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Rosenthal VD, Jin Z, Brown EC, Dongol R, De Moros DA, Alarcon-Rua J, Perez V, Stagnaro JP, Alkhawaja S, Jimenez-Alvarez LF, Cano-Medina YA, Valderrama-Beltran SL, Henao-Rodas CM, Zuniga-Chavarria MA, El-Kholy A, Agha H, Sahu S, Mishra SB, Bhattacharyya M, Kharbanda M, Poojary A, Nair PK, Myatra SN, Chawla R, Sandhu K, Mehta Y, Rajhans P, Abdellatif-Daboor M, Chian-Wern T, Gan CS, Mohd-Basri MN, Aguirre-Avalos G, Hernandez-Chena BE, Sassoe-Gonzalez A, Villegas-Mota I, Aleman-Bocanegra MC, Bat-Erdene I, Carreazo NY, Castaneda-Sabogal A, Janc J, Hlinkova S, Yildizdas D, Havan M, Koker A, Sungurtekin H, Dinleyici EC, Guclu E, Tao L, Memish ZA, Yin R. Decreasing central line-associated bloodstream infections rates in intensive care units in 30 low- and middle-income countries: An INICC approach. Am J Infect Control 2024; 52:580-587. [PMID: 38154739 DOI: 10.1016/j.ajic.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
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.
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Affiliation(s)
- Victor D Rosenthal
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Infection Prevention, INICC Foundation, International Nosocomial Infection Control Consortium, Miami, USA.
| | - Zhilin Jin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eric C Brown
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Reshma Dongol
- Department of Infection Prevention, Grande International Hospital, Kathamandu, Nepal
| | - Daisy A De Moros
- Department of Infection Prevention, Hospital Del Nino Dr Jose Renan Esquivel De Panama, Panama, Panama
| | - Johana Alarcon-Rua
- Department of Infection Prevention, Clinica Sebastian De Belalcazar, Cali, Colombia
| | - Valentina Perez
- Department of Biological Sciences, Florida International University, Miami, Fl, USA
| | - Juan P Stagnaro
- Department of Infection Prevention, Instituto Central De Medicina, Provincia De Buenos Aires, La Plata, Argentina
| | - Safaa Alkhawaja
- Department of Infection Prevention, Salmaniya Medical Complex, Manama, Bahrain
| | | | - Yuliana A Cano-Medina
- Department of Infection Prevention, Instituto Del Corazon De Bucaramanga, Bogota, Colombia
| | - Sandra L Valderrama-Beltran
- Department of Infection Prevention, Pontificia Universidad Javeriana Hospital Universitario San Ignacio, Bogota, Colombia
| | - Claudia M Henao-Rodas
- Department of Infection Prevention, Fundacion Hospital San Jose De Buga, Guadalajara De Buga, Colombia
| | - Maria A Zuniga-Chavarria
- Department of Infection Prevention, Hospital Clinica Biblica, San Jose De Costa Rica, Costa Rica
| | - Amani El-Kholy
- Department of Infection Prevention, Dar Alfouad Hospital 6th Of October City, 6th Of October City, Egypt
| | - Hala Agha
- Department of Infection Prevention, Cairo University Specialized Pediatric Hospital Cardio Thoracic Icu, Cairo, Egypt
| | - Suneeta Sahu
- Department of Infection Prevention, Apollo Hospital Bhubaneswar, Bhubaneswar, India
| | - Shakti B Mishra
- Department of Infection Prevention, IMS And SUM Hospital, Bhubaneswar, India
| | - Mahuya Bhattacharyya
- Department of Infection Prevention, Advanced Medicare Research Institute Dhakuria Unit, Kolkata, India
| | - Mohit Kharbanda
- Department of Infection Prevention, Desun Hospital & Heart Institute Kolkata, Kolkata, India
| | - Aruna Poojary
- Department of Infection Prevention, Breach Candy Hospital Trust, Mumbai, India
| | - Pravin K Nair
- Department of Infection Prevention, Holy Spirit Hospital, Mumbai, India
| | - Sheila N Myatra
- Department of Critical Care, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Rajesh Chawla
- Department of Infection Prevention, Indraprastha Apollo Hospital Delhi, New Delhi, India
| | - Kavita Sandhu
- Department of Infection Prevention, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Yatin Mehta
- Department of Critical Care, Medanta The Medicity, New Delhi, India
| | - Prasad Rajhans
- Department of Infection Prevention, Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | | | - Tai Chian-Wern
- Department of Infection Prevention, Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Chin Seng Gan
- Department of Infection Prevention, University Malaya Medical Centre Pediatric Intensive Care, Kuala Lumpur, Malaysia
| | - Mat Nor Mohd-Basri
- Department of Infection Prevention, International Islamic University Malaysia Department Of Anesthesia And Critical Care, Kuantan, Malaysia
| | - Guadalupe Aguirre-Avalos
- Department of Critical Care, Hospital Civil De Guadalajara Fray Antonio Alcalde Terapia Intensiva, Guadalajara, Mexico
| | - Blanca E Hernandez-Chena
- Department of Infection Prevention, Hospital General Regional 6 De Ciudad Madero, Madero, Mexico
| | - Alejandro Sassoe-Gonzalez
- Department of Infection Prevention, Hospital Regional De Alta Especialidad De Ixtapaluca, Ixtapaluca, Mexico
| | - Isabel Villegas-Mota
- Department of Infection Prevention, Instituto Nacional De Perinatologia Unidad De Cuidados Intensivos Neonatales, Mexico City, Mexico
| | - Mary C Aleman-Bocanegra
- Department of Infection Prevention, Hospital San José De Monterrey Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Ider Bat-Erdene
- Department of Infection Prevention, Intermed Hospital, Ulaanbaatar, Mongolia
| | - Nilton Y Carreazo
- Department of Infection Prevention, Universidad Peruana de Ciencias Aplicadas, Hospital de Emergencias Pediatricas, Lima, Peru
| | | | - Jarosław Janc
- Department of Anesthesiology and Intensive Therapy, 4th Clinical Military Hospital with Polyclinic, Wroclaw, Poland
| | - Sona Hlinkova
- Department of Infection Prevention, Catholic University In Ruzomberok Faculty Of Health Central Military Hospital Snp Ruzomberok, Ruzomberok, Slovakia
| | - Dincer Yildizdas
- Department of Infection Prevention, Balcali Hospital Pediatric Intensive Care Unit, Adana, Turkey
| | - Merve Havan
- Department of Infection Prevention, Ankara University Faculty Of Medicine, Ankara, Turkey
| | - Alper Koker
- Department of Infection Prevention, Akdeniz University Medical School, Antalya, Turkey
| | - Hulya Sungurtekin
- Department of Infection Prevention, Pamukkale University Hospital, Denizli, Turkey
| | - Ener C Dinleyici
- Department of Infection Prevention, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ertugrul Guclu
- Department of Infection Prevention, Sakarya University Training And Research Hospital, Sakarya, Turkey
| | - Lili Tao
- Department of Infection Prevention, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ziad A Memish
- Department of Infection Prevention, King Saud Medical City, Ministry of Health, Riyadh, Arabia
| | - Ruijie Yin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Rosenthal VD, Yin R, Jin Z, Perez V, Kis MA, Abdulaziz-Alkhawaja S, Valderrama-Beltran SL, Gomez K, Rodas CMH, El-Sisi A, Sahu S, Kharbanda M, Rodrigues C, Myatra SN, Chawla R, Sandhu K, Mehta Y, Rajhans P, Arjun R, Tai CW, Bhakta A, Mat Nor MB, Aguirre-Avalos G, Sassoe-Gonzalez A, Bat-Erdene I, Acharya SP, Aguilar-de-Moros D, Carreazo NY, Duszynska W, Hlinkova S, Yildizdas D, Kılıc EK, Dursun O, Odek C, Deniz SSO, Guclu E, Koksal I, Medeiros EA, Petrov MM, Tao L, Salgado E, Dueñas L, Daboor MA, Raka L, Omar AA, Ikram A, Horhat-Florin G, Memish ZA, Brown EC. Examining the impact of a 9-component bundle and the INICC multidimensional approach on catheter-associated urinary tract infection rates in 32 countries across Asia, Eastern Europe, Latin America, and the Middle East. Am J Infect Control 2024:S0196-6553(24)00105-6. [PMID: 38437883 DOI: 10.1016/j.ajic.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Catheter-Associated Urinary Tract Infections (CAUTIs) frequently occur in the intensive care unit (ICU) and are correlated with a significant burden. METHODS We implemented a strategy involving a 9-element bundle, education, surveillance of CAUTI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CAUTI rates and performance feedback. This was executed in 299 ICUs across 32 low- and middle-income countries. The dependent variable was CAUTI per 1,000 UC days, assessed at baseline and throughout the intervention, in the second month, third month, 4 to 15 months, 16 to 27 months, and 28 to 39 months. Comparisons were made using a 2-sample t test, and the exposure-outcome relationship was explored using a generalized linear mixed model with a Poisson distribution. RESULTS Over the course of 978,364 patient days, 150,258 patients utilized 652,053 UC-days. The rates of CAUTI per 1,000 UC days were measured. The rates decreased from 14.89 during the baseline period to 5.51 in the second month (risk ratio [RR] = 0.37; 95% confidence interval [CI] = 0.34-0.39; P < .001), 3.79 in the third month (RR = 0.25; 95% CI = 0.23-0.28; P < .001), 2.98 in the 4 to 15 months (RR = 0.21; 95% CI = 0.18-0.22; P < .001), 1.86 in the 16 to 27 months (RR = 0.12; 95% CI = 0.11-0.14; P < .001), and 1.71 in the 28 to 39 months (RR = 0.11; 95% CI = 0.09-0.13; P < .001). CONCLUSIONS Our intervention, without substantial costs or additional staffing, achieved an 89% reduction in CAUTI incidence in ICUs across 32 countries, demonstrating feasibility in ICUs of low- and middle-income countries.
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Affiliation(s)
- Victor D Rosenthal
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Infection Control, INICC Foundation, International Nosocomial Infection Control Consortium, Miami, USA.
