The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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 study of incidence and risk factors for central-line-associated bloodstream infections in 728 intensive care units of 41 Asian, African, Eastern European, Latin American, and Middle Eastern countries over 24 years

OBJECTIVE

To identify central-line (CL)-associated bloodstream infection (CLABSI) incidence and risk factors in low- and middle-income countries (LMICs).

DESIGN

From July 1, 1998, to February 12, 2022, we conducted a multinational multicenter prospective cohort study using online standardized surveillance system and unified forms.

SETTING

The study included 728 ICUs of 286 hospitals in 147 cities in 41 African, Asian, Eastern European, Latin American, and Middle Eastern countries.

PATIENTS

In total, 278,241 patients followed during 1,815,043 patient days acquired 3,537 CLABSIs.

METHODS

For the CLABSI rate, we used CL days as the denominator and the number of CLABSIs as the numerator. Using multiple logistic regression, outcomes are shown as adjusted odds ratios (aORs).

RESULTS

The pooled CLABSI rate was 4.82 CLABSIs per 1,000 CL days, which is significantly higher than that reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN). We analyzed 11 variables, and the following variables were independently and significantly associated with CLABSI: length of stay (LOS), risk increasing 3% daily (aOR, 1.03; 95% CI, 1.03-1.04; P < .0001), number of CL days, risk increasing 4% per CL day (aOR, 1.04; 95% CI, 1.03-1.04; P < .0001), surgical hospitalization (aOR, 1.12; 95% CI, 1.03-1.21; P < .0001), tracheostomy use (aOR, 1.52; 95% CI, 1.23-1.88; P < .0001), hospitalization at a publicly owned facility (aOR, 3.04; 95% CI, 2.31-4.01; P <.0001) or at a teaching hospital (aOR, 2.91; 95% CI, 2.22-3.83; P < .0001), hospitalization in a middle-income country (aOR, 2.41; 95% CI, 2.09-2.77; P < .0001). The ICU type with highest risk was adult oncology (aOR, 4.35; 95% CI, 3.11-6.09; P < .0001), followed by pediatric oncology (aOR, 2.51;95% CI, 1.57-3.99; P < .0001), and pediatric (aOR, 2.34; 95% CI, 1.81-3.01; P < .0001). The CL type with the highest risk was internal-jugular (aOR, 3.01; 95% CI, 2.71-3.33; P < .0001), followed by femoral (aOR, 2.29; 95% CI, 1.96-2.68; P < .0001). Peripherally inserted central catheter (PICC) was the CL with the lowest CLABSI risk (aOR, 1.48; 95% CI, 1.02-2.18; P = .04).

CONCLUSIONS

The following CLABSI risk factors are unlikely to change: country income level, facility ownership, hospitalization type, and ICU type. These findings suggest a focus on reducing LOS, CL days, and tracheostomy; using PICC instead of internal-jugular or femoral CL; 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.

An eight-year multicenter study on short-term peripheral intravenous catheter-related bloodstream infection rates in 100 intensive care units of 9 countries in Latin America: Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama, and Venezuela. Findings of the International Nosocomial Infection Control Consortium (INICC)

BACKGROUND

Data on short-term peripheral intravenous catheter-related bloodstream infections per 1,000 peripheral venous catheter days (PIVCR BSIs per 1,000 PVC days) rates from Latin America are not available, so they have not been thoroughly studied.

METHODS

International Nosocomial Infection Control Consortium (INICC) members conducted a prospective, surveillance study on PIVCR BSIs from January 2010 to March 2018 in 100 intensive care units (ICUs) among 41 hospitals, in 26 cities of 9 countries in Latin America (Argentina, Brazil, Colombia, Costa Rica, Dominican-Republic, Ecuador, Mexico, Panama, and Venezuela). The Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) definitions were applied, and INICC methodology and INICC Surveillance Online System software were used.

RESULTS

In total, 10,120 ICU patients were followed for 40,078 bed days and 38,262 PVC days. In addition, 79 PIVCR BSIs were identified, with a rate of 2.06 per 1,000 PVC days (95% confidence interval [CI], 1.635-2.257). The average length of stay (ALOS) of patients without a PIVCR BSI was 3.95 days, and the ALOS was 5.29 days for patients with a PIVCR BSI. The crude extra ALOS was 1.34 days (RR, 1.33; 95% CI, 1.0975-1.6351; P = .040).The mortality rate in patients without PIVCR BSI was 3.67%, and this rate was 6.33% in patients with a PIVCR BSI. The crude extra mortality was 1.70 times higher. The microorganism profile showed 48.5% gram-positive bacteria (coagulase-negative Staphylococci 25.7%) and 48.5% gram-negative bacteria: Acinetobacter spp, Escherichia coli, and Klebsiella spp (8.5% each one), Pseudomonas aeruginosa (5.7%), and Candida spp (2.8%). The resistances of Pseudomonas aeruginosa were 0% to amikacin and 50% to meropenem. The resistance of Acinetobacter baumanii to amikacin was 0%, and the resistance of coagulase-negative Staphylococcus to oxacillin was 75%.

CONCLUSIONS

Our PIVCR BSI rates were higher than rates from more economically developed countries and were similar to those of countries with limited resources.

Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.

Practice Guidelines for Central Venous Access 2020

These practice guidelines update the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the American Society of Anesthesiologists in 2011 and published in 2012. These updated guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist and may also serve as a resource for other physicians, nurses, or healthcare providers who manage patients with central venous catheters.

