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

Examining the impact of a 9-component bundle and the INICC multidimensional approach on catheter-associated urinary tract infection rates in 32 countries across Asia, Eastern Europe, Latin America, and the Middle East

BACKGROUND

Catheter-Associated Urinary Tract Infections (CAUTIs) frequently occur in the intensive care unit (ICU) and are correlated with a significant burden.

METHODS

We implemented a strategy involving a 9-element bundle, education, surveillance of CAUTI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CAUTI rates and performance feedback. This was executed in 299 ICUs across 32 low- and middle-income countries. The dependent variable was CAUTI per 1,000 UC days, assessed at baseline and throughout the intervention, in the second month, third month, 4 to 15 months, 16 to 27 months, and 28 to 39 months. Comparisons were made using a 2-sample t test, and the exposure-outcome relationship was explored using a generalized linear mixed model with a Poisson distribution.

RESULTS

Over the course of 978,364 patient days, 150,258 patients utilized 652,053 UC-days. The rates of CAUTI per 1,000 UC days were measured. The rates decreased from 14.89 during the baseline period to 5.51 in the second month (risk ratio [RR] = 0.37; 95% confidence interval [CI] = 0.34-0.39; P < .001), 3.79 in the third month (RR = 0.25; 95% CI = 0.23-0.28; P < .001), 2.98 in the 4 to 15 months (RR = 0.21; 95% CI = 0.18-0.22; P < .001), 1.86 in the 16 to 27 months (RR = 0.12; 95% CI = 0.11-0.14; P < .001), and 1.71 in the 28 to 39 months (RR = 0.11; 95% CI = 0.09-0.13; P < .001).

CONCLUSIONS

Our intervention, without substantial costs or additional staffing, achieved an 89% reduction in CAUTI incidence in ICUs across 32 countries, demonstrating feasibility in ICUs of low- and middle-income countries.

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.

Device-Associated Nosocomial Infections in Intensive Care Units at Al-Ahsa Hospitals, Saudi Arabia

Introduction Patients admitted to intensive care units (ICU), especially those with devices used to support their condition, are at a higher risk of getting healthcare-associated infections (HAIs). The aim of the present study was to analyze the surveillance data and assess the device-associated infection (DAI) rates such as central line-associated blood-stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP) and ventilator-associated event (VAE) in ICUs of the Ministry of Health (MoH) hospitals in Al-Ahsa region. Methodology The study was conducted retrospectively using the surveillance data of governmental hospitals' intensive care units in the Al-Ahsa region. The surveillance data was collected from 10 ICUs at six MoH hospitals in the Al-Ahsa region during the year 2022. The data from the participating hospitals was entered into the Health Electronic Surveillance Network (HESN) plus program by trained infection prevention control practitioners of the respective hospitals. Results An overall CLABSI rate of 4.29 per 1000 central line days was reported during the study period. The CAUTI rate was 0.55 with a range from 0 to 1.29 cases per 1000 urinary catheter days. VAP rate ranged from 0.33 to 2.21 cases per 1000 ventilator days (average of 1.17). The study reported VAE only for the adult medical-surgical ICU (3.36 per 1000 ventilator days). Conclusion The present study revealed that the most common DAIs in the Al-Ahsa region are CLABSI and CAUTI. DAI rates generated from this study may be used as benchmarks for regional hospitals. An educational program regarding the prevention and control of DAIs targeting all healthcare workers, especially ICU staff, has to be done in the Al-Ahsa region.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections in ICUs of 8 Latin American countries

BACKGROUND

Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors in Latin-America.

METHODS

From January 1, 2014 to February 10, 2022, we conducted a multinational multicenter prospective cohort study in 58 ICUs of 34 hospitals in 21 cities in 8 Latin American countries (Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama). We applied multiple-logistic regression. Outcomes are shown as adjusted-odds ratios (aOR).

RESULTS

About 29,385 patients were hospitalized during 92,956 days, acquired 400 CLABSIs, and pooled CLABSI rate was 4.30 CLABSIs per 1,000 CL-days. We analyzed following 10 variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization (DU) ratio, CL-type, tracheostomy use, hospitalization type, intensive care unit (ICU) type, and facility ownership, Following variables were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 3% daily (aOR=1.03;95%CI=1.02-1.04; P < .0001); number of CL-days before CLABSI acquisition, rising risk 4% per CL-day (aOR=1.04;95%CI=1.03-1.05; P < .0001); publicly-owned facility (aOR=2.33;95%CI=1.79-3.02; P < .0001). ICU with highest risk was medical-surgical (aOR=2.61;95%CI=1.41-4.81; P < .0001). CL with the highest risk were femoral (aOR=2.71;95%CI=1.61-4.55; P < .0001), and internal-jugular (aOR=2.62;95%CI=1.82-3.79; P < .0001). PICC (aOR=1.25;95%CI=0.63-2.51; P = .52) was not associated with CLABSI risk.

CONCLUSIONS

Based on these findings it is suggested to focus on reducing LOS, CL-days, using PICC instead of femoral or internal-jugular; and implementing evidence-based CLABSI prevention recommendations.

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.

Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.

Incidence of Device Associated-Healthcare Associated Infections from a Neurosurgical Intensive Care Unit of a Tertiary Care Center: A Retrospective Analysis

Background:

Deviceassociated infections (DAIs) increase the morbidity and mortality in the intensive care unit (ICU). Studies from the neurosurgical ICU in developing countries are sparse.

Aims:

The aim of this study was to assess the incidence of device-associated healthcare associated infections, pathogens isolated, antibiotic resistance, and mortality in neurosurgical ICU.

Settings and Design:

A retrospective study was conducted in the neurosurgical ICU of a tertiary care center

Materials and Methods:

This study was done by analyzing data of patients admitted in a neurosurgical ICU with one or more devices during the period from January 2011 to July 2017.

Statistical Analysis:

Quantitative variables were expressed as mean and standard deviation; qualitative variables were expressed as frequency and percentage.

Results:

During this period, 6788 patients with devices were admitted in the ICU, and 316 patients developed DAI. Two hundred and forty-eight patients had catheter-associated urinary tract infection (CAUTI), 78 had ventilator-associated pneumonia (VAP), and 53 had central line-associated bloodstream infection (CLABSI). The incidence rate for CAUTI was 17.83, VAP – 16.83, and CLABSI – 4.39 per 1000 device days. The device utilization ratio was highest for urinary catheter – 0.76, followed by central line – 0.66 and ventilator – 0.25. Predominant pathogens were Klebsiella – 90, Escherichia coli – 77, Pseudomonas – 40, Candida – 39, Acinetobacter – 30, and Enterobacter – 21. Carbapenem resistance was found in Acinetobacter (73.4%), Pseudomonas (45%), and Enterobacter (38%). S. aureus isolated in six cases; four being MRSA (66.7%). Multidrug resistance was found in Acinetobacter (80%), Pseudomonas (60%), Enterobacter (52.3%), Klebsiella (42.3%), and E. coli (33.7%). No colistin resistant Gram negative bacilli or vancomycin resistant enterococci were isolated. During this period 124 patients with DAI died, of which 52 patients had sepsis. The crude mortality rate was 1.83%.

