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.

Incidence and risk factors for catheter-associated urinary tract infection in 623 intensive care units throughout 37 Asian, African, Eastern European, Latin American, and Middle Eastern nations: A multinational prospective research of INICC.

OBJECTIVE: To identify urinary catheter (UC)-associated urinary tract infection (CAUTI) incidence and risk factors. DESIGN: A prospective cohort study. SETTING: The study was conducted across 623 ICUs of 224 hospitals in 114 cities in 37 African, Asian, Eastern European, Latin American, and Middle Eastern countries. PARTICIPANTS: The study included 169,036 patients, hospitalized for 1,166,593 patient days. METHODS: Data collection took place from January 1, 2014, to February 12, 2022. We identified CAUTI rates per 1,000 UC days and UC device utilization (DU) ratios stratified by country, by ICU type, by facility ownership type, by World Bank country classification by income level, and by UC type. To estimate CAUTI risk factors, we analyzed 11 variables using multiple logistic regression. RESULTS: Participant patients acquired 2,010 CAUTIs. The pooled CAUTI rate was 2.83 per 1,000 UC days. The highest CAUTI rate was associated with the use of suprapubic catheters (3.93 CAUTIs per 1,000 UC days); with patients hospitalized in Eastern Europe (14.03) and in Asia (6.28); with patients hospitalized in trauma (7.97), neurologic (6.28), and neurosurgical ICUs (4.95); with patients hospitalized in lower-middle-income countries (3.05); and with patients in public hospitals (5.89).The following variables were independently associated with CAUTI: Age (adjusted odds ratio [aOR], 1.01; P < .0001), female sex (aOR, 1.39; P < .0001), length of stay (LOS) before CAUTI-acquisition (aOR, 1.05; P < .0001), UC DU ratio (aOR, 1.09; P < .0001), public facilities (aOR, 2.24; P < .0001), and neurologic ICUs (aOR, 11.49; P < .0001). CONCLUSIONS: CAUTI rates are higher in patients with suprapubic catheters, in middle-income countries, in public hospitals, in trauma and neurologic ICUs, and in Eastern European and Asian facilities.Based on findings regarding risk factors for CAUTI, focus on reducing LOS and UC utilization is warranted, as well as implementing evidence-based CAUTI-prevention recommendations.

Prospective cohort study of incidence and risk factors for catheter-associated urinary tract infections in 145 intensive care units of 9 Latin American countries: INICC findings.

PURPOSE: Identify urinary catheter (UC)-associated urinary tract infections (CAUTI) incidence and risk factors (RF) in Latin American Countries. METHODS: From 01/01/2014 to 02/10/2022, we conducted a prospective cohort study in 145 ICUs of 67 hospitals in 35 cities in nine Latin American countries: Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama, and Peru. To estimate CAUTI incidence, we used the number of UC-days as the denominator, and the number of CAUTIs as numerator. To estimate CAUTI RFs, we analyzed the following 10 variables using multiple logistic regression: gender, age, length of stay (LOS) before CAUTI acquisition, UC-days before CAUTI acquisition, UC-device utilization (DU) ratio, UC-type, hospitalizationtype, ICU type, facility ownership, and time period. RESULTS: 31,631 patients, hospitalized for 214,669 patient-days, acquired 305 CAUTIs. The pooled CAUTI rate per 1000 UC-days was 2.58, for those using suprapubic catheters, it was 2.99, and for those with indwelling catheters, it was 2.21. The following variables were independently associated with CAUTI: age, rising risk 1% yearly (aOR = 1.01; 95% CI 1.01-1.02; p < 0.0001 female gender (aOR = 1.28; 95% CI 1.01-1.61; p = 0.04), LOS before CAUTI acquisition, rising risk 7% daily (aOR = 1.07; 95% CI 1.06-1.08; p < 0.0001, UC/DU ratio (aOR = 1.14; 95% CI 1.08-1.21; p < 0.0001, public facilities (aOR = 2.89; 95% CI 1.75-4.49; p < 0.0001. The periods 2014-2016 and 2017-2019 had significantly higher risks than the period 2020-2022. Suprapubic catheters showed similar risks as indwelling catheters. CONCLUSION: The following CAUTI RFs are unlikely to change: age, gender, hospitalization type, and facility ownership. Based on these findings, it is suggested to focus on reducing LOS, UC/DU ratio, and implementing evidence-based CAUTI prevention recommendations.

