Definitions and challenges in everyDefinitions and challenges in every--dayday--practice: how to establish that an infection is practice: how to establish that an infection is

healthcare associatedhealthcare associatedPrevention, diagnosis and treatmentPrevention, diagnosis and treatmentof healthcare associated infections of healthcare associated infections

in in ““realreal””lifelifeGINERBGINERB--SIMIT WorkshopSIMIT Workshop

Mario Venditti

Dipartimento di Sanità Pubblica e

Malattie Infettive Università “La Sapienza”

Roma

Nosocomial vs non-nosocomial health-care-associated infection

Definitions:

Nosocomial health-care-associated infection is defined as an infection developing in a patient hospitaliazed for > 48 hours before the onset of signs and symptoms consistent with the infection.

Non-nosocomial health-care-associated infection is defined as an infection diagnosed within 48 hours of admission in an outpatient with extended health-care contact.

However….

Some Non-nosocomial health-care-associated infections are probably acquired during a previous hospitalization

…. Others seem to develop in community after acquisition of an MDR organism during a previous hospitalization

Some examples….

MRSE as cause of PVE:relationship with time from cardiosurgery

Author, year N (% of methicillin resistance) S epidermidis isolates at months

0-2 mo. 2-12 mo. After 12 mo.

Karchmer , 83 39(87%)^ 22(87%)^ 22(9%)^^

0-12 mo. After 12 mo.

Calderwood, 86 41(84%)* 10(30%)**

^ vs ^^ p<0.05

* vs ** p<0.05

RISK FACTORS FOR CANDIDEMIA (NPT, SEVERE SEPSIS, ANTIBIOTICS, ACUTE RENAL FAILURE, CANDIDA COLONIZATION,

STEROIDS ETC)

OPEN HEART SURGERY

POST-OPERATIVE CANDIDEMIA*FROM DAMAGED INTESTINAL

MUCOSAOR CVC

adherence of Candida on prosthetic valve

biofilm formation

resistance to antifungals, no evidence of IE at echocardiography !

Late appearance of vegetations at echocardiography and/or clinical symptoms of IE

DIAGNOSIS OF CANDIDA PVE

direct intraoperative contamination

orunsuccessful antifungal

therapy & surgical debridment of

previous Candida ie

Falcone M. & Venditti M et al Medicine May issue, 2009

Candida & biofilm & time of posttoperative candidemia to endocarditis candidemia

Tempo CCH endocarditis . 250 days

Postoperative

candidemia

endocarditis candidemia

0–3 months 3–24 months >24 months

Early Delayed(low grade)

Late

S. aureusStreptococciEnterococci

Coagulase-negative staphylococci

P. acnes

S. aureusE. coli

Perioperative Haematogenous

Time

Type

Route

Cause

Signs Persistent pain,device loosening,

fistula

Fever, effusion, warmth, drainage

Acute or subacute

Types of implant infection

1. Zimmerli W et al. N Engl J Med 2004:351:1645–16542. Trampuz A, Zimmerli W. Injury 2006;37:S59–S66

• female, 70 yrs• On sept 2003, PHJ was inserted in our hospital.• On July 2004, she was admitted in our

Cardiology ward for a low grade fever and progressive dyspnoea.

• TEE disclosed a 8 mm diameter vegetation on the aortic valve and a severe aortic regurgitation…..

• Persistent bacteremia (4/4 positive blood cultures) with a methicillin resistant Staphylococcus haemolyticus was documented ………..

Case study

81 year-old male patient, living in a long-term care facility since 2 years, suffering from prostate cancer and receiving treatment for sclerotic and hypertensive cardiopathy at home with enalapril and digoxin. History of recurrent episodes of urinary tract infections managed with fluoroquinolones and ceftriaxone…February 2008: latest hospital admission with a diagnosis of cystopyelitis caused by an ESBL-producing E. coli strain. Treatment regimen: meropenem followed by ertapenem…... Indwelling urethral catheter for several months…..

