Risk adjustment performance between NNIS index and NHSN model for postoperative colorectal surgical site infection: A retrospective cohort study.

Background: Risk stratifications to predict development of surgical site infections (SSI) are crucial methods before surgery. Hence, we aimed to compare the performance of risk adjustment between the former NNIS risk index and the new NHSN procedure-specific risk model for postoperative colorectal SSI. Materials and methods: A retrospective cohort study was conducted. Data of post-colorectal SSI, indicating the use of the NNIS risk index for SSI adjustment, were retrieved from the medical records. Data were taken from patients who underwent colorectal surgery procedures between January 2005 and December 2016. Additional information regarding emergency colorectal surgery was retrieved to fulfill the requirements for calculation of the risks for SSI; via the new model. The predictive performance between the two models was compared using the means of the area under the receiver operating characteristic curve. Results: In total 1989 patients were included. Fifteen patients were excluded; thus, the remaining number of procedures was 1974. Surgical site infections occurred in 85 (4.3%) procedures. In colectomy surgery, the means of area under the curve (AUC) yielded 0.6196 and 0.5976 for the NNIS risk index model and the new NHSN risk model, respectively; differences in the AUC were not statistically significant (p = 0.39). In rectal surgery, the means of the AUC yielded 0.516 and 0.49 for the NNIS risk index model and the new NHSN procedure-specific risk model, respectively; differences in the AUC were not statistically significant (p = 0.56). Conclusion: The new NHSN procedure-specific risk model was not superior to the former NNIS risk index.

Occupational Tasks Influencing Lung Function and Respiratory Symptoms Among Charcoal-Production Workers: A Time-Series Study.

BACKGROUND: Tasks involved in traditional charcoal production expose workers to various levels of charcoal dust and wood smoke. This study aimed to identify specific tasks influencing lung function and respiratory symptoms. METHODS: Interviews, direct observation, and task/symptom checklists were used to collect data from 50 charcoal-production workers on 3 nonwork days followed by 11 workdays. The peak expiratory flow rate (PEFR) was measured four times per day. RESULTS: The PEFR was reduced and the prevalence of respiratory symptoms increased over the first 6-7 workdays. The PEFR increased until evening on nonwork days but not on workdays. Loading the kiln and collecting charcoal from within the kiln markedly reduced the PEFR and increased the odds of respiratory symptoms. CONCLUSION: Tasks involving entry into the kiln were strongly associated with a short-term drop in the PEFR and the occurrence of respiratory symptoms, suggesting a need for the use of protective equipment and/or the operation of an effective kiln ventilation system.

