The impact of COVID-19 on health care-associated infections in intensive care units in low- and middle-income countries: International Nosocomial Infection Control Consortium (INICC) findings.

BACKGROUND: This study examines the impact of the COVID-19 pandemic on health care-associated infection (HAI) incidence in low- and middle-income countries (LMICs). METHODS: Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre-COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS). RESULTS: A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p < .0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p < .0001), respectively. DISCUSSION: This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

An easy technique to measure neo-chordae length during minimally invasive mitral valve repair.

In this article, we present our experience with an easy and practical technique for measuring the length of neo-chordae during minimally invasive mitral valve repair. This technique is based on tying the knots at the level of the plane of the ring using a prolene suture passing through the transverse diameter of the ring as a guideline.

Comparison of Renoprotective Effect of Dabigatran With Low-Molecular-Weight Heparin.

OBJECTIVE: The susceptibility of tissue to ischemia-reperfusion (I/R) injury is a major obstacle to tissue regeneration and cellular survival. In this study, we investigated the possible renoprotective effect of dabigatran in an experimental renal I/R model. METHOD: A total of 25 rats were randomly divided into 5 equal groups. The control group was used to obtain basal values of oxidant and antioxidant biomarkers. The sham group was used to obtain renal prolidase and malondialdehyde (MDA) levels after renal ischemia (for 45 minutes) and reperfusion (for 1 hour). A standard diet was followed. Oral 15 mg/kg dabigatran etexilate was administrated to group I, intraperitoneal 250 U/kg enoxaparin sodium was administrated to group II, and intraperitoneal 250 U/kg bemiparin sodium was administrated to group III for 1 week before the renal I/R was performed. Renal tissue samples were obtained during the first hour of reperfusion to detect renal prolidase and MDA levels in these groups, after which the rats were euthanized. RESULTS: Renal prolidase levels were significantly higher in the sham group compared with the control group (1834.2 ± 982.3 U/g protein vs 238.8 ± 43.6U/g protein; P = .001). Lower prolidase levels were observed in groups II (838.7 ± 123.8 U/g protein) and III (1012.9 ± 302.3 U/g protein), and the lowest prolidase levels occurred in group I (533.8 ± 96.2 U/g protein; P < .05) when compared with the sham group. The MDA levels were significantly lower (P < .05) in groups I, II, and III (163.9 ± 41.5, 185.4 ± 51.0, and 138.2 ± 22.6 µmol/g protein, respectively) compared with the sham group. CONCLUSION: Dabigatran etexilate, a univalent direct thrombin inhibitor, may protect the renal tissue more effectively when compared to low-molecular-weight heparins.

Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach, over 8 years, in 11 cities of Turkey.

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.

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

BACKGROUND: Central line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey. METHODS: We conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention. RESULTS: During baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 - 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB. CONCLUSIONS: The implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Double filtration plasmapheresis for a case of Crimean-Congo hemorrhagic fever.

Crimean-Congo hemorrhagic fever (CCHF), is a fatal viral infection transmitted to humans through a tick bite or exposure to blood or tissues of viremic hosts. The clinical presentation is characterized by sudden onset high fever, headache, myalgia, abdominal pain and nausea-vomiting followed by gastrointestinal, urinary, respiratory tract and brain hemorrhage. Laboratory findings include leucopenia, thrombocytopenia, elevated liver enzymes, prolonged prothrombin time and activated partial thromboplastin time. We report a case of CCHF who was treated with a combination of DFPP and ribavirin therapy. As a result of this multimodal treatment, patient's clinical symptoms and laboratory findings improved gradually.

Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection Control Consortium findings (INICC).

BACKGROUND: We evaluate the effectiveness of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infections (CAUTIs) in 13 intensive care units (ICUs) in 10 hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of Turkey. METHODS: A before-after prospective active surveillance study was used to determine rates of CAUTI. The study was divided into baseline (phase 1) and intervention (phase 2). In phase 1, surveillance was performed applying the definitions of the Centers for Disease Control and Prevention/National Healthcare Safety Network. In phase 2, we implemented a multidimensional approach that included bundle of infection control interventions, education, surveillance and feedback on CAUTI rates, process surveillance, and performance feedback. We used random effects Poisson regression to account for clustering of CAUTI rates across time periods. RESULTS: The study included 4,231 patients, hospitalized in 13 ICUs, in 10 hospitals, in 10 cities, during 49,644 patient-days. We recorded a total of 41,871 urinary catheter (UC)-days: 5,080 in phase 1 and 36,791 in phase 2. During phase 1, the rate of CAUTI was 10.63 per 1,000 UC-days and was significantly decreased by 47% in phase 2 to 5.65 per 1,000 UC-days (relative risk, 0.53; 95% confidence interval: 0.4-0.7; P value = .0001). CONCLUSION: Our multidimensional approach was associated with a significant reduction in the rates of CAUTI in Turkey.

