International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

Evaluation of ventilator associated events in critically ill patients with invasive mechanical ventilation: A prospective cohort study at a resource limited setting in Northern India

PURPOSE

The primary aim of this study was to identify the modifiable risk factors for acquiring ventilator associated events (VAE). Secondary aims were to investigate the intensive care unit (ICU) course and impact of VAE on patient outcome.

METHODS

This prospective, observational single center cohort study included 247 patients on mechanical ventilation for 4 calendar days at a 20-bed ICU between January 2018-June 2019.

RESULTS

VAE occurred in 59 episodes (rate 11.3 per 1000 ventilator-days). The Ventilator Utilization Ratio (VUR) was 0.57. The median time to onset of VAE was 6 days. Sepsis was the most common reason for initiating patients on invasive mechanical ventilation (IMV). Cumulative fluid balance ≥2 l (Odds Ratio 30.92; 95% CI 9.82-97.37) and greater number of days with vasopressor support (Odds Ratio 1.92; 95% CI 1.57-2.36) within 7 days of initiating IMV were significant risk factors for acquiring VAE (p < 0.001). VAE cases were ventilated for significantly more days (20 vs 14 days, p = 0.001, had longer days of ICU stay (29 vs 18 days; p = 0.002) and higher hospital mortality (p = 0.02). Klebsiella pneumoniae was the most common isolate (N = 28) and 32.1% were colistin resistant.

CONCLUSIONS

Prospective intervention studies are needed to determine if targeting these risk factors can lower VAE rates in our setting.

Infection prevention practices in the United States, the Netherlands, Switzerland, and Japan: Results from national surveys

OBJECTIVE

To assess the extent to which evidence-based practices are regularly used in acute care hospitals in different countries.

DESIGN

Cross-sectional survey study. Participants and setting: Infection preventionists in acute care hospitals in the United States (US), the Netherlands, Switzerland, and Japan.

METHODS

Data collected from hospital surveys distributed between 2015 and 2017 were evaluated to determine the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central-line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Descriptive statistics were used to examine hospital characteristics and the percentage of hospitals reporting regular use of each infection prevention practice.

RESULTS

Survey response rates were 59% in the United States, 65% in the Netherlands, 77% in Switzerland, and 65% in Japan. Several recommended practices were used in the majority of hospitals: aseptic catheter insertion and maintenance (CAUTI), maximum sterile barrier precautions (CLABSI), semirecumbent patient positioning (VAP), and contact precautions and routine daily cleaning (CDI). Other prevention practices for CAUTI and VAP were used less frequently, particularly in Swiss and Japanese hospitals. Established surveillance systems were also lacking in Dutch, Swiss and Japanese hospitals.

CONCLUSIONS

Most hospitals in the United States, the Netherlands, Switzerland, and Japan have adopted certain infection prevention practices. Clear opportunities for reducing HAI risk in hospitals exist across all 4 countries surveyed.

Needleless connector decontamination for prevention of central venous access device infection: A pilot randomized controlled trial

Pilot randomized controlled trial (180 patients) of needleless connector decontamination. Central line-associated bloodstream infection occurred in 2% (1/61) of 70% isopropyl alcohol (IPA) wipe, 2% (1/59) of 70% IPA cap, and zero (0/58) infections in 2% chlorhexidine gluconate in 70% IPA wipe patients. Larger definitive trials are feasible and needed.

Nosocomial infections in in-hospital cardiac arrest patients who undergo extracorporeal cardiopulmonary resuscitation

BACKGROUND

Little is known of nosocomial infections (NI) in patients who suffer from in-hospital cardiac arrest who undergoing extracorporeal cardiopulmonary resuscitation. This study aimed to investigate clinical pictures of NI, and the association of NIs with clinical outcomes in in-hospital cardiac arrest patients who undergoing extracorporeal cardiopulmonary resuscitation.

METHODS

To evaluate the incidence and clinical characteristics of NI in patients who undergoing extracorporeal cardiopulmonary resuscitation, a retrospective cohort study was conducted in a single tertiary referral center between January 2010 and December 2018. We included adult patients who undergoing extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest and excluded patients who were out-of-hospital cardiac arrest or failed ECMO implantation. Clinical characteristics and outcomes were compared between NI and Non-NI patients, or multidrug-resistant (MDR) and non-MDR. The independent risk factors associated with NIs were also analyzed using multivariable logistic regression model.

RESULTS

Thirty-five (23.3%) patients developed a NI. These cases included 21 patients with a gram negative (G-) infection, 12 patients with a gram positive (G+) bacterial infection, and two patients with fungal infection. Pneumonia was the most common type of NIs, followed by catheter-related infection. The in-hospital mortality and neurologic outcomes at discharge were not different between the NI and non-NI groups. Multidrug-resistant (MDR) pathogens were detected in 10 cases (28.6%). The MDR NI patients had a higher ICU mortality than did those with non-MDR NI (80% vs. 32%, p = 0.028). Following multivariable adjustment, body mass index (adjusted OR 0.87, 95% CI, 0.77-0.97, p = 0.016) and cardiopulmonary resuscitation to pump on time (adjusted OR 1.04, 95% CI, 1.01-1.06, p = 0.001) were independent predictors of NI development.

CONCLUSIONS

In patients who received extracorporeal cardiopulmonary resuscitation, NIs were not associated with an increase in in-hospital mortality. However, NIs with MDR organisms do increase the risk of in-hospital mortality. Lower body mass index and longer low flow time were significant predictors of NI development.

Incidence and risk factors for hospital-acquired infection among paediatric patients in a teaching hospital: a prospective study in southeast Ethiopia

OBJECTIVES

In order to maximise the prevention of hospital-acquired infections (HAIs) and antimicrobial resistance, data on the incidence of HAIs are crucial. In Ethiopia, data about the occurrence of HAIs among hospitalised paediatric patients are lacking. We aim to determine the incidence and risk factors of HAIs among paediatric patients in Ethiopia.

DESIGN

A prospective cohort study.

SETTING

A teaching hospital in southeast Ethiopia.

PARTICIPANTS

448 hospitalised paediatric patients admitted between 1 November 2018 and 30 June 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incidence and risk factors of hospital-acquired infections.

RESULTS

A total of 448 paediatric patients were followed for 3227 patient days. The median age of the patients was 8 months (IQR: 2-26 months). The incidence rate of HAIs was 17.7 per 1000 paediatric days of follow-up; while the overall cumulative incidence was 12.7% (95% CI 9.8% to 15.8%) over 8 months. Children who stayed greater than 6 days in the hospital (median day) (adjusted risk ratio (RR): 2.58, 95% CI 1.52 to 4.38), and children with underlying disease conditions of severe acute malnutrition (adjusted RR: 2.83, 95% CI 1.61 to 4.97) had higher risks of developing HAIs.

CONCLUSIONS

The overall cumulative incidence of HAIs was about 13 per 100 admitted children. Length of stay in the hospital and underlying conditions of severe acute malnutrition were found to be important factors associated with increased risk of HAIs.

Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus

BACKGROUND

Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period.

METHODS

We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme.

RESULTS

There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n = 198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n = 184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n = 217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017.

CONCLUSIONS

The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.

Toll-like receptors in sepsis-associated cytokine storm and their endogenous negative regulators as future immunomodulatory targets

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Sepsis infects more than 48.9 million people world-wide, with 19.7 million deaths.

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Cytokine storm plays a significant role in sepsis, along with severe COVID-19.

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TLR signaling pathways plays a crucial role in generating the cytokine storm.

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Endogenous negative regulators of TLR signaling are crucial to regulate cytokine storm.