Conclusion:

The DAI with the highest incidence was CAUTI, followed by VAP and CLABSI. With the implementation of insertion bundles and adherence to aseptic precautions, the DAI rate had come down.

[Compliance with hand-hygiene practice in the General Reference Hospitals of the city of Kisangani, Democratic Republic of the Congo]

INTRODUCTION

the purpose of this study was to assess the compliance with hand-hygiene practice of health-care workers in the General Reference Hospitals (GRH) of the city of Kisangani and to identify factors contributing to it.

METHODS

we conducted a cross-sectional study in the Maternity, Surgery, Pediatric and Emergency Departments at four GRH of the city of Kisangani over the period 13th-20th June 2018. One hundred and twenty professionals recruited from among doctors, nurses, laboratory technicians and attendants were asked to complete a self-administered questionnaire to assess their level of knowledge and a grid indicating the compliance with hand-hygiene practice in 44 health professionals (1920 opportunities).

RESULTS

the rate of overall compliance with hand-hygiene practice was 39% [CI95 0.37; 0.41]; friction with hydroalcoholic solution was much less frequent (5%); cleaners and physicians had higher compliance rates (49% and 44% respectively) than nurses (33%). Approximately one third of professionals were aware of the indications for hand-hygiene according to the WHO; 37% of health professionals declared that they had followed a on-the-job training on hand-hygiene and 36% knew the importance of hand-hygiene in the healthcare environment. The gap in knowledge was not significant between the occupational categories studied (p >0.05).

CONCLUSION

this study and the results obtained from it allowed us to conclude that the level of compliance to precautions standards including hand hygiene by healthcare professionals is insufficient. It is therefore necessary to strengthen the compliance with hand-hygiene practices through training and awareness programs for healthcare professionals, the supply of hygiene products and the awareness of healthcare providers.

Health care-associated infection surveillance system in Iran: Reporting and accuracy

BACKGROUND

Valid data are a crucial aspect of infection prevention and control programs. The aim of this study was to examine the accuracy of routine reporting in the Iranian Nosocomial Infection Surveillance System in intensive care units.

METHODS

A blinded retrospective review of general intensive care unit medical records was performed with a standard case-finding form. Infection control nurses (ICNs) were also interviewed to explore possible reasons for differences.

RESULTS

The results of 951 events in 856 medical records were assessed. Sensitivity, specificity, and positive and negative predictive values of routine surveillance were 27.5%, 97.2%, 69%, and 85.3%, respectively. The results indicate 82.2%, 68.4%, 62.7%, and 57.3% under-reporting of surgical site infections, urinary tract infections, bloodstream infections, and pneumonia, respectively. Over-reporting of approximately 8%-15% was detected in 4 types of health care-associated infections (HAIs). Misinterpretation of HAI definition, high ICN workload, and inactivity of infection control link nurses were the main causes of inaccurate reporting.

CONCLUSIONS

Under and over-reporting of HAIs are main challenges of HAIs reporting in Iran. Developing guidelines, empowering ICNs through specialized training and activating infection control link nurses are necessary to achieve more accurate data in the Iranian Nosocomial Infection Surveillance System.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Risk factors for hospital-acquired infections in teaching hospitals of Amhara regional state, Ethiopia: A matched-case control study

Background

Hospital-acquired infection affects hundreds of millions of people worldwide. It is a major global issue for patient safety. Understanding the potential risk factors is important to appreciate the local context. A matched case control study design, which is the first of its kind in the study region, was undertaken to identify risk factors in teaching hospitals of Amhara regional state, Ethiopia.

Method

A matched case control study design matched with age and hospital type was used. The study was conducted in University of Gondar and Felege-Hiwot medical teaching hospital. Cases were patients who fulfilled the criteria based on CDC definition of hospital-acquired infection and controls were patients admitted to the hospital that stayed for more than 48 hours in the ward in the study period, but who did not develop infection. For one case, four controls were selected. Of 545 patients, 109 were cases and 436 were controls. Conditional logistic regression using STATA 13 was used for data analysis.

Result

The median length of stay for cases and controls was 7 and 8 days, respectively. Patients admitted in wards with the presence of medical waste container in the room had 82% less chance of developing hospital-acquired infection (AOR 0.18; 95% CI, 0.03–0.98). The odds of developing hospital-acquired infection among immune deficient patients were 2.34 times higher than their counterparts (95% CI; 1.17–4.69). Patients received antimicrobials, central vascular catheter and surgery since admission had 8.63, 6.91 and 2.35 higher odds of developing hospital-acquired infection, respectively.

Conclusion

Health providers and mangers should consider the provision and availability of healthcare materials and facilities in all of the ward rooms, follow appropriate safe medical procedures for use of external devices on patients, and give attention to the immunocompromised patients for the prevention and control of hospital-acquired infections.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

World-wide variation in incidence of Acinetobacter associated ventilator associated pneumonia: a meta-regression

Background

Acinetobacter species such as Acinetobacter baumanii are of increasing concern in association with ventilator associated pneumonia (VAP). In the ICU, Acinetobacter infections are known to be subject to seasonal variation but the extent of geographic variation is unclear. The objective here is to define the extent and possible reasons for geographic variation for Acinetobacter associated VAP whether or not these isolates are reported as Acinetobacter baumanii.

Methods

A meta-regression model of VAP associated Acinetobacter incidence within the published literature was undertaken using random effects methods. This model incorporated group level factors such as proportion of trauma admissions, year of publication and reporting practices for Acinetobacter infection.

Results

The search identified 117 studies from seven worldwide regions over 29 years. There is significant variation in Acinetobacter species associated VAP incidence among seven world-wide regions. The highest incidence is amongst reports from the Middle East (mean; 95 % confidence interval; 8.8; 6 · 2–12 · 7 per 1000 mechanical ventilation days) versus that from North American ICU’s (1 · 2; 0 · 8–2 · 1). There is a similar geographic related disparity in incidence among studies reporting specifically as Acinetobacter baumanii. The incidence in ICU’s with a majority of admission being for trauma is >2.5 times that of other ICU’s.

Conclusion

There is greater than fivefold variation in Acinetobacter associated VAP among reports from various geographic regions worldwide. This variation is not explainable by variations in rates of VAP overall, admissions for trauma, publication year or Acinetobacter reporting practices as group level variables.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1921-4) contains supplementary material, which is available to authorized users.

