Hostname: page-component-7c8c6479df-ph5wq Total loading time: 0 Render date: 2024-03-27T23:42:33.930Z Has data issue: false hasContentIssue false

Attributable Morbidity and Mortality of Catheter-Related Septicemia in Critically Ill Patients: a Matched, Risk-Adjusted, Cohort Study

Published online by Cambridge University Press:  02 January 2015

Lilia Soufir
Affiliation:
Service de réanimation polyvalente, Hôpital Saint-Joseph, Paris, France
Jean-François Timsit*
Affiliation:
Clinique de réanimation des maladies infectieuses, Hôpital Universitaire Bichat Claude-Bernard, Paris, France Service de réanimation polyvalente, Hôpital Saint-Joseph, Paris, France
Cédric Mahe
Affiliation:
Département de Biostatistique et Informatique Médicale, Hôpital Universitaire Saint-Louis, Paris, France
Jean Carlet
Affiliation:
Service de réanimation polyvalente, Hôpital Saint-Joseph, Paris, France
Bernard Regnier
Affiliation:
Clinique de réanimation des maladies infectieuses, Hôpital Universitaire Bichat Claude-Bernard, Paris, France
Sylvie Chevret
Affiliation:
Département de Biostatistique et Informatique Médicale, Hôpital Universitaire Saint-Louis, Paris, France
*
Réanimation polyvalente, Hôpital Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France

Abstract

Objective:

To determine the attributable risk of death due to catheter-related septicemia (CRS) in critically ill patients when taking into account severity of illness during the intensive-care unit (ICU) stay but before CRS.

Design:

Pairwise-matched (1:2) exposed-unexposed study.

Setting:

10-bed medical-surgical ICU and an 18-bed medical ICU.

Patients:

Patients admitted to either ICU between January 1, 1990, and December 31, 1995, were eligible. Exposed patients were defined as patients with CRS; unexposed controls were selected according to matching variables.

Methods:

Matching variables were diagnosis at ICU admission, length of central catheterization before the infection, McCabe Score, Simplified Acute Physiologic Score (SAPS) II at admission, age, and gender. Severity scores (SAPS II, Organ System Failure Score, Organ Dysfunction and Infection Score, and Logistic Organ Dysfunction System) were calculated four times for each patient: the day of ICU admission, the day of CRS onset, and 3 and 7 days before CRS. Matching was successful for 38 exposed patients. Statistical analysis was based on nonparametric tests for epidemiological data and on Cox's models for the exposed-unexposed study, with adjustment on matching variables and prognostic factors of mortality.

Results:

CRS complicated 1.17 per 100 ICU admissions during the study period. Twenty (53%) of the CRS cases were associated with septic shock. CRS was associated with a 28% increase in SAPS II. Crude ICU mortality rates from exposed and unexposed patients were 50% and 21%, respectively. CRS remained associated with mortality even when adjusted on other prognostic factors at ICU admission (relative risk [RR], 2.01; 95% confidence interval [CI95], 1.08-3.73; P=.03). However, after adjustment on severity scores calculated between ICU admission and 1 week before CRS, the increased mortality was no longer significant (RR, 1.41; CI95, 0.76-2.61; P=.27).

Conclusion:

CRS is associated with subsequent morbidity and mortality in the ICU, even when adjusted on severity factors at ICU admission. However, after adjustment on severity factors during the ICU stay and before the event, there was only a trend toward CRS-attributable mortality. The evolution of patient severity should be taken into account when evaluating excess mortality induced by nosocomial events in ICU patients.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1999

