Open versus closed IV infusion systems: a state based model to predict risk of catheter associated blood stream infections

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Conflicts of interest in infection prevention and control research: no smoke without fire. A narrative review

Conflicts of interest (COIs) do occur in healthcare research, yet their impact on research in the field of infection prevention and control (IPC) is unknown. We conducted a narrative review aiming to identify examples of COIs in IPC research. In addition to well-known instances, we conducted PubMed and Google searches to identify and report case studies of COIs in IPC and antimicrobial resistance (AMR), which were chosen arbitrarily following consensus meetings, to illustrate different types of COIs. We also searched the Retraction Watch database and blog to systematically identify retracted IPC and/or infectious disease-related papers. Our review highlights COIs in academic research linked to ties between industry and physicians, journal editors, peer-reviewed journals' choice for publication, and guideline committees participants and authors. It explores how COIs can affect research and could be managed. We also present several selected case studies that involve (1) the chlorhexidine industry and how it has used marketing trials and key opinion leaders to promote off-label use of its products; (2) the copper industry and how reporting of its trials in IPC have furthered their agenda; (3) the influence of a company developing "closed infusion systems" for catheters and how this affects networks in low- and middle-income countries and guideline development; (4) potential perverse incentives hospitals may have in reporting healthcare-associated infection or AMR rates and how government intervention may restrict AMR research for fear of bad publicity and subsequent negative economic consequences. Finally, the analysis of reasons for the retraction of previously published papers highlights the fact that misconduct in research may have other motivations than financial gain, the most visible form of COIs. COIs occur in the field of research in general, and IPC and AMR are no exceptions. Their effects pervade all aspects of the research and publication processes. We believe that, in addition to improvements in management strategies of COIs, increased public funding should be available to decrease researchers' dependency on industry ties. Further research is needed on COIs and their management.

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.

Itemizing the bundle: achieving and maintaining "zero" central line-associated bloodstream infection for over a year in a tertiary care hospital in Saudi Arabia

BACKGROUND

"Zero" central line-associated bloodstream infections (CLABSI) have not been reported from Asian countries, which usually have predominance of difficult to curtail gram negative infections. It also remains unclear whether lowering CLABSI rates below National Healthcare Safety Network (NHSN) benchmarks in such countries is even possible. In this study, we evaluated effects of a quality improvement initiative to achieve "Zero CLABSI" in our intensive care unit.

METHODS

A root cause analysis in February 2010 identified problems with clinical practice, environment, and products. Extensive education sessions were followed by implementation of strategies in the form of "itemized" bundles derived from practice guidelines, with complete enforcement starting August 2010. Results were benchmarked against NHSN data. Data were analyzed in a preintervention (1 year) and postintervention (2 years) fashion, using Poisson regression analysis to generate incidence-rate ratio (IRR).

RESULTS

In the preintervention period, CLABSI rate was 6.9/1,000 catheter-days (CDs) (35 CLABSI/5,083 CDs). In the postintervention year 1, rate was 1.06/1,000 CDs (4 CLABSI/3,787 CDs) with IRR of 0.15 (95% confidence interval: 0.04-0.44, P < .001) and reduction of 85%. In postintervention year 2, rate was 0.35/1,000 CDs (1/2,860 CDs) with IRR of 0.05 (95% confidence interval: 0.001-0.31, P < .001). There was a period of "Zero CLABSI" for 15 consecutive months, surpassing NHSN benchmarks.

CONCLUSION

CLABSIs can be eliminated in any intensive care unit regardless of the location and type of organism. NHSN data should be a realistic CLABSI benchmarking target for developing countries.

Comparative risk of bloodstream infection in hospitalized patients receiving intravenous medication by open, point-of-care, or closed delivery systems

PURPOSE

The impact of i.v. drug delivery via point-of-care (POC)-activated and closed systems versus traditional manual admixture systems on the risk of hospital-acquired bloodstream infection (BSI) is examined.

METHODS

Using data from a proprietary hospital database, a retrospective observational cohort study of patients receiving one or more i.v. drug administrations via POC-activated or closed systems during a three-year period (2007-09) was conducted. Cases of hospital-acquired BSI were identified using diagnosis codes and billing charges for blood cultures and antibiotic use. The risk of BSI in patients with exposure to POC-activated systems, closed systems, or both relative to that of patients exposed to open systems was estimated by odds ratios (ORs) calculated by multivariate logistic regression analysis.

RESULTS

The evaluated data indicated that of the 4,073,864 patients included in the study cohort, 0.5% (n = 20,251) experienced hospital-acquired BSI. After adjusting for selected confounding variables, the use of POC-activated systems was associated with a 16% reduction in BSI risk relative to the use of open systems (OR, 0.84; 95% confidence interval [CI], 0.76-0.93), and the use of closed systems correlated with a 12% risk reduction (OR, 0.88; 95% CI, 0.82-0.96). Patients who received i.v. drugs via both POC-activated and closed systems appeared to derive the greatest relative risk reduction benefit (OR, 0.12; 95% CI, 0.06-0.23).

CONCLUSION

Use of POC-activated and closed systems for i.v. drug delivery was associated with a significantly reduced risk of hospital-acquired BSI compared with exclusive use of open systems in a large population of hospitalized patients.