Multinational prospective study of incidence and risk factors for central-line-associated bloodstream infections in 728 intensive care units of 41 Asian, African, Eastern European, Latin American, and Middle Eastern countries over 24 years.

OBJECTIVE: To identify central-line (CL)-associated bloodstream infection (CLABSI) incidence and risk factors in low- and middle-income countries (LMICs). DESIGN: From July 1, 1998, to February 12, 2022, we conducted a multinational multicenter prospective cohort study using online standardized surveillance system and unified forms. SETTING: The study included 728 ICUs of 286 hospitals in 147 cities in 41 African, Asian, Eastern European, Latin American, and Middle Eastern countries. PATIENTS: In total, 278,241 patients followed during 1,815,043 patient days acquired 3,537 CLABSIs. METHODS: For the CLABSI rate, we used CL days as the denominator and the number of CLABSIs as the numerator. Using multiple logistic regression, outcomes are shown as adjusted odds ratios (aORs). RESULTS: The pooled CLABSI rate was 4.82 CLABSIs per 1,000 CL days, which is significantly higher than that reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN). We analyzed 11 variables, and the following variables were independently and significantly associated with CLABSI: length of stay (LOS), risk increasing 3% daily (aOR, 1.03; 95% CI, 1.03-1.04; P < .0001), number of CL days, risk increasing 4% per CL day (aOR, 1.04; 95% CI, 1.03-1.04; P < .0001), surgical hospitalization (aOR, 1.12; 95% CI, 1.03-1.21; P < .0001), tracheostomy use (aOR, 1.52; 95% CI, 1.23-1.88; P < .0001), hospitalization at a publicly owned facility (aOR, 3.04; 95% CI, 2.31-4.01; P <.0001) or at a teaching hospital (aOR, 2.91; 95% CI, 2.22-3.83; P < .0001), hospitalization in a middle-income country (aOR, 2.41; 95% CI, 2.09-2.77; P < .0001). The ICU type with highest risk was adult oncology (aOR, 4.35; 95% CI, 3.11-6.09; P < .0001), followed by pediatric oncology (aOR, 2.51;95% CI, 1.57-3.99; P < .0001), and pediatric (aOR, 2.34; 95% CI, 1.81-3.01; P < .0001). The CL type with the highest risk was internal-jugular (aOR, 3.01; 95% CI, 2.71-3.33; P < .0001), followed by femoral (aOR, 2.29; 95% CI, 1.96-2.68; P < .0001). Peripherally inserted central catheter (PICC) was the CL with the lowest CLABSI risk (aOR, 1.48; 95% CI, 1.02-2.18; P = .04). CONCLUSIONS: The following CLABSI risk factors are unlikely to change: country income level, facility ownership, hospitalization type, and ICU type. These findings suggest a focus on reducing LOS, CL days, and tracheostomy; using PICC instead of internal-jugular or femoral CL; and implementing evidence-based CLABSI prevention recommendations.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections in ICUs of 8 Latin American countries.

