Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC). Epidemiol Infect. 2013;141:2483-2491. [PMID: 23477492 DOI: 10.1017/s0950268813000381]

Use of nursing care bundles for the prevention of ventilator-associated pneumonia in low-middle income countries: A scoping review

BACKGROUND

Ventilator-associated pneumonia (VAP) is a significant concern in low-middle-income countries (LMICs), where the burden of hospital-acquired infections is high, and resources are low. Evidence-based guidelines exist for preventing VAP; however, these guidelines may not be adequately utilized in intensive care units of LMICs.

AIM

This scoping review examined the literature regarding the use of nursing care bundles for VAP prevention in LMICs, to understand the knowledge, practice and compliance of nurses to these guidelines, as well as the barriers preventing the implementation of these guidelines.

STUDY DESIGN

The review was conducted using Arksey and O'Malley's (2005) five-stage framework and the PRISMA-ScR guidelines guided reporting. Searches were performed across six databases: CINAHL, Medline, Embase, Global Health, Scopus and Cochrane, resulting in 401 studies.

RESULTS

After screening all studies against the eligibility criteria, 21 studies were included in the data extraction stage of the review. Across the studies, the knowledge and compliance of nurses regarding VAP prevention were reported as low to moderate. Several factors, ranging from insufficient knowledge to a lack of adequate guidelines for VAP management, served as contributing factors. Multiple barriers prevented nurses from adhering to VAP guidelines effectively, including a lack of audit/surveillance, absence of infection prevention and control (IPC) teams and inadequate training opportunities.

CONCLUSIONS

This review highlights the need for adequate quality improvement procedures and more efforts to conduct and translate research into practice in intensive care units in LMIC.

RELEVANCE TO CLINICAL PRACTICE

IPC practices are vital to protect vulnerable patients in intensive care units from developing infections and complications that worsen their prognosis. Critical care nurses should be trained and reinforced to practice effective bundle care to prevent VAP.

Interventions for improving critical care in low- and middle-income countries: a systematic review

PURPOSE

To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs).

METHODS

MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions' effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research.

RESULTS

78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows.

CONCLUSIONS

The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.

Antimicrobial Solutions for Endotracheal Tubes in Prevention of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia is one of the most frequently encountered hospital infections and is an essential issue in the healthcare field. It is usually linked to a high mortality rate and prolonged hospitalization time. There is a lack of treatment, so alternative solutions must be continuously sought. The endotracheal tube is an indwelling device that is a significant culprit for ventilator-associated pneumonia because its surface can be colonized by different types of pathogens, which generate a multispecies biofilm. In the paper, we discuss the definition of ventilator-associated pneumonia, the economic burdens, and its outcomes. Then, we present the latest technological solutions for endotracheal tube surfaces, such as active antimicrobial coatings, passive coatings, and combinatorial methods, with examples from the literature. We end our analysis by identifying the gaps existing in the present research and investigating future possibilities that can decrease ventilator-associated pneumonia cases and improve patient comfort during treatment.

The Impact of Care Bundles on Ventilator-Associated Pneumonia (VAP) Prevention in Adult ICUs: A Systematic Review

Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We aimed to identify the combined interventions that have been used to by ICUs worldwide from the implementation of "Institute for Healthcare Improvement Ventilator Bundle", i.e., from December 2004. A search was performed on the PubMed, Scopus and Science Direct databases. Finally, 38 studies met our inclusion criteria. The most common interventions monitored in the care bundles were sedation and weaning protocols, semi-recumbent positioning, oral and hand hygiene, peptic ulcer disease and deep venus thrombosis prophylaxis, subglottic suctioning, and cuff pressure control. Head-of-bed elevation was implemented by almost all studies, followed by oral hygiene, which was the second extensively used intervention. Four studies indicated a low VAP reduction, while 22 studies found an over 36% VAP decline, and in ten of them, the decrease was over 65%. Four of these studies indicated zero or nearly zero after intervention VAP rates. The studies with the highest VAP reduction adopted the "IHI Ventilator Bundle" combined with adequate endotracheal tube cuff pressure and subglottic suctioning. Multifaced techniques can lead to VAP reduction at a great extent. Multidisciplinary measures combined with long-lasting education programs and measurement of bundle's compliance should be the gold standard combination.

