Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kollef, M. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kollef, M. H.
(Chest. 2006;130:1293-1296.)
© 2006 American College of Chest Physicians

Time To Get Serious About Infection Prevention in the ICU

Marin H. Kollef, MD, FCCP

St. Louis, MO
Dr. Kollef is Professor of Medicine, Washington University School of Medicine; Director, Medical Intensive Care Unit; and Director, Respiratory Care Services, Barnes-Jewish Hospital.

Correspondence to: Marin H. Kollef, MD, FCCP, Campus Box 8052, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110; e-mail: mkollef{at}im.wustl.edu

ICUs are an important area for the emergence and spread of nosocomial infections due to the frequent use of broad-spectrum antibiotics; the crowding of patients with high levels of disease acuity within relatively small specialized areas; reductions in nursing staff and other support staff due to economic pressures that increase the likelihood of person-to-person transmission of microorganisms; and the presence of more chronically and acutely ill patients who require prolonged hospitalizations and often harbor antibiotic-resistant bacteria.123 Increasingly nosocomial infections, especially those acquired in the ICU setting, are caused by antimicrobial-resistant pathogens. Therefore, clinicians need to be aware of strategies that are not only aimed at prevention of nosocomial infections but the prevention of antimicrobial resistance as well. Many of the available prevention strategies are described in the Centers for Disease Control and Prevention 12-step program for the prevention of antimicrobial resistance (http://www.cdc.gov/drugresistance/healthcare/). One of the key elements in this strategy is to consult experts in the field of nosocomial infections and antimicrobial resistance (eg, infectious disease experts, infection control practitioners, microbiologists) when designing interventions aimed at minimizing the emergence and spread of antibiotic resistant pathogens.

ICUs worldwide are faced with increasingly rapid emergence and spread of antibiotic-resistant bacteria. Both antibiotic-resistant Gram-negative bacilli and Gram-positive bacteria are reported as important causes of hospital-acquired infections.45678910 In many circumstances, particularly with methicillin-resistant Staphylococcus aureus and Enterococcus faecium and Gram-negative bacteria producing extended-spectrum ß-lactamases and carbapenemases with resistance to multiple antibiotics, few antimicrobial agents remain for effective treatment.1112131415161718 The emergence of new strains of existing pathogens within the community setting has created additional stressors favoring the entry of resistant microorganisms into the hospital setting. This has most recently been demonstrated by the identification and spread of community-associated methicillin-resistant S aureus (MRSA).192021 These community strains of MRSA have made their way into the hospital setting, representing an important potential source of additional nosocomial infections.2223

The prolonged administration of antimicrobial regimens appears to be the most important factor promoting the emergence of antibiotic resistance that is potentially amenable to intervention.24 Other factors promoting infection with antimicrobial-resistant bacteria include prolonged hospitalization; the presence of invasive devices, such as endotracheal tubes and intravascular catheters, possibly due to the formation of biofilms on the surfaces of these devices; residence in long-term treatment facilities; and inadequate infection control practices.3 Spread of antibiotic-resistant bacteria from patient to patient represents the main pathway for the development of infection due to antibiotic-resistant bacteria among hospitalized patients.1 Antibiotic-resistant nosocomial infections are an important source of patient morbidity and health-care costs. Nosocomial infections caused by antibiotic-resistant microorganisms are frequently treated with antimicrobial regimens lacking activity against the subsequently identified microorganisms (ie, inappropriate antimicrobial therapy).25

Administration of inappropriate initial antimicrobial therapy is associated with greater hospital mortality.262728 In addition to increased hospital mortality, antimicrobial resistance is associated with excess costs. Most of the cost excess is simply associated with the acquisition of a nosocomial infection, much of which is due to potentially resistant antibiotic-resistant bacteria.2930 However, antibiotic resistance may also confer added morbidity and costs. For example, prior reports have indicated that MRSA infections as compared to those due to methicillin-sensitive S aureus are associated with worse clinical outcomes. Cosgrove et al,31 in a metaanalysis of 30 investigations focusing on bacteremia, concluded that MRSA bacteremia independently increased the risk for death. Shorr et al32 recently conducted a retrospective analysis of a large cohort of subjects with bronchoscopically confirmed ventilator-associated pneumonia (VAP) due to S aureus, suggesting that MRSA infection has important effects on ICU length of stay and health-care costs. Conservatively assuming that the costs per day of ICU care equal $2,000 in the United States, one can compute that each case of MRSA, VAP amplified hospital costs by at least $10,000 to $15,000. Similar findings have been described for infections due to antibiotic-resistant Gram-negative infections.3334 Therefore, there is an economic motive in addition to clinical efficacy for attempting to minimize the emergence and spread of antibiotic resistant infections.