| | - Ruijie Yin
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, USA
| | - Zhilin Jin
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, USA
| | - Valentina Perez
- Department of Biological Sciences, Florida International University, Miami, USA
| | - Matthew A Kis
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, USA
| | | | - Sandra L Valderrama-Beltran
- Department of Infection Control, Pontificia Universidad Javeriana Hospital Universitario San Ignacio, Bogota, Colombia
| | - Katherine Gomez
- Department of Infection Control, Clinica Sebastian de Belalcazar, Cali, Colombia
| | - Claudia M H Rodas
- Department of Infection Control, Fundacion Hospital San Jose De Buga, Guadalajara de Buga, Colombia
| | - Amal El-Sisi
- Department of Pediatric Cardiac ICU, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Suneeta Sahu
- Department of Critical Care, Apollo Hospital Bhubaneswar, Bhubaneswar, India
| | | | - Camilla Rodrigues
- Department of Infection Control, Pd Hinduja National Hospital And Medical Research Centre, Mumbai, India
| | - Sheila N Myatra
- Department of Critical Care, Tata Memorial Hospital Homi Bhabha National Institute, Mumbai, India
| | - Rajesh Chawla
- Department of Critical Care, Indraprastha Apollo Hospital Delhi, New Delhi, India
| | - Kavita Sandhu
- Department of Critical Care, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Yatin Mehta
- Department of Critical Care, Medanta The Medicity, New Delhi, India
| | - Prasad Rajhans
- Department of Critical Care, Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | - Rajalakshmi Arjun
- Department of Critical Care, Kerala Institute Of Med Sciences Thiruvananthapuram, Thiruvananthapuram, India
| | - Chian-Wern Tai
- Department of Critical Care, Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Arpita Bhakta
- Department of Critical Care, University Malaya Medical Centre Pediatric Intensive Care, Kuala Lampur, Malaysia
| | - Mohd-Basri Mat Nor
- Department of Critical Care, International Islamic University Malaysia Department of Anesthesia and Critical Care, Kuantan, Malaysia
| | - Guadalupe Aguirre-Avalos
- Department of Critical Care, Hospital Civil De Guadalajara Fray Antonio Alcalde Terapia Intensiva, Guadalajara, Mexico
| | - Alejandro Sassoe-Gonzalez
- Department of Infection Control, Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca, Mexico
| | - Ider Bat-Erdene
- Department for Quality and Safety, Intermed Hospital, Ulaanbaatar, Mongolia
| | - Subhash P Acharya
- Department of Infection Control, Grande International Hospital, Kathamandu, Nepal
| | - Daisy Aguilar-de-Moros
- Department of Infection Control, Hospital del Nino Dr Jose Renan Esquivel de Panama, Panama, Panama
| | - Nilton Yhuri Carreazo
- Department of Infection Control, Universidad Peruana de Ciencias Aplicadas Hospital de Emergencias Pediatricas, Lima, Peru
| | - Wieslawa Duszynska
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Sona Hlinkova
- Department of Critical Care, Catholic University In Ruzomberok, Faculty of Health, Central Military Hospital SNP Ruzomberok, Ruzomberok, Slovakia
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Balcali Hospital, Adana, Turkey
| | - Esra K Kılıc
- Department of Critical Care, Ankara Training And Research Hospital, Ankara, Turkey
| | - Oguz Dursun
- Department of Critical Care, Akdeniz University Medical School, Antalya, Turkey
| | - Caglar Odek
- Department of Critical Care, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Suna S O Deniz
- Department of Critical Care, Pamukkale University Hospital, Denizli, Turkey
| | - Ertugrul Guclu
- Department of Critical Care, Sakarya University Training And Research Hospital, Sakarya, Turkey
| | - Iftihar Koksal
- Department of Critical Care, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Eduardo A Medeiros
- Department of Infection Control, Hospital Sao Paulo, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Michael M Petrov
- Department of Microbiology, Faculty of Pharmacy, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Lili Tao
- Department of Pneumonology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Estuardo Salgado
- Department of Infection Control, Hospital Marie Curie, Quito, Ecuador
| | - Lourdes Dueñas
- Department of Critical Care, Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador
| | - Mohammad A Daboor
- Department of Infection Control, King Hussein Cancer Center, Amman, Jordan
| | - Lul Raka
- Department of Public Health, National Institute For Public Health, Prishtina, Kosovo
| | - Abeer A Omar
- Department of Infection Control, Infection Control Directorate. Ministry of Health, Kuwait City, Kuwait
| | - Aamer Ikram
- Department of Critical Care, Armed Forces Institute of Urology, Rawalpindi, Pakistan
| | - George Horhat-Florin
- Department of Critical Care, University of Medicine and Pharmacy Victor Babes Timisoara Emergency Clinical County Hospital Romania,Timisoara, Romania
| | - Ziad A Memish
- Department of Infection Control, King Saud Medical City, Ministry of Health, Ryhad, Saudi Arabia
| | - Eric C Brown
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, USA
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Rosenthal VD, Yin R, Nercelles P, Rivera-Molina SE, Jyoti S, Dongol R, Aguilar-De-Moros D, Tumu N, Alarcon-Rua J, Stagnaro JP, Alkhawaja S, Jimenez-Alvarez LF, Cano-Medina YA, Valderrama-Beltran SL, Henao-Rodas CM, Zuniga-Chavarria MA, El-Kholy A, Agha HM, Sahu S, Anusandhan SO, Bhattacharyya M, Kharbanda M, Poojary A, Nair PK, Myatra SN, Chawla R, Sandhu K, Mehta Y, Rajhans P, Zand F, Abdellatif-Daboor M, Tai CW, Gan CS, Mat Nor MB, Aguirre-Avalos G, Hernandez-Chena BE, Sassoe-Gonzalez A, Villegas-Mota I, Aleman-Bocanegra MC, Bat-Erdene I, Carreazo NY, Castaneda-Sabogal A, Janc J, Belskiy V, Hlinkova S, Yildizdas D, Havan M, Koker A, Sungurtekin H, Dinleyici EC, Guclu E, Tao L, Memish ZA, Jin Z. International Nosocomial Infection Control Consortium (INICC) report of health care associated infections, data summary of 45 countries for 2015 to 2020, adult and pediatric units, device-associated module. Am J Infect Control 2024:S0196-6553(23)00879-9. [PMID: 38185380 DOI: 10.1016/j.ajic.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Reporting on the International Nosocomial Infection Control Consortium study results from 2015 to 2020, conducted in 630 intensive care units across 123 cities in 45 countries spanning Africa, Asia, Eastern Europe, Latin America, and the Middle East. METHODS Prospective intensive care unit patient data collected via International Nosocomial Infection Control Consortium Surveillance Online System. Centers for Disease Control and Prevention/National Health Care Safety Network definitions applied for device-associated health care-associated infections (DA-HAI). RESULTS We gathered data from 204,770 patients, 1,480,620 patient days, 936,976 central line (CL)-days, 637,850 mechanical ventilators (MV)-days, and 1,005,589 urinary catheter (UC)-days. Our results showed 4,270 CL-associated bloodstream infections, 7,635 ventilator-associated pneumonia, and 3,005 UC-associated urinary tract infections. The combined rates of DA-HAIs were 7.28%, and 10.07 DA-HAIs per 1,000 patient days. CL-associated bloodstream infections occurred at 4.55 per 1,000 CL-days, ventilator-associated pneumonias at 11.96 per 1,000 MV-days, and UC-associated urinary tract infections at 2.91 per 1,000 UC days. In terms of resistance, Pseudomonas aeruginosa showed 50.73% resistance to imipenem, 44.99% to ceftazidime, 37.95% to ciprofloxacin, and 34.05% to amikacin. Meanwhile, Klebsiella spp had resistance rates of 48.29% to imipenem, 72.03% to ceftazidime, 61.78% to ciprofloxacin, and 40.32% to amikacin. Coagulase-negative Staphylococci and Staphylococcus aureus displayed oxacillin resistance in 81.33% and 53.83% of cases, respectively. CONCLUSIONS The high rates of DA-HAI and bacterial resistance emphasize the ongoing need for continued efforts to control them.
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Affiliation(s)
- Victor D Rosenthal
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, USA; Department of Infection Prevention, INICC Foundation, International Nosocomial Infection Control Consortium, Miami, USA.
| | - Ruijie Yin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, USA
| | | | - Sara E Rivera-Molina
- Department of Infection Prevention, Hospital Maria Especialidades Pediátricas, Tegucigalpa, Honduras
| | - Somani Jyoti
- Department of Infection Prevention, National University Hospital, Singapore, Singapore
| | - Reshma Dongol
- Department of Infection Prevention, Grande International Hospital, Kathamandu, Nepal
| | - Daisy Aguilar-De-Moros
- Department of Infection Prevention, Hospital Del Nino Dr Jose Renan Esquivel De Panama, Panama, Panama
| | - Nellie Tumu
- Department of Infection Prevention, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Johana Alarcon-Rua
- Department of Infection Prevention, Clinica Sebastian De Belalcazar, Cali, Colombia
| | - Juan P Stagnaro
- Department of Infection Prevention, Instituto Central De Medicina, Provincia De Buenos Aires, La Plata, Argentina
| | - Safaa Alkhawaja
- Department of Infection Prevention, Salmaniya Medical Complex, Manama, Bahrain
| | | | - Yuliana A Cano-Medina
- Department of Infection Prevention, Instituto Del Corazon De Bucaramanga, Bogota, Colombia
| | - Sandra L Valderrama-Beltran
- Department of Infection Prevention, Pontificia Universidad Javeriana Hospital Universitario San Ignacio, Bogota, Colombia
| | - Claudia M Henao-Rodas
- Department of Infection Prevention, Department of Infection Prevention, Fundacion Hospital San Jose De Buga, Guadalajara De Buga, Colombia
| | - Maria A Zuniga-Chavarria
- Department of Infection Prevention, Hospital Clinica Biblica, San Jose De Costa Rica, Costa Rica
| | - Amani El-Kholy
- Department of Infection Prevention, Dar Alfouad Hospital 6th Of October City, 6th Of October City, Egypt
| | - Hala Mounir Agha
- Department of Infection Prevention, Cairo University Specialized Pediatric Hospital Cardio Thoracic Icu, Cairo, Egypt
| | - Suneeta Sahu
- Department of Infection Prevention, Apollo Hospital Bhubaneswar, Bhubaneswar, India
| | - Siksha O Anusandhan
- Department of Infection Prevention, IMS And SUM Hospital, Bhubaneswar, India
| | - Mahuya Bhattacharyya
- Department of Infection Prevention, Advanced Medicare Research Institute Dhakuria Unit, Kolkata, India
| | - Mohit Kharbanda
- Department of Infection Prevention, Desun Hospital & Heart Institute Kolkata, Kolkata, India
| | - Aruna Poojary
- Department of Microbiology, Breach Candy Hospital Trust, Mumbai, India
| | - Pravin K Nair
- Department of Infection Prevention, Holy Spirit Hospital, Mumbai, India
| | - Sheila N Myatra
- Department of Critical Care, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Rajesh Chawla
- Department of Infection Prevention, Indraprastha Apollo Hospital Delhi, New Delhi, India
| | - Kavita Sandhu
- Department of Infection Prevention, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Yatin Mehta
- Department of Critical Care, Medanta The Medicity, New Delhi, India
| | - Prasad Rajhans
- Department of Infection Prevention, Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | - Farid Zand
- Department of Infection Prevention, Nemazee Hospital Shiraz University Of Medical Sciences, Shiraz, Iran
| | | | - Chian-Wern Tai
- Department of Infection Prevention, Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Chin S Gan
- Department of Infection Prevention, University Malaya Medical Centre Pediatric Intensive Care, Kuala Lumpur, Malaysia
| | - Mohd-Basri Mat Nor
- Department of Infection Prevention, International Islamic University Malaysia Department Of Anesthesia And Critical Care, Kuantan, Malaysia
| | - Guadalupe Aguirre-Avalos
- Department of Critical Care, Hospital Civil De Guadalajara Fray Antonio Alcalde Terapia Intensiva, Guadalajara, Mexico
| | - Blanca E Hernandez-Chena
- Department of Infection Prevention, Hospital General Regional 6 De Ciudad Madero, Madero, Mexico
| | - Alejandro Sassoe-Gonzalez
- Department of Infection Prevention, Hospital Regional De Alta Especialidad De Ixtapaluca, Ixtapaluca, Mexico
| | - Isabel Villegas-Mota
- Department of Infection Prevention, Instituto Nacional De Perinatologia Unidad De Cuidados Intensivos Neonatales, Mexico City, Mexico
| | - Mary C Aleman-Bocanegra
- Department of Infection Prevention, Hospital San José De Monterrey Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Ider Bat-Erdene
- Department of Infection Prevention, Intermed Hospital, Ulaanbaatar, Mongolia
| | - Nilton Y Carreazo
- Department of Infection Prevention, Hospital De Emergencias Pediatricas, Lima, Peru
| | | | - Jarosław Janc
- Department of Anesthesiology and Intensive Therapy, 4th Clinical Military Hospital with Polyclinic, Wroclaw, Poland
| | - Vladislav Belskiy
- Department of Infection Prevention, Privolzhskiy District Medical Center, Nizhniy Novgorod, Russia
| | - Sona Hlinkova
- Department of Infection Prevention, Catholic University In Ruzomberok Faculty Of Health Central Military Hospital Snp Ruzomberok, Ruzomberok, Slovakia
| | - Dincer Yildizdas
- Department of Infection Prevention, Balcali Hospital Pediatric Intensive Care Unit, Adana, Turkey
| | - Merve Havan
- Department of Infection Prevention, Ankara University Faculty Of Medicine, Ankara, Turkey
| | - Alper Koker
- Department of Infection Prevention, Akdeniz University Medical School, Antalya, Turkey
| | - Hulya Sungurtekin
- Department of Infection Prevention, Pamukkale University Hospital, Denizli, Turkey
| | - Ener C Dinleyici
- Department of Infection Prevention, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ertugrul Guclu
- Department of Infection Prevention, Sakarya University Training And Research Hospital, Sakarya, Turkey
| | - Lili Tao
- Department of Infection Prevention, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ziad A Memish
- Department of Infection Prevention, King Saud Medical City, Ministry of Health, Riyadh, Arabia
| | - Zhilin Jin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, USA
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Rosenthal VD, Yin R, Abbo LM, Lee BH, Rodrigues C, Myatra SN, Divatia JV, Kharbanda M, Nag B, Rajhans P, Shingte V, Mehta Y, Sarma S, Todi SK, Bhattacharyya M, Basu S, Sahu S, Mishra SB, Samal S, Chawla R, Jain AC, Nair PK, Kalapala D, Arjun R, Singla D, Sandhu K, Badyal B, Palaniswamy V, Bhakta A, Gan CS, Mohd-Basri MN, Lai YH, Tai CW, Lee PC, Bat-Erdene I, Begzjav T, Acharya SP, Dongol R, Ikram A, Tumu N, Tao L, Jin Z. An international prospective study of INICC analyzing the incidence and risk factors for catheter-associated urinary tract infections in 235 ICUs across 8 Asian Countries. Am J Infect Control 2024; 52:54-60. [PMID: 37499758 DOI: 10.1016/j.ajic.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Identify urinary catheter (UC)-associated urinary tract infections (CAUTI) incidence and risk factors (RF) in 235 ICUs in 8 Asian countries: India, Malaysia, Mongolia, Nepal, Pakistan, the Philippines, Thailand, and Vietnam. METHODS From January 1, 2014, to February 12, 2022, we conducted a prospective cohort study. To estimate CAUTI incidence, the number of UC days was the denominator, and CAUTI was the numerator. To estimate CAUTI RFs, we analyzed 11 variables using multiple logistic regression. RESULTS 84,920 patients hospitalized for 499,272 patient days acquired 869 CAUTIs. The pooled CAUTI rate per 1,000 UC-days was 3.08; for those using suprapubic-catheters (4.11); indwelling-catheters (2.65); trauma-ICU (10.55), neurologic-ICU (7.17), neurosurgical-ICU (5.28); in lower-middle-income countries (3.05); in upper-middle-income countries (1.71); at public-hospitals (5.98), at private-hospitals (3.09), at teaching-hospitals (2.04). The following variables were identified as CAUTI RFs: Age (adjusted odds ratio [aOR] = 1.01; 95% CI = 1.01-1.02; P < .0001); female sex (aOR = 1.39; 95% CI = 1.21-1.59; P < .0001); using suprapubic-catheter (aOR = 4.72; 95% CI = 1.69-13.21; P < .0001); length of stay before CAUTI acquisition (aOR = 1.04; 95% CI = 1.04-1.05; P < .0001); UC and device utilization-ratio (aOR = 1.07; 95% CI = 1.01-1.13; P = .02); hospitalized at trauma-ICU (aOR = 14.12; 95% CI = 4.68-42.67; P < .0001), neurologic-ICU (aOR = 14.13; 95% CI = 6.63-30.11; P < .0001), neurosurgical-ICU (aOR = 13.79; 95% CI = 6.88-27.64; P < .0001); public-facilities (aOR = 3.23; 95% CI = 2.34-4.46; P < .0001). DISCUSSION CAUTI rate and risk are higher for older patients, women, hospitalized at trauma-ICU, neurologic-ICU, neurosurgical-ICU, and public facilities. All of them are unlikely to change. CONCLUSIONS It is suggested to focus on reducing the length of stay and the Urinary catheter device utilization ratio, avoiding suprapubic catheters, and implementing evidence-based CAUTI prevention recommendations.
