15 Peer Review Papers Indexed in Pubmed Published by <strong>INICC</strong> During 2011
Author's personal copy The Time-Dependent Bias and its Effect on Extra Length of Stay due to Nosocomial <strong>Infection</strong> Adrian G. Barnett, PhD a, *, Jan Beyersmann, PhD b , Arthur Allignol, MSc b , Victor D. Rosenthal, MD, MSc, CIC c , Nicholas Graves, PhD a , Martin Wolkewitz, PhD b a Queensland University of Technology, Brisbane, Australia b Freiburg Center for Data Analysis and Modeling, Freiburg, Germany c International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina Keywords: Cost Health-care decision makers Hospital Statistics A B S T R A C T Objectives: Many studies disregard the time dependence of nosocomial infection when examining length of hospital stay and the associated financial costs. This leads to the “time-dependent bias,” which biases multiplicative hazard ratios. We demonstrate the time-dependent bias on the additive scale of extra length of stay. Methods: To estimate the extra length of stay due to infection, we used a multistate model that accounted for the time of infection. For comparison we used a generalized linear model assuming a gamma distribution, a commonly used model that ignores the time of infection. We applied these two methods to a large prospective cohort of hospital admissions from Argentina, and compared the methods’ performance using a simulation study. Results: For the Argentina data the extra length of stay due to nosocomial infection was 11.23 days when ignoring time dependence and only 1.35 days after accounting for the time of infection. The simulations showed that ignoring time dependence consistently overestimated the extra length of stay. This overestimation was similar for different rates of infection and even when an infection prolonged or shortened stay. We show examples where the timedependent bias remains unchanged for the true discharge hazard ratios, but the bias for the extra length of stay is doubled because length of stay depends on the infection hazard. Conclusions: Ignoring the timing of nosocomial infection gives estimates that greatly overestimate its effect on the extra length of hospital stay. Copyright © 2011, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. Introduction Length of stay (LOS) in hospital is a key outcome when studying the health and economic impact of nosocomial infections (NIs) [1]. A patient with an NI is likely to stay longer in hospital, incurring extra cost. The cost arises because other patients are denied access to the hospital bed while it is used to treat the infected patient. There will be only small changes to financial expenditures from reducing NI because most are fixed within the cost structures of the hospital within the time frame of Funding: Martin Wolkewitz, Jan Beyersmann and Arthur Allignol were supported by Deutsche Forschungsgemeinschaft (FOR 534). Martin Wolkewitz’s visit to Brisbane was supported by the Institute of Health and Biomedical Innovation visiting researcher program. * Address correspondence to: Adrian G Barnett, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Queensland, 4059, Australia. E-mail: a.barnett@qut.edu.au. 1098-3015/$36.00 – see front matter Copyright © 2011, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. doi:10.1016/j.jval.2010.09.008 VALUE IN HEALTH 14 (2011) 381–386 available at www.sciencedirect.com journal homepage: www.elsevier.com/locate/jval Time-dependent analysis of length of stay and mortality due to urinary tract infections in ten developing countries: <strong>INICC</strong> findings Victor D. Rosenthal a, *, Arpita Dwivedy b , María Eugenia Rodríguez Calderon c , Saban Esen d , Héctor Torres Hernandez e ,Rédouane Abouqal f , Eduardo A. Medeiros g , Teodora Atencio Espinoza h , S.S. Kanj i , Achilleas Gikas j , Adrian G. Barnett k , Nicholas Graves k , International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) Members l a International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina b Dr L H Hiranandani Hospital, Mumbai, India c Hospital La Victoria, Bogota, Colombia d Ondokuz Mayis University Medical School, Samsun, Turkey e Hospital General de Irapuato, Irapuato, Mexico f Ibn-Sina Hospital, Medical ICU, Rabat, Morocco g Hospital S~ao Paulo, S~ao Paulo, Brazil h Hospital Regional de Pucallpa, Pucallpa, Peru i American University of Beirut Medical Center, Beirut, Lebanon j University Hospital of Heraklion, Heraklion, Greece k School of Public Health, Queensland University of Technology, Brisbane, Australia Accepted 10 December 2010 Available online 17 December 2010 KEYWORDS International nosocomial infection control consortium; <strong>INICC</strong>; Urinary tract infections; Length of stay; Summary Objectives: To estimate the excess length of stay (LOS) and mortality in an intensive care unit (ICU) due to a Catheter associated urinary tract infections (CAUTI), using astatisticalmodelthataccountsforthetiming of infection in 29 ICUs from 10 countries: Argentina, Brazil, Colombia, Greece, India, Lebanon, Mexico, Morocco, Peru, and Turkey. Methods: To estimate the extra LOS due to infection in a cohort of 69,248 admissions followed for 371,452 days in 29 ICUs, we used a multi-state model, including specific censoring to ensure that we estimate the independent effect of urinary tract infection, and not the combined effects of * Corresponding author. Ave #4580, Floor 12, Apt D, ZIP 1195, Buenos Aires, Argentina. Tel.: +54 11 4865 2585 (Office), +54 9 11 5691 1775 (Mobile). E-mail address: victor_rosenthal@inicc.org (V.D. Rosenthal). l Refer Appendix section for International <strong>Infection</strong> <strong>Control</strong> Consortium, listed by country alphabetically. 