In this issue of CHEST (see page 1346), Estivariz et al35 describe an outbreak of infections attributed to Burkholderia cepacia in the ICU of a hospital with contaminated nasal spray. Although the nasal spray was contaminated, these authors linked the outbreak to extrinsic contamination of multidose albuterol used for nebulization treatments. This study has similar characteristics to other outbreaks of nosocomial infection linked to contaminated equipment or medications.363738 In general, there is often a delay in the recognition of an outbreak, significant patient morbidity can occur, and medical costs are increased as a result of the acquired infections. More challenging are the routine type of nosocomial infections occurring in the ICU setting not linked to a specific outbreak of contaminated equipment or medication. Many hospitals do not have systematic efforts in place to recognize and prevent these infections. This has lead organizations such as the Institute for Healthcare Improvement and the Keystone Project to partner with hospitals in order to enhance their infection prevention practices in addition to other practice improvements.3940

Hospitals caring for seriously ill patients need to develop and implement programs aimed at the prevention of nosocomial infections. There are many examples demonstrating the efficacy of such interventions and their impact on local health-care costs.4142434445 In addition to such interventions, hospitals should have active and accurate microbial surveillance programs in place to develop accurate antibiograms and to detect changing patterns and incidences of nosocomial infections.13 Unfortunately, such efforts can be viewed by hospital administration as cost centers without realizing their potential to improve outcomes and reduce hospital expenditures.45 Therefore, local demonstration projects may have to occur, based on prior successful interventions from other hospitals, to illustrate the potential role of infection control and surveillance.46

In summary, the prevention of nosocomial infections is an important practice in ICUs. Unfortunately, a single element or protocol is unlikely to suffice in most hospitals. Table 1 provides an outline of tasks that can assist clinicians in developing local infection control programs that also limit the emergence of antibiotic resistance.47


View this table:
[in this window]
[in a new window]

  		Table 1.. Strategies To Prevent Resistance in the ICU*

 

Footnotes

The author has no conflicts of interest to declare on this topic.

