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

Coverage and methods of surveillance of healthcare-associated infections in Middle Eastern and North African countries

BACKGROUND

Surveillance of healthcare-associated infections (HAIs) is a cornerstone for effective infection prevention and control (IPC) programs. The objective was to evaluate the coverage and methods of HAI surveillance in Middle Eastern and North African (MENA) countries.

METHODS

A cross-sectional study targeted IPC staff working in MENA countries using the Infection Control Network electronic database of the Arab countries. The study focused on self-reported surveillance-related characteristics of IPC staff, facilities, and the IPC program.

RESULTS

A total of 269 IPC staff were included. They were mainly females (68%), nurses (63%), and working in GCC countries (83%). Approximately 69% of covered facilities had surveillance activities. Hand hygiene, multidrug-resistant organisms, central line-associated bloodstream infections, and catheter-associated urinary tract infections were the most common surveillance activities (>90%). The surveillance workload consumed 27% of the average weekly working time. The scores of performing multiple surveillance, with appropriate methods and tools, were 83%, 67%, and 61% (respectively). Appropriate surveillance methods and/or tools were linked to GCC region, CBIC qualifications, surveillance training, specific setting (acute care and long term), staff-to-bed ratio, presence and active function of IPC committee, presence of IPC annual plan, communications with health care workers, and leadership support.

CONCLUSIONS

While most health care facilities in the MENA region perform multiple surveillance, surveillance methods and tools are still suboptimal and their optimization should be a priority.

Risk factors for mortality over 18 years in 317 ICUs in 9 Asian countries: The impact of healthcare-associated infections

OBJECTIVE

To identify risk factors for mortality in intensive care units (ICUs) in Asia.

DESIGN

Prospective cohort study.

SETTING

The study included 317 ICUs of 96 hospitals in 44 cities in 9 countries of Asia: China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam.

PARTICIPANTS

Patients aged >18 years admitted to ICUs.

RESULTS

In total, 157,667 patients were followed during 957,517 patient days, and 8,157 HAIs occurred. In multiple logistic regression, the following variables were associated with an increased mortality risk: central-line-associated bloodstream infection (CLABSI; aOR, 2.36; P < .0001), ventilator-associated event (VAE; aOR, 1.51; P < .0001), catheter-associated urinary tract infection (CAUTI; aOR, 1.04; P < .0001), and female sex (aOR, 1.06; P < .0001). Older age increased mortality risk by 1% per year (aOR, 1.01; P < .0001). Length of stay (LOS) increased mortality risk by 1% per bed day (aOR, 1.01; P < .0001). Central-line days increased mortality risk by 2% per central-line day (aOR, 1.02; P < .0001). Urinary catheter days increased mortality risk by 4% per urinary catheter day (aOR, 1.04; P < .0001). The highest mortality risks were associated with mechanical ventilation utilization ratio (aOR, 12.48; P < .0001), upper middle-income country (aOR, 1.09; P = .033), surgical hospitalization (aOR, 2.17; P < .0001), pediatric oncology ICU (aOR, 9.90; P < .0001), and adult oncology ICU (aOR, 4.52; P < .0001). Patients at university hospitals had the lowest mortality risk (aOR, 0.61; P < .0001).

CONCLUSIONS

Some variables associated with an increased mortality risk are unlikely to change, such as age, sex, national economy, hospitalization type, and ICU type. Some other variables can be modified, such as LOS, central-line use, urinary catheter use, and mechanical ventilation as well as and acquisition of CLABSI, VAE, or CAUTI. To reduce mortality risk, we shall focus on strategies to reduce LOS; strategies to reduce central-line, urinary catheter, and mechanical ventilation use; and HAI prevention recommendations.

Catheters with Dual-Antimicrobial Properties by Gamma Radiation-Induced Grafting

Dual antimicrobial materials that have a combination of antimicrobial and antifouling properties were developed. They were developed through modification using gamma radiation of poly (vinyl chloride) (PVC) catheters with 4-vinyl pyridine (4VP) and subsequent functionalization with 1,3-propane sultone (PS). These materials were characterized by infrared spectroscopy, thermogravimetric analysis, swelling tests, and contact angle to determine their surface characteristics. In addition, the capacity of the materials to deliver ciprofloxacin, inhibit bacterial growth, decrease bacterial and protein adhesion, and stimulate cell growth were evaluated. These materials have potential applications in the manufacturing of medical devices with antimicrobial properties, which can reinforce prophylactic potential or even help treat infections, through localized delivery systems for antibiotics.

The Impact of Healthcare-Associated Infections on Mortality in ICU: A Prospective Study in Asia, Eastern Europe, Latin America, and the Middle East

BACKGROUND

The International Nosocomial Infection Control Consortium has found a high ICU mortality rate. Our aim was to identify all-cause mortality risk factors in ICU-patients.

METHODS

Multinational, multicenter, prospective cohort study at 786 ICUs of 312 hospitals in 147 cities in 37 Latin American, Asian, African, Middle Eastern, and European countries.

RESULTS

Between 07/01/1998 and 02/12/2022, 300,827 patients, followed during 2,167,397 patient-days, acquired 21,371 HAIs. Following mortality risk factors were identified in multiple logistic regression: Central line-associated bloodstream infection (CLABSI) (aOR:1.84; p<0.0001); ventilator-associated pneumonia (VAP) (aOR:1.48; p<0.0001); catheter-associated urinary tract infection (CAUTI) (aOR:1.18;p<0.0001); medical hospitalization (aOR:1.81; p<0.0001); length of stay (LOS), risk rises 1% per day (aOR:1.01; p<0.0001); female gender (aOR:1.09; p<0.0001); age (aOR:1.012; p<0.0001); central line-days, risk rises 2% per day (aOR:1.02; p<0.0001); and mechanical ventilator (MV)-utilization ratio (aOR:10.46; p<0.0001). Coronary ICU showed the lowest risk for mortality (aOR: 0.34;p<0.0001).

CONCLUSION

Some identified risk factors are unlikely to change, such as country income-level, facility ownership, hospitalization type, gender, and age. Some can be modified; CLABSI, VAP, CAUTI, LOS, and MV-utilization. So, to lower the risk of death in ICUs, we recommend focusing on strategies to shorten the LOS, reduce MV-utilization, and use evidence-based recommendations to prevent HAIs.

Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019

BACKGROUND

Hand hygiene is at the core of effective infection prevention and control (IPC) programmes. 10 years after the development of the WHO Multimodal Hand Hygiene Improvement Strategy, we aimed to ascertain the level of hand hygiene implementation and its drivers in health-care facilities through a global WHO survey.

METHODS

From Jan 16 to Dec 31, 2019, IPC professionals were invited through email and campaigns to complete the online Hand Hygiene Self-Assessment Framework (HHSAF). A geospatial clustering algorithm selected unique health-care facilities responses and post-stratification weighting was applied to improve representativeness. Weighted median HHSAF scores and IQR were reported. Drivers of the HHSAF score were determined through a generalised estimation equation.