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.

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.

Infections and antimicrobial resistance in intensive care units in lower-middle income countries: a scoping review

Background

Intensive care units (ICUs) in lower-middle income countries (LMICs) are suspected to constitute a special risk for patients of acquiring infection due to multiple antibiotic resistant organisms. The aim of this systematic scoping review was to present the data published on ICU-acquired infections and on antimicrobial resistance observed in ICUs in LMICs over a 13-year period. A systematic scoping review was conducted according to the PRISMA extension guideline for scoping reviews and registered in the Open Science Framework.

Main body of the abstract

Articles were sought that reported on ICU-acquired infection in LMICs between 2005 and 2018. Two reviewers parallelly reviewed 1961 titles and abstracts retrieved from five data banks, found 274 eligible and finally included 51. Most LMICs had not produced reports in Q1 or Q2 journals in this period, constituting a large gap in knowledge. However, from the reported evidence it is clear that the rate of ICU-acquired infections was comparable, albeit approximately 10% higher, in LMICs compared to high income countries. In contrast, ICU mortality was much higher in LMICs (33.6%) than in high income countries (< 20%). Multidrug-resistant Gram-negative species, especially Acinetobacter baumannii and Pseudomonas aeruginosa, and Klebsiella pneumoniae played a much more dominant role in LMIC ICUs than in those in high income countries. However, interventions to improve this situation have been shown to be feasible and effective, even cost-effective.

Conclusions

Compared to high income countries the burden of ICU-acquired infection is higher in LMICs, as is the level of antimicrobial resistance; the pathogen distribution is also different. However, there is evidence that interventions are feasible and may be quite effective in these settings.

Protocol Registration The protocol was registered with Open Science Framework (https://osf.io/c8vjk)

Microbiology of Ventilator-associated Pneumonia in a Tertiary Care Cancer Hospital

Background

Ventilator-associated pneumonia (VAP) is an important cause of healthcare-associated infections, resulting in prolonged hospitalization with increased morbidity and mortality. Knowledge of predominant local pathogens and their antimicrobial susceptibility patterns helps in selection of appropriate initial antibiotic therapy in these critical cases.

Aim and objective

The aim and objective of this study is to characterize the microbiology and antimicrobial susceptibility patterns of VAP isolates in a tertiary cancer center.

Materials and methods

This is a 4-year qualitative observational study carried out at a tertiary care cancer hospital in Mumbai. All nondirect bronchoalveolar lavage specimens from patients with a clinical suspicion of VAP sent from the critical care unit to the department of microbiology were processed as per standard laboratory procedures. All isolates were identified to species level and an antimicrobial susceptibility testing was performed by the Kirby–Bauer disk diffusion method and/or the VITEK 2 automated identification and susceptibility system, according to Clinical and Laboratory Standards Institute guidelines.

Results

The study comprised 1,074 patients: 710 (66.10%) men and 364 (33.90%) women. A total of 827 bacterial isolates were obtained with 780 (94.32%) gram-negative organisms and 47 (5.68%) gram-positive organisms; of which Acinetobacter baumannii (38.7%), Pseudomonas aeruginosa (17.5%), and Klebsiella pneumoniae (16.6%) were the commonest. Of gram-negative bacilli, multidrug-resistant organisms constituted 87.50% and were susceptible to colistin.

Conclusions

VAP is associated with pathogens, such as A. baumannii, P. aeruginosa, and K. pneumoniae in our setting. High rates of resistance to aminoglycosides, β-lactam-β-lactamase inhibitor combinations, and carbapenems were noted.

