The attributable cost and length of hospital stay because of nosocomial pneumonia in intensive care units in 3 hospitals in Argentina: a prospective, matched analysis

The impact of hyperthermia and infection on acute ischemic stroke patients in the intensive care unit

INTRODUCTION

Despite the recognized deleterious effects of hyperthermia on critically ill neurological patients, few investigations have studied hyperthermia after an ischemic stroke in the intensive care unit (ICU) setting.

METHODS

Acute ischemic stroke patients admitted to the ICU were assigned to one of three groups: normothermia, mild hyperthermia (MH), or severe hyperthermia (SH). The etiology of hyperthermia was further divided into infectious and non-infectious groups.

RESULTS

Among the 150 patients included in the study, MH and SH were observed in 15 and 40 patients, respectively. Hyperthermia and the Glasgow coma scale (GCS) score were independently related to in-hospital mortality and increased length of stay in the ICU (ILOS, > or =4 days).

DISCUSSION

Infection (39 patients) was more prevalent in the SH group than in the MH group and was associated with greater ILOS.

CONCLUSIONS

Monitoring and managing infection and reducing body temperature may be important factors for determining the outcomes of patients with acute ischemic stroke admitted to the ICU.

Device-associated nosocomial infections in limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC)

NEED

The rates of health care-associated infections (HAIs) and bacterial resistance in developing countries are 3 to 5 times higher than international standards. HAIs increase length of stay (10 days), costs (US $5000 to US $12,000), and mortality (by a factor of 2 to 3).

ORGANIZATION

The International Nosocomial Infection Control Consortium (INICC), founded in 1998, is the only source of aggregated international data on the epidemiology of device-associated infections (DAIs). Its advisory board includes 12 representatives from developed countries, who help guide INICC's activities, and 8 country coordinators. The INICC network has about 5400 active researchers in 98 intensive care units (ICUs) in 18 countries on 4 continents that conduct infection control research and surveillance using standardized DAI surveillance definitions and methodologies.

SURVEILLANCE

Participating hospitals use the Centers for Disease Control and Prevention (CDC) surveillance method and DAI definitions. Unlike the CDC, the INICC collects data from patients with and without DAI and matches patients to evaluate risk factors, attributable mortality, length of stay, and costs and conducts process surveillance to measure and improve compliance with infection control guidelines.

RESULTS

INICC's surveillance at 98 ICUs in 18 limited resources countries on 4 continents for 10 years has significantly improved infection control guidelines compliance and reduced DAI rates and mortality rates. After 11 years of implementing process surveillance intervention in 77 ICUs of 34 cities of 14 countries, including observation of 88,661 opportunities for hand hygiene, education, performance monitoring, feedback, and peer support from high-level hospital administrators, hand-hygiene compliance among ICU healthcare workers increased from 35.1% to 60.7% (RR 1.73, P < 0.01). In 78 ICUs of 37 cities of 13 countries, by implementing outcome and process surveillance interventions, INICC reduced central line associated bloodstream infection (CLAB) rates from 16.1 to 10.1 CLABs per 1000 CL days (RR: 0.63, P < 0.01), ventilator associated pneumonia (VAP) from 22.5 to 18.6 VAPs per1000 device days (RR: 0.83, P < 0.01), and catheter associated urinary tract infections (CAUTI) rates from 8.2 to 6.9 CAUTIs per 1000 device days (RR: 0.85, P = 0.02).

CONCLUSION

Implementation of INICC outcome and process surveillance, education, monitoring and performance feedback methodologies increases compliance with hand hygiene and other infection-control interventions and reduces rates of DAIs.