References

  1. Carlet, J, Ben Ali, A, Chalfine, A (2004) Epidemiology and control of antibiotic resistance in the intensive care unit. Curr Opin Infect Dis 17,309-316[CrossRef][ISI][Medline]
  2. Haley, RW, Bregman, DA The role of understaffing and overcrowding in recurrent outbreaks of Staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982;145,875-885[ISI][Medline]
  3. Kollef, MH, Fraser, VJ Antibiotic resistance in the intensive care unit. Ann Intern Med 2001;134,298-314[Abstract/Free Full Text]
  4. Waldvogel, FA New resistance in Staphylococcus aureus. N Engl J Med 1999;340,556-557[Free Full Text]
  5. Quinn, JP Clinical problems posed by multiresistant nonfermenting Gram-negative pathogens. Clin Infect Dis 1998;27,S117-S124[Medline]
  6. Jones, RN, Sader, HS, Beach, ML Contemporary in vitro spectrum of activity summary for antimicrobial agents tested against 18569 strains non-fermentative Gram-negative bacilli isolated in the SENTRY Antimicrobial Surveillance Program (1997–2001). Int J Antimicrob Agents 2003;22,551-556[CrossRef][ISI][Medline]
  7. Livermore, DM Bacterial resistance: origins, epidemiology, and impact. Clin Infect Dis 2003;36,S11-S23[CrossRef][ISI][Medline]
  8. Dellinger, RP, Carlet, JM, Masur, H, et al Surviving Sepsis Campaign Management Guidelines Committee: surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32,858-873[CrossRef][ISI][Medline]
  9. Neuhauser, MM, Weinstein, RA, Rydman, R, et al Antibiotic resistance among Gram-negative bacilli in US intensive care units: implications for fluoroquinolone use. JAMA 2003;289,885-888[Abstract/Free Full Text]
  10. Smith, TL, Pearson, ML, Wilcox, KR, et al Emergence of vancomycin resistance in Staphylococcus aureus. N Engl J Med 1999;340,493-501[Abstract/Free Full Text]
  11. Van Looveren, M, Goossens, H Antimicrobial resistance of Acinetobacter spp. in Europe Clin Microbiol Infect 2004;10,684-704[CrossRef][ISI][Medline]
  12. Canton, R, Coque, TM, Baquero, F Multi-resistant Gram-negative bacilli: from epidemics to endemics. Curr Opin Infect Dis 2003;16,315-325[ISI][Medline]
  13. Pagani, L, Colinon, C, Migliavacca, R, et al Nosocomial outbreak caused by multidrug-resistant Pseudomonas aeruginosa producing IMP-13 metallo-ß-lactamase. J Clin Microbiol 2005;43,3824-3828[Abstract/Free Full Text]
  14. Naiemi, NA, Duim, B, Savelkoul, PH, et al Widespread transfer of resistance genes between bacterial species in an intensive care unit: implications for hospital epidemiology. J Clin Microbiol 2005;43,4862-4864[Abstract/Free Full Text]
  15. Cartolano, GL, Cheron, M, Benabid, D, et al Association of Hospital Bacteriologists, Virologists and Hygiene Professionals. Methicillin-resistant Staphylococcus aureus (MRSA) with reduced susceptibility to glycopeptides (GISA) in 63 French general hospitals. Clin Microbiol Infect 2004;10,448-451[CrossRef][ISI][Medline]
  16. Jones, RN Microbiological features of vancomycin in the 21st century: minimum inhibitory concentration creep, bactericidal/static activity, and applied breakpoints to predict clinical outcomes or detect resistant strains. Clin Infect Dis 2005;42,S13-S24
  17. Zaoutis, TE, Goyal, M, Chu, JH, et al Risk factors for and outcomes of bloodstream infection caused by extended-spectrum ß-lactamase-producing Escherichia coli and Klebsiella species in children. Pediatrics 2005;115,942-949[Abstract/Free Full Text]
  18. del Mar Tomas, M, Cartelle, M, Pertega, S, et al Hospital outbreak caused by a carbapenem-resistant strain of Acinetobacter baumannii: patient prognosis and risk-factors for colonisation and infection. Clin Microbiol Infect 2005;11,540-546[CrossRef][ISI][Medline]
  19. Kollef, MH, Micek, ST Methicillin-resistant Staphylococcus aureus: a new community-acquired pathogen. Curr Opin Infect Dis 2006;19,161-168[ISI][Medline]
  20. Naimi, TS, LeDell, KH, Como-Sabetti, K, et al Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 2004;290,2976-2984
  21. Fridkin, SK, Hageman, JC, Morrison, M, et al Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352,1436-1444[Abstract/Free Full Text]
  22. Klevens, RM, Edwards, JR, Tenover, FC, et al Changes in the epidemiology of methicillin-resistant Staphylococcus aureus in intensive care units in US hospitals, 1992–2003. Clin Infect Dis 2006;42,389-391[CrossRef][ISI][Medline]
  23. Schramm GE, Johnson JA, Doherty JA, et al. Increasing incidence of sterile-site infection due to non-multidrug resistant, oxacillin-resistant Staphylococcus aureus (NORSA) among hospitalized patients. Infect Control Hosp Epidemiol 2006 (in press)
  24. Kollef, MH, Micek, ST Strategies to prevent antimicrobial resistance in the intensive care unit. Crit Care Med 2005;33,1845-1853[CrossRef][ISI][Medline]
