INTRODUCTION

With high-complexity technological advances, Intensive Care Units (ICU) are looking for the best way to provide treatment to their patients. It is a complex sector that ensures greater surveillance and mastery of critically ill patients¹, equipped with an uninterrupted monitoring system, which admits potentially complex patients, with intensive support and treatment that aim to serve the client in need safely and effectively, as to achieve their clinical improvement.^2.3

These advances have provided survival to people affected by diseases that were previously considered incurable. However, along with this improvement, other complications arise, including the increase of hospital-acquired infections (HAI)⁴.

HAI impacts on hospital lethality, length of hospital stay and costs. The increase in the number of infections varies according to the level of care of each hospital and its complexity: the hospitalization of more severe and immunocompromised individuals, added to the emergence of antimicrobial resistance, make HAI specially relevant for public health. In addition, developing countries may be up to twenty times more affected by HAI than developed countries⁵. Three factors are necessary to transmit infections in the hospital environment: the susceptible host; the means of transmission; and the sources of infection, which can be employees, patients, contaminated objects, surfaces, visitors and equipment⁶.

The transmission occurs, mainly, due to assistance failure of the multidisciplinary team, either by inadequate planning, incorrect execution of aseptic techniques or by non-compliance with standard precautionary guidelines, causing harm to the patient and economic and social burden, as well as suffering for the patients themselves and their families⁶.

It is worth mentioning that these events can be avoided, since they result from mistakes in the assistance itself. Ignoring standard patient safety precautions can increase infections, morbidity and mortality in health environments.^6-9 In addition to the damage caused to the patient’s health, a study in a tertiary-level hospital in Brazil found that more than 25% of hospital-acquired infections happen in the ICU, especially bloodstream infections in surgical sites and catheter-related infections, which had higher expenses within the ICU, respectively R$ 666.47 and R$ 803.59 per day⁷.

Intensive care unit patients undergo procedures that use invasive devices that increase infection rate, such as Central Venous Catheter (CVC), Indwelling Urinary Catheter (IUC) and Mechanical Ventilation (MV)⁸. Therefore, nursing is crucial within the Hospital Infection Control Service (HICS), as it plays a continuing education role for the entire care team, bringing knowledge and information aimed at improving infection control techniques.¹⁰

In view of these considerations, this study aims to understand the clinical profile of patients with HAI in the Adult Intensive Care Unit of a public hospital in the Federal District (DF), from January to December 2015.

METHODS

This is a documentary, retrospective and descriptive study. The study site was the ICU of the Asa Norte Regional Hospital (HRAN), considered a reference hospital in the Brazilian Midwest. The ICU of this hospital has ten beds for adults, eight of which are destined to general internal medicine and two to surgical clinic.

This is a public hospital, therefore, linked to the Unified Health System (SUS) and accredited by the Ministry of Education and the Brazilian Ministry of Health as a teaching hospital. Among the specialties, the hospital, which has approximately four hundred beds, is a reference in the care of burn injuries, cleft lip, CrisDown (care for patients with Down syndrome) and bariatric surgery.

The study population consisted of all patients who presented hospital-acquired infections (HAIs) in the Adult ICU from January to December 2015. Patients who were already hospitalized in the adult ICU before January 2015 were excluded from the study.

To collect the data, a script was elaborated containing the following variables: sex, date of birth, age, date of hospitalization, time prior to the ICU, origin and reason of hospitalization (general or surgical), days of hospitalization, invasive procedures, use of antibiotics, topography, date of discharge, type of discharge or death. Data were collected by the HRAN Hospital Infection Control Center in October 2016.

The results indicators and rate were calculated according to the definition of general standards, criteria and methods stipulated by the National Health Surveillance Agency (Anvisa) in the Diagnostic Criteria for Hospital-acquired Infections manual, 2nd edition, corrected on March 3rd, 2017⁴.

Data were collected through documents referring to the indicators of hospital infection of cultures carried out in 2015, with daily active search and registration in the Hospital Infection Control Commission (HICC) database.

For result analysis, a database was created in Microsoft Office Excel 2016; then, it was analyzed and presented through simple statistics. The Project was submitted to the Ethics Committee of the Health Sciences Education and Research Foundation (Fepecs) and approved under CAAE 61219410.3.0000.5553, with protocol number number 1.809.497. The study followed the recommendations of Resolution No. 466/2012 of the National Health Council.

RESULTS

Out of the 151 hospitalizations in the Adult ICU in 2015, 51 patients met the inclusion criteria for the study, as they presented diagnostic criteria for HAI (Table 1).