Multidrug-resistant gram-negative bacteria at a long-term care facility: assessment of residents, healthcare workers,

and inanimate surfaces O’Fallon E, ICHE 2009;30:1172-9

Point-prevalence study in 4 separate wards at a 600-bed urban LTCF that was conducted from October 31, 2006 through February 5, 2007.161 LTCF residents and 13 HCWs

Nasal and rectal samples were obtained for culture from each resident, selected environmental surfaces in private and common rooms, and the hands and clothing of HCWs in each ward.

A total of 37 (22.8%), 1 (0.6%), and 18 (11.1%) residents were colonized with MDR gram-negative bacteria, VRE, and MRSA, respectively.

MDR gram-negative bacteria were also found in the environment and in HCWs

Molecular typing identified clonally related MDR gram-negative strains in LTCF residents

Common areas in LTCFs may provide a unique opportunity for person-to-person transmission of MDR gram-negative bacteria

Community-acquired UTI caused by ESBL-producing Gram-negative bacilli

in LombardyBracco et al, AMCLI, 2011

More than 13.000 cases assessed in 2010

Outpatients vs rehabilitation center patients vs long-term care facility residents

E. coli: 7% vs 17% vs 27%

Proteus spp.: 7% vs 47% vs 48%

K. pneumoniae: 4% vs 36% vs 37%

Case study81 year-old male patient, living in a long-term care facility since 2 years, suffering from prostate cancer and receiving treatment for sclerotic and hypertensive cardiopathy at home with enalapril and digoxin. History of recurrent episodes of urinary tract infections managed with fluoroquinolones and ceftriaxone…February 2008: latest hospital admission with a diagnosis of cystopyelitis caused by an ESBL-producing E. coli strain. Treatment regimen: meropenem followed by ertapenem…... Indwelling urethral catheter for several months….13/10/2008: admission to the ED with a 7-day persistent fever not responding to an antimicrobial regimen of ceftriaxone and ciprofloxacin. Worsening acute low back pain lasting 4 days, despite treatment with anti-inflammatory and analgesic agents. Patient lies in a forced supine position….Patient transferred to the Department of Internal Medicine with fever (38.5°C), tachypnea, tachycardia; complete blood cell count: WBC 19000, PMN 90%. Three blood cultures obtained, followed by administration of teicoplanin (6mg/kg q.d.) + meropenem. No overt physical findings….TTE: Mixed aortic valve disease (stenosis and regurgitation) with a 5 mm vegetation. MRI shows spondylodiscitis at L2-L3 segments…. Day 3: patient still febrile. Urine and blood culture yield MRSA; MICs: Vancomycin 1 mg/L (VITEK), Teicoplanin 2 mg/L… Teicoplanin + gentamicinDay 5: persistent fever (positive blood cultures), onset of acute renal failure (CrCl 35 ml/min per 1.73 m2)… treatment changed to daptomycin(6 mg/kg) + rifampin…Apyretic after 72 hours… Vancomycin E test : MIC 1.5 mg/L; daptomycin E test: MIC 0.12 mg/L…. 6 week treatment duration … preoperative evaluation for cardiac surgery….

Pyogenic SpondylodiscitisData collected by departments of Clinical Medicine & Infectious Disease

Clinical features COSp NSp-NPOS NSp-POS total

N. of patients 38 16 27 81

Males 57% 18% 26% 51%

Mean age 57 64 55 58

Location

-cervical 30% 60% 10% 10%

-thoracic 75% 25% - 12%

-lumbar 44% 12% 44% 59%

Fever 63% 62.5% 37% 54%

Endocarditis 6(16%) 1(6%) 0 7(9%)

Pyogenic Spondylodiscitis

Microrganism COSp NSp-NPOS NSp-POS total

MRSA 3 2 3 8

MSSA 13 3 4 20

MR-SCN 1 1 2 4

MS-SCN 3 1 0 4

Streptococcus 6 1 0 7

P. aeruginosa 2 2 4 8

Candida 0 3 1 4

Aspergillus 0 0 2 2

Others 3 2 3 8

D’Agostino C, Venditti M, Vullo V, Orsi GB Infection 2010

Epidemiology of Multidrug-Resistant Bacteriain Patients With Long Hospital Stays

Buke C et al Infect Control Hosp Epidemiol 2007; 28:1255-1260

Distribution of Multidrug-Resistant Pathogens in 439 Patients as Shown by Screening Within 3 Days After the Thirtieth Day of the Hospital Stay (D30 Screening)

13% 8% 20%

Carriage of Methicillin-Resistant Staphylococcus aureus in Home Care Settings

Lucet JC Arch Intern Med. 2009;169(15):1372-1378Variables Associated With MRSA Carriage at Hospital Discharge to Home

Health Care

eRisk categories for MRSA carriage were as follows: low risk: hematologic, orthopedic, or AIDS diagnosis; moderate risk: cancer diagnosis; substantial risk: cardiovascular or other diagnosis; and high risk: neurologic

diagnosis.

