Staphyloccus aureus sepsis: follow- up practice guidelines

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Amberly McBride
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1 Staphyloccus aureus sepsis: followup practice guidelines March 17, 2012 National Study Day Hospital Antibiotic Stewardship prof. dr. Dirk Vogelaers, Ghent University Hospital apr. Franky Buyle, Ghent University Hospital 1

2 Content Introduction ABS Quality indicators Practice guideline Ghent University Hospital Follow-up 2 2

3 Staphylococcus aureus bacteraemia: background Styers D et al. Ann Clin Microbiol Antimicrob Feb 9;5:2. 3 3

4 Staphylococcus aureus bacteraemia: background adult SAB cases in Denmark between % hospital acquired, 28% community acquired, 15% undetermined acquisition Incidence increased form 18.2 to 30.5 cases per population CA cases: annual increase by 6.4% mortality decreased from 34.5% to 26.5% HA cases annual increase by 2.2% mortality decreased from 36.2% to 20.7% Benfield et al. Clin Microbiol Infect 2007;13:

undetermined acquisition Incidence increased form 18.2 to 30.5 cases per 100.

5 Benfield et al. Clin Microbiol Infect 2007;13:

6 Staphylococcus aureus bacteraemia: background It causes ~20% of all intravascular catheter-related bacteraemia and ~35% of endocarditis. Retrospective analysis of data from 994 hospitals in 28 states during 2000 and from 986 hospitals in 33 states during 2001, representing approximately 14 million inpatient stays determine the association of S aureus infections with length of stay, total charges, and in-hospital mortality 3 times the length of hospital stay (14.3 vs 4.5 days; P<.001) 3 times the total charges (48,824 US dollars vs 14,141 US dollars; P<.001) 5 times the risk of in-hospital death (11.2% vs 2.3%; P<.001) than inpatients without this infection. 6 6

inpatient stays determine the association of S aureus infections with length of stay, total charges, and in-hospital mortality 3 times the length of hospital stay (14.

7 Content Staphylococcus aureus bacteraemia Introduction ABS Quality indicators Practice guideline Ghent University Hospital Follow-up 7 7

8 ABS quality indicators EU project ABS International - Implementing antibiotic strategies for appropriate use of antibiotics in hospitals in member states of the European Union co-financed by the European Union, DG Health and Consumer Protection Objective Develop and validate process measures and quality indicators for AB (work package 5) Scientific Coordinator: Marc Struelens 8 8

European Union, DG Health and Consumer Protection Objective Develop and validate process measures and

9 ABS project Structure indicators: 48 selected (with top ten) Process indicators (11) Prophylaxis: 4 selected Surgical prophylaxis (4) Antibiotic prophylaxis given perioperatively for surgical interventions when indicated Appropriate antibiotic choice for prophylaxis for surgical interventions according local guidelines Prophylaxis is started preoperatively within 60 minutes before incision for surgical interventions Prophylactic antibiotic is discontinued within 24 hours after surgery end time Therapy: 7 selected CAP (3) Performing blood cultures within the first 24 hours after admission in CAP patients Appropriate empiric therapy for CAP according to local practice guideline Performing Legionella urinary antigen test within 24 hours after admission in CAP patients IV/PO switch (1) Inappropriate fluoroquinolones, clindamycin, linezolid, metronidazole treatment by IV route according to local IV/PO switch guidelines SAB (3) 9 9

incision for surgical interventions Prophylactic antibiotic is discontinued within 24 hours after surgery end time Therapy: 7 selected CAP (3) Performing blood cultures within the first 24 hours

10 Staphylococcus aureus bacteraemia: 3 indicators Number off patients who have undergone echocardiography (Trans-oesophageal echocardiography (=TEE) or Transthoracic echocardiography (TTE ) within 10 days after SAB onset versus all community-onset SAB Patients who have their iv catheter (peripheral or central) present at SAB onset removed within 10 days after SAB onset versus patients with iv catheters in place at SAB onset (including confirmed and possible catheter-related infection) MSSAB patients receive 10 days of iv betalactam (penicillinase-stable in the case of penicillin resistance) therapy within 14 days of SAB onset versus all patients with MSSAB 10 10

removed within 10 days after SAB onset versus patients with iv catheters in place at SAB onset (including confirmed and possible catheter-related infection) MSSAB