Supplemental Digital Content is available in the text.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

Practical guide for safe central venous catheterization and management 2017

Central venous catheterization is a basic skill applicable in various medical fields. However, because it may occasionally cause lethal complications, we developed this practical guide that will help a novice operator successfully perform central venous catheterization using ultrasound guidance. The focus of this practical guide is patient safety. It details the fundamental knowledge and techniques that are indispensable for performing ultrasound-guided internal jugular vein catheterization (other choices of indwelling catheters, subclavian, axillary, and femoral venous catheter, or peripherally inserted central venous catheter are also described in alternatives).

'Adiós Bacteriemias': a multi-country quality improvement collaborative project to reduce the incidence of CLABSI in Latin American ICUs

QUALITY PROBLEM

The incidence of central line-associated bloodstream infections (CLABSI) in Latin America has been estimated at 4.9 episodes per 1000 central line (CL) days, compared to a pooled incidence of 0.9 in the United States. CLABSI usually result from not adhering to standardized health procedures and can be prevented using evidence-based practices.

INITIAL ASSESSMENT

The first phase of the 'Adiós Bacteriemias' Collaborative was implemented in 39 intensive care units (ICUs) from Latin America from September 2012 to September 2013 with a 56% overall reduction in the incidence of CLABSI.

CHOICE OF SOLUTION

Bundles of care for the processes of insertion and maintenance of CLs have proven to be effective in the reduction of CLABSI across different settings.

IMPLEMENTATION

Building on the results of the first phase, we implemented a second phase of the 'Adiós Bacteriemias' Collaborative between June 2014-July 2015. We adapted the Breakthrough Series (BTS) Collaborative model to guide the adoption of bundles of care for CLABSI prevention through virtual learning sessions and continuous feedback.

EVALUATION

Eighty-three ICUs from five Latin American countries actively reported process and outcome measures. The overall reduction in the CLABSI incidence rate was 22% (incidence rate 0.78; 95% CI 0.65, 0.95), from 2.58 episodes per 1000 CL days at baseline to 2.02 episodes per 1000 CL days (P < 0.01) during the intervention period.

LESSONS LEARNED

Adiós Bacteriemias was effective in reducing the incidence of CLABSI and improving the adherence to good practices for CL insertion and maintenance processes in participating ICUs in Latin America.

Managing and preventing vascular catheter infections: A position paper of the international society for infectious diseases

A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview recommendations on managing and preventing vascular catheter infections, specifically for the prevention and management of central line-associated bloodstream infections. These recommendations are intended to provide insight for healthcare professionals regarding the prevention of infection in the placement and maintenance of the catheter and diagnosis as well as treatment of catheter infection. Aspects of this area in pediatrics and in limited-resource situations and a discussion regarding the selection of empiric or targeted antimicrobial therapy are particular strengths of this position paper.

Breaking the Chain of Infection in Older Adults: A Review of Risk Factors and Strategies for Preventing Device-Related Infections

Device-related infections (DRIs) are a significant cause of morbidity and mortality among older adults. Indwelling devices (urinary catheters, percutaneous feeding tubes, and central venous catheters) are frequently used in this vulnerable population. Indwelling devices provide a portal of entry for pathogenic organisms to invade a susceptible host and cause infection and are an important target for infection prevention and antimicrobial stewardship efforts. Within the "Chain of Infection" that leads to DRIs in older adults, multiple opportunities exist to implement interventions that "break the links" and reduce colonization with multidrug-resistant organisms, reduce infections, and improve antimicrobial use.

An observational case study of hospital associated infections in a critical care unit in Astana, Kazakhstan

Background

Hospital Associated infections (HAI) are very common in Intensive Care Units (ICU) and are usually associated with use of invasive devices in the patients. This study was conducted to determine the prevalence and etiological agents of HAI in a Surgical ICU in Kazakhstan, and to assess the impact of these infections on ICU stay and mortality.

Objective

To assess the rate of device-associated infections and causative HAI etiological agents in an ICU at the National Research Center for Oncology and Transplantation (NRCOT) in Astana, Kazakhstan.

Methods

This retrospective, observational study was conducted in a 12-bed ICU at the NRCOT, Astana, Kazakhstan. We enrolled all patients who were admitted to the ICU from January, 2014 through November 2015, aged 18 to 90 years of age who developed an HAI.

Results

The most common type of HAI was surgical site infection (SSI), followed by ventilator-associated pneumonia (VAP), catheter-related blood stream infection (BSI) and catheter-associated urinary tract infection (UTI). The most common HAI was SSI with Pseudomonas aeruginosa as the most common etiological agent. The second most common HAI was VAP also with P. aeruginosa followed by BSI which was also associated with P. aeruginosa (in 2014) and Enterococcus faecalis, and Klebsiella pneumoniae (in 2015) as the most common etiological agents causing these infections.

Conclusion

We found that HAI among our study population were predominantly caused by gram-negative pathogens, including P. aeruginosa, K. pneumoniae, and E. coli. To our knowledge, this is the only study that describes ICU-related HAI situation from a country within the Central Asian region. Many developing countries such as Kazakhstan lack surveillance systems which could effectively decrease incidence of HAIs and healthcare costs for their treatment. The epidemiological data on HAI in Kazakhstan currently is underrepresented and poorly reported in the literature. Based on this and previous studies, we propose that the most important interventions to prevent HAI at the NRCOT and similar Healthcare Institutions in Kazakhstan are active surveillance, regular infection control audits, rational and effective antibacterial therapy, and general hygiene measures.