FINDINGS

3206 unique responses from 90 countries (46% WHO Member States) were included. The HHSAF score indicated an intermediate hand hygiene implementation level (350 points, IQR 248-430), which was positively associated with country income level and health-care facility funding structure. System Change had the highest score (85 points, IQR 55-100), whereby alcohol-based hand rub at the point of care has become standard practice in many health-care facilities, especially in high-income countries. Institutional Safety Climate had the lowest score (55 points, IQR 35-75). From 2015 to 2019, the median HHSAF score in health-care facilities participating in both HHSAF surveys (n=190) stagnated.

INTERPRETATION

Most health-care facilities had an intermediate level of hand hygiene implementation or higher, for which health-care facility funding and country income level were important drivers. Availability of resources, leadership, and organisational support are key elements to further improve quality of care and provide access to safe care for all.

FUNDING

WHO, Geneva University Hospitals and Faculty of Medicine, and WHO Collaborating Center on Patient Safety, Geneva, Switzerland.

The impact of COVID-19 on health care-associated infections in intensive care units in low- and middle-income countries: International Nosocomial Infection Control Consortium (INICC) findings

Background

This study examines the impact of the COVID-19 pandemic on health care–associated infection (HAI) incidence in low- and middle-income countries (LMICs).

Methods

Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre–COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS).

Results

A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p < .0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p < .0001), respectively.

Discussion

This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

Surface Engineering Strategies to Enhance the In Situ Performance of Medical Devices Including Atomic Scale Engineering

Decades of intense scientific research investigations clearly suggest that only a subset of a large number of metals, ceramics, polymers, composites, and nanomaterials are suitable as biomaterials for a growing number of biomedical devices and biomedical uses. However, biomaterials are prone to microbial infection due to Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Staphylococcus epidermidis (S. epidermidis), hepatitis, tuberculosis, human immunodeficiency virus (HIV), and many more. Hence, a range of surface engineering strategies are devised in order to achieve desired biocompatibility and antimicrobial performance in situ. Surface engineering strategies are a group of techniques that alter or modify the surface properties of the material in order to obtain a product with desired functionalities. There are two categories of surface engineering methods: conventional surface engineering methods (such as coating, bioactive coating, plasma spray coating, hydrothermal, lithography, shot peening, and electrophoretic deposition) and emerging surface engineering methods (laser treatment, robot laser treatment, electrospinning, electrospray, additive manufacturing, and radio frequency magnetron sputtering technique). Atomic-scale engineering, such as chemical vapor deposition, atomic layer etching, plasma immersion ion deposition, and atomic layer deposition, is a subsection of emerging technology that has demonstrated improved control and flexibility at finer length scales than compared to the conventional methods. With the advancements in technologies and the demand for even better control of biomaterial surfaces, research efforts in recent years are aimed at the atomic scale and molecular scale while incorporating functional agents in order to elicit optimal in situ performance. The functional agents include synthetic materials (monolithic ZnO, quaternary ammonium salts, silver nano-clusters, titanium dioxide, and graphene) and natural materials (chitosan, totarol, botanical extracts, and nisin). This review highlights the various strategies of surface engineering of biomaterial including their functional mechanism, applications, and shortcomings. Additionally, this review article emphasizes atomic scale engineering of biomaterials for fabricating antimicrobial biomaterials and explores their challenges.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module

BACKGROUND

We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific.

METHODS

Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied.

RESULTS

We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases.

CONCLUSIONS

DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Early vesus differed arterial catheterisation in critically ill patients with acute circulatory failure: a multicentre, open-label, pragmatic, randomised, non-inferiority controlled trial: the EVERDAC protocol

INTRODUCTION

The use of peripheral indwelling arterial catheter for haemodynamic monitoring is widespread in the intensive care unit and is recommended in patients with shock. However, there is no evidence that the arterial catheter could improve patient's outcome, whereas the burden of morbidity generated is significant (pain, thrombosis, infections). We hypothesise that patients with shock may be managed without an arterial catheter.

METHODS AND ANALYSIS

The EVERDAC study is an investigator-initiated, pragmatic, multicentre, randomised, controlled, open-label, non-inferiority clinical trial, comparing a less invasive intervention (ie, no arterial catheter insertion until felt absolutely needed, according to predefined safety criteria) or usual care (ie, systematic arterial catheter insertion in the early hours of shock). 1010 patients will be randomised with a 1:1 ratio in two groups according to the strategy. The primary outcome is all-cause mortality by 28 days after inclusion. A health economic analysis will be carried out.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Committee (Comité de Protection des Personnes Île de France V, registration number 61606 CAT 2, 19 july 2018) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03680963.

Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review

BACKGROUND

There is general consensus that hand hygiene is the most effective way to prevent healthcare-associated infections. However, low rates of compliance amongst healthcare workers have been reported globally. The coronavirus disease 2019 pandemic has further emphasized the need for global improvement in hand hygiene compliance by healthcare workers.

AIM

This comprehensive systematic review provides an up-to-date compilation of clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions in order to inform healthcare leaders and practitioners regarding approaches to reduce healthcare-associated infections using hand hygiene.

METHODS

CINAHL, Cochrane, EMbase, Medline, PubMed and Web of Science databases were searched for clinical trials published between March 2014 and December 2020 on the topic of hand hygiene compliance among healthcare workers. In total, 332 papers were identified from these searches, of which 57 studies met the inclusion criteria.

FINDINGS

Forty-five of the 57 studies (79%) included in this review were conducted in Asia, Europe and the USA. The large majority of these clinical trials were conducted in acute care facilities, including hospital wards and intensive care facilities. Nurses represented the largest group of healthcare workers studied (44 studies, 77%), followed by physicians (41 studies, 72%). Thirty-six studies (63%) adopted the World Health Organization's multi-modal framework or a variation of this framework, and many of them recorded hand hygiene opportunities at each of the 'Five Moments'. However, recording of hand hygiene technique was not common.

CONCLUSION

Both single intervention and multi-modal hand hygiene strategies can achieve modest-to-moderate improvements in hand hygiene compliance among healthcare workers.

Multicenter Study of Device-Associated Infection Rates, Bacterial Resistance, Length of Stay, and Mortality in Intensive Care Units of 2 Cities of Vietnam: International Nosocomial Infection Control Consortium Findings

OBJECTIVE

The aim of the study was to report the results of the International Nosocomial Infection Control Consortium (INICC) study conducted from May 2008 to March 2015.

METHODS

A device-associated healthcare-acquired infection surveillance study in three adult intensive care units (ICUs) and 1 neonatal ICU from 4 hospitals in Vietnam using U.S. the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN) definitions and criteria as well as INICC methods.

