International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009

Surveillance of device-associated infection rates at adult intensive care units in the VINCat program (2010-2022)

INTRODUCTION

Surveillance is an essential part of the control of device-related nosocomial infections (NI) in intensive care units (UCIs). The aim of this study was to analyze the evolution of device-related infection rates in ICUs over the last 13 years, including ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI) and catheter-associated urinary tract infection (CAUTI).

MATERIAL AND METHODS

Patients admitted to the 44 ICUs at 43 participating hospitals of the VINCat Program from 2010 to 2022 were included, taking into account three periods: first period (2010-2013), second period (2014-2017) and third period (2018-2022). Hospitals were classified into three groups according to their size: small (<200 beds), medium (200-500 beds) and large (>500 beds). Complexity was assessed based on the use of invasive mechanical ventilation. The incidence rate of VAP, CRBSI and CAUTI was recorded at least during three consecutive months/year in each unit by an intensivist with extensive experience.

RESULTS

The device utilization ratio (DUR) of mechanical ventilation was 0.39, varying between 0.38 in large hospitals and 0.42 in small hospitals. The DUR of central venous catheter was 0.6, ranging from 0.59 (large hospitals) to 0.64 (small). The DUR of urinary catheter was 0.66, with a range of 0.65 (large hospitals) to 0.68 (small). The complexity of the different ICUs influenced the DUR of the different devices and the infections associated with them. The average rates of VAP, CRBSI, and CAUTI were 6.4, 1.9, and 3.4 episodes per 1000 device days respectively.

CONCLUSIONS

Surveillance systems provide information on intra-ICU infections. ICU complexity, measured in terms of the use of mechanical ventilation, influences device-associated infections.

A Retrospective Closed Cohort Study on Distribution of Multidrug-Resistant Bacteria in Ventilator-Associated Pneumonia and its Impact on Patient Outcome

Objectives: Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection affecting critically ill patients undergoing mechanical ventilation. This study investigated the prevalence of multidrug-resistant (MDR) organisms in VAP, the VAP rate, and the outcomes associated with MDR-VAP. Methods: This retrospective single-center study, conducted in 2022, included adult ICU cases from April 2021 to March 2022, receiving mechanical ventilation for more than 48 h. Patient data were analyzed for demographics, comorbidities, empirical antibiotic use, and outcomes. MDR organisms were identified in respiratory cultures. Results: Among 447 patients, 133 developed VAP, with 96 cases being MDR-VAP. The mean age of the overall VAP population was 52 years, 70% of which were males. The incidence of VAP was 30.0% (95% CI: 25.7%-34.5%), while that of MDR-VAP was 21.6% (95% CI: 17.9%-25.8%). The most prevalent MDR organisms were Acinetobacter species (50%) and Klebsiella pneumoniae (46.9%). Empirical antibiotics were administered in 96% of VAP cases. The overall VAP rate was 38.03/1000 ventilator days. No single antimicrobial agent seemed to offer an empirical cover, as the susceptibility rate for most tested antimicrobials was less than 85%. Patients with MDR-VAP had a low survival rate (64.6%) and were less likely to be extubated at 13.5% compared to non-MDR-VAP (survival rate of 62.2%). COVID-19 patients had a high incidence of MDR VAP, especially with Acinetobacter. Overall, VAP mortality was 57.1%. The median ventilator days were 16 for VAP and only four for non-VAP. Conclusion: Gram-negative organisms, particularly Klebsiella and Acinetobacter, were the main MDR VAP culprits. MDR-VAP exhibited higher morbidity and mortality. A study focused on developing resistance by microorganisms is warranted for further understanding.

Development of a Weighted-Incidence Syndromic Combination Antibiogram (WISCA) to guide empiric antibiotic treatment for ventilator-associated pneumonia in a Mexican tertiary care university hospital

BACKGROUND

Ventilator-associated pneumonia (VAP) is a significant nosocomial infection in critically ill patients, leading to high morbidity, mortality, and increased healthcare costs. The diversity of local microbiology and resistance patterns complicates the empirical treatment selection. The Weighted-Incidence Syndromic Combination Antibiogram (WISCA) offers an innovative tool to optimize empirical antibiotic therapy by integrating local microbiological data and resistance profiles.

OBJECTIVE

To develop a WISCA tailored for VAP in a Mexican tertiary care university hospital, aiming to enhance empirical antibiotic coverage by addressing the unique pathogen distribution and resistance patterns within the institution.

METHODS

This retrospective study included 197 VAP episodes from 129 patients admitted to a critical care unit between June 2021 and June 2024. Clinical and microbiological data, including pathogen susceptibility profiles, were analyzed using a Bayesian hierarchical model to evaluate the coverage of multiple antibiotic regimens. We also assessed the current impact of inappropriate empiric or directed treatment on in-hospital mortality using Cox regression models to support the development of a WISCA model.

RESULTS

The median age of the patients was 44 years (IQR 35-56), with Acinetobacter baumannii (n = 71), Enterobacterales (n = 53) and Pseudomonas aeruginosa (n = 36) identified as the most frequently isolated pathogens. The developed WISCA models showed variable coverage based on antibiotic regimens and the duration of invasive mechanical ventilation (IMV). Inappropriate directed therapy during the VAP episode was associated with increased mortality, as were the diagnosis of Acute Respiratory Distress Syndrome (ARDS) and a high Sequential Organ Failure Assessment (SOFA) score (p < 0.01).

CONCLUSIONS

The tailored WISCA with Bayesian hierarchical modeling provided more adaptive, subgroup-specific estimates and managed uncertainty better compared to fixed models. The implementation of this WISCA model demonstrated potential to optimize antibiotic strategies and improve clinical outcomes in critically ill patients in our hospital.

TOPIC

Optimizing Empirical Antibiotic Therapy for Ventilator-Associated Pneumonia Using a Weighted-Incidence Syndromic Combination Antibiogram in a Mexican Tertiary Care Hospital.

Assessing the role of environment in Pseudomonas aeruginosa healthcare-associated bloodstream infections: a one-year prospective survey

BACKGROUND

Deciphering precise sources and patterns of healthcare-associated Pseudomonas aeruginosa colonization/infection is crucial in defining strategies of prevention and control.

AIM

To prospectively investigate the role of hospital environment in P. aeruginosa nosocomial bloodstream infections (Pa-BSIs) during one year in a tertiary-care hospital.

METHODS

Clinical records of patients presenting Pa-BSIs after >48 h of hospitalization were investigated to confirm the nosocomial character of BSIs and identify the routes of entry and risk factors. Environmental investigations were performed to track P. aeruginosa source/reservoir along the care pathway. Clinical and environmental strains were compared by whole-genome sequencing to identify the route of contamination from hospital environment to patients.

FINDINGS

Fifty-three BSIs episodes in 49 patients were considered as nosocomial, mostly involving men (73%), with an average age of 62.4 years, immunosuppressed in >40% of cases, and after previous antibiotic therapy in almost 92% of cases. BSIs occurred after 27 days of hospitalization on average. The main routes of entry were urinary (30%, on indwelling catheters for two-thirds of cases) and cutaneous (17%, catheter-related in almost 80% of cases). P. aeruginosa was found in 16 out of 49 investigations, representing 34 positive samples, including 54% of sink traps, 23% of water, and 20% of tap aerators. An epidemiological link was established between environmental and clinical strains only for eight patients, representing 15% of nosocomial BSIs.

CONCLUSION

The hospital environment usually considered as the main source of P. aeruginosa healthcare-associated infections was identified as responsible for nosocomial BSIs in only 15% of patients. Since the implementation of water and hospital environment management, one may hypothesize that P. aeruginosa has become a community-acquired pathogen with a nosocomial expression in infection.