BACKGROUND: Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors in Latin-America. METHODS: From January 1, 2014 to February 10, 2022, we conducted a multinational multicenter prospective cohort study in 58 ICUs of 34 hospitals in 21 cities in 8 Latin American countries (Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama). We applied multiple-logistic regression. Outcomes are shown as adjusted-odds ratios (aOR). RESULTS: About 29,385 patients were hospitalized during 92,956 days, acquired 400 CLABSIs, and pooled CLABSI rate was 4.30 CLABSIs per 1,000 CL-days. We analyzed following 10 variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization (DU) ratio, CL-type, tracheostomy use, hospitalization type, intensive care unit (ICU) type, and facility ownership, Following variables were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 3% daily (aOR=1.03;95%CI=1.02-1.04; P < .0001); number of CL-days before CLABSI acquisition, rising risk 4% per CL-day (aOR=1.04;95%CI=1.03-1.05; P < .0001); publicly-owned facility (aOR=2.33;95%CI=1.79-3.02; P < .0001). ICU with highest risk was medical-surgical (aOR=2.61;95%CI=1.41-4.81; P < .0001). CL with the highest risk were femoral (aOR=2.71;95%CI=1.61-4.55; P < .0001), and internal-jugular (aOR=2.62;95%CI=1.82-3.79; P < .0001). PICC (aOR=1.25;95%CI=0.63-2.51; P = .52) was not associated with CLABSI risk. CONCLUSIONS: Based on these findings it is suggested to focus on reducing LOS, CL-days, using PICC instead of femoral or internal-jugular; and implementing evidence-based CLABSI prevention recommendations.

Clinical Presentation and Outcomes of Kawasaki Disease in Children from Latin America: A Multicenter Observational Study from the REKAMLATINA Network.

OBJECTIVES: To describe the clinical presentation, management, and outcomes of Kawasaki disease (KD) in Latin America and to evaluate early prognostic indicators of coronary artery aneurysm (CAA). STUDY DESIGN: An observational KD registry-based study was conducted in 64 participating pediatric centers across 19 Latin American countries retrospectively between January 1, 2009, and December 31, 2013, and prospectively from June 1, 2014, to May 31, 2017. Demographic and initial clinical and laboratory data were collected. Logistic regression incorporating clinical factors and maximum coronary artery z-score at initial presentation (between 10 days before and 5 days after intravenous immunoglobulin [IVIG]) was used to develop a prognostic model for CAA during follow-up (>5 days after IVIG). RESULTS: Of 1853 patients with KD, delayed admission (>10 days after fever onset) occurred in 16%, 25% had incomplete KD, and 11% were resistant to IVIG. Among 671 subjects with reported coronary artery z-score during follow-up (median: 79 days; IQR: 36, 186), 21% had CAA, including 4% with giant aneurysms. A simple prognostic model utilizing only a maximum coronary artery z-score ≥2.5 at initial presentation was optimal to predict CAA during follow-up (area under the curve: 0.84; 95% CI: 0.80, 0.88). CONCLUSION: From our Latin American population, coronary artery z-score ≥2.5 at initial presentation was the most important prognostic factor preceding CAA during follow-up. These results highlight the importance of early echocardiography during the initial presentation of KD.

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.

Factors Associated With Hospitalization or Intensive Care Admission in Children With COVID-19 in Latin America.

Background: Limited data is available from low-middle and upper-middle income countries of the factors associated with hospitalization or admission to pediatric intensive care unit (PICU) for children with COVID-19. Objective: To describe the factors associated with hospitalization or PICU admission of children with COVID-19 in Latin America. Method: Multicenter, analytical, retrospective study of children reported from 10 different Latin American countries to the Latin-American Society of Pediatric Infectious Diseases (SLIPE-COVID) research network from June 1, 2020, and February 28, 2021. Outpatient or hospitalized children <18 years of age with COVID-19 confirmed by polymerase chain reaction or antigen detection from the nasopharynx were included. Children with multisystem inflammatory syndrome in children (MIS-C) were excluded. Associations were assessed using univariate and multivariable logistic regression models. Results: A total of 1063 children with COVID-19 were included; 500 (47%) hospitalized, with 419 (84%) to the pediatric wards and 81 (16%) to the ICU. In multivariable analyses, age <1 year (Odds Ratio [OR] 1.78; 95% CI 1.08-2.94), native race (OR 5.40; 95% CI 2.13-13.69) and having a co-morbid condition (OR 5.3; 95% CI 3.10-9.15), were associated with hospitalization. Children with metabolic or endocrine disorders (OR 4.22; 95% CI 1.76-10.11), immune deficiency (1.91; 95% CI 1.05-3.49), preterm birth (OR 2.52; 95% CI 1.41-4.49), anemia at presentation (OR 2.34; 95% CI 1.28-4.27), radiological peribronchial wall thickening (OR 2.59; 95% CI 1.15-5.84) and hypoxia, altered mental status, seizures, or shock were more likely to require PICU admission. The presence of pharyngitis (OR 0.34; 95% CI 0.25-0.48); myalgia (OR 0.47; 95% CI 0.28-0.79) or diarrhea (OR 0.38; 95% CI 0.21-0.67) were inversely associated with hospital admission. Conclusions: In this data analysis reported to the SLIPE research network in Latin America, infants, social inequalities, comorbidities, anemia, bronchial wall thickening and specific clinical findings on presentation were associated with higher rates of hospitalization or PICU admission. This evidence provides data for prioritization prevention and treatment strategies for children suffering from COVID-19.

