In 2011 WHO published a paper comparing HAI rates of USA and Germany against data published by INICC of developing countries
HAI rates in developing countries are 3 to 5 times higher than in USA and Germany
List showing countries members of INICC
IN each INICC report the HAY rate is lower
Last INICC report with data of 36 countries of Latin America, Africa, Asia and Europe
INICC rates are significantly higher than USA rates
In adult ICUs Mortality rate of patients without HAI is 10%And Mortality rate of patients with HAI is 2-3 times higher
1. Dr. Rosenthal is a Medical Doctor graduated from the University of Buenos Aires. He completed fellowshipprograms on Internal Medicine and Infectious Diseases in Buenos Aires. He is a graduate in ClinicalEffectiveness, from Harvard University and the University of Buenos Aires; and obtained a certificate inInfection Control (IC) and Hospital Epidemiology from the Chilean Society of IC.Dr. Rosenthal is the founder and chairman of the International Nosocomial Infection Control Consortium(INICC), a nonprofit international research center which focuses on Healthcare-Associated Infectionscollaborating with more than 1000 researchers in more than 200 cities in 50 countries. He is the chairman ofan Infection Control and Hospital Epidemiology Course at the Medical College of Buenos Aires. He is aVisiting professor at University of Wisconsin, USA, and a speaker at several International Scientific Meetingsworldwide (Latin America, Asia, Africa, Europe and Oceania).He is Coauthor of JCI guidelines to prevent CLAB. He is a task force member and reviewer of the InfectionControl Guidelines for the World Health Organization (WHO), and an editorial board member and scientificreviewer of several international peer reviewed journals, such as “Lancet”, “American Journal of InfectionControl (AJIC)”; “Infection Control and Hospital Epidemiology” (ICHE); “Critical Care Medicine”; “EmergingInfectious Diseases (CDC)”; “Epidemiology and Infection”; and several others. He has advised thegovernments of Colombia and Mexico, and has collaborated with edition of the Infection Control Guidelines ofArgentina, Brazil, Colombia, Peru, Hong Kong, Taiwan.Being an author of more than 350 scientific publications, Dr. Rosenthal has received several awards grantedat different international scientific meetings, including APIC, IFIC, Pan American Meetings, and others.Dr. Victor Rosenthal’sSummarized CV:
2. “Epidemiology of HAI Internationally:Review of JCI Guidelines to Prevent CLAB,and INICC Impact on CLAB RatesDr. Victor D. Rosenthal, MD, MSC, CICINICC Founder and Chairmanvictor_rosenthal@inicc.org.Global IV SummitMinneapolis, USA.May 15-17 2013
3. Agenda1. Introduction:A. Device Associated Infections (DAI) rates of High Income CountriesB. DAI rates of Limited Resources CountriesC. INICC review of CLAB rates.D. WHO paper comparing DAI rates2. INICCA. Special situation of Developing CountriesB. Mission, Objectives, Countries Members3. INICC International ReportsA. International Annual Report of DAI RatesB. International Annual Report of Surgical Site Infections (SSI) RatesC. HAI complicationsA. Extra MortalityB. Extra Length of stayC. Extra Costs4. JCI CLAB Prevention Guidelines.5. INICC Hand Hygiene Program.6. INICC Program to reduce CLAB rates and Mortality.A. CLAB rate reduction in Argentina, Mexico, and Turkey.B. CLAB rate reduction in Adult ICUs worldwide.C. CLAB rate reduction in Paediatric ICUs worldwide.D. CLAB rate reduction in New-born ICUs worldwide.
8. Rosenthal, V. D. (2009). "Central line-associated bloodstream infections in limited-resource countries:a review of the literature." Clinical infectious diseases : an official publication of the InfectiousDiseases Society of America 49(12): 1899-1907.
9. Pooled cumulative incidence densities for CLABSI inadult ICU patients, In limited resources countries-Review of the literatureSource Country/CountriesStudy Period CLABSI per1,000 CL daysSystematic review ofthe literature (1)Limited resourcescountries1995-2010 12.21. Rosenthal, V. D. (2009). "Central line-associated bloodstream infections in limited-resourcecountries: a review of the literature." Clinical infectious diseases: an official publication of theInfectious Diseases Society of America 49(12): 1899-1907.
10. 10Three ways stop cock(open connector)Single use vials, usedmultiple timesPeripheral catheter with nosterile catheter dressingCentral line with no steriledressingMultiple use vials withinserted needlesCL insertion withoutmaximal barriers
14. List of 50 countries participating in INICCLatin America1. Argentina2. Bolivia3. Brazil4. Chile5. Colombia6. Costa Rica7. Cuba8. Dominican Republic9. Ecuador10. El Salvador11. Guatemala.12. México13. Panamá14. Peru15. Puerto Rico16. Venezuela17. UruguayEurope1. Bulgaria2. Czech Republic3. Greece4. Kosovo5. Lithuania6. Macedonia7. Poland8. Romania9. Serbia10. Slovakia11. Turkey12. UkraineAsia1. Bahrain2. China3. India4. Indonesia5. Jordan6. Lebanon7. Malaysia8. Mongolia9. Pakistan10. Philippines11. Singapore12. Sri Lanka13. Saudi Arabia14. Taiwan15. Thailand16. VietnamÁfrica1. Egypt2. Morocco3. Niger4. Tunisia5. Sudan
15. Four INICC Annual ReportsPublication year 2006Number of Countries 8Peer Review Journal Annals of InternalMedicine15200818American Journalof Infection Control201025American Journal ofInfection Control201236American Journal ofInfection Control
16. Rosenthal, V. D., H. Bijie, et al. (2012). "International Nosocomial Infection Control Consortium (INICC) report,data summary of 36 countries, for 2004-2009." American journal of infection control 40(5): 396-407.