RESULTS

We followed 1592 adult ICU patients for 12,580 bed-days and 845 neonatal ICU patients for 4907 bed-days. Central line-associated bloodstream infection (CLABSI) per 1000 central line-days rate was 9.8 in medical/surgical UCIs and 1.5 in the medical ICU. Ventilator-associated pneumonia (VAP) rate per 1000 mechanical ventilator-days was 13.4 in medical/surgical ICUs and 23.7 in the medical ICU. Catheter-associated urinary tract infection (CAUTI) rate per 1000 urinary catheter-days was 0.0 in medical/surgical ICUs and 5.3 in the medical ICU. While most device-associated healthcare-acquired infection rates were similar to INICC international rates (4.9 [CLABSI]; 16.5 [VAP]; 5.3 [CAUTI]), they were higher than CDC/NHSN rates (0.8 [CLABSI], 1.1 [VAP], and 1.3 [CAUTI]) for medical/surgical ICUs, with the exception of CAUTI rate for medical/surgical ICU and CLABSI rate for the medical ICU. Because of limited resources of our Vietnamese ICUs, cultures could not be taken as required by the CDC/NHSN criteria, and therefore, there was underreporting of CLABSI and CAUTI, influencing their rates. Most device utilization ratios and bacterial resistance percentages were higher than INICC and CDC/NHSN rates.

CONCLUSIONS

Device-associated healthcare-acquired infection rates found in the ICUs of our study were higher than CDC/NHSN US rates, but similar to INICC international rates. It is necessary to build more capacity to conduct surveillance and prevention strategies.

An antibiotic potentiator retains its activity after being immobilized on silicone and prevents growth of multidrug-resistant Pseudomonas aeruginosa biofilms

Device-Associated Healthcare-Associated Infections (DA-HAI) are a major threat to public health worldwide since they are associated with increased hospital stays, morbidity, mortality, financial burden, and hospital overload. A strategy to combat DA-HAI involves the use of medical devices endowed with surfaces that can kill or repel pathogens and prevent biofilm formation. We aimed to develop low-toxic protease-resistant anti-biofilm surfaces that can sensitize drug-resistant bacteria to sub-inhibitory concentrations of antibiotics. To this end, we hypothesized that polymyxin B nonapeptide (PMBN) could retain its antibiotic-enhancing potential upon immobilization on a biocompatible polymer, such as silicone. The ability of PMBN-coated silicone to sensitize a multidrug-resistant clinical isolate of Pseudomonas aeruginosa (strain Ps4) to antibiotics and block biofilm formation was assessed by viable counting, confocal microscopy and safranin uptake. These assays demonstrated that covalently immobilized PMBN enhances not only antibiotics added exogenously but also those incorporated into the functionalized coating. As a result, the functionalized surface exerted a potent bactericidal activity that precluded biofilm formation. PMBN-coated silicone displayed a high level of stability and very low cytotoxicity and hemolytic activity in the presence of antibiotics. We demonstrated for the first time that an antibiotic enhancer can retain its activity when covalently attached to a solid surface. These findings may be applied to the development of medical devices resistant to biofilm formation.

Epidemiology and clinical outcome of ventilator-associated events at a tertiary care hospital from North India

The aim of our study was to determine the incidence, microbiological profile, risk factors and outcomes of patients diagnosed with ventilator-associated events in our tertiary care hospital. In this prospective study, intensive care patients put on mechanical ventilation for >48 h were enrolled and monitored daily for ventilator-associated event according to Disease Centre Control guidelines. A ventilator-associated event developed in 33/250 (13.2%); its incidence was 3.5/100 mechanical ventilation days. The device utilisation rate was 0.86, 36.4% of patients had early and 63.6% late-onset ventilator-associated pneumonia whose most common causative pathogen was Acinetobacter sp. (63.6%). Various factors were significantly associated with a ventilator-associated event: male gender, COPD, smoking, >2 underlying diseases, chronic kidney disease and elevated acute physiological and chronic health evaluation II scores. Therefore, stringent implementation of infection control measures is necessary to control ventilator-associated pneumonia in critical care units.

Risk factors for candidaemia: A prospective multi-centre case-control study

OBJECTIVES

Candidaemia carries a mortality of up to 40% and may be related to increasing complexity of medical care. Here, we determined risk factors for the development of candidaemia.

METHODS

We conducted a prospective, multi-centre, case-control study over 12 months. Cases were aged ≥18 years with at least one blood culture positive for Candida spp. Each case was matched with two controls, by age within 10 years, admission within 6 months, admitting unit, and admission duration at least as long as the time between admission and onset of candidaemia.

RESULTS

A total of 118 incident cases and 236 matched controls were compared. By multivariate analysis, risk factors for candidaemia included neutropenia, solid organ transplant, significant liver, respiratory or cardiovascular disease, recent gastrointestinal, biliary or urological surgery, central venous access device, intravenous drug use, urinary catheter and carbapenem receipt.

CONCLUSIONS

Risk factors for candidaemia derive from the infection source, carbapenem use, host immune function and organ-based co-morbidities. Preventive strategies should target iatrogenic disruption of mucocutaneous barriers and intravenous drug use.

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.

Implementation of the WHO hand hygiene strategy in Faranah regional hospital, Guinea

BACKGROUND

Healthcare-associated infections are the most frequent adverse events in healthcare worldwide, with limited available evidence suggesting highest burden in resource-limited settings. Recent Ebola epidemics emphasize the disastrous impact that spread of infectious agents within healthcare facilities can have, accentuating the need for improvement of infection control practices. Hand hygiene (HH) measures are considered to be the most effective tool to prevent healthcare-associated infections. However, HH knowledge and compliance are low, especially in vulnerable settings such as Guinea. The aim of PASQUALE (Partnership to Improve Patient Safety and Quality of Care) was to assess knowledge and compliance with HH and improve HH by incorporating the WHO HH Strategy within the Faranah Regional Hospital (FRH), Guinea.

METHODS

In a participatory approach, a team of FRH staff and leadership was invited to identify priorities of the hospital prior to the start of PASQUALE. The local hygiene committee was empowered to increase its activities and take ownership of the HH improvement strategy. A baseline assessment of knowledge, perception and compliance was performed months before the intervention. The main intervention consisted of local alcohol-based-hand-rub (ABHR) production, with final product efficacy testing, in conjunction with a training adapted to the needs identified in the baseline assessment. A follow-up assessment was conducted directly after the training. Effectiveness of the intervention was assessed via uncontrolled before-and-after comparison.