0163-4453/$36 ª 2011 The British <strong>Infection</strong> Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2010.12.004 www.elsevierhealth.com/journals/jinf Journal of <strong>Infection</strong> (2011) 62, 136e141 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 <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) V. D. ROSENTHAL 1 *, F. E. UDWADIA 2 , H. J. MUN˜ OZ 3 , N. ERBEN 4 , F. HIGUERA 5 , K. ABIDI 6 , E. A. MEDEIROS 7 , E. FERNÁNDEZ MALDONADO 8 , S. S. KANJ 9 , A. GIKAS 10 , A. G. BARNETT 11 , N. GRAVES 11 and the International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>)# 1 International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina; 2 Breach Candy Hospital Trust, Mumbai, India; 3 Clıńica Reina Sofıá, Bogota´, Colombia; 4 Eskisehir Osmangazi University, Eskisehir, Turkey; 5 Hospital General de Me´xico, Mexico City, Mexico; 6 Ibn-Sina Hospital, Medical ICU, Rabat, Morocco; 7 Hospital Sa˜o Paulo, Sa˜o Paulo, Brazil; 8 Clıńica San Pablo, Lima, Peru; 9 American University of Beirut Medical Center, Beirut, Lebanon; 10 University Hospital of Heraklion, Heraklion, Greece; 11 School of Public Health, Queensland University of Technology (Accepted 10 January 2011) SUMMARY 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 accounting 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. A 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. Key words: Bacterial infections, hospital-acquired (noscomial) infections, hygiene and hospital infections, pneumonia, surveillance. INTRODUCTION normally not be associated with the underlying Epidemiol. Infect., Page 1 of 7. f Cambridge University Press 2011 doi:10.1017/S0950268811000094 Device-associated infection rates in adult intensive care units of Cuban university hospitals: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) findings H. Guanche-Garcell a , O. Requejo-Pino b , V.D. Rosenthal c, *, C. Morales-Pérez a , O. Delgado-González b , D. Fernández-González b a Joaquín Albarrán Domínguez Surgical Training Hospital, Havana, Cuba b Gral. Calixto García University Hospital, Havana, Cuba c International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina International Journal of Infectious Diseases 15 (2011) e357–e362 ARTICLE INFO Article history: Received 25 June 2010 Received in revised form 20 December 2010 Accepted 1 February 2011 Corresponding Editor: Ziad Memish, Riyadh, Saudi Arabia Keywords: SUMMARY Objectives: To determine the rate of device-associated healthcare-associated infection (DA-HAI), microbiological profile, length of stay (LOS), extra mortality, and hand hygiene compliance in two intensive care units (ICUs) of two hospital members of the International <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) of Havana, Cuba. Methods: An open label, prospective cohort, active DA-HAI surveillance study was conducted on adults admitted to two tertiary-care ICUs in Cuba from May 2006 to December 2009, implementing the methodology developed by <strong>INICC</strong>. Data collection was performed in the participating ICUs, and data were uploaded and analyzed at the <strong>INICC</strong> headquarters on proprietary software. DA-HAI rates were registered by applying the definitions of the US Centers for Disease <strong>Control</strong> and Prevention National Contents lists available at ScienceDirect International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid Original Article Device-associated infection rates in intensive care units in El Salvador: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) Findings Lourdes Dueñas 1 , Ana C. Bran de Casares 1 , Victor D. Rosenthal 2 , Lilian Jesús Machuca 1 1 Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador 2 International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina ! Abstract Introduction: This study aimed to determine the rate of device-associated, health care-associated infection (DA-HAI), the excess in length of stay, the mortality, and the hand hygiene compliance in a pediatric intensive care unit (PICU) and a neonatal ICU (NICU) in a hospital member of the International <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) in El Salvador. Methodology: A prospective cohort, active DA-HAI surveillance study was conducted on patients