Cytokine storm generates during various systemic acute infections, including sepsis and current pandemic called COVID-19 (severe) causing devastating inflammatory conditions, which include multi-organ failure or multi-organ dysfunction syndrome (MODS) and death of the patient. Toll-like receptors (TLRs) are one of the major pattern recognition receptors (PRRs) expressed by immune cells as well as non-immune cells, including neurons, which play a crucial role in generating cytokine storm. They recognize microbial-associated molecular patterns (MAMPs, expressed by pathogens) and damage or death-associate molecular patterns (DAMPs; released and/expressed by damaged/killed host cells). Upon recognition of MAMPs and DAMPs, TLRs activate downstream signaling pathways releasing several pro-inflammatory mediators [cytokines, chemokines, interferons, and reactive oxygen and nitrogen species (ROS or RNS)], which cause acute inflammation meant to control the pathogen and repair the damage. Induction of an exaggerated response due to genetic makeup of the host and/or persistence of the pathogen due to its evasion mechanisms may lead to severe systemic inflammatory condition called sepsis in response to the generation of cytokine storm and organ dysfunction. The activation of TLR-induced inflammatory response is hardwired to the induction of several negative feedback mechanisms that come into play to conclude the response and maintain immune homeostasis. This state-of-the-art review describes the importance of TLR signaling in the onset of the sepsis-associated cytokine storm and discusses various host-derived endogenous negative regulators of TLR signaling pathways. The subject is very important as there is a vast array of genes and processes implicated in these negative feedback mechanisms. These molecules and mechanisms can be targeted for developing novel therapeutic drugs for cytokine storm-associated diseases, including sepsis, severe COVID-19, and other inflammatory diseases, where TLR-signaling plays a significant role.

Epidemiology and risk factors for healthcare-associated infections caused by Pseudomonas aeruginosa

Pseudomonas aeruginosa (PA) is a globally recognized cause of healthcare-associated infections (HAIs). The aim of our cross-sectional study, conducted in a Serbian tertiary care hospital, was to investigate clinical characteristics of HAIs caused by the PA, the prevalence of various drug-resistant phenotypes of this pathogen, and risk factors for their occurrence. Prolonged ICU stay and previous carbapenem administration were independent risk factors for HAIs caused by carbapenem-resistant PA, while HAIs caused by multidrug-resistant PA were more frequent in patients with prolonged stay in an ICU, who were previously hospitalized at another department and previously treated with aminoglycosides, fluoroquinolones or glycopeptides. The prolonged ICU stay was the only significant risk factor for HAIs caused by extensively drug-resistant PA. To decrease the incidence of HAIs caused by drug-resistant PA, a multifaceted approach is necessary, including staff education, antibiotic stewardship, improving hygiene, shortening hospitalization, and minimizing exposure to invasive medical procedures/devices.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 204 intensive care units of 57 hospitals in 19 cities of India: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied in developing countries, and data on their incidence by number of device-days are not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013 to May 31, 2019 in 204 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 57 hospitals in 19 cities of India. We applied US INICC definition criteria and reported methods using the INICC Surveillance Online System.

RESULTS

We followed 7,513 ICU patients for 296,893 bed-days and 295,795 short term peripheral venous catheter (PVC)-days. We identified 863 PVCR-BSIs, amounting to a rate of 2.91/1,000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 4.14%, and 11.59% in patients with PVCR-BSI. The length of stay in patients with PVC but without PVCR-BSI was 4.13 days, and 5.9 days in patients with PVCR-BSI. The micro-organism profile showed 68% of gram negative bacteria: Escherichia coli (23%), Klebsiella spp (15%), Pseudomonas aeruginosa (5%), and others. The predominant gram-positive bacteria were Staphylococcus aureus (10%).

CONCLUSIONS

PVCR-BSI rates found in our ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Epidemiology and regional variation of nonsusceptible and multidrug-resistant Pseudomonas aeruginosa isolates from intensive versus non-intensive care units across multiple centers in the United States

Nonsusceptible (NS) and multidrug-resistant (MDR) Pseudomonas aeruginosa (PsA) infections are associated with considerable mortality. This retrospective study assessed NS PsA and MDR PsA prevalence in US intensive care unit (ICU) and non-ICU settings. We evaluated nonduplicate PsA isolates collected in 2017. Data were classified by hospital admission setting. PsA isolates were evaluated for NS to each of 4 drug classes and MDR. Significantly higher rates of NS PsA and MDR PsA were found in ICU versus non-ICU settings (P < .001), except for respiratory isolates, which had high rates regardless of setting; rates also correlated with source, hospital size, urban/rural status, and geographic region. NS PsA isolates for each antibacterial category (except fluoroquinolones) and MDR PsA were significantly more likely to be classified as hospital-onset than admission-onset (P < .001). These data are consistent with previous reports and emphasize the importance of testing for resistant infection upon admission and when treating hospital-acquired infections.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 246 intensive units of 83 hospitals in 52 cities of 14 countries of Middle East: Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates-International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied, and data on their incidence by number of device-days is not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1st, 2013 to 31st Mays, 2019 in 246 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 83 hospitals in 52 cities of 14 countries in the Middle East (Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates). We applied U.S.

RESULTS

We followed 31,083 ICU patients for 189,834 bed-days and 202,375 short term peripheral venous catheter (PVC)-days. We identified 470 PVCR-BSIs, amounting to a rate of 2.32/1000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 10.38%, and 29.36% in patients with PVC and PVCR-BSI. The mean length of stay in patients with PVC but without PVCR-BSI was 5.94 days, and 16.84 days in patients with PVC and PVCR-BSI. The microorganism profile showed 55.2 % of gram-positive bacteria, with Coagulase-negative Staphylococci (31%) and Staphylococcus aureus (14%) being the predominant ones. Gram-negative bacteria accounted for 39% of cases, and included: Escherichia coli (7%), Klebsiella pneumoniae (8%), Pseudomonas aeruginosa (5%), Enterobacter spp. (3%), and others (29.9%), such as Serratia marcescens.

CONCLUSIONS

PVCR-BSI rates found in our ICUs were much higher than rates published from USA, Australia, and Italy. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

High Burden of Resistant Gram Negative Pathogens Causing Device-associated Healthcare Infections in a Tertiary Care Setting in Saudi Arabia, 2008-2016

OBJECTIVES

There is local and regional deficiency in the data examining the contribution of resistant pathogens to device-associated healthcare-associated infections (DA-HAIs). The objective was to examine such data in a multi-hospital system in Saudi Arabia in comparison with the US National Health Surveillance Network (NHSN).

METHODS

Surveillance of DA-HAIs was prospectively conducted between 2008 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Consecutive NHSN reports were used for comparisons. Definitions and methodology of DA-HAIs and bacterial resistance were based on NHSN.

RESULTS

A total 1260 pathogens causing 1141 DA-HAI events were included. Gram negative pathogens (GNPs) were responsible for 62.5% of DA-HAIs, with a significantly higher Klebsiella, Pseudomonas, Acinetobacter, and Enterobacter than NHSN hospitals. Approximately 28.3% of GNPs and 23.5% of gram positive pathogens (GPPs) had some type of resistance. Nearly 34.3% of Klebsiella were resistant to third/fourth generation cephalosporins, 4.8% of Enterobacteriaceae were carbapenem-resistant (CRE), 24.4% of Staphylococcus aureus were methicillin-resistant (MRSA), and 21.9% of Enterococci were vancomycin-resistant (VRE). Multidrug resistance (MDR) was 65.0% in Acinetobacter, 26.4% in Escherichia coli, 23.0% in Klebsiella, and 14.9% in Pseudomonas. Resistant GNPs including cephalosporin-resistant Klebsiella, MDR Klebsiella, and MDR Escherichia coli were significantly more frequent while resistant GPPs including MRSA and VRE were significantly less frequent than NHSN hospitals.

CONCLUSION

The current findings showed heavier and more resistant contribution of GNPs to DA-HAIs in Saudi hospitals compared with American hospitals. The higher resistance rates in Klebsiella and Escherichia coli are alarming and call for effective antimicrobial stewardship programs.