How to cite this article

Sangale A, Bhat V, Kelkar R, Biswas S. Microbiology of Ventilator-associated Pneumonia in a Tertiary Care Cancer Hospital. Indian J Crit Care Med 2021;25(4):421–428.

Device associated -health care associated infections monitoring, prevention and cost assessment at intensive care unit of University Hospital in Poland (2015-2017)

BACKGROUND

Device-associated health care-associated infections (DA-HAIs) in intensive care unit (ICU) patients constitute a major therapeutic issue complicating the regular hospitalisation process and having influence on patients' condition, length of hospitalisation, mortality and therapy cost.

METHODS

The study involved all patients treated > 48 h at ICU of the Medical University Teaching Hospital (Poland) from 1.01.2015 to 31.12.2017. The study showed the surveillance and prevention of DA-HAIs on International Nosocomial Infection Control Consortium (INICC) Surveillance Online System (ISOS) 3 online platform according to methodology of the INICC multidimensional approach (IMA).

RESULTS

During study period 252 HAIs were found in 1353 (549F/804M) patients and 14,700 patient-days of hospitalisation. The crude infections rate and incidence density of DA-HAIs was 18.69% and 17.49 ± 2.56 /1000 patient-days. Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI) and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 12.63 ± 1.49, 1.83 ± 0.65 and 6.5 ± 1.2, respectively. VAP(137) constituted 54.4% of HAIs, whereas CA-UTI(91) 36%, CLA-BSI(24) 9.6%.The most common pathogens in VAP and CA-UTI was multidrug-resistant (MDR) Acinetobacter baumannii (57 and 31%), and methicillin-resistant Staphylococcus epidermidis (MRSE) in CLA-BSI (45%). MDR Gram negative bacteria (GNB) 159 were responsible for 63.09% of HAIs. The length of hospitalisation of patients with a single DA-HAI at ICU was 21(14-33) days, while without infections it was 6.0 (3-11) days; p = 0.0001. The mortality rates in the hospital-acquired infection group and no infection group were 26.1% vs 26.9%; p = 0.838; OR 0.9633;95% CI (0.6733-1.3782). Extra cost of therapy caused by one ICU acquired HAI was US$ 11,475/Euro 10,035. Hand hygiene standards compliance rate was 64.7%, while VAP, CLA-BSI bundles compliance ranges were 96.2-76.8 and 29-100, respectively.

CONCLUSIONS

DA-HAIs was diagnosed at nearly 1/5 of patients. They were more frequent than in European Centre Disease Control report (except for CLA-BSI), more frequent than the USA CDC report, yet less frequent than in limited-resource countries (except for CA-UTI). They prolonged the hospitalisation period at ICU and generated substantial additional costs of treatment with no influence on mortality. The Acinetobacter baumannii MDR infections were the most problematic therapeutic issue. DA-HAIs preventive methods compliance rate needs improvement.

Nosocomial Infections and Ventilator-Associated Pneumonia in Cancer Patients

Nosocomial infections or healthcare-acquired infections are a common cause of increased morbidity and mortality among hospitalized patients. Cancer patients are at an increased risk for these infections due to their immunosuppressed states. Considering these adverse effects on and the socioeconomic burden, efforts should be made to minimize the transmission of these infections and make the hospitals a safer environment. These infection rates can be significantly reduced by the implementing and improving compliance with the “care bundles.”

This chapter will address the common nosocomial infections such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSI), including preventive strategies and care bundles for the same.

Strategies for preventing ventilator-associated pneumonia: an integrative review

ABSTRACT Objective: to identify studies about strategies for prevention of ventilator-associated pneumonia deployed in health services and classify their level of evidence. Method: integrative review of the literature, in 7 databases, which included the following descriptors: Prevention and Control AND Pneumonia Ventilator-Associated AND Intensive Care Units AND Bundle AND Patient Care. Results: twenty-three scientific productions were included. Of the preventive measures identified, 9 (39.1%) correspond from three to five strategies. The most frequent were: 22 (95.6%) lying with head elevated, 19 (82.6%) oral hygiene with chlorhexidine and 14 (60.8%) reduction of sedation whenever possible. Final Consideration: the application of measures based on scientific evidence is proven to be effective when carried out in conjunction, impacting the reduction of the incidence of ventilator-associated pneumonia.