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

OBJECTIVES: We report the results of the International Nosocomial Infection Control Consortium prospective surveillance study from January 2004 to December 2009 in 33 pediatric intensive care units of 16 countries and the impact of being in a private vs. public hospital and the income country level on device-associated health care-associated infection rates. Additionally, we aim to compare these findings with the results of the Centers for Disease Control and Prevention National Healthcare Safety Network annual report to show the differences between developed and developing countries regarding device-associated health care-associated infection rates. PATIENTS: A prospective cohort, active device-associated health care-associated infection surveillance study was conducted on 23,700 patients in International Nosocomial Infection Control Consortium pediatric intensive care units. METHODS: The protocol and methodology implemented were developed by International Nosocomial Infection Control Consortium. Data collection was performed in the participating intensive care units. Data uploading and analyses were conducted at International Nosocomial Infection Control Consortium headquarters on proprietary software. Device-associated health care-associated infection rates were recorded by applying Centers for Disease Control and Prevention National Healthcare Safety Network device-associated infection definitions, and the impact of being in a private vs. public hospital and the income country level on device-associated infection risk was evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Central line-associated bloodstream infection rates were similar in private, public, or academic hospitals (7.3 vs. 8.4 central line-associated bloodstream infection per 1,000 catheter-days [p < .35 vs. 8.2; p < .42]). Central line-associated bloodstream infection rates in lower middle-income countries were higher than low-income countries or upper middle-income countries (12.2 vs. 5.5 central line-associated bloodstream infections per 1,000 catheter-days [p < .02 vs. 7.0; p < .001]). Catheter-associated urinary tract infection rates were similar in academic, public and private hospitals: (4.2 vs. 5.2 catheter-associated urinary tract infection per 1,000 catheter-days [p = .41 vs. 3.0; p = .195]). Catheter-associated urinary tract infection rates were higher in lower middle-income countries than low-income countries or upper middle-income countries (5.9 vs. 0.6 catheter-associated urinary tract infection per 1,000 catheter-days [p < .004 vs. 3.7; p < .01]). Ventilator-associated pneumonia rates in academic hospitals were higher than private or public hospitals: (8.3 vs. 3.5 ventilator-associated pneumonias per 1,000 ventilator-days [p < .001 vs. 4.7; p < .001]). Lower middle-income countries had higher ventilator-associated pneumonia rates than low-income countries or upper middle-income countries: (9.0 vs. 0.5 per 1,000 ventilator-days [p < .001 vs. 5.4; p < .001]). Hand hygiene compliance rates were higher in public than academic or private hospitals (65.2% vs. 54.8% [p < .001 vs. 13.3%; p < .01]). CONCLUSIONS: Country socioeconomic level influence device-associated infection rates in developing countries and need to be considered when comparing device-associated infections from one country to another.

International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009.

We report the results of the International Infection Control Consortium (INICC) surveillance study from January 2003 through December 2008 in 173 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study, using Centers for Disease Control and Prevention (CDC) US National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infection Surveillance system [NNIS]) definitions for device-associated health care-associated infection, we collected prospective data from 155,358 patients hospitalized in the consortium's hospital ICUs for an aggregate of 923,624 days. Although device utilization in the developing countries' ICUs was remarkably similar to that reported from US ICUs in the CDC's NHSN, rates of device-associated nosocomial infection were markedly higher in the ICUs of the INICC hospitals: the pooled rate of central venous catheter (CVC)-associated bloodstream infections (BSI) in the INICC ICUs, 7.6 per 1000 CVC-days, is nearly 3-fold higher than the 2.0 per 1000 CVC-days reported from comparable US ICUs, and the overall rate of ventilator-associated pneumonia (VAP) was also far higher, 13.6 versus 3.3 per 1000 ventilator-days, respectively, as was the rate of catheter-associated urinary tract infection (CAUTI), 6.3 versus 3.3 per 1000 catheter-days, respectively. Most strikingly, the frequencies of resistance of Staphylococcus aureus isolates to methicillin (MRSA) (84.1% vs 56.8%, respectively), Klebsiella pneumoniae to ceftazidime or ceftriaxone (76.1% vs 27.1%, respectively), Acinetobacter baumannii to imipenem (46.3% vs 29.2%, respectively), and Pseudomonas aeruginosa to piperacillin (78.0% vs 20.2%, respectively) were also far higher in the consortium's ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 23.6% (CVC-associated bloodstream infections) to 29.3% (VAP).

Attributable mortality of imipenem-resistant nosocomial Acinetobacter baumannii bloodstream infection.

BACKGROUND: Uncertainty remains concerning the mortality attributable to infections caused by imipenem-resistant acinetobacter baumannii (IRAB). The authors have sought to examine the impact of this resistance on patient mortality. OBJECTIVE: To evaluate the effects of imipenem resistance on the mortality of patients with Acinetobacter baumannii bloodstream infection. MATERIAL AND METHOD: A cohort study was conducted to compare the survival rates between patients with IRAB and imipenem-susceptible A. baumannii (ISAB) bacteremia. RESULTS: The present study shows 35 patients (52.2%) in an IRAB group died in hospital compared to 26 patients (19.9%) in an ISAB group (p < 0.001). Multivariate analysis using Cox's proportional hazard model for controlling the confounding effects due to the severity of underlying diseases, inappropriate antibiotic treatment, and primary source of bacteremia show no statistically significant difference in mortality rates between the two groups. CONCLUSION: The observed higher mortality rate among patients with an IRAB bloodstream infection may not be attributable to imipenem resistance but may in some part be due to a more severe illness, inappropriate antimicrobial therapy, and primary source of infection.

