Preventing Nosocomial Infections to Improve Outcomes of Intensive Care

  • Brun-Buisson C. 
Conference paper
Part of the Update in Intensive Care Medicine book series (UICMSOFT, volume 39)


There are few topics that have been subjected to such controversy as the question of the influence of nosocomial infections on outcomes, especially mortality, of critically ill patients. The topic is indeed of importance, since nosocomial infection (similarly to other iatrogenic* events) is a frequent event [1, 2, 3] and probably the most frequent drawback of intensive care, and determining outcomes attributable to nosocomial intensive care unit (ICU)-acquired infections is going to bear heavily on the design and interpretation of studies aimed at prevention or treatment of such infections. Therefore, the question whether prevention of nosocomial infection will result, or not, in improved outcome from intensive care is undermined by the uncertainty surrounding the consequences of infection on outcome. For example, it is apparent that if nosocomial infections do not influence mortality, there is no point in attempting to show a difference in mortality through implementation of a preventive or therapeutic intervention. In this circumstance, the impact of the intervention on other end-points such as length of stay or antibiotic use will be examined, and this has important imphcations in terms of study design and sample size needed. In this chapter, we shall examine the available data for the most common nosocomial infections occurring in ICU patients, in terms of their impact on mortality, length of stay and resource use, including antibiotics when available. Most such studies have focused on specific sites of infection, and these will be examined separately, after a brief overview of the problem. We shall then examine the evidence, if any, regarding to what extent preventing nosocomial infection may impact on outcome of critically ill patients, and the indicators that may be used for the purpose of quality improvement processes and follow-up.