Boas práticas na prevenção de pneumonia associada à ventilação mecânica

Resumo Objetivo: Avaliar a adesão dos profissionais de saúde a um conjunto de boas práticas de prevenção de Pneumonia Associada à Ventilação Mecânica, índice de conformidade às medidas individuais e associação de características clínicas dos pacientes e adesão ao conjunto de boas práticas com a pneumonia. Métodos: Estudo de coorte prospectivo realizado em uma Unidade de Terapia Intensiva de um hospital universitário no período de maio de 2017 a outubro de 2017. A amostra foi composta por pacientes internados no período do estudo, que preencheram os critérios de inclusão, a coleta de dados foi realizada por meio de consulta a prontuários. Resultados: O item com maior adesão foi a avaliação diária da sedação e redução sempre que possível, 81 (91,0%), seguido da troca do circuito a cada 7 dias, 76 (82,6). A manutenção da pressão do cuff entre 20 e 30 mm H2O foi o item com menor adesão 22 (23,9%). A adesão ao conjunto completo apresentou conformidade em 20 (21,7%) das oportunidades. O estudo mostrou que quanto maior a adesão às medidas de boas práticas, menor é o risco de Pneumonia Associada à Ventilação Mecânica, porém não foi um dado estatisticamente significante. Os pacientes cirúrgicos e em uso de ventilação mecânica apresentaram maior risco de desenvolver PAV (p= 0,05). Conclusão: A Pneumonia Associada à Ventilação Mecânica pode trazer grave repercussão para o paciente, a aplicação de medidas com embasamento científico é fundamental, a fim de se prevenir a ocorrência deste agravo, que é uma das mais frequentes infecções relacionadas à assistência à saúde dentro das Unidades de Terapia Intensiva brasileiras.

Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on rates of ventilator-associated pneumonia in intensive care units of two hospitals in Kuwait

OBJECTIVE

To analyse the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in three intensive care units (ICUs) from two hospitals in Kuwait City from January 2014 to March 2015.

DESIGN

A prospective, before-after study on 2507 adult ICU patients. During baseline, we performed outcome surveillance of VAP applying CDC/NHSN definitions. During intervention, we implemented the IMA through the INICC Surveillance Online System (ISOS), which included: (1) a bundle of infection prevention interventions; (2) education; (3) outcome surveillance; and (4) feedback on VAP rates and consequences. Logistic regression analysis was performed to estimate the effect of the intervention on VAP, controlling for potential bias.

RESULTS

During baseline, 1990 mechanical ventilator (MV)-days and 14 VAPs were recorded, accounting for 7.0 VAPs per 1000 MV-days. During intervention, 9786 MV-days and 35 VAPs were recorded, accounting for 3.0 VAPs per 1000 MV-days. The VAP rate was reduced by 57.1% (incidence-density ratio = 0.51; 95% CI = 0.28-0.93; p = 0.042). Logistic regression showed a significant reduction in VAP rate during the intervention phase (OR = 0.39, 95% CI = 0.18-0.83), with 61% effectiveness.

CONCLUSIONS

Implementing IMA through ISOS was associated with a significant reduction in the VAP rate in Kuwait ICUs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advances in Pediatric Critical Care Research in India

Over last 2 decades, there has been a significant progress made in the field of pediatric critical care in India. There has been complementary and parallel growth in the pediatric critical care services in India and the number of pediatric critical care providers who are either formally trained in India or who have returned to India after their formal training abroad. The pediatric critical care community in India has recognized obvious differences in profiles of critical illnesses and patients between Indian subcontinent and the West. Therefore there is a growing interest in generating scientific evidence through local research which would be applicable to critically ill children in Indian subcontinent. This article focuses on advances in pediatric critical care research in India and its future directions.