Knowledge, Attitudes, and Practices of Infection Prevention and Control Nurses in Public Hospitals in the Limpopo Province: A Qualitative Study

A crucial aspect of delivering healthcare is infection prevention and control (IPC), especially in public hospitals where the high volume of patients and limited resources can heighten the risk of healthcare-associated infections. This qualitative study explores IPC nurses' knowledge, attitudes, and practices in public hospitals within the Limpopo province of South Africa. The study adopted a qualitative descriptive design. This qualitative study utilized self-developed validated semi-structured interviews with IPC nurses from 12 public hospitals (4 tertiary, 4 regional, and 4 district). The interviews were transcribed verbatim and analysed using thematic analysis to identify key themes related to knowledge, attitudes, and practices in IPC. Each interview lasted approximately 15 to 20 min. Themes and subthemes that emerged provided a structured overview of the key aspects discussed. Each theme captures a different facet of the experiences, perceptions, and challenges faced by IPC nurses in their role. The subthemes further break down these views into specific areas of focus, offering deeper insights into the nurses' experiences of their professional responsibilities. This study shows that, although IPC nurses have a good understanding of infection control and a positive attitude toward it, systemic problems and resource constraints make it difficult to consistently implement optimal practices. Affective mood, opportunity cost, coherence of the intervention, burden, perceived efficacy, self-efficacy, and ethics are among the major themes that were found. To improve IPC efforts, there is a clear need for more focused training, resources, and managerial support.

New Insights into the Antibacterial Activity of Hydroxytyrosol Extracted from Olive Leaves: Molecular Docking Simulations of its Antibacterial Mechanisms

This study investigated the biological activities of a hydroxytyrosol-rich extract from Olea europaea leaves, particularly its ability to eradicate severe pathogenic bacteria producing Extended-Spectrum Beta-Lactamases (ESBLs). The latter bacteria are emerging microorganisms that pose significant challenges due to their resistance to a broad range of potent therapeutic drugs. The extract was prepared through an accessible acid hydrolysis method. In vitro and In silico analyses through MIC, MBC analysis and molecular docking were conducted to evaluate the antibacterial properties. The extract showed remarkable antioxidant activity and significant antibacterial potential against reference species and ESBL bacteria. MIC and MBC calculations confirmed the extract's capacity to kill bacteria rather than just inhibit their growth. Further in silico analyzes demonstrated the high binding affinity of HT to the active sites of the gyrase B subunit and the peptidoglycan DD-transpeptidase domain from proteins located in the cytoplasm and the cell wall of the bacteria, respectively. Results confirmed the structure-activity relationship and the ability of HT to disrupt essential bacterial functions. This study validates the debated antimicrobial potential of HT and highlights its importance as a potential therapeutic agent against resistant bacteria, which is a critical area of research given the global challenge of antibiotic resistance.

Validity of urinary catheter specimens for diagnosis of urinary tract infection in patients with short-term catheterization

Current guidelines recommend urine culture after catheter replacement to diagnose catheter-associated urinary tract infections (CA-UTI) in patients with long-term catheters, but it's unclear if this applies to short-term catheterizations. We studied 52 patients with catheters for less than 28 days, showing symptoms of CA-UTI. We collected urine from the catheter port initially and from the new catheter within 2 hours of replacement. Positive culture rates were 36.5 % before and 28.8 % after replacement. Significant differences in urine culture results were observed in 32.7 % of cases postreplacement (P = .0184), increasing to 78.9 % after excluding negative pre-replacement cultures (P = 0.0003). Duration of catheterization didn't affect urine bacteriology changes post-replacement. This suggests that urine bacteriology often differs after catheter replacement in short-term catheterizations.

Rapid quantification of polymyxin B in human pulmonary epithelial lining fluid by LC-MS/MS and its clinical application

Pulmonary epithelial lining fluid (ELF) was commonly used for the pharmacokinetic study in lower respiratory tract infections. To characterize the intrapulmonary pharmacokinetic properties of polymyxin B following aerosol delivery, we developed and fully validated a liquid chromatography/tandem mass spectrometry (LC/MS/MS) method for quantifying polymyxin B in human bronchoalveolar lavage fluid (BALF). The ELF concentrations were calculated by the BALF values of polymyxin B using urea as a volume normalizer. Chromatographic separation was achieved on a Phonomenex Kinetex XB-C18 column(100 mm × 2.1 mm I.D., 2.6 μm)in acetonitrile and water both containing 0.2 % formic acid. The flow rate was set as 0.4 mL/min for a 3.5 min running time. Protein precipitation was used in preparing BALF samples with polymyxin E1 as an internal standard. Polymyxin B was detected under multiple reaction monitoring conditions using the electrospray ionization interface running in the positive ionization mode. The assay showed a good linear relationship over the tested concentration ranges of 0.0300/0.00306---10.0/1.02 mg/L for polymyxin B1/B2 in bronchoalveolar lavage fluid (R2 > 0.99). The inter- and inter-day precisions (RSD, %) were < 12.2 %(15.2 % for LLOQ samples)and the accuracies (%) were within the range of 94.3 ∼ 110.4 %. This reliable LC-MS/MS method for detection of polymyxin B was successfully applied to conduct a pulmonary penetration study in patients following aerosol administration.

International Nosocomial Infection Control Consortium (INICC) report of health care associated infections, data summary of 45 countries for 2015 to 2020, adult and pediatric units, device-associated module

BACKGROUND

Reporting on the International Nosocomial Infection Control Consortium study results from 2015 to 2020, conducted in 630 intensive care units across 123 cities in 45 countries spanning Africa, Asia, Eastern Europe, Latin America, and the Middle East.

METHODS

Prospective intensive care unit patient data collected via International Nosocomial Infection Control Consortium Surveillance Online System. Centers for Disease Control and Prevention/National Health Care Safety Network definitions applied for device-associated health care-associated infections (DA-HAI).

RESULTS

We gathered data from 204,770 patients, 1,480,620 patient days, 936,976 central line (CL)-days, 637,850 mechanical ventilators (MV)-days, and 1,005,589 urinary catheter (UC)-days. Our results showed 4,270 CL-associated bloodstream infections, 7,635 ventilator-associated pneumonia, and 3,005 UC-associated urinary tract infections. The combined rates of DA-HAIs were 7.28%, and 10.07 DA-HAIs per 1,000 patient days. CL-associated bloodstream infections occurred at 4.55 per 1,000 CL-days, ventilator-associated pneumonias at 11.96 per 1,000 MV-days, and UC-associated urinary tract infections at 2.91 per 1,000 UC days. In terms of resistance, Pseudomonas aeruginosa showed 50.73% resistance to imipenem, 44.99% to ceftazidime, 37.95% to ciprofloxacin, and 34.05% to amikacin. Meanwhile, Klebsiella spp had resistance rates of 48.29% to imipenem, 72.03% to ceftazidime, 61.78% to ciprofloxacin, and 40.32% to amikacin. Coagulase-negative Staphylococci and Staphylococcus aureus displayed oxacillin resistance in 81.33% and 53.83% of cases, respectively.

CONCLUSIONS

The high rates of DA-HAI and bacterial resistance emphasize the ongoing need for continued efforts to control them.

Implementation and long-term efficacy of a multifaceted intervention to reduce central line-associated bloodstream infections in intensive care units of a low-middle-income country

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) pose a significant risk to critically ill patients, particularly in intensive care units (ICU), and are a significant cause of hospital-acquired infections. We investigated whether implementation of a multifaceted intervention was associated with reduced incidence of CLABSIs.

METHODS

This was a prospective cohort study over nine years. We implemented a bundled intervention approach to prevent CLABSIs, consisting of a comprehensive unit-based safety program (CUSP). The program was implemented in the Neonatal ICU, Medical ICU, and Surgical ICU departments at the Aga Khan University Hospital in Pakistan.

