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A critical time for nosocomial infections in the ICU

Francis Colardyn
Ghent University Hospital, Belgium
E: [email protected]

Stijn Blot
Intensive Care
Ghent University Hospital, Belgium
E: [email protected]

Nosocomial infections occur approximately three to six times more frequently in patients admitted to ICUs than in patients residing in general wards.(1) Despite all the efforts made in infection control, the incidence of nosocomial infection in ICUs has increased over the past three decades. There are several reasons for this trend. First, there is the increased use of invasive techniques providing access for bacteria to enter the patient’s body. Secondly, as more patients receive immunosuppressive therapy, the host’s defence against microorganisms decreases. Thirdly, there is the improved emergency and supportive care resulting in better acute-phase survival, which leads to a growing number of long-term ICU residents. All these factors result in a pool of patients who are extremely vulnerable to nosocomial infection, grouped in units with a high workload and a degree of urgency that results in failure to comply with standard infection control measures.
In addition to the threat of nosocomial infection there is the emergence of antibiotic resistance. Risk factors for antibiotic resistance in the ICU are multiple and include prolonged hospitalisation, previous ICU admission, previous exposure to antibiotics, particularly broad-spectrum antibiotics, and failure of infection control measures.(2) The impact of nosocomial infection, and resistance in particular, on patient outcomes has been a matter of debate. It is often highlighted in the press that nosocomial infections are responsible for tens of thousands of patient deaths and that the hospital (healthcare workers) is responsible and thus accountable.

Attributable morbidity and mortality of nosocomial infections
While there is a general consensus that nosocomial infection results in higher morbidity, discussion regarding its impact in terms of mortality is ongoing. Generally, nosocomial infection occurs in patients who already have a grim prognosis. It is therefore important to distinguish mortality due to underlying conditions from mortality that can be attributed to the infection itself. Adjustment for disease severity is of major importance in order to interpret data fairly. In matched-cohort studies, following careful adjustment for severity of disease and acute illness, several showed no significant attributable mortality among critically ill patients with severe nosocomial infection.(3-5) However, nosocomial infection can cause excess mortality in critically ill patients when accurate management is lacking. Early recognition of the infection and prompt institution of adequate antimicrobial therapy is crucial for improving the survival odds of patients with nosocomial infection.(6,7) It is precisely in this task that antimicrobial resistance provides a major challenge. At the onset of infection the causative microorganism is still unknown. Therefore, the likelihood of empiric inappropriate therapy is remarkably higher when infection is caused by resistant microorganisms.(8) When initiating an empiric antimicrobial regimen, the physician must take into account the patient’s profile with particular emphasis on risk factors for involvement of antimicrobial- resistant microorganisms (eg, length of hospitalisation, prior antibiotic exposure, underlying conditions and colonisation status).(6,9) In case of severe sepsis, colonisation with antimicrobial-resistant microorganisms or a substantial risk of involvement of these germs, the empiric antimicrobial regimen must consist of a broad-spectrum antibiotic.(10) When physicians reach a high rate of timely initiated appropriate therapy, mortality is not higher among patients with infections caused by antibiotic-resistant Gram-negative bacteria.(11) Infections caused by methicillin-resistant Staphylococcus aureus (MRSA), however, appear to be associated with an increased fatality rate despite adequate therapy.(12,13)

Economic consequences of nosocomial infections
Besides their deleterious impact in terms of morbidity and sometimes mortality, it is clear that nosocomial infections and antimicrobial resistance are responsible for an enormous economic burden.(14) Important progress has been made in measuring how nosocomial infection affects the cost of patient care. The cost of caring for patients with nosocomial infection has been compared with the cost of caring for control subjects without infection who were matched for factors that may confound the cost estimate. Many studies reported massive costs attributable to nosocomial infections in ICUs.(15,16) For example, we recently reported on the economic effects of catheter- related bloodstream infection in ICU patients.(17) Catheter-related bloodstream infection was associated with excesses in duration of mechanical ventilation (7 days), duration of ICU (8 days) and hospital stays (12 days), and a significant increase in total hospital costs (€13,585). A breakdown of the total cost was performed for per-diem, pharmacy and medical expenses. For all three different types of costs, expenses were significantly higher among infected patients.

Who is liable for these nosocomial infections?
The general perception is that between a fifth and a third of these infections are preventable, but this does not solve the individual problems for the patient.(18) In some US states, a quarter of the malpractice cases of nosocomial infections ends with a verdict. The trend is also to hold the HMO more often responsible for the organisation (eg, infection control programmes) than the individual caregiver. This development in the US (which can be expected to be followed soon in Western Europe) leads to increased pressure, especially from the nurses, for quality improvement programmes, education by infection control staff and increased nurse/patient ratios among others. In Scandinavia, and soon in Belgium, a governmental no-fault system partly covers the compensation for the injured patient.

Outcome and future
There is a clear relationship between infection control programmes, appropriate antibiotic consumption and reduction of resistance and nosocomial infections. But if we take handwashing/disinfection as an example: this is one of the most simple measures, but the compliance rate is only around 50–60%, with a decrease when activities increases. (19) Therefore, the efforts and programmes used have to be repetitive, owned by the management and have a regular feedback (which is easily done in the case of MRSA incidence).

Nursing shortages, combined with a reduction in working hours, will hamper infection control programmes. Equally, a high workload has been singled out by ICU nurses as the most important factor for not complying with hand hygiene recommendations.(20) In addition, some factors oppose the efforts of infection control, such as the increasing complexity of the care required in critically ill patients, the shortening length of hospitalisation, the ageing of the patient population and the increasing disease severity.

Implementation of guidelines for a more rational use of antibiotics is even more difficult to introduce, as is the change of the habits of the individual physicians, especially as these guidelines are mostly consensus-based rather than evidence-based.

The positive news is the trend, which is not only in the USA, for health insurers to give financial incentives in cases of improved quality. Most of the time these incentives are in the form of increased reimbursement. Ranking hospitals, by whatever means, is gaining popularity and can lead to higher patient volumes and improved financial balances.

The role and the responsibilities of the management
Healthcare professionals are responsible for the quality
patient care, while the management is responsible for the organisation rendering optimal care possible. It is clear that well-designed multidisciplinary actions to reduce the burden of nosocomial infections are effective. However, implementing programmes is not enough, as most are only effective for a limited time. Efforts should be taken to stress the importance of the programme on a continuous basis. Routine quality control and strict surveillance are needed. Most programmes fail to keep up the standard of care for a substantial time period due to limited resources.

In a highly competitive market, with shortages of healthcare professionals and high costs, implementing infection control programmes with infection control specialists is a real challenge. As the presence of infection control programmes is proven to be cost-effective, reducing nosocomial infections liability will take on an even more important role.(19,21) Therefore, implementation, even with the added cost, is a must. This will eventually be compensated by a better ranking and higher reimbursement rates.

Nosocomial infections pose a real challenge to both healthcare  professionals and management. The cost for society, but especially the cost for the hospital and liability problems, combined with the awareness of the general public forces the hospital to take measures. Now is the time to act.


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