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Affiliation(s)
- Victor D Rosenthal
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, USA; Infeciton Control Department, International Nosocomial Infection Control Consortium, INICC Foundation, Miami, USA.
| | - Ruijie Yin
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, USA
| | - Lilian M Abbo
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Camilla Rodrigues
- Pd Hinduja National Hospital and Medical Research Centre, Department of Microbiology, Mumbai, India
| | - Sheila N Myatra
- Tata Memorial Hospital, Homi Bhabha National Institute, Department of Anesthesiology, Critical Care and Pain, Mumbai, India
| | | | - Mohit Kharbanda
- Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | - Bikas Nag
- Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | - Prasad Rajhans
- Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | - Vasudha Shingte
- Deenanath Mangeshkar Hospital And Research Center Erandwane Pune, Pune, India
| | - Yatin Mehta
- Medanta The Medicity, Department of Critical Care and Anesthesiology, Haryana, India
| | - Smita Sarma
- Medanta The Medicity, Department of Critical Care and Anesthesiology, Haryana, India
| | - Subhash K Todi
- Advanced Medicare Research Institute AMRI Hospitals, Department of Critical Care, Kolkata, India
| | - Mahuya Bhattacharyya
- Advanced Medicare Research Institute AMRI Hospitals, Department of Critical Care, Kolkata, India
| | - Sushmita Basu
- Advanced Medicare Research Institute Mukundapur Unit, Kolkata, India
| | | | - Shakti B Mishra
- Critical Care Department, IMS and SUM Hospital, Bhubaneswar, India
| | - Samir Samal
- Critical Care Department, IMS and SUM Hospital, Bhubaneswar, India
| | - Rajesh Chawla
- Indraprastha Apollo Hospitals, Department of Critical Care, New Delhi, India
| | - Aakanksha C Jain
- Indraprastha Apollo Hospitals, Department of Critical Care, New Delhi, India
| | - Pravin K Nair
- Critical Care Department, Holy Spirit Hospital, Mumbai, India
| | - Durga Kalapala
- Critical Care Department, Holy Spirit Hospital, Mumbai, India
| | - Rajalakshmi Arjun
- Kerala Institute Of Med Sciences Health, Department of Critical Care, Trivandrum, India
| | - Deepak Singla
- Critical Care Department, Maharaja Agrasen Hospital, New Delhi, India
| | - Kavita Sandhu
- Max Super Speciality Hospital Saket Delhi, Department of Critical Care, New Delhi, India
| | - Binesh Badyal
- Max Super Speciality Hospital Saket Delhi, Department of Critical Care, New Delhi, India
| | | | - Arpita Bhakta
- University Malaya Medical Centre, Department of Pediatric Intensive Care, Kuala Lumpur, Malaysia
| | - Chin S Gan
- University Malaya Medical Centre, Department of Pediatric Intensive Care, Kuala Lumpur, Malaysia
| | - Mat N Mohd-Basri
- International Islamic University Malaysia, Department of Anesthesia and Critical Care, Kuantan, Pahang, Malaysia
| | - Yin H Lai
- International Islamic University Malaysia, Department of Anesthesia and Critical Care, Kuantan, Pahang, Malaysia
| | - Chian-Wern Tai
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Department of Critical Care, Kuala Lumpur, Malaysia
| | - Pei-Chuen Lee
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Department of Critical Care, Kuala Lumpur, Malaysia
| | - Ider Bat-Erdene
- Critical Care Department, Intermed Hospital, Ulaanbaatar, Mongolia
| | - Tsolmon Begzjav
- Critical Care Department, Intermed Hospital, Ulaanbaatar, Mongolia
| | - Subhash P Acharya
- Critical Care Department, Grande International Hospital, Kathmandu, Nepal
| | - Reshma Dongol
- Critical Care Department, Grande International Hospital, Kathmandu, Nepal
| | - Aamer Ikram
- Critical Care Department, Armed Forces Institute of Urology, Rawalpindi, Pakistan
| | - Nellie Tumu
- Department of Public Health Sciences, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - Lili Tao
- Zhongshan Hospital, Fudan University, Department of Pneumonology, Shanghai, China
| | - Zhilin Jin
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, USA
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5
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Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
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6
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Nasa P, Azoulay E, Chakrabarti A, Divatia JV, Jain R, Rodrigues C, Rosenthal VD, Alhazzani W, Arabi YM, Bakker J, Bassetti M, De Waele J, Dimopoulos G, Du B, Einav S, Evans L, Finfer S, Guérin C, Hammond NE, Jaber S, Kleinpell RM, Koh Y, Kollef M, Levy MM, Machado FR, Mancebo J, Martin-Loeches I, Mer M, Niederman MS, Pelosi P, Perner A, Peter JV, Phua J, Piquilloud L, Pletz MW, Rhodes A, Schultz MJ, Singer M, Timsit JF, Venkatesh B, Vincent JL, Welte T, Myatra SN. Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method. Lancet Infect Dis 2022; 22:e74-e87. [PMID: 34774188 PMCID: PMC8580499 DOI: 10.1016/s1473-3099(21)00626-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 02/07/2023]
Abstract
During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.
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Affiliation(s)
- Prashant Nasa
- NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis Teaching Hospital, APHP, University of Paris, Paris, France
| | | | | | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Camilla Rodrigues
- PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University Grossman School of Medicine, New York, NY, USA; Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Erasmus University Medical Center, Rotterdam, Netherlands; Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - George Dimopoulos
- Attikon University Hospital, Athens, Greece; National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Bin Du
- State Key Laboratory of Rare, Complex and Critical Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Sharon Einav
- Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Imperial College London, London, UK
| | - Claude Guérin
- University de Lyon, Lyon, France; Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Newton, Adelaide, SA, Australia
| | - Samir Jaber
- Hôpital Saint-Éloi, Montpellier University Hospital, Montpellier, France
| | - Ruth M Kleinpell
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Younsuck Koh
- College of Medicine, University of Ulsan College of Medicine, University of Ulsan, Seoul, South Korea
| | - Marin Kollef
- Washington University School of Medicine, Washington University, St Louis, MO, USA
| | - Mitchell M Levy
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Flavia R Machado
- Hospital Sao Paulo, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa; Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paolo Pelosi
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy; University of Genoa, Genoa, Italy
| | - Anders Perner
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jason Phua
- Alexandra Hospital, National University Health System, Singapore; National University Hospital, National University Health System, Singapore
| | - Lise Piquilloud
- University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marcus J Schultz
- Amsterdam University Medical Centers, Locatie AMC, Amsterdam, Netherlands; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | - Tobias Welte
- German Center of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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7
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Nasa P, Azoulay E, Chakrabarti A, Divatia JV, Jain R, Rodrigues C, Rosenthal VD, Alhazzani W, Arabi YM, Bakker J, Bassetti M, De Waele J, Dimopoulos G, Du B, Einav S, Evans L, Finfer S, Guérin C, Hammond NE, Jaber S, Kleinpell RM, Koh Y, Kollef M, Levy MM, Machado FR, Mancebo J, Martin-Loeches I, Mer M, Niederman MS, Pelosi P, Perner A, Peter JV, Phua J, Piquilloud L, Pletz MW, Rhodes A, Schultz MJ, Singer M, Timsit JF, Venkatesh B, Vincent JL, Welte T, Myatra SN. Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method. Lancet Infect Dis 2021. [PMID: 34774188 DOI: 10.1016/s1473-3099(21)00626-5.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.