Psychiatric disorders and comorbidity in a Spanish sample of prisoners at the end of their sentence: Prevalence rates and associations with criminal history.

Introduction: This study examined, for the first time, the prevalence of mental disorders and comorbidities among inmates who were about to be released, and their association with criminal history. Methods: A Spanish sample of 140 prisoners at the end of their sentence was recruited from an occupational program. Psychiatric disorders were determined according to the Diagnostic and Statistical Manual of Mental Disorders criteria. Bivariate analyses followed by multivariate regression models were conducted to identify significant variables for repeat incarceration and violent offending. Results: The lifetime prevalence of Axis I disorders was 81.4%, with substance use disorders (SUD) and attention deficit/hyperactivity disorder (ADHD) being the most common diagnoses (51.4 and 31.4%, respectively). The current prevalence of Axis I disorders was 59.0%, including learning disorders (38.6%), ADHD (16.4%), and SUD (5.71%) among the most frequent syndromes. Thirty-six (26.5%) participants met criteria for a current Axis II disorder, which commonly was an antisocial personality disorder (12.5%). The majority of the sample (60.8%) suffered from two or more comorbid disorders during their lifetime, although the current prevalence fell to 23.3%. Childhood ADHD increased the number of imprisonments, while inmates convicted of a violent crime were more likely to present a learning disorder. Having a lifetime diagnosis of SUD or multiple psychiatric disorders appeared to be associated with both repeat incarceration and violent offending. Conclusion: Given the high rate of mental disorders still present among subjects completing prison sentences and the challenges they may encounter to benefit from vocational programs, our results suggest that appropriate psychiatric care should be provided during imprisonment and after release to facilitate their community reintegration.

Use of Adjunctive Therapy in Acute Kawasaki Disease in Latin America.

Objective: To characterize the use of adjunctive therapy in Kawasaki disease (KD) in Latin America. Methods: The study included 1,418 patients from the Latin American KD Network (REKAMLATINA) treated for KD between January 1, 2009, and May 31, 2017. Results: Of these patients, 1,152 received only a single dose of IVIG, and 266 received additional treatment. Age at onset was similar in both groups (median 2 vs. 2.2 years, respectively). The majority of patients were male (58 vs. 63.9%) and were hospitalized with the first 10 days of fever (85.1 vs. 84.2%). The most common adjunctive therapy administered was steroids for IVIG-resistance, followed by additional doses of IVIG. The use of biologics such as infliximab was limited. KD patients who received adjunctive therapy were more likely to have a lower platelet count and albumin level as well as a higher Z score of the coronary arteries. Conclusion: This is the first report of adjunctive therapies for KD across Latin America. IVIG continues to be the initial and resistance treatment, however, steroids are also used and to a lesser extent, biological therapy such as infliximab. Future studies should address the barriers to therapy in children with acute KD throughout Latin America.