14.5%

Carriage of Methicillin-Resistant Staphylococcus aureus in Home Care Settings

Lucet JC Arch Intern Med. 2009;169(15):1372-1378

Time to methicillin-resistant Staphylococcus aureus (MRSA) clearance in 148 MRSA carriers admitted to home health care then monitored for 1 year.

Health Care–Associated Bloodstream Infections in Adults: A Reason To Change the Accepted Definition of Community-Acquired Infection

N D Friedman Ann Intern Med. 2002;137:791-797.

Health Care Associated Bloodstream Infection (BSI): inclusion criteria

Positive blood cultures obtained from a patient within 48 hour Positive blood cultures obtained from a patient within 48 hour of hospital of hospital admission fulfilling any of the following:admission fulfilling any of the following:

1.1.Intravenous therapy at home in the 30 days before the BSI;Intravenous therapy at home in the 30 days before the BSI;

2.2.Wound/ulcer care at home in the 30 days before the BSI;Wound/ulcer care at home in the 30 days before the BSI;

3.3.Hemodialysis or intravenous chemotherapy in the 30 days before BHemodialysis or intravenous chemotherapy in the 30 days before BSI; SI;

4.4.Hospitalization for at least 2 days in the 90 days before the BSHospitalization for at least 2 days in the 90 days before the BSII

5.5.Resided in a nursing home or longResided in a nursing home or long--term care facilityterm care facility

Health Care–Associated Bloodstream Infections in Adults: A Reason To Change the Accepted Definition of Community-Acquired Infection

N D Friedman Ann Intern Med. 2002;137:791-797.

Nosocomial or HCA-BSI:

1. S. aureus

2. S. epidermidis

3. Enterococcus spp.

Community acquired BSI:

1. E. coli

2. S. pneumoniae

Candida spp responsible of 2/143 community-acquired BSI vs 10/175 hospital-acquired BSI ( p =0.04).

GRAM +

MRSA found in 50.3% of cases

2% Community acquired BSI

19% HCA BSI

20 % Nosocomial-BSI

PNosocomial

BSIHCA BSI

Community BSI

Nosocomial vs community

acquired BSI

Nosocomial vsHCA BSI

Community vs HCA BSI

Hospital stay (median)

23 gg 7 gg 6 gg <0.05 <0.05 NS

In hospital-mortality

30% 20% 13% 0.002 0.038 0.15

3 to 6 month Mortality rate

37% 29% 16% <0.001 0.19 0.019

Health CareHealth Care––Associated Bloodstream Infections in Adults: A Associated Bloodstream Infections in Adults: A Reason To Change the Accepted Definition of CommunityReason To Change the Accepted Definition of Community--

Acquired InfectionAcquired InfectionN D Friedman N D Friedman Ann Intern Med. 2002;137:791Ann Intern Med. 2002;137:791--797.797.

Health care- associated native valve endocarditis: importance of non-nosocomial acquisition

Benito N et al & ICE study group Ann Inten Med 150: 586, 2009

Pathogen . All NVEs . P . HCA-NVEs . P

CA HCA noso non-noso

S. aureus 20% 45% <.001 47% 42% .30

MRSA 12% 47% <.001 57% 41% .014

Enterococcus 9% 15% <.001 14% 17% .38

Staphylococcus CN 6% 13% <.001 12% 15% .23

Streptococcus Vir 28% 8% <.001 11% 6% .023

Others 27% 18% <.001 12% 14% .27

Negative blood cult. 11% 5% <.001 5% 6% .45

Surgery 51% 41% <.001 43% 38% .25

Persistent bacteremia 4% 18% <.001 18% 18% .88

In-hospital mortality 13% 25% <.001 28% 21% .09

1622 cases of NVE from 61 hospitals in 28 countries:557 (34%) HCA-NVE. 303 (54%) nosocomial NVE and 254 (42%) non-

nosocomial NVEDefinition of non-nosocomial HCA-NVE :