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Affiliation(s)
- Prashant Nasa
- NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis Teaching Hospital, APHP, University of Paris, Paris, France
| | | | | | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Camilla Rodrigues
- PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University Grossman School of Medicine, New York, NY, USA; Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Erasmus University Medical Center, Rotterdam, Netherlands; Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - George Dimopoulos
- Attikon University Hospital, Athens, Greece; National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Bin Du
- State Key Laboratory of Rare, Complex and Critical Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Sharon Einav
- Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Imperial College London, London, UK
| | - Claude Guérin
- University de Lyon, Lyon, France; Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Newton, Adelaide, SA, Australia
| | - Samir Jaber
- Hôpital Saint-Éloi, Montpellier University Hospital, Montpellier, France
| | - Ruth M Kleinpell
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Younsuck Koh
- College of Medicine, University of Ulsan College of Medicine, University of Ulsan, Seoul, South Korea
| | - Marin Kollef
- Washington University School of Medicine, Washington University, St Louis, MO, USA
| | - Mitchell M Levy
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Flavia R Machado
- Hospital Sao Paulo, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa; Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paolo Pelosi
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy; University of Genoa, Genoa, Italy
| | - Anders Perner
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jason Phua
- Alexandra Hospital, National University Health System, Singapore; National University Hospital, National University Health System, Singapore
| | - Lise Piquilloud
- University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marcus J Schultz
- Amsterdam University Medical Centers, Locatie AMC, Amsterdam, Netherlands; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | - Tobias Welte
- German Center of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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8
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Viet Hung N, Hang PT, Rosenthal VD, Thi Anh Thu L, Thi Thu Nguyet L, Quy Chau N, Anh Thu T, Anh DPP, Hanh TTM, Hang TTT, Van Trang DT, Tien NP, Hong Thoa VT, Minh ĐQ. Multicenter Study of Device-Associated Infection Rates, Bacterial Resistance, Length of Stay, and Mortality in Intensive Care Units of 2 Cities of Vietnam: International Nosocomial Infection Control Consortium Findings. J Patient Saf 2021; 17:e222-e227. [PMID: 29870516 DOI: 10.1097/pts.0000000000000499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The aim of the study was to report the results of the International Nosocomial Infection Control Consortium (INICC) study conducted from May 2008 to March 2015. METHODS A device-associated healthcare-acquired infection surveillance study in three adult intensive care units (ICUs) and 1 neonatal ICU from 4 hospitals in Vietnam using U.S. the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN) definitions and criteria as well as INICC methods. RESULTS We followed 1592 adult ICU patients for 12,580 bed-days and 845 neonatal ICU patients for 4907 bed-days. Central line-associated bloodstream infection (CLABSI) per 1000 central line-days rate was 9.8 in medical/surgical UCIs and 1.5 in the medical ICU. Ventilator-associated pneumonia (VAP) rate per 1000 mechanical ventilator-days was 13.4 in medical/surgical ICUs and 23.7 in the medical ICU. Catheter-associated urinary tract infection (CAUTI) rate per 1000 urinary catheter-days was 0.0 in medical/surgical ICUs and 5.3 in the medical ICU. While most device-associated healthcare-acquired infection rates were similar to INICC international rates (4.9 [CLABSI]; 16.5 [VAP]; 5.3 [CAUTI]), they were higher than CDC/NHSN rates (0.8 [CLABSI], 1.1 [VAP], and 1.3 [CAUTI]) for medical/surgical ICUs, with the exception of CAUTI rate for medical/surgical ICU and CLABSI rate for the medical ICU. Because of limited resources of our Vietnamese ICUs, cultures could not be taken as required by the CDC/NHSN criteria, and therefore, there was underreporting of CLABSI and CAUTI, influencing their rates. Most device utilization ratios and bacterial resistance percentages were higher than INICC and CDC/NHSN rates. CONCLUSIONS Device-associated healthcare-acquired infection rates found in the ICUs of our study were higher than CDC/NHSN US rates, but similar to INICC international rates. It is necessary to build more capacity to conduct surveillance and prevention strategies.
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Affiliation(s)
| | | | - Victor D Rosenthal
- International Nosocomial Infection Control Consortium (INICC), Buenos Aires, Argentina
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Doll M, Marra AR, Apisarnthanarak A, Al-Maani AS, Abbas S, Rosenthal VD. Prevention of Clostridioides difficile in hospitals: A position paper of the International Society for Infectious Diseases. Int J Infect Dis 2020; 102:188-195. [PMID: 33122100 DOI: 10.1016/j.ijid.2020.10.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Clostridioides difficile infection is an increasing presence worldwide. Prevention is multipronged, reflecting a complex and evolving epidemiology. Multiple guidelines exist regarding the prevention of C. difficile infection in healthcare settings; however, existing guidelines do not address C. difficile in low- and middle-income countries (LMIC). Nevertheless, the prevalence of C. difficile in LMIC likely parallels, if not exceeds, that of high-income countries, and LMIC may experience additional challenges in C. difficile diagnosis and control. A panel of experts was convened by the International Society for Infectious Diseases (ISID) to review the current state of C. difficile infections globally and make evidence-based recommendations for infection prevention that are broadly applicable.
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Affiliation(s)
- Michelle Doll
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Alexandre R Marra
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Amal Saif Al-Maani
- Department of Infection Control and Prevention, Ministry of Health, Muscat, Oman
| | - Salma Abbas
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Victor D Rosenthal
- International Nosocomial Infection Control Consortium (INICC), Buenos Aires, Argentina
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Mehtar S, Wanyoro A, Ogunsola F, Ameh EA, Nthumba P, Kilpatrick C, Revathi G, Antoniadou A, Giamarelou H, Apisarnthanarak A, Ramatowski JW, Rosenthal VD, Storr J, Osman TS, Solomkin JS. Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases. Int J Infect Dis 2020; 100:123-131. [PMID: 32712427 PMCID: PMC7378004 DOI: 10.1016/j.ijid.2020.07.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 12/26/2022] Open
Abstract
Surgical site infection (SSI) rates in low- and middle-income countries (LMICs) range from 8 to 30% of procedures, making them the most frequent healthcare-acquired infection (HAI) with substantial morbidity, mortality, and economic impacts. Presented here is an approach to surgical site infection prevention based on surveillance and focused on five critical areas identified by international experts. These five areas include 1. Collecting valid, high-quality data; 2. Linking HAIs to economic incapacity, underscoring the need to prioritize infection prevention activities; 3. Implementing SSI surveillance within infection prevention and control (IPC) programs to enact structural changes, develop procedural skills, and alter healthcare worker behaviors; 4. Prioritizing IPC training for healthcare workers in LMICs to conduct broad-based surveillance and to develop and implement locally applicable IPC programs; and 5. Developing a highly accurate and objective international system for defining SSIs, which can be translated globally in a straightforward manner. Finally, we present a clear, unambiguous framework for successful SSI guideline implementation that supports developing sustainable IPC programs in LMICs. This entails 1. Identifying index operations for targeted surveillance; 2. Identifying IPC “champions” and empowering healthcare workers; 3. Using multimodal improvement measures; 4. Positioning hand hygiene programs as the basis for IPC initiatives; 5. Use of telecommunication devices for surveillance and healthcare outcome follow-ups. Additionally, special considerations for pediatric SSIs, antimicrobial resistance development, and antibiotic stewardship programs are addressed.
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Affiliation(s)
- Shaheen Mehtar
- Infection Control Africa Network, Cape Town, South Africa
| | - Anthony Wanyoro
- Department of Obstetrics and Gynecology, Kenyatta University, Nairobi, Kenya
| | - Folasade Ogunsola
- Infection Control African Network, College of Medicine, University of Lagos, Nigeria
| | - Emmanuel A Ameh
- Division of Paediatric Surgery National Hospital, Abuja, Nigeria
| | - Peter Nthumba
- Clinical Epidemiologist and Plastic Surgeon, AIC Kijabe Hospital, and GCB, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.
| | | | - Gunturu Revathi
- Microbiology Laboratory, Aga Khan University Hospital, Nairobi, Kenya
| | | | | | | | - John W Ramatowski
- International Federation for Infectious Diseases, Boston, United States
| | | | - Julie Storr
- Consultant with S2 Incorporated, Geneva, Switzerland
| | - Tamer Saied Osman
- Global Disease Detection, US Naval Medical Research Unit 3, Cairo, Egypt
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Al-Abdely HM, Khidir Mohammed Y, Rosenthal VD, Orellano PW, ALazhary M, Kaid E, Al-Attas A, Hawsawi G, Kelany A, Hussein B, Esam B, Altowerqi R, Alkamaly MA, Tawfic NA, Cruzpero E, Al Rashidi RM, Thomas R, Molano AM, Al Enazy HA, Al Adwani FM, Casuyon Pahilanga AM, Alatawi S, Nakhla R, Al Adwani FM, Gasmin Aromin R, Balon Ubalde E, Hanafy Diab H, Kader NA, Hassan Assiry IY, Sawan FA, Ammari HE, Mashiakhy AM, Santiago EB, Chua CM, Dalis IM, Arishi HM, Lozada R, Al-Zaydani Asiri IA, Ahmed H, Jarie A, Al-Qathani AS, Al-Alkami HY, AlDalaton M, Alih SJ, Alaliany MJ, Helali NJ, Sindayen G, Malificio AA, Al Dossari HB, Algethami AG, Mohamed D, Yanne L, Tan A, Babu S, Abduljabbar SM, Rushdi H, Fernandez J, Hussain WM, Rajavel RD, Bukhari SZ, Turkistani AA, Mushtaq JJ, Albeladi E, Aboushoushah S, Qushmaq N, Shyrine L, Philipose J, Raees M, AbdulKhalik NS, Madco M, Abdulghany M, Manao A, Acostan C, Safwat R, Halwani M, Abdul Aal NA, Thomas A, Abdulatif SM, Ariola NC, Mutwalli AH, Ariola N, Bohlega E, Simon S, Damlig E, Elsherbini SG, Krishne IT, Abraham S, Ali Karrar MA, Gosn NA, Al Hindi AA, Jaha RN, AlQahtani SM, Abdul Aziz AO, Demaisip NL, Laungayan Cortez E, Cabato AF, Gonzales Celiz JM, Al Raey MA, Al Darani SA, Aziz MR, Manea BA, Samy E, Briones S, Krishnan R, Raees SS, Tabassum K, Ghalilah KM, Alradady M, Al Qatri A, Chaouali M, Elsisi M, Aldossary HA, Al-Suliman S, Al Talib AA, Albaghly N, Haqlre Mia ME, Al-Gethamy MM, Alamri DM, Al-Saadi AS, Ayugat EP, Al Hazazi NA, Al Hussain MI, Caminade Y, Santos AJ, Abdulwahab MH, Al-Garni BT. Impact of the International Nosocomial Infection Control Consortium (INICC)’s multidimensional approach on rates of ventilator-associated pneumonia in intensive care units in 22 hospitals of 14 cities of the Kingdom of Saudi Arabia. J Infect Public Health 2018; 11:677-684. [DOI: 10.1016/j.jiph.2018.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 01/09/2018] [Accepted: 06/05/2018] [Indexed: 01/30/2023] Open
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Salgado Yepez E, Bovera MM, Rosenthal VD, González Flores HA, Pazmiño L, Valencia F, Alquinga N, Ramirez V, Jara E, Lascano M, Delgado V, Cevallos C, Santacruz G, Pelaéz C, Zaruma C, Barahona Pinto D. Device-associated infection rates, mortality, length of stay and bacterial resistance in intensive care units in Ecuador: International Nosocomial Infection Control Consortium’s findings. World J Biol Chem 2017; 8:95-101. [PMID: 28289522 PMCID: PMC5329718 DOI: 10.4331/wjbc.v8.i1.95] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/06/2016] [Accepted: 01/18/2017] [Indexed: 02/05/2023] Open
Abstract
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.
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Empaire GD, Guzman Siritt ME, Rosenthal VD, Pérez F, Ruiz Y, Díaz C, Di Silvestre G, Salinas E, Orozco N. Multicenter prospective study on device-associated infection rates and bacterial resistance in intensive care units of Venezuela: International Nosocomial Infection Control Consortium (INICC) findings. Int Health 2017; 9:44-49. [DOI: 10.1093/inthealth/ihw049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 09/05/2016] [Accepted: 12/28/2016] [Indexed: 11/14/2022] Open
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Duszyńska W, Rosenthal VD, Szczęsny A, Woźnica E, Ulfik K, Ostrowska E, Litwin A, Kübler A. Urinary tract infections in intensive care unit patients - a single-centre, 3-year observational study according to the INICC project. Anaesthesiol Intensive Ther 2017; 48:1-6. [PMID: 26966105 DOI: 10.5603/ait.2016.0001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTI) in patients with urinary catheters could be a serious complication of hospitalisation in the intensive care unit (ICU). METHODS A prospective study (01.01.2012-31.12.2014) was conducted in the 20-bed ICU of the University Hospital in Wroclaw, Poland. The frequency (density, incidence) and aetiology of UTI as well as prophylactic method compliance were estimated in patients of the ICU according to the INICC project. RESULTS Among 1261 ICU patients, urinary tract infections were diagnosed in 91 (7%). The incidence index was 7.25/100 admissions to the ICU. CA-UTI constituted 36% of the device-associated, healthcare-associated infections (n = 255). A urinary catheter was used in 92.21 ± 4.51% of patients during 14,006 patient-days and 12,917 urinarycatheter- days. The density of CA-UTI/1000 catheter-days was 6.44, 6.84, 7.16 during the years 2012, 2013, and 2014, respectively. The main pathogens of CA-UTI were Enterococcus spp. (22%), Acinetobacter baumannii (20%), Klebsiella pneumoniae (18%), Pseudomonas aeruginosa (13%), and Candida spp. (13%). Only in four elements of the "Urinary Catheter Bundle" was 100% compliance noted. CONCLUSIONS In the observed period of time, the incidence of CA-UTI was higher than in the INICC (2014) report and the NHSN/CDC (2012) report. Analysis of compliance with a "Urinary Catheter Bundle" to prevent UTI shows low implementation of preventative methods with the INICC protocol.
