Evaluating the outcome of a bundle with 11 components and the INICC multidimensional approach in decreasing rates of central line-associated bloodstream infections across nine Asian countries.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) rates in intensive care units (ICUs) across Latin America exceed those in high-income countries significantly. METHODS: We implemented the INICC multidimensional approach, incorporating an 11-component bundle, in 122 ICUs spanning nine Asian countries. We computed the CLABSI rate using the CDC/NSHN definition and criteria. The CLABSI rate per 1000 CL-days was calculated at baseline and throughout different phases of the intervention, including the 2nd month, 3rd month, 4-16 month, and 17-29 month periods. A two-sample t-test was employed to compare baseline CLABSI rates with intervention rates. Additionally, we utilized a generalized linear mixed model with a Poisson distribution to analyze the association between exposure and outcome. RESULTS: A total of 124,946 patients were hospitalized over 717,270 patient-days, with 238,595 central line (CL)-days recorded. The rates of CLABSI per 1000 CL-days significantly decreased from 16.64 during the baseline period to 6.51 in the 2nd month (RR = 0.39; 95% CI = 0.36-0.42; p < 0.001), 3.71 in the 3rd month (RR = 0.22; 95% CI = 0.21-0.25; p < 0.001), 2.80 in the 4-16 month (RR = 0.17; 95% CI = 0.15-0.19; p < 0.001), and 2.18 in the 17-29 month (RR = 0.13; 95% CI = 0.11-0.15; p < 0.001) intervals. A multilevel Poisson regression model demonstrated a sustained, continuous, and statistically significant decrease in ratios of incidence rates, reaching 0.35 (p < 0.0001) during the 17-29 month period. Moreover, the all-cause in-ICU mortality rate significantly decreased from 13.23% to 10.96% (p = 0.0001) during the 17-29 month period. CONCLUSIONS: Our intervention led to an 87% reduction in CLABSI rates, with a 29-month follow-up.

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.

Assessing the impact of a multidimensional approach and an 8-component bundle in reducing incidences of ventilator-associated pneumonia across 35 countries in Latin America, Asia, the Middle East, and Eastern Europe.

BACKGROUND: Ventilator associated pneumonia (VAP) occurring in the intensive care unit (ICU) are common, costly, and potentially lethal. METHODS: We implemented a multidimensional approach and an 8-component bundle in 374 ICUs across 35 low and middle-income countries (LMICs) from Latin-America, Asia, Eastern-Europe, and the Middle-East, to reduce VAP rates in ICUs. The VAP rate per 1000 mechanical ventilator (MV)-days was measured at baseline and during intervention at the 2nd month, 3rd month, 4-15 month, 16-27 month, and 28-39 month periods. RESULTS: 174,987 patients, during 1,201,592 patient-days, used 463,592 MV-days. VAP per 1000 MV-days rates decreased from 28.46 at baseline to 17.58 at the 2nd month (RR = 0.61; 95% CI = 0.58-0.65; P < 0.001); 13.97 at the 3rd month (RR = 0.49; 95% CI = 0.46-0.52; P < 0.001); 14.44 at the 4-15 month (RR = 0.51; 95% CI = 0.48-0.53; P < 0.001); 11.40 at the 16-27 month (RR = 0.41; 95% CI = 0.38-0.42; P < 0.001), and to 9.68 at the 28-39 month (RR = 0.34; 95% CI = 0.32-0.36; P < 0.001). The multilevel Poisson regression model showed a continuous significant decrease in incidence rate ratios, reaching 0.39 (p < 0.0001) during the 28th to 39th months after implementation of the intervention. CONCLUSIONS: This intervention resulted in a significant VAP rate reduction by 66% that was maintained throughout the 39-month period.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections over 18 years in 281 ICUs of 9 Asian countries.

