Epidemiology and Control of Healthcare-Acquired Infections in Limited-Resource Settings



Epidemiology and Control of Healthcare-Acquired Infections in Limited-Resource Settings


Victor D. Rosenthal



BACKGROUND

Among the principal precepts of medical ethics is the old mandate “first, do no harm.” During the first half of the 18th century, healers from all over the world voiced their concern over patient safety and their risks of acquiring infections in hospitals as part of an iatrogenic consequence.

The concept of healthcare-associated infection (HAI) has been developed since then thanks to the work of enthusiasts such as Nightingale (1), Semmelweis (2), Pasteur (3), Koch (4), and Lister (5) at the beginning of the “Bacteriological Era.” After hospital reforms and asepsis, the victory over HAI was short-lived, as infections did not only occur in obstetric and surgical patients, but also in medical patients. The source of infection was not only bacterial but viral as well, spreading infection via air. The dissemination of Streptococcus pyogenes raised clinical awareness during the first decades of the 20th century, declining its importance after the introduction of sulfonamides and penicillin, and improved hospital hygiene methods. With the advent of serologic typing, the high incidence of cross-infection in scarlet and puerperal fever was finally elucidated (6).

It was not until the second half of the 20th century, however, that infection prevention programs were structured and systematized in hospitals. Staphylococcus aureus became a focus of medical attention for hospital cross-infection in the late 1950s, but it was the emergence of “phage 80/81 staphylococcus” in the 1960 that caused notorious epidemics worldwide (1). It soon became more evident that risks for HAI increased despite the growing sophistication on healthcare tools and procedures.

Infectious diseases have been identified as the second most common cause of death in the world (7). A wide diversity of factors strongly influences the occurrence and transmission of infectious diseases. The socioeconomic factors such as poverty, homelessness, and high unemployment rates have been acknowledged to expand infections, including HAIs. Other factors such as global travel, emergence of old debilitating and mortal diseases, and wars also play a substantial role in transmitting pathogens. Confronted with these threats, which are out of the direct medical scope, infection control professionals may feel overwhelmed by the challenge of reducing and controlling HAIs. HAIs have been shown to be among the main causes of patient morbidity and mortality worldwide. In studies from developed countries, it has been well-documented that HAIs are responsible for increasing hospital costs as well (8,9).

Because of the great vulnerability of critically ill patients, HAIs pose the most serious threats in the intensive care unit (ICU) setting. For that reason, device-associated HAIs (DA-HAIs) such as central line-associated bloodstream infection (CLA-BSI) (10,11,12,13), ventilator-associated pneumonia (VAP) (14,15,16), and catheter-associated urinary tract infection (CA-UTI) (17) represent the most serious challenges to patient safety and quality healthcare in ICUs. In a review about CLA-BSI in limited-resource countries by Rosenthal, a number of structural and behavioral reasons were associated with higher rates of CLA-BSI, and among their most common observations were overcrowded ICUs, insufficient rooms for isolation, lack of sinks, lack of medical supplies in general, including but not limited to alcohol hand rub, antiseptic soap, and paper towels (18). In addition, a lack of supplies for the wearing of maximal barriers during catheter insertion, a lack of chlorhexidine for hand hygiene (HH) and skin antisepsis purposes, and a lack of needleless connectors (and the subsequent use of three-way stopcocks) were noted. Moreover, poor performances in infection control practices, such as using cotton balls already impregnated with antiseptic contained in a contaminated container, not covering the insertion site with a sterile dressing, storing drugs in open single-use vials, reusing single-use vials, leaving needles inserted in multiple-use vials, taking fluids from a 1,000-cc container for the dilution of par-enteral solutions, and using tacky mats were paramount (18).

The World Bank classifies countries into four economic strata on the basis of 2011 gross national income per capita: low-income, middle-income (subdivided into lower-middle and upper-middle), or high-income. Together, low-income countries, lower-middle-income countries, and upper-middle-income countries’ economies are sometimes referred to as developing economies, developing countries, lower-income countries, low-resource countries, or emerging countries. In this chapter, they will be referred to as limited-resource countries. Limited-resource countries represent 144/209 (68.8%) countries of the world and >75% of the world population (19). In high-income countries, such as the United States, the Centers
for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) (previously, the National Nosocomial Infections Surveillance [NNIS] system) (20) has provided standardized definitions for HAIs, thereby allowing prospective surveillance targeted on DA-HAIs rates per 1,000 device-days to be benchmarked against rates determined in different healthcare facilities worldwide (21,22,23). Furthermore, using the CDC methodology, surveillance data for the calculation of DA-HAI rates include specific risk factors, which is fundamental to detect and improve problems at the hospital level.

In the context of an expanded framework for HAI control, most of the relevant studies of ICU-acquired infections have been carried out in high-income countries (24). In the United States, HAIs are among the top 10 causes of death, being the main healthcare complication. A study from the United States reported that the number of annual deaths attributable to HAIs ranged from 44,000 to 99,000 (25). In different studies, most from developed countries, it has been shown that with effective HAI preventive interventions, many lives and extra costs can be saved. Findings in the scientific literature have shown that original CDC infection control programs that include HAI surveillance can reduce their incidence by >30% (26). According to an estimate by the CDC in 2002, US national costs for HAI were approximately $6 billion (27); these extra costs can be reduced by 32% with the implementation of effective HAI prevention programs (28).