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Affiliation(s)
- Wiesława Duszyńska
- Chair and 1st Department of Anaesthesiology and Intensive Therapy, Wrocław Medical University, Poland.
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Viet Hung N, Anh Thu T, Rosenthal VD, Tat Thanh D, Quoc Anh N, Le Bao Tien N, Ngo Quang N. Surgical Site Infection Rates in Seven Cities in Vietnam: Findings of the International Nosocomial Infection Control Consortium. Surg Infect (Larchmt) 2016; 17:243-9. [PMID: 26885677 DOI: 10.1089/sur.2015.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are the most common healthcare-associated infections (HAI) in lower-income countries. This is the first study to report the results of surveillance on SSI stratified by surgical procedure in seven Vietnamese cities. METHODS This was a prospective, active SSI surveillance study conducted from November 2008-December 2010 in seven hospitals using the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) definitions and methods. Surgical procedures (SPs) were classified into 26 types according to the International Classification of Diseases Edition 9 criteria. RESULTS We recorded 241 SSIs, associated with 4,413 SPs (relative risk [RR] 5.5%; 95% confidence interval [95% CI] 4.8-6.2). The highest SSI rates were found for limb amputation (25%), colon surgery (33%), and small bowel surgery (21%). Compared with CDC-NHSN SSI report, our SSI rates were higher for the following SPs: Limb amputation (25% vs. 1.3%; RR 20.0; p = 0.001); appendix surgery (8.8% vs. 3.5%; RR 2.54; 95% CI 1.3-5.1; p = 0.001); gallbladder surgery (13.7% vs. 1.7%; RR 7.76; 95% CI 1.9-32.1; p = 0.001); colon surgery (18.2% vs. 4.0%; RR 4.56; 95% CI 2.0-10.2; p = 0.001); open reduction of fracture (15.8% vs. 3.4%; RR 4.70, 95% CI 1.5-15.2; p = 0.004); gastric surgery (7.3% vs. 1.7%; RR 4.26; 95% CI 2.2-8.4, p = 0.001); kidney surgery (8.9% vs. 0.9%; RR 10.2; 95% CI 3.8-27.4; p = 0.001); prostate surgery (5.1% vs. 0.9%; RR 5.71; 95% CI 1.9-17.4; p = 0.001); small bowel surgery (20.8% vs. 6.7%; RR 3.07; 95% CI 1.7-5.6; p = 0.001); thyroid or parathyroid surgery (2.4% vs. 0.3%; RR 9.27; 95% CI 1.0-89.1; p = 0.019); and vaginal hysterectomy (14.3% vs. 1.2%; RR 12.3; 95% CI 1.7-88.4; p = 0.001). CONCLUSIONS Our SSIs rates were significantly higher for 11 of the 26 types of SPs than for the CDC-NHSN. This study advances our knowledge of SSI epidemiology in Vietnam and will allow us to introduce targeted interventions.
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Affiliation(s)
| | | | - Victor D Rosenthal
- 3 International Nosocomial Infection Control Consortium , Buenos Aires, Argentina
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Richtmann R, Onzi Siliprandi EM, Rosenthal VD, Sánchez TEG, Moreira M, Rodrigues T, Baltieri SR, Camolesi F, de Almeida Silva C, Pires dos Santos R, Valente R, Apolinário D, Fagundes Stadtlober G, Giunta Cavaglieri A. Surgical Site Infection Rates in Four Cities in Brazil: Findings of the International Nosocomial Infection Control Consortium. Surg Infect (Larchmt) 2016; 17:53-7. [DOI: 10.1089/sur.2015.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Victor D. Rosenthal
- International Nosocomial Infection Control Consortium, Buenos Aires, Argentina
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17
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Duszyńska W, Rosenthal VD, Dragan B, Węgrzyn P, Mazur A, Wojtyra P, Tomala A, Kübler A. Ventilator-associated pneumonia monitoring according to the INICC project at one centre. Anaesthesiol Intensive Ther 2015; 47:34-9. [PMID: 25751291 DOI: 10.5603/ait.2015.0004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pneumonia is a common complication of hospitalisation in severely ill patients who need mechanical ventilation. The aim of this study was to assess the usefulness of the International Nosocomial Infection Control Consortium programme for the surveillance of ventilator-associated pneumonia (VAP). METHODS A prospective study (1 Jan 2012-30 June 2014) was conducted in the 20-bed ICU. The device utilisation ratios for lung ventilation and the frequency (density and incidence) and aetiology of VAP were estimated in ICU patients. RESULTS From a total of 1097 patients, VAP infections were diagnosed in 93. Thirty percent of patients with VAP died. The incidence index was 8.47 per 100 admissions to the ICU. VAP infections accounted for 46% of the overall count of device-associated healthcare-associated infections. Mechanical ventilation was used in 71 ± 8 patients during the 11 862 patient days and 8425 ventilation days. The rate of VAP per 1000 ventilator days was 11.15/9.34 /10.23 in years 2012/2013/2014 (half a year), respectively. The main VAP pathogens were Acinetobacter baumannii (45%) and Pseudomonas aeruginosa (17%). CONCLUSION During the reported time span, the incidence of VAP was lower than in the INICC report (2007-2012), but it was tenfold higher than in the NHSN/CDC report (dated 2012). Because of the unchanged VAP level during the 2.5-year observation period, the root cause needs to be determined and action should be taken to resolve this issue.
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Affiliation(s)
- Wiesława Duszyńska
- Chair and Department of Anaesthesiology and Intensive Therapy, Wrocław Medical University, Poland.
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Jahani-Sherafat S, Razaghi M, Rosenthal VD, Tajeddin E, Seyedjavadi S, Rashidan M, Alebouyeh M, Rostampour M, Haghi A, Sayarbayat M, Farazmandian S, Yarmohammadi T, Arshadi FK, Mansouri N, Sarbazi MR, Vilar M, Zali MR. Device-associated infection rates and bacterial resistance in six academic teaching hospitals of Iran: Findings from the International Nocosomial Infection Control Consortium (INICC). J Infect Public Health 2015; 8:553-61. [DOI: 10.1016/j.jiph.2015.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 03/20/2015] [Accepted: 04/03/2015] [Indexed: 01/01/2023] Open
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Ramírez-Wong FM, Atencio-Espinoza T, Rosenthal VD, Ramirez E, Torres-Zegarra SL, Díaz Tavera ZR, Sarmiento López F, Silva Astete N, Campos Guevara F, Bazan Mendoza C, Valencia Ramírez A, Soto Pastrana J. Surgical Site Infections Rates in More Than 13,000 Surgical Procedures in Three Cities in Peru: Findings of the International Nosocomial Infection Control Consortium. Surg Infect (Larchmt) 2015; 16:572-6. [PMID: 26125113 DOI: 10.1089/sur.2014.201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are a threat to patient safety. However, there are not available data on SSI rates stratified by surgical procedure (SP) in Peru. METHODS From January 2005 to December 2010, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in four hospitals in three cities of Peru. Data were recorded from hospitalized patients using the U.S. Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) methods and definitions for SSI. Surgical procedures (SPs) were classified into 4 types, according to ICD-9 criteria. RESULTS We recorded 352 SSIs, associated to 13,904 SPs (2.5%; CI, 2.3-2.8) SSI rates per type of SP were the following for this study's Peruvian hospitals, compared with rates of the INICC and CDC-NHSN reports, respectively: 2.9% for appendix surgery (vs. 2.9% vs. 1.4%); 2.8% for gallbladder surgery (vs. 2.5% vs. 0.6%); 2.2% for cesarean section (vs. 0.7% vs. 1.8%); 2.8% for vaginal hysterectomy (vs. 2.0% vs. 0.9%). CONCLUSIONS Our SSIs rates were higher in all of the four analyzed types of SPs compared with CDC-NHSN, whereas compared with INICC, most rates were similar. This study represents an important advance in the knowledge of SSI epidemiology in Peru that will allow us to introduce targeted interventions.
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Affiliation(s)
| | | | - Victor D Rosenthal
- 3 International Nosocomial Infection Control Consortium , Buenos Aires, Argentina
| | - Eliza Ramirez
- 4 ESSALUD-Red Asistencial ANCASH- Hospital III , Chimbote, Peru
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Chakravarthy M, Myatra SN, Rosenthal VD, Udwadia F, Gokul B, Divatia J, Poojary A, Sukanya R, Kelkar R, Koppikar G, Pushparaj L, Biswas S, Bhandarkar L, Raut S, Jadhav S, Sampat S, Chavan N, Bahirune S, Durgad S. The impact of the International Nosocomial Infection Control Consortium (INICC) multicenter, multidimensional hand hygiene approach in two cities of India. J Infect Public Health 2015; 8:177-86. [DOI: 10.1016/j.jiph.2014.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/15/2014] [Accepted: 08/24/2014] [Indexed: 12/27/2022] Open
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Rosenthal VD, Ramachandran B, Dueñas L, Álvarez-Moreno C, Navoa-Ng JA, Armas-Ruiz A, Ersoz G, Matta-Cortés L, Pawar M, Nevzat-Yalcin A, Rodriguez-Ferrer M, de Casares ACB, Linares C, Villanueva VD, Campuzano R, Kaya A, Rendon-Campo LF, Gupta A, Turhan O, Barahona-Guzmán N, de Jesús-Machuca L, Tolentino MCV, Mena-Brito J, Kuyucu N, Astudillo Y, Saini N, Gunay N, Sarmiento-Villa G, Gumus E, Lagares-Guzmán A, Dursun O. 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. Infect Control Hosp Epidemiol 2015; 33:696-703. [DOI: 10.1086/666341] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Maki DG, Rosenthal VD, Salomao R, Franzetti F, Rangel-Frausto MS. Impact of Switching from an Open to a Closed Infusion System on Rates of Central Line–Associated Bloodstream Infection: A Meta-analysis of Time-Sequence Cohort Studies in 4 Countries. Infect Control Hosp Epidemiol 2015; 32:50-8. [DOI: 10.1086/657632] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background.We report a meta-analysis of 4 identical time-series cohort studies of the impact of switching from use of open infusion containers (glass bottle, burette, or semirigid plastic bottle) to closed infusion containers (fully collapsible plastic containers) on central line-associated bloodstream infection (CLABSI) rates and all-cause intensive care unit (ICU) mortality in 15 adult ICUs in Argentina, Brazil, Italy, and Mexico.Methods.All ICUs used open infusion containers for 6–12 months, followed by switching to closed containers. Patient characteristics, adherence to infection control practices, CLABSI rates, and ICU mortality during the 2 periods were compared by χ2test for each country, and the results were combined using meta-analysis.Results.Similar numbers of patients participated in 2 periods (2,237 and 2,136). Patients in each period had comparable Average Severity of Illness Scores, risk factors for CLABSI, hand hygiene adherence, central line care, and mean duration of central line placement. CLABSI incidence dropped markedly in all 4 countries after switching from an open to a closed infusion container (pooled results, from 10.1 to 3.3 CLABSIs per 1,000 central line-days; relative risk [RR], 0.33 [95% confidence interval {CI}, 0.24-0.46];P<.001). All-cause ICU mortality also decreased significantiy, from 22.0 to 16.9 deaths per 100 patients (RR, 0.77 [95% CI, 0.68-0.87];P<.001).Conclusions.Switching from an open to a closed infusion container resulted in a striking reduction in the overall CLABSI incidence and all-cause ICU mortality. Data suggest that open infusion containers are associated with a greatiy increased risk of infusion-related bloodstream infection and increased ICU mortality that have been unrecognized. Furthermore, data suggest CLABSIs are associated with significant attributable mortality.