BACKGROUND: Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors (RF) in Asia. METHODS: From 03/27/2004 to 02/11/2022, we conducted a multinational multicenter prospective cohort study in 281 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam). For estimation of CLABSI rate we used CL-days as denominator and number of CLABSI as numerator. To estimate CLABSI RF for we analyzed the data using multiple logistic regression, and outcomes are shown as adjusted odds ratios (aOR). RESULTS: A total of 150,142 patients, hospitalized 853,604 days, acquired 1514 CLABSIs. Pooled CLABSI rate per 1000 CL-days was 5.08; per type of catheter were: femoral: 6.23; temporary hemodialysis: 4.08; jugular: 4.01; arterial: 3.14; PICC: 2.47; subclavian: 2.02. The highest rates were femoral, temporary for hemodialysis, and jugular, and the lowest PICC and subclavian. We analyzed following variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization ratio, CL-type, tracheostomy use, hospitalization type, ICU type, facility ownership and World Bank classifications by income level. Following were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 4% daily (aOR = 1.04; 95% CI = 1.03-1.04; p < 0.0001); number of CL-days before CLABSI acquisition, rising risk 5% per CL-day (aOR = 1.05; 95% CI 1.05-1.06; p < 0.0001); medical hospitalization (aOR = 1.21; 95% CI 1.04-1.39; p = 0.01); tracheostomy use (aOR = 2.02;95% CI 1.43-2.86; p < 0.0001); publicly-owned facility (aOR = 3.63; 95% CI 2.54-5.18; p < 0.0001); lower-middle-income country (aOR = 1.87; 95% CI 1.41-2.47; p < 0.0001). ICU with highest risk was pediatric (aOR = 2.86; 95% CI 1.71-4.82; p < 0.0001), followed by medical-surgical (aOR = 2.46; 95% CI 1.62-3.75; p < 0.0001). CL with the highest risk were internal-jugular (aOR = 3.32; 95% CI 2.84-3.88; p < 0.0001), and femoral (aOR = 3.13; 95% CI 2.48-3.95; p < 0.0001), and subclavian (aOR = 1.78; 95% CI 1.47-2.15; p < 0.0001) showed the lowest risk. CONCLUSIONS: The following CLABSI RFs are unlikely to change: country income level, facility-ownership, hospitalization type, and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, and tracheostomy; using subclavian or PICC instead of internal-jugular or femoral; and implementing evidence-based CLABSI prevention recommendations.

Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC).

Objective: Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs. Design: Prospective cohort study. Setting: This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries. Participants: The study included patients admitted to ICUs across 24 years. Results: In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16-1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07-1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23-1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57-15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21-9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34-7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17-1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15-1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22-5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78-3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79-3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51-0.77; P < .0001). Conclusions: Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.

Risk factors for mortality over 18 years in 317 ICUs in 9 Asian countries: The impact of healthcare-associated infections.

OBJECTIVE: To identify risk factors for mortality in intensive care units (ICUs) in Asia. DESIGN: Prospective cohort study. SETTING: The study included 317 ICUs of 96 hospitals in 44 cities in 9 countries of Asia: China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam. PARTICIPANTS: Patients aged >18 years admitted to ICUs. RESULTS: In total, 157,667 patients were followed during 957,517 patient days, and 8,157 HAIs occurred. In multiple logistic regression, the following variables were associated with an increased mortality risk: central-line-associated bloodstream infection (CLABSI; aOR, 2.36; P < .0001), ventilator-associated event (VAE; aOR, 1.51; P < .0001), catheter-associated urinary tract infection (CAUTI; aOR, 1.04; P < .0001), and female sex (aOR, 1.06; P < .0001). Older age increased mortality risk by 1% per year (aOR, 1.01; P < .0001). Length of stay (LOS) increased mortality risk by 1% per bed day (aOR, 1.01; P < .0001). Central-line days increased mortality risk by 2% per central-line day (aOR, 1.02; P < .0001). Urinary catheter days increased mortality risk by 4% per urinary catheter day (aOR, 1.04; P < .0001). The highest mortality risks were associated with mechanical ventilation utilization ratio (aOR, 12.48; P < .0001), upper middle-income country (aOR, 1.09; P = .033), surgical hospitalization (aOR, 2.17; P < .0001), pediatric oncology ICU (aOR, 9.90; P < .0001), and adult oncology ICU (aOR, 4.52; P < .0001). Patients at university hospitals had the lowest mortality risk (aOR, 0.61; P < .0001). CONCLUSIONS: Some variables associated with an increased mortality risk are unlikely to change, such as age, sex, national economy, hospitalization type, and ICU type. Some other variables can be modified, such as LOS, central-line use, urinary catheter use, and mechanical ventilation as well as and acquisition of CLABSI, VAE, or CAUTI. To reduce mortality risk, we shall focus on strategies to reduce LOS; strategies to reduce central-line, urinary catheter, and mechanical ventilation use; and HAI prevention recommendations.