Improving surveillance system and surgical site infection rates through a network: A pilot study from Thailand.

BACKGROUND: Surveillance of surgical site infections (SSI) provides data upon which interventions to improve patient safety can be based. In Thailand, however, SSI surveillance has not yet been standardized. OBJECTIVES: To develop a standardized SSI surveillance system and to monitor SSI rates after introduction of such a system. METHODS: We conducted a prospective study among 17,752 patients who underwent surgery in ten hospitals in Thailand from April 2004 to May 2005. The SSI rates were computed and benchmarked with the US rates, reported in terms of standardized infection ratio (SIR). We estimated the incidence rate ratio of surgical site infections by comparing the incidence in the last study period with the incidence in the first study period. RESULTS: The study included 17,869 operations and identified 248 SSIs, yielding an SSI rate of 1.4 infections/100 operations and a corresponding SIR of 0.6 (95% confidence interval [CI] = 0.5-0.7). During the study period the overall SSI rate decreased from 1.8 infections/100 operations to 1.2 infections/100 operations, yielding an incidence rate ratio of 0.65 (95% CI = 0.47-0.89). CONCLUSION: Our study highlighted that a standardized SSI surveillance in a developing country can be initiated through a network and may be followed by a decrease in SSI rates.

An outbreak of imipenem-resistant Acinetobacter baumannii at Songklanagarind Hospital: the risk factors and patient prognosis.

OBJECTIVE: To investigate for the factors associated with acquisition of imipenem-resistant Acinetobacter baumannii (IRAB) at Songklanagarind Hospital and the subsequent patient mortality outcome. DESIGN: A case-control study was conducted to evaluate the risk factors for IRAB acquisition using imipenem-sensitive A. baumannii (ISAB) as controls. A retrospective cohort study was employed to assess the factors associated with mortality in the hospital. SETTING: An 850-bed university hospital served as a medical school, training hospital, tertiary care, and referral center for the southern part of Thailand. PATIENTS: The patients who acquired A. baumannii during their stay in the hospital. RESULTS: Between July 2003 and September 2005, there were 2,130 isolates of A. baumannii from clinical specimens of 1,237 hospitalized patients. The medical records of 899 admissions to the hospital were available for review. The significant risk factors associated with IRAB acquisition, identified from a case-control study and multiple logistic regression analysis included previous admission to medical-surgical intensive care unit (ICU), respiratory care unit (RCU), previous use of multiple classes of antibiotics, and previous use of imipenem. The cohort study revealed that the mortality rate in the patients with IRAB compared to ISAB were 33.8% and 24.1% respectively, yielding an unadjusted odds ratio of 1.6 (95% CI = 1.2-2.2). However, after controlling for confounding factors by multivariate analysis IRAB did not show the increased mortality. CONCLUSION: The outbreak of IRAB at Songklanagarind Hospital is associated with increasing antibiotic pressure particularly imipenem and the admission to the ICU and RCU. The excess patient mortality rate attributable to IRAB is not significantly different from that attributable to ISAB.

