Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach in five intensive care units in three cities of China.

OBJECTIVES: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene (HH) Approach in three hospitals in three cities of China, and analyze predictors of poor hand hygiene compliance. STUDY DESIGN: A prospective before-after study from May 2009 to December 2010 in five intensive care units members of the INICC in China. METHODS: The study was divided into two periods: a 3-month baseline period and a follow-up period. A Multidimensional HH Approach was implemented, which included the following elements: 1- administrative support, 2- supplies availability, 3- education and training, 4- reminders in the workplace, 5- process surveillance and 6- performance feedback. Observations were done for HH compliance in each ICU, during randomly selected 30-min periods. RESULTS: A total of 2079 opportunities for HH were recorded. Overall HH compliance increased from 51.5% to 80.1% (95% CI 73.2-87.8; P = 0.004). Multivariate analysis indicated that several variables were significantly associated with poor HH compliance: females vs males (64% vs 55%; 95% CI 0.81-0.94; P = 0.0005), nurses vs physicians (64% vs 57%, P = 0.004), among others. CONCLUSIONS: Adherence to HH was increased significantly with the INICC multidimensional approach. Specific programs directed to improve HH in variables found to be predictors of poor HH compliance should be implemented.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC).

We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey. METHODS: A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach. RESULTS: In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.) CONCLUSIONS: The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: We aimed to evaluate the impact of a multidimensional infection control strategy for the reduction of the incidence of catheter-associated urinary tract infection (CAUTI) in patients hospitalized in adult intensive care units (AICUs) of hospitals which are members of the International Nosocomial Infection Control Consortium (INICC), from 40 cities of 15 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, Philippines, and Turkey. METHODS: We conducted a prospective before-after surveillance study of CAUTI rates on 56,429 patients hospitalized in 57 AICUs, during 360,667 bed-days. The study was divided into the baseline period (Phase 1) and the intervention period (Phase 2). In Phase 1, active surveillance was performed. In Phase 2, we implemented a multidimensional infection control approach that included: (1) a bundle of preventive measures, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CAUTI rates, and (6) feedback of performance. The rates of CAUTI obtained in Phase 1 were compared with the rates obtained in Phase 2, after interventions were implemented. RESULTS: We recorded 253,122 urinary catheter (UC)-days: 30,390 in Phase 1 and 222,732 in Phase 2. In Phase 1, before the intervention, the CAUTI rate was 7.86 per 1,000 UC-days, and in Phase 2, after intervention, the rate of CAUTI decreased to 4.95 per 1,000 UC-days [relative risk (RR) 0.63 (95% confidence interval [CI] 0.55-0.72)], showing a 37% rate reduction. CONCLUSIONS: Our study showed that the implementation of a multidimensional infection control strategy is associated with a significant reduction in the CAUTI rate in AICUs from developing countries.

Impact of a multidimensional infection control strategy on central line-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control strategy including a practice bundle to reduce the rates of central line-associated bloodstream infection (CLAB) in patients hospitalized in pediatric intensive care units (PICUs) of hospitals, which are members of the INICC, from nine cities of five developing countries: Colombia, India, Mexico, Philippines, and Turkey. METHODS: CLAB rates were determined by means of a prospective surveillance study conducted on 1,986 patients hospitalized in nine PICUs, over a period of 12,774 bed-days. The study was divided into two phases. During Phase 1 (baseline period), active surveillance was performed without the implementation of the multi-faceted approach. CLAB rates obtained in Phase 1 were compared with CLAB rates obtained in Phase 2 (intervention period), after implementation of the INICC multidimensional infection control program. RESULTS: During Phase 1, 1,029 central line (CL) days were recorded, and during Phase 2, after implementing the CL care bundle and interventions, we recorded 3,861 CL days. The CLAB rate was 10.7 per 1,000 CL days in Phase 1, and in Phase 2, the CLAB rate decreased to 5.2 per 1,000 CL days (relative risk [RR] 0.48, 95% confidence interval [CI] 0.29-0.94, P = 0.02), showing a reduction of 52% in the CLAB rate. CONCLUSIONS: This study shows that the implementation of a multidimensional infection control strategy was associated with a significant reduction in the CLAB rates in the PICUs of developing countries.

Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC.

PURPOSE: To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs). METHODS: Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria. RESULTS: Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level. CONCLUSIONS: Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.