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Maki, DG, Goldmann, DA, Rhame, FS. Infection control in intravenous therapy. Ann Intern Med 1973;79:867887.Google Scholar
2. Snydman, DR, Gorbea, HF, Pober, BR, Majka, JA, Murray, SA, Perry, LK. Predictive value of surveillance skin cultures in total parenteral nutrition-related infections. Lancet 1982;2:13851388.CrossRefGoogle Scholar
3. Smith, RL, Meixler, SM, Stimberkoff, MS. Excess mortality in critically ill patients with nosocomial bloodstream infections. Chest 1991;100:164167.Google Scholar
4. Martin, MA, Pfaller, MA, Wenzel, RP. Coagulase-negative staphylococcal bacteremia. Mortality and hospital stay. Ann Intern Med 1989;110:916.CrossRefGoogle ScholarPubMed
5. Haley, RW, Schaberg, DR, Van Allmen, SD, McGowan, JE Jr. Estimating the extra-charge and prolongation of hospitalization due to nosocomial infections: a comparison of methods. J Infect Dis 1980;141:248257.CrossRefGoogle Scholar
6. Pittet, D, Tarara, D, Wenzel, RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1994;271:15981601.CrossRefGoogle ScholarPubMed
7. Gatell, JM, Trilla, A, Latorre, X, Almela, M, Mensa, J, Moreno, A, et al. Nosocomial bacteremia in a large Spanish teaching hospital: analysis of factors influencing prognosis. Rev Infect Dis 1988;10:203210.CrossRefGoogle Scholar
8. Cobb, DK, High, KP, Sawyer, RG, Sable, CA, Adams, RB, Lindley, DA, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992;327:10621068.Google Scholar
9. Pinilla, JC, Ross, DF, Martin, T, Crump, H. Study of the incidence of intravascular catheter infection and associated septicemia in critically ill patients. Crit Care Med 1983;11:2125.CrossRefGoogle ScholarPubMed
10. Arnow, PM, Quimosing, EM, Beach, M. Consequences of intravascular catheter sepsis. Clin Infect Dis 1993;16:778784.CrossRefGoogle ScholarPubMed
11. Rello, J, Ricart, M, Mirelis, B, Quintana, E, Gurgui, M, Net, A, et al. Nosocomial bacteremia in a medical-surgical intensive care unit: epidemiologic characteristics and factors influencing mortality in 111 episodes. Intensive Care Med 1994;20:9498.Google Scholar
12. Brun-Buisson, C, Abrouk, F, Legrand, P, Huet, Y, Larabi, S, Rapin, M. Diagnosis of central venous catheter-related sepsis, critical level of quantitative tips cultures. Arch Intern Med 1987;147:873877.Google Scholar
13. Knaus, WA, Draper, EA, Draper, MS, Douglas, PW, Zimmerman, JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818829.CrossRefGoogle ScholarPubMed
14. McCabe, WR, Jackson, GG. Gram negative bacteremia, I: etiology and ecology. Arch Intern Med 1962;110:847855.CrossRefGoogle Scholar
15. Legall, JR, Lemeshow, S, Saulnier, F. A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 1993;270:29572963.Google Scholar
16. Knaus, WA, Draper, EA, Wagner, DP, Zimmerman, JE. Prognosis in acute organ-system failure. Ann Surg 1985;202:685693.Google Scholar
17. Fagon, JY, Chastre, J, Novara, A, Medioni, P, Gibert, C. Characterisation of intensive care unit patients using a model based on the presence or absence of organ dysfunctions and/or infections: the ODIN model. Intensive Care Med 1993;19:137144.Google Scholar
18. Le Gall, JR, Har, J, Lemeshow, S, Saulnier, F, Alberti, C, Artigas, A, et al. The Logistic Organ Dysfunction System. A new way to assess organ dysfunction in the intensive care unit. JAMA 1996;276:802810.Google Scholar
19. Lee, EW, Wei, LJ, Amato, DA. Cox-type regression analysis for large numbers of small groups of correlated failure time observations. In: Klein, JP, Goel, PK, eds. Survival Analysis: State of the Art. Boston, MA: Kluwer Academic Publishers; 1992:237247.Google Scholar
20. Lin, DY. MULCOX2: a general computer program for the Cox regression analysis of multivariate failure time data. Comput Methods Programs Biomed 1993;40:279293.CrossRefGoogle ScholarPubMed
21. Giraud, T, Dhainaut, JF, Vaxelaire, JF, Joseph, T, Journois, D, Bleichner, G, et al. Iatrogenic complications in adult intensive care unit: a prospective two center study. Crit Care Med 1993;21:4051.Google Scholar
22. Timsit, JF, Sébille, V, Farkas, JC, Misset, B, Martin, JB, Chevret, S, et al. Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients. A prospective randomized multicenter study. JAMA 1996;276:14161420.Google Scholar
23. Maki, DG, Stolz, SM, Wheeler, S, Mermel, LA. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter. A randomized controlled trial. Ann Intern Med 1997;127:257266.Google Scholar
24. Vincent, JL, Bihari, DJ, Suter, PM, Bruining, HA, White, J, Nicolas-Chanoin, MH, et al. The prevalence of nosocomial infection in intensive-care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. JAMA 1995;274:639644.CrossRefGoogle ScholarPubMed
25. Herwaldt, LA, Geiss, M, Kao, C, Pfaller, MA. The positive predictive value of isolating coagulase-negative staphylococci from blood cultures. Clin Infect Dis 1996;22:1420.CrossRefGoogle ScholarPubMed
26. Girou, E, Stephan, F, Novara, A, Safar, M, Fagon, JY. Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients. Am J Respir Crit Care Med 1998;157:11511158.Google Scholar
27. Timsit, JF, Chevret, S, Valcke, J, Misset, B, Renaud, B, Goldstein, FW, et al. Mortality of nosocomial pneumonia in ventilated patients: influence of diagnostic tools? Am J Respir Crit Care Med 1996;154:116123.Google Scholar
28. Yzerman, EPF, Boelens, HAM, Tjhie, JHT, Kluytmans, JAJW, Mouton, JW, Verbrugh, HA. Delta APACHE II for predicting course and outcome of nosocomial Staphylococcus aureus bacteremia and its relation to host defense. J Infect Dis 1996;173:914919.CrossRefGoogle ScholarPubMed
29. Pittet, D, Thiévent, B, Wenzel, RP, Li, N, Auckenthaler, R, Suter, MP. Bedside prediction of mortality from bacteriemic sepsis: a dynamic analysis of ICU patients. Am J Respir Crit Care Med 1996;153:684693.Google Scholar