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Vol. 45. Issue 8.
Pages e25-e28 (November 2021)
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Vol. 45. Issue 8.
Pages e25-e28 (November 2021)
Scientific Letter
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Organization of attention to infectious pathology in critical care units in Spain
Organización de la atención a la patología infecciosa en las unidades de críticos de España
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P. Vidal-Cortésa,b,c,
Corresponding author
pablo.vidal.cortes@sergas.es

Corresponding author.
, X. Nuvials-Casalsc,d, E. Maseda-Garridob,e,f, S. Sancho-Chinestab,c,g, B. Suberviola-Cañasb,c,h, R. González-Castrof,i, M. Nieto-Cabrerab,c,j, E. Díaz-Santosc,k, G. Aguilarb,f,l
a Intensive Care Unit, Complexo Hospitalario Universitario de Ourense (CHUO), Ourense, Spain
b Infectious Diseases in the Critically Ill Patient Study Group of Spanish Society for Infectious Diseases and Clinical Microbiology (GEIPC-SEIMC), Spain
c Infectious Diseases and Sepsis Working Group of Spanish Society for Intensive Care Medicine, Critical Care Medicine and Coronary Units (GTEIS-SEMICyUC), Spain
d Intensive Care Unit, Hopital Universitari Vall d’Hebron, Barcelona, Spain
e Anaesthesiology and Surgical Critical Care Unit, Hospital Universitario La Paz, Madrid, Spain
f Perioperative Infections Working Group of Spanish Society for Anesthesiology, Resuscitation and Pain Therapy (GTIPO-SEDAR), Spain
g Intensive Care Unit, Hospital Universitari I Politècnic La Fe, Valencia, Spain
h Intensive Medicine, Hospital Universitario Marques de Valdecilla, Santander, Spain
i Department of Anaesthesiology, Hospital Universitario de León, León, Spain
j Intensive Care Unit, Hospital Clínico San Carlos, Madrid, Spain
k Intensive Care Unit, Hospital Universitari Parc Taulí, Sabadell, Spain
l Department of Anaesthesiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
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Tables (2)
Table 1. Main findings of our survey.
Table 2. Scheduled training in infectious diseases during the training period.
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Dear Editor,

Both treatment and prevention of infections are an essential part of the daily routine of Intensive Care Units (ICU, assigned to Intensive Care Medicine Service) and Reanimation Units (RU, assigned to Anesthesia and Reanimation Service)

The incidence of sepsis on admission or during the stay in these units is high 1 so,1 this experience has made intensivists play an important role in the development of Sepsis Code (SC).2–4

In the field of prevention of healthcare-related infections (HCRI), the Program for Safety in the Critically Ill Patient has been developed by the Spanish Society of Intensive Care Medicine (SEMICYUC), which consists of preparing and implementing the Zero Projects (ZP): Zero Bacteremia (ZB), Zero Pneumonia, Zero Resistanceand Zero Urinary Tract Infection (Z-UTI).5

Antimicrobial Stewardship Programs (ASP),6,7 with the aim of improving the clinical outcome of infected patients and minimizing adverse effects of antibiotics (including appearance and spread of antimicrobial resistance), have a wide margin of action in critical care units, both as part of hospital ASP or as specific ICUs programs.8,9

In order to measure the degree of implementation of SC, ZP and ASP, and the role played by intensivists/anesthesiologists, the main national study groups of infection in critically ill patient (GEIPC-SEIMC, GTEIS-SEMICYUC and GTIPO-SEDAR) designed an online questionnaire that was mailed (in January 2019) to all members of the aforementioned groups requesting the response of the department heads.

We received answers from 118 units and 103 hospitals. Table 1 summarizes our main findings. Qualitative variables were compared using Chi-square.

Table 1.

Main findings of our survey.