17. INICC report – 36 countries- “2004 to 2009”.Period: January 2004 to December 2009 (6 years)Countries: 36 (Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba,Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosovo, Lebanon,Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru,Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sri Lanka, Sudan,Thailand, Tunisia, Turkey, Venezuela, Vietnam, Uruguay)ICUs: 422Patients: 313,008Bed days: 2,194,897Central Line days: 1,078,448Ventilator days: 796,847Urinary catheter days: 1,049,541BSI (n): 7,603VAP (n): 12,395CAUTI (n): 6,595Total IAD: 26,593Rosenthal, V. D., H. Bijie, et al. (2012). "InternationalNosocomial Infection Control Consortium (INICC) report,data summary of 36 countries, for 2004-2009." Americanjournal of infection control 40(5): 396-407
18. HAI rates INICC vs CDC-NHSN (USA)INICC2004–2009Pooled Mean (95% CI)U.S. NHSN2006-2008Pooled Mean (95% CI)Medical Cardiac ICUCLAB 6.2 (5.6 – 6.9) 2.0 (1.8 – 2.1)CAUTI 3.7 (3.2 – 4.3) 4.8 (4.6 – 5.1)VAP 10.8 (9.5 – 12.3) 2.1 (1.9 – 2.3)Medical-surgical ICUCLAB 6.8 (6.6 – 7.1) 1.5 (1.4 – 1.6)CAUTI 7.1 (6.9 – 7.4) 3.1 (3.0 – 3.3)VAP 18.4 (17.9 – 18.8) 1.9 (1.8 – 2.1)Pediatric ICUCLAB 4.6 (3.7 – 5.6) 3.0 (2.7 – 3.1)CAUTI 4.7 (4.1 – 5.5) 4.2 (3.8 – 4.7)VAP 6.5 (5.9 – 7.1) 1.8 (1.6 – 2.1)Newborn ICUCLAB 11.9 (10.2 – 13.9) 1.5 (1.2 – 1.9)VAP 10.1 (7.9 – 12.8) 0.8 (0.04 – 1.5)Rosenthal, V. D., H. Bijie, et al. (2012). "International Nosocomial Infection Control Consortium (INICC)report, data summary of 36 countries, for 2004-2009." American journal of infection control 40(5): 396-407
19. The burden of endemic health care-associated infection inlow- and middle-income countries
20. RESULTS:The collected data amounted to 260,973surgical procedures.Most of INICC SSI rates were 2 to 5 timesstatistically significantly higher in internationalhospitals than in USA (CDC) report, such as thefollowing:
21. AAA: Abdominal Aortic Aneurysm RepairAMP: Limb AmputationAPPY: AppendectomyBILI: Bile duct, liver or pancreatic surgeryCBGC: CABG-Chest onlyCARD: Cardiac surgeryCHOL: CholecystectomyCOLO: Colon SurgeryCRAN: CraniotomyCSEC: Cesarean sectionSSI rates: Comparing CDC-NHSN (USA) and International data (INICC)0.0%2.0%4.0%6.0%8.0%10.0%3.2%2.3%1.4%9.9%2.3% 2.9%1.3%0.6%5.6%2.6%1.8%7.7%2.7% 2.9%9.2%1.7%4.5%5.6%2.5%9.4%4.4%0.7%CDC-NNIS/NHSN INICC
22. FUSN: Spinal fusionFX: Open Reduction of FractureGAST: Gastric surgeryHER: HerniorrhaphyHPRO: Hip prosthesisHYST: Abdominal hysterectomyKPRO: Knee prosthesisLAM: LaminectomyNECK: Neck surgeryNEPH: Kidney surgerySSI rates: Comparing CDC-NHSN (USA) and International data (INICC)0.0%1.0%2.0%3.0%4.0%5.0%6.0%1.5% 1.7%2.3%2.3%1.3% 1.6%0.9% 1.0%3.5%1.5%3.2%4.2%5.5%1.8%2.6% 2.7%1.6% 1.7%3.7%3.1%CDC-NNIS/NHSN INICC
23. PRST: ProstatectomyPVBY: Peripheral vascularbypass surgeryREC: Rectal surgerySB: Small bowel surgerySPLE: Spleen surgeryTHOR: Thoracic surgeryTHYR: Thyroid and/or parathyroidsurgeryVHYS: Vaginal HysterectomyVSHN: Ventricular shuntXLAP: Exploratory abdominalsurgerySSI rates: Comparing CDC-NHSN (USA) and International data (INICC)0.0%2.0%4.0%6.0%8.0%10.0%12.0%14.0%1.2%6.7% 7.4%6.1%2.3%1.1%0.3% 0.9%5.6%2.0%2.1% 2.5%2.3%5.5% 5.6% 6.1%0.3%2.0%12.9%4.1%CDC-NNIS/NHSN INICC
24. EXTRA MORTALITY RATES in ADULT ICUsAmerican Journal of Infection Control, 2012.
25. Extra Length of Stay Rate of Central-LineAssociated Bloodstream InfectionAmerican Journal of Infection Control, 2012.
26. 27ExtraCostsandLengthof Stayof HAIs
27. 28The attributable cost, length of hospital stay, and mortality of centralline-associated BLOODSTREAM INFECTION in intensive caredepartments in Argentina: A prospective, matched analysis.Rosenthal VD, et al. Am J Infect Control 2003;31(8):475-80.
28. 29The attributable cost, length of hospital stay, and mortality of centralline-associated BLOODSTREAM INFECTION in intensive caredepartments in Argentina: A prospective, matched analysis.Case (N= 142) Control (N= 142) Extra ExpendituresTotal days 3,322 1,632 1690Average length of stay in ICU 23.39 (SE 1.49) 11.49 (SE 0.68) 11.90Total fixed cost $830,500 $408,000 $422,500Mean fixed cost $5,848 (SE 372.89) $2,873 (SE 171.07) $2,975Antibiotic utilizationTotal antibiotics (in DDD*) 4,568 1,356 3,212Mean antibiotic use per patient (DDD*)32.16 (SE 2.81) 9.54 (SE 1.05) 22.62Total cost of antibiotics $301,488 $29,832 $271,656Mean costs of antibiotics per patient $2,123 (SE 186.06) $210 (SE 23.09) $1,913Aggregate costs $1,131,988 $437,832 $694,156Mean aggregate costs per patient $7,971.74 $3,083.32 $4,888.42Average mortality 77/142 (54.2%) 42/142 (29.6%) 24.6%Rosenthal VD, et al. Am J Infect Control 2003;31(8):475-80.
29. 30BSI Controls Extra RR 95 % CI P-valueTotal patients (n) 70 140Total Antibiotic DDD, (DDD) 4243 2124Antibiotic DDD per patient, (DDD) 60.61 15.17 45.44Total Antibiotic cost (US$) 312,225.54 99,930.12Antibiotic cost per patient, (US$) 4,460.36 713.78 3,746.58Length of Stay (days) 30.58 + 20.41 6.95 + 4.89 23.6 4.40 4.08 – 4.75 0.0000Cost (US$) 9,843.35 1,937.18 7,906Total deaths (n) 23 45Crude mortality (%) 32.9% 32.1% 1.02 0.62 – 1.69 0.9316The Attributable Cost, And Length Of Hospital Stay Of Central LineAssociated BLOOD STREAM INFECTION In Intensive Care Units InBrazil. A Prospective, Matched AnalysisReinaldo Salomao, Victor D. Rosenthal, et al. APIC Meeting. Tampa, USA. June 2006.
30. 31The Attributable Cost, And Length Of Hospital Stay Of Central LineAssociated BLOOD STREAM INFECTION In Intensive Care Units InMexico. A Prospective, Matched Analysis.Control(N= 55)Case(N= 55)OverallAttributableExtraExpendituresAttributableExtraExpendituresper patientAverage length of stay in ICU(days)406 739 333 6.05Antibiotics (US$) 13,354.35 46,265.96 32,911.61 598.39Other medicaments (US$) 128,415.14 129,832.44 1,417.30 25.77Disposables (US$) 219,345.82 308,808.79 89,462.97 1,626.60Cultures (US$) 1,171.40 2,111.85 940.45 17.10Other lab tests (US$) 37,441.19 61,174.01 23,732.82 431.51X ray, Scan, etc (US$) 15,198.40 19,556.44 4,358.04 79.24Other costs (US$) 44,395.46 71,105.56 26,710.09 485.64Hospitalization (fixed costs)(US$)496,326.78 954,294.33 457,967.55 8326.68Total cost (US$) 955,648.55 1,593,149.38 637,500.83 11,590.92Higuera F, Rangel-Frausto M, Rosenthal VD, Graves N, et al.Infection Control and Hospital Epidemiology. January 2007. In Press
31. Pediatr Crit Care Med 2012 Vol. 13, No. 4
32. World Bank classification of Countries Economic Strata.According to 2011 gross national income (GNI) per capita.The World Bank classifies countries into four economic strata according to 2011gross national income (GNI) per capita.These groups are:• low income, $1,025 or less;• lower middle income, $1,026–4,035;• upper middle income, $4,036–12,475;• high income, $12,476 or more.• These economies represent 144 of 209 countries of the world (68.8%) andmore than 75% of the world population.There is very limited information regarding association between socio economiclevel of the country (Low income, mid low income, and mid high income) and DAIrates, as well as association between type of hospital (Public, Academic, andPrivate) and DAI rates.The goal of this study is to show DAIs rates stratified by socio economic level ofthe country and type of hospital and to find statistical associations among them.