Efficacy of chlorhexidine patches on central line-associated bloodstream infections in children

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are important hospital-acquired infections. Chlorhexidine-impregnated dressings (also known as chlorhexidine patches, CHG patches) are reported to decrease CLABSIs in adults. This study aims to determine the efficacy of CHG patches in reducing CLABSIs in children.

METHODS

An open-label randomized controlled trial was conducted in children aged 2 months to 18 years, requiring a short-term catheter. Patients were randomized into two groups, allocated to receive CHG patches or standard transparent dressings. Care of the catheter was in accordance with Asia Pacific Society of Infection Control (APSIC) recommendations. Central-line-associated bloodstream infections were defined using National Healthcare Safety Network surveillance criteria.

RESULTS

From April 2017 to April 2018, 192 children were enrolled. There were 108 CHG patch catheters and 101 standard dressing catheters, contributing to 3,113 catheter days. The median duration of catheter dwelling was 13 days, with an interquartile range (IQR) of 8-20 days. Half were placed at the jugular vein and 22% at the femoral vein. There were 23 CLABSI events. Incidence rates for CHG patches and standard dressings were 7.98 (95% confidence interval (CI), 4.25-13.65) and 6.74 (95% CI, 3.23-12.39) per 1,000 catheter days, respectively (incidence rate ratio 1.18; 95% CI, 0.52-2.70). The CLABSI pathogens were 15 Gram-negative bacteria, six Gram-positive bacteria, and two Candida organisms. Catheter colonization of CHG patches and standard dressings were 2.02 (95% CI, 0.42-5.91) and 3.07 (95% CI, 1.00-7.16) per 1,000 catheter days, respectively. Only local adverse effects occurred in 6.8% of the participants.

CONCLUSIONS

In our setting, there was no difference in CLABSI rates when the chlorhexidine patch dressings were compared with the standard transparent dressings. Strengthening of CLABSI prevention bundles is mandatory.

Association between sepsis at ICU admission and mortality in patients with ICU-acquired pneumonia: An infectious second-hit model

PURPOSE

We explore the hypothesis that critically ill patients developing ICU-acquired pneumonia (ICU-AP) have worse outcomes and an altered inflammatory response if their ICU admission was sepsis-related.

METHODS

Prospective cohort study in two centers. Patients with ICU-AP were evaluated according to their previous exposure to sepsis at ICU-admission. Demographic variables, comorbidities, severity scores at admission and at the time of acquisition of ICU-AP, and serum biomarkers of the inflammatory response were evaluated.

PRIMARY OUTCOME

90-day mortality.

SECONDARY OUTCOMES

ICU and hospital length of stay, mortality at days 28 and 180, in-hospital mortality, ventilator-free days (day-28), and inflammatory response. Propensity scoring weighted the risk of previously-acquired sepsis. Multivariate analysis evaluated the risk of mortality by day-90. Sensitivity analyses evaluated the primary outcome in different subgroups.

RESULTS

Of 341 patients enrolled, 147 had sepsis on ICU-admission. Adjusted risk of mortality at 90 days did not differ overall [hazard ratio (HR) = 0.94(CI:0.65-1.37)], nor in subpopulations with a confirmed etiology of pneumonia [HR = 0.93(CI:0.57-1.53)] or sepsis [HR = 0.91(0.54-1.55)], ventilator-associated pneumonia (VAP) [HR = 1.01(CI:0.61-1.68)], nor non-VAP ICU-AP [HR = 0.83(CI:0.40-1.71)]. No differences were found in clinical secondary outcomes, the inflammatory response was similar.

CONCLUSIONS

Previous sepsis does not appear to predispose to higher mortality nor worse outcomes in patients who develop ICU-acquired pneumonia.

Increased Risk for Carbapenem-Resistant Enterobacteriaceae Colonization in Intensive Care Units after Hospitalization in Emergency Department

Carbapenem-resistant Enterobacteriaceae (CRE) colonization is common in hospital patients admitted to intensive care units (ICU) from the emergency department. We evaluated the effect of previous hospitalization in the emergency department on CRE colonization at ICU admission. Our case–control study included 103 cases and 201 controls; cases were patients colonized by CRE at admission to ICU and controls were patients admitted to ICU and not colonized. Risk factors were emergency department stay, use of carbapenem, Simplified Acute Physiology Score, upper digestive endoscopy, and transfer from another hospital. We found that ED stay before ICU admission was associated with CRE colonization at admission to the ICU. Our findings indicate that addressing infection control problems in EDs will help to control carbapenem resistance in ICUs.

Potentially preventable urinary tract infection in patients with type 2 diabetes - A hospital-based study

Aim

To investigate the prevalence of urinary tract infections in hospitalized patients with type 2 diabetes mellitus and identify corresponding risk factors.

Methods

We conducted a cross-sectional study on 7.347 patients with type 2 diabetes mellitus as the principal diagnosis, using hospitalization discharge summary data from January 1 to December 31, 2015. Disease stages were classified as stages 1, 2, and 3.

Results

Of 7.347 patients, 16.2% had urinary tract infections. The urinary tract infection prevalence was 24.4% in 428 patients in stage 1 and 4.8% in 2.840 patients in stage 2; it was higher among patients who underwent medical procedures than among those who underwent surgery (24.4% vs 4.8%). In multivariate regression analysis, age (OR = 1.031; 95% CI = 1.02-1.04), length of hospitalization (OR = 1.018; 95% CI = 1.013-1.024), sex (woman) (OR = 2.248; 95% CI = 1.778-2.842), comorbidity of stage 3 cerebrovascular disease (OR = 1.737; 95% CI = 1.111-2.714), and comorbidity of stage 1 colorectal cancer (OR = 2.417; 95% CI = 1.152-5.074) were found to be the risk factors of urinary tract infection in the ten hospitals considered.

Conclusions

Our findings suggest that urinary tract infection prevalence was higher in women without evidence of organ injury and those receiving medical treatment. Comorbidities (cerebrovascular disease and colorectal cancer) were identified as risk factors.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 727 intensive care units of 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific Regions: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheter-related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.

RESULTS

We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%).

CONCLUSIONS

PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries.

Impacts of Skeletonized Bilateral Internal Mammary Artery Bypass Grafting on the Risk of Deep Sternal Wound Infection

This single-center study aimed to evaluate the incidence of deep sternal wound infection (DSWI) following skeletonized bilateral internal mammary artery (BIMA) harvest in a Chinese cohort. Using propensity score matching, this study also provided a present-day assessment of the impacts of skeletonized BIMA grafting versus skeletonized single internal mammary artery (SIMA) grafting on early outcomes.From January 2014 to December 2017, 2403 eligible patients were entered into either a BIMA group (n = 368) or a SIMA group (n = 2035). The incidence of DSWI was recorded. Analysis of early outcomes was further performed for propensity score-matched (1:1) cohorts.The BIMA group received a similar incidence of DSWI as did the SIMA group (1.6% versus 0.9%, P = 0.247). No significant differences between subgroup diabetic-BIMA, subgroup nondiabetic-BIMA, subgroup diabetic-SIMA, and subgroup nondiabetic-SIMA were found regarding the incidence of DSWI (2.0%, 1.4%, 1.0%, and 0.7%, respectively; P > 0.05 between groups). After matching, treatment type (skeletonized BIMA grafting versus skeletonized SIMA grafting) was not an independent risk factor for postoperative DSWI (OR = 1.309, 95% CI 0.897-2.714, P = 0.704) or predictors of other early outcomes. Additionally, the two matched groups shared similar early outcomes (including postoperative DSWI), regardless of whether or not the merger with diabetes (all P > 0.05).Skeletonized BIMA harvest as compared with skeletonized SIMA harvest was not associated with an increased risk of DSWI, regardless of whether or not the merger with diabetes. Patients with skeletonized BIMA grafting received similar surgical mortality and major postoperative morbidity as did matched patients with skeletonized SIMA grafting.

