Impact of INICC Multidimensional Hand Hygiene Approach in ICUs in Four Cities in Argentina.

We evaluated the impact of the International Nosocomial Infection Control Consortium multidimensional approach to hand hygiene in 11 intensive care units in 4 cities in Argentina and analyzed predictors of poor hand hygiene compliance. We had a baseline period and a follow-up period. We observed 21 100 hand hygiene opportunities. Hand hygiene compliance increased from 28.3% to 64.8% (P = .0001). Males versus females (56.8% vs 66.4%; P < .001) and physicians versus nurses (46.6% vs 67.8%; P < .001) were significantly associated with poor hand hygiene compliance.

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.

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.

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.

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.

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

BACKGROUND: Central line (CL)-associated bloodstream infections (CLABSIs) occurring in the intensive care unit (ICU) are common and associated with a high burden. METHODS: We implemented a multidimensional approach, incorporating an 11-element bundle, education, surveillance of CLABSI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CLABSI rates and clinical outcomes, and performance feedback in 316 ICUs across 30 low- and middle-income countries. Our dependent variables were CLABSI per 1,000-CL-days and in-ICU all-cause mortality rates. These variables were measured at baseline and during the intervention, specifically during the second month, third month, 4 to 16 months, and 17 to 29 months. Comparisons were conducted using a two-sample t test. To explore the exposure-outcome relationship, we used a generalized linear mixed model with a Poisson distribution to model the number of CLABSIs. RESULTS: During 1,837,750 patient-days, 283,087 patients, used 1,218,882 CL-days. CLABSI per 1,000 CL-days rates decreased from 15.34 at the baseline period to 7.97 in the 2nd month (relative risk (RR) = 0.52; 95% confidence interval [CI] = 0.48-0.56; P < .001), 5.34 in the 3rd month (RR = 0.35; 95% CI = 0.32-0.38; P < .001), and 2.23 in the 17 to 29 months (RR = 0.15; 95% CI = 0.13-0.17; P < .001). In-ICU all-cause mortality rate decreased from 16.17% at baseline to 13.68% (RR = 0.84; P = .0013) at 17 to 29 months. CONCLUSIONS: The implemented approach was effective, and a similar intervention could be applied in other ICUs of low- and middle-income countries to reduce CLABSI and in-ICU all-cause mortality rates.

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.

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.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in adult intensive care units from 14 developing countries of four continents: findings of the International Nosocomial Infection Control Consortium.

OBJECTIVES: The aim of this study was to analyze the effect of the International Nosocomial Infection Control Consortium's multidimensional approach on the reduction of ventilator-associated pneumonia in patients hospitalized in intensive care units. DESIGN: A prospective active surveillance before-after study. The study was divided into two phases. During phase 1, the infection control team at each intensive care unit conducted active prospective surveillance of ventilator-associated pneumonia by applying the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the methodology of International Nosocomial Infection Control Consortium. During phase 2, the multidimensional approach for ventilator-associated pneumonia was implemented at each intensive care unit, in addition to the active surveillance. SETTING: Forty-four adult intensive care units in 38 hospitals, members of the International Nosocomial Infection Control Consortium, from 31 cities of the following 14 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, and Turkey. PATIENTS: A total of 55,507 adult patients admitted to 44 intensive care units in 38 hospitals. INTERVENTIONS: The International Nosocomial Infection Control Consortium ventilator-associated pneumonia multidimensional approach included the following measures: 1) bundle of infection-control interventions; 2) education; 3) outcome surveillance; 4) process surveillance; 5) feedback of ventilator-associated pneumonia rates; and 6) performance feedback of infection-control practices. MEASUREMENTS: The ventilator-associated pneumonia rates obtained in phase 1 were compared with the rates obtained in phase 2. We performed a time-series analysis to analyze the impact of our intervention. MAIN RESULT: During phase 1, we recorded 10,292 mechanical ventilator days, and during phase 2, with the implementation of the multidimensional approach, we recorded 127,374 mechanical ventilator days. The rate of ventilator-associated pneumonia was 22.0 per 1,000 mechanical ventilator days during phase 1, and 17.2 per 1,000 mechanical ventilator days during phase 2.The adjusted model of linear trend shows a 55.83% reduction in the rate of ventilator-associated pneumonia at the end of the study period; that is, the ventilator-associated pneumonia rate was 55.83% lower than it was at the beginning of the study. CONCLUSION: The implementation the International Nosocomial Infection Control Consortium multidimensional approach for ventilator-associated pneumonia was associated with a significant reduction in the ventilator-associated pneumonia rate in the adult intensive care units setting of developing countries.