33. 19.17.0 7.60510152025Low income Mid-low Mid-highCLAB per 1,000 CL daysCLAB Rates Stratified Socio-Economic Level95%CI 18.06-20.1 6.5-7.5 7.3-7.8Rosenthal VD, et al. INICC data. SHEA Meeting. Atlanta, USA, March 2010
34. 10 9.25.802468101214Academic Public PrivateCLAB per 1,000 CL daysCLAB Rates Stratified By Hospital Type95%CI 9.6-10.3 8.6-9.9 5.4-6.3Rosenthal VD, et al. INICC data. SHEA Meeting. Atlanta, USA, March 2010
35. http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
36. This monograph was authored by The Joint Commission,Joint Commission Resources, and Joint CommissionInternational. They partnered with infection preventionleaders from the following organizations:Association for Professionals in Infection Control andEpidemiology (APIC)Association for Vascular Access (AVA)Infectious Diseases Society of America (IDSA)International Nosocomial Infection Control Consortium(INICC)National Institutes of Health (NIH)Society for Healthcare Epidemiology of America (SHEA)http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
37. Technical Advisory PanelAnucha Apisarnthanarak, MD• Associate Professor, Thammasat University Hospital,Thailand International Representative, ThailandHanan Balkhy, MD, MMed, FAAP, CIC• Director, WHO Collaborating Centre and GCC Centrefor Infection Control Associate Professor and ExecutiveDirector, Infection Prevention and Control Departmentat King Saud Bin Abdulaziz University for HealthSciences, Kingdom of Saudi Arabia InternationalRepresentative, Saudi ArabiaLillian Burns, MT, MPH, CIC• Administrative Director, Infection Control/Epidemiology,Staten Island University Hospital, New YorkRepresentative, Association for Professionals inInfection Control and Epidemiology, USAAmani El Kholy, MD, PhD• Professor of Clinical Pathology, Faculty of Medicine,Cairo University Director of Microbiology Laboratory,Cairo University Hospitals Member of SupremeCommittee for Infection Prevention and Control inUniversity Hospital Director of Microbiology Laboratoryand Infection Prevention and Control, Dar Al FouadHospital International Representative, EgyptLynelle Foster RN, MN, FRCNA• Clinical Nurse Consultant, Infusion Therapy, GoldCoast Health Service District, Australia InternationalRepresentative, AustraliaLeonard Mermel, DO, ScM, AM (Hon), FSHEA, FIDSA,FACP• Professor of Medicine, Warren Alpert Medical Schoolof Brown University Medical Director, Department ofEpidemiology and Infection Control, Rhode IslandHospital Representative, Society for HealthcareEpidemiology of America and the Infectious DiseasesSociety of America, USANaomi P. O’Grady, MD• Staff Clinician and Medical Director, Procedures,Vascular Access, and Conscious Sedation ServicesRepresentative, National Institutes of Health, Maryland,USAVictor D. Rosenthal, MD, CIC, MSc• Founder and Chairman, International NosocomialInfection Control Consortium (INICC) Chairman andProfessor of Infection Control Post Graduate Course ofMedical College of Buenos Aires, Argentina Task ForceMember of First Global Patient Safety Challenge(―Clean Care Is Safer Care‖) of World HealthOrganization Editorial Board Member of AmericanJournal of Infection Control ArgentinaMarcia Ryder PhD, MS, RN• Ryder Science, Medical Biofilm Research, CaliforniaRepresentative, Association for Vascular Access, USAPatricia W. Stone, PhD, RN, FAAN• Centennial Professor in Health Policy Director of theCenter for Health Policy Director of the PhD ProgramColumbia University, School of Nursing, New York,USAWalter Zingg, MD• Infection Control Program, University of GenevaHospitals, Switzerland International Representative,Geneva, Switzerland
38. CLABSI Prevention Strategies, Techniques, and Technologies1. Education and Training of Health CarePersonnel2. Hand Hygiene3. Aseptic Technique4. CVC Insertion Preparationa. Maximal Sterile Barrier Precautionsb. Skin Preparationc. Catheter Selection• Number of Lumens• Antimicrobial- or Antiseptic-Impregnated Cathetersd. Use of Catheter Kits or Carts5. CVC Insertiona. Insertion Under Ultrasound Guidanceb. Catheter Site Dressing Regimensc. Securement Devicesd. Use of a CVC Insertion Bundle6. CVC Maintenancea. Prophylactic Antibiotic Lock Solutions,Antimicrobial Flush Solutions, and CatheterLock Solutionsb. Disinfection of Catheter Hubs, Connectors,and Injection Ports Needle les connectorsc. Chlorhexidine Bathingd. Use of a CVC Maintenance Bundle7. Removal or Replacement of Catheters orSystem Componentsa. Changing Administration SystemComponentsb. CVC Exchanges over a Guidewire8. Tools and Techniquesa. Checklistsb. Vascular Access Teamsc. Safe Practices for Parenteral Fluid andMedication Administration and Vial Accesshttp://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
39. Education and Training of HealthCare PersonnelThe appropriate indications for CVC insertion:• Administration of medications, such as chemotherapy or antibiotics• Administration of fluids, including blood or blood products• Monitoring of central venous pressure• Providing parenteral nutrition• Providing hemodialysishttp://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
40. Education, Training and Staffing4.222.9400.511.522.533.544.5Baseline EducationCLAB per1000 CL…Pérez Parra A, Cruz Menárguez M, Pérez Granda MJ, TomeyMJ, Padilla B, Bouza E. A simple educational intervention todecrease incidence of central line–associated bloodstreaminfection (CLABSI) in intensive care units with low baselineincidence of CLABSI. Infect Control Hosp Epidemiol. 2010Sep;31(9):964–9188.8.131.5223456Baseline Self ModulesCLAB per1000 CL…Warren DK, et al. An educational intervention to preventcatheter- associated bloodstream infections in anonteaching, community medical center. Crit Care Med. 2003Jul;31(7):1959–1963.Strattegy: 15-minute lecture for all ICU HCW; 10 ofthe evidence-based strategies in the CDC GuidlinesStrategy: Self-studymodules, education, along with lecturesand posters
41. Hand HygieneHand hygiene is a key component of any effective patientsafety and infection prevention program.Hand hygiene is generally accepted as the single mostimportant measure in preventing the spread of infection.Both soap and water and alcohol-based hand rub productscan be used to achieve proper hand hygiene.- Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association forProfessionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene In Health-CareSettings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene TaskForce. Infect Control Hosp Epidemiol. 2002 Dec;23(12 Suppl):S3–40.- World Health Organization: WHO Guidelines on Hand Hygiene in Health Care. 2009. Accessed Mar 18, 2012. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf.- Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on theincidence of catheter-related bloodstream infections. Crit Care Med. 2009 Jul;37(7):2167–2173; quiz 2180.- Haas JP. Hand Hygiene. In Carrico R, editor: APIC Text of Infection Control and Epidemiology, 3rd ed. Washington, DC: Association for Professionalsin Infection Control and Epidemiology, 2009, 19.1–19.6.- Pessoa-Silva CL, Hugonnet S, Pfister R, Touveneau S, Dharan S, Posfay-Barbe K, Pittet D. Reduction of health care associated infection risk inneonates by successful hand hygiene promotion. Pediatrics. 2007 Aug;120(2):e382–390.- The Joint Commission. Measuring Hand Hygiene Adherence: Overcoming the Challenges. Oak Brook, IL: Joint Commission Resources, 2009.- Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital inArgentina. Am J Infect Control. 2005 Sep;33(7):392–397.
