (IQR) 1.8–4.9], followed by surgical wound infection (median 1.6%; IQR 0.8–2.3), catheter-related bloodstream infection (median 1.3%; IQR 0.8–2.1), mediastinitis (median 1.1%; IQR 0.4–1.6), urinary tract infection (median 0.6; IQR 0.4–1.4) and nosocomial endocarditis (median 0.2%; IQR 0.0–0.9). Median mortality was 4.7% (IQR 2.7–8.4) and median infection-related mortality was 1% (IQR 0.5–2.7). Regarding VAP, 18% of the ICUs did not routinely pursue a diagnosis. Microbiological information was quantitative in 35% of cases and exclusively qualitative in 65% of cases. An infectious disease specialist was regularly involved in VAP management in only 35% of the ICUs, and the therapeutic approach to VAP involved de-escalation in 59% of the ICUs. MHS ICUs in Europe still have a high rate of postoperative infections. Well-recognized routine practices for the diagnosis and treatment of VAP are not implemented regularly in many European institutions.

Introduction

Data regarding nosocomial infections in European intensive care units (ICUs) have been reported previously.1, 2 However, this information includes patients with different diseases and underlying conditions.

Patients undergoing major heart surgery (MHS) may be at increased risk for nosocomial infections because they are usually older than other ICU patients, need long surgical procedures, and suffer frequent invasive manoeuvres during the postoperative period.3, 4, 5

However, few studies have addressed the incidence of postoperative infections specifically in patients undergoing MHS. In addition, information from the USA may not be extrapolated to Europe, where the proportion of coronary artery bypass grafts (CABG) is much lower.

The aim of this study was to determine the incidence of nosocomial infections in patients undergoing MHS in Europe during 2001. Particular attention was given to ventilator-associated pneumonia (VAP) and the most common practices related to its diagnosis and treatment.

Section snippets

Materials and methods

This study was a joint venture between the European Study Group of Nosocomial Infections (ESGNI) of the European Society of Clinical Microbiology and Infection Diseases and the European Working Party of Cardiothoracic Intensivists (EWCI). Informed consent was not required from an ethics committee as confidentiality was guaranteed and no interventions were performed.

ESGNI 007 was a voluntary, observational study that was carried out by a standard questionnaire sent to European hospitals

Characteristics of participating institutions

Overall, 17 hospitals in seven different European countries participated in the study. The total number of patients undergoing MHS during 2001 in the participating centres was 11 915 (median 501; IQR 294–1000). The distribution by hospitals and countries is shown in Table I.

The 17 participating institutions were either teaching (77%) or non-teaching hospitals (23%), and the majority were public centres (82%). The distribution of hospitals according to the number of beds was as follows: ≤500

Discussion

This study found a high incidence of nosocomial infections after MHS in European institutions, and a significant lack of compliance with some well-established guidelines. Infection occurred in 9.9% of all patients and was attributed to 22% of all postoperative deaths in ICUs. The most common infectious complication was VAP, and this study found that there is room for improvement in the diagnostic and therapeutic approach to VAP.

A high proportion of patients receive postoperative care in ICUs

Acknowledgements

The authors thank Lawrence J.C. Baron for reviewing the English version of the manuscript and Cristina Fernández for her contribution to the statistical analysis. The authors also thank Dr. M. Desco and Dr. J. Pascau of the Medical Image Laboratory of Experimental Medicine for their help with electronic retrieval of the data. This study was presented, in part, as an abstract (Abstract K-1297) at the 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy, September 2003, Chicago,