Using a collaborative to reduce ventilator-associated pneumonia in Thailand.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a serious nosocomial infection, leading to high mortality and high costs of treatment in developed and limited-resource countries. A collaborative quality improvement (QI) project was conducted in 18 secondary and tertiary care hospitals in Thailand to address the problem. METHODS: The project, conducted between February 2004 and May 2005, entailed three face-to-face meetings--two national workshops and two regional workshops (each conducted twice). Education on VAP prevention, including guidelines and the ventilator bundle, was conducted for intensive care unit staff and all relevant personnel. The collaborative's effectiveness was assessed by VAP rate, a self-administered questionnaire, and face-to-face interviews. RESULTS: Within 12 months, the pooled VAP rate decreased from 13.3 to 8.3 per 1,000 ventilator-days. The costs of antibiotic treatment for VAP decreased by more than one half. More than 80% of interviewed participants reported that the QI method could be applied effectively in their organization. DISCUSSION: VAP surveillance during this project revealed a gradual reduction of the VAP rate. The project's relative overall success appears to reflect, as reported elsewhere, a well-organized program, support from hospital administrators, and workshop leaders' presentation of proven QI methods and clinical interventions.

Risk of surgical site infection and efficacy of antibiotic prophylaxis: a cohort study of appendectomy patients in Thailand.

BACKGROUND: No data currently exist about use of antibiotics to prevent surgical site infections (SSI) among patients undergoing appendectomy in Thailand. We therefore examined risk factors, use, and efficacy of prophylactic antibiotics for surgical site infection SSI among patients with uncomplicated open appendectomy. METHODS: From July 1, 2003 to June 30, 2004 we conducted a prospective cohort study in eight hospitals in Thailand. We used the National Nosocomial Infection Surveillance (NNIS) system criteria to identify SSI associated with appendectomy. We used logistic regression analysis to obtain relative risk estimates for predictors of SSI. RESULTS: Among 2139 appendectomy patients, we identified 26 SSIs, yielding a SSI rate of 1.2 infections/100 operations. Ninety-two percent of all patients (95% CI, 91.0-93.3) received antibiotic prophylaxis. Metronidazole and gentamicin were the two most common antibiotic agents, with a combined single dose administered in 39% of cases. In 54% of cases, antibiotic prophylaxis was administered for one day. We found that a prolonged duration of operation was significantly associated with an increased SSI risk. Antibiotic prophylaxis was significantly associated with a decreased risk of SSI regardless of whether the antibiotic was administered preoperatively or intraoperatively. Compared with no antibiotic prophylaxis, SSI relative risks for combined single-dose of metronidazole and gentamicin, one-day prophylaxis, and multiple-day antibiotic prophylaxis were 0.28 (0.09-0.90), 0.30 (0.11-0.88) and 0.32 (0.10-0.98), respectively. CONCLUSION: Single-dose combination of metronidazole and gentamicin seems sufficient to reduce SSIs in uncomplicated appendicitis patients despite whether the antibiotic was administered preoperatively or intraoperatively.

Standardized incidence rates of surgical site infection: a multicenter study in Thailand.

BACKGROUND: No previous multicenter data regarding the incidence of surgical site infection (SSI) are available in Thailand. The magnitude of the problem resulting from SSI at the national level could not be assessed. The purpose of this study was to estimate the incidence of SSI in 9 hospitals, together with patterns of surgical antibiotic prophylaxis, risk factors for SSI, and common causative pathogens. METHODS: A prospective data collection among patients undergoing surgery in 9 hospitals in Thailand was conducted. The National Nosocomial Infection Surveillance (NNIS) system criteria and method were used for identifying and diagnosing SSI. The SSI rates were benchmarked with the NNIS report by means of indirect standardization and reported in terms of standardized infection ratio (SIR). Antibiotic prophylaxis was categorized into preoperative, intraoperative, and postoperative. Risk factors for SSI were evaluated using multiple logistic regression models. RESULTS: From July 1, 2003, to February 29, 2004, the study included 8764 patients with 8854 major operations and identified 127 SSIs, yielding an SSI rate of 1.4 infections/100 operations and a corresponding SIR of 0.6 (95% CI: 0.5-0.8). Of these, 35 SSIs (27.6%) were detected postdischarge. The 3 most common operative procedures were cesarean section, appendectomy, and hysterectomy. The 3 most common pathogens isolated were Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa, which accounted for 15.3%, 8.5%, and 6.8% of infections, respectively. The 3 most common antibiotics used for prophylaxis were ampicillin/amoxicillin, cefazolin, and gentamicin. The proportion of types of antibiotic prophylaxis administered were 51.6% preoperative, 24.3% intraoperative, and 24.1% postoperative. Factors significantly associated with SSI were high degree of wound contamination, prolonged preoperative hospital stay, emergency operation, and prolonged duration of operation. CONCLUSION: Overall SSI rates were less than the average NNIS rates. The causative pathogens of SSI were different from those of other reports. There was a crucial proportion of operations that did not comply with the antibiotic guidelines. The risk factors for SSI identified in this study were consistent with most other reports.