RESULTS

The three intervention ICUs combined were associated with an overall 36% reduction in CLABSI rates and a sustained reduction in CLABSI rates for > a year (5 quarters). The Neonatal ICU experienced a decrease of 77% in CLABSI rates lasting ∼1 year (4 quarters). An attendance rate above 88% across all stakeholder groups in each CUSP meeting correlated with a better and more sustained infection reduction.

CONCLUSIONS

Our multifaceted approach using the CUSP model was associated with reduced CLABSI-associated morbidity and mortality in resource-limited settings. Our findings suggest that a higher attendance rate (>85%) at meetings may be necessary to achieve sustained effects post-intervention.

Extra-cardiac management of cardiogenic shock in the intensive care unit

Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.

Reducing catheter-associated urinary tract infection in high dependency unit: an eighteen-month quality improvement intervention study period

Background

The urinary catheter usually leads to a catheter-associated urinary tract infection (CAUTI) contributing to further morbidity and mortality. There is very limited data on the CAUTI incidence rate in high-dependency units (HDUs) in the Kingdom of Saudi Arabia. The institutional CAUTI incidence rate in HDU was six times higher compared to the United States National Healthcare Safety Network (US-NHSN) in 2021.

Objective

To reduce 50% CAUTI incidence rate by the end of 2022.

Method

A prospective study was conducted in tertiary HDU from January 2022 to June 2023. A gap analysis was assessed between the hospital practices and the Society Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) basic recommendations. The Kotter and Rathgebers' changing behavior model was applied at the beginning of the project. Formal education and prevention of CAUTI were applied using the National Strategy Model. Surveillance and statistical data analysis were carried out using US-NHSN guidelines.

Results

The overall CAUTI incidence rate declined from 7.07- to 3.57/1000 urinary catheter days despite of significant increase in the utilization ratio from 0.79 to 0.94 (P value 0.0001). The compliance rate of the bundle CAUTI prevention was improved and sustained above 90%. A CAUTI incidence rate reduction was observed following the combination of the changing behavior and SHEA/IDSA of CAUTI prevention models over 18 months.

Conclusion

We assumed the combination of the changing behavior and the prevention models for a long period is useful in reducing the CAUTI incidence rate and possibly applied to reduce other healthcare-associated infections.

Decreasing central line-associated bloodstream infections rates in intensive care units in 30 low- and middle-income countries: An INICC approach

BACKGROUND

Central line (CL)-associated bloodstream infections (CLABSIs) occurring in the intensive care unit (ICU) are common and associated with a high burden.

METHODS

We implemented a multidimensional approach, incorporating an 11-element bundle, education, surveillance of CLABSI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CLABSI rates and clinical outcomes, and performance feedback in 316 ICUs across 30 low- and middle-income countries. Our dependent variables were CLABSI per 1,000-CL-days and in-ICU all-cause mortality rates. These variables were measured at baseline and during the intervention, specifically during the second month, third month, 4 to 16 months, and 17 to 29 months. Comparisons were conducted using a two-sample t test. To explore the exposure-outcome relationship, we used a generalized linear mixed model with a Poisson distribution to model the number of CLABSIs.

RESULTS

During 1,837,750 patient-days, 283,087 patients, used 1,218,882 CL-days. CLABSI per 1,000 CL-days rates decreased from 15.34 at the baseline period to 7.97 in the 2nd month (relative risk (RR) = 0.52; 95% confidence interval [CI] = 0.48-0.56; P < .001), 5.34 in the 3rd month (RR = 0.35; 95% CI = 0.32-0.38; P < .001), and 2.23 in the 17 to 29 months (RR = 0.15; 95% CI = 0.13-0.17; P < .001). In-ICU all-cause mortality rate decreased from 16.17% at baseline to 13.68% (RR = 0.84; P = .0013) at 17 to 29 months.

CONCLUSIONS

The implemented approach was effective, and a similar intervention could be applied in other ICUs of low- and middle-income countries to reduce CLABSI and in-ICU all-cause mortality rates.

Bacteriology of endotracheal tube biofilms and antibiotic resistance: a systematic review

Bacteria commonly adhere to surfaces and produce polymeric material to encase the attached cells to form communities called biofilms. Within these biofilms, bacteria can appear to be many times more resistant to antibiotics or disinfectants. This systematic review explores the prevalence and microbial profile associated with biofilm production of bacteria isolated from endotracheal tubes and its associations with antimicrobial resistance. A comprehensive search was performed on databases PubMed, Embase, and Google Scholar for relevant articles published between 1st January 2000 and 31st December 2022. The relevant articles were exported to Mendeley Desktop 1.19.8 and screened by title and abstract, followed by full text screening based on the eligibility criteria of the study. Quality assessment of the studies was performed using the Newcastle-Ottawa Scale (NOS) customized for cross-sectional studies. Furthermore, the prevalence of antimicrobial resistance in biofilm-producers isolated from endotracheal tube specimens was investigated. Twenty studies encompassing 981 endotracheal tubes met the eligibility criteria. Pseudomonas spp. and Acinetobacter spp. were predominant isolates among the biofilm producers. These biofilms provided strong resistance against commonly used antibiotics. The highest resistance rate observed in Pseudomonas spp. was against fluoroquinolones whereas the least resistance was seen against piperacillin-tazobactam. A similar trend of susceptibility was observed in Acinetobacter spp. with a very high resistance rate against fluoroquinolones, third-generation cephalosporins and carbapenems. In conclusion, endotracheal tubes were associated with colonization by biofilm forming bacteria with varying levels of antimicrobial resistance. Biofilms may promote the occurrence of recalcitrant infections in endotracheal tubes which need to be managed with appropriate protocols and antimicrobial stewardship. Research focus should shift towards meticulous exploration of biofilm-associated infections to improve detection and management.

Risk factors for ventilator-associated lower respiratory tract infection in COVID-19, a retrospective multicenter cohort study in Sweden

BACKGROUND

Ventilator-associated lower respiratory tract infections (VA-LRTI) increase morbidity and mortality in intensive care unit (ICU) patients. Higher incidences of VA-LRTI have been reported among COVID-19 patients requiring invasive mechanical ventilation (IMV). The primary objectives of this study were to describe clinical characteristics, incidence, and risk factors comparing patients who developed VA-LRTI to patients who did not, in a cohort of Swedish ICU patients with acute hypoxemic respiratory failure due to COVID-19. Secondary objectives were to decipher changes over the three initial pandemic waves, common microbiology and the effect of VA-LTRI on morbidity and mortality.

METHODS

We conducted a multicenter, retrospective cohort study of all patients admitted to 10 ICUs in southeast Sweden between March 1, 2020 and May 31, 2021 because of acute hypoxemic respiratory failure due to COVID-19 and were mechanically ventilated for at least 48 h. The primary outcome was culture verified VA-LRTI. Patient characteristics, ICU management, clinical course, treatments, microbiological findings, and mortality were registered. Logistic regression analysis was conducted to determine risk factors for first VA-LRTI.

RESULTS

Of a total of 536 included patients, 153 (28.5%) developed VA-LRTI. Incidence rate of first VA-LRTI was 20.8 per 1000 days of IMV. Comparing patients with VA-LRTI to those without, no differences in mortality, age, sex, or number of comorbidities were found. Patients with VA-LRTI had fewer ventilator-free days, longer ICU stay, were more frequently ventilated in prone position, received corticosteroids more often and were more frequently on antibiotics at intubation. Regression analysis revealed increased adjusted odds-ratio (aOR) for first VA-LRTI in patients treated with corticosteroids (aOR 2.64 [95% confidence interval [CI]] [1.31-5.74]), antibiotics at intubation (aOR 2.01 95% CI [1.14-3.66]), and days of IMV (aOR 1.05 per day of IMV, 95% CI [1.03-1.07]). Few multidrug-resistant pathogens were identified. Incidence of VA-LRTI increased from 14.5 per 1000 days of IMV during the first wave to 24.8 per 1000 days of IMV during the subsequent waves.

