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Tropical Medicine & Surgery
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Case Control Study for Hospital Infections Caused by Gram-Negative Bacilli in Emergency Intensive Care Unit

WU Yu-qi1*, SHAN Hong-wei2 , YU Min1, QIAN Min1 , ZHANG Xin-Li1 , LÜ Xiao-Ling1 , CHEN Qun-xia3 and YANG Xin-yi2

1Critical Care Medicine, The People’s Hospital of Three Gorge University, The First People’s Hospital, China

2Department of Emergency, Shanghai Changzheng Hospital, Second Military Medical University, China

3Department of Pediatrics, Jinshan Maternal and Child Health Care Hospital, China

*Corresponding Author:
WU Yu-qi
The People’s Hospital of Three Gorge University
The First People’s Hospital
Yichang 443002, Hubei, China
Tel: 15871663872
E-mail: [email protected]

Received Date: May 28, 2013; Accepted Date: November 19, 2013; Published Date: November 21, 2013

Citation: Yu-qi W, Hong-wei S, Min Y, Min Q, Xin-Li Z, et al. (2013) Case Control Study for Hospital Infections Caused by Gram-Negative Bacilli in Emergency Intensive Care Unit. Trop Med Surg 1:155. doi: 10.4172/2329-9088.1000155

Copyright: © 2013 Yu-qi W, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: A case study was performed in EICU to evaluate the potential patient factors associated with hospital
infections caused by gram-negative bacilli in EICU.
Methods: We adopted the method of retrospective case-control study and multivariable logistic regression
analysis.
Results: Unvaried analysis revealed an association between numerous patient factors and multivariate analysis
revealed four factors to be associated independently with hospital infections caused by gram-negative bacilli:
Mechanical ventilation, Corticoid use, Length of stay, Coma.
Conclusion: We must have the comprehensive preventive measures to deal with the risk factor of hospital
infections in EICU.

Keywords

Hospital infections; Risk factor; Case cohort study

Abbreviations

CI 95: 95% Confidence Interview; EICU: Emergency Intensive Care Unit; OR: Odds Ratio

Introduction

Almost all hospitals face the problem of the hospital infections. To find out the risk factors and preventive methods of hospital infections in Emergency Intensive Care Unit (EICU), it has became the important method to understand the incidence and affecting factor of hospital infections and provide the basis for the preventing. Many investigations were conducted at home and abroad, but the domestic method described to study before accurately could not measure the strength of contraction between the factors with the hospital infections. For this purpose, adopted method of retrospective case-control study to be conducted. This study was designed to determine the patient risk factors that would prove useful in designing strategies to limit the spread of gram-negative bacilli. Reduction or elimination of these risk factors should extend the usefulness of antibiotic.

Patients and Methods

Patients In EICU, in the Department of Emergency of Changzhen Hospital, Shanghai, we investigated 146 ones as case (on January 2002-December 2006) who had hospital infections caused by Pseudomonas aeruginosa (43 case), Klebsiella pneumonia (43 case) and Anietobacter baumanniil (60 case), 35 cases as the control suffered from hospital infections caused by Escherichia coli, case-control study was conducted.

Diagnosis standard

According to hospital infections with the diagnosis standard established by National Ministry of Health, China, 2001.

Contents of the investigation and method

We adopt the method of retrospective case-control study. To fill blank with the factor in the table established.

Statistical analysis

To collect and arrange materials from their medical inpatients, set up data storage system and give a description of analysis. The data were analyzed by using the SPSS. The variables found to be predictors of hospital infections based on unvaried analysis were subjected to multivariable logistic regression analysis in order to identify a subset of variables for predicting infection. A p-value <0.05 was considered statistically significant.

The standard to exclude

The patients of automatic discharge were eliminated; the patients who can be separated by pathogenic bacteria without the infection symptom were eliminated too.

Results

The morbidity rate of hospital infections

On January 2002-December 2006, EICU received the 1950 patients; among in 1950 cases we investigated 146 ones as case who had hospital infections caused by Pseudomonas aeruginosa (43 case), Klebsiella pneumonia (43 case) and Anietobacter baumanniil (60 case). The morbidity rate was 2.94%, 2.94%, 3.07%. Female 61 cases, Male 85 cases.