Extra charge and extra length of postoperative stay attributable to surgical site infection in six selected operations.

BACKGROUND: Information concerning the economic impact of surgical site infection (SSI) is very rare in Thailand. As the national health care financial system has been changing, the need for such data is critical. OBJECTIVE: The purpose of this study is to estimate the extra charge and excess postoperative hospitalization attributable to SSI in six surgical operative procedures comprising appendectomy, herniorrhaphy, mastectomy, cholecystectomy, colectomy, and craniotomy. MATERIAL AND METHOD: The study population consisted of patients undergoing major operations admitted to Songklanagarind Hospital from January, 1998 to December, 2003. Data were prospectively collected to identify demographic data, surgical operations, development of SSI, and outcomes of SSI. The study used one-to-one matched-pair strategy to compare case (patient with SSI) and controls (patient without SSI). The matching criteria were same final diagnosis, same operative procedure, and same American Society of Anesthesiologists (ASA) score. Data were calculated for mean difference, median difference, and 95% confidence intervals (95% C.I) of hospital charge and postoperative stay. RESULTS: The study could identify 140 matched-pairs of case and control. When compared to matched controls, cases had higher hospital charge and greater postoperative length of stay. Mean of extra hospital charge attributable to SSI was 43,658 (95% C.I; 30,228-57,088) baht and mean of excess postoperative stay was 21.3 (95% C.I; 16.6-26.0) days. Median of extra expenditure was 31,140 (95% CI; 17,327-49,081) baht and median of prolongation of postoperative stay was 14 (95% C.I, 12-18) days. CONCLUSION: This study supports the findings of the previous published reports that patients who have SSI incur enormous excess cost and hospital stay.

Device-associated infections and patterns of antimicrobial resistance in a medical-surgical intensive care unit in a university hospital in Thailand.

BACKGROUND: Surveillance of nosocomial infection in the intensive care unit (ICU) received a high level of attention and outcome indicators are now used in benchmarking the quality of patient care. Since 1999 the surveillance has targeted three site-specific, device-associated infections, including ventilator-associated pneumonia (VAP), central-line-related bloodstream infection (CR-BSI), and catheter-related urinary tract infection (CR-UTI). The authors conducted a two-year prospective study on the incidences of these infections acquired in an ICU and report herein, together with the antibiotic susceptibility patterns of the microorganisms isolated in an ICU. PATIENTS AND METHOD: Continuous prospective data collection was conducted on patients admitted to an adult medical-surgical ICU of a university hospital in Thailand from June 2000 to May 2002. RESULTS: A total 1422 patients with a total of 9370 patient-days were enrolled in the study. The incidence of VAP, CR-BSI, and CR-UTI were 10.8/1000 ventilator-days (95% C.I: 8.5-13.6), 2.6/1000 central-line-days (95%C.I. 1.5-4.4), and 13.8/1000 urinary-catheter-days (95%C.I: 10.7-17.5) respectively. The most common causative pathogens were Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. The proportion of methicillin-resistant Staphylococcus aureus, imipenem-resistant P. aeruginosa, ceftazidime-resistant A. baumannii, third-generation-cephalosporin-resistant K. pneumoniae, and quinolone-resistant E. coli were 68.8%, 30.9%, 68.5%, 44.6%, 38.3% respectively. CONCLUSION: The incidences of VAP and CR-BSI were comparable to the National Nosocomial Infection Surveillance (NNIS) report. But the incidence of CR-UTI was over the 90th percentile. The antibiotic resistance had become a serious problem.