42. Aseptic TechniqueAseptic technique is a method used to prevent contamination withmicroorganisms.Aseptic technique is applicable in all health care settings whereproviders perform surgery or other invasive procedures, includingthe insertion of CVCs or urinary catheters.Aseptic technique is recommended by the evidence-basedguidelines for all instances of CVC insertion and care.In aseptic technique, only sterile-to-sterile contact is allowed;sterile-to-nonsterile contact must be avoided.- Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter- related infection with pulmonary arterySwan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 1991; 91:197S–205.- Abi-Said D, Raad I, Umphrey J, et al. Infusion therapy team and dressing changes of central venous catheters. Infect Control Hosp Epidemiol1999; 20:101–5.- Capdevila JA, Segarra A, Pahissa A. Catheter-related bacteremia in patients undergoing hemodialysis. Ann Intern Med 1998; 128:600.- Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautionsduring insertion. Infect Control Hosp Epidemiol 1994; 15:231–8.
43. CVC Insertion Preparation:Maximal Sterile Barrier PrecautionsMaximal sterile barrier (MSB)precautions require:• The CVC inserter to wear• Mask,• cap,• sterile gown,• sterile gloves.• to use a large (head-to-toe) steriledrape over the patient during theplacement of a CVC or exchange ofa catheter over a guidewire.Several studies have demonstrated the benefit, either alone or as part ofmultimodal CLABSI prevention strategies, of using MSB precautionsduring CVC placement to reduce the risk of CLABSIs
44. CVC Insertion Preparation:Maximal Sterile Barrier Precautions3.50.600.511.522.533.54Control MSB% ofCLABRaad, II, D. C. Hohn, et al. (1994). "Prevention of centralvenous catheter-related infections by using maximal sterilebarrier precautions during insertion." Infection control andhospital epidemiology : 15(4 Pt 1): 231-238.4.512.9200.511.522.533.544.55Baseline MaximalBarriersCLABper…Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, StreedSA, Kiger B, Flynn L, Hayes S, Strong S, Cruz J, BowtonDL, Hulgan T, Haponik EF. Education of physicians-in-trainingcan decrease the risk for vascular catheter infection. Ann InternMed. 2000 Apr 18;132(8):641–648.Strattegy: Maximal Steriel Barrier Precautions Strategy: Standardize CL insertion with MSBprecautions, educational program for first postgraduateyear
45. CVC Insertion Preparation:Skin PreparationReducing colonization at the insertion site is a critical component of CLABSI prevention.A number of studies have shown that chlorhexidine gluconate preparations are superior to bothiodophors and alcohol for skin antisepsis.The following summarizes current recommendations forskin antisepsis prior to CVC insertion and during dressingchanges:• Apply antiseptics to clean skin.• Apply chlorhexidine/alcohol in a concentration of at least0.5% in alcohol.• If there is a contraindication to chlorhexidine;iodophor, or alcohol as an alternative.• Allow the antiseptic solution to dry before placing thecatheter.
46. CVC Insertion Preparation:Skin Preparation
47. CVC Insertion Preparation:Skin Preparation
48. CVC Insertion Preparation:Catheter Selection: Number of LumensEvidence-based guidelines recommend that a CVC with the minimum number oflumens necessary for the management of the patient be used.
49. CVC Insertion Preparation:Catheter Selection: Number of Lumens21%14%0%5%10%15%20%25%Doble Lumen Single LumenCLremovedue CLABEarly TF, Gregory RT, Wheeler JR, Snyder SO Jr., Gayle RG. Increased infection rate in double-lumen versus single-lumen Hickman catheters in cancer patients. South Med J 1990; 83:34–6.2.010.8200.511.522.5Doble Lumen Single LumenCLAB per1000 CL…Strattegy: Doble Lumen vs Single Lumen
50. CVC Insertion Preparation:Catheter Selection:Antimicrobial- or Antiseptic-Impregnated CathetersEvidence-based guidelines support the use of antimicrobial- or antiseptic-impregnated catheters if CLABSI rates are not decreasing after theimplementation of a comprehensive strategy to reduce thoserates.Such a comprehensive strategy should include, at a minimum, the following:Educating health care personnel who insert and maintain CVCs.Using maximal sterile barrier precautions.Using a greater than 0.5% chlorhexidine preparation with alcohol for skinpreparation prior to CVC insertion.Should CLABSI rates not be reduced with the aforementioned strategies,evidence-based guidelines recommend the use of chlorhexidine/silversulfadiazine or minocycline/rifampin- impregnated CVCs for use inpatients expected to have a CVC in place for an extended period of time,though the suggested time frame varies—from ―more than 5 days‖ to ―from 1to 3 weeks.‖
51. CVC Insertion Preparation:Use of Catheter Kits or CartsHaving standardized supply carts or kits with all the necessary CVCinsertion and care supplies and equipment in ―ready to go‖ locationsIt is essential that the carts or kits are always stocked and readilyaccessible.Carts and kits must contain all supplies recommended by evidence- basedpractices—for example:• chlorhexidine for skin antisepsis;• cap, mask, and sterile gloves for inserters and those assisting with theprocedure• a large sterile drape for insertion procedures (rather than a small drape);http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
52. CVC Insertion: Catheter site selectionData derived from several observational studies of CVC insertions suggest that the greatestrisk of infection in adults is associated with use of the femoral vein as the insertion site, andthe lowest risk is associated with subclavian site insertions, with an intermediate level of riskassociated with internal jugular vein insertions for nontunneled CVCs• Avoid using the femoral site for CVC access in adult patients.
53. CVC Insertion: Catheter site selection54.04.8 4.70.010.020.030.040.050.060.0Colonizationper 1000 daysGoetz, A. M., M. M. Wagener, et al. (1998). "Risk of infection due to central venous catheters: effect of site of placementand catheter type." Infection Control & Hospital Epidemiology 19(11): 842-8184.108.40.206.6024681012CLAB per1000 CL…ColonizationStrattegy: Femoral vs Jugular, vs SubclavianCLABThere was a trend for associationwith femoral location by Coxregression (hazard, 4.7;CI95, 0.82-26; P=.08).
54. CVC Insertion:Catheter Site Dressing RegimensA clean and dry dressing at the insertion site isimportant to protect the site and to minimize the riskof infection.There are generally two types of dressings that canbe used to cover and protect the insertion site:• sterile gauze and tape• sterile, semipermeable ―transparent‖ polyurethanedressings.Studies have shown no clinically differences in sitecolonization or CLABSI rates between them.Transparent dressings permit continuous visualinspection of the insertion site, help to secure thedevice, and do not need to be changed as often asgauze and tape dressings.
55. Chlorhexidine impregnated DressingsChlorhexidine-impregnated dressings have been usedto reduce the risk of CLABSI.Trials showed that patients in the chlorhexidine-impregnated dressing group had significantly fewerCLABSIs than those in the group randomized to astandard dressing.