Epidemiology and burden of multidrug-resistant bacterial infection in a developing country

Little is known about the excess mortality caused by multidrug-resistant (MDR) bacterial infection in low- and middle-income countries (LMICs). We retrospectively obtained microbiology laboratory and hospital databases of nine public hospitals in northeast Thailand from 2004 to 2010, and linked these with the national death registry to obtain the 30-day mortality outcome. The 30-day mortality in those with MDR community-acquired bacteraemia, healthcare-associated bacteraemia, and hospital-acquired bacteraemia were 35% (549/1555), 49% (247/500), and 53% (640/1198), respectively. We estimate that 19,122 of 45,209 (43%) deaths in patients with hospital-acquired infection due to MDR bacteria in Thailand in 2010 represented excess mortality caused by MDR. We demonstrate that national statistics on the epidemiology and burden of MDR in LMICs could be improved by integrating information from readily available databases. The prevalence and mortality attributable to MDR in Thailand are high. This is likely to reflect the situation in other LMICs.

DOI:http://dx.doi.org/10.7554/eLife.18082.001

Antimicrobial resistance is a global problem. Each year, an estimated 23,000 deaths in the United States and 25,000 deaths in the European Union are extra deaths caused by bacteria resistant to antibiotics. People in low- and middle-income countries are also using more antibiotics, in part because of rising incomes, lower costs of antibiotics, and a lack of control of antimicrobial usage in the hospitals and over-the-counter sales of the drugs. These factors are thought to be driving the development and spread of bacteria that are resistant to multiple antibiotics in countries such as China, India, Indonesia and Thailand. However, a lack of information makes it difficult to estimate the size of the problem and, then, to track how antimicrobial resistance and multi-drug resistance is changing over time in these and other low- and middle-income countries.

Now, by integrating routinely collected data from a range of databases, Lim, Takahashi et al. estimate that around an extra 19,000 deaths are caused by multi-drug resistant bacteria in Thailand each year. Thailand has a population of about 70 million, and so, per capita, this estimate is about 3 to 5 times larger than those for the United States and European Union (which have a populations of about 300 million and 500 million, respectively). Lim, Takahashi et al. also show that more of the bacteria collected from patients are resistant to multiple antimicrobial drugs and that the burden of antimicrobial resistance in Thailand is worsening over time.

These findings suggest that more studies with a systematic approach need to be done in other low- and middle-income countries, especially in countries where microbiological laboratories are readily available and routinely used. Further work is also needed to identify where resources and attentions are most needed to effectively fight against antimicrobial resistance in low- and middle-income countries.

DOI:http://dx.doi.org/10.7554/eLife.18082.002

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.

Assessing nursing quality in paediatric intensive care units: a cross-sectional study in China

BACKGROUND

Nursing-sensitive indicators are considered effective tools for improving the quality of care in hospitals. However, these have not been used in paediatric intensive care units (PICUs) in China.

AIM

To develop nursing-sensitive indicators for PICUs and to assess the quality of nursing in PICUs in China based on the nursing-sensitive indicators.

DESIGN

Multi-centre, cross-sectional study.

METHODS

Structure, process and outcome indicators were developed and measured from 1 January to 31 March 2014 in seven PICUs in China.

RESULTS

The structure indicators showed that one nurse cared for an average of 2·8 patients in a PICU, and 44% of nurses had a bachelor's degree. The process indicators revealed that hand-washing compliance varied across PICUs, whereas pain management and physical restraint have not been adequately addressed in China. The outcome indicators revealed that the incidence rates of ventilator-associated pneumonia and central-line-associated blood stream infections were 2·96 and 0·7, respectively, per 1000 device days. Patients were intubated for a total of 4392 mechanical ventilator days, and 32 patients (7·29‰) had an unplanned extubation. Nurses were moderately satisfied in their jobs (3·1 ± 0·3), and parents reported that nurses provide high quality of care.

CONCLUSIONS

This study developed and used nursing-sensitive indicators to assess the quality of nursing in PICUs in China, which provided a reference for national and international comparisons of nursing quality in PICUs. Nursing staffing levels and education should be improved. Pain management and physical restraints should be regulated in China's PICUs. Nurse managers need to explore staff attitudes towards implementation of family-centred care. The development of a national database of nursing quality indicators can contribute to quality and safety improvement.

RELEVANCE TO CLINICAL PRACTICE

This study developed a set of nursing-sensitive indicators, and these indicators were used to assess and improve the quality of nursing in PICUs.

Nosocomial infections and resistance pattern of common bacterial isolates in an intensive care unit of a tertiary hospital in Nigeria: A 4-year review

INTRODUCTION

Infection is a major determinant of clinical outcome among patients in the intensive care unit. However, these data are lacking in most developing countries; hence, we set out to describe the profile of nosocomial infection in one of the major tertiary hospitals in northern Nigeria.

METHOD

Case records of patients who were admitted into the intensive care unit over a 4-year period were retrospectively reviewed. A preformed questionnaire was administered, and data on clinical and microbiological profile of patients with documented infection were obtained.

RESULTS

Eighty-our episodes of nosocomial infections were identified in 76 patients. Road traffic accident (29/76, 38.2%) was the leading cause of admission. The most common infections were skin and soft tissue infections (30/84, 35.7%) followed by urinary tract infection (23/84, 27.4%). The most frequent isolates were Staphylococcus aureus (35/84, 41.7%), Klebsiella pneumoniae (18/84, 21.4%), and Escherichia coli (13/84, 15.5%). High rate of resistance to cloxacillin (19/35, 54.3%) and cotrimoxazole (17/26, 65.4%) was noted among the S aureus isolates. All the Enterobacteriaceae isolates were susceptible to meropenem, whereas resistance rate to ceftriaxone was high (E coli, 55.6%; K pneumoniae, 71.4%; Proteus spp, 50%).

CONCLUSION

Infection control practice and measures to curtail the emergence of antimicrobial resistance need to be improved.

Medical Device-Associated Candida Infections in a Rural Tertiary Care Teaching Hospital of India

Health care associated infections (HCAIs) add incrementally to the morbidity, mortality, and cost expected of the patient's underlying diseases alone. Approximately, about half all cases of HCAIs are associated with medical devices. As Candida medical device-associated infection is highly drug resistant and can lead to serious life-threatening complications, there is a need of continuous surveillance of these infections to initiate preventive and corrective measures. The present study was conducted at a rural tertiary care hospital of India with an aim to evaluate the rate of medical device-associated Candida infections. Three commonly encountered medical device-associated infections (MDAI), catheter-associated urinary tract infection (CA-UTI), intravascular catheter-related blood stream infections (CR-BSI), and ventilator-associated pneumonia (VAP), were targeted. The overall rate of MDAI in our hospital was 2.1 per 1000 device days. The rate of Candida related CA-UTI and CR-BSI was noted as 1.0 and 0.3, respectively. Untiring efforts taken by team members of Hospital Acquired Infection Control Committee along with maintenance of meticulous hygiene of the hospital and wards may explain the low MDAI rates in our institute. The present surveillance helped us for systematic generation of institutional data regarding MDAI with special reference to role of Candida spp.