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Barnett AG, Graves N, Rosenthal VD, Salomao R, Rangel-Frausto MS. Excess Length of Stay Due to Central Line–Associated Bloodstream Infection in Intensive Care Units in Argentina, Brazil, and Mexico. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/653028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To estimate the excess length of stay in an intensive care unit (ICU) due to a central line-associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection.Design.A cohort of 3,560 patients followed up for 36,806 days in ICUs.Setting.Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico.Patients.All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours.Results.The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from -1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI.Conclusions.CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case-mix of admissions and differences in the ways that hospitals deal with infections.
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Barnett AG, Graves N, Rosenthal VD, Salomao R, Rangel-Frausto MS. Excess Length of Stay Due to Central Line–Associated Bloodstream Infection in Intensive Care Units in Argentina, Brazil, and Mexico. Infect Control Hosp Epidemiol 2015; 31:1106-14. [DOI: 10.1086/656593] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To estimate the excess length of stay in an intensive care unit (ICU) due to a central line-associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection.Design.A cohort of 3,560 patients followed up for 36,806 days in ICUs.Setting.Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico.Patients.All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours.Results.The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from -1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI.Conclusions.CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case-mix of admissions and differences in the ways that hospitals deal with infections.
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Duszynska W, Rosenthal VD, Litwin A, Woznica E, Kubler A. Catheter-associated bloodstream infections in an ICU of a university hospital in Wroclaw, Poland: an international nosocomial infection control consortium's findings. Crit Care 2015. [PMCID: PMC4470674 DOI: 10.1186/cc14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Medeiros EA, Grinberg G, Rosenthal VD, Bicudo Angelieri D, Buchner Ferreira I, Bauer Cechinel R, Zanandrea BB, Rohnkohl C, Regalin M, Spessatto JL, Scopel Pasini R, Ferla S. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 3 cities in Brazil. Am J Infect Control 2015; 43:10-5. [PMID: 25564118 DOI: 10.1016/j.ajic.2014.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/29/2014] [Accepted: 10/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hand hygiene (HH) is the main tool for cross-infection prevention, but adherence to guidelines is low in limited-resource countries, and there are not available published data from Brazil. METHODS This is an observational, prospective, interventional, before-and-after study conducted in 4 intensive care units in 4 hospitals, which are members of the International Nosocomial Infection Control Consortium (INICC), from June 2006-April 2008. The study was divided into a 3-month baseline period and a follow-up period. A multidimensional HH approach was introduced, which included administrative support, supplies availability, education and training, reminders in the workplace, process surveillance, and performance feedback. Health care workers were observed for HH practices in each intensive care unit during randomly selected 30-minute periods. RESULTS We recorded 4,837 opportunities for HH, with an overall HH compliance that increased from 27%-58% (P < .01). Multivariate analysis showed that some variables were associated with poor HH compliance: men versus women (49% vs 38%, P < .001), nurses versus doctors (55% vs 48%, P < .02), among others. CONCLUSIONS With the implementation of the INICC approach, adherence to HH was significantly increased. Programs should be aimed at improving HH in variables found to be predictors of poor HH compliance.
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Leblebicioglu H, Koksal I, Rosenthal VD, Akan ÖA, Özgültekin A, Kendirli T, Erben N, Yalcin AN, Ulusoy S, Sirmatel F, Ozdemir D, Alp E, Yıldızdaş D, Esen S, Ulger F, Dilek A, Yilmaz H, Yýlmaz G, Kaya S, Ulusoy H, Tulunay M, Oral M, Ünal N, Turan G, Akgün N, İnan A, Ince E, Karbuz A, Çiftçi E, Taşyapar N, Güneş M, Ozgunes I, Usluer G, Turhan O, Gunay N, Gumus E, Dursun O, Arda B, Bacakoglu F, Cengiz M, Yilmaz L, Geyik MF, Şahin A, Erdogan S, Kılıc AU, Horoz OO. Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach, over 8 years, in 11 cities of Turkey. J Infect Prev 2014; 16:146-154. [PMID: 28989420 DOI: 10.1177/1757177414560249] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 10/19/2014] [Indexed: 12/12/2022] Open
Abstract
AIMS To evaluate the effectiveness of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach in Turkey and analyse predictors of poor hand hygiene compliance. DESIGN An observational, prospective, interventional, before-and-after study was conducted from August 2003 to August 2011 in 12 intensive care units (ICU) of 12 hospitals in 11 cities. The study was divided into a baseline and a follow-up period and included random 30-minute observations for hand hygiene compliance in ICU. The hand hygiene approach included administrative support, supplies availability, education and training, reminders in the workplace, process surveillance, and performance feedback. RESULTS We observed 21,145 opportunities for hand hygiene. Overall hand hygiene compliance increased from 28.8% to 91% (95% CI 87.6-93.0, p 0.0001). Multivariate and univariate analyses showed that several variables were significantly associated with poor hand hygiene compliance: males vs. females (39% vs. 48%; 95% CI 0.79-0.84, p 0.0001), ancillary staff vs. physicians (35% vs. 46%, 95% CI 0.73-0.78, p 0.0001), and adult vs. pediatric ICUs (42% vs. 74%, 95% CI 0.54-0.60, p 0.0001). CONCLUSIONS Adherence to hand hygiene was significantly increased with the INICC Hand Hygiene Approach. Specific programmes should be directed to improve hand hygiene in variables found to be predictors of poor hand hygiene compliance.
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Affiliation(s)
| | - Iftihar Koksal
- Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Victor D Rosenthal
- International Nosocomial Infection Control Consortium (INICC), Buenos Aires, Argentina
| | - Özay Arıkan Akan
- Ankara University School of Medicine, Ibni-Sina Hospital, Ankara, Turkey
| | - Asu Özgültekin
- Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Tanil Kendirli
- Department of Pediatric Critical Care Medicine, Ankara University School of Medicine, Ankara, Turkey
| | | | | | | | | | - Davut Ozdemir
- Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce, Turkey
| | - Emine Alp
- Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | | | - Saban Esen
- Ondokuz Mayis University Medical School, Samsun, Turkey
| | - Fatma Ulger
- Ondokuz Mayis University Medical School, Samsun, Turkey
| | - Ahmet Dilek
- Ondokuz Mayis University Medical School, Samsun, Turkey
| | - Hava Yilmaz
- Ondokuz Mayis University Medical School, Samsun, Turkey
| | - Gürdal Yýlmaz
- Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Selçuk Kaya
- Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Hülya Ulusoy
- Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Melek Tulunay
- Ankara University School of Medicine, Ibni-Sina Hospital, Ankara, Turkey
| | - Mehmet Oral
- Ankara University School of Medicine, Ibni-Sina Hospital, Ankara, Turkey
| | - Necmettin Ünal
- Ankara University School of Medicine, Ibni-Sina Hospital, Ankara, Turkey
| | - Güldem Turan
- Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Nur Akgün
- Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Asuman İnan
- Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Erdal Ince
- Department of Pediatric Critical Care Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Adem Karbuz
- Department of Pediatric Critical Care Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Ergin Çiftçi
- Department of Pediatric Critical Care Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Nevin Taşyapar
- Department of Pediatric Critical Care Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Melek Güneş
- Department of Pediatric Critical Care Medicine, Ankara University School of Medicine, Ankara, Turkey
| | | | - Gaye Usluer
- Eskisehir Osmangazi University, Eskisehir, Turkey
| | | | | | | | | | - Bilgin Arda
- Ege University Medical Faculty, Izmir, Turkey
| | | | - Mustafa Cengiz
- Harran University, Faculty of Medicine, Sanliurfa, Turkey
| | - Leyla Yilmaz
- Harran University, Faculty of Medicine, Sanliurfa, Turkey
| | - Mehmet Faruk Geyik
- Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce, Turkey
| | - Ahmet Şahin
- Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce, Turkey
| | - Selvi Erdogan
- Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce, Turkey
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Portillo-Gallo JH, Miranda-Novales MG, Rosenthal VD, Sánchez M, Ayala-Gaytan JJ, Ortiz-Juárez VR, Aguilera-Almazán F, Iglesias-Miramontes G, Vázquez-Olivas MDR, Sánchez-Chávez A, Angulo-Espinoza Y, Zamudio-Lugo I. Surgical site infection rates in four Mexican cities: Findings of the International Nosocomial Infection Control Consortium (INICC). J Infect Public Health 2014; 7:465-71. [DOI: 10.1016/j.jiph.2014.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 07/08/2014] [Accepted: 07/17/2014] [Indexed: 01/08/2023] Open
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Álvarez-Moreno C, Pérez-Fernández AM, Rosenthal VD, Quintero J, Chapeta-Parada E, Linares C, Pinilla-Martínez IF, Martínez-Saleg PA, Sierra P, Mindiola-Rochel AE. Surgical site infection rates in 4 cities in Colombia: findings of the International Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2014; 42:1089-92. [PMID: 25278399 DOI: 10.1016/j.ajic.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/05/2014] [Accepted: 06/16/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are a threat to patient safety. However, there are no available data on SSI rates stratified by surgical procedure (SP) in Colombia. METHODS From January 2008-December 2010, a prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in 4 hospitals in 4 cities within Colombia using the definitions of the Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN). SPs were classified into 10 types, according to ICD-9 criteria. RESULTS We recorded 193 SSIs associated with 5,063 SPs. SSI rates per type of SP were the following, compared with INICC and CDC-NHSN rates, respectively: 9.1% for laminectomy (vs 1.7% and 1.0%), 8.3% for cardiac surgery (vs 5.6% and 1.3%), 3.9% for appendix surgery (vs 2.9% and 1.4%), 5.5% for abdominal hysterectomy (vs 2.7% and 1.6%), 4.4% for prostate surgery (vs 2.1% and 1.2%), 4.5% for spleen surgery (vs 5.6% and 2.3%), 4.3% for vaginal hysterectomy (vs 2.0% and 0.9%), and 3.0% for gallbladder surgery (vs 2.5% and 0.6%). CONCLUSIONS Compared with CDC-NHSN rates, SSIs rates in our study hospitals were higher in most types of SPs, whereas compared with INICC, they were similar in 5 of the analyzed types, and higher in 4 types. This study represents an important advance toward knowledge of epidemiology in Colombia that will allow us to introduce targeted interventions.
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Barahona-Guzmán N, Rodríguez-Calderón ME, Rosenthal VD, Olarte N, Villamil-Gómez W, Rojas C, Rodríguez-Ferrer M, Sarmiento-Villa G, Lagares-Guzmán A, Valderrama A, Menco A, Arrieta P, Dajud-Cassas LE, Mendoza M, Sabogal A, Carvajal Y, Silva E. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in three cities of Colombia. Int J Infect Dis 2014; 19:67-73. [DOI: 10.1016/j.ijid.2013.10.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 10/28/2013] [Accepted: 10/28/2013] [Indexed: 02/07/2023] Open
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Navoa-Ng JA, Berba R, Rosenthal VD, Villanueva VD, Tolentino MCV, Genuino GAS, Consunji RJ, Mantaring JBV. Impact of an International Nosocomial Infection Control Consortium multidimensional approach on catheter-associated urinary tract infections in adult intensive care units in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings. J Infect Public Health 2013; 6:389-99. [PMID: 23999340 DOI: 10.1016/j.jiph.2013.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/11/2013] [Accepted: 03/21/2013] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To assess the impact of a multidimensional infection control approach on the reduction of catheter-associated urinary tract infection (CAUTI) rates in adult intensive care units (AICUs) in two hospitals in the Philippines that are members of the International Nosocomial Infection Control Consortium. MATERIALS AND METHODS This was a before-after prospective active surveillance study to determine the rates of CAUTI in 3183 patients hospitalized in 4 ICUS over 14,426 bed-days. The study was divided into baseline and intervention periods. During baseline, surveillance was performed using the definitions of the US Centers for Disease Control and Prevention and the National Healthcare Safety Network (CDC/NHSN). During intervention, we implemented a multidimensional approach that included: (1) a bundle of infection control interventions, (2) education, (3) surveillance of CAUTI rates, (4) feedback on CAUTI rates, (5) process surveillance and (6) performance feedback. We used random effects Poisson regression to account for the clustering of CAUTI rates across time. RESULTS We recorded 8720 urinary catheter (UC)-days: 819 at baseline and 7901 during intervention. The rate of CAUTI was 11.0 per 1000 UC-days at baseline and was decreased by 76% to 2.66 per 1000 UC-days during intervention [rate ratio [RR], 0.24; 95% confidence interval [CI], 0.11-0.53; P-value, 0.0001]. CONCLUSIONS Our multidimensional approach was associated with a significant reduction in the CAUTI rates in the ICU setting of a limited-resource country.