56. Chlorhexidine impregnated dressingTimsit JF, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-relatedinfections in critically ill adults: A randomized controlled trial. JAMA. 2009 Mar 25;301(12):1231–1241.1.30.400.20.40.60.811.21.4Control Sponge withCHGCLAB per1000 CL daysStrattegy: Chlorhexidine impregnated sponge
57. Chlorhexidine BathingRecently the innovative practice of bathing patientswho have CVCs with chlorhexidine as a total-bodybathing solution has been studied as a strategy tolower CLABSI rates.The rationale for the use of chlorhexidine bathing inplace of soap and water bathing relates to the patient’sresident skin flora that can enter the bloodstream at theCVC insertion site or the extraluminal surface of thecatheter.Reducing skin contaminants should further reduce therisk of CLABSI.
58. Chlorhexidine BathingDixon JM, Carver RL. Daily chlorhexidine gluconate bathing with impregnated cloths results in statistically significantreduction in central line–associated bloodstream infections. Am J Infect Control. 2010 Dec;38:817–8220.127.116.11468101214Bath ControlCLAB per1000 CL daysStrattegy: Chlorhexidine impregnated sponge
59. CVC Maintenance:Disinfection of catheter hubs, connectors, and injectionportsThe external surface of a catheter hub, connector, orinjection port is the immediate portal of entry ofmicroorganisms to the intraluminal surface of thecatheter.The colonizing microorganisms form within theneedleless connector, catheter hub, and lumen andcan be dispersed into the bloodstream, resulting inCLABSI.It is critical, therefore, that these surfaces bethoroughly disinfected before they are accessed.http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
60. CVC Maintenance:Disinfection of catheter hubs, connectors, and injectionports• ―Three Ways Stopcocks‖ should be ―avoided‖,as they represent a potential portal of entry formicroorganisms into vascular access cathetersand IV fluids.• Closed catheter access systems are associatedwith fewer infections than open systems andshould be used preferentiallyhttp://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
61. CVC Maintenance:Needleless Intravascular Catheter SystemsWhen needleless systems are used,a ―Split Septum‖ may be preferred over‖Mechanical Valves‖due to increased risk of infection with themechanical valves [1-4]. Category II1. Rupp ME, Sholtz LA, Jourdan DR, et al. Outbreak of bloodstream infection temporally associated withthe use of an intravascular needleless valve. Clin Infect Dis 2007; 44:1408–14.2. Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Increased rate of catheter-related bloodstreaminfection associated with use of a needleless mechanical valve device at a long-term acute carehospital. Infect Control Hosp Epidemiol 2007; 28:684–8.3. Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates afterthe introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol2006; 27:67–70.4. Field K, McFarlane C, Cheng AC, et al. Incidence of catheter-related bloodstream infection amongpatients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit. Infect Control Hosp Epidemiol 2007; 28:610–3.
62. Background:Needleless Intravascular Catheter Systems:Split Septum vs Mechanical Valve10.433.870.002.004.006.008.0010.0012.00MechanicalValveSplit SeptumCLABRate• Rupp M et al. CID 2007;44:1408-14• Kathryn Field, MBBS et al. Infection Control and Hospital Epidemiology, May 2007, Vol. 28, No 5Strattegy: Split Septum against Mechanical Valve5.802.600.001.002.003.004.005.006.007.00MechanicalValveSplit SeptumCLABRate
63. Single Use Prefilled Flush Syringe• INS:• Flushing is an important element of intermittentI.V .therapy. Flushing with preservative-free 0.9 %sodium chloride (USP) or other flush solutionsshall be performed before and after theadministration of incompatible medications andsolutions• Single-use flushing systems shall be used.* CDC: Based on recent HCV outbreak,* CDC ―strongly encourages‖ use of pre-fills orsingle dose vials.* JCAHO: Sentinel Events Alert identifies* ― single-use IV flush vials‖ as important strategy toreduce the risk of nosocomial infections.4- Infusion Nurse Society Standard. 20115- CDC6- JCAHO Sentinel events
64. Background:Manually Filled Syringe vsPre-Filled Syringe6.302.700.001.002.003.004.005.006.007.00Manually filledsyringePre FilledSyringesCLABRate(%)Bertoglio et al. Pre-filled normal saline syringes to reduce totally implantable venous access device-associated bloodstream infection: a single institution pilot study. Journal of Hospital Infection 2013, in PressStrattegy: Manually filled syringe vs Pre-filled syringe0.370.240.000.050.18.104.22.168.300.350.40Manually filledsyringePre FilledSyringesCLABper1000CL…P value: 0.01
65. Open vs Closed Infusion IV Container
66. Meta Analysis–CLABSI per 1000 CL DaysFor CLABSI per 1000 CL days, both the pooled (P<.001) and all four individual by-country analysesfavored the closed infusion container. All of the analyses achieved statistical significance.Maki DG, Rosenthal VD, et al. Infection Control and Hospital Epidemiology (ICHE) 2010, in press
67. Removal or Replacement of Catheters or System Components:Daily review of line necessityRisk of CLABSI increases with the duration oftime the catheter is left in place,So daily evaluation of the continued need for acatheter is an important aspect of CLABSIprevention; catheters that are no longer neededshould be promptly removed.
68. Removal or Replacement of Catheters or System Components:Changing administration system components• The administration system, which includes the primaryand any secondary sets and add- on devices, bechanged on a regular basis.• The most appropriate interval for routine replacementof IV administration sets is every 96 hours.• For fat emulsions, nutrition, and blood products, tubingand add-on devices should be changed within 24hours.
69. Tools and Techniques:Vascular access teamsStudies have shown that the use of IV teams, consisting oftrained nurses or technicians who use strict aseptic techniqueduring catheter insertion and follow-up care, can reduce therisk of phlebitis, bloodstream infections, and costs.Few studies have been performed regarding the specificimpact of such teams on CLABSI rates, categorizing the useof IV teams as an unresolved issue.http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
70. CVC Insertion:Use of a CVC insertion bundleBundles facilitate the use of evidence-basedpractices, and their use is recommended inCLABSI guidelinesStudies have shown that can lead to significant,sustained reductions in CLABSI rates.The Institute for Healthcare Improvement (IHI)describes a ―bundle‖ as ―group of best practicesthat individually improve care, but when appliedtogether result in substantially greaterimprovement.‖http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
71. CVC Insertion:Use of a CVC insertion bundle7.71.40123456789Baseline BundleCLAB per1000 Cl…Pronovost, P., D. Needham, et al. (2006). "An intervention todecrease catheter-related bloodstream infections in the ICU."The New England journal of medicine 355(26): 2725-2722.214.171.1244681012Baseline BundleCLAB per1000 CL…Rosenthal, V. D., B. Ramachandran, et al. (2012). "Impact of amultidimensional infection control strategy on central line-associatedbloodstream infection rates in pediatric intensive care units of fivedeveloping countries: findings of the International Nosocomial InfectionControl Consortium (INICC)." Infection 40(4): 415-423.INICC PICUs of 5 CountriesStrattegy: Bundle Strategy: Bundle
72. Tools and Techniques: ChecklistsA checklist is a list of criteria or action items that are arranged in asystematic order.Standardized CVC checklists reflect the elements based on evidence-based practices, included in the bundle and serve to remind health carepersonnel of key steps and procedures that need to be done with eachCVC insertion or maintenance episode that can help prevent CLABSI,thereby reducing ambiguity about what should be done.Using a checklist requires at least two staff members: the inserter, whoperforms the procedure, and the observer, who records the informationon the checklist.http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
75. The INICC HAI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Feedback of HAI rates,5- Process surveillance,6- Performance feedback of infection controlpractices
76. EducationMonthly sessions of educationprovided by ICP to the HCWs incharge of the insertion, care, andmaintenance of CLs for HAI preventionbased on CDC, WHO APIC, SHEA,and IDSA guidelines to prevent HAI.
