Novas tecnologias para oNovas tecnologias para o
diagnóstico e prevenção das diagnóstico e prevenção das
infecções em terapia intensivainfecções em terapia intensiva
Novas tecnologias para oNovas tecnologias para o
diagnóstico e prevenção das diagnóstico e prevenção das
infecções em terapia intensivainfecções em terapia intensivaAlexandre R. Marra
Hospital Israelita Albert Einstein, São PauloUniversidade Federal de São Paulo (UNIFESP)
www.webbertraining.com 29 Outubro, 2013
Patrocinadopor
www.gojo.com.br
Conflito de interesse
• Nada a declarar
Objetivos
• “Novas” e “velhas” tecnologias
• Prevenção – estratégias para redução de risco
• Diagnóstico – novos métodos para tomada de decisão (é ou não é infecção?)
• Medidas de desfechos clínicos
• Da bancada à beira leito
Densidade de Incidência das Infecções Nosocomiais – UTI HIAEDensidade de Incidência por 1000 pac-dia na UTI Adulto
18,7
24,122,3
23,722,1
27,2
20,6
10,9
0,0
10,0
20,0
30,0
2001 2002 2003 2004 2005 2006 2007 2008
Ano 2001 2002 2003 2004 2005 2006 2007 2008
Nº de IH 137 200 236 197 217 203 210 113Nº de Pac-dia 7338 8296 8685 8839 9146 9841 9520 10366TDI anual 1000 pac-dia 18,7 24,1 27,2 22,3 23,7 20,6 22,1 10,9
O CVC é o principal fator de risco para ICS
Como o hospedeiro não pode ser modificado, medidas preventivas são importantes para atuarem nos fatores de risco: uso do CVC, duração, permanência e manipulação
Fatores de risco: a dinâmica da
interação
UNITs2007 2008
Comparisionbetween 2 periods
CVC rate
2008
UTI Adulto
Semi Adulto
Coronariana
Oncologia
TMO
UTI Neonatal
CTI Pediátrico
CMC
HIAE
CVC-associated BSI(per 1000 CVC-days)
2007
5.7
1.6
5.1
3.6
9.6
13.3
2.0
5.3
4.7
3.0
1.6
2.5
2.0
5.3
5.9
3.7
1.0
2.2
47.4%
0
51.0%
44.4%
44.8%
55.6%
85%
81.1%
53.2 %
0.72
0.36
0.29
0.55
0.95
0.17
0.37
0.13
0.25
0.67
0.37
0.31
0.60
0.98
0.15
0.34
0.12
0.26
Infecção da corrente sanguínea associada ao cateter venoso central - HIAE
0
0
0
0
11.2
13.9
23.3
0
1.1
Dec2008
Redução de 61% - incidência ICS primária
(16,8 vs. 6,4/1.000 cateteres dia)
Crit Care Med 2009;37:1858-1865
Climo MW et al. N Engl J Med 2013;368:533-542
7 ICUs
CHGIS reduced risk of infection even when background infection rates were low (<2/1,000 catheter days)
VASCULAR ACCESS ULTRASOUND
VASCULAR ACCESS ULTRASOUND
Crit Care 2006; 10(6): R162
Nosocomial Bloodstream Infections
• 12-25% attributable mortality
• Risk for bloodstream infection:BSI per 1,000 catheter/days
Subclavian or internal jugular CVC 5-7
Hickman/Broviac (cuffed, tunneled) 1
PICC 0.2 - 2.2
Catheter type and expected duration of use should be taken into consideration
New choices for CVC – Financial implications
Variables Standard vs. CSS CVC
Standard vs. RM CVC
CSS vs. RM CVC
Primary BSI incidence
33.0 x 13.6 33.0 vs. 5.1 13.6 vs. 5.1
Saving primary BSI
$165.88 $200.48 $283.53
Shorr FAH et al. Chest 2003;124:275-84
Camargo LFA et al. J Hosp Infect 2009ICU - HIAE
Pneumonia associada à VM na UTI-A
Densidade de Incidência de Pneumonia associada a VM na UTI Adulto (por 1000 VM-dia)
18,8
15,0
10,6
14,1
3,4
0,0
5,0
10,0
15,0
20,0
2004 2005 2006 2007 2008
redução de 76%
Bundle compliance and ventilator associated pneumonia (VAP) rate per 1,000 ventilator days from April 2007 to September 2008
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
80,0
90,0
100,0
apr/2
007
may
/2007
jun/0
7jul
/07
aug/2
007
sep/
2007
oct/2
007
nov/0
7
dec/2
007
jan/0
8
feb/
2008
mar
/08
apr/2
008
may
/2008
jun/0
8jul
/08
aug/2
008
sep/
2008
0,0
5,0
10,0
15,0
20,0
25,0
30,0
Bundle compliance (%)VAP/1,000 ventilator-days
*oral decontamination with chlorhexidine 0.12% (since October/2007)**continuous aspiration of subglottic secretions (CASS) endotracheal tube (since February/2008)
Am J Infect Control 2009; 37:619-25
ICU - HIAE
54 hospitais americanos
Infecção do trato urinario associada à SV – UTI - HIAEDensidade de Incidência de ITU associada a cateter
vesical na UTI Adulto (por 1000 cat vesc-dia)
5,0
11,8
5,36,8 6,1
0,0
2,0
4,0
6,0
8,0
10,0
12,0
14,0
2004 2005 2006 2007 2008
Densidade de Incidência de ITU associada a cateter vesical na UTI Adulto (por 1000 cat vesc-dia)
7,5 7,4 7,6
2,03,7
11,3
4,2
13,3
5,4 4,7
13,7
5,44,2 4,9
8,4 8,1
4,2 3,4 4,36,5
7,8 8,77,2
3,3
0,0
4,0
8,0
12,0
16,0
j2007
m m j s n j2008
m m j s n
Portable bladder scanners
Avoid unnecessary catheterization!