CONCLUSION

We report a high incidence of culture-verified VA-LRTI in a cohort of critically ill COVID-19 patients from the first three pandemic waves. VA-LRTI was associated with increased morbidity but not 30-, 60-, or 90-day mortality. Corticosteroid treatment, antibiotics at intubation and time on IMV were associated with increased aOR of first VA-LRTI.

[Diagnosis and antibiotic therapy of nosocomial pneumonia in adults: from recommendations to real practice. A review]

Nosocomial pneumonia is a healthcare-associated infection with significant consequences for the patient and the healthcare system. The efficacy of treatment significantly depends on the timeliness and adequacy of the antibiotic therapy regimen. The growth of resistance of gram-negative pathogens of nosocomial pneumonia to antimicrobial agents increases the risk of prescribing inadequate empirical therapy, which worsens the results of patient treatment. Identification of risk factors for infection with multidrug-resistant microorganisms, careful local microbiological monitoring with detection of resistance mechanisms, implementation of antimicrobial therapy control strategy and use of rational combinations of antibacterial drugs are of great importance. In addition, the importance of using new drugs with activity against carbapenem-resistant strains, including ceftazidime/aviabactam, must be understood. This review outlines the current data on the etiology, features of diagnosis and antibacterial therapy of nosocomial pneumonia.

Promoting Patient Safety: Exploring Device-Associated Healthcare Infections and Antimicrobial Susceptibility Pattern in a Multidisciplinary Intensive Care Units

INTRODUCTION

Device-associated healthcare infections are among the prevailing threats to patient safety worldwide. They constitute the third most common adverse event during healthcare delivery, resulting in heightened morbidity, mortality, and healthcare costs. Patients in intensive care units (ICUs) are at increased risk for device-associated healthcare infections. Focused active surveillance is a crucial measure for assessing the prevalence of healthcare-associated infections and controlling the transmission of pathogens, ultimately contributing to the establishment of quality outcome indicators. This study aimed to investigate and establish the baseline rates of healthcare-associated infections associated with medical devices in adult multidisciplinary ICUs within a tertiary care institute.

MATERIAL AND METHODS

 This hospital-based prospective observational study was conducted in two adult ICUs of a tertiary care institute in Central India over nine months. Targeted active surveillance for three device-associated health care infections namely central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated event (VAE) was conducted as per the Center for Disease Control (CDC)/National Healthcare Safety Network (NHSN) 2016 surveillance definitions and criteria. Pathogens associated with device-associated healthcare infections were identified and their antimicrobial susceptibility profile was studied.

RESULTS

 During the study period, a total of 5,773 patient days were investigated. Of 1,270 patients, 28 episodes of device-associated healthcare infections were detected in 26 patients, this suggests a collective occurrence of five device-associated healthcare infections for every 1,000 patient days in the ICUs. The device utilization ratios of the central line, mechanical ventilator, and urinary catheters were 0.33, 0.27, and 0.68, respectively. VAE, CLABSI, and CAUTI rates were 8.92, 5.68, and 0.76 per 1,000 device days, respectively. The most common pathogen isolated from device-associated healthcare infections was Klebsiella pneumoniae (39%) followed by Acinetobacter baumanii (22%). The majority (82.3%) of pathogens were multidrug resistant. The death rate among device-associated healthcare infections was 69.2% with a crude excess mortality rate of 37.7%.

CONCLUSION

The study sheds light on the proportion, types of device-associated healthcare infections, and underlying etiological agents associated with these infections in our institute's ICUs, thereby facilitating a better understanding of the healthcare-associated infection landscape within our facility. Moreover, the susceptibility pattern of pathogens associated with these infections offers crucial information for guiding the selection of appropriate antimicrobial therapies and infection control measures.

Adult patients with tetanus in Slovenia 2006-2021 : Results of a national cohort study

INTRODUCTION

The aim of the present study was to determine the demographic, epidemiological and clinical characteristics of adult patients with tetanus in Slovenia between 2006 and 2021, as well as to determine the therapeutic approaches which have been successfully used in the intensive care unit (ICU) of the Infectious Diseases Department in the University Medical Centre Ljubljana (UMC).

METHODS

We included all adult patients who were treated for tetanus in the ICU of the Department of Infectious Diseases Ljubljana between January 1st, 2006, and December 31th, 2021, in the retrospective study. Available epidemiological and clinical characteristics were reviewed from the medical documentation.

RESULTS

There were 31 patients included in the study, four (12.9%) males and 27 (87.1%) females. The vast majority of patients required mechanical ventilation (MV) (87.1%) which lasted (± SD) on average 35.4 ± 16.0 days. Autonomic dysfunction was present in 29 (93.5%) patients and was statistically significantly associated with shorter disease evolution (p = 0.005) and presence of healthcare-associated infection (p = 0.020). During the hospitalization, 27 (87.1%) patients acquired at least one healthcare-associated infection, most commonly ventilator-associated pneumonia. The average length of stay in the ICU (± SD) was 42.5 ± 21.3 days. With increasing age, MV lasted statistically significantly longer (p = 0.001), length of stay was longer (p = 0.015), and healthcare-associated infections occurred (p = 0.003) more frequently. Four patients (12.9%) died.

CONCLUSIONS

Although the tetanus incidence rate in Slovenia is high in comparison to other European countries on average, our therapeutic approach resulted in a good survival rate and low mortality.

Study on Effects of Probiotics on Gut Microbiome and Clinical Course in Patients with Critical Care Illnesses

Ventilator-associated pneumonia (VAP) is a nosocomial infection contracted by ventilator patients in which bacteria colonize the upper digestive tract and contaminated secretions are released into the lower airway. This nosocomial infection increases the morbidity and mortality of the patients as well as the cost of treatment. Probiotic formulations have recently been proposed to prevent the colonization of these pathogenic bacteria. In this prospective observational study, we aimed to investigate the effects of probiotics on gut microbiota and their relation to clinical outcomes in mechanically ventilated patients. For this study, 35 patients were recruited (22 probiotic-treated and 13 without probiotic treatment) from a cohort of 169 patients. Patients in the probiotic group were given a dose of 6 capsules of a commercially available probiotic (VSL#3®:112.5 billion CFU/cap) in three divided doses for 10 days. Sampling was carried out after each dose to monitor the temporal change in the gut microbiota composition. To profile the microbiota, we used a 16S rRNA metagenomic approach, and differences among the groups were computed using multivariate statistical analyses. Differences in gut microbial diversity (Bray Curtis and Jaccard distance, p-value > 0.05) between the probiotic-treated group and the control group were not observed. Furthermore, treatment with probiotics resulted in the enrichment of Lactobacillus and Streptococcus in the gut microbiota of the probiotic-treated groups. Our results demonstrated that probiotics might lead to favorable alterations in gut microbiome characteristics. Future studies should focus on the appropriate dosages and frequency of probiotics, which can lead to improved clinical outcomes.

Prophylactic antibiotics for preventing ventilator-associated pneumonia: a pairwise and Bayesian network meta-analysis

BACKGROUND

The role of prophylactic antibiotics in preventing ventilator-associated pneumonia (VAP) in patients undergoing invasive mechanical ventilation (IMV) remains unclear. This network meta-analysis compared the efficacy and safety of antibiotic prophylaxis in preventing VAP in an IMV population in intensive-care units (ICUs).

METHODS

We searched the PubMed, Web of Science, Embase, and Cochrane Library databases from inception to December 2021, to identify relevant studies assessing the impact of prophylactic antibiotics on the incidence of VAP, the mortality, and the duration of ICU stays and hospitalization to perform a meta-analysis.

