Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC)

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.     

Device-associated infection rates and mortality in intensive care units of Peruvian hospitals: findings of the International Nosocomial Infection Control Consortium

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, and attributable mortality in intensive care units (ICUs) in hospitals in Peru that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in ICUs in four hospitals applying the definitions for nosocomial infections of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS) and National Healthcare Safety Network (NHSN). RESULTS: From September 2003 to October 2007 1 920 patients hospitalized in ICUs for an aggregate of 9 997 days acquired 249 DAIs, accounting for a rate of 13.0% and 24.9 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 31.3 per 1 000 ventilator-days; the central venous catheter-associated bloodstream infections (CVC-BSI) rate was 7.7 cases per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 5.1 cases per 1 000 catheter-days. Extra mortality for VAP was 24.5% (RR 2.07, P < 0.001); for CVC-BSI the rate was 15.0% (RR 2.75, P = 0.028). Methicillin-resistant strains accounted for 73.5% of all Staphylococcus aureus DAIs; 40.5% of the Enterobacteriaceae were resistant to ceftriaxone, 40.8% were resistant to ceftazidime, and 32.0% were resistant to piperacillin-tazobactam. Sixty-five percent of Pseudomonas aeruginosa isolates were resistant to ciprofloxacin, 62.0% were resistant to ceftazidime, 29.4% were resistant to piperacillin-tazobactam, and 36.1% were resistant to imipenem. CONCLUSIONS: The high rates of DAIs in the Peruvian hospitals in this study indicate the need for active infection control. Programs consisting of surveillance of DAIs and implementation of guidelines for infection prevention can ensure improved patient safety in the ICUs and throughout hospitals.     

Device-associated nosocomial infection rates in Turkish medical-surgical intensive care units.

OBJECTIVE: To describe the incidence of device-associated nosocomial infections in medical-surgical intensive care units (MS ICUs) in a university hospital in Turkey and compare it with National Nosocomial Infections Surveillance (NNIS) system rates. DESIGN: Prospective surveillance study during a period of 27 months. Device utilization ratios and device-associated infection rates were calculated using US Centers for Disease Control and Prevention and NNIS definitions. SETTING: Two separate MS ICUs at Akdeniz University Hospital, Antalya, Turkey. PATIENTS: All patients were included who presented with no signs and symptoms of infection within the first 48 hours after admission. RESULTS: Data on 1,985 patients with a total of 16,892 patient-days were analyzed. The mean overall infection rate per 100 patients was 29.1 infections, and the mean infection rate per 1,000 patient-days was 34.2 infections. The rate of ventilator-associated pneumonia was 20.76 infections per 1,000 ventilator-days, the rate of catheter-associated urinary tract infection was 13.63 infections per 1,000 urinary catheter-days, and the rate of catheter-associated bloodstream infection was 9.69 infections per 1,000 central line-days. The most frequently isolated pathogens were Pseudomonas species among patients with ventilator-associated pneumonias (35.8% of cases), Candida species among patients with catheter-associated urinary tract infections (37.1% of cases), and coagulase-negative staphylococci among patients with catheter-associated bloodstream infections (20.0% of cases). CONCLUSION: We found both higher device-associated infection rates and higher device utilization ratios in our MS ICUs than those reported by the NNIS system. To reduce the rate of infection, implementation of infection control practices and comprehensive education are required, and an appropriate nationwide nosocomial infection and control system is needed in Turkey.     

Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium.