Risk factors for acquisition of carbapenem resistant Enterobacteriaceae in an acute tertiary care hospital in Singapore

Background

Carbapenem resistant Enterobacteriaceae (CRE) is increasingly reported worldwide. A similar increase is seen in Singapore since identification of its first case in 2008. The aim of this study was to identify local risk factors for carriage of CRE in patients from an acute tertiary care hospital in Singapore.

Method

A matched case-control study was conducted on inpatients treated from January 1, 2011 till December 31, 2013. Two hundred and three cases of CRE infection or colonization were matched with 203 controls. CRE types were identified by PCR. Statistical analysis of data including a multivariate logistic regression analysis was done using SPSS 21.0.

Results

CREs were commonly seen in Klebsiella pneumoniae (42.2 %), Escherichia coli (24.3 %) and Enterobacter cloacae complex (17.2 %) in the 268 isolates. NDM-1 was the commonest CRE type seen (44.4 %), followed by KPC (39.9 %) whilst OXA-48 only constituted (7.8 %). Univariate analysis identified key risk factors associated with CRE as history of previous overseas hospitalization (OR: 33.667; 95 % CI: 4.539-259.700), admission to ICU (OR: 11.899; 95 % CI: 4.986-28.399) and HD/ICA (OR: 6.557; 95 % CI: 4.057-10.596); whilst a multivariate analysis revealed exposure to antibiotics penicillin (OR: 4.640; 95 % CI: 1.529-14.079] and glycopeptide (OR: 5.162; 95 % CI: 1.377-19.346) and presence of central line device (OR: 3.117; 95 % CI: 1.167-8.330) as significant independent predictors.

Conclusions

The identification of risk factors amongst our local population helped to refine the criteria used for target active surveillance screening for CRE amongst inpatients at time of hospital admission.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part III Effectiveness of a Multidimensional Infection Control Approach to Reduce Central Line—Associated Bloodstream Infections in the Neonatal Intensive Care Units of 4 Developing Countries

Objective.

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce central line-associated bloodstream infection (CLABSI) rates.

Setting.

Four neonatal intensive care units (NICUs) of INICC member hospitals from El Salvador, Mexico, Philippines, and Tunisia.

Patients.

A total of 2,241 patients hospitalized in 4 NICUs for 40,045 bed-days.

Methods.

We conducted a before-after prospective surveillance study. During Phase 1 we performed active surveillance, and during phase 2 the INICC multidimensional infection control approach was implemented, including the following practices: (1) central line care bundle, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CLABSI rates, and (6) performance feedback of infection control practices. We compared CLABSI rates obtained during the 2 phases. We calculated crude stratified rates, and, using random-effects Poisson regression to allow for clustering by ICU, we calculated the incidence rate ratio (IRR) for each follow-up time period compared with the 3-month baseline.

Results.

During phase 1 we recorded 2,105 CL-days, and during phase 2 we recorded 17,117 CL-days. After implementation of the multidimensional approach, the CLABSI rate decreased by 55%, from 21.4 per 1,000 CL-days during phase 1 to 9.7 per 1,000 CL-days during phase 2 (rate ratio, 0.45 [95% confidence interval, 0.33–0.63]). The IRR was 0.53 during the 4–12-month period and 0.07 during the final period of the study (more than 45 months).

Conclusions.

Implementation of a multidimensional infection control approach was associated with a significant reduction in CLABSI rates in NICUs.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part III Effectiveness of a Multidimensional Infection Control Approach to Reduce Central Line—Associated Bloodstream Infections in the Neonatal Intensive Care Units of 4 Developing Countries

Objective.

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce central line-associated bloodstream infection (CLABSI) rates.

Setting.

Four neonatal intensive care units (NICUs) of INICC member hospitals from El Salvador, Mexico, Philippines, and Tunisia.

Patients.

A total of 2,241 patients hospitalized in 4 NICUs for 40,045 bed-days.

Methods.

We conducted a before-after prospective surveillance study. During Phase 1 we performed active surveillance, and during phase 2 the INICC multidimensional infection control approach was implemented, including the following practices: (1) central line care bundle, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CLABSI rates, and (6) performance feedback of infection control practices. We compared CLABSI rates obtained during the 2 phases. We calculated crude stratified rates, and, using random-effects Poisson regression to allow for clustering by ICU, we calculated the incidence rate ratio (IRR) for each follow-up time period compared with the 3-month baseline.

Results.

During phase 1 we recorded 2,105 CL-days, and during phase 2 we recorded 17,117 CL-days. After implementation of the multidimensional approach, the CLABSI rate decreased by 55%, from 21.4 per 1,000 CL-days during phase 1 to 9.7 per 1,000 CL-days during phase 2 (rate ratio, 0.45 [95% confidence interval, 0.33–0.63]). The IRR was 0.53 during the 4–12-month period and 0.07 during the final period of the study (more than 45 months).

Conclusions.

Implementation of a multidimensional infection control approach was associated with a significant reduction in CLABSI rates in NICUs.

Excess Length of Stay Due to Central Line–Associated Bloodstream Infection in Intensive Care Units in Argentina, Brazil, and Mexico

Objective.

To estimate the excess length of stay in an intensive care unit (ICU) due to a central line-associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection.

Design.

A cohort of 3,560 patients followed up for 36,806 days in ICUs.

Setting.

Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico.

Patients.

All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours.

Results.

The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from -1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI.

Conclusions.

CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case-mix of admissions and differences in the ways that hospitals deal with infections.

Excess Length of Stay Due to Central Line–Associated Bloodstream Infection in Intensive Care Units in Argentina, Brazil, and Mexico

Objective.

To estimate the excess length of stay in an intensive care unit (ICU) due to a central line-associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection.

Design.

A cohort of 3,560 patients followed up for 36,806 days in ICUs.

Setting.

Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico.

Patients.

All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours.

Results.

The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from -1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI.

Conclusions.

CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case-mix of admissions and differences in the ways that hospitals deal with infections.