77. Outcome SurveillanceOutcome Surveillance included rates of HAI per 1000 device-days,use of invasive devices (CL, mechanical ventilator, and urinarycatheter), severity illness score, underlying diseases, use ofantibiotics, culture taken, microorganism profile, bacterial resistance,length of stay, mortality in their ICUs.HAI definitions and surveillance methods were performed applyingthe definitions for healthcare-associated infection (HAI) developed bythe U.S. Centers for Disease Control and Prevention (CDC) for theNational Healthcare Safety Network (NHSN) program.Additionally, INICC methods were adapted to the limited-resourcesetting of developing countries, due to their different socioeconomicstatus.ASIS score was used instead of APACHE II score due to budgetlimitations of participating ICUs from this limited-resource country.Thus, we decided to use ASIS score, as historically used by the CDCNNIS .
78. Process SurveillanceProcess surveillance was designed toassess compliance with easilymeasurable key infection controlpractices, such as surveillance ofcompliance rates for hand hygienepractices and specific measures for theprevention of HAI.
79. Process Surveillance of HHHand hygiene (HH) compliance rate was based on thefrequency with which HH was performed as indicated inHCWs infection control training. Observing ICPs weretrained to record HH opportunities and compliance on aform, during randomly selected observation periods of 30minutes to 1 hour, 3 times a week. In particular, the INICCdirect observation comprised the ―Five Moments for HandHygiene‖ as recommended by the World HealthOrganization (WHO). The ―Five Moments‖ included themonitoring of the following moments: (1) before patientcontact, (2) before an aseptic task, (3) after body fluidexposure risk, (4) after patient contact, and (5) after contactwith patient surroundings.Although HCWs knew that handhygiene practices were regularly monitored, they were notinformed of the schedule for HH observations.
80. Feedback of DA-HAI ratesUpon processing the hospitals’ outcome surveillance data on amonthly basis, the INICC Research Team, at INICC Headquarterslocated in Buenos Aires, prepares and sends to each ICT a finalreport on the results of outcome surveillance rates; that is, monthlyDA-HAI rates, length of stay, bacterial profile and resistance, andmortality.Feedback of DA-HAI rates is provided to HCWs working in the AICUby communicating the outcomes of the patients.The resulting rates are reviewed by the ICT at monthly meetings,where charts are analyzed, and statistical graphs and visuals areposted inside the ICU, to provide an overview of rates of DA-HAIs.This infection control tool is key to increase awareness aboutoutcomes of patients at their ICU, enable the ICT and ICU staff tofocus on the necessary issues and apply specific strategies forimprovement of high DA-HAI rates.
81. Performance FeedbackUpon processing the hospitals’ process surveillance data on amonthly basis, the INICC Research Team, at INICCHeadquarters located in Buenos Aires, prepares and sends toeach ICT a final report on the results of process surveillancerates, including compliance with hand hygiene, and care of CL.Performance feedback is provided to HCWs working in the AICUby communicating the assessment of practices routinelyperformed by them.The resulting rates are reviewed by the ICT at monthly meetings,where charts are analyzed, and statistical graphs and visuals areposted inside the ICU, to provide an overview of rates measuringcompliance with infection control practices.This infection control tool is key to enable the ICT and ICU staff tofocus on the necessary strategies for improvement of lowcompliance rates.
82. Statistical MethodsPatients’ characteristics during baseline and duringintervention period in each ICU were comparedusing Fishers exact test for dichotomous variablesand unmatched Students t-test for continuousvariables. Confidence intervals (CI) of 95% werecalculated using VCStat (Castiglia). Relative risk(RR) ratios with 95% confidence intervals (CI) werecalculated for comparisons of rates of HAI usingEPI Info V6. P-values <0.05 by two-sided testswere considered significant.
83. Statistical MethodsIn order to analyze progressive HAI rate reduction, we used Poissonregression.We divided the data into the first three months (baseline period),followed by a nine-month period (intervention period), and annualfollow-up periods for the following years.We compared the HAI rates for each follow-up period with the baselineHAI rate.For this comparison, we used as baseline data only those hospitals thatcontributed to follow-up in that period (i.e. excluding from the baselinehospitals with long lengths of follow-up that only contributed a shorterlength of surveillance).We used random effects Poisson regression to account for clustering ofCLAB rates within hospitals across time periods.These models were estimated using Stata 11.0. For this analysis weused IRR, 95% CI, and P value.
84. Infection Control and Hospital Epidemiology.April 2013METHODS:INICC Multidimensional HH Approach include:1- administrative support,2- supplies availability,3- education and training,4- reminders in the workplace,5- process surveillance and6- performance feedback.Observations were done for HH compliance in each ICU,during randomly selected 30-minute periods.
87. Characteristics of the Participating Hospitals(from April 1999 to December 2012).ICUs, n Number of observationsCountryArgentina 11 21998Brazil 4 4837China 5 2079Colombia 11 13512Costa Rica 1 303Cuba 1 434Greece 1 2315El Salvador 3 1691India 18 32869Lebanon 1 1728Lithuania 1 1565Macedonia 1 3418Mexico 10 13201Pakistan 3 1830Panama 1 551Peru 5 6610Philippines 9 17844Poland 1 102Turkey 12 22840All countries 99 149,727Type of ICU, nAdult 80 (81%) 131882Pediatric 9 (9%) 9081New Born 10 (10%) 8764All ICUs 99 (100%) 149,727Type of hospital, n (%)Academic Teaching 27 (42%) 50515Public Hospital 16 (25%) 40530Private Community 22 (34%) 58682All hospitals 65 (100%) 149,727
88. Hand Hygiene Compliance by Type of Variable.Logistic Regression, Multivariate AnalysisVariable Adjusted OR 95% CI P. valueGender (baseline: Female) 1.0Male 0.91 0.89 – 0.93 < 0.001Type of professional (baseline: nurses) 1.0Physicians 0.68 0.66 – 0.70 < 0.001Ancillary Staff 0.52 0.51 – 0.54 < 0.001Type of contact (baseline: invasive) 1.0Non-invasive 0.95 0.93 – 0.98 < 0.001Type of ICU (baseline: New Born) 1.0Adult ICU 0.49 0.47 – 0.52 < 0.001Pediatric ICU 0.58 0.54 – 0.62 < 0.001Work Shift (baseline: Night) 1.0Afternoon 0.79 0.76 – 0.81 < 0.001Morning 0.83 0.81 – 0.86 < 0.001Womenbetter thanmen: 9%Nurses better thanDoctors: 32%Invasive better thanNon Invasive: 5%Neonatal better thanAdult ICU: 51%Night better thanMorning: 17%
89. Table 5. Hand Hygiene Improvement by Year of ParticipationYears since joining INICC HHobservationsNumber ofICUs IncludedHH % (95% CI) Adjusted ORFirst 3 months (baseline) 11267 99 48.3% (47.6 – 49.0) 1.0Second 3 months 7214 99 61.2% (60.5 – 61.9) 1.72 (1.65 – 1.81)Third 3 months 5511 89 67.2% (66.4 – 67.8) 2.10 (1.99 – 2.2)Fourth 3 months 4639 81 69.4% (68.6 – 70.1) 2.21 (2.10 – 2.33)2nd year 8190 69 71.4% (70.9 – 71.9) 3.07 (2.92 – 3.23)3rd year 5573 45 69.1% (68.4 – 69.7) 3.03 (2.84 – 3.22)4th and 5th year 4278 32 81.2% (80.1 – 81.6) 3.3 (3.07 – 3.52)6th and 7th year 1120 15 86.0% (85.2 – 86.8) 2.87 (2.57 – 3.19)Infection Control and Hospital Epidemiology. April 2013
90. Reducing CLAB rate inICUs of Argentina
91. Characteristics of Patients in both Periods
92. Process Surveillance
93. Rates of CLABRosenthal, V. D., S. Guzman, et al. (2003). "Effect of an infection control program using education andperformance feedback on rates of intravascular device-associated bloodstream infections in intensive careunits in Argentina." American Journal of Infection Control 31(7): 405-409.BSIs per 1000IVD-daysRR P- valuePhase 1 45.94 (56/1219)Phase 2 17.06 (10/586) 0.37** <0.001Phase 3 9.90 (41/4140) 0.58*** 0.11
94. Reducing CLAB rate andMortality rate in ICUs inMexico
95. Higuera, F., V. D. Rosenthal, et al. (2005). "The effect ofprocess control on the incidence of central venouscatheter-associated bloodstream infections andmortality in intensive care units in Mexico." Critical CareMedicine 33(9): 2022-2027.