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The risk and outcome of bloodstream infections (BSIs) were evaluated following surgery. BSIs were identified in Helsinki University Hospital during 2009–2014 as part of the national surveillance. Of 711 BSIs identified, 51% were secondary and 49% primary. The rate was highest after cardiovascular surgery (8.7 per 1000 procedures) and lowest after gynaecologic (1.0 per 1000). Surgical site infection was the most frequent source of secondary BSIs (34%) and 45% of primary BSIs were central-line-associated. The 28-day case fatality ranged from zero in gynaecology/obstetrics to 21% in cardiovascular surgery. Besides BSIs related to surgical site infections, half of BSIs were primary, providing additional foci for prevention.
Med-Score 24: A multivariable prediction model for poststernotomy mediastinitis 24 hours after admission to the intensive care unit
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Mediastinitis is a serious complication of heart surgery. In this study, we developed a bedside risk score for poststernotomy mediastinitis.
Data were prospectively collected from 4625 patients admitted to our intensive care unit after heart surgery (January 2005-June 2011). Mediastinitis was defined according to Centers for Disease Control and Prevention criteria. A logistic model was constructed in a randomly selected subgroup of 2618 patients and validated in a second cohort of 1352, as well as in a prospective cohort of 2615 (June 2011-December 2015). Model discriminatory power was assessed according to the area under the receiver operating characteristic curve (AUROC). The β coefficients of the model were used to define 3 levels of mediastinitis risk as a score designated Med-Score 24. Its performance to predict mediastinitis was compared with that of the logistic EuroSCORE and Society of Thoracic Surgeons score.
Ninety-four (2.36%) patients developed mediastinitis. The risk factors identified as predictive of mediastinitis (AUROC 0.80) were 4 preoperative variables (age >70 years, chronic obstructive lung disease, obesity, and antiplatelet therapy) and 3 perioperative variables (prolonged ischemia, emergency reoperation, and prolonged intubation). AUROCs for the Society of Thoracic Surgeons score and logistic EuroSCORE were 0.63 and 0.55, respectively, both differing significantly from the area calculated for Med-Score 24 (P < .001).
The score developed showed excellent predictive power 24 hours after admission to the intensive care unit for mediastinitis risk. This simple tool helps stratify patients according to this risk, thus identifying high-risk patients for preventive measures. In our patient cohort, Med-Score 24 performed better than other scores used for this purpose.
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Analizar las infecciones en Pacientes críticos postOperados de Cirugía Cardiaca (POCC).
Unidades de cuidados intensivos (UCI).
Estudio observacional, prospectivo y multicéntrico.
Se incluyeron los pacientes POCC incluidos en el registro ENVIN-HELICS entre los años 2005-2011.
Neumonías relacionadas con ventilación mecánica (N-VM), infecciones urinarias relacionadas con sonda uretral (IU-SU), bacteriemias primarias y/o relacionadas con catéteres vasculares (BP-BCV) y bacteriemias secundarias (BS).
De los 97.692 pacientes registrados 9.089 (9,3%) fueron POCC. En 440 (4,8%) POCC se identificaron una o más de las infecciones controladas. La densidad de infección fue de 9,94 episodios de N-VM por 1.000 días de VM; 3,4 episodios de IU-SU por 1.000 días de SU, 3,10 episodios de BP-BCV por 1.000 días de CVC; y 1,84 episodios de BS por 1.000 días de estancia en UCI. Los factores de riesgo estadísticamente significativos fueron estancia en UCI (OR 1,18; IC95% 1,16-1,20), APACHE II al ingreso en UCI (OR 1,05; IC95% 1,03-1,07), cirugía urgente (OR 1,67; IC95% 1,13-2,47), tratamiento antibiótico previo (OR 1,38; IC95% 1,04- 1,83), colonización previa de Pseudomonas aeruginosa (OR 18,25; IC95% 3,74-89,06) o enterobacterias productoras de betalactamasas de espectro extendido (OR 16,97; IC95% 5,4-53,2). La mortalidad intra-UCI fue del 4,1%; del 32,2% en aquellos que desarrollaron una o más infecciones y del 2,9% en los pacientes sin infección (p < 0,001).
El 9,3% de los pacientes incluidos en el registro fueron POCC. La mortalidad global de los POCC es baja pero aumenta significativamente en aquellos que desarrollaron una o más infecciones.
To analyze postoperative infections in critically ill patients undergoing heart surgery.
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An observational, prospective, multicenter study was carried out.
Patients in the postoperative period of heart surgery admitted to the ICU and included in the ENVIN-HELICS registry between 2005 and 2011.
Mechanical ventilation associated pneumonia (MVP), urinary catheter-related infection (UCI), primary bacteremia (PB), PB related to vascular catheters (PB-VC) and secondary bacteremia.