Risk factors for colonization due to carbapenem-resistant Enterobacteriaceae among patients exposed to long-term acute care and acute care facilities

BACKGROUND

This study aimed to identify risk factors associated with carbapenem-resistant Enterobacteriaceae (CRE) colonization among patients screened with rectal cultures upon admission to a hospital or long-term acute care (LTAC) center and to compare risk factors among patients who were screen positive for CRE at the time of hospital admission with those screen positive prior to LTAC admission.

METHODS

A retrospective nested matched case-control study was conducted from June 2009 to December 2011. Patients with recent LTAC exposure were screened for CRE carriage at the time of hospital admission, and patients admitted to a regional LTAC facility were screened prior to LTAC admission. Cases were patients with a positive CRE screening culture, and controls (matched in a 3∶1 ratio to cases) were patients with negative screening cultures.

RESULTS

Nine hundred five cultures were performed on 679 patients. Forty-eight (7.1%) cases were matched to 144 controls. One hundred fifty-eight patients were screened upon hospital admission and 521 prior to LTAC admission. Independent predictors for CRE colonization included Charlson's score greater than 3 (odds ratio [OR], 4.85 [95% confidence interval (CI), 1.64-14.41]), immunosuppression (OR, 3.92 [95% CI, 1.08-1.28]), presence of indwelling devices (OR, 5.21 [95% CI, 1.09-2.96]), and prior antimicrobial exposures (OR, 3.89 [95% CI, 0.71-21.47]). Risk factors among patients screened upon hospital admission were similar to the entire cohort. Among patients screened prior to LTAC admission, the characteristics of the CRE-colonized and noncolonized patients were similar.

CONCLUSIONS

These results can be used to identify patients at increased risk for CRE colonization and to help target active surveillance programs in healthcare settings.

Increasing incidence of hospital-acquired and healthcare-associated bacteremia in northeast Thailand: a multicenter surveillance study

Background

Little is known about the epidemiology of nosocomial bloodstream infections in public hospitals in developing countries. We evaluated trends in incidence of hospital-acquired bacteremia (HAB) and healthcare-associated bacteremia (HCAB) and associated mortality in a developing country using routinely available databases.

Methods

Information from the microbiology and hospital databases of 10 provincial hospitals in northeast Thailand was linked with the national death registry for 2004–2010. Bacteremia was considered hospital-acquired if detected after the first two days of hospital admission, and healthcare-associated if detected within two days of hospital admission with a prior inpatient episode in the preceding 30 days.

Results

A total of 3,424 patients out of 1,069,443 at risk developed HAB and 2,184 out of 119,286 at risk had HCAB. Of these 1,559 (45.5%) and 913 (41.8%) died within 30 days, respectively. Between 2004 and 2010, the incidence rate of HAB increased from 0.6 to 0.8 per 1,000 patient-days at risk (p<0.001), and the cumulative incidence of HCAB increased from 1.2 to 2.0 per 100 readmissions (p<0.001). The most common causes of HAB were Acinetobacter spp. (16.2%), Klebsiella pneumoniae (13.9%), and Staphylococcus aureus (13.9%), while those of HCAB were Escherichia coli (26.3%), S. aureus (14.0%), and K. pneumoniae (9.7%). There was an overall increase over time in the proportions of ESBL-producing E. coli causing HAB and HCAB.

Conclusions

This study demonstrates a high and increasing incidence of HAB and HCAB in provincial hospitals in northeast Thailand, increasing proportions of ESBL-producing isolates, and very high associated mortality.

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.

Carbapenem resistance in Pseudomonas aeruginosa and Acinetobacter baumannii in the nosocomial setting in Latin America

Increasing prevalence of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii strains in the nosocomial setting in Latin America represents an emerging challenge to public health, as the range of therapeutic agents active against these pathogens becomes increasingly constrained. We review published reports from 2002 to 2013, compiling data from throughout the region on prevalence, mechanisms of resistance and molecular epidemiology of carbapenem-resistant strains of P. aeruginosa and A. baumannii. We find rates of carbapenem resistance up to 66% for P. aeruginosa and as high as 90% for A. baumannii isolates across the different countries of Latin America, with the resistance rate of A. baumannii isolates greater than 50% in many countries. An outbreak of the SPM-1 carbapenemase is a chief cause of resistance in P. aeruginosa strains in Brazil. Elsewhere in Latin America, members of the VIM family are the most important carbapenemases among P. aeruginosa strains. Carbapenem resistance in A. baumannii in Latin America is predominantly due to the oxacillinases OXA-23, OXA-58 and (in Brazil) OXA-143. Susceptibility of P. aeruginosa and A. baumannii to colistin remains high, however, development of resistance has already been detected in some countries. Better epidemiological data are needed to design effective infection control interventions.

Respiratory infections in patients undergoing mechanical ventilation

Lower respiratory tract infections in mechanically ventilated patients are a frequent cause of antibiotic treatment in intensive-care units. These infections present as severe sepsis or septic shock with respiratory dysfunction in intubated patients. Purulent respiratory secretions are needed for diagnosis, but distinguishing between pneumonia and tracheobronchitis is not easy. Both presentations are associated with longlasting mechanical ventilation and extended intensive-care unit stay, providing a rationale for antibiotic treatment initiation. Differentiation of colonisers from true pathogens is difficult, and microbiological data show Staphylococcus aureus and Pseudomonas aeruginosa to be of great concern because of clinical outcomes and therapeutic challenges. Key management issues include identification of the pathogen, choice of initial empirical antibiotic, and decisions with regard to the resolution pattern.

Protecting patient safety in resource-poor settings

A crucial element in the delivery of high-quality health care is patient safety. The rate of adverse events among hospital patients is an indication of patient safety. A systematic review of in-hospital adverse events revealed the median incidence of adverse events as 9.2%; 7.4% were lethal and 43.5% preventable. All the studies in the systemic review were from developed countries, as research is lacking from developing countries. In 2012, data from 10 developing countries reported adverse events ranging from 2.5 to 18.4% per country; 30% were lethal and 83% preventable. This study places patient safety as one of the major concerns of the health policy agenda in developing countries. Human resources for health deficits in developing countries constitute a major structural constraint for ensuring patient safety. The key to reducing adverse events in health care is system-based interventions rather than clinical interventions or technologies. Patient safety skills training, effective communication, and good team work are essential in improving patient safety in developing countries. Research on patient safety is needed to address the knowledge gap in developing countries.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

PURPOSE

To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey.

METHODS

A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach.

RESULTS

In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.)

CONCLUSIONS

The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Improving outcomes and reducing costs by modular training in infection control in a resource-limited setting

OBJECTIVE

To study the impact of modular training and implementation of infection control practices on all health-care-associated infections (HAIs) in a cardiac surgery (CVTS) program of a tertiary care hospital.

DESIGN

Baseline data were compared with post-intervention (with modular training) data.