96. Characteristics of Patients in both Periods
97. Process Surveillance
98. Rates of intravascular device-associatedbloodstream infection and mortalityPhase 1 Phase 2 RR (P value)BSI (n) 28 55IVD days (n) 605 2,824BSI per 1000 IVD days 46.3 19.5 0.42 (p 0.001)Total patients (n= 470) 132 338Total deaths (n=175) 64 111Crude mortality 48.5% 32.8% 0.68 (p 0.0001)Higuera, F., V. D. Rosenthal, et al. (2005). "The effect of process control on the incidence of centralvenous catheter-associated bloodstream infections and mortality in intensive care units in Mexico."Critical Care Medicine 33(9): 2022-2027.
99. Reducing CLAB rate inTurkey
100. Impact of a Multidimensional Infection Control Approach onCentral Line-Associated Bloodstream Infections Rates in AdultIntensive Care Units of 8 Cities of Turkey: Findings of theInternational Nosocomial Infection Control Consortium (INICC)Hakan Leblebicioglu,1 Recep Öztürk,2 Victor Daniel Rosenthal,3 ÖzayArıkan Akan,4 Fatma Sirmatel,5 Davut Ozdemir,6 Cengiz Uzun,7Huseyin Turgut,8 Gulden Ersoz,9 Iftíhar Koksal,10 Asu Özgültekin,11Saban Esen, 1 Fatma Ulger,1 Ahmet Dilek,1 Hava Yilmaz,1 YalimDikmen,2 Gökhan Aygún,2 Melek Tulunay,4 Mehmet Oral,4 NecmettinÜnal,4 Mustafa Cengiz,5 Leyla Yilmaz,5 Mehmet Faruk Geyik,6 AhmetŞahin,6 Selvi Erdogan,6 Suzan Sacar,8 Hülya Sungurtekin,8 DoğaçUğurcan,8 Ali Kaya,9 Necdet Kuyucu,9 Gürdal Yýlmaz,10 SelçukKaya,10 Hülya Ulusoy,10 Asuman İnan.11ACMA 2013, Accepted and In press
101. Characteristics of Patients in the Baseline Period and Intervention PeriodPatients’ CharacteristicsBaseline Intervention RR* 95% CI P- ValueStudy period by hospital in months,mean ± SD (range)3 15.6 ± 9.2 (4 – 36)Number of Patients 560 3457*Bed days, n 5517 37232**No. of CL days, n 3129 23463***CL use, mean 0.57 0.63 1.1 1.07 – 1.15 0.0001CL duration, mean ± SD 5.6 ± 9.0 6.8 ± 11.0 - - 0.014Age, mean ± SD 54.1 ± 22.0 52.3 ± 21.4 - - 0.08ASIS score, mean ± SD 3.2 ± 1.1 3.6 ± 1.14 - - 0.0001Male 305 (57%) 2,048 (60%) 1.05 0.91 – 1.21 0.5Female 230 (43%) 1379 (40%) - - -Abdominal Surgery, n (%) 58 (10%) 349 (10%) 0.97 0.74 – 1.3 0.84Cardiac Surgery, n (%) 11 (2%) 72 (2%) 1.1 0.56 – 2.22 0.9Trauma, n (%) 58 (10%) 357 (10%) 0.99 0.75 – 1.34 0.97Previous Infections, n (%) 81 (14%) 415 (12%) 0.83 0.653 – 1.1 0.13Endocrine diseases, n (%) 43 (8%) 250 (7%) 0.94 0.68 – 1.33 0.7Chronic Obstructive, n (%) 150 (27%) 904 (26%) 0.98 0.82 – 1.17 0.8Renal Impairment, n (%) 33 (6%) 180 (5%) 0.9 0.61 – 1.3 0.5Hepatic Failure, n (%) 13 (2%) 50 (1%) 0.62 0.33 – 1.25 0.14Thoracic Surgery, n (%) 27 (5%) 151 (4%) 0.91 0.6 – 1.42 0.62Stroke, n (%) 14 (3%) 64 (2%) 0.74 0.4 – 1.43 0.3H Leblebicioglu, R Öztürk, VD Rosenthal, et al. Impact of a Multidimensional Infection Control Approach on Central Line-Associated Bloodstream Infections Rates in Adult Intensive Care Units of 8 Cities of Turkey: Findings of the InternationalNosocomial Infection Control Consortium (INICC). ACMA 2013, Accepted and In press
102. Process SurveillancePatients’ CharacteristicsBaseline Intervention RR* 95% CI P- ValueStudy period by hospital inmonths, mean ± SD (range)3 15.6 ± 9.2 (4 – 36)Hand Hygiene compliance% (n/n)32% (427/1328) 49% (5260/10786) 1.52 1.4 – 1.7 0.0001Date on administration set% (n/n)33% (1544/4656) 39% (14159/36472) 1.17 1.11 – 1.2 0.0001Placed sterile dressing %(n/n)78% (3617/4656) 90% (32895/36472) 1.2 1.12 – 1.2 0.0001Correct condition ofdressing % (n/n)76% (3537/4656) 73% (26699/36472) 0.96 0.93 – 0.99 0.04H Leblebicioglu, R Öztürk, VD Rosenthal, et al. Impact of a Multidimensional Infection Control Approach on Central Line-Associated Bloodstream Infections Rates in Adult Intensive Care Units of 8 Cities of Turkey: Findings of the InternationalNosocomial Infection Control Consortium (INICC). ACMA 2013, Accepted and In press
103. Central Line Associated Blood Stream Infection Rates Stratified By The LengthOf Time That Each Intensive Care Unit Has Participated In The InternationalNosocomial Infection Control Consortium. Poisson regressionTime sincejoining INICCNº ofICUs,nCentralline days,nCLAB,nCrudeCLABrate/1000CL daysIRR accounting forclustering by ICUP value1-3 months(baseline)13 3,129 62 19.81 1 -4-12 months 13 9,751 160 16.41 0.864 (0.637 – 1.17) 0.347Second year 11 7,287 109 15.0 0.643 (0.46 – 0.9) 0.01Third year 6 6,425 77 12.0 0.613 (0.43 – 0.87) 0.007H Leblebicioglu, R Öztürk, VD Rosenthal, et al. Impact of a Multidimensional Infection Control Approach on Central Line-Associated Bloodstream Infections Rates in Adult Intensive Care Units of 8 Cities of Turkey: Findings of the InternationalNosocomial Infection Control Consortium (INICC). ACMA 2013, Accepted and In press
104. CLAB Rate and Mortality RateReduction in Adult ICUs of15 Countries of4 Continents
106. Characteristics of Patients in both Periods
107. Process Surveillance
108. REDUCTION OF CLAB86 ICUs of 15 CountriesCLAB per1000 CLdaysRR= 0.67 95%CI=(0.58 - 0.77)P= 0.000133% BSI rate reductionRR= 0.4695% CI= (0.33 - 0.63)P= 0.000154% BSI rate reductionRosenthal, V. D., D. G. Maki, et al. (2010). "Impact of International Nosocomial Infection Control Consortium (INICC) strategy oncentral line-associated bloodstream infection rates in the intensive care units of 15 developing countries." Infection control andhospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America 31(12): 1264-1272.CLAB rateReduction by 54%
