**1. Introduction**

Infections are a major cause of admissions and prolonged stays in intensive care units (ICUs). They affect approximately 30% of patients, with large variations between different geographical regions [1–7], and they are the leading cause of death in non-cardiac ICUs, with still very high mortality rates and associated costs [8,9].

Sepsis and septic shock can complicate both community-acquired infections, which account for up to 70% of all cases of sepsis [8], and healthcare-associated infections (HAI),

**Citation:** Montrucchio, G.; Sales, G.; Catozzi, G.; Bosso, S.; Scanu, M.; Vignola, T.V.; Costamagna, A.; Corcione, S.; Urbino, R.; Filippini, C.; et al. Effectiveness of an Active and Continuous Surveillance Program for Intensive Care Units Infections Based on the EPIC III (Extended Prevalence of Infection in Intensive Care) Approach. *J. Clin. Med.* **2022**, *11*, 2482. https://doi.org/10.3390/ jcm11092482

Academic Editor: Olivier Mimoz

Received: 17 March 2022 Accepted: 27 April 2022 Published: 28 April 2022

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which would be mostly preventable by adequate infection prevention and control (IPC) measures [10–12].

Although extremely variable in the literature, data regarding the real prevalence of HAIs remains high in Europe (6.5%) [13,14], with values probably much higher in ICUs. Unfortunately, many articles do not report the differentiation between community and hospital-acquired sepsis, leading to a possible underestimation of the impact of HAIs, however potentially prevented in about 55% of cases by the implementation of multifaceted IPC interventions [15–17].

Epidemiological information on the underlying source of infections, associated microorganisms, treatment and outcomes are essential to identify gaps and optimize patient management. Unfortunately, although surveillance systems have been proposed at local [18] and international levels [19,20], adherence to them is not uniform in terms of both data collection and definitions [21], and this limits the comparability of the data over time. In particular, the integration between infection and/or colonization systematic data collection, control measures, and their application and evolution over time is complex. Moreover, data complexity does not allow their timely use, given the long processing and interpretation times, partially limiting the possibility of continuous and proactive surveillance. Another point to be considered is the lack of local comparisons, on a national or regional basis, capable of reflecting the specific characteristics of the population, the intensity of care, as well as the microbiological trend of the local ecology.

In this scenario, the use of punctual prevalence studies, which are more easily achievable and repeatable over time, has been proposed, especially in ICUs. Their validity and reliability, however, might be limited, given the method and timing of the data collection used [22].

Recently, a worldwide study [9] collected comprehensive data on the global epidemiology of ICU infections in 1150 centers in 88 countries, reporting that 54% of admitted patients had suspected or proven infection, 70% received at least one antibiotic, and Gram-negative bacteria were the predominant microorganisms (67%). One of the strengths of this study was the use of an exhaustive but essential data collection protocol, widely applicable in different contexts, which guaranteed great participation and reliability of the collected data.

As valid epidemiological data are needed to increase the awareness of the impact of infection among ICU patients, we applied the EPIC III protocol to estimate the prevalence of community and hospital-associated infections, associated risk factors and distribution of antimicrobial use in the ICUs of the Intensive and Critical Care Department of the University Hospital of Turin. We also evaluated the effectiveness of this data collection protocol as an active surveillance tool.

#### **2. Materials and Methods**

#### *2.1. Study Design*

This is a 24-h prospective observational point prevalence study, with repeated observations every 2 months. Surveillance was carried out in all medical/surgical ICUs of the Department of Anesthesia and Resuscitation of the Città della Salute e della Scienza Hospital of Turin for a total of 8 ICUs and 72 ICU beds.

The study was approved by the local ethics committee (prot. No.0000255), and informed consent was obtained from each patient enrolled.

The overall duration of the study was 1 year; each observation lasted 24 h, and the follow-up for the outcome was performed at 60 days, regardless of the patient location. Six observations were performed throughout the year, evenly distributed over 12 months. Data were recorded for all patients present or admitted to ICU during the 24-h periods of study, from 1 December 2017, 08:00 to 2 December 2018, 07:59.

All patients hospitalized or admitted to ICU on one of the days of the study were involved, with no exclusion criteria, except for the absence of informed consent.

#### *2.2. Study Context*

All ICUs were able to perform blood cultures or qualitative respiratory cultures. Intermittent and continuous renal replacement therapies, high nasal oxygen flow, echocardiography and invasive monitoring were available in all units and extracorporeal membrane oxygenation (ECMO) in two units. An infectious disease specialist or clinical microbiologist was available 12 h a day, 5 days a week, and on-call during nights and weekends. Therapeutic drug monitoring was available for vancomycin, voriconazole, aminoglycosides and beta-lactams.