Anti-fouling strategies for central venous catheters

Central venous catheters (CVCs) are ubiquitous in the healthcare industry and carry two common complications, catheter related infections and occlusion, particularly by thrombus. Catheter-related bloodstream infections (CRBSI) are an important cause of nosocomial infections that increase patient morbidity, mortality, and hospital cost. Innovative design strategies for intravenous catheters can help reduce these preventable infections. Antimicrobial coatings can play a major role in preventing disease. These coatings can be divided into two major categories: drug eluting and non-drug eluting. Much of these catheter designs are targeted at preventing the formation of microbial biofilms that make treatment of CRBSI nearly impossible without removal of the intravenous device. Exciting developments in catheter impregnation with antibiotics as well as nanoscale surface design promise innovative changes in the way that physicians manage intravenous catheters. Occlusion of a catheter renders the catheter unusable and is often treated by tissue plasminogen activator administration or replacement of the line. Prevention of this complication requires a thorough understanding of the mechanisms of platelet aggregation, signaling and cross-linking. This article will look at the advances in biomaterial design specifically drug eluting, non-drug eluting, lubricious coatings and micropatterning as well as some of the characteristics of each as they relate to CVCs.

Efficacy of a care bundle to prevent multiple infections in the intensive care unit: A quasi-experimental pretest-posttest design study

BACKGROUND

Healthcare-associated infections extend hospitalization time, increase treatment costs and increase morbidity-mortality rates.

OBJECTIVES

To evaluate the efficacy of a care bundle aimed at preventing three most frequent intensive care unit-acquired infections.

MATERIALS AND METHOD

This quasi-experimental study occurred in an 18-bed tertiary care intensive care unit at a university hospital in Turkey. The sample consisted of 120 patients older than 18years and receiving invasive mechanical ventilation therapy, or had a central venous catheter or urinary catheter. The study comprised three stages. In stage one, the intensive care unit nurses were trained in infection measures, VAP, CA-UTIs and CLABSIs sections of the care bundle. In stage two, the trained nurses applied the care bundle and received feedback on any problematic issues. In stage three, the nurses' compatibility and efficacy of the infection prevention care bundle on the infection rates of VAP, CA-UTIs and CLABSIs were evaluated over three 3-month periods.

RESULTS

Over 1000 ventilation days, ventilator-associated pneumonia infection rates were 23.4, 12.6, and 11.5, during January-March, April-June and July-September, respectively, with January-March and April-June showing a significant decrease (χ²=6.934, p=0.031). The central line-associated bloodstream infection rates were 8.9, 4.2, and 9.9 per 1000 catheter days, during January-March, April-June and July-September, respectively, but were not significantly different based on pair-wise comparisons (p>0.05). The catheter-associated urinary tract infection rates were higher during July-September (6.7/1000 catheter days) compared to January-March (5.7/1000 catheter days) and April-June (10.4/1000 catheter days) but the differences were not significant (p>0.05).

CONCLUSIONS

The infection rates decreased with increased compatibility of the care bundle prepared from evidence-based guidelines.

Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India

Objective

To evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India.

Design

This prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center.

Setting

We conducted this study over a period of 16 months at a tertiary care referral medical center.

Participants

All patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled.

Intervention and main outcome measures

Patient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done.

Results

There were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality.

Conclusions

Our results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses' chart for site inspection and alerts in all shifts are some measures planned at our center.

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.

Poor adherence to guidelines for preventing central line-associated bloodstream infections (CLABSI): results of a worldwide survey

Background

Central line-associated bloodstream infections (CLABSI) are a cause of increased morbidity and mortality, and are largely preventable. We documented attitudes and practices in intensive care units (ICUs) in 2015 in order to assess compliance with CLABSI prevention guidelines.

Methods

Between June and October 2015, an online questionnaire was made available to medical doctors and nurses working in ICUs worldwide. We investigated practices related to central line (CL) insertion, maintenance and measurement of CLABSI-related data following the SHEA guidelines as a standard. We computed weighted estimates for high, middle and low-income countries using country population as a weight. Only countries providing at least 10 complete responses were included in these estimates.

Results

Ninety five countries provided 3407 individual responses; no low income, 14 middle income (MIC) and 27 high income (HIC) countries provided 10 or more responses. Of the total respondents, 80% (MIC, SE = 1.5) and 81% (HIC, SE = 1.0) reported availability of written clinical guidelines for CLABSI prevention in their ICU; 23% (MIC,SE = 1.7) and 62% (HIC,SE = 1.4) reported compliance to the following (combined) recommendations for CL insertion: hand hygiene, full barrier precaution, chlorhexidine >0.5%, no topic or systemic antimicrobial prophylaxis; 60% (MIC,SE = 2.0) and 73% (HIC,SE = 1.2) reported daily assessment for the need of a central line. Most considered CLABSI measurement key to quality improvement, however few were able to report their CLABSI rate. Heterogeneity between countries was high and country specific results are made available.

Conclusions

This study has identified areas for improvement in CLABSI prevention practices linked to CL insertion and maintenance. Priorities for intervention differ between countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0139-y) contains supplementary material, which is available to authorized users.

[Essential measures for prehospital treatment of severely injured patients: The trauma care bundle]

BACKGROUND

In order to ensure adequate treatment and to avoid complications, care bundles are increasingly being implemented. These are comprehensive and evidence-based procedures for the treatment of individual diseases or injuries which should be carried out for every patient. The aim of this study was to define a care bundle for the prehospital treatment of severely injured patients.