109. Deaths in patients with central line-associated bloodstreaminfection during baseline and intervention periods.Cohort ICUs, nNo.patients atriskDeaths ofpatients withCLAB, nCLAB-associateddeaths per100 patients(%)RR* (95%CI)P-valueMonths 1-3(Baseline)86 7,376 77 1.04 - -Months 5-7 86 7,522 46 0.61 0.59(0.41-0.84)0.004Months 11-1368 4,718 22 0.47 0.45(0.28-0.72)0.001Months 17-1943 3,527 16 0.45 0.43(0.25-0.74)0.002Months 23-2528 2,264 10 0.44 0.42(0.22-0.82)0.008Rosenthal, V. D., D. G. Maki, et al. (2010). "Impact of International Nosocomial Infection Control Consortium(INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developingcountries." Infection control and hospital epidemiology 31(12): 1264-1272.Mortalityreduction by 58%
110. Rosenthal, V. D., B. Ramachandran, et al. (2012). "Impact of a multidimensional infection control strategy on centralline-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings ofthe International Nosocomial Infection Control Consortium (INICC)." Infection 40(4): 415-423.DPROOFCL I NI CA L AND EPI DEMI OL OGI CAL STUDY12 Impact of a multidimensional infection control strategy on central3 line-associated bloodstream infection rates in pediatric intensive4 care units of ﬁve developing countries: ﬁndings5 of the International Nosocomial Infection Control Consortium6 (INICC)7 V. D. Rosenthal • B. Ramachandran • W. Villamil-Go´mez • A. A. Ruiz • J. A. Navoa-Ng •8 L. Matta-Corte´s • M. Pawar • A. Nevzat-Yalcin • M. Rodrı´guez-Ferrer • R. D. Yıldızdas¸ •9 A. Menco • R. Campuzano • V. D. Villanueva • L. F. Rendon-Campo • A. Gupta • O. Turhan •10 N. Barahona-Guzma´n • O. O. Horoz • P. Arrieta • J. M. Brito • M. C. V. Tolentino • Y. Astudillo •11 N. Saini • N. Gunay • G. Sarmiento-Villa • E. Gumus • A. Lagares-Guzma´n • O. Dursun12 Received: 3 August 2011/ Accepted: 4 February 201213 Ó Springer-Verlag 201214 Abstract15 Purpose To analyze the impact of the International16 Nosocomial Infection Control Consortium (INICC) multi-17 dimensional infection control strategy including a practice2without the implementation of the multi-faceted approach.3CLAB rates obtained in Phase 1 were compared with3CLAB ratesobtained in Phase 2 (intervention period), after3implementation of the INICC multidimensional infectionInfectionDOI 10.1007/s15010-012-0246-5
111. Characteristics of Patients in both Periods
112. Process Surveillance
113. CLAB Rates in Phase 1 (Baseline Period) andin Phase 2 (Intervention Period)Phase 1 (months 1-3) Phase 2 RR (95% CI) P ValueNo. of CLAB 16 40No. of CL days 1,229 5,841CL use, mean 0.39 0.36 0.93 (0.87 – 0.99) 0.0198CLAB Rate per1000 CL days13.0 6.9 0.53 (0.29 – 0.94) 0.0271Rosenthal, V. D., B. Ramachandran, et al. (2012). "Impact of a multidimensional infection control strategy on centralline-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings ofthe International Nosocomial Infection Control Consortium (INICC)." Infection 40(4): 415-423.CLAB rateReduction by 47%
114. Overall Mortality Reduction comparing Phase 1(Baseline Period) and Phase 2 (Intervention Period)Baseline period(months 1-3)InterventionperiodRR (95% CI) P ValueNo. of Patients 1,272 3,067No. of deaths 145 253Percentage ofdeaths10.3% 7.0% 0.69 (0.49 – 0.95) 0.0234Rosenthal, V. D., B. Ramachandran, et al. (2012). "Impact of a multidimensional infection control strategy on centralline-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings ofthe International Nosocomial Infection Control Consortium (INICC)." Infection 40(4): 415-423.Mortalityreduction by 31%
115. Characteristics of Patients in both Periods
116. Process Surveillance
117. Central Line-Associated Bloodstream Infection Stratified by theLength of Time that each unit has participated in INICC. Crudestratified rates, using random effects Poisson regression.Months sincejoining INICCICUs, n CL days CLABSI Crude CLABSI rate/1000 CL daysIRR accounting forclustering by ICU(95% CI)0-3 months(baseline)4 2105 46 21.8 -4-12 months 4 6514 72 11.1 0.53 (0.36 – 0.78)13-23 months 2 7445 73 9.8 0.46 (0.31 – 0.68)24-35 months 2 2692 19 7.1 0.43 (0.23 – 0.81)36-48 months 1 466 1 2.1 0.07 (0.01 – 1.26) **CLAB rateReduction by 91%
118. Evolution of Central Line-Associated Bloodstream Infection ineach Neonatal Intensive Care Unit14.310.69.6 7.147.616.912.127.025.20.0 126.96.36.199.05.010.015.020.025.030.035.040.045.050.00-3 months 4-12 months 13-23 months 24-48 monthsNICU ANICU BNICU CNICU D
119. Conclusions IAccording with WHO paper, based on INICC peer reviewpublications, HAI rates in ICUs in limited resourcescountries are higher than in USA and Europe.INICC was successful training health care workers of 50limited resources countries since 1998 to use incidencedensity of HAI rates; and all them currently are members ofINICC.INICC was successful to generate a useful benchmark tocompare HAI rates between hospitals and countries.INICC was successful to measure adverse consequencesof HAI (mortality, extra length of stay, cost, bacterialresistance)
120. Conclusions IISix Components of INICC strategy:1. Bundles,2. Education,3. Outcome Surveillance (HAI rates, extra mortality, extra LOS, extra cost,bacterial resistance, etc.)4. Process Surveillance (Compliance with hand hygiene, with invasive devicecare)5. Feedback of HAI rates and consequences6. Performance FeedbackIt was effective to:• Increase compliance with:• Hand hygiene• Vascular catheter care.• Reduce rates of:• CLAB in ICUs of Adults (54%), pediatric (47%) and neonatal ICUs (90%)• Mortality (58%)
121. Thank you very muchContact us by email:Info@inicc.orgContact us in our Web Page:www.INICC.orgFollow us :- in facebo in “Hospital Infection INICC”- in Twitter in in “@inicc_org”