An international observational study to assess the impact of the Omicron variant emergence on the clinical epidemiology of COVID-19 in hospitalised patients

BackgroundWhilst timely clinical characterisation of infections caused by novel SARS-CoV-2 variants is necessary for evidence-based policy response, individual-level data on infecting variants are typically only available for a minority of patients and settings. MethodsHere, we propose an innovative approach to study changes in COVID-19 hospital presentation and outcomes after the Omicron variant emergence using publicly available population-level data on variant relative frequency to infer SARS-CoV-2 variants likely responsible for clinical cases. We apply this method to data collected by a large international clinical consortium before and after the emergence of the Omicron variant in different countries. ResultsOur analysis, that includes more than 100,000 patients from 28 countries, suggests that in many settings patients hospitalised with Omicron variant infection less often presented with commonly reported symptoms compared to patients infected with pre-Omicron variants. Patients with COVID-19 admitted to hospital after Omicron variant emergence had lower mortality compared to patients admitted during the period when Omicron variant was responsible for only a minority of infections (odds ratio in a mixed-effects logistic regression adjusted for likely confounders, 0.67 [95% confidence interval 0.61 - 0.75]). Qualitatively similar findings were observed in sensitivity analyses with different assumptions on population-level Omicron variant relative frequencies, and in analyses using available individual-level data on infecting variant for a subset of the study population. ConclusionsAlthough clinical studies with matching viral genomic information should remain a priority, our approach combining publicly available data on variant frequency and a multi-country clinical characterisation dataset with more than 100,000 records allowed analysis of data from a wide range of settings and novel insights on real-world heterogeneity of COVID-19 presentation and clinical outcome.

Point-of-Care Procalcitonin to Guide the Discontinuation of Antibiotic Treatment in the Intensive Care Unit: A Malaysian Randomised Controlled Trial

@#Introduction: This work aims to establish the practicality of simple point-of-care (POC) measurements of procalcitonin (PCT) coupled with the standard PCT-guided antibiotic treatment discontinuation algorithm to guide the cessation of antibiotic treatment in intensive care unit (ICU). Methods: In this randomised-controlled trial, 80 adult patients with suspected bacterial infections were randomised to either the POC PCT-guided arm (n = 40) or the standard-of-care arm (n = 40). The decision to discontinue antibiotic treatment in the POC PCT-guided arm was based on the POC PCT-guided antibiotic-treatment discontinuation strategy, which states that discontinuation is urged once the PCT concentration has reduced by ≥ 80% or to < 0.5 ng/mL. In the standard-of-care arm, the antibiotic-treatment duration followed the local guidelines. Results: The median duration of antibiotic treatment was 6.5 [IQR = 5.0-7.0] days in the POC PCT-guided antibiotic-treatment arm versus 7.5 [IQR = 5.0-14.0] days in the standard-of-care arm (p = 0.010). The mean antibiotic-free days in the first 30 days after study inclusion was 20.7 (SD = 5.3) days in the POC PCT-guided antibiotic-treatment arm versus 16.4 (SD = 7.4) days in the standard-of-care arm (p = 0.004). The number of patients who took an antibiotic for more than 10 days was 2 (5%) in the POC PCT-guided antibiotic-treatment arm versus 13 (32.5%) in the standard-of-care arm (p = 0.002). Conclusion: Antibiotic use in patients with symptoms of bacterial infections in the ICU was substantially minimised with the installation of a POC PCT-guided antibiotic-treatment cessation.

Validation of the 28-day mortality prognostic performance of the modified Nutrition Risk in Critically Ill (mNUTRIC) score in a Malaysian intensive care unit

@#Introduction: The mNUTRIC score is a nutritional assessment tool to identify critically ill patients with high nutritional risk who could benefit from nutritional interventions. This study was conducted to validate the 28-day mortality prognostic performance of the mNUTRIC score in a Malaysian intensive care unit (ICU). Methods: This was a retrospective cohort study of adult patients who were consecutively admitted to the ICU from January 2017 to December 2018 for >24 hours. Data were collected on variables required to calculate the mNUTRIC score. Patients with mNUTRIC score ≥5 points were considered to be at high nutritional risk. Main outcome was 28- day mortality from all causes; ICU length of stay (LOS) and prolonged mechanical ventilation (MV) (>2 days) were secondary outcomes. Results: From a total of 432 admissions, 382 (88.4%) patients fulfilled the study criteria. Seventy-seven (20.2%) of these patients were at high nutritional risk. They had longer mean ICU LOS (7.1±7.5 days versus 4.2±4.0 days, p=0.001), greater proportion of prolonged MV (57.1% versus 14.4%, p<0.001) and higher 28-day mortality (44.2% versus 10.2%, p<0.001) compared to patients with low mNUTRIC score (≤4 points). High mNUTRIC score predicted 28-day mortality with area under the curve (AUC) of 0.797 (95% confidence interval: 0.738-0.856). Conclusion: High mNUTRIC score was associated with a higher 28-day mortality. The prognostic performance for 28-day mortality of the mNUTRIC score is clinically valid as indicated by AUC >0.7 and is comparable to the results of other validation studies. In addition, patients with high mNUTRIC score had increased ICU LOS and prolonged MV.