admitted in the pediatric and neonatal ICUs from January 2007 to November 2009. The protocol and methodology implemented were developed by <strong>INICC</strong>. Data were collected in the participating ICUs, and analyzed at <strong>INICC</strong> headquarters by proprietary software. DA-HAI rates were recorded by applying the definitions of the Centers for Disease <strong>Control</strong> and Prevention National Healthcare Safety Network. Results: Of 1,145 patients hospitalized in the PICU for 9,517 days, 177 acquired DA-HAIs (overall rate 15.5%), and 18.6 DA-HAIs per 1,000 ICU-days. Furthermore, 1,270 patients hospitalized in the NICU for 30,663 days acquired 302 DA-HAIs (overall rate 23.8%), and 9.8 Device-associated infections rates in adult, pediatric, and neonatal intensive care units of hospitals in the Philippines: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) findings Josephine Anne Navoa-Ng, MD, a Regina Berba, MD, b Yolanda Arreza Galapia, RN, c Victor Daniel Rosenthal, MD, CIC, MSc, d Victoria D. Villanueva, MD, a Marıa Corazon V. Tolentino, RN, a Glenn Angelo S. Genuino, MD, b Rafael J. Consunji, MD, b and Jacinto Blas V. Mantaring III, MD b Quezon City and Manila, Philippines; and Buenos Aires, Argentina Background: This study investigated the rate of device-associated health care–associated infection (DA-HAI), microbiological profiles, bacterial resistance, length of stay (LOS), and mortality rate in 9 intensive care units (ICUs) of 3 hospital members of the International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) in the Philippines. Methods: This was an open-label, prospective cohort, active DA-HAI surveillance study of adult, pediatric, and newborn patients admitted to 9 tertiary care ICUs in the Philippines between January 2005 and December 2009, implementing methodology developed by the <strong>INICC</strong>. Data collection was performed in the participating ICUs, and data were uploaded and analyzed at the <strong>INICC</strong> headquarters using proprietary software. DA-HAI rates were registered based on definitions promulgated by the Centers for Disease <strong>Control</strong> and Prevention’s National Healthcare Safety Network. Results: Over a 5-year period, 4952 patients hospitalized in ICUs for a total of 40,733 days acquired 199 DA-HAIs, for an overall rate of 4.9 infections per 1,000 ICU-days. Ventilator-associated pneumonia posed the greatest risk (16.7 per 1,000 ventilator-days in the adult ICUs, 12.8 per 1,000 ventilator-days in the pediatric ICU, and 0.44 per 1,000 ventilator-days in the neonatal ICUs), followed by central line–associated bloodstream infections (4.6 per 1,000 catheter-days in the adult ICUs, 8.23 per 1,000 ventilator-days in the pediatric ICU, and 9.6 per 1,000 ventilator-days in the neonatal ICUs) and catheter-associated urinary tract infections (4.2 per 1,000 catheter-days in the adult ICUs and 0.0 in the pediatric ICU). Conclusion: DA-HAIs pose far greater threats to patient safety in Philippine ICUs than in US ICUs. The establishment of active infection control programs that involve infection surveillance and implement guidelines for prevention can improve patient safety and should become a priority. Key Words: Nosocomial infection; hospital infection; health care–acquired infection; device associated infection; central line– associated bloodstream infection; ventilator-associated pneumonia; catheter-associated urinary tract infection; developing country; limited-resource country; infection control; surveillance; incidence density; length of stay; mortality; microorganism profile; bacterial resistance. Copyright ª 2011 by the Association for Professionals in <strong>Infection</strong> <strong>Control</strong> and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. (Am J Infect <strong>Control</strong> 2011;n:1-7.) In the United States as well as several other highincome countries, device-associated (DA) health care– associated infection (HAI) surveillance in the intensive care unit (ICU) plays an important role in hospital infection control and quality assurance. 1 Likewise, surveillance was reported by the Centers for Disease <strong>Control</strong> and Prevention’s (CDC) Study of the Efficacy of Nosocomial <strong>Infection</strong> <strong>Control</strong> as an efficacious tool to reduce DA-HAIs. 2 In a growing body of literature, DA-HAIs are considered the principal threat to patient safety in the ICU and are among the main causes of patient morbidity and mortality. 3-5 The CDC’s National Nosocomial <strong>Infection</strong> Surveillance System and National Healthcare Safety Network (NHSN) have promulgated standardized criteria for DA-HAI surveillance. 6,7 This standardized From St. Luke’s Medical Center, Quezon City, Philippines a ; Philippine General Hospital, Manila, Philippines b ; National Kidney and Transplant Institute, Quezon City, Philippines c ; and International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina. d Address correspondence to Victor Daniel Rosenthal, MD, CIC, MSc, International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Corrientes Ave, No. 4580, Floor 11, Apt A, Buenos Aires (1195), Argentina. E-mail: victor_rosenthal@inicc.org. Conflict of interest: None to report. 