Presentation and Outcomes of Kawasaki Disease in Latin American Infants Younger Than 6 Months of Age: A Multinational Multicenter Study of the REKAMLATINA Network.

Objective: To characterize the clinical presentation and outcomes of Kawasaki disease (KD) in infants <6 months of age as compared to those ≥6 months in Latin America. Methods: We evaluated 36 infants <6 months old and 940 infants ≥6 months old diagnosed with KD in Latin America. We compared differences in laboratory data, clinical presentation, treatment response, and coronary artery outcomes between the two cohorts. Results: The majority (78.1%) of infants and children ≥6 months of age were initially diagnosed with KD, as compared to only 38.2% of infants <6 months. Clinical features of KD were more commonly observed in the older cohort: oral changes (92 vs. 75%, P = 0.0023), extremity changes (74.6 vs. 57.1%, P = 0.029), and cervical lymphadenopathy (67.6 vs. 37.1%, P = 0.0004). Whether treated in the first 10 days of illness or after the 10th day, infants <6 months were at greater risk of developing a coronary artery aneurysm compared to KD patients ≥6 months treated at the same point in the course of illness [ ≤ 10 days (53.8 vs. 9.4%, P = 0.00012); >10 days (50 vs. 7.4%, P = 0.043)]. Conclusion: Our data show that despite treatment in the first 10 days of illness, infants <6 months of age in Latin America have a higher risk of developing a coronary artery aneurysm. Delay in the diagnosis leads to larger coronary artery aneurysms disproportionately in these infants. Thus, suspicion for KD should be high in this vulnerable population.

Epidemiología del dengue en Centroamérica y República Dominicana / Epidemiology of dengue in Central America and the Dominican Republic

Resumen Introducción: Centroamérica experimenta una alta carga de la enfermedad por dengue aportando cerca de 8% de todos los casos del continente. Este trabajo reporta la epidemiología del dengue en la subregión en un período de 10 años. Objetivos: Documentar la epidemiología del dengue en Centro América y República Dominicana. Material y Métodos: Período de estudio: años 2005-2014. Se recopilaron y analizaron los datos de casos y muertes por dengue de los países de Centro América y República Dominicana, reportados por los Ministerios de Salud y se corroboró con los datos publicados en los boletines en línea y la base de datos interactiva de la Organización Panamericana de la Salud (OPS). Se obtuvieron estadísticas poblacionales de los Institutos Nacionales de Estadística y Censo de cada país. Resultados: Durante el período de estudio fueron notificados 1.118.464 casos de dengue. Reportados 32.431 casos graves, 888 personas fallecidas. La letalidad por caso de dengue fue en promedio 0,08%. Los cuatro serotipos de dengue circularon durante el decenio estudiado. Discusión: La información clínica y epidemiológica, indica tasas de incidencia alta, que han fluctuado en los últimos años, con co-circulación significativa de varios serotipos a la vez. Conclusiones: Se identificaron diferencias notorias en la recolección de datos de la vigilancia entre países. Se determinó un patrón epidemiológico heterogéneo.

Background: Central America experiences a high burden of dengue reporting about 8% of all cases in the continent. This work reports the epidemiology of dengue in the sub region in a 10 years period. Aim: To describe the epidemiology of dengue in Central America and the Dominican Republic. Methods: Study period from 2005 to 2014. The data on dengue cases and deaths of the countries of Central America and the Dominican Republic, reported by the Ministries of Health, were compiled and analyzed and corroborated with the data published in the online bulletins and the interactive database of the Pan American Health Organization (PAHO). Population statistics were obtained from the National Statistics and Census Institutes of each country. Results: During the study period, 1,118,464 cases of dengue were notified. There were 32,431 serious cases reported, 888 people died. The lethality per case of dengue was on average 0.08%. The four dengue serotypes circulated during the decade analyzed. Discussion: Clinical and epidemiological information indicates high incidence rates, which have fluctuated in recent years, with significant co-circulation of several serotypes at the same time. Conclusions: Notorious surveillance data collection differences were identified between countries, determining a heterologous epidemiological pattern.

[Epidemiology of dengue in Central America and the Dominican Republic]. / Epidemiología del dengue en Centroamérica y República Dominicana.

BACKGROUND: Central America experiences a high burden of dengue reporting about 8% of all cases in the continent. This work reports the epidemiology of dengue in the sub region in a 10 years period. AIM: To describe the epidemiology of dengue in Central America and the Dominican Republic. METHODS: Study period from 2005 to 2014. The data on dengue cases and deaths of the countries of Central America and the Dominican Republic, reported by the Ministries of Health, were compiled and analyzed and corroborated with the data published in the online bulletins and the interactive database of the Pan American Health Organization (PAHO). Population statistics were obtained from the National Statistics and Census Institutes of each country. RESULTS: During the study period, 1,118,464 cases of dengue were notified. There were 32,431 serious cases reported, 888 people died. The lethality per case of dengue was on average 0.08%. The four dengue serotypes circulated during the decade analyzed. DISCUSSION: Clinical and epidemiological information indicates high incidence rates, which have fluctuated in recent years, with significant co-circulation of several serotypes at the same time. CONCLUSIONS: Notorious surveillance data collection differences were identified between countries, determining a heterologous epidemiological pattern.

Congenital and perinatal complications of chikungunya fever: a Latin American experience.

BACKGROUND: During the years 2014 and 2015, the Region of the Americas underwent a devastating epidemic of chikungunya virus (CHIKV) of the Asian genotype, resulting in millions of affected individuals. However, epidemiological and clinical information on this experience is scarce. Prior knowledge of congenital and neonatal illness caused by CHIKV is limited and almost exclusively based on data obtained from a single outbreak of the East/Central/South African (ECSA) genotype. The effect of chikungunya fever (CHIKF) on pregnancy outcomes and its consequences for infants born to infected mothers at the peak of the epidemic wave in Latin America are reviewed herein. Epidemiological and clinical data on maternal and neonatal infections were collected prospectively and analyzed. METHODS: One hundred sixty-nine symptomatic newborns with CHIKF seen at four large regional maternity hospitals in three different Central and South American countries were evaluated prospectively. The outcomes of pregnancies in symptomatic infected mothers at two of these clinical centers were also analyzed. RESULTS: The observed vertical transmission rate ranged between 27.7% and 48.29%. The incidence of congenital disease was unrelated to the use of cesarean section or natural delivery. The case fatality rate (CFR) at the only center that reported deaths was 5.3%. The most common clinical manifestations included fever, irritability, rash, hyperalgesia syndrome, diffuse limb edema, meningoencephalitis, and bullous dermatitis. Severe complications included meningoencephalitis, myocarditis, seizures, and acute respiratory failure. Leukocytosis with neutrophilia and normal or increased platelets was a common finding, and in those with signs of meningeal involvement, moderate lymphocytic pleocytosis with normal glucose and protein levels was typical. CONCLUSIONS: This study presents the largest number of symptomatic neonates with CHIKF analyzed so far in any region and is the first involving infection with the Asian genotype of CHIKV. Although the clinical manifestations found were similar to those reported previously, the percentage of neurological complications was lower. The CFR was comparatively high. Chikungunya represented a substantial risk for neonates born to symptomatic parturients during the chikungunya outbreak in the Americas Region, with important clinical and public health implications.

Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010.