Acute Respiratory Distress Syndrome Nosocomial Infection Intensive Care Unit Patient Intensive Care Unit Stay Hand Hygiene 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP (2000) Nosocomial infections in combined medical-surgical intensive care units in the United States Infect Control Hosp Epidemiol 21510–515PubMedCrossRefGoogle Scholar
  2. 2.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP (1999) Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System Crit Care Med 27887–892PubMedCrossRefGoogle Scholar
  3. 3.
    CDC. Nosocomial Infections Surveillance Activity, Hospital Infection Program, National Center for Infectious Diseases (2000) Monitoring hospital-acquired infections to promote patient safety — United States, 1990–1999 Morbidity and Mortality Weekly Report MMWR 49149–153Google Scholar
  4. 4.
    Vincent JL, Bihari D, Suter PM, et al (1995) The prevalence of nosocomial infection in intensive care in Europe. Results of the European prevalence of infection in intensive care (EPIC) study JAMA 274639–644PubMedCrossRefGoogle Scholar
  5. 5.
    Kauffman CA, Vazquez JA, Sobel JD, et al (2000) Prospective multicenter study of funguria in hospitalized patients Clin Infect Dis 3014–18PubMedCrossRefGoogle Scholar
  6. 6.
    Hanberger H, Garcia-Rodriguez J-A, Gobernado M, et al (1999) Antibiotic susceptibility among aerobic Gram-negative bacilli in intensive care units in 5 European countries JAMA 28167–71PubMedCrossRefGoogle Scholar
  7. 7.
    Kollef MH, Sherman G, Ward S, Fraser VJ (1999) Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients Chest 115462–474PubMedCrossRefGoogle Scholar
  8. 8.
    Le Gall JR, Klar J, Lemeshow S, et al (1996) The logistic organ dysfunction system: A new way to assess organ dysfunction in the intensive care unit JAMA 276802–810PubMedCrossRefGoogle Scholar
  9. 9.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score based on a European-North American multicenter study JAMA 2702957–2963PubMedCrossRefGoogle Scholar
  10. 10.
    Brun-Buisson C, Doyon F, Carlet J, et al (1995) Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units JAMA 274968–974PubMedCrossRefGoogle Scholar
  11. 11.
    Britt MR, Schleupner CJ, Matsumiya S (1978) Severity of underlying disease as a predictor of nosocomial infection. Utility in the control of nosocomial infection JAMA 2391047–1051PubMedCrossRefGoogle Scholar
  12. 12.
    Gross PA, DeMauro PJ, van Antwerpen C, Wallenstein S, Chiang S (1988). Number of comorbidities as a predictor of nosocomial infection acquisition Infect Control Hosp Epidemiol 9497–500PubMedCrossRefGoogle Scholar
  13. 13.
    Gross PA, van Antwerpen C (1983) Nosocomial infections and hospital deaths, A case-control study Am J Med 75658–662PubMedCrossRefGoogle Scholar
  14. 14.
    Gross PA, Neu HC, Aswapokee P, van Antwerpen C, Aswapokee N (1980) Deaths from nosocomial infections: experience in a university hospital and a community hospital Am J Med 68219–223PubMedCrossRefGoogle Scholar
  15. 15.
    Bueno-Cavanillas A, Delgado-Rodriguez M, Lopez-Luque A, Schaffmo-Cano S, Calvez-Vargas R (1994) Influence of nosocomial infection on mortality rate in an intensive care unit Crit Care Med 2255–60PubMedGoogle Scholar
  16. 16.
    Bueno-Cavanillas A, Contreras RR, Lopez-Luque A, Delgado-Rodriguez M, Galves-Vargas R (1991) Usefulness of severity indices in intensive care medicine as a predictor of nosocomial infection risk Intensive Care Med 17336–339PubMedCrossRefGoogle Scholar
  17. 17.
    Girou E, Stephan F, Novara A, Safar M, Fagon JY (1998) Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients Am J Respir Crit Care Med 1571151–1158PubMedGoogle Scholar
  18. 18.
    Girou E, Pinsard M, Auriant I, Canonne M (1996) Influence of the severity of illness measured by the simplified acute physiology score (SAPS) on occurrence of nosocomial infections in ICU patients J Hosp Infect 34131–138PubMedCrossRefGoogle Scholar
  19. 19.
    Digiovine B, Chenoweth C, Watts C, Higgins M (1999) The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit Am J Respir Crit Care Med 160976–981PubMedGoogle Scholar
  20. 20.
    Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S (1999). Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study Infect Control Hosp Epidemiol 20396–401PubMedCrossRefGoogle Scholar
  21. 21.
    Renaud B, Brun-Buisson C (2001) Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients Am I Respir Crit Care Med 1631584–1590Google Scholar
  22. 22.
    Mermel LA (2000) Prevention of intravascular catheter-related infections Ann Intern Med 132391–402PubMedGoogle Scholar
  23. 23.
    Wenzel RP (1998) Perspective: attributable mortality — the promise of better antimicrobial therapy Clin Infect Dis 178917–919Google Scholar
  24. 24.
    Leu HS, Kaiser DL, Mori M, Woolson RF, Wenzel RP (1989) Hospital-acquired pneumonia: attributable mortality and morbidity Am ] Epidemiol 1291258–1267Google Scholar
  25. 25.
    Fagon JY, Chastre J, Domart Y, Trouillet J-L, Gibert C (1996) Mortality due to ventilator-associated pneumonia or colonization with Pseudomonas or Acinetobacter species: assessment by quantitative culture of samples obtained by a protected specimen brush Clin Infect Dis 23538–542PubMedCrossRefGoogle Scholar
  26. 26.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C, The Canadian Crifical Care Trials Group (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient Am J Respir Crit Care Med 1591249–1256Google Scholar
  27. 27.
    Bregeon F, Papazian L, Visconti A, Gregoire R, Thirion X, Gouin F (1997) Relafionship of microbiologic diagnostic criteria to morbidity and mortality in patients with ventilator-associated pneumonia JAMA 277655–662PubMedCrossRefGoogle Scholar
  28. 28.
    Papazian L, Bregeon F, Thirion X, et al (1996) Effect of ventilator-associated pneumonia of mortality and morbidity Am J Respir Crit Care Med 15491–97PubMedGoogle Scholar
  29. 29.
    Timsit JF, Chevret S, Valcke J, et al (1996) Mortality of nosocomial pneumonia in ventilated patients: influence of diagnostic tools Am J Respir Crit Care Med 154116–123PubMedGoogle Scholar
  30. 30.
    Baker AM, Meredith JW, Haponik EF (1996) Pneumonia in intubated trauma patients. Microbiology and outcome Am J Respir Crit Care Med 153343–349PubMedGoogle Scholar
  31. 31.
    Hsieh AHH, Bishop MJ, Kubihs PS, Newell DW, Pierson DJ (1992) Pneumonia following closed-head injury Am J Respir Crit Care Med 146290–294Google Scholar
  32. 32.
    Chastre J, Trouillet J-L, Vuagnat A, et al (1998) Nosocomial pneumonia in patients with acute respiratory distress syndrome Am J Respir Crit Care Med 1571165–1172PubMedGoogle Scholar
  33. 33.
    Delclaux C, Roupie E, Blot F, Brochard L, Lemaire F, Brun-Buisson C (1997) Lower respiratory tract colonization and infection during severe acute respiratory distress syndrome. Incidence and diagnosis Am J Respir Crit Care Med 1561092–1098PubMedGoogle Scholar
  34. 34.
    Markowicz P, Wolff M, Djedaini K, et al (2000) Multicenter prospective study of ventilatorassociated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group Am J Respir Crit Care Med 1611942–1948PubMedGoogle Scholar
  35. 35.
    D’Amico R, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberafi A (1998) Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials Br Med J 3161275–1285CrossRefGoogle Scholar
  36. 36.
    Nathens AB, Marshall JC (1999) Selective decontamination of the digestive tract in surgical patients. A systematic review of the evidence Arch Surg 134170–176PubMedCrossRefGoogle Scholar
  37. 37.
    Nouira S, Marghli S, Belghith M, Besbes L, Elatrous S, Abroug F (2001 ) Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial Lancet 3582020–2025PubMedCrossRefGoogle Scholar
  38. 38.
    Maki DG (1989) Risk factors for nosocomial infection in intensive care. “Devices vs. nature” and goals for the next decade Arch Intern Med 14930–35PubMedCrossRefGoogle Scholar
  39. 39.
    Vieillard-Baron A, Girou E, Valente E, et al (2000) Predictors of mortality in acute respiratory distress syndrome. Focus On the role of right heart catheterization Am J Respir Grit Care Med 1611597–1601Google Scholar
  40. 40.
    Girou E, Schortgen F, Delclaux C, et al (2000) Association of non-invasive ventilation with nosocomial infections and survival in critically ill patients JAMA 2842361–2367PubMedCrossRefGoogle Scholar
  41. 41.
    Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D (2000) Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care Lancet 3551864–1868PubMedCrossRefGoogle Scholar
  42. 42.
    Pittet D, Mourouga P, Perneger TV (1999) Compliance with handwashing in a teaching hospital Ann Intern Med 130126–130PubMedGoogle Scholar
  43. 43.
    Pittet D, Hugonnet S, Harbarth S, et al (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene Lancet 3561307–1312PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2003

Authors and Affiliations

  • Brun-Buisson C. 
    • 1
  1. 1.Dept of Intensive CareHôpital Henri MondorCréteilFrance

Personalised recommendations