J Antimicrob Chemother 2012; 67: 1565 – 1567 doi:10.1093/jac/dks054 Advance Access publication 20 February 2012
Comment on: Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens Roger Sorde´1*, Benito Almirante1, Mercedes Palomar2 and Albert Pahissa1 1
Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Universitat Auto`noma de Barcelona, Spanish Network for Research in Infectious Diseases (REIPI), Barcelona, Spain; 2Department of Critical Care, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Universitat Auto`noma de Barcelona, Barcelona, Spain *Corresponding author. Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, Universitat Auto`noma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain. Tel: +34-93-274-6090; Fax: +34-93-489-4091; E-mail:
[email protected] /
[email protected]
Keywords: CRBSIs, Gram-negative bacteria, antimicrobial
therapy Sir, Marcos et al.1 recently published an epidemiological study reporting an increasing incidence of Gram-negative bacteria in central venous catheter-related bloodstream infections (CRBSIs) in their setting from 1991 to 2008. The authors concluded that, if similar data are found in other series, current management of CRBSIs should be revised. The latest Infectious Diseases Society of America (IDSA) guidelines for empirical antimicrobial therapy only recommend routine coverage for Gram-positive bacteria, whereas coverage for Gramnegative microorganisms is reserved for certain circumstances (critically ill or neutropenic patients, those with a femoral catheter and patients with a known Gram-negative infection).2 In this regard, generalization of broad-spectrum empirical therapy in common infections such as CRBSIs could lead to adverse ecological effects and a potential increase in the incidence of nosocomial infections due to multidrug-resistant bacteria.3 In order to contrast the results reported by Marcos et al.,1 we conducted a descriptive study to investigate the microbiological epidemiology of CRBSIs in our setting, a 1200 bed teaching hospital, from January 2007 to December 2010.
Data were collected from a daily updated database of all patients with CRBSIs, which is part of a continuous, laboratorybased, prospective surveillance programme for hospital-acquired bacteraemia in our general hospital. All adults with CRBSIs are diagnosed by conventional criteria according to IDSA guidelines and are evaluated, treated and followed-up by infectious disease specialists. The main results [episodes of CRBSIs, episodes of CRBSIs due to Gram-negative bacteria (GN-CRBSIs), percentage of GN-CRBSIs relative to overall CRBSI cases and incidence rates] are shown in Table 1. A significant increase over time in the number of GN-CRBSIs in relation to the total CRBSI cases occurred exclusively in our critical care units, whereas the percentage has remained stable (even showing a slight decrease in 2010) in the conventional wards. Analysis of the incidence rates yielded a progressive decrease in CRBSIs (from 0.54 to 0.31 episodes/1000 patient-days) that was more evident in critical care units (from 3.17 to 1.12 episodes/ 1000 patient-days) than in the remaining hospital wards. These epidemiological findings, which differ from those reported by Marcos et al.,1 can be explained by implementation of a bundled strategy for CRBSI prevention in our hospital, starting in 2008. This strategy consisted of multifaceted interventional and educational programmes for all involved staff to improve compliance with evidence-based recommended practices regarding the insertion, maintenance and removal of catheters.4 This approach has resulted in a significant decrease in the overall incidence of CRBSIs, but not of GN-CRBSIs. Similar results have been reported by other authors, who observed an important decrease in the percentages of Gram-positive and fungal CRBSIs with implementation of a multifaceted strategy.5 In conclusion, knowledge of the epidemiological trends in CRBSIs in our setting has prompted physicians to continue with the current recommendations for empirical treatment. Gramnegative coverage is mainly considered for critically ill patients, which is precisely the patient profile in critical care units, the only wards where the percentage of GN-CRBSIs is increasing. Our experience illustrates the importance of having local data to enable adaptation of the general recommendations proposed by global agencies.
Transparency declarations None to declare.
References 1 Marcos M, Soriano A, In˜urrieta A et al. Changing epidemiology of central venous catheter-related bloodstream infections: increasing
# The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail:
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1565
1566
41.37 8.57 12.50 19.79
prevalence of Gram-negative pathogens. J Antimicrob Chemother 2011; 66: 2119– 25.
12/0.46 3/0.01 4/0.03 19/0.06
2 Mermel LA, Allon M, Bouza E et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49: 1 –45. 3 Anderson DJ, Kaye KS. Controlling antimicrobial resistance in the hospital. Infect Dis Clin North Am 2009; 23: 847–64, vii– viii.
29/1.12 35/0.22 32/0.27 96/0.31
4 O’Grady NP, Alexander M, Burns LA et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52: e162–93.
11/0.56 16/0.09 5/0.04 32/0.10
35.48 32.65 19.23 30.18
5 Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control 2011; 39: 640– 6.
31/1.59 49/0.30 26/0.23 106/0.36
J Antimicrob Chemother 2012 doi:10.1093/jac/dks093 Advance Access publication 19 March 2012
27.86 20.37 13.20 20.83
Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens –authors’ response
17/0.84 11/0.06 7/0.06 35/0.11
Alex Soriano1, Miguel Marcos1,2*, Jose´-Antonio Martı´nez1 and Josep Mensa1 1
61/3.04 54/0.32 53/0.46 168/0.55
Department of Infectious Diseases, Hospital Clı´nic of Barcelona, Barcelona, Spain; 2Department of Internal Medicine, University Hospital of Salamanca, Salamanca, Spain *Corresponding author. Tel: +34-923291437; Fax: +34-923294739; E-mail:
[email protected]
Keywords: CRBSIs, Gram-negative bacteria, antimicrobial
28.12 15.09 8.69 18.40 Incidence rate: episodes/1000 patient-days.
therapy
a
18/0.89 8/0.05 4/0.03 30/0.09 64/3.17 53/0.31 46/0.39 163/0.54 Critical care units Surgical wards Medical wards Overall
GN-CRBSIs, % n/incidence GN-CRBSIs GN-CRBSIs, % CRBSIs, n/incidence GN-CRBSIs n/incidencea GN-CRBSIs, % CRBSIs, n/incidence GN-CRBSIs n/incidencea GN-CRBSIs, % CRBSIs, n/incidence GN-CRBSIs n/incidencea CRBSIs, n/incidencea
2007
Table 1. Epidemiological trends in CRBSIs
2008
2009
2010
Letters to the Editor
Sir, We have read with interest the letter from Sorde´ et al.,1 where two aspects of our previous study2 are discussed: the need to implement a bundle of measures to reduce the incidence of catheter-related bacteraemia (CRB); and the rationale to start broad-spectrum empirical therapy including coverage for Gramnegative bacteria when CRB is suspected. We totally agree concerning the importance of implementing a bundle of measures to reduce the risk of CRB. In our hospital the incidence of CRB has been monitored since 1991, and our rate in 2007– 08 was 0.31 episodes/1000 patient-days,2 which is lower than those reported by Sorde´ et al.1 in 2007 and 2008 (0.54 and 0.55, respectively). Their implementation of a bundle of measures led to a significant decrease in the incidence of CRB in 2010 (0.31). Their data suggest, however, that preventive measures were capable of reducing mainly Gram-positive CRB, leading to an