• Community onset or within 48 hours of hospital admission+ any of the following:

• Intravenous therapy, wound care or nursing care through a health care facility in the previous 30 days

• Hemodialysis or intravenous chemotherapy in the previous 30 days • Patient hospitaliazed for 2 or more days in the previous 90 days

• Patient resides in a rehabilitation center or a long-term care facility

Empirical treatment of S. aureus bacteremia

Previous MRSA colonization or infection≥ 2 MRSA risk factors

if any of the following:Severe sepsis & septic shockIntravascular devices (PM, heart valve prosthesis...)

No YesDaptomycin

8-10 mg/kg q.d.

VancomycinVancomycin1515--20 mg/kg loading dose; 500 mg IV every 6 20 mg/kg loading dose; 500 mg IV every 6

hours or CIhours or CI□□ After 48 hours: check for plasma After 48 hours: check for plasma

trough concentrationtrough concentration

□□ Keep plasma trough concentration Keep plasma trough concentration at 15 at 15 µµg/mlg/ml

oxacillinoxacillin

Vancomycin MIC (µg/ml))

>>11<1<1

MRSAMRSAMSSA

Targeted therapy for S. aureus bacteremia

blood cultures

Daptomycin

6-8 mg/kg/24 hr

VancomycinVancomycin

Kaplan-Meier survival curves for cirrhotic patients with (red) and without (blue) infection

Merli M, Lucci C, Giannelli V, Giusto M, Riggio O, Falcone M, Ridola L, Attili AF, Venditti MClin Gastroenterol Hepatol 8: 979, 2010

survival

not infected

infected

Epidemiology, risk factors and outcome of bacterial infection inhospitalized cirrhotic patients

In a cohort of hospitalized cirrhotic patients (n = 150), all episodes of bacterial infections were recorded prospectively

54 infections were observed among 50 patients (12 CA, 22 HCA e 20 HA)

Mortality rate: 37% in HA, 36% in HCA, 0% in CA

Infectious episodes determined further liver function deterioration in 62% of patients

(pathogenetic mechanism linked to proinflammatory cytokines release with residual hepatic function “breakdown”)

Cirrhotic patients are at risk for healthcare-associated bacterial infectionsMerli M, Lucci C, Giannelli V, Giusto M, Riggio O, Falcone M, Ridola L, Attili AF, Venditti M

Clin Gastroenterol Hepatol 8: 979, 2010

Cirrhotic patients are at risk for healthcare-associated bacterial infectionsMerli M, Lucci C, Giannelli V, Giusto M, Riggio O, Falcone M, Ridola L, Attili AF, Venditti M

Clin Gastroenterol Hepatol 8: 979, 2010

survival

Non infetti

infetti

6/9 ESBL

0/2 ESBL

Health care-associated pneumonia (HCAP)

Definition.

A patient fulfilling any of the following criteria is considered to have HCAP:

1) attended a hospital or hemodialysis clinic or received intravenous therapies in the 30 days before the development of pneumonia.

2) was hospitalized for at least 2 days in the 30-180 days before pneumonia.

3) resided in a nursing home or long-term care facility.

MRSA:6 % of CAP

Vs18% of HCAP

Vs 17% of HAP

•P. aeruginosa & non-fermenters

•ESBL-Enterobacteriaceae +

•MRSA

Outcomes of patients hospitalized with CAP, Outcomes of patients hospitalized with CAP, HCAP or HAPHCAP or HAP

Venditti M, Falcone M, Corrao S, Licata S, Serra P & SIMI, Ann IVenditti M, Falcone M, Corrao S, Licata S, Serra P & SIMI, Ann Intern Med; 150: 19, 2009ntern Med; 150: 19, 2009