RESULTS

Thirteen studies (2144 patients) were included, 12 of which were selected for the primary analysis, which revealed that treatment with prophylactic antibiotics resulted in a lower VAP rate compared with control groups [risk ratio (RR) = 0.62]. Bayesian network meta-analysis indicated that aerosolized tobramycin and intravenous ampicillin-sulbactam presented the greatest likelihood being the most efficient regimen for reducing VAP.

CONCLUSIONS

Antibiotic prophylaxis may reduce the incidence of VAP, but not the mortality, for adult patients undergoing IMV in ICUs. Tobramycin via nebulization and ampicillin-sulbactam via intravenous administration presented the greatest likelihood of being the most efficient regimen for preventing VAP. However, well-designed randomized studies are warranted before definite recommendations can be made.

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.

Impact of staffing levels and resources of intensive care units on compliance to standard mechanical ventilator guidelines: A city-wide study in times of COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV).

AIM

This study aims to examine the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan.

METHODS

A cross-sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self-structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle.

RESULTS

The unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient-to-nurse and patient-to-doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21-28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19-26) and 28 (IQR = 23-30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (r_s  = 0.654, p value = .011). Similarly, 24-h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (r_s  = 0.676, p value = .008) while routine subglottic aspiration was correlated with the number of doctors (r_s  = 0.636, p value = .014).

CONCLUSION

Our study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels.

RELEVANCE TO CLINICAL PRACTICE

Critical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non-compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care.

Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC)

OBJECTIVE

Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs.

DESIGN

Prospective cohort study.

SETTING

This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries.

PARTICIPANTS

The study included patients admitted to ICUs across 24 years.

RESULTS

In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16-1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07-1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23-1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57-15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21-9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34-7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17-1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15-1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22-5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78-3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79-3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51-0.77; P < .0001).

CONCLUSIONS

Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.

Risk factors for mortality in ICU patients in 10 middle eastern countries: The role of healthcare-associated infections

PURPOSE

The International Nosocomial Infection Control Consortium (INICC) found a high mortality rate in ICUs of the Middle East (ME). Our goal was to identify mortality risk factor (RF) in ICUs of the ME.

MATERIALS

From 08/01/2003 to 02/12/2022, we conducted a prospective cohort study in 236 ICUs of 77 hospitals in 44 cities in 10 countries of ME. We analyzed 16 independent variables using multiple logistic regression.

RESULTS

66,440 patients, hospitalized during 652,167 patient-days, and 13,974 died. We identified following mortality RF: Age (adjusted odds ratio (aOR):1.02;p < 0.0001) rising risk 2% yearly; length of stay (LOS) (aOR:1.02;p < 0.0001) rising the risk 2% per day; central line (CL)-days (aOR:1.01;p < 0.0001) rising risk 1% per day; mechanicalventilator (MV) utilization-ratio (aOR:14.51;p < 0.0001); CL-associated bloodstream infection (CLABSI) acquisition (aOR):1.49;p < 0.0001); ventilator-associated pneumonia (VAP) acquisition (aOR:1.50;p < 0.0001); female gender (OR:1.14;p < 0.0001); hospitalization at a public-hospital (OR:1.31;p < 0.0001); and medical-hospitalization (aOR:1.64;p < 0.0001). High-income countries showed lowest risk (aOR:0.59;p < 0.0001).

CONCLUSION

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

Obesity and the risk of catheter-related bloodstream infection: a systematic review and meta-analysis

Background

The role of obesity in catheter-related bloodstream infection has been reported in several studies, but it is still controversial. We conducted this meta-analysis to summarize existing evidence to assess the relationship between obesity and the risk of catheter-related bloodstream infection.

Methods

We searched MEDLINE, EMBASE, PubMed and Web of Science for the related studies published before January 2022. Meta-analysis was performed by use of a random-effects model.

Results

A total of 5 articles were included in this meta-analysis. Patients with body mass index  ≥ 25 kg/m² had an increased risk of catheter-related bloodstream infection (OR 1.75, 95% CI 1.38–2.22) in overall analysis. Further analysis indicated that patients with overweight, obesity and severely obesity were all significantly associated with a higher risk of for catheter-related bloodstream infection (OR 1.51 [1.10–2.08], OR 1.43 [1.12–1.82] and OR 2.74 [1.85–4.05], respectively).

Conclusion

This meta-analysis provided evidence that obesity was significantly associated with a higher risk of catheter-related bloodstream infection. Close attention should be paid to the complications and prognosis of obese patients with vascular catheterization in clinical work.

Antibacterial and antibiofilm effects of silver nanoparticles against the uropathogen Escherichia coli U12

The drug-resistant bacterial strains' emergence increases day by day. This may be a result of biofilm presence, which protects bacteria from antimicrobial agents. Thus, new approaches must be used to control biofilm-related infections in healthcare settings. In such a study, biological silver nanoparticles were introduced in such a study as an anti-biofilm agent against multidrug-resistant E. coli U12 on urinary catheters. Seven different silver nanoparticles concentrations were tested for their antimicrobial activities. Also, anti-biofilm activities against E. coli U12 were tested. Using the dilution method, the silver nanoparticles concentration of 85 μg/ml was the MIC (Minimum Inhibitory Concentration) that had excellent biocompatibility and showed significant antibacterial activity against E. coli U12. Scanning electron microscopy (SEM) confirmed that the highest efficient dose of silver nanoparticles was 340 μg/ml at 144 h that reduced adhesion of E. coli U12 to the urinary catheter. E. coli U12 cells ruptured cell walls and cell membranes after being examined using transmission electron microscopy (TEM). Thus, biologically prepared silver nanoparticles could be used to coat medical devices since it is effective and promising to inhibit biofilm formation by impregnating urinary catheters with silver nanoparticles.

Multinational Prospective Cohort Study of Mortality Risk Factors in 198 ICUs of 12 Latin American Countries over 24 Years: The Effects of Healthcare-Associated Infections

BACKGROUND

The International Nosocomial Infection Control Consortium (INICC) has found a high ICU mortality rate in Latin America.

METHODS

A prospective cohort study in 198 ICUs of 96 hospitals in 46 cities in 12 Latin American countries to identify mortality risk factors (RF), and data were analyzed using multiple logistic regression.

RESULTS

Between 07/01/1998 and 02/12/2022, 71,685 patients, followed during 652,167 patient-days, acquired 4700 HAIs, and 10,890 died. We prospectively collected data of 16 variables. Following 11 independent mortality RFs were identified in multiple logistic regression: ventilator-associated pneumonia (VAP) acquisition (adjusted odds ratio [aOR] = 1.17; 95% CI: 1.06-1.30; p < 0.0001); catheter-associated urinary tract infection (CAUTI) acquisition (aOR = 1.34; 95% CI: 1.15-1.56; p < 0.0001); older age, rising risk 2% yearly (aOR = 1.02; 95% CI: 1.01-1.02; p < 0.0001); longer indwelling central line(CL)-days, rising risk 3% daily (aOR = 1.03; 95% CI: 1.02-1.03; p < 0.0001); longer indwelling urinary catheter(UC)-days, rising risk 1% daily (aOR = 1.01; 95% CI: 1.01-1.26; p < 0.0001); higher mechanical ventilation (MV) (aOR = 6.47; 95% CI: 5.96-7.03; p < 0.0001) and urinary catheter-utilization ratio (aOR = 1.19; 95% CI: 1.11-1.27; p < 0.0001); lower-middle level income country (aOR = 2.94; 95% CI: 2.10-4.12; p < 0.0001); private (aOR = 1.50; 95% CI: 1.27-1.77; p < 0.0001) or public hospital (aOR = 1.47; 95% CI: 1.24-1.74; p < 0.0001) compared with university hospitals; medical hospitalization instead of surgical (aOR = 1.67; 95% CI: 1.59-1.75; p < 0.0001); neurologic ICU (aOR = 4.48; 95% CI: 2.68-7.50; p < 0.0001); adult oncology ICU (aOR = 3.48; 95% CI: 2.14-5.65; p < 0.0001); and others.