Risk factors for hospital infections

Unvaried analysis of risk factors for hospital infections caused by gram-negative bacilli: Risk factors of Pseudomonas aeruginosa are Mechanical ventilation, Mechanical ventilation time, Stay in EICU (d), Corticosteroid use, Coma, Length of stay, Tracheotomy, Repeat endotracheal intubations, Intra-abdominal operation; Risk factors of Klebsiella pneumoniae are Mechanical ventilation time (d), Length of stay (d), Stay in EICU (d), Tracheotomy, Coma, Intra-abdominal operation, Mechanical ventilation, Length of stay>31d; Risk factors of Anietobacter baumanniil are Mechanical ventilation time (d), Intra abdominal operation, Mechanical ventilation ,Corticosteroid use, as opposed to Escherichia coli. Gender, Age, Urinary catheter and so on is not the risk factor (Tables 1-3).

Variable   Control(35) Case (43) χ2 P-value
Age (y)   51.4 ± 20.79 53.56±18.85 t=-0.461 0.646
Treatment duration (d)   36.96 41.57 Z =-0.895 0.371
Time to initial hospital infection (d)   38.74 40.12 Z =-0.267 0.790
Mechanical ventilation time (d)   27.16 49.55 Z =-4.679 0.000
Length of stay (d)   31.37 46.13 Z =-2.860 0.004
Stay in ICU (d)   31.33 46.15 Z =-2.875 0.004
Gender (%) female 12 (34.28) 24 (55.81) 0.026 0.872
male 23 (65.71) 19 (44.18)
Age (%) >60 13 (37.14) 15 (34.88) 0.797 0.671
30-60 14 (40) 21 (48.83)
0-30 8 (22.85) 7 (16.27)
Hypoalbuminemia (%) yes 11 (31.42) 17 (39.53) 0.551 0.458
no 24 (68.57) 26 (60.46)
Hepatic impairment (%) yes 22 (62.85) 27 (62.79) 0.257 0.612
no 13 (37.14) 16 (37.20)
H2 blocker (%) yes 24 (68.57) 35 (81.39) 1.722 0.189
no 11 (31.24) 8 (18.60)
Hyperglycemia requiring insulin (%) yes 9 (25.71) 17 (39.53) 1.658 0.198
no 26( 74.28) 26 (60.46)
Multiple operations (%) yes 7 (20) 14 (32.55) 1.547 0.214
no 28 (80) 29 (67.44)
Repeat blood transfusions (%) yes 25 (71.42) 35 (81.39) 1.080 0.299
no 10 (28.57) 8 (18.60)
Hypertension (%) yes 9 (25.71) 14 (32.55) 0.435 0.510
no 26 (74.28) 29 (67.44)
Total parenteral nutrition (%) yes 23 (65.71) 28 (65.11) 0.003 0.956
no 12 (34.28) 15 (34.88)
Cardiopulmonary resuscitation (%) yes 10 (28.57) 10 (23.25) 0.286 0.593
no 25 (71.42) 33 (76.74)
Urinary catheter (%) yes 30 (85.71) 39 (90.69) 1.046 0.306
no 5 (14.28) 4 (9.30)    
Length of stay (%) >60d 6 (17.14) 15 (34.88) 9.5 0.009
30-60d 10 (28.57) 19 (44.18)
0-30d 19 (54.28) 9 (20.93)
Repeat endotracheal intubations (%) yes 3 (8.57) 12 (27.9) 4.644 0.031
no 32 (91.42) 31 (72.09)
Tracheotomy (%) yes 18 (51.42) 37 (86.04) 11.121 0.001
no 17 (48.57) 5 (11.62)
Corticosteroid use (%) yes 12 (34.28) 31 (72.09) 11.149 0.001
no 23 (65.71) 12 (27.90)
Coma (%) yes 7 (20) 20 (46.51) 5.992 0.014
no 28 (80) 23 (43.49)
Mechanical ventilation (%) >3week 3 (8.57) 15 (34.88) 24.605 0.000
1-2week 5 (14.28) 19 (44.18)
<1week 27 (77.14) 9 (20.93)
Intra-abdominal operation (%) yes 22 (62.85) 11 (25.58) 10.984 0.001
no 13 (37.14) 32 (74.41)

Table 1: Univariate Analysis of the Risk Factors for the Hospital Infections Cause by Pseudomonas aeruginosa, as opposed to Escherichia coli.