OBJECTIVE: To report the results of a surveillance study on surgical site infections (SSIs) conducted by the International Nosocomial Infection Control Consortium (INICC). DESIGN: Cohort prospective multinational multicenter surveillance study. SETTING: Eighty-two hospitals of 66 cities in 30 countries (Argentina, Brazil, Colombia, Cuba, Dominican Republic, Egypt, Greece, India, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Poland, Salvador, Saudi Arabia, Serbia, Singapore, Slovakia, Sudan, Thailand, Turkey, Uruguay, and Vietnam) from 4 continents (America, Asia, Africa, and Europe). PATIENTS: Patients undergoing surgical procedures (SPs) from January 2005 to December 2010. METHODS: Data were gathered and recorded from patients hospitalized in INICC member hospitals by using the methods and definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) for SSI. SPs were classified into 31 types according to International Classification of Diseases, Ninth Revision, criteria. RESULTS: We gathered data from 7,523 SSIs associated with 260,973 SPs. SSI rates were significantly higher for most SPs in INICC hospitals compared with CDC-NHSN data, including the rates of SSI after hip prosthesis (2.6% vs. 1.3%; relative risk [RR], 2.06 [95% confidence interval (CI), 1.8-2.4]; P < .001), coronary bypass with chest and donor incision (4.5% vs. 2.9%; RR, 1.52 [95% CI, 1.4-1.6]; [P < .001); abdominal hysterectomy (2.7% vs. 1.6%; RR, 1.66 [95% CI, 1.4-2.0]; P < .001); exploratory abdominal surgery (4.1% vs. 2.0%; RR, 2.05 [95% CI, 1.6-2.6]; P < .001); ventricular shunt, 12.9% vs. 5.6% (RR, 2.3 [95% CI, 1.9-2.6]; P < .001, and others. CONCLUSIONS: SSI rates were higher for most SPs in INICC hospitals compared with CDC-NHSN data.

Improving waste segregation while reducing costs in a tertiary-care hospital in a lower-middle-income country in Central America.

Healthcare waste (HCW) management and segregation are essential to ensure safety, environmental protection and cost control. Poor HCW management increase risks and costs for healthcare institutions. On-going surveillance and training are important to maintain good HCW practices. Our objectives were to evaluate and improve HCW practices at Hospital Bloom, San Salvador, El Salvador. We studied HCW disposal practices by observing waste containers, re-segregating waste placed in biohazardous waste bags, and administering a seven-itemsknowledge survey before and after training in waste management at Hospital Bloom. The training was based on national and international standards. We followed total biohazardous waste production before and after the training. The hospital staff was knowledgeable about waste segregation practices, but had poor compliance with national policies. Re-segregating waste in biohazardous waste bags showed that 61% of this waste was common waste, suggesting that the staff was possibly unaware of the cost of mis-segregating healthcare waste. After staff training in HCW management, the correct responses increased by 44% and biohazardous waste disposal at the hospital reduced by 48%. Better segregation of biohazardous waste and important savings can be obtained by HCW management education of hospital staff. Hospitals can benefit from maximising the use of available resources by sustaining best practices of HCW, especially those in hospitals in lower-middle-income countries.

Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe.

OBJECTIVE: To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance. DESIGN: An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period. SETTING: Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey. PARTICIPANTS: Healthcare workers at 99 ICU members of the INICC. METHODS: A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods. RESULTS: A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% ([Formula: see text]). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; [Formula: see text]), physicians versus nurses (62% vs 72%; [Formula: see text]), and adult versus neonatal ICUs (67% vs 81%; [Formula: see text]), among others. CONCLUSIONS: Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.

Findings of the International Nosocomial Infection Control Consortium (INICC), part III: effectiveness of a multidimensional infection control approach to reduce central line-associated bloodstream infections in the neonatal intensive care units of 4 developing countries.