CONCLUSION

Some of the identified mortality RFs are unlikely to change, such as the income level of the country, facility ownership, hospitalization type, ICU type, and age. But some of the mortality RFs we found can be changed, and efforts should be made to reduce CL-days, UC-days, MV-utilization ratio, UC-utilization ratio, and lower VAPs and CAUTI rates.

Pathogens Identified by Minimally Invasive Tissue Sampling in India and Pakistan From Preterm Neonatal Deaths: The PURPOSE Study

BACKGROUND

We identified pathogens found in internal organs and placentas of deceased preterm infants cared for in hospitals in India and Pakistan.

METHODS

Prospective, observational study conducted in delivery units and neonatal intensive care units. Tissue samples from deceased neonates obtained by minimally invasive tissue sampling and placentas were examined for 73 different pathogens using multiplex polymerase chain reaction (PCR).

RESULTS

Tissue for pathogen PCR was obtained from liver, lung, brain, blood, cerebrospinal fluid, and placentas from 377 deceased preterm infants. Between 17.6% and 34.1% of each type of tissue had at least 1 organism identified. Organism detection was highest in blood (34.1%), followed by lung (31.1%), liver (23.3%), cerebrospinal fluid (22.3%), and brain (17.6%). A total of 49.7% of the deceased infants had at least 1 organism. Acinetobacter baumannii was in 28.4% of the neonates compared with 14.6% for Klebsiella pneumoniae, 11.9% for Escherichia coli/Shigella, and 11.1% for Haemophilus influenzae. Group B streptococcus was identified in only 1.3% of the neonatal deaths. A. baumannii was rarely found in the placenta and was found more commonly in the internal organs of neonates who died later in the neonatal period. The most common organism found in placentas was Ureaplasma urealyticum in 34% of the samples, with no other organism found in >4% of samples.

CONCLUSIONS

In organ samples from deceased infants in India and Pakistan, evaluated with multiplex pathogen PCR, A. baumannii was the most commonly identified organism. Group B streptococcus was rarely found. A. baumannii was rarely found in the placentas of these deceased neonates.

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.

What is the best technic to dislodge Staphylococcus epidermidis biofilm on medical implants?

Background

Bacterial biofilm can occur on all medical implanted devices and lead to infection and/or dysfunction of the device.

In this study, artificial biofilm was formed on four different medical implants (silicone, piccline, peripheral venous catheter and endotracheal tube) of interest for our daily clinical and/or research practice. We investigated the best conventional technic to dislodge the biofilm on the implants and quantified the number of bacteria. Staphylococcus epidermidis previously isolated from a breast implant capsular contracture on a patient in the university hospital of Dijon was selected for its ability to produce biofilm on the implants. Different technics (sonication, Digest-EUR®, mechanized bead mill, combination of sonication plus Digest-EUR®) were tested and compared to detach the biofilm before quantifying viable bacteria by colony counting.

Results

For all treatments, the optical and scanning electron microscope images showed substantial less biofilm biomass remaining on the silicone implant compared to non-treated implant.

This study demonstrated that the US procedure was statistically superior to the other physical treatment: beads, Digest-EUR® alone and Digest-EUR® + US (p < 0.001) for the flexible materials (picc-line, PIV, and silicone). The number of bacteria released by the US is significantly higher with a difference of 1 log on each material. The result for a rigid endotracheal tube were different with superiority for the chemical treatment dithiothreitol: Digest-EUR®. Surprisingly the combination of the US plus Digest-EUR® treatment was consistently inferior for the four materials.

Conclusions

Depending on the materials used, the biofilm dislodging technique must be adapted. The US procedure was the best technic to dislodge S. epidermidis biofilm on silicone, piccline, peripheral venous catheter but not endotracheal tube. This suggested that scientists should compare themselves different methods before designing a protocol of biofilm study on a given material.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-022-02606-x.

An Overview of Healthcare Associated Infections and Their Detection Methods Caused by Pathogen Bacteria in Romania and Europe

Healthcare-associated infections can occur in different care units and can affect both patients and healthcare professionals. Bacteria represent the most common cause of nosocomial infections and, due to the excessive and irrational use of antibiotics, resistant organisms have appeared. The most important healthcare-associated infections are central line-associated bloodstream infections, catheter-associated urinary tract infections, surgical site, soft tissue infections, ventilator-associated pneumonia, hospital acquired pneumonia, and Clostridioides difficile colitis. In Europe, some hospitalized patients develop nosocomial infections that lead to increased costs and prolonged hospitalizations. Healthcare-associated infection prevalence in developed countries is lower than in low-income and middle-income countries such as Romania, an Eastern European country, where several factors contribute to the occurrence of many nosocomial infections, but official data show a low reporting rate. For the rapid identification of bacteria that can cause these infections, fast, sensitive, and specific methods are needed, and they should be cost-effective. Therefore, this review focuses on the current situation regarding healthcare-associated infections in Europe and Romania, with discussions regarding the causes and possible solutions. As a possible weapon in the fight against the healthcare-associated infections, the diagnosis methods and tests used to determine the bacteria involved in healthcare-associated infections are evaluated.

Screening Biomarkers and Constructing a Predictive Model for Symptomatic Urinary Tract Infection and Asymptomatic Bacteriuria in Patients Undergoing Cutaneous Ureterostomy: A Metagenomic Next-Generation Sequencing Study

Objectives. To investigate the clinical diagnostic value of differential flora as biomarkers in patients with symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) undergoing cutaneous ureterostomy based on metagenomic next-generation sequencing and construct predictive models to provide a scientific reference for clinical diagnosis and treatment. Material and Methods. According to standard procedures, samples were taken from each patient for routine tests (urine, ureteral stent, and skin swab around the stoma). Cytokine levels in the blood were also detected. Urinary microflora were measured by mNGS, and potential biomarkers for distinguishing UTI and ASB were identified by differential flora. Finally, we generated the predictive models for ASB and UTI using the Lasso method and cytokine levels. Results. Urine culture was performed for 50 patients with cutaneous ureterostomy; 44 of these patients developed bacteriuria. The incidence of symptomatic bacteriuria was 54.55%. Biomarker analysis showed that Propionimicrobium lymphophilum, Staphylococcus haemolyticus, Stenotrophomonas maltophilia, Ralstonia insidiosa, and Aspergillus sydowii all had good predictive performance and were combined in a single model. The predictive model exhibited good prediction performance (area under the curve $\left(\text{AUC}\right)=0.8729$ , $\text{sensitivity}=80\%$ , $\text{specificity}=83.3\%$ , and $\text{cutoff}=1.855$ ). We also identified a significant negative correlation between the weight sum of the abundance for these five characteristic pathogens (Sum_weighted_Reads) and levels of the cytokine IL-6 and IL-1β ( $P<0.05$ ). Conclusion. mNGS had a higher positive detection rate for pathogens in urine samples. The selected differential bacteria can be used as biomarkers of ASB and UTI, and the prediction model has good predictive performance. Analysis also showed that the occurrence of symptoms was related to individual immunity. Combined with the Sum_weighted_Reads cutoff and cytokine levels (IL-6 and IL-1β) of differential flora, it was possible to judge the severity of symptoms in cutaneous ureterostomy patients with bacteriuria and provide new insights for the treatment and intervention of ASB and UTI.