Variable   Control(35) Case (43) χ2 P-value
Age (y)   53.74 ± 21.26 48.44 ± 20.13 t=1.155 0.252
Time to initial hospital infection (d)   38.59 40.24 Z =-0.322 0.747
Treatment duration (d)   40.06 39.05 Z =-0.196 0.845
Mechanical ventilation time  (d)   30.43 46.88 Z =-3.554 0.000
Length of stay (d)   32.61 45.10 Z =-2.423 0.015
Stay in ICU (d)   33.29 44.56 Z =-2.187 0.029
Gender (%) female 10 (28.57) 12 (27.9) 0.004 0.948
male 25 (71.42) 31 (72.09)
Age (%) >60Y 14 (40) 11 (25.58) 1.866 0.393
30-60Y 14 (40) 22 (51.16)
0-30Y 7 (20) 10 (23.25)
Hypoalbuminemia (%) yes 11 (31.42) 21 (48.83) 2.417 0.120
no 24 (68.57) 22 (51.16)
Repeat endotracheal intubation (%) yes 4 (11.42) 8 (18.60) 0.763 0.382
no 31 (88.57) 35 (81.39)
Hepatic impairment (%) yes 18 (51.42) 31 (72.09) 3.528 0.06
no 17 (48.57) 12 (27.90)    
Nasogastric tube (%)  yes 30 (85.71) 37 (86.04) 1.253 0.534
no 5(14.28) 6 (13.95)
Thoracic or abdominal drainage (%) yes 24 (68.57) 25 (58.13) 0.899 0.343
no 11 (31.42) 18 (41.86)
Corticosteroid use (%) yes 14 (40) 24 (55.81) 1.931 0.165
  no 21 (60) 19 (44.18)
  H2 blocker(%) yes 26 (74.28) 33  (76.74) 0.063 0.801
no 9 (27.71) 20 (46.51)
Multiple operations (%) yes 6 (17.14) 8 (18.60) 0.028 0.867
no 29 (82.85) 35 (81.39)
Repeat blood transfusions (%) yes 26 (74.26) 33 (76.74) 0.063 0.801
no 9(25.71) 10 (23.25)
Hypertension (%) yes 11 (31.42) 6 (13.95) 3.457 0.063
no 24 (68.57) 37 (86.04)
Total parenteral nutrition (%) yes 24 (68.57) 25 (58.13) 0.899 0.343
no 11 (31.42) 18 (41.86)
Tracheotomy (%) yes 19 (54.28) 34 (79.07) 5.442 0.020
no 16 (45.71) 9 (20.93)
Coma (%) yes 7 (20) 23 (53.49) 9.142 0.002
no 28 (80) 20 (46.50)
Intra-abdominal operation (%) yes 24 (68.57) 10 (23.25) 16.114 0.000
no 11 (31.42) 33 (76.74)
Mechanical ventilation (%) >3week 2 (5.714) 11 (25.58) 12.905 0.002
1-2week 6 (17.14) 16 (37.20)
<1week 27 (77.14) 16 (37.20)
Length of stay0-10d (%) yes 4 (11.42) 3 (7.00) 0.458 0.494
no 31 (88.57) 40 (93)
Length of stay11-20d (%) yes 7 (20) 3 (7.00) 2.928 0.087
no 28 (80) 40 (93)
Length of stay21-30d (%) yes 8 (22.85) 5 (11.62) 1.752 0.186
no 27 (77.14) 38(81.39)
Length of stay >31d (%) yes 16 (45.71) 32 (74.41) 6.717 0.010
  no 19 (54.28) 11 (25.58)

Table 2: Univariate Analysis of the Risk Factors for the Hospital Infections Caused by Klebsiella pneumoniae, as Opposed to Escherichia coli.