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Rosenthal VD, Richtmann R, Singh S, Apisarnthanarak A, Kübler A, Viet-Hung N, Ramírez-Wong FM, Portillo-Gallo JH, Toscani J, Gikas A, Dueñas L, El-Kholy A, Ghazal S, Fisher D, Mitrev Z, Gamar-Elanbya MO, Kanj SS, Arreza-Galapia Y, Leblebicioglu H, Hlinková S, Memon BA, Guanche-Garcell H, Gurskis V, Alvarez-Moreno C, Barkat A, Mejía N, Rojas-Bonilla M, Ristic G, Raka L, Yuet-Meng C. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010. Infect Control Hosp Epidemiol 2013; 34:597-604. [PMID: 23651890 DOI: 10.1086/670626] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report the results of a surveillance study on surgical site infections (SSIs) conducted by the International Nosocomial Infection Control Consortium (INICC). DESIGN Cohort prospective multinational multicenter surveillance study. SETTING Eighty-two hospitals of 66 cities in 30 countries (Argentina, Brazil, Colombia, Cuba, Dominican Republic, Egypt, Greece, India, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Poland, Salvador, Saudi Arabia, Serbia, Singapore, Slovakia, Sudan, Thailand, Turkey, Uruguay, and Vietnam) from 4 continents (America, Asia, Africa, and Europe). PATIENTS Patients undergoing surgical procedures (SPs) from January 2005 to December 2010. METHODS Data were gathered and recorded from patients hospitalized in INICC member hospitals by using the methods and definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) for SSI. SPs were classified into 31 types according to International Classification of Diseases, Ninth Revision, criteria. RESULTS We gathered data from 7,523 SSIs associated with 260,973 SPs. SSI rates were significantly higher for most SPs in INICC hospitals compared with CDC-NHSN data, including the rates of SSI after hip prosthesis (2.6% vs. 1.3%; relative risk [RR], 2.06 [95% confidence interval (CI), 1.8-2.4]; P < .001), coronary bypass with chest and donor incision (4.5% vs. 2.9%; RR, 1.52 [95% CI, 1.4-1.6]; [P < .001); abdominal hysterectomy (2.7% vs. 1.6%; RR, 1.66 [95% CI, 1.4-2.0]; P < .001); exploratory abdominal surgery (4.1% vs. 2.0%; RR, 2.05 [95% CI, 1.6-2.6]; P < .001); ventricular shunt, 12.9% vs. 5.6% (RR, 2.3 [95% CI, 1.9-2.6]; P < .001, and others. CONCLUSIONS SSI rates were higher for most SPs in INICC hospitals compared with CDC-NHSN data.
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Affiliation(s)
- Victor D Rosenthal
- International Nosocomial Infection Control Consortium, Buenos Aires, Argentina.
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Hu B, Tao L, Rosenthal VD, Liu K, Yun Y, Suo Y, Gao X, Li R, Su D, Wang H, Hao C, Pan W, Saunders CL. Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings. Am J Infect Control 2013; 41:301-6. [PMID: 23040491 DOI: 10.1016/j.ajic.2012.03.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Bijie Hu
- Department of Respiratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villamil-Gómez W, Armas-Ruiz A, Cuéllar LE, Medeiros EA, Mitrev Z, Gikas A, Yang Y, Ahmed A, Kanj SS, Dueñas L, Gurskis V, Mapp T, Guanche-Garcell H, Fernández-Hidalgo R, Kübler A. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol 2013; 34:415-23. [PMID: 23466916 DOI: 10.1086/669860] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance. DESIGN An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period. SETTING Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey. PARTICIPANTS Healthcare workers at 99 ICU members of the INICC. METHODS A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods. RESULTS A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% ([Formula: see text]). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; [Formula: see text]), physicians versus nurses (62% vs 72%; [Formula: see text]), and adult versus neonatal ICUs (67% vs 81%; [Formula: see text]), among others. CONCLUSIONS Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.
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Affiliation(s)
- Victor D Rosenthal
- International Nosocomial Infection Control Consortium, Buenos Aires, Argentina.
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Guanche-Garcell H, Morales-Pérez C, Rosenthal VD. 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). J Infect Public Health 2013; 6:98-107. [PMID: 23537822 DOI: 10.1016/j.jiph.2012.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 10/27/2012] [Accepted: 11/07/2012] [Indexed: 12/18/2022] Open
Abstract
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.
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Rasslan O, Seliem ZS, Ghazi IA, El Sabour MA, El Kholy AA, Sadeq FM, Kalil M, Abdel-Aziz D, Sharaf HY, Saeed A, Agha H, El-Abdeen SAEWZ, El Gafarey M, El Tantawy A, Fouad L, Abel-Haleim MM, Muhamed T, Saeed H, Rosenthal VD. Device-associated infection rates in adult and pediatric intensive care units of hospitals in Egypt. International Nosocomial Infection Control Consortium (INICC) findings. J Infect Public Health 2012; 5:394-402. [DOI: 10.1016/j.jiph.2012.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 07/19/2012] [Accepted: 07/22/2012] [Indexed: 01/30/2023] Open
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Rosenthal VD, Rodrigues C, álvarez-Moreno C, Madani N, Mitrev Z, Ye G, Salomao R, Ulger F, Guanche-Garcell H, Kanj SS, Cuéllar LE, Higuera F, Mapp T, Fernández-Hidalgo R. Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in adult intensive care units from 14 developing countries of four continents. Crit Care Med 2012; 40:3121-8. [DOI: 10.1097/ccm.0b013e3182657916] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rosenthal VD, Álvarez-Moreno C, Villamil-Gómez W, Singh S, Ramachandran B, Navoa-Ng JA, Dueñas L, Yalcin AN, Ersoz G, Menco A, Arrieta P, Bran-de Casares AC, de Jesus Machuca L, Radhakrishnan K, Villanueva VD, Tolentino MC, Turhan O, Keskin S, Gumus E, Dursun O, Kaya A, Kuyucu N. Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings. Am J Infect Control 2012; 40:497-501. [PMID: 22054689 DOI: 10.1016/j.ajic.2011.08.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 07/29/2011] [Accepted: 08/01/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries. METHODS This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology. RESULTS During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P = .02), demonstrating a 31% reduction in VAP rate. CONCLUSIONS Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.
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Rosenthal VD, Rodríguez-Calderón ME, Rodríguez-Ferrer M, Singhal T, Pawar M, Sobreyra-Oropeza M, Barkat A, Atencio-Espinoza T, Berba R, Navoa-Ng JA, Dueñas L, Ben-Jaballah N, Ozdemir D, Ersoz G, Aygun C. Findings of the International Nosocomial Infection Control Consortium (INICC), Part II: Impact of a multidimensional strategy to reduce ventilator-associated pneumonia in neonatal intensive care units in 10 developing countries. Infect Control Hosp Epidemiol 2012; 33:704-10. [PMID: 22669232 DOI: 10.1086/666342] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Design. Before-after prospective surveillance study to assess the efficacy of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control program to reduce the rate of occurrence of ventilator-associated pneumonia (VAP). Setting. Neonatal intensive care units (NICUs) of INICC member hospitals from 15 cities in the following 10 developing countries: Argentina, Colombia, El Salvador, India, Mexico, Morocco, Peru, Philippines, Tunisia, and Turkey. Patients. NICU inpatients. Methods. VAP rates were determined during a first period of active surveillance without the implementation of the multidimensional approach (phase 1) to be then compared with VAP rates after implementation of the INICC multidimensional infection control program (phase 2), which included the following practices: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices. This study was conducted by infection control professionals who applied National Health Safety Network (NHSN) definitions for healthcare-associated infections and INICC surveillance methodology. Results. During phase 1, we recorded 3,153 mechanical ventilation (MV)-days, and during phase 2, after the implementation of the bundle of interventions, we recorded 15,981 MV-days. The VAP rate was 17.8 cases per 1,000 MV-days during phase 1 and 12.0 cases per 1,000 MV-days during phase 2 (relative risk, 0.67 [95% confidence interval, 0.50-0.91]; [Formula: see text]), indicating a 33% reduction in VAP rate. Conclusions. Our results demonstrate that an implementation of the INICC multidimensional infection control program was associated with a significant reduction in VAP rate in NICUs in developing countries.
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Affiliation(s)
- Victor D Rosenthal
- International Nosocomial Infection Control Consortium, Avenue Corrientes4580,Buenos Aires, Argentina.
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Dilek A, Ulger F, Esen S, Acar M, Leblebicioglu H, Rosenthal VD. Impact of Education and Process Surveillance on Device-Associated Health Care-Associated Infection Rates in a Turkish ICU: Findings of the International Nosocomial Infection Control Consortium (INICC). Balkan Med J 2012. [DOI: 10.5152/balkanmedj.2011.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Rosenthal VD, Ramachandran B, Villamil-Gómez W, Armas-Ruiz A, Navoa-Ng JA, Matta-Cortés L, Pawar M, Nevzat-Yalcin A, Rodríguez-Ferrer M, Yıldızdaş RD, Menco A, Campuzano R, Villanueva VD, Rendon-Campo LF, Gupta A, Turhan O, Barahona-Guzmán N, Horoz OO, Arrieta P, Brito JM, Tolentino MCV, Astudillo Y, Saini N, Gunay N, Sarmiento-Villa G, Gumus E, Lagares-Guzmán A, Dursun O. Impact of a multidimensional infection control strategy on central line-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings of the International Nosocomial Infection Control Consortium (INICC). Infection 2012; 40:415-23. [PMID: 22371234 DOI: 10.1007/s15010-012-0246-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 02/04/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control strategy including a practice bundle to reduce the rates of central line-associated bloodstream infection (CLAB) in patients hospitalized in pediatric intensive care units (PICUs) of hospitals, which are members of the INICC, from nine cities of five developing countries: Colombia, India, Mexico, Philippines, and Turkey. METHODS CLAB rates were determined by means of a prospective surveillance study conducted on 1,986 patients hospitalized in nine PICUs, over a period of 12,774 bed-days. The study was divided into two phases. During Phase 1 (baseline period), active surveillance was performed without the implementation of the multi-faceted approach. CLAB rates obtained in Phase 1 were compared with CLAB rates obtained in Phase 2 (intervention period), after implementation of the INICC multidimensional infection control program. RESULTS During Phase 1, 1,029 central line (CL) days were recorded, and during Phase 2, after implementing the CL care bundle and interventions, we recorded 3,861 CL days. The CLAB rate was 10.7 per 1,000 CL days in Phase 1, and in Phase 2, the CLAB rate decreased to 5.2 per 1,000 CL days (relative risk [RR] 0.48, 95% confidence interval [CI] 0.29-0.94, P = 0.02), showing a reduction of 52% in the CLAB rate. CONCLUSIONS This study shows that the implementation of a multidimensional infection control strategy was associated with a significant reduction in the CLAB rates in the PICUs of developing countries.
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Affiliation(s)
- V D Rosenthal
- International Nosocomial Infection Control Consortium, Corrientes Ave #4580, Floor 11, Apt. A, 1195 Buenos Aires, Argentina.
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Turpin RS, Canada T, Rosenthal VD, Nitzki-George D, Liu FX, Mercaldi CJ, Pontes-Arruda A. Bloodstream Infections Associated With Parenteral Nutrition Preparation Methods in the United States. JPEN J Parenter Enteral Nutr 2011; 36:169-76. [DOI: 10.1177/0148607111414714] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Robin S. Turpin
- Global Health Economics, Baxter Healthcare, Deerfield, Illinois
- Public Policy Department, Thomas Jefferson Hospital, Philadelphia, Pennsylvania
| | - Todd Canada
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor D. Rosenthal
- International Nosocomial Infection Control Consortium, Buenos Aires, Argentina
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Rosenthal VD, Lynch P, Jarvis WR, Khader IA, Richtmann R, Jaballah NB, Aygun C, Villamil-Gómez W, Dueñas L, Atencio-Espinoza T, Navoa-Ng JA, Pawar M, Sobreyra-Oropeza M, Barkat A, Mejía N, Yuet-Meng C, Apisarnthanarak A. Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC. Infection 2011; 39:439-50. [PMID: 21732120 DOI: 10.1007/s15010-011-0136-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 06/09/2011] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs). METHODS Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria. RESULTS Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level. CONCLUSIONS Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.