Among them, 22 (43.1%) were older adults – over 60 years old. Considering the unit of origin, most of the patients (n=10) came from the emergency room (41.6%), followed by 4 (16.7%), who came from the operating room and 1 (4.1%) from the burn injury unit (Table 1).

Table 2 describes the invasive procedures, topographies, antibiotic use and the type of discharge of patients with HAI in adult ICU.

DISCUSSION

In the studied hospital, we found 51 patients with HAI (34% of all ICU patients). Another study, conducted in Recife in 2015, found that between 20% and 50% of ICU patients present hospital-acquired infections.¹¹

Regarding the sociodemographic profile of the surveyed patients, the male sex patients (27, 53%) predominated in relation to females – 24 cases (47%). Two national studies that characterize hospital-acquired infections in ICU patients corroborate the data we found; one of them, conducted in 2010 in a philanthropic hospital in the state of Paraná, found that the infection rate predominates in males, with a percentage of 58.9%;¹²the other, conducted in 2006 at the teaching hospital of the University of São Paulo, presented data from a retrospective study finding higher infection incidence in males, with a percentage of 56.6%.¹³This is expected because the male sex is mistakenly considered protected from possible organic and psychological problems, distancing themselves from health care, especially preventive aspects; besides, they have low treatment adherence, which increases the number of infections. The literature points out other risk factors, such as homicide and suicide attempt that occur frequently, increasing the incidence of deaths or hospitalizations.¹⁴ These events, however, were not significant in this study.

The mean age of the population of this study was 56 years old. The largest share of hospitalizations, 29 (56.8%), was composed of adults. Twenty-two (43.1%) older adults were identified, who, in relation to younger patients, presented numerous risk situations that predisposed them to HAI, a condition that increases morbidity and mortality.¹⁵

The results regarding the reason for hospitalization indicated that 76.4% of the patients came from general internal medicine and 23.5% from surgical procedure – surgical (2) and clinical (8) beds. Another study pointed out similar results, with 39 general internal medicine patients.¹⁶

The HAI risk is closely related to the performed procedures, the nutritional conditions of the patients and the length of hospitalization, among other aspects.¹⁷ Thus, according to Table 2, the 51 (100%) patients underwent invasive procedures: 48 (94.1%) mechanical ventilation; 38 tracheostomy (74.5%); 51 indwelling urinary catheterization (100%); and 41 feeding tube (80.3%). These rates vary between 9% and 40% of infections acquired within the ICU. The high incidence is due to the invasive procedures to which patients are submitted.¹⁸

The most frequent infection in this study was pneumonia, associated with mechanical ventilation – 23 patients (45.1%). Colonization and aspiration of microorganisms from endogenous or exogenous microbiota are one of the main ways of acquiring ventilator-associated pneumonia (VAP).¹⁹ A study found that VAP – among hospital-acquired infections – has the highest incidence in ICU. It develops between 48 and 72 hours after tracheal intubation and may also appear 48 hours after extubation.¹⁸

In this study, urinary tract infection (UTI) associated with the indwelling urinary catheter was identified in 18 patients (35.2%). The interval registered by the National Health Surveillance Agency (Anvisa) has rates from 3.1 to 7.4/1,000 catheters/day.²⁰The risk of UTI-CR is directly related to how long the catheter is used: 2.5% in one day, 10% in two or three days and 12.2% in four or five days. The risk can reach 26.9% when the catheter permanence time is equal to or greater than six days.²¹

The UTI bundle – preventive measures packages – may vary between institutions. The main measures include avoiding using urinary catheters in situations where they are not properly indicated, implementing institutional protocols for early catheter insertion and removal (checklist or daily plan and interventions, such as electronic or manual reminders) and appropriate techniques for catheter insertion and maintenance (sterile insertion and closed drainage system).²¹

The implementation of prevention bundles has been proven to decrease patient exposure and the development of invasive device-related infection in up to 88%.²³

Therefore, when analyzing the factors associated with the occurrence of UTI – as well as the variables influenced by the performance of the professionals involved in this procedure – it is necessary to pay close attention to the nurse’s role, who should be active in the multidisciplinary team when evaluating ICU patients and discussing the use of the indwelling urinary catheter (IUC), as well as its insertion and maintenance.²⁴

The third most frequent infection found in this study was primary bloodstream infection, associated with the use of CVC – 16 patients (31.3%). The central venous catheter is frequently used in the care of patients requiring complex therapeutic interventions, usually with several venous punctures throughout treatment, which, added to the irritating and/or vesicant characteristics of each drug, can lead to vascular fragility and stiffening, making it difficult to visualize and puncture, which favors extravasation.²⁵ We would like to point out that, in ICU treatment, obtaining safe and reliable vascular access is extremely important so the patient is not exposed to risks.²⁵

Infections are the most well-known causes of death in patients with serious illnesses. More severe conditions (severe sepsis, septic shock and multiple organ dysfunction syndrome) are the main cause of ICU mortality.²⁶

Considered potentially severe, sepsis is characterized as a systemic reaction in the body. For the most part, epidemiological reports on sepsis come from developed countries.