MATERIAL AND METHODS

The scientific contents of the bundle were gathered from the interdisciplinary evidence-based S3 guidelines for the treatment of severely injured patients by the German Trauma Society. The ABCDE scheme suggested by the prehospital trauma life support (PHTLS®) and the advanced trauma life support (ATLS®) functioned as a matrix for the individual elements in the bundles. The identified elements were finalized by a consensus process.

RESULTS AND DISCUSSION

A bundle of six elements was suggested and a comprehensive summary of key items during prehospital management of severely injured patients was identified. In a next step the effectiveness of the care bundle should be evaluated in a clinical trial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESOURCES

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

COMMENTS

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

Predicting clinical outcomes in patients with negative peripheral and positive central blood culture with coagulase negative Staphylococcus species

OBJECTIVES

Clinical outcomes in patients with negative peripheral and positive central blood culture with coagulase negative staphylococci (CoNS) based on different treatment approach such as intravenous antibiotics, removal of CVC, combined approach or just observation are not known.

METHODS

We conducted a retrospective review of patients with negative peripheral and paired positive central blood culture with CoNS admitted at our affiliated hospital between 2008 to 2013. We compared clinical outcomes such as bacteremia, catheter related blood stream infection (CRBSI), mortality and Intensive care unit (ICU) admission over the next 90 days between the 4 groups based on the treatment approach: (1) No treatment received, 2) catheter removed, no antibiotics administered, 3) antibiotics administered, catheter not removed and 4) antibiotics administered, catheter removed). Logistic regression was used to assess the association between treatment approach and outcomes after adjusting for confounding variables.

RESULTS

181 patients were included in the study and followed for 90 days after their initial positive blood cultures. 25 patients (14%) had bacteremia, 4 patients (2%) had CRBSI, 40 patients (22%) died and 10 patients (6%) had an ICU admission in the next 90 days. None of the outcomes differed statistically between the 4 groups.

CONCLUSION

Our study is the first to report no difference in the clinical outcomes in patients with negative peripheral and positive central blood culture with CoNS when compared based on treatment approach. Our study provides initial evidence that treating patients with an isolated central blood culture with CoNS does not change short term clinical outcomes.

Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis

BACKGROUND

Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections.

METHODS

We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models.

FINDINGS

We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2-46·3; IQR 3·1-9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6-31·1; 4·8-9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6-24·1; 3·7-16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2-4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8-10·9) to 2·5 per 1000 catheter-days (1·4-4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39-0·50, p<0·0001; I(2)=89%).

INTERPRETATION

Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs.

FUNDING

None.

Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC)

BACKGROUND

Three-way stopcocks (3WSCs) are open systems used on intravenous tubing. Split septums (SSs) are closed systems with prepierced septums. Single-use prefilled flushing devices (SUFs) carry a lower risk of contamination than standard intravenous flushing. 3WSC and standard flushing are widely used in developing countries. This is the first randomized clinical trial (RCT) to compare rates of central line-associated bloodstream infection (CLABSI) between patients using an SS + SUF and those using a 3WSC.

METHODS

An RCT with 1096 patients in 5 adult intensive care units was conducted between April 2012 and August 2014 to evaluate their impact on CLABSI rates. Centers for Disease Control and Prevention/National Healthcare Safety Network definitions were applied and International Nosocomial Infection Control Consortium methodology were followed.

RESULTS

The study cohort included 547 patients and 3619 central line (CL)-days for the SS + SUF group, and 549 patients and 4061 CL-days for the 3WSC group. CLABSI rates were 2.21 per 1000 CL-days for SS + SUF and 6.40 per 1000 CL-days for 3WSC (relative risk, 0.35; 95% confidence interval [CI], 0.16-0.76; P = .006). The SS + SUF group had significantly better cumulative infection-free catheter survival compared with the 3WSC group (hazard ration, 0.33; 95% CI, 0.15-0.73; P = .006). Using an SS + SUF represents savings of $402.88 and an increase in quality-adjusted life years of 0.0008 per patient. For each extra dollar invested in an SS + SUF, $124 was saved.

CONCLUSION

The use of SS + SUF is cost-effective and associated with a significantly lower CLABSI rate compared with the use of 3WSC.

Improving compliance with central venous catheter care bundles using electronic records

BACKGROUND

Health care associated infections are a major contributor to avoidable harm experienced by patients in modern health care settings. Recent reports suggest that electronic checklists for the documentation of a central line bundle may significantly enhance documented process compliance and help to reduce catheter-related bloodstream infection rates.

AIMS

This paper describes the use of our electronic tool to monitor and feedback process compliance in conjunction of introducing bespoke central line insertion packs to tackle catheter-related bloodstream infections in our intensive care unit in a medium-sized district general hospital.

DESIGN AND METHODS

Continuous quality improvement programme with 'Plan-Do-Study-Act' cycles was implemented. The central venous catheter insertion and maintenance bundle was rolled out in 2007. To monitor compliance with the bundle elements, an electronic tool was designed as part of our bedside Clinical Information System. From 2009, regular quarterly feedback was provided on the number of central venous catheter lines inserted, compliance with the insertion and maintenance bundle and catheter-related bloodstream infection rate using the data collected through the Clinical Information System. We have also introduced dedicated line insertion trolleys and factory-prepared insertion packs. We used segmented regression analysis to assess the changes in the catheter-related bloodstream infection rate before and after implementation of the central venous catheter bundle.