Surgical site infections in patients undergoing major operations in a university hospital: using standardized infection ratio as a benchmarking tool.

BACKGROUND: Because patterns of infection acquired in patients undergoing operation are ever changing, it is an essential part of nosocomial infection surveillance programs to periodically document the epidemiologic features of infection in these patients. This study was conducted with the primary intention of describing the incidence and risk factors of the surgical site infection (SSI). METHODS: We performed a prospective study in patients undergoing certain major operations at a 750-bed university hospital in Thailand. The National Nosocomial Infection Surveillance (NNIS) system method and criteria were used for identifying and diagnosing infection. The infection rates were benchmarked with the NNIS report by means of indirect standardization and reported in terms of standardized infection ratio. Risk factors for SSI were evaluated using the multiple logistic regression model. RESULTS: From September 1998 to March 2000, the study included 4193 patients with 4437 major operations. The study identified 192 SSIs, 76 urinary catheter-related urinary tract infections, 26 central line-related bloodstream infections, and 39 instances of ventilator-associated pneumonia (VAP), yielding an infection rate of 4.3 SSIs/100 operations, 11.0 catheter-related urinary tract infections/1000 urinary catheter-days, 6.1 central line-related bloodstream infections/1000 central line-days, and 11.0 VAPs/1000 ventilator-days. When compared with data from NNIS, the standardized infection ratio of SSI, catheter-related urinary tract infection, central line-related bloodstream infection, and VAP were 2.3, 2.1, 1.1, and 0.8, respectively. The factors that significantly associated with SSI were duration of operation in minutes, American Society of Anesthesiologists (ASA) class, and degree of wound contamination. CONCLUSION: All of the infection rates identified, except VAP, were higher than the average NNIS rates. The risk factors for SSI were prolonged duration of operation, poor physical status according to ASA classification, and higher degree of wound contamination.

Trauma severity scoring systems as predictors of nosocomial infection.

OBJECTIVES: To describe the patterns of nosocomial infections in patients with traumatic injuries and to compare the associations between injury severity, derived from various severity scoring systems, and subsequent nosocomial infections. DESIGN: Prospective observational study. SETTING: A 750-bed university hospital serving as a medical school and referral center for the southern part of Thailand. PARTICIPANTS: All trauma patients admitted to the hospital for more than 3 days during 1996 to 1999 were eligible for this study. METHODS: The severity of injuries was measured in terms of injury severity score (ISS), revised trauma score (RTS), new injury severity score (NISS), and trauma injury severity score (TRISS). Infections acquired during hospitalization were categorized using Centers for Disease Control and Prevention criteria. The association between severity of injury and nosocomial infection was examined with Poisson regression models. RESULTS: There were 222 nosocomial infections identified among 146 patients, yielding an infection rate of 0.8 infections per 100 patient-days. Surgical-site infection was the most common site-specific infection, accounting for 31.1% of all infections. The incidence of intravenous catheter-related bloodstream infection was 1.6 infections per 100 catheter-days. The bladder catheter-related urinary tract infection rate was 2.8 infections per 100 catheter-days. The rate of ventilator-associated pneumonia was 3.2 infections per 100 ventilator-days. The incidence of infection correlated well with injury severity. The infection incidence rate ratios for one severity category increment of ISS, NISS, RTS, and TRISS were 1.65 (95% confidence interval [CI95], 1.42 to 1.92), 1.79 (CI95, 1.55 to 2.05), 1.64 (CI95 1.43 to 1.88), and 1.32 (CI95, 1.14 to 1.52), respectively. CONCLUSIONS: Surgical-site infection was the most common site-specific nosocomial infection. The NISS might be the most appropriate severity scoring system for adjustment of infection rates in trauma patients.