  Overall  ICU  RU  p  By number of hospital bedsp 
          <200  200–500  >500   
n (%)  118  68 (57.6)  50 (42.4)    13 (12.6)  47 (45.6)  43 (41.7)   
Antimicrobial stewardship programs
ICU or RU ASP  44 (37.3)  31 (45.6)  13 (26)  0.03  3 (21.4)  18 (34.6)  23 (44.2)  0.255 
Relation with hospital ASP
The same ASP  8 (18.2)  4 (12.9)  4 (30.8)    1 (33.3)  3 (16.7)  4 (17.4)   
Independent ASPs  10 (22.7)  9 (29)  1 (7.7)    2 (66.7)  5 (27.8)  3 (13)   
Coordinated ASPs  26 (59.1)  18 (58.1)  8 (61.5)    10 (55.6)  16 (69.6)   
Members of ICU or RU ASP
Intensive Care Medicine  33 (75)  31 (100)  2 (15.4)  <0.001  3 (100)  14 (77.9)  16 (69.6)  0.488 
Anaesthesiology  9 (20.5)  9 (69.2)  <0.001  3 (16.7)  6 (26.1)  0.502 
Infectious Diseases  10 (22.7)  4 (12.9)  6 (40)  0.016  2 (11.1)  8 (34.8)  0.124 
Pharmacy  7 (15.9)  4 (12.9)  3 (23.1)  0.400  2 (11.1)  5 (21.7)  0.482 
Microbiology  9 (20.5)  6 (19.4)  3 (23.1)  0.780  4 (22.2)  5 (21.7)  0.661 
Sepsis Code
Active Sepsis Code  51 (49.5)        5 (38.5)  23 (53.5)  23 (48.9)  0.633 
Sepsis Code Components
Management protocol  48 (94.1)        5 (100)  22 (95.7)  21 (91.3)  0.691 
Educational program  32 (62.7)        2 (40)  15 (65.2)  15 (65.2)  0.541 
Early detection system  41 (80.4)        2 (40)  19 (82.6)  20 (87)  0.053 
Rapid response team  24 (47.1)        1 (20)  10 (43.5)  13 (56.5)  0.299 
Sepsis unit  15 (29.4)        1 (20)  7 (30.4)  7 (30.4)  0.888 
Sepsis Code Members
Intensive Care Medicine  43 (84.3)        3 (60)  22 (95.7)  18 (78.3)  0.078 
Anaesthesiology  19 (37.3)        1 (20)  12 (52.2)  6 (26.1)  0.132 
Infectious diseases  33 (64.7)        2 (40)  15 (65.2)  16 (69.6)  0.455 
Emergency Medicine  42 (82.4)        4 (80)  18 (78.3)  20 (87)  0.734 
Pharmacy  25 (49)        3 (60)  10 (43.5)  12 (52.2)  0.735 
Microbiology  39 (76.5)        3 (60)  19 (82.6)  17 (73.9)  0.517 
Surgery  18 (35.3)        2 (40)  10 (43.5)  6 (26.1)  0.455 
Pneumology  7 (13.7)        1 (20)  3 (13)  3 (13)  0.912 
Sepsis Code Coordinator*
Intensive Care Medicine  37 (72.5)        1 (20)  21 (91.3)  15 (65.2)  0.003 
Anaesthesiology  5 (9.8)        1 (20)  2 (8.7)  2 (8.7)  0.722 
Infectious Diseases  14 (27.5)        1 (20)  5 (21.7)  8 (34.8)  0.586 
Emergency Medicine  9 (17.6)        1 (20)  3 (13)  5 (21.7)  0.734 
Pharmacy  2 (3.9)        1 (4.3)  1 (4.3)  0.893 
Microbiology  6 (11.8)        4 (17.4)  2 (8.7)  0.455 
Zero Projects
ENVIN  87 (73.7)  65 (95.6)  22 (44)  <0.001         
Zero Bacteremia  92 (78)  61 (89.7)  31 (62)  <0.001         
Zero Pneumonia  88 (74.6)  60 (88.2)  28 (56)  <0.001         
Zero Resistance  77 (65.3)  58 (85.3)  19 (38)  <0.001         
Zero-UTI  74 (62.7)  55 (80.9)  19 (25.7)  <0.001         
Reference expert in infectious diseases
Overall  95 (80.5)  59 (86.8)  36 (72)  0.045  8 (57.1)  43 (82.7)  44 (84.6)  0.061 
Intensive Care Medicine  56 (58.9)  56 (94.9)           
Anaesthesiology  31 (32.6)  31 (86.1)           
Infectious Diseases  7 (7.4)  2 (3.4)  5 (13.9)           
Pharmacy  1 (1.1)  1 (1.7)           
Stipulated dedication  24 (25.2)  14 (23.7)  10 (27.8)  0.659  1 (12.5)  9 (20.9)  14 (31.8)  0.347 
Exclusive dedication  2 (2.1)  1 (1.7)  1 (2.8)  0.721  2 (4.5)  0.306 
Dedicated time (hours)  2 (1, 3)  2 (1, 3.25)  1 (1.5, 3)  0.931  1 (0, 2.25)  1 (0, 2)  2 (0, 2)  0.19 
*

Sepsis Code Coordinator: 18 Sepsis Code have at least two coordinators, with the combination Intensive Care Medicine-Infectious Disease-Emergency Medicine being the most frequent.

We observed that ZP is implemented in most units, ranging from 62.7% for Zero-UTI (the latest program) to 78.0% for ZB. We must bear in mind that adherence is higher in ICUs (80.9% of ICUs have joined Zero-UTI and up to 89.7% take part in ZB; compared to RUs, in which only 25.7% have implanted Zero-UTI, increasing to 62% for ZB. 3 out of every 4 units uses the Spanish Study for Monitoring Nosocomial Infection (ENVIN, developed by SEMICYUC) as a monitoring tool for HCRI. Its use is widespread in ICUs (95.6%) and scarce in RUs (44%).