Criteria for HCAPCriteria for HCAP

28%

Severity of illness at admissionSeverity of illness at admission

Outcomes of patients hospitalized with CAP, HCAP or HAPOutcomes of patients hospitalized with CAP, HCAP or HAPVenditti M, Falcone M, Corrao S, Licata S, Serra P & SIMI, Ann IVenditti M, Falcone M, Corrao S, Licata S, Serra P & SIMI, Ann Intern Med; 150: 19, 2009ntern Med; 150: 19, 2009

Results

In-hospital mortality

17.8%17.8%

p = 0.02p = 0.02p > 0.05p > 0.05

CAP HCAP HAP

18.4%18.4%6.7%6.7%

Outcomes of patients hospitalized with community-acquired, healthcare-associated, and hospital-acquired pneumonia

Venditti M et Ann Intern Med 150: 19-26, 2009

Multinomial logistic regression

Factors associated with HCAP

RRR (95% CI)

histamine-2 blocker or antacid administration*

3.3 (1.6 to 7.1)

Hospital stay longer than 20 days*

2.7 (1.2 to 6.2)

empirical antibiotic therapy not recommended by international guidelines* 4.1 (1.6 to 10.4)

RRR= relative risk ratio, CI= Confidence Interval; * p <0.05

Logistic regression analysis

Factors associated with enhanced risk of mortality

OR (95% CI)

Depression of consciousness 3.2 (1.0 to 9.8)

Leukopenia 6.2 (1.0 to 37.6)

empirical antibiotic therapy not recommended by international guidelines

6.4 (2.3 to 17.6)

OR= Odds ratio, CI= Confidence Interval;

Outcomes of patients hospitalized with community-acquired, healthcare-associated, and hospital-acquired pneumonia

Venditti M et Ann Intern Med 150: 19-26, 2009

Mortality rates(%) for CAP and HCAP in different studies

0

5

10

15

20

25

30

35

Kollef 2005

Micek2007

Carratalà2007

Webster2007

Venditti2009

Shindo2009

Rello2010

CAPHCAP

Falcone M, Shindo Y, Venditti M & Kollef M

p<0.001

p<0.001

p<0.001

p<0.001

p<0.007

p<0.052

p<0.02

Risk of MDR bacteria as etiologic agents

CAP HCAP HAP

Risk of mortality

Carratalà2

(Spain)Shindo5

(Japan)

Kollef3

Micek4

(USA)

Falcone &

Venditti Italy

Pneumonia treated in the internal medicine department: a nationwide study in Spain

M. Giannella*, E. Bunsow, B. Pinilla, J.A. Capdevila, J. Martínez Alarcón, P. Muñoz and E. Bouzaon behalf of the ENEMI Study Group

Figure 1. Study flow diagramPotential eligible patients

(n=1,043)

Patients enrolled (n=1,031)

Patients with data not available (n=12)

Patients who did not fulfil pneumonia criteria (n=29)

Patients analyzed (n=1,002)

First week (n=685) Second week (n=317)

Incident cases (n=612) Incident cases (n=276)

Table 2. Etiology

01 CAP and HCAP; ^P < 0 01 CAP and HAP; †P < 0 01 HCAP and HAP

10.250.520.77

01 (4.8)

00

2 (3.1)0

3 (4.6)2 (3.1)

5 (3.4)1 (0.7)3 (2)3 (2)

OthersM. tuberculosisP. jiroveciiPolimicrobial+Othersº

0.27<0.001*^

0.340.86

0.008

5 (23.8)6 (28.6)

00

2 (9.5)

8 (12.3)11 (16.9)2 (3.1)3 (4.6)

0

17 (11.5)5 (3.4)

11 (7.4)5 (3.4)

0

Gram negativeEnterobacteriaceaeP. aeruginosaL. pneumophilaH. influenzaeA. baumanii

<0.001*^<0.001*

0.03

3 (14.3)2 (9.5)2 (9.5)

25 (38.5)8 (12.3)1 (1.5)

94 (63.5)1 (0.7)1 (0.7)

Gram positiveS. pneumoniaeMRSAMSSA

1002 (1.4)VirusInfluenza A (H1N1)v

PHAPN=21 (%)

HCAPN=65 (%)

CAPN=148 (%)

10.250.520.77

01 (4.8)

00

2 (3.1)0

3 (4.6)2 (3.1)