Ten-year resistance trends in pathogens causing healthcare-associated infections; reflection of infection control interventions at a multi-hospital healthcare system in Saudi Arabia, 2007-2016

Background

Studying temporal changes in resistant pathogens causing healthcare-associated infections (HAIs) is crucial in improving local antimicrobial and infection control practices. The objective was to describe ten-year trends of resistance in pathogens causing HAIs in a tertiary care setting in Saudi Arabia and to compare such trends with those of US National Health Surveillance Network (NHSN).

Methods

Pooled analysis of surveillance data that were prospectively collected between 2007 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Definitions and methodology of HAIs and antimicrobial resistance were based on NHSN. Consecutive NHSN reports were used for comparisons.

Results

A total 1544 pathogens causing 1531 HAI events were included. Gram negative pathogens (GNP) were responsible for 63% of HAIs, with a significant increasing trend in Klebsiella spp. and a decreasing trend in Acinetobacter. Methicillin-resistant Staphylococcus aureus (27.0%) was consistently less frequent than NHSN. Vancomycin-resistant Enterococci (VRE, 20.3%) were more than doubled during the study, closing the gap with NHSN. Carbapenem resistance was highest with Acinetobacter (68.3%) and Pseudomonas (36.8%). Increasing trends of carbapenem resistance were highest in Pseudomonas and Enterobacteriaceae, closing initial gaps with NHSN. With the exception of Klebsiella and Enterobacter, multidrug-resistant (MDR) GNPs were generally decreasing, mainly due to the decreasing resistance towards cephalosporins, fluoroquinolones, and aminoglycosides.

Conclusion

The findings showed increasing trends of carbapenem resistance and VRE, which may reflect heavy use of carbapenems and vancomycin. These findings may highlight the need for effective antimicrobial stewardship programs, including monitoring and feedback on antimicrobial use and resistance.

Surveillance of external ventricular drainage-associated meningitis and ventriculitis in German intensive care units

OBJECTIVE

In light of the infection risk associated with external ventricular drainage (EVD), we decided to establish the surveillance of EVD-associated meningitis/ventriculitis in German intensive care units (ICUs) in the framework of the German national nosocomial infection surveillance system (KISS). Here, we present the current reference data and subsequent risk-factor analysis for EVD-associated meningitis/ventriculitis rates.

METHODS

The surveillance method corresponds with the surveillance methods for device-associated infections recommended by the National Healthcare Safety Network (NHSN). All ICUs participating for at least 1 month from 2008 to 2016 in the module ICU-KISS were included in the reference dataset and the multivariate analysis.

RESULTS

Current reference data (2008-2016) are based on input from 157 ICUs. The mean EVD-associated meningitis/ventriculitis rate per 1,000 EVD days was 3.96, with little variation between neurosurgical, surgical, interdisciplinary (hospitals with >400 beds), and neurological ICUs. In total, 893 EVD-associated meningitis/ventriculitis cases and 225,351 EVD days were included in the risk-factor analysis. After multivariate analysis, 2 factors remained significant: (1) stay in an ICU labeled other than neurosurgical, surgical, interdisciplinary (>400 beds), and neurological as a protective factor and (2) EVD utilization rate above the 75th quantile as a risk factor for acquisition of EVD-associated meningitis/ventriculitis.

CONCLUSIONS

EVD-associated meningitis and ventriculitis are frequent complications of care in intensive care patients at risk. A long hospital stay and/or the presence of the EVD puts the patient at high risk for pathogen acquisition with subsequent infection.

Length of stay, cost, and mortality of healthcare-acquired bloodstream infections in children and neonates: A systematic review and meta-analysis

OBJECTIVE

To estimate the attributable mortality, length of stay (LOS), and healthcare cost of pediatric and neonatal healthcare-acquired bloodstream infections (HA-BSIs).

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search (January 2000-September 2018) was conducted in PubMed, Cochrane, and CINAHL databases. Reference lists of selected articles were screened to identify additional studies. Case-control or cohort studies were eligible for inclusion when full text was available in English and data for at least 1 of the following criteria were provided: attributable or excess LOS, healthcare cost, or mortality rate due to HA-BSI. Study quality was evaluated using the Critical Appraisal Skills Programme Tool (CASP). Study selection and quality assessment were conducted by 2 independent researchers, and a third researcher was consulted to resolve any disagreements. Fixed- or random-effect models, as appropriate, were used to synthesize data. Heterogeneity and publication bias were evaluated.

RESULTS

In total, 21 studies were included in the systematic review and 13 studies were included in the meta-analysis. Attributable mean LOS ranged between 4 and 27.8 days; healthcare cost ranged between $1,642.16 and $160,804 (2019 USD) per patient with HA-BSI; and mortality rate ranged between 1.43% and 24%. The pooled mean attributable hospital LOS was 16.91 days (95% confidence interval [CI], 13.70-20.11) and the pooled attributable mortality rate was 8% (95% CI, 6-9). A meta-analysis was not conducted for cost due to lack of eligible studies.

CONCLUSIONS

Pediatric HA-BSIs have a significant impact on mortality, LOS, and healthcare cost, further highlighting the need for implementation of HA-BSI prevention strategies.

Incidence, Microbiological Profile, and Impact of Preventive Measures on Central Line-associated Bloodstream Infection in Liver Care Intensive Care Unit

Aims and objectives

Central line-associated bloodstream infection (CLABSI) is among one of the preventable healthcare-associated infections (HAIs). The data for the CLABSI rate in liver care intensive care unit (LCICU) patients are scarce, so the present study was conducted to ascertain the CLABSI rate, the microbiological profile, and the impact of preventive measures for reduction of infection.

Materials and methods

This is a prospective observational study done on LCICU patients during the period of January 2017–December 2018. We followed up patients on the central venous catheter for the development of CLABSI as a part of routine surveillance of HAIs. The impact of introduction and implementation of the CLABSI bundle to reduce the CLABSI rate was analyzed and the microbiological profile of infection was determined.

Results

During the study period, the total number of patients admitted in LCICU were 1,336 (648 in 2017 and 688 in 2018) and a total of 995 central lines were inserted for various indications. A total of 57 patients were meeting the CLABSI criteria among 7,324 central line catheter days of surveillance. In year 2017, rate of CLABSI was 11.78/1,000 catheter days and after implementation of the bundle in 2018 the rate reduced to 3.99/1,000 catheter days. Gram-negative organisms (86%) predominated with Pseudomonas aeruginosa being the most common pathogen (19.3%). Out of 49 isolates of gram-negative bacilli (GNB), 40 (81.6%) were multidrug resistant (MDR) and 9 (18.4%) were pan-drug resistant.

Conclusion

We found significant reduction in the CLABSI rate after implementation of the bundle of care. Gram-negative bacilli were the most common pathogen in our study and antimicrobial resistance was very high, which suggest hospital environment as a source of infection.

Clinical significance

Knowledge of the microbiological profile and the preventive strategy of CLABSI is essential for prevention and timely initiation of the most appropriate anti-infective therapy, if it happens.

How to cite this article

Khodare A, Kale P, Pindi G, Joy L, Khillan V. Incidence, Microbiological Profile, and Impact of Preventive Measures on Central Line-associated Bloodstream Infection in Liver Care Intensive Care Unit. Indian J Crit Care Med 2020;24(1):17–22.

Impact of International Nosocomial Infection Control Consortium's multidimensional approach on central line-associated bloodstream infection rates in Bahrain

BACKGROUND

Central line-associated bloodstream infections are serious life-threatening infections in the intensive care unit setting.