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.

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.

Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method.

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.

The time-dependent bias and its effect on extra length of stay due to nosocomial infection.

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.

Prevention of Clostridioides difficile in hospitals: A position paper of the International Society for Infectious Diseases.

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.

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.

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.

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.

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 euro 18,241 and euro 9,087, respectively (p < 0.001). On average, the extra cost for drugs was euro 843 (p < 0.001), for supplies euro 133 (p = 0.116), for lab tests euro 171 (p < 0.001), and for specialist visits euro 15 (p = 0.019). The mean extra cost for hospital stay (overhead) was euro 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.

Should we use closed or open infusion containers for prevention of bloodstream infections?

BACKGROUND: Hospitalized patients in critical care settings are at risk for bloodstream infections (BSI). Most BSIs originate from a central line (CL), and they increase length of stay, cost, and mortality. Open infusion containers may increase the risk of contamination and administration-related (CLAB) because they allow the entry of air into the system, thereby also providing an opportunity for microbial entry. Closed infusion containers were designed to overcome this flaw. However, open infusion containers are still widely used throughout the world.The objective of the study was to determine the effect of switching from open (glass, burettes, and semi-rigid) infusion containers to closed, fully collapsible, plastic infusion containers (Viaflex) on the rate and time to onset of central line-associated bloodstream infections CLABs. METHODS: An open label, prospective cohort, active healthcare-associated infection surveillance, sequential study was conducted in four ICUs in Mexico. Centers for Disease Control National Nosocomial Infections Surveillance Systems definitions were used to define device-associated infections. RESULTS: A total of 1,096 adult patients who had a central line in place for >24 hours were enrolled. The CLAB rate was significantly higher during the open versus the closed container period (16.1 versus 3.2 CLAB/1000 central line days; RR = 0.20, 95% CI = 0.11-0.36, P < 0.0001). The probability of developing CLAB remained relatively constant in the closed container period (1.4% Days 2-4 to 0.5% Days 8-10), but increased in the open container period (4.9% Days 2-4 to 5.4% Days 8-10). The chance of acquiring a CLAB was significantly decreased (81%) in the closed container period (Cox proportional hazard ratio 0.19, P < 0.0001). Mortality was statistically significantly lower during the closed versus the open container period (23.4% versus 16.1%; RR = 0.69, 95% CI = 0.54-0.88, P < 0.01). CONCLUSIONS: Closed infusion containers significantly reduced CLAB rate, the probability of acquiring CLAB, and mortality.

Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases.

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.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 246 intensive units of 83 hospitals in 52 cities of 14 countries of Middle East: Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates-International Nosocomial Infection Control Consortium (INICC) findings.

BACKGROUND: Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied, and data on their incidence by number of device-days is not available. METHODS: Prospective, surveillance study on PVCR-BSI conducted from September 1st, 2013 to 31st Mays, 2019 in 246 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 83 hospitals in 52 cities of 14 countries in the Middle East (Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates). We applied U.S. RESULTS: We followed 31,083 ICU patients for 189,834 bed-days and 202,375 short term peripheral venous catheter (PVC)-days. We identified 470 PVCR-BSIs, amounting to a rate of 2.32/1000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 10.38%, and 29.36% in patients with PVC and PVCR-BSI. The mean length of stay in patients with PVC but without PVCR-BSI was 5.94 days, and 16.84 days in patients with PVC and PVCR-BSI. The microorganism profile showed 55.2 % of gram-positive bacteria, with Coagulase-negative Staphylococci (31%) and Staphylococcus aureus (14%) being the predominant ones. Gram-negative bacteria accounted for 39% of cases, and included: Escherichia coli (7%), Klebsiella pneumoniae (8%), Pseudomonas aeruginosa (5%), Enterobacter spp. (3%), and others (29.9%), such as Serratia marcescens. CONCLUSIONS: PVCR-BSI rates found in our ICUs were much higher than rates published from USA, Australia, and Italy. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Central line-associated bloodstream infections in limited-resource countries: a review of the literature.