The International Nosocomial Infection Control Consortium (INICC): goals and objectives, description of surveillance methods, and operational activities

We have shown that intensive care units (ICUs) in countries with limited resources have rates of device-associated health care-associated infection (HAI), including central line-related bloodstream infection (CLAB), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI), 3 to 5 times higher than rates reported from North American, Western European, and Australian ICUs. The International Nosocomial Infection Control Consortium (INICC) is an international ongoing collaborative HAI control program with a surveillance system based on that of the US National Healthcare Safety Network. The INICC was founded 10 years ago to promote evidence-based infection control in hospitals in limited-resource countries and in hospitals of developed countries without sufficient experience in HAI surveillance and control, through the analysis and feedback of surveillance data collected voluntarily by the member hospitals. It developed from a handful of South American hospitals in 1998 to a dynamic network of 98 ICUs in 18 countries, and is the only source of aggregate standardized international data on HAI epidemiology. Herein we report the criteria and mechanisms for gaining membership in INICC; the training of personnel in INICC hospitals; the INICC protocol for outcome surveillance of CLABs, VAPs, and CAUTIs in ICUs, microorganism profiles, bacterial resistance, antibiotic use, extra length of stay, extra costs, extra mortality, and risk factor analysis, and for process surveillance, including compliance rates for hand hygiene, vascular catheter care, urinary catheter care, and measures for prevention of VAP; and the use of surveillance data feedback as a powerful weapon for control of HAIs. The INICC will continue to evolve in its quest to find more effective and efficient ways to assess patient risk and improve patient safety in hospitals.

Efficacy and safety of doripenem versus piperacillin/tazobactam in nosocomial pneumonia: a randomized, open-label, multicenter study

OBJECTIVE

Doripenem is a new carbapenem that has broad-spectrum activity against bacterial pathogens commonly responsible for nosocomial pneumonia (NP). It has several advantages over currently available carbapenems and other classes of drugs used in this indication. This prospective, randomized, open-label, multicenter study was designed to establish whether doripenem was noninferior to piperacillin/tazobactam in NP.

METHODS

Adults (n=448) with signs and symptoms of NP, including non-ventilated patients and those ventilated for <5 days, were stratified by ventilation mode, illness severity (Acute Physiology and Chronic Health Evaluation II score), and geographic region and then randomly allocated to treatment with doripenem 500 mg every 8 h by a 1-h intravenous (IV) infusion or piperacillin/tazobactam 4.5 g every 6 h by 30-min IV infusion. After receiving IV study drug for at least 72 h, eligible patients could be switched to oral levofloxacin 750 mg once daily. Antibiotic therapy was continued for a total of 7-14 days. The primary endpoint was the clinical cure rate, assessed 7-14 days after treatment completion, in clinically evaluable patients and in the clinical modified intent-to-treat population (cMITT).

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00211003.

RESULTS

Doripenem was noninferior to piperacillin/tazobactam. Clinical cure rates in clinically evaluable patients (n=253) were 81.3% in the doripenem arm and 79.8% in the piperacillin/tazobactam arm (between-treatment difference: 1.5%; 95% confidence interval [CI], -9.1 to 12.1%) and in the cMITT population 69.5% and 64.1%, respectively, (between-treatment difference: 5.4%; 95% CI, -4.1 to 14.8%). Baseline resistance of Klebsiella pneumoniae and Pseudomonas aeruginosa to piperacillin/tazobactam was 44% and 26.9%, respectively; a doripenem minimum inhibitory concentration (MIC) >8 mug/mL occurred in 0% and 7.7%, respectively. Favorable microbiological outcome rates against Gram-negative pathogens were numerically higher with doripenem than with piperacillin/tazobactam, but the difference was not statistically significant. Both study drugs were generally well tolerated, as only 16.1% and 17.6% of patients receiving doripenem and piperacillin/tazobactam, respectively, had a drug-related adverse event. Study limitations included the open-label design, the low rate of monotherapy (adjunctive use of aminoglycoside was required when P. aeruginosa was suspected), and the exclusion of the most critically ill and immunocompromized patients.

CONCLUSIONS

Doripenem was clinically and microbiologically effective in patents with NP, including those with early-onset ventilator-associated pneumonia, and was therapeutically noninferior to piperacillin/tazobactam.

A Simulation-Based Evaluation of Methods to Estimate the Impact of an Adverse Event on Hospital Length of Stay

INTRODUCTION

We used agent-based simulation to examine the problem of time-varying confounding when estimating the effect of an adverse event on hospital length of stay. Conventional analytic methods were compared with inverse probability weighting (IPW).