METHODS

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and INICC Surveillance Online System (ISOS) on central line-associated bloodstream infection rates in Bahrain from January 2013 to December 2016, we conducted a prospective, before-after surveillance, cohort, observational study in one intensive care unit in Bahrain. During baseline, we performed outcome and process surveillance of central line-associated bloodstream infection on 2320 intensive care unit patients, applying Centers for Disease Control and Prevention's National Healthcare Safety Network definitions. During intervention, we implemented IMA through ISOS, including (1) a bundle of infection prevention interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on central line-associated bloodstream infection rates and consequences, and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention on the central line-associated bloodstream infection rate.

RESULTS

During baseline, 672 central line days and 7 central line-associated bloodstream infections were recorded, accounting for 10.4 central line-associated bloodstream infections per 1000 central line days. During intervention, 13,020 central line days and 48 central line-associated bloodstream infections were recorded. After the second year, there was a sustained 89% cumulative central line-associated bloodstream infection rate reduction to 1.2 central line-associated bloodstream infections per 1000 central line days (incidence density rate, 0.11; 95% confidence interval 0.1-0.3; p, 0.001). The average extra length of stay of patients with central line-associated bloodstream infection was 23.3 days, and due to the reduction of central line-associated bloodstream infections, 367 days of hospitalization were saved, amounting to a reduction in hospitalization costs of US$1,100,553.

CONCLUSION

Implementing IMA was associated with a significant reduction in the central line-associated bloodstream infection rate in Bahrain.

'Adiós Bacteriemias': a multi-country quality improvement collaborative project to reduce the incidence of CLABSI in Latin American ICUs

QUALITY PROBLEM

The incidence of central line-associated bloodstream infections (CLABSI) in Latin America has been estimated at 4.9 episodes per 1000 central line (CL) days, compared to a pooled incidence of 0.9 in the United States. CLABSI usually result from not adhering to standardized health procedures and can be prevented using evidence-based practices.

INITIAL ASSESSMENT

The first phase of the 'Adiós Bacteriemias' Collaborative was implemented in 39 intensive care units (ICUs) from Latin America from September 2012 to September 2013 with a 56% overall reduction in the incidence of CLABSI.

CHOICE OF SOLUTION

Bundles of care for the processes of insertion and maintenance of CLs have proven to be effective in the reduction of CLABSI across different settings.

IMPLEMENTATION

Building on the results of the first phase, we implemented a second phase of the 'Adiós Bacteriemias' Collaborative between June 2014-July 2015. We adapted the Breakthrough Series (BTS) Collaborative model to guide the adoption of bundles of care for CLABSI prevention through virtual learning sessions and continuous feedback.

EVALUATION

Eighty-three ICUs from five Latin American countries actively reported process and outcome measures. The overall reduction in the CLABSI incidence rate was 22% (incidence rate 0.78; 95% CI 0.65, 0.95), from 2.58 episodes per 1000 CL days at baseline to 2.02 episodes per 1000 CL days (P < 0.01) during the intervention period.

LESSONS LEARNED

Adiós Bacteriemias was effective in reducing the incidence of CLABSI and improving the adherence to good practices for CL insertion and maintenance processes in participating ICUs in Latin America.

The incidence, aetiology and antimicrobial susceptibility of central line-associated bloodstream infections in intensive care unit patients at a private tertiary care hospital in Mumbai, India

Background

There is a need to generate accurate data on temporal trends in incidence rates, aetiology and antimicrobial susceptibility of central line-associated bloodstream infections (CLABSIs) in the Indian setting.

Aim

To study the incidence, aetiology and antimicrobial susceptibility of CLABSI in adult, paediatric and neonatal intensive care units (NICUs) in a tertiary care private hospital in Mumbai, India.

Materials and Methods

This is a prospective observational study conducted at the adult, paediatric and NICUs of tertiary care private hospital from 2011 to 2018. CLABSI was defined as per the Centers for Disease Control criteria. Surveillance of CLABSI in the intensive care units (ICUs) was conducted using a form adapted from the International Nosocomial Infection Control Consortium surveillance system. The incidence rates of CLABSI (per 1000 central line days), crude mortality, aetiology and antimicrobial susceptibility were calculated and reported.

Results

Six hundred and eighty-six episodes of CLABSI were recorded, and the overall incidence of CLABSI was 5/1000 catheter days, 4.1 in the adult ICU, 5 in the paediatric ICU and 9 in the newborn ICU. Crude mortality in patients with CLABSI in the adult, paediatric and NICUs was 45%, 30% and 7%, respectively. Of the 752 isolates, 80% were Gram negative, 10% Gram positive and 10% yeast. The prevalence of extended-spectrum beta-lactamase producers was 80%, and rates of carbapenem resistance were on an average 50%.

Conclusions

The CLABSI rates at a well-equipped tertiary care hospital are still significantly higher than the USA benchmarks. Alarming rates of drug resistance in Gram-negative pathogens were seen.

Chlorhexidine disinfectant can reduce the risk of central venous catheter infection compared with povidone: a meta-analysis

OBJECTIVE

Assess the efficacy of chlorhexidine with povidone solutions as a skin disinfectant for central venous catheter (CVC) care.

BACKGROUND

Central venous catheters are widely used for critically ill patients. Catheter maintenance can easily lead to a catheter-related bloodstream infection (CRBSI), which is the manifestation of a bloodstream infection (BSI) in a patient who carries a catheter or removes the catheter within 48 hours. There is no clear source of BSIs except for indwelling catheters in the blood vessels, and BSIs significantly increase the morbidity and mortality of patients. We assess the efficacy of chlorhexidine with povidone as a skin disinfectant for CVC care.

METHODS

In July 2018, we searched the Cochrane Library, PubMed, EMBASE, Web of Science, OVID, CNKI, SinoMed, WanFangData, CqVip, and DuXiu for publications in English and Chinese. By searching articles published before July 2018, we were able to extract data on study design, participants, antiseptics compared, sample size, and main outcomes. We conducted meta-analyses of the efficacy of chlorhexidine vs povidone solutions as a skin disinfectant for CVC care.

RESULTS

We included 10 randomized controlled trial studies. After conducting subgroup analysis, the results indicated that chlorhexidine was significantly better than povidone in preventing CRBSIs (P = .12; I² = 36%; risk ratio [RR] = 0.49; 95% confidence interval [CI], 0.29-0.85). Compared with povidone, the chlorhexidine catheterization rate of CRBSIs was reduced (P = .16; I² = 32%; RR = 0.54; 95% CI, 0.42-0.69). There was no clear difference in the rates of skin reaction between chlorhexidine and povidone (P = .006; I² = 87%; RR = 1.92; 95% CI, 0.55-6.72). The comparison was underpowered for BSIs without a clear source.

CONCLUSIONS

Chlorhexidine solution for CVC care may significantly reduce rates of CRBSIs and catheter colonization compared with povidone solutions. The disinfection effect of chlorhexidine-alcohol is better than that of other solutions. Because the quality of the studies evaluated is relatively low, the true effects may be different, so more evidence is needed.

High incidence of multiresistant bacterial isolates from bloodstream infections in trauma emergency department and intensive care unit in Serbia

We investigated the incidence of bloodstream infections (BSIs) in trauma emergency department (ED) and intensive care unit (ICU), to assess ED- and ICU-related predictors of BSI and to describe the most common bacteria causing BSI and their antimicrobial resistance markers. A prospective study was conducted in two trauma ICUs of the ED of Clinical Center of Serbia. Overall, 62 BSIs were diagnosed in 406 patients, of which 13 were catheter-related BSI (3.0/1,000 CVC-days) and 30 BSIs of unknown origin, while 15% were attributed to ED CVC exposure. Lactate ≥2 mmol/L and SOFA score were independent ED-related predictors of BSI, while CVC in place for >7 days and mechanical ventilation >7 days were significant ICU-related predictors. The most common bacteria recovered were Acinetobacter spp., Klebsiella spp., and Pseudomonas aeruginosa. All Staphylococcus aureus and coagulase-negative staphylococci isolates were methicillin-resistant, whereas 66% of Enterococcus spp. were vancomycin-resistant. All isolates of Enterobacteriaceae were resistant to third-generation cephalosporins, whereas 87.5% of P. aeruginosa and 95.8% of Acinetobacter spp. isolates were resistant to carbapenems. ED BSI contributes substantially to overall ICU incidence of BSI. Lactate level and SOFA score can help to identify patients with higher risk of developing BSI. Better overall and CVC-specific control measures in patients with trauma are needed.