0196-6553/$36.00 Copyright ª 2011 by the Association for Professionals in <strong>Infection</strong> <strong>Control</strong> and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2010.10.018 1 Página 1 de 1 http://www.ncbi.nlm.nih.gov/pubmed/21846591 OBJECTIVES: METHODS: RESULTS: CONCLUSIONS: Display Settings: Abstract Int J Infect Dis. 2011 Aug 14. [Epub ahead of print] Device-associated infection rates in 398 intensive care units in Shanghai, China: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) findings. Tao L, Hu B, Rosenthal VD, Gao X, He L. Department of Respiratory Medicine, Huadong Hospital, Fudan University, Shanghai, China. Abstract To determine device-associated healthcare-associated infection (DA-HAI) rates and the microorganism profile in 398 intensive care units (ICUs) of 70 hospitals in Shanghai, China. An open-label, prospective, cohort, active DA-HAI surveillance study was conducted on patients admitted to 398 tertiary-care ICUs in China from September 2004 to December 2009, implementing the methodology developed by the International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>). The data were collected in the participating ICUs, and uploaded and analyzed at the <strong>INICC</strong> headquarters on proprietary software. DA-HAI rates were registered by applying the definitions of the US Centers for Disease <strong>Control</strong> and Prevention (CDC) National Healthcare Safety Network (NHSN). We analyzed the rates of DAI-HAI, ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI), and their microorganism profiles. During the 5 years and 4 months of the study, 391 527 patients hospitalized in an ICU for an aggregate of 3 245 244 days, acquired 20 866 DA-HAIs, an overall rate of 5.3% (95% confidence interval (CI) 5.3-5.4) and 6.4 (95% CI 6.3-6.5) infections per 1000 ICU-days. VAP posed the greatest risk (20.8 per 1000 ventilator-days, 95% CI 20.4-21.1), followed by CAUTI (6.4 per 1000 catheter-days, 95% CI 6.3-6.6) and CLABSI (3.1 per 1000 catheter-days, 95% CI 3.0-3.2). The most common isolated microorganism was Acinetobacter baumannii (19.1%), followed by Pseudomonas aeruginosa (17.2%), Klebsiella pneumoniae (11.9%), and Staphylococcus aureus (11.9%). DA-HAIs in the ICUs of Shanghai pose a far greater threat to patient safety than in ICUs in the USA. This is particularly the case for the VAP rate, which is much higher than the rates found in developed countries. Active infection control programs that carry out infection surveillance and implement prevention guidelines can improve patient safety and must become a priority. Copyright © 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. PMID: 21846591 [PubMed - as supplied by publisher] PubMed LinkOut - more resources 1 Device-Associated <strong>Infection</strong>s Rate in an Intensive Care Unit of a Lebanese University Hospital: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) Findings. Kanj SS 1 , Nada Zahreddine 1 , Rosenthal VD 2 , Nisreen Sidani 1 , Lamia Alamaddni Jurdi 1 , Zeina Kanafani 1 . 1-American University of Beirut Medical Center, Beirut, Lebanon; 2- International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina. Key words: Lebanon, intensive care unit, nosocomial infection, hospital infection, health care associated infection, device associated infection, central line associated blood stream infection, ventilator associated pneumonia, catheter associated urinary tract infection, surveillance, hand hygiene, international nosocomial infection control consortium, <strong>INICC</strong>. Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium's (<strong>INICC</strong>) findings Andrzej Kübler a , Wieslawa Duszynska a , Victor D Rosenthal b,⁎ , Malgorzata Fleischer a , Teresa Kaiser a , Ewa Szewczyk a , Barbara Barteczko-Grajek a a Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland b International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina Keywords: Poland; Europe; Health care–associated infection; Hospital infections; Nosocomial infection; Central line–associated blood stream infection; Ventilator-associated pneumonia; Catheter-associated urinary tract infection; Intensive care unit; Length of stay Abstract Purpose: The aim of this study was to determine device-associated health care–associated infections (DA-HAI) rates, microbiologic profile, bacterial resistance, and length of stay in one intensive care unit (ICU) of a hospital member of the International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) in Poland. Materials and Methods: AprospectiveDA-HAIsurveillancestudywasconductedonanadultICUfrom January 2007 to May 2010. Data were collected by implementing the methodology developed by <strong>INICC</strong> and applying