Binding communication to improve peripheral venous catheter monitoring

BACKGROUND

Optimizing the monitoring of peripheral venous catheters is essential. We developed a nursing record system at bedside (Patient Smart Reader) to track peripheral venous catheter acts.

AIMS

The aim of the present study was to improve peripheral venous catheter monitoring. To improve the quality of monitoring, we aimed to increase the usage of the nursing record system at the bedside.

METHODS

We developed a 'commitment intervention' course based on a binding communication paradigm. The corresponding effect on monitoring was analysed using a p-chart and time series analysis.

FINDINGS

Nurses observed a significant improvement in compliance with catheter monitoring over time (shifts after shifts), ranging from 27.6% (CI = [25.3; 30.0]) compliance before the commitment intervention to 47.4% (CI = [45.0; 49.9]) compliance after training. The commitment intervention increased the chances of carrying out monitoring through the tool for acts related to peripheral venous catheters by a factor of 2.42 (odds ratio) (CI = [1.88; 3.11]).

CONCLUSION

Binding communication provides an effective method for changing nurses' behaviours in terms of safe care. The determinants of engagement (individual vs collective) can be indicators for defining future communication and training strategies in care centers for all health care workers.

Exploring synergy and its role in antimicrobial peptide biology

Antimicrobial peptides will be an essential component in combating the escalating issue of antibiotic resistance. Identifying synergistic combinations of two or more substances will increase the value of these peptides further. Several potential pitfalls in conducting synergy testing with peptides are discussed in detail. As case studies, we describe observations of AMP synergy with peptides, antibiotics, and metal ions as well as some of the mechanistic details that have been uncovered. The Bliss and Loewe models for synergy are presented prior to recommending protocols for conducting checkerboard, minimal inhibitory concentration, and time-kill assays. Establishing mechanisms of action and exploring the potential for resistance will be crucial to translate these studies into the clinic.

Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy

Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).

Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective

Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.

Antibacterial surfaces: Strategies and applications

Antibacterial surfaces are surfaces that can resist bacteria, relying on the nature of the material itself. It is significant for safe food and water, human health, and industrial equipment. Biofilm is the main form of bacterial contamination on the material surface. Preventing the formation of biofilm is an efficient way to develop antibacterial surfaces. The strategy for constructing the antibacterial surface is divided into bacteria repelling and bacteria killing based on the formation of the biofilm. Material surface wettability, adhesion, and steric hindrance determine bacteria repelling performance. Bacteria should be killed by surface chemistry or physical structures when they are attached to a material surface irreversibly. Killing approaches are usually in the light of the cell membrane of bacteria. This review summarizes the fabrication methods and applications of antibacterial surfaces from the view of the treatment of the material surfaces. We also present several crucial points for developing long-term stability, no drug resistance, broad-spectrum, and even programable antibacterial surfaces.

Comparison of chlorhexidine impregnated dressing and standard dressing for the prevention of central-line associated blood stream infection and colonization in critically ill pediatric patients: A randomized controlled trial

BACKGROUND

The aim of this study was to compare chlorhexidine gluconate (CHG)-impregnated dressing and standard dressing with respect to the frequency of central-line-associated bloodstream infection (CLABSI), catheter-related bloodstream infection, primary bloodstream infection, and catheter colonization in critically ill pediatric patients with short-term central venous catheters.

METHODS

Children who were admitted to the pediatric intensive care unit of a tertiary institution between May 2018 and December 2019 and received placement of a short-term central venous catheter were included in this single-center randomized controlled trial. Patients were grouped according to the type of catheter fixation applied.

RESULTS

A total of 307 patients (151 CHG-impregnated dressing, 156 standard dressing), with 307 catheters (amounting to a collective total of 4,993 catheter days), were included in the study. The CHG-impregnated dressing did not significantly decrease the incidence of CLABSI (6.36 vs 7.59 per 1,000 catheter days; hazard ratio (HR): 0.93, P = 0.76), catheter related bloodstream infection (3.82 vs 4.18 per 1,000 catheter days; HR: 0.98; P = 0.98), and primary bloodstream infection (2.54 vs 3.42 catheter days; HR: 0.79; P = 0.67). The CHG-impregnated dressing significantly decreased the incidence of catheter colonization (3.82 vs 7.59 per 1,000 catheter days; HR: 0.40; P = 0.04). In both groups, the most frequent microorganisms isolated in CLABSI or catheter colonization were Gram-positive bacteria (the majority were coagulase-negative staphylococci).

CONCLUSIONS

The use of CHG-impregnated dressing does not decrease CLABSI incidence in critically ill pediatric patients but it significantly reduced catheter colonization. Coagulase-negative staphylococci were the most common microorganisms causing CLABSI or catheter colonization.

Multidrug-resistant Acinetobacter baumannii infections: looming threat in the Indian clinical setting

INTRODUCTION

The recent increase in multidrug-resistant strains of A. baumannii has increased the incidences of ventilator-associated pneumoniae, catheter-associated urinary tract infections, and central line-associated blood stream infections, together increasing hospital stay, treatment cost, and mortality. Resistance genes blaOXA and blaNDM are dominant in India. Carbapenem-resistant A. baumannii (CRAB) International clone-2 (IC-2) are rising in India. High dependency on carbapenems and last-resort combination of tigecycline and polymyxins have aggravated outcomes. Despite nursing barriers, ward closure, environmental disinfections etc for detecting and controlling transmission, MDR isolates and CRAB nosocomial outbreaks continue. Treatment cost overruns by AMR adversely affect 80% of Indians without insurance cover.

AREA COVERED

This narrative review will cover epidemiology, resistance pattern, genetic diversity, device-related infection, cost, and mortality due to multidrug-resistant and CRAB in India. A comprehensive literature search in PubMed and Google Scholar using appropriate keywords at different time points yielded relevant articles.

EXPERT OPINION

It is challenging to enforce policies to control MDR A. baumannii in India. Government and hospitals should enforce stringent infection control measures, surveillance, and antimicrobial stewardship to prevent further spread and emergence of more virulent and resistant strains. Knowledge on antibiotic resistance mechanisms can help design novel antibiotics that can evade, resistance.

Bacterial Superinfection Pneumonia in Patients Mechanically Ventilated for COVID-19 Pneumonia

Rationale: Current guidelines recommend patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia receive empirical antibiotics for suspected bacterial superinfection on the basis of weak evidence. Rates of ventilator-associated pneumonia (VAP) in clinical trials of patients with SARS-CoV-2 pneumonia are unexpectedly low.

Objectives: We conducted an observational single-center study to determine the prevalence and etiology of bacterial superinfection at the time of initial intubation and the incidence and etiology of subsequent bacterial VAP in patients with severe SARS-CoV-2 pneumonia.

Methods: Bronchoscopic BAL fluid samples from all patients with SARS-CoV-2 pneumonia requiring mechanical ventilation were analyzed using quantitative cultures and a multiplex PCR panel. Actual antibiotic use was compared with guideline-recommended therapy.

Measurements and Main Results: We analyzed 386 BAL samples from 179 patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. Bacterial superinfection within 48 hours of intubation was detected in 21% of patients. Seventy-two patients (44.4%) developed at least one VAP episode (VAP incidence rate = 45.2/1,000 ventilator days); 15 (20.8%) initial VAPs were caused by difficult-to-treat pathogens. The clinical criteria did not distinguish between patients with or without bacterial superinfection. BAL-based management was associated with significantly reduced antibiotic use compared with guideline recommendations.

Conclusions: In patients with SARS-CoV-2 pneumonia requiring mechanical ventilation, bacterial superinfection at the time of intubation occurs in <25% of patients. Guideline-based empirical antibiotic management at the time of intubation results in antibiotic overuse. Bacterial VAP developed in 44% of patients and could not be accurately identified in the absence of microbiologic analysis of BAL fluid.

