Jean-Louis Vincent1, Yasser Sakr2, Mervyn Singer3, Ignacio Martin-Loeches4,5, Flavia R Machado6, John C Marshall7, Simon Finfer8, Paolo Pelosi9,10, Luca Brazzi11, Dita Aditianingsih12, Jean-François Timsit13, Bin Du14, Xavier Wittebole15, Jan Máca16, Santhana Kannan17, Luis A Gorordo-Delsol18, Jan J De Waele19, Yatin Mehta20, Marc J M Bonten21, Ashish K Khanna22,23, Marin Kollef24, Mariesa Human25, Derek C Angus26. 1. Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. 2. Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany. 3. Bloomsbury Institute of Intensive Care Medicine, University College London, London, England. 4. Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland. 5. Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERES, Barcelona, Spain. 6. Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil. 7. Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada. 8. George Institute for Global Health, University of New South Wales, Sydney, Australia. 9. Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy. 10. Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. 11. Department of Surgical Science, University of Turin, University Hospital Città della Salute e della Scienza, Turin, Italy. 12. Department of Anesthesia and Intensive Care, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta. 13. Medical and Infectious Diseases ICU, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France. 14. Medical ICU, Peking Union Medical College Hospital, Beijing, China. 15. Critical Care Department, Cliniques Universitaires St Luc, UCL, Brussels, Belgium. 16. Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic. 17. Department of Anaesthesia and Critical Care, SWBH Trust, Birmingham, England. 18. Unidad de Cuidados Intensivos Adultos, Hospital Juárez de México, Mexico City. 19. Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium. 20. Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurugram, India. 21. Department of Medical Microbiology, University Medical Center, Utrecht University, Utrecht, the Netherlands. 22. Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. 23. Outcomes Research Consortium, Cleveland, Ohio. 24. Division of Pulmonary and Critical Care Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri. 25. Level l Trauma Centre, Netcare Union/Clinton Hospitals, Alberton, South Africa. 26. Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Abstract
IMPORTANCE: Infection is frequent among patients in the intensive care unit (ICU). Contemporary information about the types of infections, causative pathogens, and outcomes can aid the development of policies for prevention, diagnosis, treatment, and resource allocation and may assist in the design of interventional studies. OBJECTIVE: To provide information about the prevalence and outcomes of infection and the available resources in ICUs worldwide. DESIGN, SETTING, AND PARTICIPANTS: Observational 24-hour point prevalence study with longitudinal follow-up at 1150 centers in 88 countries. All adult patients (aged ≥18 years) treated at a participating ICU during a 24-hour period commencing at 08:00 on September 13, 2017, were included. The final follow-up date was November 13, 2017. EXPOSURES: Infection diagnosis and receipt of antibiotics. MAIN OUTCOMES AND MEASURES: Prevalence of infection and antibiotic exposure (cross-sectional design) and all-cause in-hospital mortality (longitudinal design). RESULTS: Among 15 202 included patients (mean age, 61.1 years [SD, 17.3 years]; 9181 were men [60.4%]), infection data were available for 15 165 (99.8%); 8135 (54%) had suspected or proven infection, including 1760 (22%) with ICU-acquired infection. A total of 10 640 patients (70%) received at least 1 antibiotic. The proportion of patients with suspected or proven infection ranged from 43% (141/328) in Australasia to 60% (1892/3150) in Asia and the Middle East. Among the 8135 patients with suspected or proven infection, 5259 (65%) had at least 1 positive microbiological culture; gram-negative microorganisms were identified in 67% of these patients (n = 3540), gram-positive microorganisms in 37% (n = 1946), and fungal microorganisms in 16% (n = 864). The in-hospital mortality rate was 30% (2404/7936) in patients with suspected or proven infection. In a multilevel analysis, ICU-acquired infection was independently associated with higher risk of mortality compared with community-acquired infection (odds ratio [OR], 1.32 [95% CI, 1.10-1.60]; P = .003). Among antibiotic-resistant microorganisms, infection with vancomycin-resistant Enterococcus (OR, 2.41 [95% CI, 1.43-4.06]; P = .001), Klebsiella resistant to β-lactam antibiotics, including third-generation cephalosporins and carbapenems (OR, 1.29 [95% CI, 1.02-1.63]; P = .03), or carbapenem-resistant Acinetobacter species (OR, 1.40 [95% CI, 1.08-1.81]; P = .01) was independently associated with a higher risk of death vs infection with another microorganism. CONCLUSIONS AND RELEVANCE: In a worldwide sample of patients admitted to ICUs in September 2017, the prevalence of suspected or proven infection was high, with a substantial risk of in-hospital mortality.
IMPORTANCE: Infection is frequent among patients in the intensive care unit (ICU). Contemporary information about the types of infections, causative pathogens, and outcomes can aid the development of policies for prevention, diagnosis, treatment, and resource allocation and may assist in the design of interventional studies. OBJECTIVE: To provide information about the prevalence and outcomes of infection and the available resources in ICUs worldwide. DESIGN, SETTING, AND PARTICIPANTS: Observational 24-hour point prevalence study with longitudinal follow-up at 1150 centers in 88 countries. All adult patients (aged ≥18 years) treated at a participating ICU during a 24-hour period commencing at 08:00 on September 13, 2017, were included. The final follow-up date was November 13, 2017. EXPOSURES: Infection diagnosis and receipt of antibiotics. MAIN OUTCOMES AND MEASURES: Prevalence of infection and antibiotic exposure (cross-sectional design) and all-cause in-hospital mortality (longitudinal design). RESULTS: Among 15 202 included patients (mean age, 61.1 years [SD, 17.3 years]; 9181 were men [60.4%]), infection data were available for 15 165 (99.8%); 8135 (54%) had suspected or proven infection, including 1760 (22%) with ICU-acquired infection. A total of 10 640 patients (70%) received at least 1 antibiotic. The proportion of patients with suspected or proven infection ranged from 43% (141/328) in Australasia to 60% (1892/3150) in Asia and the Middle East. Among the 8135 patients with suspected or proven infection, 5259 (65%) had at least 1 positive microbiological culture; gram-negative microorganisms were identified in 67% of these patients (n = 3540), gram-positive microorganisms in 37% (n = 1946), and fungal microorganisms in 16% (n = 864). The in-hospital mortality rate was 30% (2404/7936) in patients with suspected or proven infection. In a multilevel analysis, ICU-acquired infection was independently associated with higher risk of mortality compared with community-acquired infection (odds ratio [OR], 1.32 [95% CI, 1.10-1.60]; P = .003). Among antibiotic-resistant microorganisms, infection with vancomycin-resistant Enterococcus (OR, 2.41 [95% CI, 1.43-4.06]; P = .001), Klebsiella resistant to β-lactam antibiotics, including third-generation cephalosporins and carbapenems (OR, 1.29 [95% CI, 1.02-1.63]; P = .03), or carbapenem-resistant Acinetobacter species (OR, 1.40 [95% CI, 1.08-1.81]; P = .01) was independently associated with a higher risk of death vs infection with another microorganism. CONCLUSIONS AND RELEVANCE: In a worldwide sample of patients admitted to ICUs in September 2017, the prevalence of suspected or proven infection was high, with a substantial risk of in-hospital mortality.
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