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