Colonization, infection and dissemination in intensive care patients

University dissertation from Stockholm : Karolinska Institutet, Department of Clinical Sciences

Abstract: Nosocomial infections are a substantial problem in hospitals all over the world and the incidence is among the highest in the intensive care unit, affecting mortality and morbidity for the individual patient and cost for the society. In order to prevent these infections it is important to gain knowledge about colonization and infection pathways as well as about bacterial dissemination between patients. The overall aim of the present study was to investigate bacterial and fungal colonization pattern, dissemination pattern within and between patients and the incidence of some ICU-acquired infections in intensive care patients, treated in a multidisciplinary Swedish university hospital ICU. Colonization and dissemination patterns of microorganisms were studied by microbiological analyses and antimicrobial susceptibility was monitored over time. Subtyping was performed by using phenotyping as well as genotyping methods, such as the Phene-Plate system and PFGE (pulsed-field gel-electrophoresis). Fungal colonization index and other risk factors for acquiring invasive candida infection, were studied in patients with a length of stay of at least 7 days. In addition, the status of the immunosystem was monitored with HLA-DR expression once a week in these patients. The main results and conclusions of this thesis can be summarized as: ' Intubated intensive care patients are often heavily colonized in the lower airways with potentially pathogenic microorganisms, aerobic and anaerobic bacteria as well as yeasts. ' Different colonization routes were demonstrated for different species; primary colonization of the oropharynx or concomitantly in the lower airways, was shown for Staphylococcus, Enterococcus, Enterobacteriaceae and Candida spp., while Pseudomonas spp. and other non-fermenting gram-negative rods and several anaerobic species often primarily colonized the trachea. ' The dissemination rate of CoNS between ICU patients was high, 70% of patients treated for more than 3 days were involved in at least one transmission event. ' Prolonged ICU stay was correlated to an increased rate of cross-transmission between patients as well as a significant higher risk of being colonized with multi-resistant strains. ' Diversity of colonizing CoNS was significantly decreased in ICU patients with a length of stay of at least 5 days. ' Resistant clones were shown to be increasingly and endogenously spread over time within the patient¡¯s skin and mucosal membranes. ' The incidence of invasive candida infections was high in the ICU patient population studied, despite a frequent use of antifungal agents, probably due to that the majority of the patients were burdened by several risk factors. ' High colonization index (¡Ý 0.8) and recent extensive abdominal surgery was identified as significant risk factors for acquiring invasive candida infection in ICU patients with a length of stay of at least 7 days. In conclusion, the results of the present study emphasize the importance of compliance to barrier treatment, implementation and continuously follow-up of infection control programmes. Furthermore, the results underline the importance of a prudent use of antimicrobial agents for therapy and prophylaxis, based on daily reconsideration of the treatment according to microbiological and laboratory results and the patient¡¯s condition, especially in this vulnerable patient population.

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