11 Staphylococcus aureus bacteraemia: retrospective observational study Number of cases: 500 in 9 hospitals (3 Austria, 2 Belgium, 1 Czech Republic, 2 Germany, 1 Slovenia) Ratio female/male: 199/301 Mean age (SD): 61,5 (17.6) Workload for measuring CRF 26 min/crf 11 11

Czech Republic, 2 Germany, 1 Slovenia) Ratio female/male: 199/301

12 Staphylococcus aureus bacteraemia: results indicator

13 Staphylococcus aureus bacteraemia:type of echo performed 13 13

14 Staphylococcus aureus bacteraemia: results indicator

15 Staphylococcus aureus bacteraemia: results indicator 2 Device type Numerator Denominator Indicator rate Peripheral catheter ,80 Central catheter ,20 Permanent implanted catheter cardiac pacemaker other devices (e.g. shunt, prosthetic heart valve)

Central catheter 74 90 82,20 Permanent implanted catheter 26 51 51

16 Staphylococcus aureus bacteraemia: results indicator

17 Staphylococcus aureus bacteraemia: results Quality indicator, SAB Data Availability (%) Median (range) Hospital Performance Rate (%) Reliability (PP, Median (range) Kappa) ITT PP Case-mix stability gender/age SAB I ( echocardiography ) SAB II ( iv device removal ) SAB III ( iv betalactam therapy ) 97 (88-100) 89 (65-100) 87 (76-100) (9-75) 65 (30-78) 60 (38-74) 68 (10-75) 67 (47-90) 67 (44-82) y/y y/y y/y 17 17

SAB I ( echocardiography ) SAB II ( iv device removal ) SAB III ( iv betalactam therapy ) 97 (88-100) 89

18 Conclusion For S. aureus bacteraemia management, the QI bundle with the largest sample, median indicator rates ranged from 60 to 65%, with major interhospital performance variation. This indicates that these clinical procedures remain challenging in all centres All three QI were demonstrated to be generally feasible in the participating centres from 5 countries, reliable to measure in spite of the diverse expertise of data reviewers, and informative about local needs for further improvement towards the best standards of care. Data collection workload appeared reasonable (1 to 3 days working time by bundle)

19 NED TIJDSCHR GENEESKD. 2011;155:A

20 Results Ghent University Hospital 20 20

21 Content Introduction Staphylococcus aureus bacteraemia ABS Quality indicators Practice guideline Ghent University Hospital Follow-up 21 21

22 22 22

23 23 23

24 Criteria set for guiding echocardiography in nosocomial SAB Patients with nosocomial SAB: European cohort: INSTINCT (N = 304) American cohort: SABG (N = 432) Evaluation for presence of criteria, predicting increased risk of infective endocarditis: Prolonged bacteremia > 4 days Presence of permanent intracardiac device Hemodialysis dependency Spinal infection Nonvertebral osteomyelitis Kaasch A J et al. Clin Infect Dis. 2011;53:

25 Criteria set for guiding echocardiography in nosocomial SAB INSTINCT (N = 304) SABG (N = 432) Infective endocarditis 13 (4.3%) 40 (9.3%) Echocardiography (within 14d after pos blood culture) 39.8% 57.4% Most common prediction criteria: -Prolonged bacteremia -Intracardiac device 69.2% 53.8% 90% 32.5% Kaasch A J et al. Clin Infect Dis. 2011;53:

26 Kaasch A J et al. Clin Infect Dis. 2011;53:

27 Relative frequency of infective endocarditis by number of positive criteria (error bars denote exact 95% confidence intervals) in the Invasive S. aureus Infection Cohort (INSTINCT; n = 304) and S. aureus Bacteremia Group (SABG; n = 432) cohorts. Kaasch A J et al. Clin Infect Dis. 2011;53:

28 Kaasch A J et al. Clin Infect Dis. 2011;53:

29 Content Introduction Staphylococcus aureus bacteraemia ABS Quality indicators Practice guideline Ghent University Hospital Follow-up 29 29

30 Multidisciplinary infection team Systematic followup of all patients with S aureus bacteremia Including unsollicited consulting Daily multidisciplinary discussion in a forum of trainees, infectious disease consultants, medical microbiologists and clinical pharmacists 30 30

Hemodialysis catheter infection

Hemodialysis catheter infection Scary facts In 2006, 82% of patients in the United States initiated dialysis via a catheter The overall likelihood of Tunneled cuffed catheters use was 35% greater in 2005