SETTING

This study was conducted in a cardiovascular surgical unit.

PARTICIPANTS

In total, 2838 patients were admitted in cardiovascular surgical service.

INTERVENTIONS

Two training modules and online continuous education were delivered to all health-care workers in CVTS unit.

MAIN OUTCOME MEASURES

All four HAIs, such as surgical site infections (SSI), central line-associated blood stream infection (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CA-UTI), were studied. Additional outcome measures included average length of stay cost of avoidance mortality and readmission rates.

RESULTS

The SSI rate had decreased in the post-intervention phase from 46 to 3.27% per 100 surgeries (P < 0.0001), CLABSI had decreased from 44 to 3.10% per 1000 catheter days (P < 0.009), VAP was reduced from 65 to 4.8% per 1000 ventilator days (P < 0.0001) and CA-UTI had reduced from 37 to 3.48% per 1000 urinary catheter days (P < 1.0). For every $1 spent on training, the return on investment was $236 as cost of avoidance of healthcare associated infections (HAIs).

CONCLUSIONS

Standardization of infection control training and practices is the most cost-effective way to reduce HCAIs and related adverse outcomes.

International nosocomial infection control consortium findings of device-associated infections rate in an intensive care unit of a lebanese university hospital

OBJECTIVES

To determine the rates of device-associated healthcare-associated infections (DA-HAI), microbiological profile, bacterial resistance, length of stay (LOS), excess mortality and hand hygiene compliance in one intensive care unit (ICU) of a hospital member of the International Infection Control Consortium (INICC) in Beirut, Lebanon.

MATERIALS AND METHODS

An open label, prospective cohort, active DA-HAI surveillance study was conducted on adults admitted to a tertiary-care ICU in Lebanon from November 2007 to March 2010. The protocol and methodology implemented were developed by INICC. Data collection was performed in the participating ICUs. Data uploading and analyses were conducted at INICC headquarters on proprietary software. DA-HAI rates were recorded by applying the definitions of the National Healthcare Safety Network (NHSN) at the US Centers for Disease Control and Prevention (CDC). We analyzed the DA-HAI, mechanical ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CAUTI) rates, microorganism profile, excess LOS, excess mortality, and hand hygiene compliance.

RESULTS

A total of 666 patients hospitalized for 5,506 days acquired 65 DA-HAIs, an overall rate of 9.8% [(95% confidence interval (CI) 7.6-12.3], and 11.8 (95% CI 9.1-15.0) DA-HAIs per 1000 ICU-days. The CLA-BSI rate was 5.2 (95% CI 2.8-8.7) per 1000 catheter-days; the VAP rate was 8.1 (95% CI 5.5-11.7) per 1000 ventilator-days; and the CAUTI rate was 4.1 (95% CI 2.6-6.2) per 1000 catheter-days. LOS of patients was 7.3 days for those without DA-HAI, 13.8 days for those with CLA-BSI, 18.8 days for those with VAP. Excess mortality was 40.9% [relative risk (RR) 3.14; P 0.004] for CLA-BSI. Mortality of VAP and CAUTI was not significantly different from patients without DA-HAI. Escherichia coli was the most common isolated microorganism. Overall hand hygiene compliance was 84.9% (95% CI 82.3-87.3).

CONCLUSIONS

DA-HAI rates, bacterial resistance, LOS and mortality were moderately high, below INICC overall data and above CDC-NHSN data. Infection control programs including surveillance and antibiotic policies are essential and continue to be a priority in Lebanon.

Surveillance on secular trends of incidence and mortality for device-associated infection in the intensive care unit setting at a tertiary medical center in Taiwan, 2000-2008: a retrospective observational study

Background

Device–associated infection (DAI) plays an important part in nosocomial infection. Active surveillance and infection control are needed to disclose the specific situation in each hospital and to cope with this problem effectively. We examined the rates of DAI by antimicrobial-resistant pathogens, and 30–day and in–hospital mortality in the intensive care unit (ICU).

Methods

Prospective surveillance was conducted in a mixed medical and surgical ICU at a major teaching hospital from 2000 through 2008. Trend analysis was performed and logistic regression was used to assess prognostic factors of mortality.

Results

The overall rate of DAIs was 3.03 episodes per 1000 device–days. The most common DAI type was catheter–associated urinary tract infection (3.76 per 1000 urinary catheter–days). There was a decrease in DAI rates in 2005 and rates of ventilator–associated pneumonia (VAP, 3.18 per 1000 ventilator–days) have remained low since then (p < 0.001). The crude rates of 30–day (33.6%) and in–hospital (52.3%) mortality, as well as infection by antibiotic-resistant VAP pathogens also decreased. The most common antimicrobial-resistant pathogens were methicillin–resistant Staphylococcus aureus (94.9%) and imipenem–resistant Acinetobacter baumannii (p < 0.001), which also increased at the most rapid rate. The rate of antimicrobial resistance among Enterobacteriaceae also increased significantly (p < 0.05). After controlling for potentially confounding factors, the DAI was an independent prognostic factor for both 30–day mortality (OR 2.51, 95% confidence interval [CI] 1.99–3.17, p = 0.001) and in–hospital mortality (OR 3.61, 95% CI 2.10–3.25, p < 0.001).

Conclusions

The decrease in the rate of DAI and infection by resistant bacteria on the impact of severe acute respiratory syndrome can be attributed to active infection control and improved adherence after 2003.

Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries.

METHODS

This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology.

RESULTS

During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P = .02), demonstrating a 31% reduction in VAP rate.

CONCLUSIONS

Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.

Device-associated nosocomial infection rates in intensive care units at Cairo University hospitals: first step toward initiating surveillance programs in a resource-limited country

BACKGROUND

Device associated infections (DAIs) have major impact on patient morbidity and mortality.

METHODS

This study involved active prospective surveillance to measure the incidence of DAIs, evaluate microbiological profiles, and investigate excessive mortality in intensive care units (ICUs) in 3 hospitals of Cairo University applying the US Centers for Disease Control and Prevention's National Healthcare Safety Network case definitions for ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central-line associated bloodstream infection (CLABSI). Data were collected between March 2009 and May 2010.

RESULTS

A total of 1,101 patients were hospitalized for a total of 10,869 days, had 4,734 device-days, and acquired 97 DAIs, with an overall rate of 20.5/1,000 ICU days. VAP was the most commonly identified infection (88.7%); followed by CLABSI (8.2%) and CAUTI (3.1%). Excess mortality was 48% (relative risk, 1.9; P < .001) for CAUTI, 12.9% (relative risk, 1.2; 95% confidence interval, 1.1-1.4; P < .05) for VAP, and 45.7% for CLABSI. Acinetobacter baumannii was the most frequently isolated pathogen (36.1%), followed by Klebsiella pneumoniae (29.2%) and Pseudomonas aeruginosa (22.2%). High antimicrobial resistance was identified, with 85% of A baumannii isolates resistant to ciprofloxacin and imipenem, 76% of K pneumoniae isolates were extended-spectrum β-lactamase producers, and 56.3% P aeruginosa isolates resistant to imipenem (56.3%).