RESULTS

Baseline knowledge score (13.0/25) showed a significant increase to 19.0/25 in follow-up. Baseline-Compliance was 23.7% and increased significantly to 71.5% in follow-up. Compliance rose significantly across all professional groups except for midwifes and in all indications for HH, with the largest in the indication "Before aseptic tasks". The increase in compliance was associated with the intervention and remained significant after adjusting for confounders. The local pharmacy successfully supplies the entire hospital. The local supply resulted in a ten-fold increase of monthly hospital disinfectant consumption.

CONCLUSION

The WHO HH strategy is an adaptable and effective method to improve HH knowledge and compliance in a resource-limited setting. Local production is a feasible method for providing self-sufficient supply of ABHR to regional hospitals like the FRH. Participatory approaches like hygiene committee ownership builds confidence of sustainability.

Six-year study on peripheral venous catheter-associated BSI rates in 262 ICUs in eight countries of South-East Asia: International Nosocomial Infection Control Consortium findings

BACKGROUND

Short-term peripheral venous catheter-associated bloodstream infection rates have not been systematically studied in Asian countries, and data on peripheral venous catheter-associated bloodstream infections incidence by number of short-term peripheral venous catheter days are not available.

METHODS

Prospective, surveillance study on peripheral venous catheter-associated bloodstream infections conducted from 1 September 2013 to 31 May 2019 in 262 intensive care units, members of the International Nosocomial Infection Control Consortium, from 78 hospitals in 32 cities of 8 countries in the South-East Asia Region: China, India, Malaysia, Mongolia, Nepal, Philippines, Thailand, and Vietnam. 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 83,295 intensive care unit patients for 369,371 bed-days and 376,492 peripheral venous catheter-days. We identified 999 peripheral venous catheter-associated bloodstream infections, amounting to a rate of 2.65/1000 peripheral venous catheter-days. Mortality in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.53% and 12.21% in patients with peripheral venous catheter-associated bloodstream infections. The mean length of stay in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.40 days and 7.11 days in patients with peripheral venous catheter and peripheral venous catheter-associated bloodstream infections. The microorganism profile showed 67.1% were Gram-negative bacteria: Escherichia coli (22.9%), Klebsiella spp (10.7%), Pseudomonas aeruginosa (5.3%), Enterobacter spp. (4.5%), and others (23.7%). The predominant Gram-positive bacteria were Staphylococcus aureus (11.4%).

CONCLUSIONS

Infection prevention programs must be implemented to reduce the incidence of peripheral venous catheter-associated bloodstream 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.

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.

Central line-related bloodstream infections and microbiological study in an Egyptian Ministry of Health Hospital

BACKGROUND

Central line-associated bloodstream infections continue to be one of the most important health problems in ICU.

OBJECTIVES

To identify the central line-related bloodstream infections and their microbiological characteristics Specific objectives to the identify the incidence, predisposing factors of central line-related bloodstream Infections and study the antibiotic sensitivity patterns of the isolated organisms.

MATERIAL AND METHODS

Patients' demographic, clinical data, central venous catheter related data,and blood culture specimen collection data were collected utilizing a descriptive exploratory design from a purposive sample of 120 ICU patients underwent insertion central venous catheter.

RESULTS

out of 120 central line catheters sent for culture from patients immediately and seven days after insertion., 13(10.83%) were positive seven days after insertion. Of the 13 infection cases, 10 cases were Staphylococcus epidermis and the others were Staphylococcus aureus. In addition, most infected patients were overweight and obese, diabetic, had sub-clavian route, and their length of hospital stayed more than7 days.

CONCLUSION

10.83 % developed bacterial blood stream infection 7 days after insertion of central venous catheters, and most of bacterial isolates were Staphylococcus epidermis and were sensitive to Vancomycin and Amikain.

Determinants of surgeons' adherence to preventive intraoperative measures of surgical site infection in Gaza Strip hospitals: a multi-centre cross-sectional study

Background

Surgical site infection (SSI) is one of the most common hospital-acquired infections and is associated with serious impact on the rates of morbidity, mortality as well as healthcare costs. This study examined factors influencing the application of several intraoperative preventive measures of SSI by surgeons and surgical residents in the Gaza Strip.

Methods

A cross-sectional study was conducted from December 2016 to February 2017 at the operation rooms of the three major hospitals located in the Gaza-Strip, Palestine. Inclusion criteria for patients were being adult (aged ≥18 years), no history of wound infection at time of operation and surgical procedure under general anaesthesia with endotracheal intubation. The association between different patient- and procedure-related SSI risk factors and adherence to several intraoperative SSI preventive measures was tested.

Results

In total, 281 operations were observed. The mean patient age ± standard deviation (SD) was 38.4 ± 14.6 years and the mean duration of surgery ± SD was 58.2 ± 32.1 minutes. A hundred-thirty-two patients (47.0%) were male. Location and time of the operation were found to have significant associations with adherence to all SSI preventive measures except for antibiotic prophylaxis. Type of operation had a significant association with performing all measures except changing surgical instruments. Patient age did not have a statistically significant association with adherence to any measure.

Conclusion

The results suggest that the surgeon could be a major factor that can lead to a better outcome of surgical procedures by reducing postoperative complications of SSI. Operating department professionals would benefit from clinical guidance and continuous training, highlighting the importance of persistent implementation of SSI preventive measures in everyday practice to improve the quality of care provided to surgical patients.

Point prevalence surveys of health-care-associated infections: a systematic review

Health-care-associated infections (HAIs) are considered a serious public health issues that contribute substantially to the global burden of mortality and morbidity with respect to infectious diseases. The aim is to assess the burden of health-care-associated infections by collation of available data from published point prevalence surveys (PPS) on HAIs to give future guidance. Study protocol and methodology were designed according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Published research papers that conducted a point prevalence survey of HAIs in hospital settings by following the structured survey methodology employed by European Centre of Disease Prevention and Control (ECDC) were included. Of 1212 articles, 67 studies were included in the final analysis conducted across different countries. Overall, 35 studies were conducted in Europe, 21 in Asia, 9 in America, and 2 in Africa. The highest prevalence of HAIs was recorded in a study conducted in adult ICU settings of 75 regions of Europe (51.3%). The majority of the studies included HAI data on urinary tract infections, respiratory tract infections, and bloodstream infections. Klebsiella pneumonia, Pseudomonas aeruginosa and E. coli were the most frequent pathogens responsible for HAIs. PPS is an useful tool to quantify HAIs and provides a robust baseline data for policymakers. However, a standardize surveillance method is required. In order to minimize the burden of HAIs, infection prevention and control programs and antibiotic stewardship may be effective strategies to minimize the risk of HAIs.

Candidaemia and a risk predictive model for overall mortality: a prospective multicentre study

Background

Candidaemia is associated with high mortality. Variables associated with mortality have been published previously, but not developed into a risk predictive model for mortality. We sought to describe the current epidemiology of candidaemia in Australia, analyse predictors of 30-day all-cause mortality, and develop and validate a mortality risk predictive model.