the definitions of DA-HAI provided by the National Healthcare Safety Network at the US Centers for Disease <strong>Control</strong> and Prevention. Results: Atotalof847patientshospitalizedfor9386daysacquired 206 DA-HAIs, an overall rate of 24.3% (95% confidence interval [CI], 21.5-27.4), and 21.9 (95% CI, 19.0-25.1) DA-HAIs per 1000 ICU-days. Central line–associated bloodstream infection rate was 4.01 (95% CI, 2.8-5.6) per 1000 catheter-days, ventilator-associated pneumonia rate was 18.2 (95% CI, 15.5-21.6) per 1000 ventilator-days, and catheterassociated urinary tract infection rate was 4.8 (95% CI, 3.5-6.5) per 1000 catheter-days. Length of stay was 6.9 days for those patients without DA-HAI, 10.0 days for those with central line–associated bloodstream infection, 15.5 days for those with ventilator-associated pneumonia, and 15.0 for those with catheterassociated urinary tract infection. Conclusions: Most DA-HAI rates are lower in Poland than in <strong>INICC</strong>, but higher than in the National Healthcare Safety Network, expressing the feasibility of lowering infection rates and increasing patient safety. ©2011ElsevierInc.Allrightsreserved. 1. Introduction In most developed countries, including the United States, as well as several other high-income countries, the deviceassociated health care–associated infection (DA-HAI) ⁎ Corresponding author. Corrientes Ave # 4580, Floor 11, Apt A, ZIP 1195, Buenos Aires, Argentina. E-mail address: victor_rosenthal@inicc.org (V.D. Rosenthal). Website: www.inicc.org. 0883-9441/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2011.05.018 Journal of Critical Care (2011) xx, xxx–xxx Special communication International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>) report, data summary of 36 countries, for 2004-2009 Victor D. Rosenthal MD, MSc, CIC a, *, Hu Bijie MD b , Dennis G. Maki MD c , Yatin Mehta MD d , Anucha Apisarnthanarak MD e , Eduardo A. Medeiros MD f , Hakan Leblebicioglu MD g , Dale Fisher MD h , Carlos Álvarez-Moreno MD i , Ilham Abu Khader MD j , Marisela Del Rocío González Martínez MD k , Luis E. Cuellar MD l , Josephine Anne Navoa-Ng MD m , Rédouane Abouqal MD n , Humberto Guanche Garcell MD o , Zan Mitrev MD p , María Catalina Pirez García MD q , Asma Hamdi MD r , Lourdes Dueñas MD s , Elsie Cancel MD t , Vaidotas Gurskis MD u , Ossama Rasslan MD v , Altaf Ahmed MD w , Souha S. Kanj MD x , Olber Chavarría Ugalde RN y , Trudell Mapp RN z , Lul Raka MD aa , Cheong Yuet Meng MD bb , Le Thi Anh Thu MD cc , Sameeh Ghazal MD dd , Achilleas Gikas MD ee , Leonardo Pazmiño Narváez MD ff , Nepomuceno Mejía MD gg , Nassya Hadjieva MD hh , May Osman Gamar Elanbya MD ii , María Eugenia Guzmán Siritt MD jj , Kushlani Jayatilleke MD kk a From the International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina b Zhongshan Hospital, Shanghai, China c University of Wisconsin Medical School, Madison, WI d Medanta the Medcity, New Delhi, India e Thammasat University Hospital, Pratumthani, Thailand f Hospital São Paulo, São Paulo, Brazil g Ondokuz Mayis University Medical School, Samsun, Turkey h National University Hospital, Singapore, Republic of Singapore i Hospital Universitario San Ignacio, Universidad Pontificia Javeriana, Bogotá, Colombia j Jordan University Hospital, Amman, Jordan k Instituto Mexicano del Seguro Social, Torreón, Mexico l Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru m St. Luke’s Medical Center, Quezon City, Philippines n Ibn Sina Medical ICU, Rabat, Morocco o Hospital Docente Clínico Quirúrgico “Joaquín Albarrán Domínguez,” Havana, Cuba p Filip II Special Hospital for Surgery, Skopje, Macedonia q Centro Hospitalario Pereira Rosell Bouar, Montevideo, Uruguay r Hôpital d’Enfants, Tunis, Tunisia s Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador t San Jorge Children’s Hospital, Asociación Epidemiólogos de Puerto Rico, Guaynabo, Puerto Rico u Hospital of Kaunas University of Medicine, Kaunas, Lithuania v Ain Shams Faculty of Medicine, Cairo, Egypt w Liaquat National Hospital, Karachi, Pakistan x American University of Beirut Medical Center, Beirut, Lebanon y Hospital Hotel La Católica, San José, Costa Rica z Clínica Hospital San Fernando, Panama City, Panama aa National Institute for Public Health of Kosova and Medical School, Prishtina University, Prishtina, Kosovo bb Sunway Medical Centre Berhad and Monash University Sunway Campus, Petaling Jaya, Malaysia cc Cho Ray Hospital, Ho Chi Minh City, Vietnam dd King Fahad Medical City, Riyadh, Saudi Arabia ee University Hospital of Heraklion, Heraklion, Greece ff Hospital Eugenio Espejo, Quito, Ecuador gg Hospital General de la Plaza de la Salud, Santo Domingo, Dominican Republic hh University Hospital “Queen Giovanna-ISUL,” Sofia, Bulgaria ii Bahry Accident and Emergency Hospital, Khartoum, Sudan jj Hospital Militar Dr Carlos Arvelo, Caracas, Venezuela kk Sri Jayewardenepura General Hospital, Nugegoda, Sri Lanka * Address correspondence to Victor