CONCLUSION

High rates of DAI and antimicrobial resistance require strengthening infection control, instituting surveillance systems, and implementing evidence-based preventive strategies.

Socioeconomic impact on device-associated infections in pediatric intensive care units of 16 limited-resource countries: international Nosocomial Infection Control Consortium findings

OBJECTIVES

We report the results of the International Nosocomial Infection Control Consortium prospective surveillance study from January 2004 to December 2009 in 33 pediatric intensive care units of 16 countries and the impact of being in a private vs. public hospital and the income country level on device-associated health care-associated infection rates. Additionally, we aim to compare these findings with the results of the Centers for Disease Control and Prevention National Healthcare Safety Network annual report to show the differences between developed and developing countries regarding device-associated health care-associated infection rates.

PATIENTS

A prospective cohort, active device-associated health care-associated infection surveillance study was conducted on 23,700 patients in International Nosocomial Infection Control Consortium pediatric intensive care units.

METHODS

The protocol and methodology implemented were developed by International Nosocomial Infection Control Consortium. Data collection was performed in the participating intensive care units. Data uploading and analyses were conducted at International Nosocomial Infection Control Consortium headquarters on proprietary software. Device-associated health care-associated infection rates were recorded by applying Centers for Disease Control and Prevention National Healthcare Safety Network device-associated infection definitions, and the impact of being in a private vs. public hospital and the income country level on device-associated infection risk was evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Central line-associated bloodstream infection rates were similar in private, public, or academic hospitals (7.3 vs. 8.4 central line-associated bloodstream infection per 1,000 catheter-days [p < .35 vs. 8.2; p < .42]). Central line-associated bloodstream infection rates in lower middle-income countries were higher than low-income countries or upper middle-income countries (12.2 vs. 5.5 central line-associated bloodstream infections per 1,000 catheter-days [p < .02 vs. 7.0; p < .001]). Catheter-associated urinary tract infection rates were similar in academic, public and private hospitals: (4.2 vs. 5.2 catheter-associated urinary tract infection per 1,000 catheter-days [p = .41 vs. 3.0; p = .195]). Catheter-associated urinary tract infection rates were higher in lower middle-income countries than low-income countries or upper middle-income countries (5.9 vs. 0.6 catheter-associated urinary tract infection per 1,000 catheter-days [p < .004 vs. 3.7; p < .01]). Ventilator-associated pneumonia rates in academic hospitals were higher than private or public hospitals: (8.3 vs. 3.5 ventilator-associated pneumonias per 1,000 ventilator-days [p < .001 vs. 4.7; p < .001]). Lower middle-income countries had higher ventilator-associated pneumonia rates than low-income countries or upper middle-income countries: (9.0 vs. 0.5 per 1,000 ventilator-days [p < .001 vs. 5.4; p < .001]). Hand hygiene compliance rates were higher in public than academic or private hospitals (65.2% vs. 54.8% [p < .001 vs. 13.3%; p < .01]).

CONCLUSIONS

Country socioeconomic level influence device-associated infection rates in developing countries and need to be considered when comparing device-associated infections from one country to another.

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

The results of a surveillance study conducted by the International Nosocomial Infection Control Consortium (INICC) from January 2004 through December 2009 in 422 intensive care units (ICUs) of 36 countries in Latin America, Asia, Africa, and Europe are reported. During the 6-year study period, using Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infection Surveillance system [NNIS]) definitions for device-associated health care-associated infections, we gathered prospective data from 313,008 patients hospitalized in the consortium's ICUs for an aggregate of 2,194,897 ICU bed-days. Despite the fact that the use of devices in the developing countries' ICUs was remarkably similar to that reported in US ICUs in the CDC's NHSN, rates of device-associated nosocomial infection were significantly higher in the ICUs of the INICC hospitals; the pooled rate of central line-associated bloodstream infection in the INICC ICUs of 6.8 per 1,000 central line-days was more than 3-fold higher than the 2.0 per 1,000 central line-days reported in comparable US ICUs. The overall rate of ventilator-associated pneumonia also was far higher (15.8 vs 3.3 per 1,000 ventilator-days), as was the rate of catheter-associated urinary tract infection (6.3 vs. 3.3 per 1,000 catheter-days). Notably, the frequencies of resistance of Pseudomonas aeruginosa isolates to imipenem (47.2% vs 23.0%), Klebsiella pneumoniae isolates to ceftazidime (76.3% vs 27.1%), Escherichia coli isolates to ceftazidime (66.7% vs 8.1%), Staphylococcus aureus isolates to methicillin (84.4% vs 56.8%), were also higher in the consortium's ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 7.3% (for catheter-associated urinary tract infection) to 15.2% (for ventilator-associated pneumonia).

Bladder pressure measurements and urinary tract infection in trauma patients

BACKGROUND

The purpose of this trial was to determine if using a closed technique for bladder pressure measurements (BPMs) would eliminate them as a risk factor for urinary tract infection (UTI) in trauma patients, as was shown previously using an open technique.

METHODS

Data were collected prospectively from January 2006 until December 2009 by a dedicated epidemiology nurse and combined with trauma registry data at our Level 1 trauma center. All trauma patients admitted to the surgical trauma intensive care unit (STICU) with and without UTIs were compared for demographic and epidemiologic data. A closed system was used in which the urinary drainage catheter (UDC) remained connected to the bag and 45 mL of saline was injected through a two-way valved sideport, with subsequent measurements through the sideport.

RESULTS

There were 1,641 patients in the trial. The UTI group was sicker (Injury Severity Score [ISS] 18.7±11.9 no UTI vs. 28±10.7 UTI; p<0.0001), with longer stays (11.4±12.4 days no UTI vs. 37.9±20.3 days UTI; p<0.0001) and more UDC days (4.3±6.6 no UTI vs. 23.9±16.6 UTI; p<0.0001). The BPM group had more UDC days (15.6 days±16.0 BPM vs. 5.4 days±7.3 no BPM; p<0.0001), yet no difference in UTI rate/1,000 UDC days (5.7 no BPM vs. 8.0 BPM; p=0.5291). Logistic regression demonstrated only UDC days to be a predictor of UTI (1.125; 95% confidence interval [CI] 1.097-1.154; p<0.0001), whereas ISS (1.083, 95% CI 1.063-1.104; p<0.0001) and age (1.051, 95% CI 1.037-1.065; p<0.0001) were the only predictors of death.