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MESH Headings
- Catheter-Related Infections/epidemiology
- Catheter-Related Infections/microbiology
- Catheter-Related Infections/mortality
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/mortality
- Cross Infection/blood
- Cross Infection/epidemiology
- Cross Infection/microbiology
- Cross Infection/mortality
- Developing Countries
- Equipment Contamination
- Hospitals, Private/classification
- Hospitals, Public/classification
- Hospitals, Teaching/classification
- Humans
- Infant, Newborn
- Intensive Care Units, Neonatal
- Pneumonia, Ventilator-Associated/epidemiology
- Pneumonia, Ventilator-Associated/mortality
- Prospective Studies
- Socioeconomic Factors
- Ventilators, Mechanical/adverse effects
- Ventilators, Mechanical/microbiology
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Affiliation(s)
- V D Rosenthal
- International Nosocomial Infection Control Consortium, Corrientes Ave #4580, Buenos Aires, Argentina.
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Kübler A, Duszynska W, Rosenthal VD, Fleischer M, Kaiser T, Szewczyk E, Barteczko-Grajek B. Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial Infection Control Consortium's (INICC) findings. J Crit Care 2011; 27:105.e5-10. [PMID: 21737244 DOI: 10.1016/j.jcrc.2011.05.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 04/13/2011] [Accepted: 05/09/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study was to determine device-associated health care-associated infections (DA-HAI) rates, microbiologic profile, bacterial resistance, and length of stay in one intensive care unit (ICU) of a hospital member of the International Nosocomial Infection Control Consortium (INICC) in Poland. MATERIALS AND METHODS A prospective DA-HAI surveillance study was conducted on an adult ICU from January 2007 to May 2010. Data were collected by implementing the methodology developed by INICC and applying the definitions of DA-HAI provided by the National Healthcare Safety Network at the US Centers for Disease Control and Prevention. RESULTS A total of 847 patients hospitalized for 9386 days acquired 206 DA-HAIs, an overall rate of 24.3% (95% confidence interval [CI], 21.5-27.4), and 21.9 (95% CI, 19.0-25.1) DA-HAIs per 1000 ICU-days. Central line-associated bloodstream infection rate was 4.01 (95% CI, 2.8-5.6) per 1000 catheter-days, ventilator-associated pneumonia rate was 18.2 (95% CI, 15.5-21.6) per 1000 ventilator-days, and catheter-associated urinary tract infection rate was 4.8 (95% CI, 3.5-6.5) per 1000 catheter-days. Length of stay was 6.9 days for those patients without DA-HAI, 10.0 days for those with central line-associated bloodstream infection, 15.5 days for those with ventilator-associated pneumonia, and 15.0 for those with catheter-associated urinary tract infection. CONCLUSIONS Most DA-HAI rates are lower in Poland than in INICC, but higher than in the National Healthcare Safety Network, expressing the feasibility of lowering infection rates and increasing patient safety.
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Affiliation(s)
- Andrzej Kübler
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
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Barnett AG, Beyersmann J, Allignol A, Rosenthal VD, Graves N, Wolkewitz M. The time-dependent bias and its effect on extra length of stay due to nosocomial infection. Value Health 2011; 14:381-386. [PMID: 21402305 DOI: 10.1016/j.jval.2010.09.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 08/24/2010] [Accepted: 09/22/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Many studies disregard the time dependence of nosocomial infection when examining length of hospital stay and the associated financial costs. This leads to the "time-dependent bias," which biases multiplicative hazard ratios. We demonstrate the time-dependent bias on the additive scale of extra length of stay. METHODS To estimate the extra length of stay due to infection, we used a multistate model that accounted for the time of infection. For comparison we used a generalized linear model assuming a gamma distribution, a commonly used model that ignores the time of infection. We applied these two methods to a large prospective cohort of hospital admissions from Argentina, and compared the methods' performance using a simulation study. RESULTS For the Argentina data the extra length of stay due to nosocomial infection was 11.23 days when ignoring time dependence and only 1.35 days after accounting for the time of infection. The simulations showed that ignoring time dependence consistently overestimated the extra length of stay. This overestimation was similar for different rates of infection and even when an infection prolonged or shortened stay. We show examples where the time-dependent bias remains unchanged for the true discharge hazard ratios, but the bias for the extra length of stay is doubled because length of stay depends on the infection hazard. CONCLUSIONS Ignoring the timing of nosocomial infection gives estimates that greatly overestimate its effect on the extra length of hospital stay.
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Affiliation(s)
- Victor D Rosenthal
- International Nosocomial Infection Control Consortium, Infection Control, Buenos Aires 1195, Argentina.
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Abstract
Objectives To quantify the change in risk of central line associated blood stream infection (CLABSI) following the introduction of a closed infusion container in intensive care units (ICUs) in two Latin American cities. Design A state-space model was used to describe the flow of admissions through the ICU. This approach correctly treats infection as a time-dependent covariate. Results A closed system reduced the risk of CLABSI. The hazard ratios for the closed versus open container were between 0.15 and 0.31 (p values<0.001), indicating a clinically significant reduction in the risk of admissions having a CLABSI. A simulation study showed that a closed system reduced the number of infections, costs and deaths. Conclusions The data reveal costs are saved and health benefits gained from fewer cases of CLABSI after adoption of a closed infusion system. Information is required on the costs of implementing the closed system widely in these settings.
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Affiliation(s)
- Nicholas Graves
- Institute of Health and Biomedical Innovation and School of Public Health, Queensland University of Technology, Brisbane, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation and School of Public Health, Queensland University of Technology, Brisbane, Australia
| | - Victor D Rosenthal
- Bernal Medical Center, Colegiales Medical Center, Department of Infectious Diseases and Hospital Epidemiology, Buenos Aires, Argentina
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Rosenthal VD, Dwivedy A, Calderón MER, Esen S, Hernández HT, Abouqal R, Medeiros EA, Espinoza TA, Kanj SS, Gikas A, Barnett AG, Graves N. Time-dependent analysis of length of stay and mortality due to urinary tract infections in ten developing countries: INICC findings. J Infect 2010; 62:136-41. [PMID: 21168440 DOI: 10.1016/j.jinf.2010.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 11/26/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To estimate the excess length of stay (LOS) and mortality in an intensive care unit (ICU) due to a Catheter associated urinary tract infections (CAUTI), using a statistical model that accounts for the timing of infection in 29 ICUs from 10 countries: Argentina, Brazil, Colombia, Greece, India, Lebanon, Mexico, Morocco, Peru, and Turkey. METHODS To estimate the extra LOS due to infection in a cohort of 69,248 admissions followed for 371,452 days in 29 ICUs, we used a multi-state model, including specific censoring to ensure that we estimate the independent effect of urinary tract infection, and not the combined effects of multiple infections. We estimated the extra length of stay and increased risk of death independently in each country, and then combined the results using a random effects meta-analysis. RESULTS A CAUTI prolonged length of ICU stay by an average of 1.59 days (95% CI: 0.58, 2.59 days), and increased the risk of death by 15% (95% CI: 3, 28%). CONCLUSIONS A CAUTI leads to a small increased LOS in ICU. The increased risk of death due to CAUTI may be due to confounding with patient morbidity.
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Affiliation(s)
- Victor D Rosenthal
- International Nosocomial Infection Control Consortium, Buenos Aires, Argentina.
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Rosenthal VD, Maki DG, Rodrigues C, Alvarez-Moreno C, Leblebicioglu H, Sobreyra-Oropeza M, Berba R, Madani N, Medeiros EA, Cuéllar LE, Mitrev Z, Dueñas L, Guanche-Garcell H, Mapp T, Kanj SS, Fernández-Hidalgo R. Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries. Infect Control Hosp Epidemiol 2010; 31:1264-72. [PMID: 21029008 DOI: 10.1086/657140] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The International Nosocomial Infection Control Consortium (INICC) was established in 15 developing countries to reduce infection rates in resource-limited hospitals by focusing on education and feedback of outcome surveillance (infection rates) and process surveillance (adherence to infection control measures). We report a time-sequence analysis of the effectiveness of this approach in reducing rates of central line-associated bloodstream infection (CLABSI) and associated deaths in 86 intensive care units with a minimum of 6-month INICC membership. METHODS Pooled CLABSI rates during the first 3 months (baseline) were compared with rates at 6-month intervals during the first 24 months in 53,719 patients (190,905 central line-days). Process surveillance results at baseline were compared with intervention period data. RESULTS During the first 6 months, CLABSI incidence decreased by 33% (from 14.5 to 9.7 CLABSIs per 1,000 central line-days). Over the first 24 months there was a cumulative reduction from baseline of 54% (from 16.0 to 7.4 CLABSIs per 1,000 central line-days; relative risk, 0.46 [95% confidence interval, 0.33-0.63]; P < .001). The number of deaths in patients with CLABSI decreased by 58%. During the intervention period, hand hygiene adherence improved from 50% to 60% (P < .001); the percentage of intensive care units that used maximal sterile barriers at insertion increased from 45% to 85% (P < .001), that adopted chlorhexidine for antisepsis increased from 7% to 27% (P < .001), and that sought to remove unneeded catheters increased from 37% to 83% (P < .001); and the duration of central line placement decreased from 4.1 to 3.5 days (P < .001). CONCLUSIONS Education, performance feedback, and outcome and process surveillance of CLABSI rates significantly improved infection control adherence, reducing the CLABSI incidence by 54% and the number of CLABSI-associated deaths by 58% in INICC hospitals during the first 2 years.
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Tarricone R, Torbica A, Franzetti F, Rosenthal VD. Hospital costs of central line-associated bloodstream infections and cost-effectiveness of closed vs. open infusion containers. The case of Intensive Care Units in Italy. Cost Eff Resour Alloc 2010; 8:8. [PMID: 20459753 PMCID: PMC2889855 DOI: 10.1186/1478-7547-8-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 05/10/2010] [Indexed: 12/02/2022] Open
Abstract
Objectives The aim was to evaluate direct health care costs of central line-associated bloodstream infections (CLABSI) and to calculate the cost-effectiveness ratio of closed fully collapsible plastic intravenous infusion containers vs. open (glass) infusion containers. Methods A two-year, prospective case-control study was undertaken in four intensive care units in an Italian teaching hospital. Patients with CLABSI (cases) and patients without CLABSI (controls) were matched for admission departments, gender, age, and average severity of illness score. Costs were estimated according to micro-costing approach. In the cost effectiveness analysis, the cost component was assessed as the difference between production costs while effectiveness was measured by CLABSI rate (number of CLABSI per 1000 central line days) associated with the two infusion containers. Results A total of 43 cases of CLABSI were compared with 97 matched controls. The mean age of cases and controls was 62.1 and 66.6 years, respectively (p = 0.143); 56% of the cases and 57% of the controls were females (p = 0.922). The mean length of stay of cases and controls was 17.41 and 8.55 days, respectively (p < 0.001). Overall, the mean total costs of patients with and without CLABSI were € 18,241 and € 9,087, respectively (p < 0.001). On average, the extra cost for drugs was € 843 (p < 0.001), for supplies € 133 (p = 0.116), for lab tests € 171 (p < 0.001), and for specialist visits € 15 (p = 0.019). The mean extra cost for hospital stay (overhead) was € 7,180 (p < 0.001). The closed infusion container was a dominant strategy. It resulted in lower CLABSI rates (3.5 vs. 8.2 CLABSIs per 1000 central line days for closed vs. open infusion container) without any significant difference in total production costs. The higher acquisition cost of the closed infusion container was offset by savings incurred in other phases of production, especially waste management. Conclusions CLABSI results in considerable and significant increase in utilization of hospital resources. Use of innovative technologies such as closed infusion containers can significantly reduce the incidence of healthcare acquired infection without posing additional burden on hospital budgets.
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