Therapeutic plasma exchange in an intensive care unit (ICU): a 10-year, single-center experience.

Therapeutic plasma exchange (TPE) is a blood purification method that effectively allows for the removal of waste substances by separating out plasma from other components of blood and the removed plasma is replaced with solutions such as albumin and/or plasma, or crystalloid/colloid solutions. Plasma exchange therapies are becoming increasingly essential, being used in daily practice in critical care settings for various indications, either as a first-line therapeutic intervention or as an adjunct to conventional therapies. This retrospective clinical study analyzes 10-year therapeutic plasma exchange activity experience in an 18-bed ICU at a tertiary care university hospital with a large, critically-ill patient population. Medical records of 1188 plasma exchange procedures on 329 patients with different diagnoses admitted from January 2000 to July 2010 were evaluated. The aim of the study was to determine the TPE indications and outcomes of the patients who underwent TPE in the ICU with conventional therapy. The secondary endpoints were to determine the differences between different patient groups (septic vs. non-septic indications) in terms of adverse events and procedural differences.

Fatal polyarteritis nodosa with gastrointestinal involvement in a child.

Polyarteritis nodosa (PAN) is a necrotizing angiitis that predominantly affects small- and medium-sized arteries. Polyarteritis nodosa occurs rarely during childhood. Boys and girls seem to be equally affected, with a peak at the age of 10 years. Rarely, severe and fatal gastrointestinal involvement is seen in PAN. Here, we report a 15-year-old boy with PAN, who had gastrointestinal involvement with multiple aneurysms of the hepatic and superior mesenteric arteries. This involvement could be demonstrated with conventional angiography and gastrointestinal bleeding scintigraphy. The progression of the symptoms and the decrease in the size of the aneurysms were noted after combination treatment with cyclophosphamide and prednisolone, but there was severe bleeding from small bowel, and it was taken under control by resection of jejunum. However, the patient died because of sepsis. In conclusion, severe gastrointestinal involvement in PAN is usually fatal despite aggressive therapy, as is the case in our patient.

Effects of replacement fluids used for therapeutic plasma exchange on plasma viscosity and plasma oncotic pressure.

INTRODUCTION: Apheresis is a procedure in which one of the components of blood is removed. The aim of therapeutic plasma exchange (TPE) is to remove a large fraction of the patient's plasma from the body, and to exchange this with replacement solutions using automatic devices. With this procedure circulating pathogens and toxins are reduced. Before each TPE results of a baseline basal complete blood count, serum protein electrophoresis, coagulation tests and serum electrolytes must be known. The efficacy of this therapy is assessed only by these values. The proteins responsible for disease may be monoclonal proteins, cryoglobulins, lipoproteins, auto or allo antibodies or toxins. In this study, we aimed to compare the effects of several replacement fluids on plasma viscosity and oncotic pressure. At the same time, we evaluated the correlation between plasma viscosity and oncotic pressure. MATERIAL AND METHODS: 111 TPE were performed on 42 patients. Before TPE, the patients whose veins were not suitable were catheterised either by using a subclavian or jugular 11F dialysis catheter. At each session, approximately 1-1.5L of plasma was exchanged. The procedure was performed with albumin in patients whose albumin was under 3gr/dl. Over this value, the exchange fluids were randomised. RESULTS: When the overall results were analysed, there was no statistically significant difference between groups 1 (HES+albumin) and group 3 (albumin). The statistical difference between group 2 and 3 was significant, but no difference was observed between group 1 and 2. According to the decreasing plasma viscosity, there was a significant difference between group 2 and group 3, but there was no difference between group 1 and group 2. CONCLUSIONS: The replacement solutions used for plasmapheresis are similar when compared for hemorheologic effects, but we have chosen fresh frozen plasma because of fewer side effects.