5 (3.4)1 (0.7)3 (2)3 (2)

OthersM. tuberculosisP. jiroveciPolymicrobialOther

0.27<0.001*^

0.340.86

0.008

5 (23.8)6 (28.6)

00

2 (9.5)

8 (12.3)11 (16.9)2 (3.1)3 (4.6)

0

17 (11.5)5 (3.4)

11 (7.4)5 (3.4)

0

Gram-negativeEnterobacteriaceaeP. aeruginosaL. pneumophilaH. influenzaeA. baumannii

<0.001*^<0.001*

0.03

3 (14.3)2 (9.5)2 (9.5)

25 (38.5)8 (12.3)1 (1.5)

94 (63.5)1 (0.7)1 (0.7)

Gram-positiveS. pneumoniaeMRSAMSSA

1002 (1.4)VirusInfluenza A (H1N1)v

PHAPN=21 (%)

HCAPN=65 (%)

CAPN=148 (%)

Table 3. Therapeutic management and outcome.

0.050.001*^

0.05<0.001*^

0.02<0.004*<0.001*^0.002^

024 (23.1)

9 (8.7)21 (20.2)

2 (1.9)3 (2.9)

28 (26.9)11, 6-16

3 (1)45 (14.8)10 (3.3)34 (11)4 (1.3)

11 (3.6)58 (18.9)9, 6-14

17 (2.9)46 (7.8)20 (3.4)33 (5.6)1 (0.2)4 (0.7)

46 (7.8)8, 5-13

OutcomeEmpyemaSeptic shockNeed for intubationMulti-organ failurePersistent bacteremiaEmergence of MDR In-hospital mortalityDays of hospital stayº (median, IQR)

0.100.79

<0.001*^†

0.11<0.001*^†

0.79

102 (98)74 (71.2)58 (55.8)

15/20 (75)35 (33.7)12, 9-15

302 (98.4)211 (68.7)70 (22.8)

29/45 (64.4)162 (53)11, 9-15

588 (99.5)420 (71)413 (70)

54/68 (79.4)409 (69)11, 9-14

Therapeutic managementEmpirical therapyAdministration within 6 hAdherence to guidelines#

Adequacy according to sensibilitySwitch from IV to oralDays of therapy (median, IQR)

PHAPN=104 (%)

HCAPN=307 (%)

CAPN=591 (%)

0.050.001*^

0.05<0.001*^

0.02<0.004*<0.001*^0.002^

024 (23.1)

9 (8.7)21 (20.2)

2 (1.9)3 (2.9)

28 (26.9)11, 6-16

3 (1)45 (14.7)10 (3.3)34 (11)4 (1.3)

11 (3.6)58 (18.9)9, 6-14

17 (2.9)46 (7.8)20 (3.4)33 (5.6)1 (0.2)4 (0.7)

46 (7.8)8, 5-13

OutcomeEmpyemaSeptic shockNeed for intubationMulti-organ failurePersistent bacteremiaEmergence of MDR In-hospital mortalityDays of hospital stay (median, IQR)

0.100.79

<0.001*^†

0.11<0.001*^†

0.79

102 (98)74 (71.2)58 (55.8)

15/20 (75)35 (33.7)12, 9-15

302 (98.4)211 (68.7)70 (22.8)

29/45 (64.4)162 (53)11, 9-15

588 (99.5)420 (71)413 (70)

54/68 (79.4)409 (69)11, 9-14

Therapeutic managementEmpirical therapyAdministration within 6 hAdherence to guidelines#

Adequacy according to sensitivitySwitch from IV to oralDays of therapy (median, IQR)

PHAPN=104 (%)

HCAPN=307 (%)

CAPN=591 (%)

HEALTHCARE-ASSOCIATED PNEUMONIA: DIAGNOSTIC CRITERIA AND DISTINCTION FROM COMMUNITY-ACQUIRED PNEUMONIA

Falcone M, Shindo Y, Vanditti M, Kollef M, Int J Infect Dis early on line, 2011

Odd ratios for mortality in patients with HCAP treated with inappropriate antimicrobial therapy or with antibiotics not recommended in the ATS/IDSA guidelines