  25. Kollef, MH Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis 2000;31,S131-S138[CrossRef][ISI][Medline]
  26. Micek, ST, Lloyd, AE, Ritchie, DJ, et al Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment. Antimicrob Agents Chemother 2005;49,1306-1311[Abstract/Free Full Text]
  27. Dhainaut, JF, Laterre, PF, LaRosa, S, et al The clinical evaluation committee in a large multicenter phase 3 trial of drotrecogin alfa (activated) in patients with severe sepsis (PROWESS): role, methodology, and results. Crit Care Med 2003;31,2291-2301[CrossRef][ISI][Medline]
  28. Harbarth, S, Garbino, JK, Pugin, J, et al Inappropriate initial antimicrobial therapy and its effects on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med 2003;115,529-535[CrossRef][ISI][Medline]
  29. Trouillet, JL, Chastre, J, Vuagnat, A, et al Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 1998;157,531-539[ISI][Medline]
  30. Rello, J, Ollendorf, DA, Oster, G, et al Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122,2115-2121[CrossRef][ISI][Medline]
  31. Cosgrove, SE, Sakoulas, G, Perencevich, EN, et al Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis 2003;36,53-59[CrossRef][ISI][Medline]
  32. Shorr, AF, Combes, A, Kollef, MH, et al Methicillin-resistant Staphylococcus aureus prolongs intensive care unit length of stay in ventilator-associated pneumonia—despite initially appropriate antibiotic therapy. Crit Care Med 2006;34,700-706[CrossRef][ISI][Medline]
  33. Carmeli, Y, Troillet, N, Karchmer, AW, et al Health and economic outcomes of antibiotic resistance in Pseudomonas aeruginosa. Arch Intern Med 1999;159,1127-1132[Abstract/Free Full Text]
  34. Niederman, MS Impact of antibiotic resistance on clinical outcomes and the cost of care. Crit Care Med 2001;29,N114-N120[CrossRef][ISI][Medline]
  35. Estivariz, CF, Bhatti, IL, Pati, R, et al An outbreak of Burkholderia cepacia associated with contamination of albuterol and nasal spray. Chest 2006;130,1346-1353[Medline]
  36. Fraser, VJ, Jones, M, Murray, PR, et al Contamination of flexible fiberoptic bronchoscopes with Mycobacterium chelonae linked to an automated bronchoscope disinfection machine. Am Rev Respir Dis 1992;145,853-855[ISI][Medline]
  37. Srinivasan, A, Wolfenden, LL, Song, X, et al An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes. N Engl J Med 2003;348,221-227[Abstract/Free Full Text]
  38. Corne, P, Godreuil, S, Jean-Pierre, H, et al Unusual implication of biopsy forceps in outbreaks of Pseudomonas aeruginosa infections and pseudo-infections related to bronchoscopy. J Hosp Infect 2005;61,20-26[CrossRef][ISI][Medline]
  39. The Academic Medical Center Working Group of the Institute for Healthcare Improvement.. The imperative for quality: a call for action to medical schools and teaching hospitals. Acad Med 2003;78,1085-1089[CrossRef][ISI][Medline]
  40. Robeznieks, A ICU effort saved lives, money: organizers: more than 70 hospitals took part in the Keystone: ICU program. Modern Healthcare 2005;35,16[Medline]
  41. Kollef, MH Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 2004;32,1396-1405[CrossRef][ISI][Medline]
  42. Babcock, HM, Zack, JE, Garrison, T, et al An educational intervention to reduce ventilator-associated pneumonia in multiple hospitals: a comparison of effects. Chest 2004;125,2224-2231[CrossRef][ISI][Medline]
  43. Warren, DK, Hill, HA, Merz, LR, et al Cycling empirical antimicrobial agents to prevent emergence of antimicrobial-resistant Gram-negative bacteria among intensive care unit patients. Crit Care Med 2004;32,2450-2456[CrossRef][ISI][Medline]
  44. Coopersmith, CM, Rebmann, TL, Zack, JE, et al Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med 2002;30,59-64[CrossRef][ISI][Medline]
  45. Warren, DK, Zack, JE, Mayfield, JL, et al The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest 2004;126,1612-1618[CrossRef][ISI][Medline]
  46. Gastmeier, P Nosocomial infection surveillance and control policies. Curr Opin Infect Dis 2004;17,295-301[CrossRef][ISI][Medline]
  47. Kollef, MH Surgical Infection Society Twenty-Fifth Annual Altemeier Lecture: the intensive care unit as a research laboratory; developing strategies to prevent antimicrobial resistance. Surg Infect 2006;7,1-15[CrossRef]



This article has been cited by other articles:


Home page
 ChestHome page
M. Kollef
SMART Approaches for Reducing Nosocomial Infections in the ICU
Chest, August 1, 2008; 134(2): 447 - 456.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kollef, M. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kollef, M. H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS