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.

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.

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 over 18 years of the risk factors for ventilator-associated pneumonia in 9 Asian countries: INICC findings.

BACKGROUND: Ventilator associated pneumonia (VAP) rates in Asia are several times above those of US. The objective of this study is to identify VAP risk factors. METHODS: We conducted a prospective cohort study, between March 27, 2004 and November 2, 2022, in 279 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, Vietnam). RESULTS: 153,717 patients, followed during 892,996 patient-days, acquired 3,369 VAPs. We analyzed 10 independent variables. Using multiple logistic regression we identified following independent VAP RFs= Age, rising VAP risk 1% per year (aOR=1.01; 95%CI=1.00-1.01, P<.0001); male gender (OR=1.17; 95%CI=1.08-1.26, P<.0001); length of stay, rising VAP risk 7% daily (aOR=1.07; 95%CI=1.06-1.07, P<.0001); mechanical ventilation (MV) device utilization (DU) ratio (OR=1.43; 95%CI=1.36-1.51; p<.0001); tracheostomy connected to a MV (OR=11.17; 95%CI=9.55-14.27; p<.0001); public (OR=1.84; 95%CI=1.49-2.26, P<.0001), and private (OR=1.57; 95%CI=1.29-1.91, P<.0001) compared with teaching hospitals; upper-middle income country (OR=1.86; 95%CI=1.63-2.14, P<.0001). Regarding ICUs, Medical-Surgical (OR=4.61; 95%CI=3.43-6.17; P<.0001), Neurologic (OR=3.76; 95%CI=2.43-5.82; P<.0001), Medical (OR=2.78; 95%CI=2.04-3.79; P<.0001), and Neuro-Surgical (OR=2.33; 95%CI=1.61-3.92; P<.0001) showed the highest risk. CONCLUSIONS: Some identified VAP RFs are unlikely to change= age, gender, ICU type, facility ownership, country income level. Based on our results, we recommend limit use of tracheostomy, reducing LOS, reducing the MV/DU ratio, and implementing an evidence-based set of 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.

Potentially Preventable Deaths by Intensive Care Medicine in Mongolian Hospitals.

Purpose. To evaluate the portion of hospitalized patients dying without prior intensive care unit (ICU) admission and assess whether death could have been prevented by intensive care. Methods. In this prospective, observational, multicenter study, data of adults dying in and outside the ICU in 5 tertiary and 14 secondary hospitals were collected during six months. A group of experts categorized patients dying without prior ICU admission as whether their death was potentially preventable or not. Results. 617 patients died (72.9% in and 27.1% outside the ICU) during the observation period. In 54/113 patients (32.3%) dying in the hospital without prior ICU admission, death was considered potentially preventable. The highest number of these deaths was seen in patients aged 16-30 years and those who suffered from an infection (83.3%), underwent surgery (58.3%), or sustained trauma (52%). Potentially preventable deaths resulted in a total number of 1,078 years of life lost and 709 productive years of life lost. Conclusions. Twenty-seven percent of adults dying in Mongolian secondary and tertiary level hospitals do so without prior ICU admission. One-third, mostly young patients suffering from acute reversible conditions, may have potentially been saved by intensive care medicine.

The epidemiology and outcome of critical illness in Mongolia: A multicenter, prospective, observational cohort study.

CONTEXT: The epidemiology and outcome of critical illness in Mongolia remain undefined. AIM: The aim of this study was to evaluate the epidemiology and outcome of critical illness in Mongolia. SETTINGS AND DESIGN: This is a multicenter, prospective, observational cohort study including 19 Mongolian centers. MATERIALS AND METHODS: Demographic, clinical, and outcome data of patients >15 years admitted to the Intensive Care Units (ICUs) were collected during a 6-month period. STATISTICAL ANALYSIS: Descriptive methods, Mann-Whitney-U test, Fisher's exact or Chi-square test, and logistic regression analyses were used for statistical analysis. RESULTS: Two thousand and thirty-two patients (53.6% male) with a median age of 49 years (36-62 years) were included. The most frequent ICU admission diagnoses were stroke (17.4%), liver failure (9.2%), heart failure (9%), infection (8.3%), severe trauma (7.5%), traumatic brain injury (7.1%), acute abdomen (7%), pre-eclampsia/eclampsia (5.8%), renal failure (3.9%), and postoperative care following elective and emergency surgeries (3.2%). ICU mortality was 23.5% in the study population and 26.6% when maternal cases were excluded. The five ICU admission diagnoses with the highest ICU mortality were lung tuberculosis (51.9%), traumatic brain injury (42.1%), liver failure (33.7%), stroke (31.9%), and infection (30.8%). The five ICU admission diagnoses causing most death cases were stroke (n = 113), liver failure (n = 63), traumatic brain injury (n = 61), infection (n = 52), and acute abdomen (n = 38). CONCLUSION: Critical illness in Mongolia affects younger patients compared to high-income countries. ICU admission diagnoses are similar with a particularly high incidence of stroke and liver failure. ICU mortality is approximately 25% with most deaths caused by stroke, liver failure, and traumatic brain injury.

