Hospital Aquired Infection - Neonatal European Information System

Hospital Aquired InfectionEuroNeoStat II, 26-10-2010, CopenhagenHelmut Hummler, MD, MBAChildren‘s HospitalUniversity of Ulm

WP No. 7 Specific Objectives• Expansion of the information system• Study of the indicators and actions to preventadverse events• Development of a specific dataset relatedto nosocomial infections• Data collection and analysis• Discussion• Educational packages• Educational studies?

Neo-KISS: Surveillance – Systemfor hospital acquired infectionsfor VLBWI in Germany• Mandatory since 2006 for all Neonatal Centersin Germany• Surveillance system in all infants

Neo-KISS: Surveillance – SystemDefinitions• Sepsis• NEC• Pneumonia

Definition Sepsis• Two of the following clinical signs• Temp >38°C or temperature instability orhypothermia (200/min) or new/morebradycardias• Cap refill >2s• New or more apneas (>20s)• Unexplained met. acidosis (BE < -10 mEqu/l)• Hyperglycemia (new) def. Dex >140 mg/dl)• Other signs of sepsis: color, more resp. support,hemodynamics unstable, less responsive (CNS)• + …

Definition Sepsis cont.• …either one of the following situations:• Clinical sepsis• Culture proven sepsis• Culture proven sepsis (Coag neg staph)

Definition Sepsis cont.• Clinical sepsis (all of the following):• Physician decides for Abx for at least 5d• No cultures taken or no positive blood culture• No obvious other (local) infection

Definition Sepsis cont.• Culture proven sepsis:• Blood or CSF culture positive with bacteriaother than coag. neg. Staph.

• Standardisized infection rateobserved number of nosocomial Infectionsexpected number of n.i.• Incidence (infections / 1000 Pat.-days)• Usage of central and peripheral lines, mech.Ventilation, CPAP• Device associated infection rate (number of devicerelatedInfections / 1000 days of device)• Annual reportNeo-KISS – Data analysis• Annual meeting of participating centers (Berlin)• Annual Euro Neo Stat meeting?

Impact on local results: Children‘sHospital University of Ulm, Germany

NeoKISS: Children‘s Hospital Ulm4-12 / 2006 2007N 102 101Surv.-days 3424 3809GA (wks) 28,1(23,3-34,6)27,6(23,6-36,9)BW (g) 970(350-1490)930(400-1490)CRIBscore 1 (0-16) 2 (0-16)Survival 95 (93%) 96 (95%)Transfer

Standardized Infection Rate BW < 1500gUlm vs. National Reference Data(Rate of observed / expected infections)21,54-12 / 2006N: 10210,50SIR UlmRef. Median[Reference values 2003-2007]Ref. 25% QuantilRef, 75% Quantil

Standardized Infection Rate BW < 1500gUlm vs. National Reference Data(Rate of observed / expected infections)21,510,504-12 / 2006N: 1022007101SIR UlmRef. Median[Reference values 2003-2007]Ref. 25% QuantilRef, 75% Quantil

?Enterobacter????Candida?KNS?Aspergillus??SerratiamarcescensWhat to do??Pseudomonas?Staph. aureus?E.Coli

Guidelines for prevention of nosocomial infection in VLBWI 2007• 60 different points on 90 pages• Recommendations category I – IV• (Expert opinion … evidence from RCT‘s…)

Different approaches in our NICU was foundin 10/60 points

Number of nosocomial infectionsPatient/nurse ratio NICU201816141210864204/06 5/06 6/06 7/06 8/06 9/06 10/06 11/06 12/06N nosokom. Infectionsdays with >2 patients/nurse

Actions taken• Hygiene consultations in the NICU• Teaching in the NICU as care goes on• Changes acoording to published recommendations• Parental information handout on Hygiene• Teaching of cleaning personel• Regular Workshops „Routine hand desinfection“• More nurses• Study of skin desinfection/culture before catheterinsertion• …

desinfection of handswashing hands

NEO-KISS – Surveillance in ELBWIUlm 2006/2007 vs. 2008/20092006/07, n = 109 2008/09, n = 12237%13%49%14%81%6%no NI, n=53 1 NI, n = 40>1 NI, n=16no NI, n=99 1 NI, n = 16>1 NI, n=7NI – nosocomial infection

NEO-KISS – Surveillance in preterm infants(1000-1499g), Ulm 2006/2007 vs. 2008/20092006/07, n = 100 2008/09, n = 9088%12%94%6%no NI, n=88 1 NI, n = 12no NI, n=84 1 NI, n = 5NI – nosocomial infection

Standardised Infection Rate in VLBWIin Ulm and National Reference Data (NeoKISS)(Ratio Actual Infection Rate / Expected Infection Rate21,510,502006N: 103200710820081052009104SIR UlmRef. Median[Referenzwerte 2003-2007]Ref. 25% QuantilRef, 75% Quantil

„Educational“ Study

Device Associated Nosocomial Infectionratefor Central Venous Line in Ulm, Germany(before and after implementation of a bundle of interventions)Infectionrate/1000 device days2520151050-64%2006 2007 2008 2009VLBWI: N = 211 N= 209

Rate of bacterial skin contamination immediately afterinsertion of a peripheral venous line and deviceassociated nosocomial infection rate in Ulm, GermanyImplementation of improved andstandardised skin desinfectionDevice ass. infection rate(N/1000 device days)1614121086420-50%-43%1614121086420Positive skin culture (%)4/2008-1/09 2/2009-2/10VLBWI: N = 78 N= 100

WP 7 Specific dataset to study hospitalacquired infectionRoad Map• Decide on inclusion of a surveillance system in thedataset of EuroNeoStat– voluntary• Decide on dataset/definitions– German definitions• Arbitrary (expert panel)• Advantage: reference data available (Valls-i-Soler et al. NeoReviews2010;11 e403)– Suggestion:• only nosocomial sepsis• Do not use definitions for pneumonia and NEC• Proposed start of data collection in other centers by1-1-2011

WP 7 Specific dataset to study hospitalacquired infectionRoad Map• Educational packages (to be available by 1-1-2012)– Guidelines for infection control (in national languages)– Teaching videos for standard procedures• „Educational Studies“?• Deliverable 11: M 36:– Report on actions potentially able to prevent adverseevents threatening VLBWI on the basis of selectedindicators and including an educational package toprevent hospital-acquired infections.

Thank you very much

• Sepsis• NEC• PneumoniaNeo-KISS: Surveillance – SystemDefinitions

Definition Pneumonia• At least one of the following radiological signs• New or progressive infiltrate• Opacification on CXR• Fluid within the interlobar or pleural space• + deteriorating gas exchange or desaturations• + …

Definition Pneumonia• At least 4 of the following clinical signs• New or more bradycardias (< 80/min) or new/moreepisodes tachycardia (>200/min)• New/more episodes of tachypnea (>60/min) or new/moreapneas (>20s)• Tracheal secretions suggesting pus• Isolation of bacteria in tracheal secretions• New/more dyspnea (retractions, nasal flaring, grunting)• Temperature instability (Hyper-/Hypothermia)• More tracheal secretions requiring more suctioning• CrP > 2,0 mg/dl• IT-Ratio > 0,2

Definition NecrotizingEnterocolitis (NEC)• At least 2 of the following clinical signs orsymtoms without other obvious cause• Vomiting• Distended abdomen• Gastric residuals• Infiltration of abdominal wall• Repeated hem + stools or macroscopic blood instool• + one of the following radiological signs• Free abdominal air• Pneumatosis intestinalis• Fixed bowel loops

Definition NecrotizingEnterocolitis (NEC)• Or diagnosis of NEC by histology