METHODS

A cohort of hospitalized patients, at risk for experiencing an adverse event, was simulated. Synthetic individuals were assigned a severity of illness score on admission. The score varied during hospitalization according to an autoregressive equation. A linear relationship between severity of illness and the logarithm of the discharge rate was assumed. Depending on the model conditions, adverse event status was influenced by prior severity of illness and, in turn, influenced subsequent severity. Conditions were varied to represent different levels of confounding and categories of effect. The simulation output was analyzed by Cox proportional hazards regression and by a weighted regression analysis, using the method of IPW. The magnitude of bias was calculated for each method of analysis.

RESULTS

Estimates of the population causal hazard ratio based on IPW were consistently unbiased across a range of conditions. In contrast, hazard ratio estimates generated by Cox proportional hazards regression demonstrated substantial bias when severity of illness was both a time-varying confounder and intermediate variable. The direction and magnitude of bias depended on how severity of illness was incorporated into the Cox regression model.

CONCLUSIONS

In this simulation study, IPW exhibited less bias than conventional regression methods when used to analyze the impact of adverse event status on hospital length of stay.

Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC)

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.

Device-associated hospital-acquired infection rates in Turkish intensive care units. Findings of the International Nosocomial Infection Control Consortium (INICC)

We conducted a prospective study of targeted surveillance of healthcare-associated infections (HAIs) in 13 intensive care units (ICUs) from 12 Turkish hospitals, all members of the International Nosocomial Infection Control Consortium (INICC). The definitions of the US Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (NNISS) were applied. During the three-year study, 3288 patients for accumulated duration of 37 631 days acquired 1277 device-associated infections (DAI), an overall rate of 38.3% or 33.9 DAIs per 1000 ICU-days. Ventilator-associated pneumonia (VAP) (47.4% of all DAI, 26.5 cases per 1000 ventilator-days) gave the highest risk, followed by central venous catheter (CVC)-related bloodstream infections (30.4% of all DAI, 17.6 cases per 1000 catheter-days) and catheter-associated urinary tract infections (22.1% of all DAI, 8.3 cases per 1000 catheter-days). Overall 89.2% of all Staphylococcus aureus infections were caused by methicillin-resistant strains, 48.2% of the Enterobacteriaceae isolates were resistant to ceftriaxone, 52.0% to ceftazidime, and 33.2% to piperacilin-tazobactam; 51.1% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.7% to ceftazidime, 38.7% to imipenem, and 30.0% to piperacilin-tazobactam; 1.9% of Enterococcus sp. isolates were resistant to vancomycin. This is the first multi-centre study showing DAI in Turkish ICUs. DAI rates in the ICUs of Turkey are higher than reports from industrialized countries.

Nosocomial pneumonia: aetiology, diagnosis and treatment

PURPOSE OF REVIEW

This review highlights recent advances in the aetiology of nosocomial pneumonia, and in strategies to increase accuracy of diagnosis and antibiotic prescription while limiting unnecessary antibiotic consumption.

RECENT FINDINGS

Bacterial pathogens still cause the bulk of nosocomial pneumonia and are of concern because of ever-rising antimicrobial resistance. Yet, the pathogenic role of fungal and viral organisms is increasingly recognized. Since early appropriate antimicrobial therapy is the cornerstone of an effective treatment, further studies have been conducted to improve appropriateness of early antibiotic therapy. De-escalation strategies combine initial broad-spectrum antibiotics to maximize early antibiotic coverage with a subsequent focusing of the antibiotic spectrum when the cause is identified. Invasive techniques probably do not alter the immediate outcome but have the potential to reduce unnecessary antibiotic exposure. Decisions to stop or change antibiotic therapy are hampered due to a lack of reliable parameters to assess the resolution of pneumonia.

SUMMARY

Increasing antimicrobial resistance in nosocomial pneumonia both challenges treatment and mandates limitation of selection pressure by reducing antibiotic burden. Treating physicians should be both aggressive in initiating antimicrobials when suspecting nosocomial pneumonia but willing to discontinue antimicrobials when diagnostic results point to an alternative diagnosis. Efforts should be made to limit duration of antibiotic therapy when possible.

Device-associated nosocomial infection rates in intensive care units in four Mexican public hospitals

BACKGROUND

Routine surveillance of nosocomial infections has become an integral part of infection control and quality assurance in US hospitals.