Microbial cause of ICU-acquired pneumonia: hospital-acquired pneumonia versus ventilator-associated pneumonia

PURPOSE OF REVIEW

Successful treatment of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remains a difficult and complex undertaking. Better knowledge of the pathogens involved in that setting may allow reassessment of our current modalities of therapy and definition of better protocols.

RECENT FINDINGS

Microorganisms responsible for HAP/VAP differ according to geographic areas, ICU patients' specific characteristics, durations of hospital and ICU stays before onset of the disease, and risk factors for MDR pathogens. However, a number of studies have shown that Gram-negative bacilli (GNB) - particularly Pseudomonas aeruginosa and Enterobacteriaceae - cause many of the respiratory infections in this setting, with minimal differences between HAP and VAP, indicating that the cause depends more on the underlying clinical condition of patients rather than previous intubation.

SUMMARY

When selecting initial antimicrobial therapy in patients with HAP/VAP, more attention should be paid to individual risk factors for MDR pathogens, severity of the clinical situation, and the local epidemiology than to the type of pneumonia.

Should the CDC's recommendations for promptly removing unnecessary centrally inserted central catheters be enhanced? Ultrasound-guided peripheral venous cannulation to fully comply

PURPOSE

In an effort to reduce catheter-related bloodstream infection's incidence rates in an intensive care unit, several evidence-based procedures recommended by the Centers for Disease Control and Prevention for centrally inserted central catheters were implemented. A failure to fully comply with the recommendation for prompt removal of the centrally inserted central catheters was attributed, mainly to the difficulties and inadequacies raised from establishing peripheral venous access.

METHODS

The ultrasound-guided peripheral venous cannulation method as a supplementary intervention to the Centers for Disease Control and Prevention's recommendations was incorporated and examined during the subsequent year.

RESULTS

A significant reduction on catheter-related bloodstream infection incidence rates out of the expected range was found. Centrally inserted central catheters utilization ratios were reduced by 10.7% (p < 0.05; 58%-47%) and the catheter-related bloodstream infection incidence rate was reduced by 11.7 per thousand device-days (15.9-4.16/1000 centrally inserted central catheters days (2015-2016 group, respectively)).

CONCLUSION

The reduction of catheter-related bloodstream infection was higher than that described in the published literature. This probably shows that the combination of the five evidence-based procedures recommended by the Centers for Disease Control and Prevention together with that of ultrasound-guided peripheral venous cannulation method can increase the compliance with the Category IA recommendation for removal or avoidance of unnecessary placement of centrally inserted central catheters and decrease the catheter-related bloodstream infections in a more effective way, by affecting the patients' centrally inserted central catheter exposure.

Risk factors for vascular catheter-related bloodstream infections in pediatric intensive care units

Objectives

To determine the risk factors for acquiring central line-associated blood stream infections (CLABSI) in pediatric intensive care units and to investigate the incidence and etiology of CLABSI in pediatric intensive care units with different profiles.

Methods

The study was a prospective cohort study in three hospitals. One of the hospitals is a large metropolitan public hospital with two pediatric intensive care units and a total of nineteen pediatric intensive care unit beds, another is a regional hospital with eight pediatric intensive care unit beds, and the third is a private hospital with fifteen beds. Patients between the ages of 1 month old and 18 years old who used a central venous catheter for over 24 hours were included. We recorded patients’ daily progress. General patient and catheter-related data were collected and used as variables. All the data were analyzed using Statistical Package for Social Science (SPSS), version 13.0, to compare patients with CLABSI with or without risk factors.

Results

A total of 728 patients were admitted to the pediatric intensive care units, and 170 had a central line in place for at least 24 hours. The median age was 32 months, and 97 (57%) of the patients were males. The CLABSI incidence rate was 3.9/1000 central venous catheter-days. The incidence among hospitals varied from 1.6 to 6.6. The overall mortality rate was 11.1%, and the CLABSI and non-CLABSI mortality rates were 12.9% and 10.7%, respectively. In multivariate analysis, independent risk factors for CLABSI were a longer duration of central venous catheter use (OR: 1.07; 95%CI 1.00 - 1.14; p = 0.019) and the use of more than one central venous catheter at once (OR: 2.59; 95%CI 1.17 - 5.73; p = 0.048).

Conclusion

A longer duration of central venous catheter use and the use of more than one central venous catheter at once were the main risk factors for CLABSI in pediatric intensive care units.

Effectiveness of a Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia at the PICU: A Systematic Review and Meta-Analysis

OBJECTIVES

Ventilator-associated pneumonia is one of the most frequent hospital-acquired infections in mechanically ventilated children. We reviewed the literature on the effectiveness of ventilator care bundles in critically ill children.

DATA SOURCES

Embase, Medline OvidSP, Web-of-Science, Cochrane Library, and PubMed were searched from January 1990 until April 2017.

STUDY SELECTION

Studies were included if they met the following criteria: 1) implementation of a ventilator care bundle in PICU setting; 2) quality improvement or multicomponent approach with the (primary) objective to lower the ventilator-associated pneumonia rate (expressed as ventilator-associated pneumonia episodes/1,000 ventilator days); and 3) made a comparison, for example, with or without ventilator care bundle, using an experimental randomized or nonrandomized study design, or an interrupted-times series. Exclusion criteria were (systematic) reviews, guidelines, descriptive studies, editorials, or poster publications.

DATA EXTRACTION

The following data were collected from each study: design, setting, patient characteristics (if available), number of ventilator-associated pneumonia per 1,000 ventilator days, ventilator-associated pneumonia definitions used, elements of the ventilator care bundle, and implementation strategy. Ambiguities about data extraction were resolved after discussion and consulting a third reviewer (M.N., E.I.) when necessary. We quantitatively pooled the results of individual studies, where suitable. The primary outcome, reduction in ventilator-associated pneumonia per 1,000 ventilator days, was expressed as an incidence risk ratio with a 95% CI. All data for meta-analysis were pooled by using a DerSimonian and Laird random effect model.

DATA SYNTHESIS

Eleven articles were included. The median ventilator-associated pneumonia incidence decreased from 9.8 (interquartile range, 5.8-18.5) per 1,000 ventilator days to 4.6 (interquartile range, 1.2-8.6) per 1,000 ventilator days after implementation of a ventilator care bundle. The meta-analysis showed that the implementation of a ventilator care bundle resulted in significantly reduced ventilator-associated pneumonia incidences (incidence risk ratio = 0.45; 95% CI, 0.33-0.60; p < 0.0001; I = 55%).

CONCLUSIONS

Implementation of a ventilator-associated pneumonia bundle has the potential to reduce the prevalence of ventilator-associated pneumonia in mechanically ventilated children.

