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.

Morbidity, mortality, and emerging drug resistance in Device-associated infections (DAIs) in intensive care patients at a 1000-bedded tertiary care teaching hospital

Background

Device-associated infections (DAIs) such as ventilator associated pneumonia (VAP), central line-associated blood stream infection (CLABSI), and catheter-related urinary tract infection (CAUTI) are principal contributors to health hazard and a major preventable threat to patient safety. Robust surveillance of DAI delineates infections, pathogens, resistograms, and facilitates antimicrobial therapy, infection-control, antimicrobial stewardship, and improvement in quality of care.

Methods

This prospective outcome surveillance study was conducted amongst 2067 ICU patients in a 1000-bedded teaching hospital. Clinical, laboratory, and environmental surveillance, as well as screening of health care professionals (HCPs) were conducted using the modified US Centers for Disease Control and Prevention-National Healthcare Safety Network definitions and methods. Morbidity, mortality, and health-care indices were analyzed and two-tier infection prevention and control was promulgated.

Results

Mean occupancy was 95.34% for 2061 patients of 7381 patients/bed/ICU days. One hundred seventeen episodes of DAI occurred in 1258 patients of 12,882 device-days with mean device utilization ratio of 1.79. Mean rate of DAI was 7.40 per 1000 device days. Multiresistant Pseudomonas aeruginosa was most commonly followed by Acinetobacter. Mean all-cause mortality in ICU was 24.85%, whereas all-cause mortality after DAI was 9.79%. Methicillin-resistant Staphylococcus aureus prevalence was 38.46% amongst health-care professionals.

Conclusion

Mean rates of VAP, CLABSI, and CAUTI were 20.69, 2.53, and 2.23 per 1000 device days comparable with Indian and global ICUs. Resolute conviction and sustained momentum in infection prevention and control is an essential step toward patient safety.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical impact of needle-free connector design: A systematic review of literature

The objective of this systematic review is to analyze types of needle-free connectors and open systems and their effects on central line–associated bloodstream infection rates and other adverse outcomes through a research protocol consistent with the Preferred Reporting Items for Systematic Reviews’ recommendations. MEDLINE and Cochrane databases of systematic reviews were searched for relevant comparative studies published from January 2000 to September 2017. Eighteen studies compared central line–associated bloodstream infection (according to the Centers for Disease Control and Prevention/National Healthcare Safety Network definition), internal microbial contamination, occlusions, phlebitis, and other outcomes associated with needle-free connectors with a positive displacement device, negative displacement device, neutral displacement device, or three-way stopcock. Ten studies reported central line–associated bloodstream infection rates, which were lower with positive displacement devices versus negative displacement devices/neutral displacement devices (one study) and with negative displacement devices versus three-way stopcocks (three studies), but varied with different positive displacement device and negative displacement device/neutral displacement device designs (four studies). Seven studies reported internal microbial contamination rates, which were higher with three-way stopcocks versus negative displacement devices (two studies) and positive displacement devices (two studies), lower when positive displacement devices were used versus neutral displacement devices (one study), and varied with different types of negative displacement device (one study). Central line–associated bloodstream infection rates and most other outcomes analyzed were statistically significantly higher with three-way stopcocks (open devices) versus positive displacement device, negative displacement devices, and neutral displacement devices, but varied among closed device designs.