OBJECTIVE: To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce central line-associated bloodstream infection (CLABSI) rates. SETTING: Four neonatal intensive care units (NICUs) of INICC member hospitals from El Salvador, Mexico, Philippines, and Tunisia. PATIENTS: A total of 2,241 patients hospitalized in 4 NICUs for 40,045 bed-days. METHODS: We conducted a before-after prospective surveillance study. During Phase 1 we performed active surveillance, and during phase 2 the INICC multidimensional infection control approach was implemented, including the following practices: (1) central line care bundle, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CLABSI rates, and (6) performance feedback of infection control practices. We compared CLABSI rates obtained during the 2 phases. We calculated crude stratified rates, and, using random-effects Poisson regression to allow for clustering by ICU, we calculated the incidence rate ratio (IRR) for each follow-up time period compared with the 3-month baseline. RESULTS: During phase 1 we recorded 2,105 CL-days, and during phase 2 we recorded 17,117 CL-days. After implementation of the multidimensional approach, the CLABSI rate decreased by 55%, from 21.4 per 1,000 CL-days during phase 1 to 9.7 per 1,000 CL-days during phase 2 (rate ratio, 0.45 [95% confidence interval, 0.33-0.63]). The IRR was 0.53 during the 4-12-month period and 0.07 during the final period of the study (more than 45 months). CONCLUSIONS: Implementation of a multidimensional infection control approach was associated with a significant reduction in CLABSI rates in NICUs.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part I: Effectiveness of a multidimensional infection control approach on catheter-associated urinary tract infection rates in pediatric intensive care units of 6 developing countries.

DESIGN: A before-after prospective surveillance study to assess the impact of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infection (CAUTI) rates. SETTING: Pediatric intensive care units (PICUs) of hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of the following 6 developing countries: Colombia, El Salvador, India, Mexico, Philippines, and Turkey. PATIENTS: PICU inpatients. METHODS: We performed a prospective active surveillance to determine rates of CAUTI among 3,877 patients hospitalized in 10 PICUs for a total of 27,345 bed-days. The study was divided into a baseline period (phase 1) and an intervention period (phase 2). In phase 1, surveillance was performed without the implementation of the multidimensional approach. In phase 2, we implemented a multidimensional infection control approach that included outcome surveillance, process surveillance, feedback on CAUTI rates, feedback on performance, education, and a bundle of preventive measures. The rates of CAUTI obtained in phase 1 were compared with the rates obtained in phase 2, after interventions were implemented. RESULTS: During the study period, we recorded 8,513 urinary catheter (UC) days, including 1,513 UC-days in phase 1 and 7,000 UC-days in phase 2. In phase 1, the CAUTI rate was 5.9 cases per 1,000 UC-days, and in phase 2, after implementing the multidimensional infection control approach for CAUTI prevention, the rate of CAUTI decreased to 2.6 cases per 1,000 UC-days (relative risk, 0.43 [95% confidence interval, 0.21-1.0]), indicating a rate reduction of 57%. CONCLUSIONS: Our findings demonstrated that implementing a multidimensional infection control approach is associated with a significant reduction in the CAUTI rate of PICUs in developing countries.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part II: Impact of a multidimensional strategy to reduce ventilator-associated pneumonia in neonatal intensive care units in 10 developing countries.

Design. Before-after prospective surveillance study to assess the efficacy of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control program to reduce the rate of occurrence of ventilator-associated pneumonia (VAP). Setting. Neonatal intensive care units (NICUs) of INICC member hospitals from 15 cities in the following 10 developing countries: Argentina, Colombia, El Salvador, India, Mexico, Morocco, Peru, Philippines, Tunisia, and Turkey. Patients. NICU inpatients. Methods. VAP rates were determined during a first period of active surveillance without the implementation of the multidimensional approach (phase 1) to be then compared with VAP rates after implementation of the INICC multidimensional infection control program (phase 2), which included the following practices: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices. This study was conducted by infection control professionals who applied National Health Safety Network (NHSN) definitions for healthcare-associated infections and INICC surveillance methodology. Results. During phase 1, we recorded 3,153 mechanical ventilation (MV)-days, and during phase 2, after the implementation of the bundle of interventions, we recorded 15,981 MV-days. The VAP rate was 17.8 cases per 1,000 MV-days during phase 1 and 12.0 cases per 1,000 MV-days during phase 2 (relative risk, 0.67 [95% confidence interval, 0.50-0.91]; [Formula: see text]), indicating a 33% reduction in VAP rate. Conclusions. Our results demonstrate that an implementation of the INICC multidimensional infection control program was associated with a significant reduction in VAP rate in NICUs in developing countries.