Variable   Control (35) Case (60) χ2 P-value
Age (y)   51.4 ± 20.79 52.48 ± 20.38 t=-0.228 0.820
Length of stay (d)   45.09 49.28 Z =-0.787 0.431
Time to initial hospital infection (d)   48.77 47.55 Z =-0.209 0.835
Mechanical ventilation time  (d)   38.84 53.34 Z =-2.556 0.011
Gender female (%) yes 12 (34.28) 25 (41.67) 0.937 0.333
no 23 (65.71) 35 (58.33)
Age (%) >60Y 13 (37.14) 22 (36.67) 0.356 0.837
30-60Y 14 (40) 27 (45)
0-30Y 8 (22.85) 11 (18.33)
Length of stay (%) >60d 6 (17.14) 16 (26.67) 1.128 0.569
30-60d 10 (28.57) 15 (25)
0-30d 19 (54.28) 29 (48.33)
Hypoalbuminemia (%) yes 11 (31.42) 24 (40) 0.698 0.403
no 24 (68.57) 36 (60)
Repeat endotracheal intubations (%) yes 3 (8.57) 10 (16.67) 1.226 0.268
no 32 (74.41) 50 (83.33)
Hepatic impairment (%) yes 20 (57.14) 33 (55) 0.041 0.839
no 15 (34.88) 27 (45)
Tracheotomy (%) yes 18 (51.42) 39 (65) 1.696 0.193
no 17 (48.57) 21 (35)
H2 blocker (%) yes 24 (68.57) 46 (76.66) 0.747 0.387
no 11 (31.42) 14 (23.33)
Hyperglycemia requiring insulin (%) yes 9 (25.71) 19 (31.67) 0.377 0.539
no 26 (74.26) 41 (68.33)
Multiple operations (%) yes 7 (20) 7 (11.67) 1.222 0.269
no 28 (80) 53 (88.33)
Repeat blood transfusions (%) yes 25 (71.42) 45 (75) 0.145 0.703
no 10 (28.57) 15 (25)
Hypertension (%) yes 9 (25.71) 15 (25) 0.006 0.938
no 26 (74.26) 45 (75)  
Total parenteral nutrition (%) yes 23 (65.71) 35 (58.33) 0.506 0.477
no 12 (34.28) 25 (41.66)
Cardiopulmonary resuscitation (%) yes 10 (28.57) 16 (26.67) 0.04 0.841
no 25 (71.42) 44 (73.33)
Urinary catheter (%) yes 30 (85.71) 54 (90) 0.397 0.529
no 5 (14.26) 6 (10)
Intra-abdominal operation (%) yes 22(62.85) 21 (35) 6.924 0.009
no 13 (37.14) 39 (65)
Mechanical ventilation (%) >3week 3 (8.57) 19  (31.67) 10.014 0.007
1-2week 5  (14.28) 14 (23.33)
<1week 27 (77.14) 27 (45) —. —.
Corticosteroid use (%) yes 12 (34.28) 37 (61.67) 6.636 0.010
no 23 (65.71) 23  (38.33)
Coma (%) yes 7 (20) 24 (40) 4.022 0.045
no 28 (80) 36 (60)
Thoracic or abdominal drainage (%) yes 23 (65.71) 27 (45) 3.305 0.051
  no 12 (34.28) 33 (55)

Table 3: Univariate Analysis of the Risk Factors for the Hospital Infections Caused By Anietobaxter baumanniil, as Opposed to Escherichia coli.

Multivariable logistic regression analysis of risk factors for hospital infections: Mechanical ventilation, Corticoid use, length of stay, Coma are the independent risk factors for hospital infections caused by gram-negative bacilli (Table 4).

