Are most ICU infections really nosocomial? A prospective observational cohort study in mechanically ventilated patients

Silvestri, Luciano; Bragadin, Carlo Monti; Milanese, Marco; Gregori, Darío; Consales, Claudia; Gullo, Antonino; Saene, H. K. F. van

doi:10.1053/jhin.1998.0550

Cited by 74 publications

(42 citation statements)

References 34 publications

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“…The 48-h cut-offpoint was introduced following the common experience of specific incubation times associated with highly pathogenic microorganisms (8,10). Though it assists in treating infections, this classification raises some practical problems (8). For example, if an infection emerges in the ICU and is caused by a microbe carried by a patient on admission to the ICU, then this infection cannot be considered as a nosocomial (ICU-acquired) one, although it develops after 48-h, because the causative microorganism does not originate from the ICU ecology.…”

Section: Discussionmentioning

confidence: 99%

“…The 48-h cutoffis used to distinguish community-and hospital-acquired infections from ICU-acquired infections (8,13). For the better understanding of this proposed classification, the following definitions are used: Carriage (or carrier state) is defined as isolation of the same strain of microorganism (in any concentration) from at least two consecutive surveillance samples over a period of at least one week (8,12). Three types of rcu infections are defined using the carrier state criterion: Primary endogenous (PE), secondary endogenous (SE) and exogenous (EX) infections.…”

Section: Definitionsmentioning

confidence: 99%

“…This high prevalence of infections occurring in the ICUs is related to the special conditions in these hospital sections and to the high-risk factors for infections in ICUs, such as the use of intravenous catheters, urinary catheters, mechanical ventilation, endotracheal intubation, tracheotomy, long-term use of antimicrobials and steroids, etc. (8).…”

mentioning

confidence: 99%

“…Controlling infections occurring in the hospital environment, consequently in the ICU, can be achieved through the classification of infections into categories according to certain criteria; this process is crucial for the infection surveillance programmes, in order to control the nosocomial and especially the ICU-acquired infections (8)(9). The classification of infections which is applied nowadays and conforms with CDC (4,10), is based on the 48-h cut-off, starting from the admission of the patient to the hospital (II).…”

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confidence: 99%

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Epidemiological Study and Classification of ICU Infections, Using the Carrier State Criterion

et al. 2010

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This work aims at the better comprehension of epidemiology of ICU infections, using a classification based on the carrier state of the patient. This classification distinguishes the infections in primary endogenous (PE), secondary endogenous (SE) and exogenous (EX) infections. The material used was derived from ICU patients who were admitted to the ICU without being transferred from another ward of the same hospital or another hospital. Culture swabs were obtained from the pharynx and perineum of the patients at ICU admission and from then onwards every 3 days during their hospitalization. At the same time, cultures of clinical samples were carried out, on suspicion of infection. Ninety-six ICU patients were studied. In 31 of these, a total of 78 infections were developed. According to the proposed classification, 26 of the infections were PE (rate 33.3%), 34 SE (rate 43.6%) and 18 EX (rate 23.1%). Using the carrier state criterion, there were 11 fewer infections characterized as nosocomial (rate 14.1%), contrary to the 48-hour criterion. Based on this new taxonomy ofinfections, we are able to know in advance the source of the causative microorganisms and reduce the prevalence of ICU infections, by applying appropriate prevention and treatment strategies.Infections occurring in the hospital environment are one of the major factors affecting the duration of hospitalization of patients and outcome of their treatment. The hospital-acquired (nosocomial) infections constitute one of the major issues which trouble global health (1). They affect two million patients (5% of hospitalized patients) in the U.S.A., leading to 77,000 deaths and costs of 4.5 billion dollars each year (2).This problem becomes more intense, especially in the ICUs. In a French survey in 1996 involving 58% of total hospital beds nationwide, a total rate of 6.7% of nosocomial infections was found, whereas in ICUs this rate rose up to 22% (3). Other studies report rates of nosocomial infections which vary from 13% to 42% (4-7). This high prevalence of infections occurring in the ICUs is related to the special conditions in these hospital sections and to the high-risk factors for infections in ICUs, such as the use of intravenous catheters, urinary catheters,

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Section: Discussionmentioning

confidence: 99%

Section: Definitionsmentioning

confidence: 99%

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confidence: 99%

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Epidemiological Study and Classification of ICU Infections, Using the Carrier State Criterion

et al. 2010

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“…Another approach of the infections acquired in the ICU considers three types of infection: primary endogenous, secondary endogenous and exogenous [12]. These different patterns have speci®c microbial pro®les and can be distinguished only by surveillance cultures in all intubated patients admitted in ICU.…”

Section: Bacterial Pathogens Associated With Ventilator-associated Pnmentioning

confidence: 99%

Microbial investigation in ventilator-associated pneumonia

Ioanăş¹,

Ferrer²,

Angrill³

et al. 2001

Eur Respir J

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Ventilator-associated pneumonia (VAP) is a serious infectious condition in intensive care unit (ICU) patients, currently related to a high mortality rate. Therefore, this complication of mechanical ventilation requires a prompt diagnosis and adequate antibiotic treatment. The detection of the causative organism is imperative for guiding an appropriate therapy as there is strong evidence of the adverse effect of inadequate empirical treatment on outcome. The major difficulty of the microbial investigation is to obtain the sample from the lower respiratory tract, mainly because of the potential contamination with upper airways flora, which may result in a misinterpretation of the cultures.Microbial investigation in VAP is based on the culture of samples obtained from lower respiratory tract by noninvasive or invasive methods. The most common techniques of sampling are the endotracheal aspirate (ETA), which is considered a noninvasive method, the protected specimen brush (PSB) and the bronchoalveolar lavage (BAL), both being invasive methods of investigation. The latter were designed as an attempt to avoid the colonizing flora of the upper airways. The best of these diagnostic approaches is still controversial. In terms of outcome, there is strong evidence that the impact of both invasive and noninvasive methods seems to be similar. In terms of cost, however, the endotracheal aspirate is less expensive compared to BAL or PSB. On the other hand, invasive methods could be particularly beneficial in patients who are not responding to the initial empirical antibiotic treatment.The rationale for the quantitative culture of the respiratory samples is to differentiate between infection and colonization of lower airways, because the bacterial colonization is a frequent event in mechanically ventilated patients. The thresholds currently employed for the diagnosis of the pneumonia are the following: ETA samples, ≥105–106colony forming units (cfu)·mL−1; PSB samples, ≥103cfu·mL−1; and BAL samples, ≥104 cfu·mL−1.Intending to provide a practical approach to the issue, the present manuscript reviews the available noninvasive (blood culture, endotracheal aspirate) and invasive (protected specimen brush, bronchoalveolar lavage, blinded methods and lung biopsy) techniques used for the diagnosis of ventilator-associated pneumonia.

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