1. European Surveillance of Surgical Site Infections and ICU-acquired Infections, 2004-2008
Carl Suetens
Surveillance Unit European Centre for Disease Prevention and Control
7th HIS International Conference, Liverpool, October 2010

2. Standardized surveillance of Healthcare-Associated Infections in European hospitals
Surveillance of Surgical Site Infections (SSI)
Surveillance of ICU-acquired Infections (ICU)
Point Prevalence Surveys as alternative to hospital-wide surveillance of all HAI types (PPS)

3. Standardisation of SSI & ICU surveillance methods
Methodological differences between national protocols:
Fair agreement in 2000 for SSI surveillance (7 countries), similar to CDC/NNIS methodology
Larger differences for surveillance of ICU-acquired infections in 2000 (5 countries, 4 patient-based, 1 unit-based)
Agree on common surveillance methodology and case definitions: questionnaire (2000), meetings ( ), final protocols
Work towards standardized interpretation of standard methodology
Develop indicators that take into account inter-country differences in methodology and case-mix

4. Participation to HAI surveillance (HAI-Net), status in 2010
SIRO
NOIS
SSHAIP
INST HYG
HISC
PREZIES
NHS
HPA
NSIH
KISS
ANIS
RAISIN
NNSR
ASR
ENVIN
ISC III
HELICS
SPIN-UTI

5. Surveillance of Surgical Site Infections: EU methods vs CDC/NHSN
Same as CDC/NHSN methodology, except:
Hospital discharge date required
Options: ICD9-CM codes, post-discharge date & status
Selection of procedures: CABG, CHOL, COLO, CSEC, HPRO, KPRO, LAM
Indicators:
% SSI within 30 d / 1 year
% in-hospital SSI (post-discharge excluded)
Incidence density: # in-hospital SSI/1000 patient-days:
Adjustment for differences in post-discharge surveillance
Adjustment for differences in post-operative length of stay
Incidence density for Deep-Organ/Space infections only: adjustment for differences in reporting superficial infections
Stratification per NNIS risk index for all indicators

6. European surveillance of Surgical Site Infections
: protocol analysis, questionnaire, meetings
6 countries in 2000 => 12 countries (15 networks), 1422 hospitals in 2008

7. SSI cumulative incidence by operation category and year, 2004-2008

8. Surveillance of SSI in hip prosthesis, 2004-2008

9. Differences in post-discharge surveillance and type of SSI
Post-discharge SSI included
Post-discharge SSI excluded
Percentage of SSI detected after discharge from the hospital by surgical procedure

10. EU reference tables, e.g. SSI incidence density in HPRO

11. European surveillance of ICU-acquired infections
: protocol analysis, questionnaire, retrospective data analysis, meetings
Collaboration with ESICM
654 hospitals from 12 countries in 2008
2 levels:
Unit-based (minimal data, trends)
Patient-based: risk adjustment, Standardised Infection Ratio (Observed/Expected)

12. Surveillance of ICU-acquired infections

13. Patient-based surveillance in the ICU

14. Methodology of EU surveillance of ICU-acquired infections
Patients staying less than 3 days in the ICU excluded from denominators (different from US-NHSN/DE-KISS)
Length of stay in the ICU (days) by country

15. Methodology of EU surveillance of ICU-acquired infections
Case definitions differ from CDC/NHSN definitions:
Bloodstream Infections: include secondary BSI
Pneumonia:
based on CDC PNU definition, not identical
Intubator-Associated (IAP) vs Ventilator-Associated (VAP)
Definition of “nosocomial” or “ICU-acquired”: >48 h, in practice > Day 2, instead of “not present or in incubation at admission”
ECDC outsourced Concordance study of HAI case definitions CDC/NHSN vs. IPSE/HELICS ( , P. Gastmeier et al):
Quantify difference in case classification (concordance) => kappa
Results show excellent concordance (kappa>=0.99) for PN and primary BSI

16. HELICS case definition of pneumonia (2003) – also in ECDC PPS protocol
X-ray(s) + clinical symptoms (t°/wbc + sput./ronchi…)
PN1: protected sample + quantitative culture (104 CFU/ml BAL/103 PB,DPA)
PN2: non-protected sample (ETA) + quantitative culture (106 CFU/ml)
PN3: alternative microbiological criteria
PN4: sputum bacteriology or non-quantitative ETA
PN5: no microbiological criterion

17. Differences in diagnostic practices of ICU-acquired pneumonia, 2008

18. Date of onset pneumonia

19. Micro-organisms isolated in ICU-acquired infections, 2004-2008
Pneumonia
Bloodstream infections

20. EU reference tables, e.g. device-adjusted ICU-acquired pneumonia rates

21. Support to HAI surveillance : on-site HAI surveillance workshops
Technical support visit to help set up HAI surveillance networks (4 in 2010)
2 x ½ day workshop
Intensive Care (ICU), Surgical Site Infections (SSI) or both
Typically 20 participants from hospitals
Including case studies of HAI case definitions and computer exercises (HELICSwin)
+ support to national coordination team & installation of software tools
HAI surveillance workshop, Sofia, Nov 2009
Hungarian HELICSwin, Budapest workshop, June 2009

22. EU HAI surveillance integrated in TESSy
Pre-TESSY
TESSy = “The European Surveillance System” = ECDC’s online database, upload and reporting system for all communicable diseases under surveillance
Integration of all dedicated surveillance networks
October (4-8/10): HAI TESSy training for national surveillance coordinators and data managers

23. HAI surveillance: ICU & SSI now integrated in ECDC’s TESSy system

24. From IPSE to HAI-Net: What has changed?
Naming conventions:
Healthcare-Associated Infections: HAI instead of HCAI
IPSE => HAI-Net
Unit-based protocols: “level 1” => “light”
Patient-based protocols: “level 2” => “standard” (full)
Changes agreed at HAI surveillance Annual Meeting:
SSI: “Light” version, coverage, post-discharge method
ICU: Some variables/options dropped, AMR target list
New minimal AMR marker set (PPS)

25. Conclusions
Standardized surveillance of surgical site infections and ICU-acquired infections: based on HELICS/IPSE network, now continued by ECDC
27+ countries = 27+ opinions, but large majority in favour of agreeing on single method
Need for extension of surveillance, but setting up HAI surveillance networks requires important resources (hospitals, national coordination)
training of trainers and on-site training
translation of protocols
free software tools, multilingual
Standardized methods/definitions  standardized surveillance practices!
From January 2011: ECDC HAI surveillance website + interactive data analysis

26. Thank you to all national surveillance networks and participating hospitals!