OBJECTIVE: To perform active targeted prospective surveillance to measure device-associated infection (DAI) rates, attributable mortality due to DAI, and the microbiological and antibiotic resistance profiles of infecting pathogens at 10 intensive care units (ICUs) in 9 hospitals in Colombia, all of which are members of the International Infection Control Consortium. METHODS: We conducted prospective surveillance of healthcare-associated infection in 9 hospitals by using the definitions of the US Centers for Disease Control and Prevention National Nosocomial Surveillance System (NNIS). DAI rates were calculated as the number of infections per 100 ICU patients and per 1,000 device-days. RESULTS: During the 3-year study, 2,172 patients hospitalized in an ICU for an aggregate duration of 14,603 days acquired 266 DAIs, for an overall DAI rate of 12.2%, or 18.2 DAIs per 1,000 patient-days. Central venous catheter (CVC)-related bloodstream infection (BSI) (47.4% of DAIs; 11.3 cases per 1,000 catheter-days) was the most common DAI, followed by ventilator-associated pneumonia (VAP) (32.3% of DAIs; 10.0 cases per 1,000 ventilator-days) and catheter-associated urinary tract infection (CAUTI) (20.3% of DAIs; 4.3 cases per 1,000 catheter-days). Overall, 65.4% of all Staphylococcus aureus infections were caused by methicillin-resistant strains; 40.0% of Enterobacteriaceae isolates were resistant to ceftriaxone and 28.3% were resistant to ceftazidime; and 40.0% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.0% were resistant to ceftazidime, 33.3% were resistant to piperacillin-tazobactam, and 19.0% were resistant to imipenem. The crude unadjusted attributable mortality was 16.9% among patients with VAP (relative risk [RR], 1.93; 95% confidence interval [CI], 1.24-3.00; P=.002); 18.5 among those with CVC-associated BSI (RR, 2.02; 95% CI, 1.42-2.87; P<.001); and 10.5% among those with CAUTI (RR, 1.58; 95% CI, 0.78-3.18; P=.19). CONCLUSION: The rates of DAI in the Colombian ICUs were lower than those published in some reports from other Latin American countries and were higher than those reported in US ICUs by the NNIS. These data show the need for more-effective infection control interventions in Colombia.     

Device-associated nosocomial infection rates in intensive care units in Greece.

Site-specific, risk-adjusted incidence rates of intensive care unit (ICU)-acquired infections were obtained through standardized surveillance in 8 ICUs in Greece. High rates were observed for central line-associated bloodstream infection (12.1 infections per 1,000 device-days) and ventilator-associated pneumonia (12.5 infections per 1,000 device-days). Gram-negative microorganisms accounted for 60.4% of the isolates recovered, and Acinetobacter species were predominant. To reduce infection rates in Greek ICUs, comprehensive infection control programs are required.     

Device-associated nosocomial infection rates in intensive care units of Argentina.

BACKGROUND: Nosocomial infections are an important public health problem in many developing countries, particularly in the intensive care unit (ICU) setting. No previous data are available on the incidence of device-associated nosocomial infections in different types of ICUs in Argentina. METHODS: We performed a prospective nosocomial infection surveillance study during the first year of an infection control program in six Argentinean ICUs. Nosocomial infections were identified using the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System definitions, and site-specific nosocomial infection rates were calculated. RESULTS: The rate of catheter-associated bloodstream infections in medical-surgical ICUs was 30.3 per 1,000 device-days; it was 14.2 per 1,000 device-days in coronary care units (CCUs). The rate of ventilator-associated pneumonia in medical-surgical ICUs was 46.3 per 1,000 device-days; it was 45.5 per 1,000 device-days in CCUs. The rate of symptomatic catheter-associated urinary tract infections in medical-surgical ICUs was 18.5 per 1,000 device-days; it was 12.1 per 1,000 device-days in CCUs. CONCLUSION: The high rate of nosocomial infections in Argentinean ICUs found during our surveillance suggests that ongoing targeted surveillance and implementation of proven infection control strategies is needed in developing countries such as Argentina.     

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.     

Time-dependent analysis of extra length of stay and mortality due to ventilator-associated pneumonia in intensive-care units of ten limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC)

Ventilator-associated pneumonias (VAPs) are a worldwide problem that significantly increases patient morbidity, mortality, and length of stay (LoS), and their effects should be estimated to account for the timing of infection. The purpose of the study was to estimate extra LoS and mortality in an intensive-care unit (ICU) due to a VAP in a cohort of 69,248 admissions followed for 283,069 days in ICUs from 10 countries. Data were arranged according to the multi-state format. Extra LoS and increased risk of death were estimated independently in each country, and their results were combined using a random-effects meta-analysis. VAP prolonged LoS by an average of 2·03 days (95% CI 1·52-2·54 days), and increased the risk of death by 14% (95% CI 2-27). The increased risk of death due to VAP was explained by confounding with patient morbidity.     