Assessment of the Potential for Inducing Resistance in Multidrug-Resistant Organisms from Exposure to Minocycline, Rifampin, and Chlorhexidine Used To Treat Intravascular Devices

To assess the potential for the induction of antimicrobial resistance following repeated subinhibitory exposures to the combination minocycline (MIN), rifampin (RIF), and chlorhexidine (CHX), a total of 29 clinical microbial pathogenic isolates were repeatedly exposed to subinhibitory concentrations of MIN, RIF, and CHX for 20 passages. MICs of the MIN, RIF, and CHX combination were assessed at each passage to evaluate the potential for resistance to have been induced. The combination of MIN, RIF, and CHX showed significant antimicrobial efficacy and synergy against organisms resistant to all 3 individual components (MIC of ≥16 μg/ml for MIN or MIC of ≥4 μg/ml for RIF or CHX). Among the organisms originally resistant to 2 or more individual components and the organisms originally susceptible to 2 or more individual components, there was no evidence that organisms became resistant following 20 repeated subinhibitory exposure cycles to the triple combination. The risk of resistance developing to the triple combination is extremely low because microbes are inhibited or killed before resistance can simultaneously emerge to all three agents. Surveillance studies monitoring the development of resistance should be conducted in a clinical setting.

Epidemiology and risk factors for nosocomial infection in the respiratory intensive care unit of a teaching hospital in China: A prospective surveillance during 2013 and 2015

BACKGROUND

To determine the epidemiology and risk factors for nosocomial infection (NI) in the Respiratory Intensive Care Unit (RICU) of a teaching hospital in Northwest China.

METHODS

An observational, prospective surveillance was conducted in the RICU from 2013 to 2015. The overall infection rate, distribution of infection sites, device-associated infections and pathogen in the RICU were investigated. Then, the logistic regression analysis was used to test the risk factors for RICU infection.

RESULTS

In this study, 102 out of 1347 patients experienced NI. Among them, 87 were device-associated infection. The overall prevalence of NI was 7.57% with varied rates from 7.19 to 7.73% over the 3 years. The lower respiratory tract (43.1%), urinary tract (26.5%) and bloodstream (20.6%) infections accounted for the majority of infections. The device-associated infection rates of urinary catheter, central catheter and ventilator were 9.8, 7.4 and 7.4 per 1000 days, respectively.The most frequently isolated pathogens were Staphylococcus aureus (20.9%), Klebsiella pneumoniae (16.4%) and Pseudomonas aeruginosa (10.7%). Multivariate analysis showed that the categories D or E of Average Severity of Illness Score (ASIS), length of stay (10-30, 30-60, ≥60 days), immunosuppressive therapy and ventilator use are the independent risk factors for RICU infection with an adjusted odds ratio (OR) of 1.65 (95% CI: 1.15~2.37), 5.22 (95% CI: 2.63~10.38)), 2.32 (95% CI: 1.19~4.65), 8.93 (95% CI: 3.17~21.23), 31.25 (95% CI: 11.80~63.65)) and 2.70 (95% CI: 1.33~5.35), respectively.

CONCLUSION

A relatively low and stable rate of NI was observed in our RICU through year 2013-2015. The ASIS-D、E, stay ≥10 days, immunosuppressive therapy and ventilator use are the independent risk factors for RICU infection.

Pooled prevalence and trends of antimicrobial resistance in Pseudomonas aeruginosa clinical isolates over the past 10 years in Turkey: A meta-analysis

OBJECTIVES

This meta-analysis aimed to evaluate the current prevalence and trends over the past 10 years of Pseudomonas aeruginosa (P. aeruginosa) antimicrobial resistance. Two researches independently searched two national (ULAKBİM, Türk Medline) and two international databases (PubMed, Web of Science) to identify studies on P. aeruginosa resistance to antimicrobials from 2007 to 2017.

METHODS

Homogeneity across studies was assessed using Cochrane guidelines, and total variability due to between-study variations was reflected in the I² index. A random effects model was developed to estimate the antimicrobial resistance rates and their corresponding 95% CI. Pooled antibiotic resistance rates between 2007-2011 and 2012-2016 were compared to calculate the change in antibiotic resistance over time. Electronic searches with MeSH terms and text words identified 1017 papers. After applying exclusion and inclusion criteria, 45 articles were selected.

RESULTS

Pooled resistance prevalence of P. aeruginosa to piperacillin-tazobactam, ceftazidime, cefepime, meropenem, imipenem, ciprofloxacin, gentamicin, amikacin, tobramycin and colistin were 33.9%, 38.6%, 35.6%, 30.1%, 28.0%, 30.7%, 28.2%, 17.8%, 15.7% and 2.2%, respectively. The resistance rates of piperacillin, piperacillin-tazobactam, imipenem, meropenem, amikacin and colistin significantly increased in the second 5 years (P<0.05); however, gentamicin, tobramycin and ciprofloxacin resistance rates significantly decreased (P<0.05). Comparing the resistance rates between the isolates of intensive care unit (ICU) patients and non-ICU patients, meropenem and piperacillin-tazobactam resistance in ICU isolates were significantly higher than non-ICU (P<0.05).

CONCLUSIONS

These results suggest that antibiotic resistance is high in P. aeruginosa and the trends in antimicrobial resistance continue to increase, mainly in carbapenems and penicillins, in Turkey.

Infection control and patient safety measures addressed in nursing pedagogical projects

OBJECTIVE

To characterize teaching about patient safety and standard precautionary measures for infection prevention and control in undergraduate nursing courses.

METHOD

A descriptive documentary analysis study carried out in undergraduate courses, with a concept equal to or greater than three in the National Student Performance Exam and in the Preliminary Course Concept, located in the state of Goiás, Brazil.

RESULTS

Six education institutions participated, with the majority being private with curricular structure by discipline. Six pedagogical projects and 273 subject plans were analyzed. The most discussed topics for patient safety development were human factors related to communication, interpersonal relationships, and principles and techniques. Thirty-nine (39) disciplines contemplated teaching infection prevention and control measures, and the most approached topics were personal protective equipment and hand hygiene.

CONCLUSION

Teaching about patient safety presented strong gaps in the six evaluated courses. There is fragility in teaching infection prevention and control measures. The data indicate the need to review the Course Pedagogical Projects in order to incorporate necessary educational demands for training professionals so that they develop safe and quality care.

A Systematic Review and Meta-analysis of Ventilator-associated Pneumonia in Adults in Asia: An Analysis of National Income Level on Incidence and Etiology

Background

Ventilator-associated pneumonia (VAP) is the commonest hospital-acquired infection (HAI) in intensive care. In Asia, VAP is increasingly caused by resistant gram-negative organisms. Despite the global antimicrobial resistance crisis, the epidemiology of VAP is poorly documented in Asia.

Methods

We systematically reviewed literature published on Ovid Medline, Embase Classic, and Embase from 1 January 1990 to 17 August 2017 to estimate incidence, prevalence, and etiology of VAP. We performed a meta-analysis to give pooled rates and rates by country income level.

Results

Pooled incidence density of VAP was high in lower- and upper-middle-income countries and lower in high-income countries (18.5, 15.2, and 9.0 per 1000 ventilator-days, respectively). Acinetobacter baumannii (n = 3687 [26%]) and Pseudomonas aeruginosa (n = 3176 [22%]) were leading causes of VAP; Staphylococcus aureus caused 14% (n = 1999). Carbapenem resistance was common (57.1%).

Conclusions

VAP remains a common cause of HAI, especially in low- and middle-income countries, and antibiotic resistance is high.