METHODS

As part of the International Nosocomial Infection Control Consortium, we performed a prospective nosocomial infection surveillance cohort study in 5 adult intensive care units of 4 Mexican public hospitals using the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance system definitions. Site-specific nosocomial infection rates were calculated.

RESULTS

The overall nosocomial infection rate was 24.4% (257/1055) and 39.0 (257/6590) per 1000 patient days. The most common infection was catheter-associated bloodstream infection, 57.98% (149/257), followed by ventilator-associated pneumonia, 20.23% (52/257), and catheter-associated urinary tract infection, 21.79% (56/257). The overall rate of catheter-associated bloodstream infections was 23.1 per 1000 device-days (149/6450); ventilator-associated pneumonia rate was 21.8 per 1000 device-days (52/2390); and catheter-associated urinary tract infection rate was 13.4 per 1000 device-days (56/4184).

CONCLUSION

Our rates are similar to other hospitals of Latin America and higher than US hospitals.

Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium

OBJECTIVE

To perform active targeted prospective surveillance to measure device-associated infection (DAI) rates, attributable mortality due to DAI, and the microbiological and antibiotic resistance profiles of infecting pathogens at 10 intensive care units (ICUs) in 9 hospitals in Colombia, all of which are members of the International Infection Control Consortium.

METHODS

We conducted prospective surveillance of healthcare-associated infection in 9 hospitals by using the definitions of the US Centers for Disease Control and Prevention National Nosocomial Surveillance System (NNIS). DAI rates were calculated as the number of infections per 100 ICU patients and per 1,000 device-days.

RESULTS

During the 3-year study, 2,172 patients hospitalized in an ICU for an aggregate duration of 14,603 days acquired 266 DAIs, for an overall DAI rate of 12.2%, or 18.2 DAIs per 1,000 patient-days. Central venous catheter (CVC)-related bloodstream infection (BSI) (47.4% of DAIs; 11.3 cases per 1,000 catheter-days) was the most common DAI, followed by ventilator-associated pneumonia (VAP) (32.3% of DAIs; 10.0 cases per 1,000 ventilator-days) and catheter-associated urinary tract infection (CAUTI) (20.3% of DAIs; 4.3 cases per 1,000 catheter-days). Overall, 65.4% of all Staphylococcus aureus infections were caused by methicillin-resistant strains; 40.0% of Enterobacteriaceae isolates were resistant to ceftriaxone and 28.3% were resistant to ceftazidime; and 40.0% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.0% were resistant to ceftazidime, 33.3% were resistant to piperacillin-tazobactam, and 19.0% were resistant to imipenem. The crude unadjusted attributable mortality was 16.9% among patients with VAP (relative risk [RR], 1.93; 95% confidence interval [CI], 1.24-3.00; P=.002); 18.5 among those with CVC-associated BSI (RR, 2.02; 95% CI, 1.42-2.87; P<.001); and 10.5% among those with CAUTI (RR, 1.58; 95% CI, 0.78-3.18; P=.19).

CONCLUSION

The rates of DAI in the Colombian ICUs were lower than those published in some reports from other Latin American countries and were higher than those reported in US ICUs by the NNIS. These data show the need for more-effective infection control interventions in Colombia.

Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals

BACKGROUND

Hospitalized, critically ill patients have a significant risk of developing nosocomial infection. Most episodes of nosocomial pneumonia occur in patients undergoing mechanical ventilation (MV).

OBJECTIVE

To ascertain the effect of an infection control program on rates of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in Argentina.

METHODS

All adult patients who received MV for at least 24 hours in 4, level III adult ICUs in 2 Argentinean hospitals were included in the study. A before-after study in which rates of VAP were determined during a period of active surveillance without an infection control program (phase 1) were compared with rates of VAP after implementation of an infection control program that included educational and surveillance feedback components (phase 2).

RESULTS

One thousand six hundred thirty-eight MV-days were accumulated in phase 1, and 1520 MV-days were accumulated during phase 2. Rates of VAP were significantly lower in phase 2 than in phase 1 (51.28 vs 35.50 episodes of VAP per 1000 MV-days, respectively, RR = 0.69, 95% CI: 0.49-0.98, P <or= .003).

CONCLUSION

Implementation of a multicomponent infection control program in Argentinean ICUs was associated with significant reductions in rates of VAP.