In the ICU, bacteriuria associated with bladder catheter, urinary infections and ventilator-related pneumonias are found, all with high morbidity and mortality.¹⁵

Another study conducted in a teaching hospital in Recife found that 60% of HAI occur through four types of infections: UTI, pneumonia (RTI PAV) – usually associated with mechanical ventilation –, catheter-related bloodstream infection (CRBSI) and surgical site infection (SSI), which, within the ICU, represents between 14% and 17% of the infections.¹¹

The use of antimicrobials and the unit environment – which makes natural selection favorable to the development of microorganisms and, consequently, colonization and/or infection – are considered inadequate in approximately 50% of the cases.²⁷

These heavy, broad-spectrum antimicrobials, associated with routine invasive procedures, contribute to the increasing rates of HAI.²⁸As for the use of antimicrobials, only 2% of patients did not use them; even though antibiotics mean a major advance for medicine in the treatment of infections, when used indiscriminately they may cause microorganisms to develop mechanisms of resistance.²⁹

According to a study conducted in the ICU of a university hospital in the city of São Paulo, 50 patients acquired HAI and 19 of them died.¹⁶ In our study, in 2015, 51 patients were admitted to the ICU and diagnosed with hospital-acquired infection, 30 of them had a favorable outcome, with hospital discharge; 2 remained hospitalized and 19 died, all related to HAI. Therefore, there was no significant difference in the quantitative comparison of deaths between the two studies, even with the 10-year difference between them.

It should be emphasized that, regardless of all technology used, health professionals should join the campaign “Protecting million lives,” coordinated by the Healthcare Improvement Institute (HII), which promotes the prevention of infection in invasive procedures and recommends packages of preventive measures (bundles) that, individually, result in even more substantial improvements.³⁰

These bundles are evidence-based actions. When performed in an integrated, structured, uniform and reliable way, they improve the processes and results related to patient care.³¹

Thus, professional awareness is of paramount importance to increase patient safety in relation to bacterial transmission, effectively contributing to reduce HAI.

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the main causes of hospital infections. It increases morbidity and mortality rates, prolongs hospitalization and swells costs.³³

In a study conducted in China³³ with 1,347 patients, 102 had nosocomial (hospital) infection. Prevalence was 7.57%, with rates ranging from 7.19% to 7.73% over the three years of the study. Lower respiratory tract (43.1%), urinary tract (26.5%) and bloodstream infections (20.6%) were the most common. The most frequently isolated pathogens were Staphylococcus aureus (20.9%), Klebsiella pneumoniae (16.4%) and Pseudomonas aeruginosa (10.7%). Multivariate analysis showed that categories D or E of mean severity of the disease and the use of mechanical ventilator are the independent risk factors for infection³.

In a retrospective study with 65 patients hospitalized with liver cirrhosis, who had developed hospital-acquired infections, the epidemiology of these infections was examined regarding resistance to the most commonly used antimicrobials and the patient-specific risk factors associated with the development of pathogen infection.³⁴ The most frequently isolated organisms were Enterococcus spp. (. = 34, 52.3%), Klebsiellaspp. (. = 10, 15.4%) and e. coli (. = 6, 9.2%). Of these, 35 isolated organisms (53.8%) were identified as multidrug resistant bacteria (MDR) and 30 (46.2%) did not present MDR. The overall resistance to ceftriaxone was 92%. Thus, we emphasize the need for institutions to individualize protocols for the treatment of hospital-acquired infections, particularly in immunocompromised populations.³⁵

The emergence of multidrug-resistant bacteria is a challenge for physicians, who have limited therapeutic options. Contaminated environment surfaces are a potential reservoir for the transmission of many pathogens associated with health care. Pathogens can survive or persist in the environment for months and are a possible source of infection, when proper hygiene and disinfection procedures are inefficient.³⁷

Limitations in this study were the fact that this research was carried out in a single center, as well as the lack of evaluation of the patients’ basis diagnosis and, also, the way of access to data: medical records in which, supposedly, information is lost due to lack of details and quality of data. Data collection occurred retrospectively and, therefore, problems were noted in data records in the electronic registers. We were not allowed to collect the involved strains. Moreover, the reality analyzed was that of the ICU of the studied hospital.

This study allowed the identification of the sociodemographic profile and clinical characteristics of patients admitted to an ICU of a public hospital.

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