Catheter removal and outcomes of multidrug-resistant central-line-associated bloodstream infection

Central-line-associated bloodstream infections (CLABSIs) are responsible for ∼1/3 of all deaths from healthcare-associated infections in the United States. Of these, multidrug-resistant organisms (MDROs) are responsible for 20% to 67%. However, whether catheter removal affects clinical outcomes for MDRO CLABSIs has not been studied. Our objective was to determine the relationship between failure to remove a central venous catheter (CVC) and 30-day all-cause mortality in patients with MDRO CLABSIs. We used a retrospective cohort from Barnes-Jewish Hospital (1/1/2009-10/1/2015) to study patients with a multidrug-resistant Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, Acinetobacter species, or Pseudomonas aeruginosa CLABSI. Risk factors for 30-day mortality, including catheter removal, were assessed for association with 30-day mortality using Cox proportional hazards models. The CLABSIs were assessed prospectively at the time of occurrence by infection prevention specialists. A total of 430 patients met inclusion criteria, 173 (40.2%) with Enterococcus, 116 (27.0%) Enterobacteriaceae, 81 (18.8%) S aureus, 44 (10.2%) polymicrobial, 11 (2.6%) P aeruginosa, and 5 (1.2%) Acinetobacter CLABSIs. Removal of a CVC occurred in 50.2% of patients, of which 4.2% died by 30 days (n = 9). For patients whose CVC remained in place, 45.3% died (n = 97). Failure to remove a CVC was strongly associated with 30-day all-cause mortality with a hazard ratio of 13.5 (6.8-26.7), P < .001. Other risk factors for 30-day mortality included patient comorbidities (cardiovascular disease, congestive heart failure, cirrhosis), and being in an intensive care unit at the time of MDRO isolation. Failure to remove a CVC was strongly associated with 30-day all-cause mortality for patients with MDRO CLABSIs in this single center retrospective cohort. This suggests that patients presenting with MDRO CLABSIs should all undergo CVC removal.

Respiratory Care for the Ventilated Neonate

Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.

Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach'

Background

Healthcare-associated infections (HCAI/HAIs) are one of the most common adverse events in patient care and account for substantial morbidity and mortality. The high rates of HCAIs in a facility are an indicator of poor quality of healthcare services. According to the World Health Organization, at any time, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI. These infections also present a significant economic burden at the societal level. However, a large percentage of HAIs are preventable through effective infection prevention and control measures.

Objectives

Prevention of these infections also needs to be prioritised in view of the growing antimicrobial resistance in HAIs. The bundle approach to the prevention of HAIs is a relatively new concept that is revolutionising the care of high-risk patients in the Intensive Care Units. This report details the bundle approach for the prevention of HAIs, particularly the device-associated infections, for low- and middle-income countries.

Conclusion

With the escalating armamentarium of antimicrobial resistance, healthcare sector has to go back to the very basics of hospital infection control; develop, assess and implement bundles of prevention. These are cost-effective and easily adaptable, to cater to the increasing HCAIs and MDR infections in the LMICs.

Infection control bundles in intensive care: an international cross-sectional survey in low- and middle-income countries

BACKGROUND

In low- and middle-income countries (LMICs), the burden of healthcare-associated infections (HCAIs) is not known due to a lack of national surveillance systems, standardized infection definitions, and paucity of infection prevention and control (IPC) organizations and legal infrastructure.

AIM

To determine the status of IPC bundle practice and the most frequent interventional variables in LMICs.

METHODS

A questionnaire was emailed to Infectious Diseases International Research Initiative (ID-IRI) Group Members and dedicated IPC doctors working in LMICs to examine self-reported practices/policies regarding IPC bundles. Responding country incomes were classified by World Bank definitions into low, middle, and high. Comparison of LMIC results was then made to a control group of high-income countries (HICs).

FINDINGS

This survey reports practices from one low-income country (LIC), 16 middle-income countries (MICs) (13 European), compared to eight high-income countries (HICs). Eighteen (95%) MICs had an IPC committee in their hospital, 12 (63.2%) had an annual agreed programme and produced an HCAI report. Annual agreed programmes (87.5% vs 63.2%, respectively) and an annual HCAI report (75.0% vs 63.2%, respectively) were more common in HICs than MICs. All HICs had at least one invasive device-related surveillance programme. Seven (37%) MICs had no invasive device-related surveillance programme, six (32%) had no ventilator-associated pneumonia prevention bundles, seven (37%) had no catheter-associated urinary tract infection prevention bundles, and five (27%) had no central line-associated bloodstream infection prevention bundles.

CONCLUSION

LMICs need to develop their own bundles with low-cost and high-level-of-evidence variables adapted to the limited resources, with further validation in reducing infection rates.

Implementing infection prevention practices across European hospitals: an in-depth qualitative assessment

Objective

The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals.

Methods

Qualitative comparative case study in 6 of the 14 European PROHIBIT hospitals. Data were collected through interviews with key stakeholders and ethnographic observations conducted during 2-day site visits, before and 1 year into the PROHIBIT intervention. Qualitative measures of implementation success included intervention fidelity, adaptation to local context and satisfaction with the intervention programme.

Results

Three meta-themes emerged related to implementation success: ‘implementation agendas’, ‘resources’ and ‘boundary-spanning’. Hospitals established unique implementation agendas that, while not always aligned with the project goals, shaped subsequent actions. Successful implementation required having sufficient human and material resources and dedicated change agents who helped make the intervention an institutional priority. The salary provided for a dedicated study nurse was a key facilitator. Personal commitment of influential individuals and boundary spanners helped overcome resource restrictions and intrainstitutional segregation.

Conclusion

This qualitative study revealed patterns across cases that were associated with successful implementation. Consideration of the intervention–context relation was indispensable to understanding the observed outcomes.

Healthcare-associated infections in the neurological intensive care unit: Results of a 6-year surveillance study at a major tertiary care center

BACKGROUND

Healthcare-associated infections (HAIs) occur frequently in neurological intensive care units (neuro-ICUs); however, data differentiating associations with various diagnostic categories and resulting burdens are limited. This prospective cohort study reported incidence rates, pathogen distribution, and patient-related outcomes of HAIs in a neuro-ICU population from April 2010 to March 2016.

METHODS

Laboratory results and specific clinical indicators were used to categorize infections as per National Healthcare Safety Network nosocomial infection surveillance definitions. Patient outcomes studied included length of stay and mortality.

RESULTS

There were 6,033 neuro-ICU admissions resulting in 20,800 neuro-ICU days over the 6-year study period. A total of 227 HAIs were identified for a rate of 10.9/1,000 ICU days. Device-associated infections accounted for 80.6% of HAIs, with incidence rates (per 1,000 device days) being 18.4 for ventilator-associated pneumonia; 4.9 for catheter-associated urinary tract infections (CAUTIs); 4.0 for ventriculostomy-associated infections; and 0.6 for central line-associated blood stream infections (CLABSIs). Of the various diagnostic categories, subdural hematoma and intracerebral/intraventricular hemorrhage were associated with the highest pooled HAIs, with incidence rates of 21.3 and 21.1 per 1,000 neuro-ICU days, respectively. Prolonged neuro-ICU length of stay was strongly associated with all HAIs.

CONCLUSIONS

This large-scale surveillance study provides estimates of the risk of common HAIs in neurocritical care patients and their effect on hospitalization. Preventive strategies kept rates of infection very low, in particular CAUTI, CLABSI, and Clostridium difficile infections, and inhibited the emergence of resistant organisms.

Impact of the International Nosocomial Infection Control Consortium's multidimensional approach on rates of ventilator-associated pneumonia in 14 intensive care units in 11 hospitals of 5 cities within Argentina

BACKGROUND

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in 11 hospitals within 5 cities of Argentina from January 2014-April 2017.

METHODS

A multicenter, prospective, before-after surveillance study was conducted through the use of International Nosocomial Infection Control Consortium Surveillance Online System. During baseline, we performed outcome surveillance of VAP applying the definitions of the Centers for Disease Control andPrevention's National Healthcare Safety Network. During intervention, we implemented the IMA, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on VAP rates and consequences, and performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention.

RESULTS

We recorded 3,940 patients admitted to 14 intensive care units. At baseline, there were 19.9 VAPs per 1,000 mechanical ventilator (MV)-days-with 2,920 MV-days and 58 VAPs, which was reduced during intervention to 9.4 VAPs per 1,000 MV-days-with 9,261 MV-days and 103 VAPs. This accounted for a 52% rate reduction (incidence density rate, 0.48; 95% confidence interval, 0.3-0.7; P .001).

CONCLUSIONS

Implementing the IMA was associated with significant reductions in VAP rates in intensive care units within Argentina.