Device-associated infection rates in adult intensive care units of Cuban university hospitals: International Nosocomial Infection Control Consortium (INICC) findings.

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 Healthcare Safety Network (CDC NHSN). We analyzed the mechanical ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CAUTI) rates, microorganism profile, extra length of stay (ELOS), extra mortality, and hand hygiene compliance. RESULTS: During 14 512 days of hospitalization, 1982 patients acquired 444 DA-HAIs, an overall rate of 22.4% (95% CI 20.6-24.3) or 30.6 (95% CI 27.8-33.5) DA-HAIs per 1000 ICU-days. The CLA-BSI rate was 2.0 (95% CI 1.2-3.1) per 1000 central line-days, the VAP rate was 52.5 (95% CI 47.2-58.3) per 1000 ventilator-days, and the CAUTI rate was 8.1 (95% CI 6.5-10.0) per 1000 catheter-days. LOS of patients was 4.9 days for those without DA-HAI, 23.3 days for those with CLA-BSI, and 23.8 days for those with VAP. CAUTI LOS was not calculated due to the lack of data. Extra mortality was 47% (relative risk (RR) 2.42; p=0.0693) for VAP and 17% (RR 1.52; p=0.5552) for CLA-BSI. The only patient with CAUTI died, but there was too little mortality data regarding this infection type to consider this significant. Escherichia coli was the most commonly isolated microorganism. The overall hand hygiene compliance was 48.6% (95% CI 42.8-54.3). CONCLUSIONS: DA-HAI rates, LOS, and mortality were found to be high, and hand hygiene low. It is of primary importance that infection control programs that include outcome and process surveillance are implemented in Cuba.

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.

Impact on rates and time to first central vascular-associated bloodstream infection when switching from open to closed intravenous infusion containers in a hospital setting.

An open-label, prospective cohort, active healthcare-associated infection surveillance sequential study was conducted in four Italian intensive-care units. The aim was to determine the effect of switching from open (glass) to closed fully collapsible plastic intravenous (i.v.) infusion containers (Viaflo) on rate and time to onset of central venous catheter-associated bloodstream infections (CVC-BSI). A total of 1173 adult patients were enrolled. The CVC-BSI rate during the open container period was significantly higher than during the closed container period (8.2 vs. 3.5 BSI/1000 CVC days, relative risk 0.43, 95% confidence interval 0.22-0.84, P=0.01). The probability of developing a CVC-BSI was assessed over time comparing open and closed i.v. infusion containers. In the closed container period, it remained fairly constant (0.8% at days 1-3 to 1.4% at days 7-9) whereas during the open container period it increased (2% at days 1-3 to 5.8% at days 7-9). Overall, the chance of acquiring a CVC-BSI significantly decreased by 61% in the closed container period (Cox proportional hazard ratio 0.39, P=0.004).

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 hospital-acquired infection rates in Turkish intensive care units. Findings of the International Nosocomial Infection Control Consortium (INICC).

We conducted a prospective study of targeted surveillance of healthcare-associated infections (HAIs) in 13 intensive care units (ICUs) from 12 Turkish hospitals, all members of the International Nosocomial Infection Control Consortium (INICC). The definitions of the US Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (NNISS) were applied. During the three-year study, 3288 patients for accumulated duration of 37 631 days acquired 1277 device-associated infections (DAI), an overall rate of 38.3% or 33.9 DAIs per 1000 ICU-days. Ventilator-associated pneumonia (VAP) (47.4% of all DAI, 26.5 cases per 1000 ventilator-days) gave the highest risk, followed by central venous catheter (CVC)-related bloodstream infections (30.4% of all DAI, 17.6 cases per 1000 catheter-days) and catheter-associated urinary tract infections (22.1% of all DAI, 8.3 cases per 1000 catheter-days). Overall 89.2% of all Staphylococcus aureus infections were caused by methicillin-resistant strains, 48.2% of the Enterobacteriaceae isolates were resistant to ceftriaxone, 52.0% to ceftazidime, and 33.2% to piperacilin-tazobactam; 51.1% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.7% to ceftazidime, 38.7% to imipenem, and 30.0% to piperacilin-tazobactam; 1.9% of Enterococcus sp. isolates were resistant to vancomycin. This is the first multi-centre study showing DAI in Turkish ICUs. DAI rates in the ICUs of Turkey are higher than reports from industrialized countries.