Device-associated, device-day infection rates in an Israeli adult general intensive care unit

Surveillance is an essential element of hospital infection control programs. Previous studies have shown that interhospital comparison of intensive care unit (ICU) nosocomial infections (NI) may be best made by comparing ICU-type-specific, device-associated infection rates and that these adjusted rates vary by ICU type. The aim of this study was to evaluate whether significant structural improvements introduced in an adult general ICU were associated with changes in the NI rates in this unit. In addition, we compared these rates with those of ICUs reported by the National Nosocomial Infections Surveillance (NNIS) System of the Centers for Diseases Control and Prevention. During a 12-month period 337 patients were surveyed. There were 20 ventilator-associated pneumonias (VAP)/1000 ventilator (VEN)-days, 12 bloodstream infections (BSI)/1000 central vascular catheter (CVC)-days and 14 urinary tract infection (UTI)/1000 indwelling urinary catheter (IUC)-days. Structural changes and reduction in device utilization ratios were not followed by change in NI rates in this unit. VAP and BSI rates were comparable to those reported for neurosurgical and burn ICUs, respectively, in the NNIS System, despite a much higher device utilization ratios. The present study provides specific surveillance data for further interhospital comparison with similar types of ICUs.     

Nosocomial infection and multidrug-resistant bacteria surveillance in intensive care units: a survey in France.

OBJECTIVES: To evaluate nosocomial infection (NI) surveillance strategies in French ICUs and to identify similar patterns defining subsets within which comparisons can be made. DESIGN: A questionnaire was sent to all French ICUs, and a random sample of nonresponders was interviewed. PARTICIPANTS: Three hundred ninety-five responder ICUs (69%) in France. RESULTS: In 282 ICUs (71%), a dedicated ICU staff member was responsible for infection control activities. The microbiology laboratory was usually in the hospital (90%) and computerized (94%) but issued regular hospital microbiology records in only 48% of cases. Patients receiving mechanical ventilation, central venous catheterization, and urinary catheterization were 90%, 79%, and 60%, respectively. Patients were screened for carriage of multidrug-resistant bacteria on admission and during the stay in 70% and 60% of ICUs, respectively, most often targeting MRSA. Quantitative cultures were used to diagnose ventilator-associated pneumonia (VAP) in 90% of ICUs, including distal specimens in 80% and bronchoscopy specimens in 60%. Quantitative central venous catheter (CVC)-segment cultures were used in 70% of ICUs. All CVCs were cultured routinely in 53% of the ICUs. Despite wide variations in infection control and surveillance strategies, multiple correspondence analysis identified 13 key points (4 structural variables and 9 variables concerning the diagnosis of VAP, the surveillance and diagnosis of catheter-related and urinary tract infections, and the mode of screening of MRSA carriers) that categorize the variability of French ICUs' approaches to NIs. CONCLUSION: This study revealed profound differences in NI surveillance strategies across ICUs, indicating a need for caution when using NI surveillance data for comparisons and benchmarking.     

Nosocomial infections in combined medical-surgical intensive care units in the United States.

OBJECTIVE: To describe the epidemiology of nosocomial infections in combined medical-surgical (MS) intensive care units (ICUs) participating in the National Nosocomial Infection Surveillance (NNIS) System. DESIGN: Analysis of surveillance data on 498,998 patients with 1,554,070 patient-days, collected between 1992 and 1998 from 205 MS ICUs following the NNIS Intensive Care Unit protocol, representing 152 participating NNIS hospitals in the United States. RESULTS: Infections at three major sites represented 68% of all reported infections (nosocomial pneumonia, 31%; urinary tract infections (UTIs), 23%; and primary bloodstream infections (BSIs), 14%: 83% of episodes of nosocomial pneumonia were associated with mechanical ventilation, 97% of UTIs occurred in catheterized patients, and 87% of primary BSIs in patients with a central line. In patients with primary BSIs, coagulase-negative staphylococci (39%) were the most common pathogens reported; Staphylococcus aureus (12%) was as frequently reported as enterococci (11%). Coagulase-negative staphylococcal BSIs were increasingly reported over the 6 years, but no increase was seen in candidemia or enterococcal bacteremia. In patients with pneumonia, S. aureus (17%) was the most frequently reported isolate. Of reported isolates, 59% were gram-negative bacilli. In patients with UTIs, Escherichia coli (19%) was the most frequently reported isolate. Of reported isolates, 31% were fungi. In patients with surgical-site infections, Enterococcus (17%) was the single most frequently reported pathogen. Device-associated nosocomial infection rates for BSIs, pneumonia, and UTIs did not correlate with length of ICU stay, hospital bed size, number of beds in the ICU, or season. Combined MS ICUs in major teaching hospitals had higher device-associated infection rates compared to all other hospitals with combined medical-surgical units. CONCLUSIONS: Nosocomial infections in MS ICUs at the most frequent infection sites (bloodstream, urinary, and respiratory tract) almost always were associated with use of an invasive device. Device-associated infection rates were the best available comparative rates between combined MS ICUs, but the distribution of device-associated rates should be stratified by a hospital's major teaching affiliation status.     