D. Rosenthal, MD, MSc, CIC, International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium (<strong>INICC</strong>), Corrientes Ave 4580, Floor 11, Apt A, Buenos Aires 1195, Argentina. E-mail address: victor_rosenthal@inicc.org (V.D. Rosenthal). Victor D. Rosenthal and the Foundation to Fight Against Nosocomial <strong>Infection</strong>s funds all of the activities at <strong>INICC</strong> headquarters. Conflict of interest: None to report. Contents lists available at ScienceDirect American Journal of <strong>Infection</strong> <strong>Control</strong> journal homepage: www.ajicjournal.org American Journal of <strong>Infection</strong> <strong>Control</strong> 0196-6553/$36.00 - Copyright Ó 2011 by the Association for Professionals in <strong>Infection</strong> <strong>Control</strong> and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.05.020 American Journal of <strong>Infection</strong> <strong>Control</strong> xxx (2011) 1-12 5.1.0 DTD Š YMIC2159_proof Š 5 September 2011 Š 4:40 pm Š ce PROOF 1 infection control and hospital epidemiology january 2011, vol. 32, no. 1 Thursday Nov 11 2010 12:37 PM/ICHE/v32n1/31587/MCORRADO original article Impact of Switching from an Open to a Closed Infusion System on Rates of Central Line–Associated Bloodstream <strong>Infection</strong>: A Meta- Analysis of Time-Sequence Cohort Studies in 4 Countries Dennis G. Maki, MD; Victor D. Rosenthal, MD, MSc, CIC; Reinaldo Salomao, MD; Fabio Franzetti, MD; Manuel Sigfrido Rangel-Frausto, MD background. We report a meta-analysis of 4 identical time-series cohort studies of the impact of switching from use of open infusion containers (glass bottle, burette, or semirigid plastic bottle) to closed infusion containers (fully collapsible plastic containers) on central line–associated bloodstream infection (CLABSI) rates and all-cause intensive care unit (ICU) mortality in 15 adult ICUs in Argentina, Brazil, Italy, and Mexico. methods. All ICUs used open infusion containers for 6–12 months, followed by switching to closed containers. Patient characteristics, adherence to infection control practices, CLABSI rates, and ICU mortality during the 2 periods were compared by x 2 test for each country, and the results were combined using meta-analysis. results. Similar numbers of patients participated in 2 periods (2,237 and 2,136). Patients in each period had comparable Average Severity of Illness Scores, risk factors for CLABSI, hand hygiene adherence, central line care, and mean duration of central line placement. CLABSI incidence dropped markedly in all 4 countries after switching from an open to a closed infusion container (pooled results, from 10.1 to 3.3 CLABSIs per 1,000 central line–days; relative risk [RR], 0.33 [95% confidence interval {CI}, 0.24–0.46]; ). All-cause P ! .001 ICU mortality also decreased significantly, from 22.0 to 16.9 deaths per 100 patients (RR, 0.77 [95% CI, 0.68–0.87]; ). P ! .001 conclusions. Switching from an open to a closed infusion container resulted in a striking reduction in the overall CLABSI incidence and all-cause ICU mortality. Data suggest that open infusion containers are associated with a greatly increased risk of infusion-related bloodstream infection and increased ICU mortality that have been unrecognized. Furthermore, data suggest CLABSIs are associated with significant attributable mortality. Infect <strong>Control</strong> Hosp Epidemiol 2011; 32(1):000-000 From the University of Wisconsin School of Medicine and Public Health, Madison (D.G.M.); Colegiales and Bernal Medical Centers, Buenos Aires, Argentina (V.D.R.); Santa Marcelina Hospital, Sao Paulo, Brazil (R.S.); Sacco Hospital, Milan, Italy (F.F.); and Specialties Instituto Mexicano del Seguro Social Hospital, Mexico City, Mexico (M.S.R.-F.). Received April 26, 2010; accepted July 7, 2010; electronically published November XX, 2010. 2011 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3201-00XX$15.00. DOI: 10.1086/657632 Critically ill patients hospitalized in intensive care units (ICUs) commonly require central lines for administration of large volumes of parenteral fluids, blood products, intravenous medications such as pressors, and hemodynamic monitoring. The greatest iatrogenic threat to the safety of these patients is healthcare-associated infection, especially central line–associated bloodstream infection (CLABSI). 1,2 There are 2 major sources of CLABSI: (1) colonization of the catheter, or catheter-related infection, and (2) contamination of the fluid administered through the device, or infusate-related infection. 3 Contaminated infusate has been shown to be the cause of most epidemics of nosocomial bloodstream infection and has not been thought to be a common cause of endemic CLABSI. 4 Recent pathogenetic studies using molecular subtyping have shown that most CLABSIs with noncuffed and nontunneled short-term vascular catheters derive from microorganisms in the patient’s cutaneous microflora that gain access to the implanted device, colonize the external surface or lumen, most often during catheter insertion, and subsequently produce CLABSI. 