CONCLUSION

Although patients undergoing BPM have more UTIs than patients without BPM, the measurements are not an independent predictor of UTI when done by the closed technique. These findings emphasize the judicious use of BPM with a closed system and, more importantly, the need for early removal of catheters.

Teaching aseptic technique for central venous access under ultrasound guidance: a randomized trial comparing didactic training alone to didactic plus simulation-based training

BACKGROUND

Our goal was to determine whether simulation combined with didactic training improves sterile technique during ultrasound (US)-guided central venous catheter (CVC) insertion compared with didactic training alone among novices. We hypothesized that novices who receive combined didactic and simulation-based training would perform similarly to experienced residents in aseptic technique, knowledge, and perception of comfort during US-guided CVC insertion on a simulator.

METHODS

Seventy-two subjects were enrolled in a randomized, controlled trial of an educational intervention. Fifty-four novices were randomized into either the didactic group or the simulation combined with didactic group. Both groups received didactic training but the simulation combined with didactic group also received simulation-based CVC insertion training. Both groups were tested by demonstrating US-guided CVC insertion on a simulator. Aseptic technique was scored on 8 steps as "yes/no" and also using a 7-point Likert scale with 7 being "excellent technique" by a rater blinded to subject randomization. After initial testing, the didactic group was offered simulation-based training and retesting. Both groups also took a pre- and posttraining test of knowledge and rated their comfort with US and CVC insertion pre- and posttraining on a 5-point Likert scale. Subsequently, 18 experienced residents also took the test of knowledge, rated their comfort level, and were scored while performing aseptic US-guided CVC insertion using a simulator.

RESULTS

The simulation combined with didactic group achieved a 167% (95% confidence interval [CI] 133%-167%) incremental increase in yes/no scores and 115% (CI 112%-127%) incremental increase in Likert scale ratings on aseptic technique compared with novices in the didactic group. Compared with experienced residents, simulation combined with didactic trained novices achieved an increase in aseptic scores with a 33.3% (CI 16.7%-50%) increase in yes/no ratings and a 20% (CI 13.3%-40%) increase in Likert scaled ratings, and scored 2.5-fold higher on the test of knowledge. There was a 3-fold increase in knowledge and 2-fold increase in comfort level among all novices (P < 0.001) after combined didactic and simulation-based training.

CONCLUSION

Simulation combined with didactic training is superior to didactic training alone for acquisition of clinical skills such as US-guided CVC insertion. After combined didactic and simulation-based training, novices can outperform experienced residents in aseptic technique as well as in measurements of knowledge.

Effectiveness of a hand hygiene promotion strategy using alcohol-based handrub in 6 intensive care units in Colombia

BACKGROUND

Hand hygiene is an effective strategy for the prevention of health care-associated infection (HAI). We investigated the effect of a hand hygiene promotion strategy introducing alcohol-based handrub (AHBR) on the incidence of HAI in a university hospital in Colombia.

METHODS

A Prospective cohort study was performed in 6 intensive care units from January 2001 to December 2005. HAI were identified using standard US Centers for Disease Control and Prevention definitions. Alcohol-based handrub dispensers were installed between February and June 2002.

RESULTS

Total ABHR consumption was 5,794 L (mean, 28.9 L per 1,000 patient-days) and significantly increased over time (+9.2% per year; P < .001). Of 14,516 patients cumulating 166,498 patient-days, 2,398 (16.5%) acquired a total of 3,490 HAI episodes (20.9 per 1,000 patient-days). Incidence densities for central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia, and urinary tract infections were 7.7, 10.6, and 3.6 episodes per 1,000 device-days, respectively. A significant decrease was observed for CLABSI (-12.7% per year; P < .001) with low nurse-to-patient ratio independently associated with infection (odds ratio, 1.11; 95% confidence interval: 1.07-1.16; P < .001).

CONCLUSION

Improved hand hygiene measured by increased ABHR consumption resulted in CLABSI reduction. Low nurse-to-patient ratio is independently associated with HAI in an upper-middle income country.

Device-associated infections rates in adult, pediatric, and neonatal intensive care units of hospitals in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

This study investigated the rate of device-associated health care-associated infection (DA-HAI), microbiological profiles, bacterial resistance, length of stay (LOS), and mortality rate in 9 intensive care units (ICUs) of 3 hospital members of the International Nosocomial Infection Control Consortium (INICC) in the Philippines.

METHODS

This was an open-label, prospective cohort, active DA-HAI surveillance study of adult, pediatric, and newborn patients admitted to 9 tertiary care ICUs in the Philippines between January 2005 and December 2009, implementing methodology developed by the INICC. Data collection was performed in the participating ICUs, and data were uploaded and analyzed at the INICC headquarters using proprietary software. DA-HAI rates were registered based on definitions promulgated by the Centers for Disease Control and Prevention's National Healthcare Safety Network.

RESULTS

Over a 5-year period, 4952 patients hospitalized in ICUs for a total of 40,733 days acquired 199 DA-HAIs, for an overall rate of 4.9 infections per 1,000 ICU-days. Ventilator-associated pneumonia posed the greatest risk (16.7 per 1,000 ventilator-days in the adult ICUs, 12.8 per 1,000 ventilator-days in the pediatric ICU, and 0.44 per 1,000 ventilator-days in the neonatal ICUs), followed by central line-associated bloodstream infections (4.6 per 1,000 catheter-days in the adult ICUs, 8.23 per 1,000 ventilator-days in the pediatric ICU, and 9.6 per 1,000 ventilator-days in the neonatal ICUs) and catheter-associated urinary tract infections (4.2 per 1,000 catheter-days in the adult ICUs and 0.0 in the pediatric ICU).

CONCLUSION

DA-HAIs pose far greater threats to patient safety in Philippine ICUs than in US ICUs. The establishment of active infection control programs that involve infection surveillance and implement guidelines for prevention can improve patient safety and should become a priority.

[Urinary tract colonization and infection in critically ill patients]

Urinary tract infections (UTIs) account for 20-50% of all hospital-acquired infections occurring in the intensive care unit (ICU). In some reports UTI was found to be more frequent than hospital-acquired pneumonia and intravascular device bacteremia, with a greater incidence in developing countries. The risk factors associated with the appearance of UTI include the severity of illness at the time of admission to the ICU, female status, prolonged urinary catheterization or a longer ICU stay and poor urinary catheter management - mainly disconnection of the closed system. about the present study offers data on the epidemiology of UTI in the ICU, the identified risk factors, etiology, diagnosis, impact upon morbidity and mortality, and the measures to prevent its appearance.

Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC

PURPOSE

To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs).

METHODS

Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria.

RESULTS

Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level.

CONCLUSIONS

Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.