Methods

Adults with candidaemia were studied prospectively over 12 months at eight institutions. Clinical and laboratory variables at time of blood culture-positivity were subject to multivariate analysis for association with 30-day all-cause mortality. A predictive score for mortality was examined by area under receiver operator characteristic curves and a historical data set was used for validation.

Results

The median age of 133 patients with candidaemia was 62 years; 76 (57%) were male and 57 (43%) were female. Co-morbidities included underlying haematologic malignancy (n = 20; 15%), and solid organ malignancy in (n = 25; 19%); 55 (41%) were in an intensive care unit (ICU). Non-albicans Candida spp. accounted for 61% of cases (81/133). All-cause 30-day mortality was 31%. A gastrointestinal or unknown source was associated with higher overall mortality than an intravascular or urologic source (p < 0.01). A risk predictive score based on age > 65 years, ICU admission, chronic organ dysfunction, preceding surgery within 30 days, haematological malignancy, source of candidaemia and antibiotic therapy for ≥10 days stratified patients into < 20% or ≥ 20% predicted mortality. The model retained accuracy when validated against a historical dataset (n = 741).

Conclusions

Mortality in patients with candidaemia remains high. A simple mortality risk predictive score stratifying patients with candidaemia into < 20% and ≥ 20% 30-day mortality is presented. This model uses information available at time of candidaemia diagnosis is easy to incorporate into decision support systems. Further validation of this model is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4065-5) contains supplementary material, which is available to authorized users.

Analysis of Risk Factors for Multiantibiotic-Resistant Infections Among Surgical Patients at a Children's Hospital

BACKGROUND

To identify the potential risk factors for multiantibiotic-resistant infections and provide sufficient evidence for multiantibiotic resistance prevention and control.

MATERIALS AND METHODS

We conducted a retrospective study of all patients in pediatric orthopedics, pediatric heart surgery, and pediatric general surgery at a level 3, grade A children's hospital from January to December 2016. The clinical laboratory information monitoring system and the medical record system were used to collect patient information regarding age, surgery type, preoperative length of stay, admission season, incision type, preoperative infection, intraoperative blood loss, postoperative use of invasive equipment, duration of catheter drainage, and timepoint of intraoperative prophylactic antibiotics administration. We used logistic univariate and multivariate regression analysis to analyze the potential risk factors for multiantibiotic-resistant infections among pediatric surgical patients. SPSS 21.0 and Excel software packages were used for the statistical analysis.

RESULTS

In total, 2,973 patients met the inclusion criteria: 1,247 patients in pediatric orthopedics, 1,089 patients in pediatric heart surgery, and 637 patients in pediatric general surgery. At the end of the study, 113 patients were multiantibiotic-resistant infection cases; the rate of multiantibiotic-resistant infections was 3.80%, and the detection rate was 84.79%. Multivariate analysis indicated that the multiantibiotic-resistant infection cases were influenced by age, department, admission season, incision type, preoperative infection, and duration of catheter drainage.

CONCLUSIONS

Age, department, admission season, incision type, preoperative infection, and duration of catheter drainage may provide possible evidence for prevention and control strategies of multiantibiotic-resistant infections.

Influence of bacterial resistance on mortality in intensive care units: a registry study from 2000 to 2013 (IICU Study)

BACKGROUND

Bacterial resistance to antibiotics is a daily concern in intensive care units. However, few data are available concerning the clinical consequences of in-vitro-defined resistance.

AIM

To compare the mortality of patients with nosocomial infections according to bacterial resistance profiles.

METHODS

The prospective surveillance registry in 29 French intensive care units (ICUs) participating during the years 2000-2013 was retrospectively analysed. All patients presenting with a nosocomial infection in ICU were included.

FINDINGS

The registry contained 88,000 eligible patients, including 10,001 patients with a nosocomial infection. Among them, 3092 (36.7%) were related to resistant micro-organisms. Gram-negative bacilli exhibited the highest rate of resistance compared to Gram-positive cocci (52.8% vs 48.1%; P < 0.001). In-hospital mortality was higher in cases of patients with antibiotic-resistant infectious agents (51.9% vs 45.5%; P < 0.001), and critical care length of stay was longer (33 ± 26 vs 29 ± 22 days; P < 0.001). These results remained significant after SAPS II matching (P < 0.001) and in the Gram-negative bacilli and Gram-positive cocci subgroups. No difference in mortality was found with respect to origin prior to admission.

CONCLUSION

Patients with bacterial resistance had higher ICU mortality and increased length of stay, regardless of the bacterial species or origin of the patient.

Conflicts of interest in infection prevention and control research: no smoke without fire. A narrative review

Conflicts of interest (COIs) do occur in healthcare research, yet their impact on research in the field of infection prevention and control (IPC) is unknown. We conducted a narrative review aiming to identify examples of COIs in IPC research. In addition to well-known instances, we conducted PubMed and Google searches to identify and report case studies of COIs in IPC and antimicrobial resistance (AMR), which were chosen arbitrarily following consensus meetings, to illustrate different types of COIs. We also searched the Retraction Watch database and blog to systematically identify retracted IPC and/or infectious disease-related papers. Our review highlights COIs in academic research linked to ties between industry and physicians, journal editors, peer-reviewed journals' choice for publication, and guideline committees participants and authors. It explores how COIs can affect research and could be managed. We also present several selected case studies that involve (1) the chlorhexidine industry and how it has used marketing trials and key opinion leaders to promote off-label use of its products; (2) the copper industry and how reporting of its trials in IPC have furthered their agenda; (3) the influence of a company developing "closed infusion systems" for catheters and how this affects networks in low- and middle-income countries and guideline development; (4) potential perverse incentives hospitals may have in reporting healthcare-associated infection or AMR rates and how government intervention may restrict AMR research for fear of bad publicity and subsequent negative economic consequences. Finally, the analysis of reasons for the retraction of previously published papers highlights the fact that misconduct in research may have other motivations than financial gain, the most visible form of COIs. COIs occur in the field of research in general, and IPC and AMR are no exceptions. Their effects pervade all aspects of the research and publication processes. We believe that, in addition to improvements in management strategies of COIs, increased public funding should be available to decrease researchers' dependency on industry ties. Further research is needed on COIs and their management.