5-8 All of these studies have been done in developed Western countries where closed infusion systems, consisting of nonvented, fully collapsible plastic fluid containers, are used exclusively. There are 2 types of intravenous fluid containers in use worldwide: a glass bottle, burette, or semirigid plastic bottle that must be externally vented to allow ambient air to enter for the fluid to egress (an open infusion container), and a fully collapsible plastic container that does not require external venting for the bag to empty (a closed infusion container). Open systems with rigid containers were used worldwide for more than 75 years until a nationwide outbreak of gram-negative bacteremia was traced to the intrinsically conq1 q2 q3 186 www.thelancet.com Vol 377 January 15, 2011 Health-care-associated infections in developing countries Health-care-associated infections in developing countries are a serious issue that is scarcely addressed in the scientific literature. Hence, the systematic review and meta-analysis in The Lancet by Benedetta Allegranzi and colleagues from WHO, which assessed the epidemiology of health-care-associated infections, is impressive. 1 In this study, the investigators analysed pooled data from 220 selected publications from 1995 to 2008, including data from the Americas (22%), Europe (20%), southeast Asia (16%), the eastern Mediterranean (8%), Africa (5%), and other regions (29%). The prevalence of health-care-associated infections in developing pre-eclampsia and eclampsia. Studies have been done on calcium supplementation and low-dose aspirin as preventive measures in pregnancy, 8–10 but evidence on effectiveness and on which interventions can be delivered at various levels of the health system is not always clear. 8 The Collaborative E trial (Magpie) provided evidence that magnesium sulphate should be the treatment of choice for preventing eclamptic seizures or their recurrence, and should be used in preference to diazepam, phenytoin, and a lytic cocktail. The Magpie trial also showed that magnesium sulphate halves eclampsia risk after pre-eclampsia, and probably reduces the risk of maternal death. 11 In addition to the limitations noted by the investigators, it is important to recognise that the PIERS prediction is only useful if the health system and the community in which the woman lives have appropriate and sufficient transportation and referral systems, and the capacity to administer drugs (magnesium sulphate, antihypertensive drugs), induce labour, and provide post partum care. We urge the maternal and neonatal health community to consider the study in the context of the large continuum of interventions that need to be in place. Recently, synergies and connections between the maternal and neonatal health fields have been emphasised. 12 Hypertension in pregnancy and pre-eclampsia challenge the public health community because of the need to simultaneously protect the mother and baby, and to balance sometimes competing needs to bring forward or delay the end of the pregnancy. This study focuses mainly on maternal outcomes but also has implications for neonatal health. Hypertension in pregnancy and pre-eclampsia are conditions that call for further collaboration between maternal and neonatal health experts. We applaud von Dadelszen and colleagues in their efforts to validate the fullPIERS model and thereby advance future treatments and interventions. We hope that this new knowledge will be translated into effective and immediate action and further adapted and validated for use in low-income and middle-income countries, and thus used to its greatest advantage to save the lives of mothers and babies. Katherine C Teela, Rebecca M Ferguson, France A Donnay, *Gary L Darmstadt Family Health Division, Global Health Program, Bill & Melinda Gates Foundation, Seattle, WA 98102, USA gary.darmstadt@gatesfoundation.org We declare that we have no conflicts of interest. 1 Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23. 2 Rajaratnam JK, Marcus JR, Flaxman AD, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010; 375: 1988–2008. 3 Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J Obstet Gynaecol 1992; 99: 547–53. 4 Jim B, Sharma S, Kebede T, Acharya A. Hypertension in pregnancy: a comprehensive update. Cardiol Rev 2010; 18: 178–89. 5 Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol 2009; 33: 130–37. 6 Von Dadelszen P, Payne B, Li J, et al, for the PIERS Study Group. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet 2010; published online Dec 24. DOI:10.1016/S0140-6736(10)61351-7. 7 Danso KA, Opare-Addo HS. Challenges associated with hypertensive disease during pregnancy in low-income countries. Int J Gynaecol Obstet 2010; 110: 78–81. 8 Ronsmans C, Campbell O. Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy. BMC Public Health (in press). 9 Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2006; 3: CD1001059. 