Infection Control Guidelines - INICC

Author's personal copy
The Time-Dependent Bias and its Effect on Extra Length of
Stay due to Nosocomial Infection
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 Infection Control 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: INICC 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 Infection Control Consortium
(INICC) Members l
a International Nosocomial Infection Control 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;
INICC;
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 Infection Control Consortium, listed by country alphabetically.
0163-4453/$36 ª 2011 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jinf.2010.12.004
www.elsevierhealth.com/journals/jinf
Journal of Infection (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 Infection Control Consortium (INICC)
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 Infection Control Consortium (INICC)#
1 International Nosocomial Infection Control 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 Infection Control Consortium (INICC) 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 Infection Control 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 Infection Control Consortium
(INICC) 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 INICC. Data collection was performed in the participating ICUs, and data
were uploaded and analyzed at the INICC headquarters on proprietary software. DA-HAI rates were
registered by applying the definitions of the US Centers for Disease Control 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 Infection Control Consortium (INICC) 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 Infection Control 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 Infection Control Consortium (INICC) 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 INICC. Data were collected in
the participating ICUs, and analyzed at INICC headquarters by proprietary software. DA-HAI rates were recorded by applying the definitions
of the Centers for Disease Control 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 Infection
Control Consortium (INICC) 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 Infection Control Consortium (INICC) 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 INICC. Data collection was performed in the participating ICUs, and data were uploaded and analyzed at the INICC
headquarters using proprietary software. DA-HAI rates were registered based on definitions promulgated by the Centers for Disease
Control 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 Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights
reserved. (Am J Infect Control 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
Control and Prevention’s (CDC) Study of the Efficacy
of Nosocomial Infection Control 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 Infection
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 Infection
Control Consortium, Buenos Aires, Argentina. d
Address correspondence to Victor Daniel Rosenthal, MD, CIC, MSc, International
Nosocomial Infection Control 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 Infection
Control 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 Infection Control Consortium (INICC) 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 Infection Control Consortium (INICC). The data were collected in the
participating ICUs, and uploaded and analyzed at the INICC headquarters on proprietary software. DA-HAI rates were
registered by applying the definitions of the US Centers for Disease Control 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]
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1
Device-Associated Infections Rate in an Intensive Care Unit of a Lebanese University
Hospital: International Nosocomial Infection Control Consortium (INICC) 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 Infection Control 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, INICC.
Device-associated infection rates and extra length of stay in
an intensive care unit of a university hospital in Wroclaw,
Poland: International Nosocomial Infection Control
Consortium's (INICC) 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 Infection Control 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 Infection Control Consortium (INICC) in Poland.
Materials and Methods: AprospectiveDA-HAIsurveillancestudywasconductedonanadultICUfrom
January 2007 to May 2010. Data were collected by implementing the methodology developed by INICC and
applying the definitions of DA-HAI provided by the National Healthcare Safety Network at the US Centers for
Disease Control 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 INICC, 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 Infection Control Consortium (INICC) 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 Infection Control 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 Infection Control Consortium (INICC), 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 Infections
funds all of the activities at INICC headquarters.
Conflict of interest: None to report.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of
Infection Control
0196-6553/$36.00 - Copyright Ó 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ajic.2011.05.020
American Journal of Infection Control 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 Infection: 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 Control 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 INICC
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 • INICC 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 Control 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 Infection Control Consortium
A2
(INICC) members, see Appendix.
A3
V. D. Rosenthal (&)
A4
International Nosocomial Infection Control Consortium
A5 (INICC), 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
Infection
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 Infection Control 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 Infection Control 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 Infection Control
journal homepage: www.ajicjournal.org
American Journal of
Infection Control
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