Less than half of hospitals have an active SC, 38.5% in the smallest. SC have several components: 94.1% of SC have a protocol; early detection systems are the next most commonly implemented component (80%), and only 29.4% SC have a team specifically focused on sepsis management. The role of intensivists in SC is remarkable: they are only absent in 15.7 and coordinate 72.5%. Also notable is the role of Emergency Medicine physicians, who are present in 82.4% of teams and especially important in the smallest hospitals.

Only 37.3% of units have an ASP, being more common in large hospitals. In general, the ICU-RU ASP works in a coordination with the hospital ASP although it is notable that 29% of ICU-ASPs are independent. At least one intensivist participates in all ICU-ASPs, supported essentially by the Microbiology Department. The composition of RU-ASP is heterogeneous with the participation of specialists from Infectious Diseases (ID), Pharmacy and Microbiology units, in addition to anesthesiologists themselves.

It is noteworthy that 80.5% of units have a reference expert in infectious diseases; more frequent in ICUs (86.8%) than in RUs (72.0%) (p=0.045) and, often, a specialist from the unit itself (94.9% of ICUs and 86.1% of RUs). Despite the workload of these programs, only 25.2% of reference experts have a reserved daily work time dedicated to these programs.

A high percentage of units taking part in our study train residents in Intensive Care Medicine (ICM) or Anesthesiology (Table 2). Less than half of residents have a scheduled stay in an ID unit, being more common among ICM residents (62.5% vs 22.7%, p<0.001). Stays in the Microbiology Department are anecdotal. We have observed a significant discrepancy between the importance attributed to sepsis and antibiotic courses (according to the perception of the person who answers the survey) and the number of residents who have these courses scheduled.

Table 2.

Scheduled training in infectious diseases during the training period.

  Overall  Intensive Care Medicine  Anaesthesiology and Reanimation  p 
Specialized training  92 (78)  48 (70.6)  44 (88)  0.024 
Stay in Infectious Diseases Unit  40 (43.5)  30 (62.5)  10 (22.7)  <0.001 
First training year  22 (23.9)  17 (35.4)  5 (11.4)   
Second training year  14 (15.2)  12 (25)  2 (4.5)   
Third training year  4 (4.3)  2 (4.2)  2 (4.5)   
Fourth training year  3 (3.3)  2 (4.2)  1 (2.3)   
Fifth training year   
Stay duration (months)  2 (1, 2)  2 (2, 3)  1 (10, 1.75)  0.009 
Stay in Microbiology Department  3 (3.3)  3 (6.3)  0 (0)  0.09 
Sepsis Course Importance (1–10)  10 (8, 10)  10 (8, 10)  10 (8.25, 10)  0.3 
Scheduled Antimicrobial Course  55 (59.8)  28 (58.3)  27 (61.4)  0.767 
Antibiotics Course Importance (1–10)  10 (8.25, 10)  9.5 (9, 10)  10 (9, 10)  0.22 
Scheduled Antibiotics Course  49 (53.3)  23 (47.9)  26 (59.1)  0.283 

Our study has detected important differences between ICUs and RUs. First, adherence to ZP is significantly higher in ICUs than in RUs. Secondly, the number of ICUs in which an ASP has been implanted is significantly higher than RUs. Thirdly, the participation of intensivists in SC is greater; leading most of the active SCs in Spain. Finally, ICM resident training programs place greater importance to infectious diseases, with a greater number and longer stays in ID units.

The data provided by this study may be of interest to design strategies from scientific societies or autonomous communities, aimed at increasing the implantation of these programs. Given that HCRI prevention programs are broadly implanted, in our opinion, efforts should be directed at creating ASPs and SC, especially in hospitals with less than 200 beds (only 38.5% have a Sepsis Code and 21.4% an ASP for critically ill patients). Those units with more developed programs may serve as a model for others interested in developing them.

Another point for improvement detected is the lack of specific training in infectious diseases of residents in ICM and especially, Anesthesiology.

One of the limitations of this study is that participation was voluntary, and it is possible that just the units most interested in these programs have participated. Despite this, a good number of units took part and almost all Spanish Autonomous Communities were represented (16 of 17). The degree of real adherence to each project was not evaluated either.

From our results it could be inferred that, despite the existence of several programs related to infectious pathology in the critically ill patient (as SC, ZP and ASP), in ICUs and RUs of our environment, there are no structures or specialists with enough dedication to implant them optimally, follow them and coordinate them. We could hypothesize that initiatives such as SEMICYUC accreditation of experts in infectious pathology in the critically ill patient, together with allocation of specific resources to these programs (especially working time for specialists who lead them) would increase the number and quality of active programs.

Acknowledgements

We want to record our appreciation to the 118 colleagues who have answered the questionnaire and participated in this survey.

The authors thank the Illustrious Medical College of Ourense for their collaboration in the English translation of this article.

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Copyright © 2020. Elsevier España, S.L.U. and SEMICYUC
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