Risk factor Regression coefficient SE P OR CI95
Pseudomonas aeruginosa’s Mechanical ventilation 1.414 0.433 0.001 4.112 1.758-9.618
Pseudomonas aeruginosa’s Corticosteroid use 1.262 0.578 0.029 3.532 1.137-10.976
klebsiella pneumoniae’s Length of stay 0.994 0.457 0.029 2.702 1.404-6.611
klebsiella pneumoniae’s Coma 1.588 0.770 0.039 4.894 1.081-22.146
Anietobacter baumanniil’s Mechanical ventilation 0.917 0.373 0.014 22.502 1.203-5.203

Table 4: Multivariate Logistic Regression of the Risk Factors for the Hospital Infections Cause by Gram-Negative Bacilli in EICU.

Site of hospital infections: The most common position of infection was lower respiratory tract and lung 54.79% (80/146), the second one was the urinary tract 15.06% (22/146), the 3rd one is in the abdomen cavity 8.21% (12/146), the other is in the chest 6.84% (10/146) and blood 6.84% (10/146), the wound 4.10% (6/146) and catheter 4.10% (6/146).

Discussion

Recent years have witnessed, Length of stay which the patients had the hospital infections was prolonged, were independently associated with hospital infections [1,2].

The research shows that length of stay of the case was much longer than the control, and length of stay in ICU of the case increase in significantly with literature. The researchers reported that length of stay for a long time is risk factor of the hospital infections infection. Some investigation showed the number of length of stay were prolonged more than one double [1,3]. The lengths of stay are the risk factor for the infection with klebsiella pneumoniae, a dramatic increase was observed when the lengths of stay was greater than 31 days. An explanation of those associations might be the fact that the hospital is an ecological niche, where the use of antimicrobial agents tends to create a selective pressure that promotes the emergence of resistant organisms and predisposes to colonization with such organisms [4].

The Mechanical ventilation time of case cause by Pseudomonas aeruginosa, Klebsiella pneumoniae and Anietobacter baumanniil was longer than Control, they were considered statistically significant. Rank-sum test (Z=-4.679, P=0.000; Z=-3.554, P=0.000; Z=-2.556, P=0.011).

There are many kinds of immunity mechanism in human beings, for example, anatomy barriers, Cough reflect, macrophage and leukocytemediated cellular immunity and humeral immunity [5]. Mechanical ventilation destroys anatomy barriers of body. It gave the chance, let the pathogenic bacteria invade body, and led to get hospital infection easily. It was observed by the case of the Pseudomonas aeruginosa and Anietobacter baumanniil [5,6]. Noninvasive ventilation (NIV) was as effective as conventional ventilation in improving gas exchange and was associated with fewer serious complications and shorter stays in the intensive care unit. The use of NIV instead of mechanical ventilation is associated with a lower risk of hospital infections, less antibiotic use, shorter length of ICU stay, and lower mortality [7,8].

Corticosteroid use is one of the risk factors of hospital infections, the group of the Pseudomonas aeruginosa was observed. Immune factor was damaged or suppressed by Corticosteroid therapy. It effected on host’s lymphocytes, monocytes/macrophages and others: Lymphocytes, Reversible lymphopenia, CD4 depletion (>50% reduction) [9] decreased proliferation and migration of lymphocytes [10], Impaired delayed-type hypersensitivity [11] Impaired natural killer cell cytotoxicity [12]. Decreased lymphokine production (interleukin-2, TNF -α, interleukin-12, interferon γ) Th1/Th2 deregulation of T-helper cells (decreased Th1 and increased Th2 cytokine production) Impaired phagocyte effecter cell function and cellular immune response [13]. Neutrophils: Impaired phagocytosis, degranulation and oxidative burst [10,14]. Reduced cytokine production [15] Impaired formation of nitric oxide. Defective adherence to endothelium, extravasations, and chemo taxis [14]. Inhibition of apoptosis [15] Monocytes/macrophages, Reversible monocytopenia (>40% reduction), Impaired phagocytosis and oxidative killing, decreased chemo taxis and migration to sites of inflammation, Impaired maturation of monocytes to macrophages [16].

Above all, as opposed to Escherichia coli, the independent risk factors of hospital infections caused by gram-negative bacilli are: Mechanical ventilation, Corticoid use, Length of stay and Coma.

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