Clin Infect Dis 2008;46:243-50
40%
Silicone-based, silver-impregnated Foley catheters were not effective in preventing NUTIs!
New antibacterial agents approved in the United States, 1983–2007, per 5-year period
BAD BUGS NO DRUGS NO ESKAPE!
Clin Infect Dis 2009;48:1-12
Procalcitonin• Very useful for endocarditis diagnosis (21 EB vs. 46
NEB**control??)
• Limiting antimicrobial therapy – CAP– Median 5 vs. 12 days, p<0.001
• Prognosis – Decreasing PCT levels in <24 hours - (thanks
god!)
Circulation 2004;109:1707-1710
Am J Resp Crit Care Med 2006;174:84-93
J Clin Endocrinol Metab 2004;89:1512-1525
Empiric contact precautions - 2007,2008 e 20092007 MDR Rate (%) 2008 MDR Rate (%) 2009 Rate Taxa (%)
Jan
3 0 0 5 4 80 5 3 60
Feb
1 0 0 1 1 100 3 3 100
March
1 0 0 7 2 28 8 6 75
April
2 0 0 0 0 0 2 1 500
May
2 0 0 1 1 100
June
6 2 33 4 4 100
July
1 1 100 3 3 100
Ago
4 3 75 3 2 66
Sept
4 2 50 4 3 75
Oct
2 2 100 2 1 50
Nov
1 0 0 4 3 75
Dec
0 0 0 2 1 50
Total
27 10 37 36 25 70 18 13 72
MRSA - PCR • PCR for readmission screening reduces:
– the number of unnecessary preemptive isolation-days by 54% (from 6.88 to 3.14 isolation-days)
– related costs by 45% (from US dollars 113.2 to US dollars 62.1) for patients who test negative for MRSA
– median time to notification from four days to one day
Uçkay I et al. Infect Control Hosp Epidemiol 2008;29:1077-9
Harbarth S et al. Crit Care 2006;10:R25
• It reduces MRSA cross-infections in the medical but not in the surgical ICU
PROS
CONS
Harbarth S et al. Crit Care 2006;10:R25
A universal, rapid MRSA admission screening
strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence
Rapid Screening for Carriage of Methicillin-Resistant Staphylococcus
aureus by PCR
• PCR tests are valuable for the rapid detection of MRSA carriers
• In patient populations with low MRSA endemicity, the broad use of PCR probably is not cost-effective
Bühlmann M. J Clin Microbiol 2008;46:2151-56
MRSA screening – HIAE experience
From Oct 2008-Mar 2009 (ICU/HIAE)
5,576 patient days
977 screened patients for MRSA (>85%)
20 MRSA+ patients (11 MRSA converted)
MRSA incidence=1% or 1.9 MRSA+ per 1,000 patient days
• Real time PCR in blood samples
• Deliver the answers in under 6-hours (without the need for prior incubation or culture steps)
• Identify the 25 most important bacterial and fungal species causing bloodstream infections
• 2,5 mL blood sample EDTA tube - PCR
SeptiFast Project - HIAE
Louie RF et al. Crit Care Med 2008;36:1487-92
Early detection of microorganisms has the potential to facilitate evidence-based treatment decisions, antimicrobial selection, and adequacy of antimicrobial therapy
Devemos estar abertos às novasDevemos estar abertos às novas
tecnologiastecnologias
Observem os seus desfechos clínicosObservem os seus desfechos clínicos
Observem o mundo real da sua UTIObservem o mundo real da sua UTI
Analisem o custo-efetividade de Analisem o custo-efetividade de
determinados processosdeterminados processos
CONCLUSCONCLUSÕESÕES
The End