Of a total of 97,692 patients included in the study, 9089 (9.3%) had undergone heart surgery. In 440 patients (4.8%), one or more infections were recorded. Infection rates were 9.94 episodes of MVP per 1000 days of mechanical ventilation, 3.4 episodes of UCI per 1000 days of urinary catheterization, 3.10 episodes of BP-VC per 1000 days of central venous catheter, and 1.84 episodes of secondary bacteremia per 1000 days of ICU stay. Statistically significant risk factors for infection were ICU stay (odds ratio [OR] 1.18, 95%CI 1.16-1.20), APACHE II upon admission to the ICU (OR 1.05, 95%CI 1.03-1.07), emergency surgery (OR 1.67, 95%CI 1.13-2.47), previous antibiotic treatment (OR 1.38, 95%CI 1.04-1.83), and previous colonization by Pseudomonas aeruginosa (OR 18.25, 95%CI 3.74-89.06) or extended spectrum beta-lactamase producing enterobacteria (OR 16.97, 95%CI 5.4-53.2). The overall ICU mortality rate was 4.1% (32.2% in patients who developed one or more infections and 2.9% in uninfected patients) (P < .001).
Of the patients included in the ENVIN-HELICS registry, 9.3% were postoperative heart surgery patients. The overall mortality was low but increased significantly in patients who developed one or more infection episodes.
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Las infecciones del sitio quirúrgico (ISQ) en pacientes sometidos a cirugía cardiaca constituyen una complicación relevante que puede incrementar la estancia hospitalaria y la morbimortalidad.
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During the considered period it was detected 189 cases of SSIs in patients undergoing cardiac surgery. Ninety-five patients (50.3%) had undergone heart valve surgery and 94 patients (49.7%) had undergone coronary bypass. The mean age was 62.8 years (median 69). SSIs that were observed consisted in superficial incisional infection (69 patients, 37%), deep incisional (68 patients, 36%) and organ or space (52 patients, 27%). One hundred eighty bacterial species were isolated in these patients. The most frequently isolated microorganisms were coagulase-negative staphylococci (37%), methicillin sensitive Staphylococcus aureus (15.5%), methicillin resistant S. aureus (6.6%), Enterococcus spp (6.1%), Escherichia coli (5%), Enterobacter cloacae (5%) and Serratia marcescens (4.4%). There were no significant differences in etiology when comparing cases of SSI after valve surgery and coronary bypass surgery or did between incisional infections and organ or space infections.
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Citation Excerpt :
There is a clear need to have robust ICU protocols to prevent infections such as IE occurring as a result of invasive devices.42 Central venous catheter associated blood stream infections are common in the ICU setting and are known to cause IE in susceptible patients such as those with prosthetic valves, known valve disease or patients post-cardiac surgery.6,20,43–45 Adequate precautions and care should be taken in these patients to prevent nosocomial IE as a result of their ICU stay.
Infective endocarditis is a rising problem in the intensive care setting. Patients admitted to the intensive care unit (ICU) are at a high risk of developing infective endocarditis because of the frequent use of invasive monitoring and therapeutic devices in the intensive care environment. In particular, cardiac surgery patients are at a high risk of developing nosocomial infective endocarditis in the ICU. Staphylococci and Streptococci are the predominant organisms causing infective endocarditis in this setting, while fungal endocarditis remains a less frequent condition that may be on the rise. Infective endocarditis in the intensive care can be challenging to diagnose and manage. Morbidity and mortality from infective endocarditis can be high in the intensive care setting because of pre-existing pathologies in patients as well as the more complex nature of the disease in patients who need admission to the ICU. A multidisciplinary team approach is essential to improve clinical outcomes of patients with this condition. Particular emphasis has to be placed on the prevention of nosocomial endocarditis in the ICU through the use of strict aseptic conditions during placement and manipulation of invasive devices as well as appropriate endocarditis prophylaxis in selected patients.

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Infections following major heart surgery in European intensive care units: there is room for improvement (ESGNI 007 Study)

Summary

Introduction

Section snippets

Materials and methods

Characteristics of participating institutions

Discussion

Acknowledgements

Am J Infect Control

J Thorac Cardiovasc Surg

Chest

Chest

Chest

Chest

Chest

The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) study. EPIC International Advisory Committee

JAMA

Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study

Intensive Care Med

Ventilator-associated pneumonia after heart surgery: a prospective analysis and the value of surveillance

Crit Care Med

Severe sepsis in cardiac surgical patients

Eur J Surg

Ventilator-associated pneumonia. A multivariate analysis

JAMA