Central line-associated bloodstream infections (CLABSIs) are considered a significant cause of mortality in hospitalized patients; however, the incidence of CLABSIs in limited-resource countries has not been explored analytically. Likewise, the appropriate interventions to prevent, control, and reduce CLABSIs have yet to be analyzed thoroughly. This review demonstrates that the CLABSI rate ranged from 1.6 to 44.6 cases per 1000 central line days in adult and pediatric intensive care units (ICUs) and from 2.6 to 60.0 cases per 1000 central line days in neonatal ICUs and is associated with significant extra mortality, with an odds ratio ranging from 2.8 to 9.5. The results of 6 sequential prospective interventional studies showed that hand hygiene and educational programs were related to a significant reduction in CLABSI rates. CLABSI rates in limited-resource countries are higher than US National Healthcare Safety Network benchmark rates and have a significant impact on mortality. Studies showing successful interventions for a reduction in CLABSIs are few. Subsequently, it can be inferred that additional epidemiological studies need to be conducted to achieve an appreciation of the effects of CLABSIs and to develop more-definitive approaches for CLABSI prevention in the form of practical, low-cost, low-technology measures that are feasible to implement in limited-resource countries.

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.

BACKGROUND: To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and use of INICC Surveillance Online System (ISOS) on ventilator-associated pneumonia (VAP) rates in Saudi Arabia from September 2013 to February 2017. METHODS: A multicenter, prospective, before-after surveillance study on 14,961 patients in 37 intensive care units (ICUs) of 22 hospitals. During baseline, we performed outcome surveillance of VAP applying the definitions of the CDC/NHSN. During intervention, we implemented the IMA and the ISOS, which included: (1) a bundle of infection prevention practice interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on VAP rates and consequences and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using generalized linear mixed models to estimate the effect of intervention. RESULTS: The baseline rate of 7.84 VAPs per 1000 mechanical-ventilator (MV)-days-with 20,927 MV-days and 164 VAPs-, was reduced to 4.74 VAPs per 1000 MV-days-with 118,929 MV-days and 771 VAPs-, accounting for a 39% rate reduction (IDR 0.61; 95% CI 0.5-0.7; P 0.001). CONCLUSIONS: Implementing the IMA was associated with significant reductions in VAP rates in ICUs of Saudi Arabia.

Device-associated nosocomial infections in 55 intensive care units of 8 developing countries.

BACKGROUND: Health care-associated infections from invasive medical devices in the intensive care unit (ICU) are a major threat to patient safety. Most published studies of ICU-acquired infections have come from industrialized western countries. In a Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) System report, the U.S. pooled mean rates of central venous catheter (CVC)-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections were 4.0 per 1000 CVC days, 5.4 per 1000 mechanical ventilator days, and 3.9 per Foley catheter days, respectively. OBJECTIVE: To ascertain the incidence of device-associated infections in the ICUs of developing countries. DESIGN: Multicenter, prospective cohort surveillance of device-associated infection by using the CDC NNIS System definitions. SETTING: 55 ICUs of 46 hospitals in Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey that are members of the International Nosocomial Infection Control Consortium (INICC). MEASUREMENTS: Rates of device-associated infection per 100 patients and per 1000 device days. RESULTS: During 2002-2005, 21,069 patients who were hospitalized in ICUs for an aggregate 137,740 days acquired 3095 device-associated infections for an overall rate of 14.7% or 22.5 infections per 1000 ICU days. Ventilator-associated pneumonia posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by CVC-related bloodstream infections (30% of all device-associated infections or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days). Notably, 84% of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were resistant to ceftriaxone, and 59% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones. The crude mortality rate for patients with device-associated infections ranged from 35.2% (for CVC-associated bloodstream infection) to 44.9% (for ventilator-associated pneumonia). LIMITATIONS: These initial data are not adequate to represent any entire country, and likely variations in the efficiency of surveillance and institutional resources may have affected the rates that were detected. CONCLUSIONS: Device-associated infections in the ICUs of these developing countries pose greater threats to patient safety than in U.S. ICUs. Active infection control programs that perform surveillance of infection and implement guidelines for prevention can improve patient safety and must become a priority in every country.