A practical tool to assess the incidence of nosocomial infection in Japanese intensive care units: the Japanese Nosocomial Infection Surveillance System

SUMMARY: Infection control professionals have the means to calculate infection rates in their hospitals but not to assess them. They require a practical tool that enables them to compare observed infection rates with external standards. Based on the data obtained from the intensive care unit (ICU) component of the Japanese Nosocomial Infection Surveillance (JANIS) system, a spreadsheet was developed to calculate a standardized infection ratio (SIR) as a risk-adjusted indicator. Out of the factors associated with the development of nosocomial infections in a multi-variate analysis, the following three factors were selected for stratification: APACHE II score (0-10, 11-20, 21+), operation (yes, no) and ventilator use (user, non-user). Infection rates in 2001 were determined (per 1000 patient-days), stratified by the three factors, as a benchmark. The spreadsheet was designed to calculate SIRs on the basis of the Japanese benchmark infection rates using Microsoft Excel software. The user of the spreadsheet should input the number of observed nosocomial infections and patient-days by APACHE II score, operation and ventilator use. When applied to eight Japanese ICUs, the spreadsheet revealed relative differences and temporal changes in the incidence of nosocomial infections within these ICUs.     

Nosocomial pulmonary infection by antimicrobial-resistant bacteria of patients hospitalized in intensive care units: risk factors and survival

The objectives of this study were to identify the risk factors of nosocomial pulmonary infection (NPI) in intensive care units (ICUs) associated with antimicrobial-resistant bacteria (NPI-ARB) and to compare survival after NPI-ARB with NPI due to antimicrobial-sensitive bacteria (NPI-ASB). We analysed data from a surveillance network monitoring nosocomial infections in 27 mixed ICUs in the south-east of France. NPI surveillance data were recorded for 628 patients with documented NPI. The patients were stratified into 2 groups by type of pneumonia: NPI-ASB (445 patients) vs. NPI-ARB (183 patients). Variables associated with NPI-ARB were identified++ by multivariate logistic regression. Survival was calculated using the Kaplan-Meier method. A medical condition for ICU admission [odds ratio (OR) 1.98, 95% confidence interval (95% CI) 1.35-2.91], transfer from another hospital ward [OR 1.66, 95% CI (1.14-2.42)], a colonized central venous catheter [OR 3.47, 95% CI (1.46-8.21)], a stay of [eight days [OR 1.02, 95% CI (1.01-1. 05)] and mechanical ventilation [OR 2.10, 95% CI (1.31-3.36)] were independent risk factors of NPI-ARB. Median survival was 35 days after NPI-ARB and 32 days after NPI-ASB (P=0.92). Survival after bacterial NPI was not associated with antimicrobial susceptibility.     

Prevalence of healthcare-associated infection in Scottish intensive care units

A national point prevalence survey of healthcare-associated infection (HCAI) in all acute hospitals, including intensive care units (ICUs), was carried out in Scotland from October 2005 to October 2006. The survey measured the prevalence of HCAIs to determine the burden on ICU resources. HCAI prevalence in ICUs was compared with HCAI prevalence in patients outside ICU. The prevalence of HCAI in ICU patients was 27.1%, significantly higher than HCAI prevalence in patients outside ICU, which was 9.3%. The prevalence of specific infections, namely pneumonia and lower respiratory tract, bloodstream and surgical site infections, was also significantly higher in ICU patients compared with non-ICU patients. These results highlight the burden on ICU resources from all HCAIs, regardless of site of infection. High HCAI prevalence in Scottish ICUs has major implications for patient safety and ICU resources and emphasises the need for continuing strong collaboration between intensivists and infection control teams.     

新生儿重症监护室医院感染管理现状

目的了解河北省各综合医院新生儿重症监护室(NICU)的医院感染及医疗安全管理工作现状。方法以《医院感染管理办法》和《河北省新生儿室医院感染管理考核标准》为依据,对河北省A、B两市的5所三级医院和6所二级医院NICU的医院感染管理现状进行考核评估。结果发现各级医院普遍存在NICU环境布局不合理、手卫生设施不符合要求、治疗室和沐浴问管理不规范、未严格执行消毒隔离等规章制度的问题,且在二级医院这些问题更加明显。结论应加强NICU环境布局和工作流程及手卫生设施的合理化建设,提高医院感染管理的执行力,推进NICU的规范化管理进程。