RESULTS

Bundle compliance increased during the implementation period and reached over 95% within 6 months. We observed a significant reduction in the catheter-related bloodstream infection rate from 15.6/1000 days to 0.4/1000 days. Regression analysis showed that only the compliance had significant effect on the number and prevalence of catheter-related bloodstream infections.

CONCLUSION/IMPLICATIONS

Implementation of evidence-based care bundles reinforced by real-time feedback on the performance of caregivers can significantly reduce the rate of catheter-related bloodstream infection in the intensive care unit. Ensuring that change processes are seamlessly integrated in the workflow with minimal administrative burden is crucial to the quality improvement process.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part I: Effectiveness of a Multidimensional Infection Control Approach on Catheter-Associated Urinary Tract Infection Rates in Pediatric Intensive Care Units of 6 Developing Countries

Design.

A before-after prospective surveillance study to assess the impact of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infection (CAUTI) rates.

Setting.

Pediatric intensive care units (PICUs) of hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of the following 6 developing countries: Colombia, El Salvador, India, Mexico, Philippines, and Turkey.

Patients.

PICU inpatients.

Methods.

We performed a prospective active surveillance to determine rates of CAUTI among 3,877 patients hospitalized in 10 PICUs for a total of 27,345 bed-days. The study was divided into a baseline period (phase 1) and an intervention period (phase 2). In phase 1, surveillance was performed without the implementation of the multidimensional approach. In phase 2, we implemented a multidimensional infection control approach that included outcome surveillance, process surveillance, feedback on CAUTI rates, feedback on performance, education, and a bundle of preventive measures. The rates of CAUTI obtained in phase 1 were compared with the rates obtained in phase 2, after interventions were implemented.

Results.

During the study period, we recorded 8,513 urinary catheter (UC) days, including 1,513 UC-days in phase 1 and 7,000 UC-days in phase 2. In phase 1, the CAUTI rate was 5.9 cases per 1,000 UC-days, and in phase 2, after implementing the multidimensional infection control approach for CAUTI prevention, the rate of CAUTI decreased to 2.6 cases per 1,000 UC-days (relative risk, 0.43 [95% confidence interval, 0.21–1.0]), indicating a rate reduction of 57%.

Conclusions.

Our findings demonstrated that implementing a multidimensional infection control approach is associated with a significant reduction in the CAUTI rate of PICUs in developing countries.

Attributable Cost and Length of Stay for Patients With Central Venous Catheter—Associated Bloodstream Infection in Mexico City Intensive Care Units A Prospective, Matched Analysis

Background.

No information is available about the financial impact of central venous catheter (CVC)-associated bloodstream infection (BSI) in Mexico.

Objective.

To calculate the costs associated with BSI in intensive care units (ICUs) in Mexico City.

Design.

An 18-month (June 2002 through November 2003), prospective, nested case-control study of patients with and patients without BSI.

Setting.

Adult ICUs in 3 hospitals in Mexico City.

Patients and Methods.

A total of 55 patients with BSI (case patients) and 55 patients without BSI (control patients) were compared with respect to hospital, type of ICU, year of hospital admission, length of ICU stay, sex, age, and mean severity of illness score. Information about the length of ICU stay was obtained prospectively during daily rounds. The daily cost of ICU stay was provided by the finance department of each hospital. The cost of antibiotics prescribed for BSI was provided by the hospitals' pharmacy departments.

Results.

For case patients, the mean extra length of stay was 6.1 days, the mean extra cost of antibiotics was $598, the mean extra hospital cost was $11,591, and the attributable extra mortality was 20%.

Conclusions.

In this study, the duration of ICU stay for patients with central venous catheter-associated BSI was significantly longer than that for control patients, resulting in increased healthcare costs and a higher attributable mortality. These conclusions support the need to implement preventive measures for hospitalized patients with central venous catheters in Mexico.

Prevention of Central Venous Catheter-Associated Bloodstream Infections in Pediatric Intensive Care Units A Performance Improvement Collaborative

Objective.

The goal of this effort was to reduce central venous catheter (CVC)-associated bloodstream infections (BSIs) in pediatric intensive care unit (ICU) patients by means of a multicenter evidence-based intervention.

Methods.

An observational study was conducted in 26 freestanding children's hospitals with pediatric or cardiac ICUs that joined a Child Health Corporation of America collaborative. CVC-associated BSI protocols were implemented using a collaborative process that included catheter insertion and maintenance bundles, daily review of CVC necessity, and daily goals. The primary goal was either a 50% reduction in the CVC-associated BSI rate or a rate of 1.5 CVC-associated BSIs per 1,000 CVC-days in each ICU at the end of a 9-month improvement period. A 12-month sustain period followed the initial improvement period, with the primary goal of maintaining the improvements achieved.

Results.

The collaborative median CVC-associated BSI rate decreased from 6.3 CVC-associated BSIs per 1,000 CVC-days at the start of the collaborative to 4.3 CVC-associated BSIs per 1,000 CVC-days at the end of the collaborative. Sixty-five percent of all participants documented a decrease in their CVC-associated BSI rate. Sixty-nine CVC-associated BSIs were prevented across all teams, with an estimated cost avoidance of $2.9 million. Hospitals were able to sustain their improvements during a 12-month sustain period and prevent another 198 infections.

Conclusions.