A Nationwide Census of ICU Capacity and Admissions in Mongolia.

In Mongolia, a Central Asian lower-middle income country, intensive care medicine is an under-resourced and-developed medical specialty. The burden of critical illness and capacity of intensive care unit (ICU) services in the country is unknown. In this nationwide census, we collected data on adult and pediatric/neonatal ICU capacities and the number of ICU admissions in 2014. All hospitals registered to run an ICU service in Mongolia were surveyed. Data on the availability of an adult and/or pediatric/neonatal ICU service, the number of available ICU beds, the number of available functional mechanical ventilators, the number of patients admitted to the ICU, and the number of patients admitted to the study hospital were collected. In total, 70 ICUs with 349 ICU beds were counted in Mongolia (11.7 ICU beds/100,000 inhabitants; 1.7 ICU beds/100 hospital beds). Of these, 241 (69%) were adult and 108 (31%) pediatric/neonatal ICU beds. Functional mechanical ventilators were available for approximately half of the ICU beds (5.1 mechanical ventilators/100,000 inhabitants). While all provincial hospitals ran a pediatric/neonatal ICU, only dedicated pediatric hospitals in Ulaanbaatar did so. The number of adult and pediatric/neonatal ICU admissions varied between provinces. The number of adult ICU beds and adult ICU admissions per 100,000 inhabitants correlated (r = 0.5; p = 0.02), while the number of pediatric/neonatal ICU beds and pediatric/neonatal ICU admissions per 100,000 inhabitants did not (r = 0.25; p = 0.26). In conclusion, with 11.7 ICU beds per 100,000 inhabitants the ICU capacity in Mongolia is higher than in other low- and lower-middle-income countries. Substantial heterogeneities in the standardized ICU capacity and ICU admissions exist between Mongolian provinces. Functional mechanical ventilators are available for only half of the ICU beds. Pediatric/neonatal ICU beds make up one third of the national ICU capacity and appear to meet or even exceed the demand of pediatric/neonatal critical care.

Multicenter study of device-associated infection rates in hospitals of Mongolia: Findings of the International Nosocomial Infection Control Consortium (INICC).

BACKGROUND: To report the results of the International Nosocomial Infection Control Consortium (INICC) multicenter study conducted in Mongolia from September 2013-March 2015. METHODS: A device-associated health care-associated infection prospective surveillance study in 3 adult intensive care units (ICUs) from 3 hospitals using the U.S. Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) definitions and INICC methods. RESULTS: We documented 467 ICU patients for 2,133 bed days. The central line-associated bloodstream infection (CLABSI) rate was 19.7 per 1,000 central line days, the ventilator-associated pneumonia (VAP) rate was 43.7 per 1,000 mechanical ventilator days, and the catheter-associated urinary tract infection (CAUTI) rate was 15.7 per 1,000 urinary catheter days; all of the rates are higher than the INICC rates (CLABSI: 4.9; VAP: 16.5; and CAUTI: 5.3) and CDC-NHSN rates (CLABSI: 0.8; VAP: 1.1; and CAUTI: 1.3). Device use ratios were also higher than the CDC-NHSN and INICC ratios, except for the mechanical ventilator device use ratio, which was lower than the INICC ratio. Resistance of Staphylococcus aureus to oxacillin was 100%. Extra length of stay was 15.1 days for patients with CLABSI, 7.8 days for patients with VAP, and 8.2 days for patients with CAUTI. Extra crude mortality in the ICUs was 18.6% for CLABSI, 17.1% for VAP, and 5.1% for CAUTI. CONCLUSION: Device-associated health care-associated infection rates and most device use ratios in our Mongolian hospitals' ICUs are higher than the CDC-NSHN and INICC rates.