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European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008

European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008. Carl Suetens Surveillance Unit European Centre for Disease Prevention and Control 7th HIS International Conference, Liverpool, 10-13 October 2010.

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European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008

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  1. European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008 Carl Suetens Surveillance UnitEuropean Centre for Disease Prevention and Control 7th HIS International Conference, Liverpool, 10-13 October 2010

  2. Standardized surveillance of Healthcare-Associated Infections in European hospitals • Surveillance of Surgical Site Infections (SSI) • Surveillance of ICU-acquired Infections (ICU) • Point Prevalence Surveys as alternative to hospital-wide surveillance of all HAI types (PPS)

  3. Standardisation of SSI & ICU surveillance methods Methodological differences between national protocols: • Fair agreement in 2000 for SSI surveillance (7 countries), similar to CDC/NNIS methodology • Larger differences for surveillance of ICU-acquired infections in 2000 (5 countries, 4 patient-based, 1 unit-based) • Agree on common surveillance methodology and case definitions: questionnaire (2000), meetings (2000-2002), final protocols 2002-2003 • Work towards standardized interpretation of standard methodology • Develop indicators that take into account inter-country differences in methodology and case-mix

  4. Participation to HAI surveillance (HAI-Net), status in 2010 SIRO NOIS SSHAIP INST HYG HISC PREZIES HPA NHS NSIH KISS ANIS NNSR RAISIN ASR ENVIN ISC III HELICS SPIN-UTI

  5. Surveillance of Surgical Site Infections: EU methods vs CDC/NHSN • Same as CDC/NHSN methodology, except: • Hospital discharge date required • Options: ICD9-CM codes, post-discharge date & status • Selection of procedures: CABG, CHOL, COLO, CSEC, HPRO, KPRO, LAM • Indicators: • % SSI within 30 d / 1 year • % in-hospital SSI (post-discharge excluded) • Incidence density: # in-hospital SSI/1000 patient-days: • Adjustment for differences in post-discharge surveillance • Adjustment for differences in post-operative length of stay • Incidence density for Deep-Organ/Space infections only: adjustment for differences in reporting superficial infections • Stratification per NNIS risk index for all indicators

  6. European surveillance of Surgical Site Infections • 2000-2001: protocol analysis, questionnaire, meetings • 6 countries in 2000 => 12 countries (15 networks), 1422 hospitals in 2008

  7. SSI cumulative incidence by operation category and year, 2004-2008

  8. Surveillance of SSI in hip prosthesis, 2004-2008

  9. Differences in post-discharge surveillance and type of SSI Post-discharge SSI excluded Post-discharge SSI included Percentage of SSI detected after discharge from the hospital by surgical procedure

  10. EU reference tables, e.g. SSI incidence density in HPRO

  11. European surveillance of ICU-acquired infections • 2000-2002: protocol analysis, questionnaire, retrospective data analysis, meetings • Collaboration with ESICM • 654 hospitals from 12 countries in 2008 • 2 levels: • Unit-based (minimal data, trends) • Patient-based: risk adjustment, Standardised Infection Ratio (Observed/Expected)

  12. Surveillance of ICU-acquired infections

  13. Patient-based surveillance in the ICU

  14. Methodology of EU surveillance of ICU-acquired infections • Patients staying less than 3 days in the ICU excluded from denominators (different from US-NHSN/DE-KISS) Length of stay in the ICU (days) by country

  15. Methodology of EU surveillance of ICU-acquired infections • Case definitions differ from CDC/NHSN definitions: • Bloodstream Infections: include secondary BSI • Pneumonia: • based on CDC PNU definition, not identical • Intubator-Associated (IAP) vs Ventilator-Associated (VAP) • Definition of “nosocomial” or “ICU-acquired”: >48 h, in practice > Day 2, instead of “not present or in incubation at admission” • ECDC outsourced Concordance study of HAI case definitions CDC/NHSN vs. IPSE/HELICS (2009-2010, P. Gastmeier et al): • Quantify difference in case classification (concordance) => kappa • Results show excellent concordance (kappa>=0.99) for PN and primary BSI

  16. HELICS case definition of pneumonia(2003) – also in ECDC PPS protocol X-ray(s) + clinical symptoms (t°/wbc + sput./ronchi…) • PN1: protected sample + quantitative culture (104 CFU/ml BAL/103 PB,DPA) • PN2: non-protected sample (ETA) + quantitative culture (106 CFU/ml) • PN3: alternative microbiological criteria • PN4: sputum bacteriology or non-quantitative ETA • PN5: no microbiological criterion

  17. Differences in diagnostic practices of ICU-acquired pneumonia, 2008

  18. Date of onset pneumonia

  19. Micro-organisms isolated in ICU-acquired infections, 2004-2008 Pneumonia Bloodstream infections

  20. EU reference tables, e.g. device-adjusted ICU-acquired pneumonia rates

  21. Support to HAI surveillance : on-site HAI surveillance workshops • Technical support visit to help set up HAI surveillance networks (4 in 2010) • 2 x ½ day workshop • Intensive Care (ICU), Surgical Site Infections (SSI) or both • Typically 20 participants from hospitals • Including case studies of HAI case definitions and computer exercises (HELICSwin) • + support to national coordination team & installation of software tools HAI surveillance workshop, Sofia, Nov 2009 Hungarian HELICSwin, Budapest workshop, June 2009

  22. EU HAI surveillance integrated in TESSy Pre-TESSY • TESSy = “The European Surveillance System” = ECDC’s online database, upload and reporting system for all communicable diseases under surveillance • Integration of all dedicated surveillance networks • October (4-8/10): HAI TESSy training for national surveillance coordinators and data managers

  23. HAI surveillance: ICU & SSI now integrated in ECDC’s TESSy system

  24. From IPSE to HAI-Net: What has changed? Naming conventions: Healthcare-Associated Infections: HAI instead of HCAI IPSE => HAI-Net Unit-based protocols: “level 1” => “light” Patient-based protocols: “level 2” => “standard” (full) Changes agreed at HAI surveillance Annual Meeting: SSI: “Light” version, coverage, post-discharge method ICU: Some variables/options dropped, AMR target list New minimal AMR marker set (PPS)

  25. Conclusions • Standardized surveillance of surgical site infections and ICU-acquired infections: based on HELICS/IPSE network, now continued by ECDC • 27+ countries = 27+ opinions, but large majority in favour of agreeing on single method • Need for extension of surveillance, but setting up HAI surveillance networks requires important resources (hospitals, national coordination) • training of trainers and on-site training • translation of protocols • free software tools, multilingual • Standardized methods/definitions  standardized surveillance practices! • From January 2011: ECDC HAI surveillance website + interactive data analysis

  26. Thank you to all national surveillance networks and participating hospitals! www.ecdc.europa.eu| info@ecdc.europa.eu

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