Strengthening infection prevention and control and systematic surveillance of healthcare associated infections in India

Establishing and expanding government led networks to strengthen infection prevention and control and healthcare associated infection surveillance are essential to effectively tackle antimicrobial resistance. Soumya Swaminathan and colleagues discuss the progress in India

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.

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.

Ventilator-associated pneumonia: A persistent healthcare problem in Indian Intensive Care Units!

Background:

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection acquired by patients in the Intensive Care Unit (ICU). However, there are scarce clinical data, particularly from Indian ICUs on the occurrence of this infection.

Aims:

To collect data on the incidence, microbiological profile, and outcomes of patients with VAP.

Settings and Design:

Tertiary level, medical-surgical ICU; prospective, observational study.

Subjects and Methods:

All patients who were mechanically ventilated for >48 h in the ICU during the study were enrolled. VAP was diagnosed according to the Centre for Disease Control (CDC) criteria.

Results:

A total of 95 (38%) patients developed VAP infections, an incidence of 40.1 VAP infections/1000 mechanical ventilation days. These were predominantly caused by Gram-negative organisms, especially the Acinetobacter species (58 isolates, 53.2%). Many of the VAP-causing isolates (27.3%) demonstrated multidrug resistance. Patients with VAP infections experienced a significantly longer ICU stay (13 days [Interquartile Range (IQ) range = 10–21] vs. 6 days [IQ = 4–8], P < 0.0001) and total hospital stay (21 days [IQ = 14–33] vs. 11 days [IQ = 6–18], P < 0.0001). While the overall mortality rates were similar between patients with or without VAP infections, (68.4% vs. 61.3%, P = 0.200), on subgroup analysis, elderly patients (>60 years) and those with higher Acute Physiology and Chronic Health Evaluation II scores at admission had significantly greater mortality rates if they acquired a VAP infection (P = 0.010).

Conclusions:

VAP continues to be a major threat to patients who are admitted for mechanical ventilation into the critical care unit, emphasizing the urgent need for infection control measures.

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.

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.

Device-Associated Infection Rates in 20 Cities of India, Data Summary for 2004–2013: Findings of the International Nosocomial Infection Control Consortium

OBJECTIVE

To report the International Nosocomial Infection Control Consortium surveillance data from 40 hospitals (20 cities) in India 2004–2013.

METHODS

Surveillance using US National Healthcare Safety Network’s criteria and definitions, and International Nosocomial Infection Control Consortium methodology.

RESULTS

We collected data from 236,700 ICU patients for 970,713 bed-days

Pooled device-associated healthcare-associated infection rates for adult and pediatric ICUs were 5.1 central line–associated bloodstream infections (CLABSIs)/1,000 central line–days, 9.4 cases of ventilator-associated pneumonia (VAPs)/1,000 mechanical ventilator–days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter–days

In neonatal ICUs (NICUs) pooled rates were 36.2 CLABSIs/1,000 central line–days and 1.9 VAPs/1,000 mechanical ventilator–days

Extra length of stay in adult and pediatric ICUs was 9.5 for CLABSI, 9.1 for VAP, and 10.0 for catheter-associated urinary tract infections. Extra length of stay in NICUs was 14.7 for CLABSI and 38.7 for VAP

Crude extra mortality was 16.3% for CLABSI, 22.7% for VAP, and 6.6% for catheter-associated urinary tract infections in adult and pediatric ICUs, and 1.2% for CLABSI and 8.3% for VAP in NICUs

Pooled device use ratios were 0.21 for mechanical ventilator, 0.39 for central line, and 0.53 for urinary catheter in adult and pediatric ICUs; and 0.07 for mechanical ventilator and 0.06 for central line in NICUs.

CONCLUSIONS

Despite a lower device use ratio in our ICUs, our device-associated healthcare-associated infection rates are higher than National Healthcare Safety Network, but lower than International Nosocomial Infection Control Consortium Report.