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.

A Multi-Point Surveillance for Antimicrobial Resistance Profiles among Clinical Isolates of Gram-Negative Bacteria Recovered from Major Ha'il Hospitals, Saudi Arabia

The devastating nosocomial resistance is an on-going global concern. Surveillance of resistance is crucial for efficient patient care. This study was aimed to conduct a surveillance in four major Ha'il Hospitals from September to December 2020. Using a multipoint program, records of 621 non-duplicate Gram-negative cultures were tested across 21 drugs belonging to different categories. Major species were Klebsiella pneumoniae (n = 187, 30%), E. coli (n = 151, 24.5%), Pseudomonas aeruginosa, (n = 84, 13.6%), Acinetobacter baumannii (n = 82, 13.3%), and Proteus mirabilis (n = 46, 7%). Based on recent resistance classifications, A. baumanni, P. aeruginosa, and enteric bacteria were defined as pan-resistant, extremely resistant, and multi-drug resistant, respectively. A. baumannii (35%) and K. pneumoniae (23%) dominated among coinfections in SARS-CoV2 patients. The "other Gram-negative bacteria" (n = 77, 12.5%) from diverse sources showed unique species-specific resistance patterns, while sharing a common Gram-negative resistance profile. Among these, Providencia stuartii was reported for the first time in Ha'il. In addition, specimen source, age, and gender differences played significant roles in susceptibility. Overall infection rates were 30% in ICU, 17.5% in medical wards, and 13.5% in COVID-19 zones, mostly in male (59%) senior (54%) patients. In ICU, infections were caused by P. mirabilis (52%), A. baumannii (49%), P. aeruginosa (41%), K. pneumoniae (24%), and E.&nbsp;coli (21%), and most of the respiratory infections were caused by carbapenem-resistant A. baumannii and K. pneumoniae and UTI by K. pneumoniae and E.&nbsp;coli. While impressive IC, hospital performances, and alternative treatment options still exist, the spread of resistant Gram-negative bacteria is concerning especially in geriatric patients. The high selective SARS-CoV2 coinfection by A. baumannii and K. pneumoniae, unlike the low global rates, warrants further vertical studies. Attributes of resistances are multifactorial in Saudi Arabia because of its global partnership as the largest economic and pilgrimage hub with close social and cultural ties in the region, especially during conflicts and political unrests. However, introduction of advanced inter-laboratory networks for genome-based surveillances is expected to reduce nosocomial resistances.

Trends of central line-associated bloodstream infections in the intensive care unit in the Kingdom of Bahrain: Four years’ experience

BACKGROUND

The central venous line is an essential component in monitoring and managing critically ill patients. However, it poses patients with increased risks of severe infections with a higher probability of morbidity and mortality.

AIM

To define the trends of the rates of central line-associated bloodstream infections (CLABSI) over four years, its predicted risk factors, aetiology, and the antimicrobial susceptibility of the isolated pathogens.

METHODS

The study was a prospective case-control study, performed according to the guidelines of the Center for Disease Control surveillance methodology for CLABSI in patients admitted to the adult intensive care unit (ICU) and auditing the implementation of its prevention bundle.

RESULTS

Thirty-four CLABSI identified over the study period, giving an average CLABSI rate of 3.2/1000 central line days. The infection's time trend displayed significant reductions over time concomitantly with the CLABSI prevention bundle's reinforcement from 4.7/1000 central line days at the beginning of 2016 to 1.4/1000 central line days by 2018. The most frequently identified pathogens causing CLABSI in our ICU were gram-negative organisms (59%). The most common offending organisms were Acinetobacter, Enterococcus, and Staphylococcus epidermidis, each of them accounted for 5 cases (15%). Multidrug-resistant organisms contributed to 56% of CLABSI. Its rate was higher when using femoral access and longer hospitalisation duration, especially in the ICU. Insertion of the central line in the non-ICU setting was another identified risk factor.

CONCLUSION

Implementing the prevention bundles reduced CLABSI significantly in our ICU. Implementing the CLABSI prevention bundle is crucial to maintain a substantial reduction in the CLABSI rate in the ICU setting.

The Influence of Cesarean Section on the Composition and Development of Gut Microbiota During the First 3 Months of Life

The intestinal microbiota has emerged as a critical regulator of growth and development in the early postnatal period of life. Cesarean section (CS) delivery is one of the strongest disrupting factors of the normal colonization process and has been reported as a risk factor for disorders in later life. In this study, we dynamically and longitudinally evaluated the impact of CS on the initial colonization pattern and development of gut microbiota by 16 healthy Chinese infants with fecal samples collected at 9 time points (day 5, day 8, day 11, week 2, week 4, week 6, week 7, month 2, and month 3) during the first 3 months of life. The V3–V4 regions of 16S rRNA gene were analyzed by Illumina sequencing. In comparison with vaginally delivered (VD) infants, infants born by CS showed decreased relative abundance of Bacteroides and Parabacteroides and enrichment of Clostridium_sensu_stricto_1, Enterococcus, Klebsiella, Clostridioides, and Veillonella. Most interestingly, Firmicutes/Bacteroidetes ratio was found to be significantly higher in the CS group than in the VD group from day 5 until month 3. Besides, the results of microbial functions showed that the VD group harbored significantly higher levels of functional genes in vitamin B6 metabolism at day 5, day 8, week 2, week 4, week 6, week 7, month 2, and month 3 and taurine and hypotaurine metabolism at day 5, while the phosphotransferase system and starch and sucrose metabolism involved functional genes were plentiful in the CS group at day 11, week 2, week 4, week 6, week 7, and month 2 and at week 2, week 7, and month 2, respectively. Our results establish a new evidence that CS affected the composition and development of gut microbiota in the first 3 months and provide a novel insight into strategies for CS-related disorders in later life.

Antibacterial and antibiofilm activities of silver-decorated zinc ferrite nanoparticles synthesized by a gamma irradiation-coupled sol-gel method against some pathogenic bacteria from medical operating room surfaces

This work aimed at the gamma irradiation-assisted synthesis of silver (Ag)-decorated ZnFe2O4 (ZFO) ferrite nanoparticles (NPs), which were tested for their antibacterial and antibiofilm activities against some pathogenic bacteria from medical operating room surfaces. The prepared Ag-decorated ZFO NPs were characterized via XRD, SEM, EDX, elemental mapping, and FTIR analysis. The antibacterial potential was tested as ZOI and MIC, while antibiofilm activity was estimated by the tube method. The growth curve assay, the effect of UV on the antimicrobial activity, and cell membrane leakage were evaluated, and the antibacterial reaction mechanism was investigated by SEM/EDX analysis. The XRD and FTIR results confirmed the successful preparation of Ag-decorated ZFO NPs. Antibacterial results revealed that the most potent decorated sample was Ag0.75@ZFO NPs, recording the most significant inhibition zone against Staphylococcus vitulinus (24.67 ± 0.577 mm) and low MIC (0.097 μg mL-1) against S. vitulinus. The antibiofilm activity of Ag0.75@ZFO NPs was the highest, recorded as 97.3% for S. aureus and 95.25% for Enterococcus columbae. In the case of UV exposure, bacterial growth reached the lowest grade. Finally, it was seen that the amount of cellular protein released from bacterial cells is directly proportional to the concentration of Ag0.75@ZFO NPs, which clearly explains the formation of pits in the cell membrane. The synthesized nanocomposites may find an application after mixing with operating room paints to reduce the harmful effect of pathogenic microbes and, therefore, eliminate bacterial contamination.

A scoping review of registry captured indicators for evaluating quality of critical care in ICU

BACKGROUND

Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation.

METHOD

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance.

RESULTS

The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).

CONCLUSIONS

Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.