We conclude that our collaborative quality improvement project demonstrated that significant reduction in CVC-associated BSI rates and related costs can be realized by means of evidence-based prevention interventions, enhanced communication among caregivers, standardization of CVC insertion and maintenance processes, enhanced measurement, and empowerment of team members to enforce adherence to best practices.

Device-related infections in long-term healthcare facilities: the challenge of prevention

The world is aging and the number of elderly multimorbid patients is steadily increasing. The limited numbers of acute care beds in hospitals, in addition to the need to reduce costs, has led to the introduction of efficient discharge policies, which in turn have increased demand for beds in nursing homes and long-term care facilities (LTCFs). As a consequence, the number of postacute LTCF residents is rising, as is the number of residents requiring complex medical care delivered by use of indwelling medical devices. These devices place patients at a heightened risk for infection. Furthermore, infection control resources in LTCFs are often limited. This article reviews the preventive measures that should be taken in LTCFs to reduce the risk of device-related infections.

Effectiveness of silver-impregnated central venous catheters for preventing catheter-related blood stream infections: a meta-analysis

OBJECTIVES

The purpose of this meta-analysis was to examine the effectiveness of silver-impregnated central venous catheters (CVCs) in preventing catheter bacterial colonization and catheter-related blood stream infections (CRBSIs).

METHODS

PubMed, Cochrane, and Embase databases were searched up to April 30, 2014. Studies in which other antiseptic reagents were used (e.g., chlorhexidine, octenidine dihydrochloride, urokinase rinses, benzalkonium chloride, rifampin-minocycline) were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Tests of heterogeneity and publication bias were performed.

RESULTS

Twelve studies were included in the meta-analysis. The studies enrolled a total of 2854 patients; 1440 received a standard CVC and 1414 received a silver-impregnated CVC. No significant difference in catheter bacterial colonization rates was found between silver-impregnated and standard CVCs (OR 0.907, 95% CI 0.758-1.087, p=0.290). No significant difference in CRBSI rates was found between silver-impregnated and standard CVCs (pooled OR 0.721, 95% CI 0.476-1.094, p=0.124). No significant heterogeneity or publication bias was noted.

CONCLUSIONS

Silver-impregnated CVCs are not associated with reduced rates of bacterial colonization or CRBSI.

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.

A Prevalence Survey of Intravascular Catheter use in a General Hospital

Purpose

Survey of intravascular catheter management is an essential step in the control and prevention of catheter-related infection. In recent years, most surveillance studies only included catheters from intensive care units (ICUs). Data regarding the level of care and adherence to international guidelines in a whole general institution are scarce. Our objective was to evaluate the care situation of intravascular catheters in our adult units of a General Hospital.

Methods

We surveyed adults hospitalized in non-psychiatric/maternity wards. In a week, a nurse visited all the adult hospitalized patients. Data were registered in a protocol that included variables, such as no. of catheters, location of catheter, type of catheter, date of placement and the need of an indication of each catheter in the visit day.

Results

We included in the study a total of 753 adult patients. Of them, 653 (86.7%) had one or more inserted catheters at the moment of the study visit (total: 797 catheters). Of all the catheters, 144 (18.0%) were central venous catheters and 653 (81.9%) were peripheral lines. The hospitalization units where the patients were admitted were ICU, 52 (6.9%); and non-ICU, 601 (92.0%). There were 183 (22.9%) catheters with no need to remain in place in the day of the study. Overall, we found 464 (71.0%) patients with one or more opportunities for catheter care improvement.

Conclusions

A rapid survey of the care situation of intravascular catheters is feasible and easy to do with our methodology. The data show great opportunity for improvement, mainly in the non-ICU areas.

The impact of central line insertion bundle on central line-associated bloodstream infection

BACKGROUND

Knowledge about the impact of each central line insertion bundle on central line-associated bloodstream infection (CLABSI) is limited.

METHODS

A quality-improvement intervention, including education, central venous catheter (CVC) insertion bundle, process and outcome surveillance, have been introduced since March 2013. Outcome surveillances, including CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days, and catheter utilization rates (days of catheter use divided by total inpatient-days), were measured. As a baseline measurement for a comparison, we retrospectively collected data from March 1, 2012 to December 31, 2012.

RESULTS

During this 10-month period, there were a total of 687 CVC insertions, and 627 (91.2%) insertions were performed by intensivists. The rate of CLABSI significantly declined from 1.65 per 1000 catheter-day during the pre-intervention period to 0.65 per 1000 catheter-day post-intervention period (P=0.039). CLABSI more likely developed in subjects in which a maximal sterile barrier was not used compared with subjects in which it was used (P=0.03). Moreover, CVC inserted by non-intensivists were more likely to become infected than CVC inserted by intensivists (P=0.010).

CONCLUSIONS

This multidisciplinary infection control intervention, including a central line insertion care bundle, can effectively reduce the rate of CLABSI. The impact of different care bundle varies, and a maximal sterile barrier precaution during catheter insertion is an essential component of the care line insertion bundle.

Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis

This systematic review and meta-analysis examines the impact of quality improvement interventions on central line-associated bloodstream infections in adult intensive care units. Studies were identified through Medline and manual searches (1995-June 2012). Random-effects meta-analysis obtained pooled odds ratios (ORs) and 95% confidence intervals (CIs). Meta-regression assessed the impact of bundle/checklist interventions and high baseline rates on intervention effect. Forty-one before-after studies identified an infection rate decrease (OR, 0.39 [95% CI, .33-.46]; P < .001). This effect was more pronounced for trials implementing a bundle or checklist approach (P = .03). Furthermore, meta-analysis of 6 interrupted time series studies revealed an infection rate reduction 3 months postintervention (OR, 0.30 [95% CI, .10-.88]; P = .03). There was no difference in infection rates between studies with low or high baseline rates (P = .18). These results suggest that quality improvement interventions contribute to the prevention of central line-associated bloodstream infections. Implementation of care bundles and checklists appears to yield stronger risk reductions.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

A multicenter quasi-experimental study: impact of a central line infection control program using auditing and performance feedback in five Belgian intensive care units

Background

We analyzed the impact associated with an intervention based on process control and performance feedback to decrease central line-associated bloodstream infection (CLABSI) rates.

This study was conducted from March 2011 to September 2012 in five adult intensive care units (ICU) located in two Belgian tertiary hospitals A and B, with a total of 53 beds.

Methods

This study was divided in three phases: P1 (baseline), P2 (intervention) and P3 (post intervention).

During P2, external monitoring of five central venous catheters (CVC) care critical processes and monthly reporting (meetings and feedbacks reports posted) of performance indicators (CLABSI rate, CVC utilization ratio, compliance rate with each care process, and insertion site) to ICU workers were performed. The external monitoring of process measures was assessed by the same trained research nurse.

A Poisson regression analysis was used to compare CLABSI incidence density rate per phase. Statistical significance was achieved with 2-sided p-value of <0.05. For the analysis, we separated the five ICU in hospital A and B when appropriate.

Results

Significantly improved total mean compliance was achieved for hand hygiene, CVC handling and CVC dressing. CLABSI rate declined from 4.00 (95% confidence interval (CI): 1.94-6.06) to 1.81 (0.46-3.17) per 1,000 CVC-days in P2 with an incidence rate ratio (IRR) of 0.49 (0.24-0.98, p = 0.043). A better response was observed in hospital A where the nurse participation at the monthly meeting was significantly higher than in hospital B (p < 0.001) as the percentage of feedbacks reports posted in ICU (p < 0.001). The decline in the CLABSI rate observed during P2 in comparison with P1 was independent of the insertion site (femoral or non-femoral; p = 0.054). The overall CLABSI rate increased to 2.73 (1.17-4.29) per 1,000 CVC-days with IRR of 0.67 (0.36-1.26, p = 0.212) in P3 compared to P1, but a high nursing turnover was observed in both hospitals.

Conclusions

Our intervention focused on external auditing and performance feedback resulted in significant reduction in rates of CLABSI. Investigation continues regarding the most effective way to sustain CLABSI prevention practices and to improve the culture of safety in healthcare.

Implementing the central venous catheter infection prevention bundle in the emergency department: experiences among early adopters

STUDY OBJECTIVE

Central line-associated bloodstream infections (CLABSI) cause preventable morbidity and mortality. Hospitals have reduced CLABSI by using a bundle of evidence-based infection prevention practices. Systems factors in the emergency department (ED) present unique barriers to bundle adoption, and no guidelines exist for bundle implementation. We aim to identify barriers and facilitators to central line bundle adoption in EDs.

METHODS

We used a qualitative, grounded theory approach, enrolling 6 EDs that were early adopters of the central line bundle. We interviewed 49 administrators and staff (nurses and physicians) through 26 semistructured interviews and 3 focus groups of 6 to 8 individuals. Investigators read each transcript and then iteratively built and refined a set of themes that emerged from the data.

RESULTS

Barriers to central line bundle adoption included high acuity, time constraints, staffing, space, ED culture, high ED volume and acuity, role ambiguity, and a lack of methods to track compliance and infection surveillance. Facilitators included champions, staff engagement, workflow redesign that includes a checklist and central line kit or cart, clear staff responsibilities, observer empowerment, and compliance and infection surveillance data.

CONCLUSION

The strategies for implementing and sustaining a central line infection prevention bundle in the ED are distinct from those of other clinical settings. Our findings describe the central line bundle workflow in the ED, staff motivations, and the critical systems factors that impede and foster its use. Knowledge of these systems factors should improve bundle adoption in the ED and thereby reduce hospital incidence of CLABSIs.

Impact of an international nosocomial infection control consortium multidimensional approach on central line-associated bloodstream infection rates in adult intensive care units in eight cities in India

OBJECTIVE

To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach on central line-associated bloodstream infection (CLABSI) rates in eight cities of India.

METHODS

This was a prospective, before-and-after cohort study of 35650 patients hospitalized in 16 adult intensive care units of 11 hospitals. During the baseline period, outcome surveillance of CLABSI was performed, applying the definitions of the CDC/NHSN (US Centers for Disease Control and Prevention/National Healthcare Safety Network). During the intervention, the INICC approach was implemented, which included a bundle of interventions, education, outcome surveillance, process surveillance, feedback on CLABSI rates and consequences, and performance feedback. Random effects Poisson regression was used for clustering of CLABSI rates across time periods.

RESULTS

During the baseline period, 9472 central line (CL)-days and 61 CLABSIs were recorded; during the intervention period, 80898 CL-days and 404 CLABSIs were recorded. The baseline rate was 6.4 CLABSIs per 1000 CL-days, which was reduced to 3.9 CLABSIs per 1000 CL-days in the second year and maintained for 36 months of follow-up, accounting for a 53% CLABSI rate reduction (incidence rate ratio 0.47, 95% confidence interval 0.31-0.70; p=0.0001).