WMSS: A Web-Based Multitiered Surveillance System for Predicting CLABSI

Central-line-associated bloodstream infection (CLABSI) rates are a key quality metric for comparing hospital quality and safety. Manual surveillance systems for CLABSIs are time-consuming and often limited to intensive care units (ICUs). A computer-automated method of CLABSI detection can improve the validity of surveillance. A new web-based, multitiered surveillance system for predicting and reducing CLABSI is proposed. The system has the capability to collect patient-related data from hospital databases and hence predict the patient infection automatically based on knowledge discovery rules and CLABSI decision standard algorithms. In addition, the system has a built-in simulator for generating patients' data records, when needed, offering the capability to train nurses and medical staff for enhancing their qualifications. Applying the proposed system, both CLABSI rates and patient treatment costs can be reduced significantly. The system has many benefits, among which there is the following: it is a web-based system that can collect real patients' data from many IT resources using iPhone, iPad, laptops, Internet, scanners, and hospital databases. These facilities help to collect patients' actual data quickly and safely in electronic format and hence predict CLABSI efficiently. Automation of the patients' data diagnosis process helps in reducing CLABSI detection times. The system is multimedia-based; it uses text, colors, and graphics to enhance patient healthcare report generation and charts. It helps healthcare decision makers to review and approve policies and surveillance plans to reduce and prevent CLABSI.

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.

Surgical site infection surveillance following total knee arthroplasty: Tertiary care hospital experience

Introduction

Surgical Site Infection (SSI) after knee arthroplasty is a major cause of morbidity and mortality that increases the hospital stay, financial burden and mental anguish of the patient. Infection Control Unit at Aga Khan University Hospital (AKUH) incorporated total knee arthroplasty in its surgical care surveillance program and started collecting data in June 2012. The purpose of this study is to review Surgical Site Infection (SSI) rates in patients undergoing primary total knee replacement (TKR) surgery.

Patients and methodology

All patients from June 2012 to December 2013 undergoing knee arthroplasty at our hospital were included. Data was acquired from the hospital SSI database for knee arthroplasty surgery. Data was collected by SSI nurses for inpatients a well as post-discharge monitoring in clinics till 90 days post-op follow-up. The work has been reported in line with the PROCESS criteria.

Results

During this time period a total of 164 patients had primary TKR at AKUH. Out of these, 85 patients (52%) had bilateral TKR while 79 (48%) had unilateral TKR. The overall SSI was in 2 patients (1.2%).

Conclusion

Identifying SSIs is multidimensional. Since our 2 infected cases after TKR occurred after discharge, this highlights the importance of post-discharge surveillance and not limiting the surveillance for inpatients only. Furthermore, the SSI program may be effective in controlling postoperative wound infections.

•

Surgical Site Infection (SSI) after knee arthroplasty is a major cause of morbidity and mortality.

•

It increases the hospital stay, financial burden and mental anguish of the patient.

•

The purpose of this study is to review SSI rates in patients undergoing primary total knee replacement.

•

Identifying SSIs is multidimensional.

•

The importance of post-discharge surveillance and not limiting the surveillance for inpatients only is highlighted here.

Antimicrobial and Antifouling Strategies for Polymeric Medical Devices

Hospital-acquired infections arising from implanted polymeric medical devices continue to pose a significant challenge for medical professionals and patients. Often times, these infections arise from biofilm accumulation on the device, which is difficult to eradicate and usually requires antibiotic treatment and device removal. In response, significant efforts have been made to design functional polymeric devices or coatings that possess antimicrobial or antifouling properties that limit biofilm formation and subsequent infection by inhibiting or eliminating bacteria near the device surface or by limiting the initial attachment of proteins and bacteria. In this Viewpoint, we highlight the magnitude of device-associated infections, the role of biofilm formation in human pathogenesis, and recent advances in antimicrobial and antifouling polymers, as well as current strategies employed in commercial devices for preventing infection.

A simplified prevention bundle with dual hand hygiene audit reduces early-onset ventilator-associated pneumonia in cardiovascular surgery units: An interrupted time-series analysis

BACKGROUND

To investigate the effect of a simplified prevention bundle with alcohol-based, dual hand hygiene (HH) audit on the incidence of early-onset ventilation-associated pneumonia (VAP).

METHODS

This 3-year, quasi-experimental study with interrupted time-series analysis was conducted in two cardiovascular surgery intensive care units in a medical center. Unaware external HH audit (eHH) performed by non-unit-based observers was a routine task before and after bundle implementation. Based on the realistic ICU settings, we implemented a 3-component bundle, which included: a compulsory education program, a knowing internal HH audit (iHH) performed by unit-based observers, and a standardized oral care (OC) protocol with 0.1% chlorhexidine gluconate. The study periods comprised 4 phases: 12-month pre-implementation phase 1 (eHH+/education-/iHH-/OC-), 3-month run-in phase 2 (eHH+/education+/iHH+/OC+), 15-month implementation phase 3 (eHH+/education+/iHH+/OC+), and 6-month post-implementation phase 4 (eHH+/education-/iHH+/OC-).

RESULTS

A total of 2553 ventilator-days were observed. VAP incidences (events/1000 ventilator days) in phase 1-4 were 39.1, 40.5, 15.9, and 20.4, respectively. VAP was significantly reduced by 59% in phase 3 (vs. phase 1, incidence rate ratio [IRR] 0.41, P = 0.002), but rebounded in phase 4. Moreover, VAP incidence was inversely correlated to compliance of OC (r2 = 0.531, P = 0.001) and eHH (r2 = 0.878, P < 0.001), but not applied for iHH, despite iHH compliance was higher than eHH compliance during phase 2 to 4. Compared to eHH, iHH provided more efficient and faster improvements for standard HH practice. The minimal compliances required for significant VAP reduction were 85% and 75% for OC and eHH (both P < 0.05, IRR 0.28 and 0.42, respectively).

CONCLUSIONS

This simplified prevention bundle effectively reduces early-onset VAP incidence. An unaware HH compliance correlates with VAP incidence. A knowing HH audit provides better improvement in HH practice. Accordingly, we suggest dual HH audit and consistent bundle performance does matter in quality-of-care VAP prevention.

Building conditions and the risk of nosocomial infection from microbial contamination of hospital appliances in a health care facility

Nosocomial infections (NIs) remain a global health burden with higher incidence in Africa. We assessed building conditions and risk of NIs from microbial contamination of appliances and surfaces in a Specialist hospital in Southwest Nigeria. The study sampled 120 surfaces in 12 wards during normal occupational activities. Moulds on ceilings and dusty surfaces were observed in the wards. Microbial burden (1038.0 × 10⁵ cfu) peaked in the ICU but was lowest (446.9 × 10⁵ cfu) in the male ward. Bacteria counts ( × 10⁵ cfu) of 234.7, 199.7 and 67.0 were measured on ICU tap, doorknob and ECG, respectively. Theatre diatomy machine, anaesthetic machine and operating lamp had bacteria counts ( × 10⁵ cfu) of 40.0, 85.0 and 109.0, respectively. Highest total fungal count (58.2 × 10⁵ cfu) was recorded on ICU trolley handle, switch and suturing tube. Our study established surfaces as major environmental routes for NI transmission in this health care facility.