10 Caritis S, Sibai B, Hauth J, et al, and the National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Low-dose aspirin to prevent preeclampsia in women at high risk. N Engl J Med 1998; 338: 701–05. 11 The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 360: 1331–32. 12 Bhutta ZA, Ali S, Cousens S, et al. Alma-Ata: Rebirth and Revision 6. Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make Lancet 2008; 372: 972–89. Published Online December 10, 2010 DOI:10.1016/S0140- 6736(10)62005-3 See Articles page 228 CORRECTED PROOF CLINICAL AND EPIDEMIOLOGICAL STUDY 1 2 Socioeconomic impact on device-associated infections 3 in limited-resource neonatal intensive care units: 4 findings of the <strong>INICC</strong> 5 V. D. Rosenthal • P. Lynch • W. R. Jarvis • I. A. Khader • R. Richtmann • N. B. Jaballah • 6 C. Aygun • W. V. Gómez • L. Dueñas • T. A. Espinoza • J. A. Navoa-Ng • M. Pawar • 7 M. S. Oropeza • A. Barkat • N. Mejía • C. Y. Meng • A. Apisarnthanarak • <strong>INICC</strong> members 8 Received: 30 September 2010 / Accepted: 9 June 2011 9 Ó Springer-Verlag 2011 10 Abstract 11 Purpose To evaluate the impact of country socioeco- 12 nomic status and hospital type on device-associated 13 healthcare-associated infections (DA-HAIs) in neonatal 14 intensive care units (NICUs). 15 Methods Data were collected on DA-HAIs from Sep- 16 tember 2003 to February 2010 on 13,251 patients in 30 17 NICUs in 15 countries. DA-HAIs were defined using cri- 18 teria formulated by the Centers for Disease <strong>Control</strong> and 19 Prevention. Country socioeconomic status was defined 20 using World Bank criteria. 21 Results Central-line-associated bloodstream infection 22 (CLA-BSI) rates in NICU patients were significantly lower 23 in private than academic hospitals (10.8 vs. 14.3 CLA-BSI 24 per 1,000 catheter-days; p \ 0.03), but not different in 25 public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 26 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI A1 For a list of International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium A2 (<strong>INICC</strong>) members, see Appendix. A3 V. D. Rosenthal (&) A4 International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium A5 (<strong>INICC</strong>), Corrientes Ave #4580, Floor 12, Apt D, A6 1195 Buenos Aires, Argentina A7 e-mail: victor_rosenthal@inicc.org A8 P. Lynch A9 Epidemiology Associates, Redmond, WA, USA A10 W. R. Jarvis A11 Jason and Jarvis Associates, LLC, Hilton Head Island, SC, USA A12 I. A. Khader A13 Jordan University Hospital, Amman, Jordan A14 R. Richtmann A15 Hospital e Maternidade Santa Joana, Sao Paulo, Brazil A16 N. B. Jaballah A17 Hôpital d’Enfants, Tunis, Tunisia A18 C. Aygun A25 T. A. Espinoza A26 Hospital Regional de Pucallpa, Pucallpa, Peru A27 J. A. Navoa-Ng A28 St. Luke’s Medical Center, Quezon, Philippines A29 M. Pawar A30 Pushpanjali Crosslay Hospital, Ghaziabad, India A31 M. S. Oropeza A32 Hospital de la Mujer, Mexico, Mexico A33 A. Barkat A34 Children Hôspital of Rabat, Rabat, Morocco A35 N. Mejía A36 Hospital General de la Plaza de la Salud/Universidad A37 Iberoamericana, Santo Domingo, Dominican Republic A38 C. Y. Meng A39 Sunway Medical Centre Berhad and Monash University Sunway A40 Campus, Petaling Jaya, Selangar, Malaysia <strong>Infection</strong> DOI 10.1007/s15010-011-0136-2 Author Proof Major article Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium findings Q1 Victor D. Rosenthal a, *, Carlos Álvarez-Moreno b , Wilmer Villamil-Gómez c , Sanjeev Singh d , Bala Ramachandran e , Josephine A. Navoa-Ng f , Lourdes Dueñas g , Ata N. Yalcin h , Gulden Ersoz i , Antonio Menco c , Patrick Arrieta c , Ana C. Bran-de Casares g , Lilian de Jesus Machuca g , Kavitha Radhakrishnan d , Victoria D. Villanueva f , Maria C.V. Tolentino f , Ozge Turhan h , Sevim Keskin h , Eylul Gumus h , Oguz Dursun h , Ali Kaya i , Necdet Kuyucu i a International Nosocomial <strong>Infection</strong> <strong>Control</strong> Consortium, Buenos Aires, Argentina b Hospital Universitario San Ignacio, Universidad Pontificia Javeriana, Bogota, Colombia c Clinica Santa Maria, Sucre, Colombia d Amrita Institute of Medical Sciences and Research Center, Kochi, India e KK Childs Trust Hospital, Ghaziabad, India f St Luke’s Medical Center, Quezon City, Philippines g Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador h Akdeniz University, Antalya, Turkey i Faculty of Medicine, Mersin University, Mersin, Turkey Key Words: Hospital infection Background: Ventilator-associated pneumonia (VAP) is one of the most common health careeassociated Contents lists available at ScienceDirect American Journal of <strong>Infection</strong> <strong>Control</strong> journal homepage: www.ajicjournal.org American Journal of <strong>Infection</strong> <strong>Control</strong> American Journal of <strong>Infection</strong> <strong>Control</strong> xxx (2011) 1-5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81
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