Am J Crit Care Med 2005; 171: 388-416

Geographical distribution of medical centers included in Geographical distribution of medical centers included in the second SIMI studythe second SIMI study

Falcone M,Venditti M, Corrao S, Serra P unpublished dataFalcone M,Venditti M, Corrao S, Serra P unpublished data

Antibiotic Therapy of Health-Care-Associated Pneumonia: a multicenter outcomes research interventional studyFalcone M, Corrao S, Licata G, Serra P, Venditti M & SIMI study group

Antibiotic Therapy of Health-Care-Associated Pneumonia: a multicenter outcomes research interventional study

Falcone M, Corrao S, Licata G, Serra P, Venditti M & SIMI study group

Antibiotic Therapy of Health-Care-Associated Pneumonia: a multicenter outcomes research interventional study

Falcone M, Corrao S, Licata G, Serra P, Venditti M & SIMI study group

Antibiotic Therapy of Health-Care-Associated Pneumonia: a multicenter outcomes research interventional study

Falcone M, Corrao S, Licata G, Serra P, Venditti M & SIMI study group

Antibiotic Therapy of Health-Care-Associated Pneumonia: a multicenter outcomes research interventional study

Falcone M, Corrao S, Licata G, Serra P, Venditti M & SIMI study group

Risk factors for HCAP %

Hospitalization in the previous 3 months 37.9

Residence in a long-term care facility 35.4Home intravenous therapy in the previous 30 days

9.4

Hemodialysis in the previous 30 days 11.6

Wound care 2.5

Known colonization with resistant pathogens 6.5

““Epidemiology, Antibiotic therapy, and Clinical Epidemiology, Antibiotic therapy, and Clinical Outcomes in HCAP: a UK cohort StudyOutcomes in HCAP: a UK cohort Study””

Chalmers Chalmers et al. CID et al. CID 2011;53:1072011;53:107––113113

Clinical feautures of 1348 patients enrolled in the prospective observational study.

Microbiologic comparison between patients with CAP and HCAP

Chalmers Chalmers et al. CID et al. CID 2011;53:1072011;53:107––113113

““Epidemiology, Antibiotic therapy, and Clinical Epidemiology, Antibiotic therapy, and Clinical Outcomes in HCAP: a UK cohort StudyOutcomes in HCAP: a UK cohort Study””

Pneumonia severity

HCAPHCAP CAPCAP pp

CURBCURB--6565 2.4 (SD 1.3)2.4 (SD 1.3) 1.9 (SD 1.3)1.9 (SD 1.3) <0.0001<0.0001

PSIPSI--scorescore 3.7 (SD 1.1)3.7 (SD 1.1) 3.1 (SD 1.3)3.1 (SD 1.3) <0.0001<0.0001

Chalmers Chalmers et al. Clinical infectious diseaseet al. Clinical infectious disease 2011;53:1072011;53:107––113113

Most of patients with both CAP (96%) and HCAP (92.8%) were empirically treated according to BTS guidelines with Ceftriaxone + claritromicina.

FLUOROQUINOLONES ADMINISTRATION IS NEVER RECOMMENDED

EMPIRICAL TREATMENT NOT EFFECTIVE AGAISNT MRSA OR P. auruginosa

P<0.002

7.5%

14.9%

0

5

7,5

10

12,5

15

17,5

% m

orti

Community-acquired pneumonia

Health care-associated pneumonia

Mortality odds ratio (30 days) for HCAP 2.15 (1.44-3.22) P=0.002.

OR reduced to 0,97 ( 0.61-1.55

)P =0.3 after adjustment for potential confounders:•PSI score• Comorbidities,•Antibiotic therapy•Risk factors for aspiration • Functional status.

Conclusions: when to consider a community-onset infection as a HCI and anyway caused by MDR?

Knowledge of local epidemiology (have you any idea about the epidemiology in our country nursing homes and long-term care facilities?)

Criterium of lenght of previous hospital stay :2 days or 30 days,or…..?

Comorbidities associated with persistent MDR colonization: i.e. diabetes mellitus, psoriasis, foreign bodies, immune deficiency… advanced age > 70 aa intrinsically associated with comorbidities

Diagnosis of non nosocomial HCI remain a complex clinical decision

Medicine

is

an art