Antifouling and antimicrobial biomaterials: an overview

The use of implantable medical devices is a common and indispensable part of medical care for both diagnostic and therapeutic purposes. However, as side effect, the implant of medical devices quite often leads to the occurrence of difficult-to-treat infections, as a consequence of the colonization of their abiotic surfaces by biofilm-growing microorganisms increasingly resistant to antimicrobial therapies. A promising strategy to combat device-related infections is based on anti-infective biomaterials that either repel microbes, so they cannot attach to the device surfaces, or kill them in the surrounding areas. In general, such biomaterials are characterized by antifouling coatings, exhibiting low adhesion or even repellent properties towards microorganisms, or antimicrobial coatings, able to kill microbes approaching the surface. In this light, the present overview will address the development in the last two decades of antifouling and antimicrobial biomaterials designed to potentially limit the initial stages of microbial adhesion, as well as the microbial growth and biofilm formation on medical device surfaces.

Device-associated infection rates, mortality, length of stay and bacterial resistance in intensive care units in Ecuador: International Nosocomial Infection Control Consortium’s findings

AIM

To report the results of the International Nosocomial Infection Control Consortium (INICC) study conducted in Quito, Ecuador.

METHODS

A device-associated healthcare-acquired infection (DA-HAI) prospective surveillance study conducted from October 2013 to January 2015 in 2 adult intensive care units (ICUs) from 2 hospitals using the United States Centers for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions and INICC methods.

RESULTS

We followed 776 ICU patients for 4818 bed-days. The central line-associated bloodstream infection (CLABSI) rate was 6.5 per 1000 central line (CL)-days, the ventilator-associated pneumonia (VAP) rate was 44.3 per 1000 mechanical ventilator (MV)-days, and the catheter-associated urinary tract infection (CAUTI) rate was 5.7 per 1000 urinary catheter (UC)-days. CLABSI and CAUTI rates in our ICUs were similar to INICC rates [4.9 (CLABSI) and 5.3 (CAUTI)] and higher than NHSN rates [0.8 (CLABSI) and 1.3 (CAUTI)] - although device use ratios for CL and UC were higher than INICC and CDC/NSHN’s ratios. By contrast, despite the VAP rate was higher than INICC (16.5) and NHSN’s rates (1.1), MV DUR was lower in our ICUs. Resistance of A. baumannii to imipenem and meropenem was 75.0%, and of Pseudomonas aeruginosa to ciprofloxacin and piperacillin-tazobactam was higher than 72.7%, all them higher than CDC/NHSN rates. Excess length of stay was 7.4 d for patients with CLABSI, 4.8 for patients with VAP and 9.2 for patients CAUTI. Excess crude mortality in ICUs was 30.9% for CLABSI, 14.5% for VAP and 17.6% for CAUTI.

CONCLUSION

DA-HAI rates in our ICUs from Ecuador are higher than United States CDC/NSHN rates and similar to INICC international rates.

Device-Associated Healthcare-Associated Infections (DA-HAI) and the caveat of multiresistance in a multidisciplinary intensive care unit

BACKGROUND

Device-Associated Healthcare-Associated Infections (DA-HAI), including Ventilator-Associated Pneumonia (VAP), Central-Line-Associated Blood Stream Infection (CLABSI), and Catheter-Related Urinary Tract Infection (CAUTI), are considered as principal contributors to healthcare hazard and threat to patient safety as they can cause prolonged hospital stay, sepsis, and mortality in the ICU. The study intends to characterize DA-HAI in a tertiary care multidisciplinary ICU of a teaching hospital in eastern India.

METHODS

This prospective outcome-surveillance study was conducted among 2157 ICU patients of a 760-bedded teaching hospital in Eastern India. Clinical, laboratory and environmental surveillance, and screening of HCPs were conducted using the US Centers for Disease Control and Prevention (CDC)'s National Healthcare Safety Network (NHSN) definitions and methods.

RESULTS

With 8824 patient/bed/ICU days and 14,676 device days, pooled average device utilization ratio was 1.66, total episodes of DA-HAI were 114, and mean monthly rates of DA-HAI, VAP, CLABSI, and CAUTI were 4.75, 2, 1.4, and 1.25/1000 device days. Most common pathogens isolated from DA-HAI patients were Klebsiella pneumoniae (24.6%), Escherichia coli (21.9%), and Pseudomonas aeruginosa (20.2%). All Acinetobacter baumanii, >80% K. pneumoniae and E. coli, and >70% P. aeruginosa were susceptible only to colistin and tigecycline. One P. aeruginosa isolate was panresistant.

CONCLUSION

Mean rates of VAP, CLABSI, and CAUTI were 14.4, 8.1, and 4.5 per 1000 device days, which are comparable with Indian and global ICUs. Patients and HCPs form important reservoirs of infection. Resolute conviction and sustained momentum in Infection Control Initiatives are an essential step toward patient safety.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

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 INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Multicenter study in Colombia: Impact of a multidimensional International Nosocomial Infection Control Consortium (INICC) approach on central line-associated bloodstream infection rates

BACKGROUND

The objective of this study was to analyze the impact of a multidimensional infection control approach and the use of the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System on central line-associated bloodstream infection (CLABSI) rates from June 2003-April 2010.

METHODS

We conducted a prospective, before-after surveillance study of 2,564 patients hospitalized in 4 adult intensive care units (ICUs) and 424 patients in 2 pediatric ICUs of 4 hospitals in 2 cities of Colombia. During baseline, we performed outcome surveillance of CLABSI applying the Centers for Disease Control and Prevention's National Healthcare Safety Network definitions. During intervention, we implemented the INICC multidimensional approach and the ISOS, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on CLABSI 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 on the CLABSI rate.

RESULTS

The baseline rate of 12.9 CLABSIs per 1,000 central line (CL) days, with 3,032 CL days and 39 CLABSIs, was reduced to 3.5 CLABSIs per 1,000 CL days, with 3,686 CL days and 13 CLABSIs, accounting for a 73% CLABSI rate reduction (relative risk, 0.27; 95% confidence interval, 0.14-0.52; P=.002).

CONCLUSIONS

Implementing the INICC multidimensional infection control approach for CLABSI prevention was associated with a significant reduction in the CLABSI rate of ICUs of Colombia.

International Nosocomial Infection Control Consortium (INICC) resources: INICC multidimensional approach and INICC surveillance online system

BACKGROUND

The International Nosocomial Infection Control Consortium (INICC) is an international, nonprofit, multicentric health care-associated infection (HAI) cohort surveillance network with a methodology based on the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN). The INICC was founded in 1998 to promote evidence-based infection control in limited-resource countries through the analysis of surveillance data collected by their affiliated hospitals. The INICC is comprised of >3,000-affiliated infection control professionals from 1,000 hospitals in 67 countries and is the only source of aggregate standardized international data on HAI epidemiology. Having published reports on device-associated (DA) HAI (HAI) and surgical site infections (SSIs) from 43 countries and several reports per individual country, the INICC showed DA HAI and SSI rates in limited-resources countries are 3-5 times higher than in high-income countries.