Physiological and Psychological Effects of Listening To Holy Quran Recitation in the Intensive Care Unit Patients: A Systematic Review

@#Stress and anxiety are common among intensive care unit (ICU) patients especially those who are on mechanical ventilation. Non-pharmacological interventions such as music and prayer are recommended because they are opioid sparing, easy to provide, cheap and safe. There is a growing body of evidence on the effects of Holy Quran Recitation (HQR) in reducing stress and anxiety in critically ill Muslim patients. The aim of this review is to evaluate the physiological and psychological effects of HQR specifically in ICU setting. This review was performed on articles published between 2007 and 2018. Extensive search was done using PubMed, ISI Web of Knowledge, Scopus and Google Scholar. Systematic review articles are also assessed and relevant literatures are hand searched based on reference lists and citations made in key publications. Studies related to HQR which were done outside adult ICU setting were excluded. A total of nine articles are included in the final list for detail analysis. Findings of this review revealed six studies with significant results in improving stress responses, hemodynamic stability and conscious levels. HQR is a potential nonpharmacological tool to reduce stress and can also be used as auditory stimulus to improve conscious level in comatose patients. More studies in this area are recommended aiming for low risk of bias, appropriate calculation of sample size and adequately powered to detect significant outcomes.

Validating a Lower Urine Output Criteria in Predicting Death in Critically Ill Patients

Introduction: Urine output provides a rapid estimate for kidney function, and its use has been incorporated in the diagnosis of acute kidney injury. However, not many studies had validated its use compared to the plasma creatinine. It has been showed that the ideal urine output threshold for prediction of death or the need for dialysis was 0.3 ml/kg/h. We aim to assess this threshold in our local ICU population. Methods: This was a secondary analysis of an observational study done in critically ill patients. Hourly urine output data was collected, and a moving average of 6-hourly urine output was calculated over the first 48 hours of ICU admission. AKIuo was defined if urine output ≤ 0.5 ml/kg/h, and UO0.3 was defined as urine output ≤ 0.3 ml/kg/h. Results: 143 patients were recruited into the study, of these, 87 (61%) had AKIuo, and 52 (36%) had UO0.3. The AUC of AKIuo in predicting death was 0.62 (0.51 to 0.72), and UO0.3 was 0.66 (0.55 to 0.77). There was lower survival in patients with AKIuo and UO0.3 compared to those without (p=0.01, and 0.001, respectively). However, only UO0.3 but not AKIuo independently predicted death (HR 2.44 (1.15 to 5.18). Conclusions: A threshold of 6 hourly urine output of 0.3 ml/kg/h but not 0.5 ml/kg/h independently predictive of death. This support previous finding of a lower threshold of urine output criteria for optimal prediction.

The Impact of Fluid Balances in the First 48 Hours on Mortality in the Critically Ill Patients

Introduction: There has been increasing evidence of detrimental effects of cumulative positive fluid balance in critically ill patients. The postulated mechanism of harm is the development of interstitial oedema, with resultant increase morbidity and mortality. We aim to assess the impact of positive fluid balance within the first 48 hours on mortality in our local ICU population. Methods: This was a secondary analysis of a single centre, prospective observational study. All ICU patients more than 18 years were screened for inclusion in the study. Admission of less than 48 hours, post-elective surgery and ICU readmission were excluded. Cumulative fluid balance either as volume or percentage of body weight from admission was calculated over 6, 24 and 48 hour period from ICU admission. Results: A total of 143 patients were recruited, of these 33 died. There were higher cumulative fluid balances at 6, 24 and 48 hours in nonsurvivors compared to survivors. However, after adjusted for severity of illness, APACHE II Score, they were not predictive of mortality. Sensitivity analysis on sub-cohort of patients with acute kidney injury (AKI) showed only an actual 48-hour cumulative fluid balance was independently predictive of mortality (1.21 (1.03 to 1.42)). Conclusions: Cumulative fluid balance was not independently predictive of mortality in a heterogenous group of critically ill patients. However, in subcohort of patients with AKI, a 48-hour cumulative fluid balance was independently predictive of mortality. An additional tile is thus added to the mosaic of findings on the impact of fluid balance in a hetergenous group of critically ill patients, and in subcohort of AKI patients.