Infect. Control Hosp. Epidemiol. 2016;37(2):172–181

Ventilator-associated events prevention, learning lessons from the past: A systematic review

BACKGROUND

Preventing Ventilator-associated events (VAE) is a major challenge. Strictly monitoring for ventilator-associated pneumonia (VAP) is not sufficient to ensure positive outcomes. Therefore, the surveillance definition was updated and a change to the broader VAE was advocated.

OBJECTIVE

This paper summarizes the scientific efforts assessing VAP preventive bundles and the recent transition in surveillance methods.

METHODS

We conducted a systematic review to identify lessons from past clinical studies assessing VAP prevention bundles. We then performed a thorough literature review on the recent VAE surveillance algorithm, highlighting its advantages and limitations.

CONCLUSION

VAP prevention bundles have historically proven their efficacy and the introduction of the new VAE definition aimed at refining and objectivizing surveillance methods. Randomized controlled trials remain vital to determine the effect of VAE prevention on patient outcomes. We recommend expanding beyond limited VAP prevention strategies towards VAE prevention bundles.

Incidence and attributable costs of ventilator-associated pneumonia (VAP) in a tertiary-level intensive care unit (ICU) in northern India

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection acquired by patients in the intensive care unit (ICU). However, the economic effects of such infections remain unclear particularly in developing countries.

METHODS

Patients who were mechanically ventilated for more than 48 h in the ICU were studied for the occurrence of VAP. Total drug costs and hospital costs were noted, and attributable costs were calculated after adjusting for potential confounders.

RESULTS

Ninety-five (38%) patients who were ventilated for more than 48 h developed VAP, which resulted in an incidence of 40.1 VAP infections/1000 mechanical ventilation days. The patients with VAP experienced significantly longer hospital stay [21 (IQ = 14-33) days versus 11 (IQ = 6-18) days, P < 0.0001)] and incurred greater hospital costs [USD $6250.92 (IQ = 3525.39-9667.57) versus $2598.84 (IQ = 1644.33-4477.65), P < 0.0001]. Multiple regression analysis revealed that the cost-driving factors in our study population were the occurrence of VAP infections (P < 0.0001) and the duration of hospital stay (P < 0.0001). The attributable cost of VAP infection was calculated to be USD $5200 (95% CI = 3245-7152).

CONCLUSION

We conclude that VAP significantly increases the costs of treatment in low-income developing countries. This study highlights the need to implement urgent measures to reduce the incidence of this disease in ICUs.

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

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.

Prevention of ventilator-associated pneumonia in the intensive care unit: a review of the clinically relevant recent advancements

Ventilator-associated pneumonia (VAP) is one of the most commonly encountered hospital-acquired infections in intensive care units and is associated with significant morbidity and high costs of care. The pathophysiology, epidemiology, treatment and prevention of VAP have been extensively studied for decades, but a clear prevention strategy has not yet emerged. In this article we will review recent literature pertaining to evidence-based VAP-prevention strategies that have resulted in clinically relevant outcomes. A multidisciplinary strategy for prevention of VAP is recommended. Those interventions that have been shown to have a clinical impact include the following: (i) Non-invasive positive pressure ventilation for able patients, especially in immunocompromised patients, with acute exacerbation of chronic obstructive pulmonary disease or pulmonary oedema, (ii) Sedation and weaning protocols for those patients who do require mechanical ventilation, (iii) Mechanical ventilation protocols including head of bed elevation above 30 degrees and oral care, and (iv) Removal of subglottic secretions. Other interventions, such as selective digestive tract decontamination, selective oropharyngeal decontamination and antimicrobial-coated endotracheal tubes, have been tested in different studies. However, the evidence for the efficacy of these measures to reduce VAP rates is not strong enough to recommend their use in clinical practice. In numerous studies, the implementation of VAP prevention bundles to clinical practice was associated with a significant reduction in VAP rates. Future research that considers clinical outcomes as primary endpoints will hopefully result in more detailed prevention strategies.