Risk factors for healthcare associated infections and in-hospital mortality in a neurological intensive care unit in a tertiary hospital in Belgrade, Serbia: A prospective cohort study

Stefan Vidaković; Ranko Raičević; Marija Grunauer; Viktor Pasovski; Vesna Šuljagić

doi:10.2298/VSP180422184V

Stefan Vidaković University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Ranko Raičević University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Marija Grunauer Military Medical Academy, Clinic for Neurology, Belgrade, Serbia
Viktor Pasovski University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Vesna Šuljagić University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP180422184V

Keywords: cross infection, neurology, critical care, risk factors, monitoring, physiologic, drug, resistance microbial

Abstract

Background/Aim. Patients in a neurologic intensive care unit (ICU) are especially susceptible to healthcare-associated infections (HAIs). HAIs are cause of significant morbidity and mortality. Aim of this study was to assess the incidence of HAIs, to identify significant risk factors (RFs) and causative microorganisms for HAIs and to identify RFs for in-hospital mortality in a neurological ICU. Methods. A prospective cohort study was conducted in the six-bed ICU of the Clinic for Neurology, Military Medical Academy in Belgrade from January 1, 2014 to December 31, 2016. Active surveillance on HAIs was performed by the hospital infection control team, using methodologies of the European Centre for Disease Prevention and Control and the National Healthcare Safety Network/Centres for Disease Prevention and Control. Results. One hundred forty eight patients with a total of 2,708 patient-days were enrolled. There were 49 HAIs in 39 patients during the study period. The incidence and incidence density of HAIs were 26.3% and 18.1 per 1000 patient-days, respectively. The most frequent HAIs were urinary tract infections (15.5%), pneumonia (10.1%) and bloodstream infections (4%). RFs independently associated with HAIs in the neurological ICU were: urinary catheter [risk ratio (RR): 5.6; 95% confidence interval (CI): 1.153–27.632], urinary catheter-days (RR: 1.1; 95% CI: 1.057–1.188), central-line days (RR: 1.1; 95% CI: 1.010–1.150), and mechanical ventilation (RR: 0.3; 95% CI: 0.079–0.859). The most common microorganism was Klebsiella spp. RFs independently associated with in-hospital mortality in the neurological ICU were: mechanical ventilation (RR: 6.5; 95% CI: 2.868–14.116), Glasgow Coma Score (RR: 2.7; 95% CI: 1.135–6,396), and age (RR: 1.03; 95% CI: 1.005–1.055). Conclusion. Usage of invasive procedures during ICU hospitalization carries significant risk for development of HAIs. HAIs in ICU setting are most often caused by Gram-negative bacteria with substantial antimicrobial resistance. These results stress the importance of infection prevention.

Author Biographies

Stefan Vidaković, University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

Doktor medicine

Ranko Raičević, University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

Prof. dr sci. med. ; neurolog

Marija Grunauer, Military Medical Academy, Clinic for Neurology, Belgrade, Serbia

Doktor medicine, neurolog

Viktor Pasovski, University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

Doktor medicine, neurolog

Vesna Šuljagić, University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

Prof. dr sci. med. ; epidemiolog

References

Daschner FD, Frey P, Wolff G, Baumann PC, Suter P. Nosocomi-al infections in intensive care wards: a multicenter prospective study. Intensive Care Med 1982; 8(1): 5‒9.

Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al. EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 302(21): 2323‒9.

Cevik MA, Yilmaz GR, Erdinc FS, Ucler S, Tulek NE. Rela-tionship between nosocomial infection and mortality in a neu-rology intensive care unit in Turkey. J Hosp Infect 2005; 59(4): 324–30.

Dettenkofer M, Ebner W, Els T, Babikir R, Lucking C, Pelz K, et al. Surveillance of nosocomial infections in a neurology inten-sive care unit. J Neurol. 2001; 248(11): 959–64.

Coello R, Gastmeier P, de Boer AS. Surveillance of hospital-acquired infection in England, Germany, and The Nether-lands: will international comparison of rates be possible? In-fect Control Hosp Epidemiol 2001; 22(6): 393‒7.

Tekin R, Dal T, Çevik MU. Fourteen Year Surveillance of Nosocomial Infections in Neurology Unit. J Bacteriol Parasi-tol 2012; 3(7): 3–5.

European Centre for Disease Prevention and Control. European Surveillance of Healthcare-Associated Infections in Intensive Care Units– HAI-Net ICU protocol, version 1.01. 2010. Available from:

https://ecdc.europa.eu/.../european-surveillance-healthcare-associa...

Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J In-fect Control 2008; 36(5): 309–32.

Zolldann D, Spitzer C, Häfner H, Waitschies B, Klein W, Sohr D, et al. Surveillance of nosocomial infections in a neurologic in-tensive care unit. Infect Control Hosp Epidemiol 2005; 26(8): 726–31.

Abulhasan YB, Rachel SP, Châtillon-Angle MO, Alabdulraheem N, Schiller I, Dendukuri N, et al. Healthcare-associated infections in the neurological intensive care unit: Results of a 6-year sur-veillance study at a major tertiary care center. Am J Infect Control 2018; 46(6): 656‒62.

Jarvis WR, Edwards JR, Culver DH, Hughes JM, Horan T, Emori TG, et al. Nosocomial infection rates in adult and pediatric in-tensive care units in the United States. National Nosocomial Infections Surveillance System. Am J Med 1991; 91(3B): 185S‒191S.

Dudeck MA, Horan TC, Peterson KD, Allen-Bridson K, Morrell GC, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2009, device-associated module. Am J Infect Control 2011; 39(5): 349‒67.

Djordjevic Z, Jankovic S, Gajovic O, Djonovic N, Folic N, Bukumiric Z. Hospital infections in a neurological intensive care unit: In-cidence, causative agents and risk factors. J Infect Dev Ctries 2012; 6(11): 798–805.

Borgatta B, Rello J. How to approach and treat VAP in ICU pa-tients. BMC Infect Dis 2014; 14(1): 211.

European Centre for Disease Prevention and Control. Healthcare-associated infections acquired in intensive care units. In: ECDC. Annual epidemiological report for 2015. Stockholm: ECDC; 2017.

Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001–2010. Am J Infect Control 2014; 42(10): 1028–32.

Brown K, Valenta K, Fisman D, Simor A, Daneman N. Hospital ward antibiotic prescribing and the risks of Clostridium dif-ficile infection. JAMA Intern Med 2015; 175(4): 626–33.

Bouza E, Rodríguez-Créixems M, Alcalá L, Marín M, de Egea V, Braojos F, et al. Is Clostridium difficile infection an increasing-ly common severe disease in adult intensive care units? A 10-year experience. J Crit Care 2015; 30(3): 543–9.

Micek ST, Schramm G, Morrow L, Frazee E, Personett H, Doherty JA, et al. Clostridium difficile infection: a multicenter study of epidemiology and outcomes in mechanically ventilated pa-tients. Crit Care Med 2013; 41(8): 1968–75.

Vincent J, Lefrant J, Kotfis K, Nanchal R, Martin-Loeches I,Wittebole X, et al. Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP). Intensive Care Med 2018; 44(3): 337‒44.

Colpan A, Akinci E, Erbay A, Balaban N, Bodur H. Evaluation of risk factors for mortality in intensive care units: a prospec-tive study from a referral hospital in Turkey. Am J Infect Con-trol 2005; 33(1): 42‒7.