METHODS

The INICC developed the INICC Multidimensional Approach (IMA) for HAI prevention with 6 components, bundles with 7-13 elements, and the INICC Surveillance Online System (ISOS) with 15 modules.

RESOURCES

In this article the IMA, the ISOS for outcome surveillance of HAIs and process surveillance of bundles to prevent HAIs, and the use of surveillance data feedback are described.

COMMENTS

Remarkable features of the IMA and ISOS are INICC's applying of the latest published CDC-NHSN HAI definitions, including their updates and revisions in 2008, 2013, 2015 and 2016; INICC's informatics system to check accuracy of fulfillment of CDC-NHSN HAI criteria; and INICC's system to check compliance with each bundle element.

Device-associated infection rates, bacterial resistance, length of stay, and mortality in Kuwait: International Nosocomial Infection Consortium findings

BACKGROUND

To report the results of the International Infection Control Consortium (INICC) study conducted in Kuwait from November 2013-March 2015.

METHODS

A device-associated health care-acquired infection (DA-HAI) prospective surveillance study in 7 adult, pediatric, and neonatal intensive care units (ICUs) using the U.S. Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN) definitions and INICC methods.

RESULTS

We followed 3,732 adult and pediatric patients for 21,611 bed days and 671 neonatal patients for 4,515 bed days. In the medical-surgical ICUs, the central line-associated bloodstream infection (CLABSI) rate was 3.5 per 1,000 central line days, the ventilator-associated pneumonia (VAP) rate was 4.0 per 1,000 mechanical ventilator days, and the catheter-associated urinary tract infection (CAUTI) rate was 3.3 per 1,000 urinary catheter days; all of them were lower than INICC rates (CLABSI: 4.9; VAP: 16.5; and CAUTI: 5.3) and higher than NHSN rates (CLABSI: 0.9; VAP: 1.1; and CAUTI: 1.2). Resistance of Staphylococcus aureus to oxacillin was 100%, resistance of Acinetobacter baumannii to imipenem and meropenem was 77.6%, and resistance of Klebsiella pneumoniae to imipenem and meropenem was 29.4%. Extra length of stay was 27.1 days for CLABSI, 22.2 days for VAP, and 19.2 days for CAUTI in adult and pediatric ICUs. Extra crude mortality was 19.9% for CLABSI, 30.9% for VAP, and 11.1% for CAUTI in adult and pediatric ICUs.

CONCLUSIONS

DA-HAI rates in our ICUs are higher than the CDC-NSHN rates and lower than the INICC international rates.

Multicenter study of device-associated infection rates in hospitals of Mongolia: Findings of the International Nosocomial Infection Control Consortium (INICC)

BACKGROUND

To report the results of the International Nosocomial Infection Control Consortium (INICC) multicenter study conducted in Mongolia from September 2013-March 2015.

METHODS

A device-associated health care-associated infection prospective surveillance study in 3 adult intensive care units (ICUs) from 3 hospitals using the U.S. Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) definitions and INICC methods.

RESULTS

We documented 467 ICU patients for 2,133 bed days. The central line-associated bloodstream infection (CLABSI) rate was 19.7 per 1,000 central line days, the ventilator-associated pneumonia (VAP) rate was 43.7 per 1,000 mechanical ventilator days, and the catheter-associated urinary tract infection (CAUTI) rate was 15.7 per 1,000 urinary catheter days; all of the rates are higher than the INICC rates (CLABSI: 4.9; VAP: 16.5; and CAUTI: 5.3) and CDC-NHSN rates (CLABSI: 0.8; VAP: 1.1; and CAUTI: 1.3). Device use ratios were also higher than the CDC-NHSN and INICC ratios, except for the mechanical ventilator device use ratio, which was lower than the INICC ratio. Resistance of Staphylococcus aureus to oxacillin was 100%. Extra length of stay was 15.1 days for patients with CLABSI, 7.8 days for patients with VAP, and 8.2 days for patients with CAUTI. Extra crude mortality in the ICUs was 18.6% for CLABSI, 17.1% for VAP, and 5.1% for CAUTI.

CONCLUSION

Device-associated health care-associated infection rates and most device use ratios in our Mongolian hospitals' ICUs are higher than the CDC-NSHN and INICC rates.

Surgical Site Infection Rates in Seven Cities in Vietnam: Findings of the International Nosocomial Infection Control Consortium

BACKGROUND

Surgical site infections (SSIs) are the most common healthcare-associated infections (HAI) in lower-income countries. This is the first study to report the results of surveillance on SSI stratified by surgical procedure in seven Vietnamese cities.

METHODS

This was a prospective, active SSI surveillance study conducted from November 2008-December 2010 in seven hospitals using the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) definitions and methods. Surgical procedures (SPs) were classified into 26 types according to the International Classification of Diseases Edition 9 criteria.

RESULTS

We recorded 241 SSIs, associated with 4,413 SPs (relative risk [RR] 5.5%; 95% confidence interval [95% CI] 4.8-6.2). The highest SSI rates were found for limb amputation (25%), colon surgery (33%), and small bowel surgery (21%). Compared with CDC-NHSN SSI report, our SSI rates were higher for the following SPs: Limb amputation (25% vs. 1.3%; RR 20.0; p = 0.001); appendix surgery (8.8% vs. 3.5%; RR 2.54; 95% CI 1.3-5.1; p = 0.001); gallbladder surgery (13.7% vs. 1.7%; RR 7.76; 95% CI 1.9-32.1; p = 0.001); colon surgery (18.2% vs. 4.0%; RR 4.56; 95% CI 2.0-10.2; p = 0.001); open reduction of fracture (15.8% vs. 3.4%; RR 4.70, 95% CI 1.5-15.2; p = 0.004); gastric surgery (7.3% vs. 1.7%; RR 4.26; 95% CI 2.2-8.4, p = 0.001); kidney surgery (8.9% vs. 0.9%; RR 10.2; 95% CI 3.8-27.4; p = 0.001); prostate surgery (5.1% vs. 0.9%; RR 5.71; 95% CI 1.9-17.4; p = 0.001); small bowel surgery (20.8% vs. 6.7%; RR 3.07; 95% CI 1.7-5.6; p = 0.001); thyroid or parathyroid surgery (2.4% vs. 0.3%; RR 9.27; 95% CI 1.0-89.1; p = 0.019); and vaginal hysterectomy (14.3% vs. 1.2%; RR 12.3; 95% CI 1.7-88.4; p = 0.001).

CONCLUSIONS

Our SSIs rates were significantly higher for 11 of the 26 types of SPs than for the CDC-NHSN. This study advances our knowledge of SSI epidemiology in Vietnam and will allow us to introduce targeted interventions.