CONCLUSIONS

Implementing the six components of the INICC approach simultaneously was associated with a significant reduction in the CLABSI rate in India, which remained stable during 36 months of follow-up.

Impact of a multidimensional infection control approach on central line-associated bloodstream infections rates in adult intensive care units of 8 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

Background

Central line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey.

Methods

We conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention.

Results

During baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 – 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB.

Conclusions

The implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Prevention of nosocomial infections in developing countries, a systematic review

BACKGROUND

Prevention of nosocomial infection is key to providing good quality, safe healthcare. Infection control programmes (hand-hygiene campaigns and antibiotic stewardship) are effective in reducing nosocomial infections in developed countries. However, the effectiveness of these programmes in developing countries is uncertain.

OBJECTIVE

To evaluate the effectiveness of interventions for preventing nosocomial infections in developing countries.

METHODS

A systematic search for studies which evaluated interventions to prevent nosocomial infection in both adults and children in developing countries was undertaken using PubMed. Only intervention trials with a randomized controlled, quasi-experimental or sequential design were included. Where there was adequate homogeneity, a meta-analysis of specific interventions was performed using the Mantel-Haenzel fixed effects method to estimate the pooled risk difference.

RESULTS

Thirty-four studies were found. Most studies were from South America and Asia. Most were before-and-after intervention studies from tertiary urban hospitals. Hand-hygiene campaigns that were a major component of multifaceted interventions (18 studies) showed the strongest effectiveness for reducing nosocomial infection rates (median effect 49%, effect range 12.7-100%). Hand-hygiene campaigns alone and studies of antibiotic stewardship to improve rational antibiotic use reduced nosocomial infection rates in three studies [risk difference (RD) of -0.09 (95%CI -0.12 to -0.07) and RD of -0.02 (95% CI -0.02 to -0.01), respectively].

CONCLUSIONS

Multifaceted interventions including hand-hygiene campaigns, antibiotic stewardship and other elementary infection control practices are effective in developing countries. The modest effect size of hand-hygiene campaigns alone and negligible effect size of antibiotic stewardship reflect the limited number of studies with sufficient homogeneity to conduct meta-analyses.

Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings

BACKGROUND

Little data exist on the burden of device-associated health care-associated infection (DA-HAI) in China. This study examined the DA-HAI rate and evaluated its association with device use (DU), length of stay (LOS), and mortality in intensive care units (ICUs) in 4 Chinese hospitals.

METHODS

This was a prospective cohort surveillance study conducted in 7 ICUs in 4 hospitals. We applied International Nosocomial Control Consortium methods and Centers for Disease Control and Prevention (CDC)/National Health and Safety Network (NHSN) definitions to determine rates of central line-associated blood stream infection (CLABSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), DU, crude extra length of hospital stay (LOS), and mortality.

RESULTS

Between August 2008 and July 2010, there were a total of 2,631 admissions to the 7 ICUs in the study hospitals. The rate of VAP was 10.46/1,000 mechanical ventilator (MV)-days, the CLABSI rate was 7.66/1,000 central line (CL)-days, and the CAUTI rate was 1.29/1,000 urinary catheter (UC)-days. Pooled DU ratios were 0.43 for MV, 0.71 for CL, and 0.76 for UC. Crude extra LOS was 15 days for patients with CLABSI, 20.5 days for patients with VAP, and 27 days for patients with CAUTI. Crude extra mortality was 14% for patients with CLABSI, 22% for patients with VAP, and 43% for patients with CAUTI.

CONCLUSIONS

In the study ICUs, VAP and CLABSI rates were higher than CDC/NHSN's reported data, and LOS and mortality were increased. Compared with the CDC/NHSN and INICC data, the pooled DU ratio for MV was similar, and DU ratios for CL and UC use ratios were slightly higher.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Effectiveness of a multidimensional approach for the prevention of ventilator-associated pneumonia in an adult intensive care unit in Cuba: findings of the International Nosocomial Infection Control Consortium (INICC)

OBJECTIVE

This study sought to assess the effect of the multidimensional approach developed by the International Nosocomial Infection Control Consortium (INICC) on the reduction of ventilator-associated pneumonia (VAP) rates in patients hospitalized in an adult intensive care unit (AICU) in an INICC member hospital in Havana, Cuba.

METHODS

We conducted a prospective surveillance pre-post study in AICU patients. The study was divided into two periods:baseline and intervention. During the baseline period, we conducted active prospective surveillance of VAP using the Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) definition and INICC methods. During the intervention period, we implemented the INICC multidimensional approach for VAP, in addition to performing active surveillance. This multidimensional approach included the following measures: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback of VAP rates and performance feedback of infection control practices. The baseline rates of VAP were compared to the rates obtained after intervention, and we analyzed the impact of our interventions by Poisson regression.

RESULTS

During the baseline period, we recorded 114 mechanical ventilator (MV) days, whereas we recorded 2350MV days during the intervention period. The baseline rate of VAP was 52.63 per 1000MV days and 15.32 per 1000MV days during the intervention. At the end of the study period, we achieved a 70% reduction in the rate of VAP (RR, 0.3; 95% CI, 0.12-0.7; P value, 0.003.).

CONCLUSIONS

The implementation the INICC multidimensional approach for VAP was associated with a significant reduction in the VAP rate in the participating AICU of Cuba.

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.