In different countries, national conferences were organized to examine the burden of HAI from a broader perspective. This issue became of primary importance in several countries, where medical institutions established committees to start the appointment of Infection Control coordinators in healthcare facilities, the implementation of infection control programs, and the organization of workshops to respond to the need for training in infection control.

There have been good examples of global planning, such as during the severe acute respiratory syndrome (SARS) worldwide outbreak in 2003, which resulted in great mobilization of resources from the World Health Organization (WHO), in coordination with experts, pharmaceutical research and laboratories in national agencies worldwide. This global approach resulted in successful tracking and containment of spread. Additionally, in 2005 the WHO has launched a global health initiative related for HAI prevention called “Clean Care is Safer Care” with the aim of promoting HH worldwide (29). Then in 2009, the WHO published its guidelines, including a combination of previously published data, a new formulation for alcohol hand-rub products, among several other recommendations (30).

In limited-resource countries, with the emergence of the International Nosocomial Infection Control Consortium (INICC) in 1998 in Argentina, which was expanded internationally in 2002, HAI surveillance and HAI prevention interventions were expanded worldwide (31,32,33,34,35). INICC started to conduct surveillance by applying standardized definitions of the CDC-NNIS, and NHSN (20,21,22,23). In order to raise global awareness and help reduce HAI rates, INICC has been dedicated to provide free tools, to measure HAIs and their adverse consequences, and to measure and improve compliance with infection control practices (31,32,33,34,35). INICC became the first international HAI surveillance program to measure, prevent, and control HAIs by means of the analysis and feedback of outcome and process surveillance data collected by hospital collaborators worldwide; this system currently exists in hospitals in 46 countries of Africa, Asia, Europe, and Latin America (Argentina, Bolivia, Brazil, Bulgaria, China, Colombia, Costa Rica, Croatia, Cuba, Czech Republic, Dominican Republic, Ecuador, Egypt, El Salvador, Greece, India, Italy, Iran, Jordan, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Nigeria, Pakistan, Panama, Peru, Philippines, Poland, Puerto Rico, Romania, Saudi Arabia, Serbia, Singapore, Slovakia, Sri Lanka, Sudan, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam) (31,32,33,34,35). Data from these hospitals has greatly expanded our knowledge of the epidemiology of and prevention of HAIs in limited-resource countries (36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53).


PRIORITIES FOR INFECTION CONTROL IN LIMITED-RESOURCE SETTINGS

Allocation of national resources comes within the competence of governments, and decisions on funding are made according to different priorities. So, public health needs must compete for funding against other important national matters, many times more visible, including educational, environmental, political, social, economic, and other fundamental issues. Given the high visibility of improvements in a country’s infrastructure, not-so-visible positive outcomes of HAI prevention programs may be left behind by policy makers and managers of national programs. Thus, the resources needed for the implementation of infection control strategies at the hospital level are often insufficient. However, even if underestimated, public health is primary for the successful functioning of other national priorities, affecting different social aspects, such as work and social well-being. Promoting global health, therefore, is beneficial to the population as a whole, and should be treated as a global priority not only in instances of epidemic diseases, but ideally, to cover every aspect of health and infection prevention.

There are several factors that may render infection control initiatives ineffective, namely lack of attention and proper promotion of health improvement by agencies at national and international levels. Poverty and insufficient engagement by hospital administrators, governments, and health ministers are among the other negative factors. Moreover, professional infection control societies of nurses, physicians, and laboratorians (if any) are not fully committed to the promotion of infection prevention.

A major limitation on the progress of infection control has been lack of priority in the agenda of policy makers. Fortunately, the field of infection prevention and control of HAIs via surveillance programs has reached the limited-resource countries during the last decade. Many problems remain unresolved, such as how to implement surveillance programs for the effective prevention and control of HAIs. A lack of a global perspective has limited the scope of organized strategies and research agenda, whose items revolve around minor questions and fragmented approaches, squandering considerable resources.

Global initiatives focused on the prevention and control of HAIs have only emerged in the last decade. At present, different global health initiatives have been well-coordinated and have provided great benefit to the recipients and donors. A list of priorities that addresses these issues and provides a framework for finding a solution for these needs in limited-resource settings was developed by a wide range of independent international organizations, including INICC, the WHO, the Joint Commission
International (JCI), the International Federation of Infection Control (IFIC), the International Healthcare Worker Safety Center, the Asia Pacific Society of Infection Control (APSIC), Eastern Mediterranean Regional Network for Infection Control (EMR-NIC), Baltic Network for Infection Control and Containment of Antimicrobial Resistance (BALTICCARE), Southeastern Europe Infection Control (SEEIC), Pan American Association of Infection Control, The Infection Prevention & Control Africa Network (IPCAN), and others.

These priorities focus on raising awareness, fostering research, developing guidelines, promoting education, surveillance, prevention, and control of HAI and can be condensed into the following:



  • Assessment of facilities, infrastructure, supplies, and human resources dedicated to surveillance, prevention, and control of HAIs.


  • Surveillance of DA-HAIs in ICUs (CLA-BSI, VAP, and CA-UTI) and their consequences, such as mortality, extra length of stay (LOS), and cost.


  • Surveillance of surgical site infections (SSIs), and their consequences such as mortality, extra LOS, and cost.


  • Assessment of prevention strategies for CLA-BSI, VAP, and CA-UTI.


  • Assessment of prevention strategies for SSI.


  • Measuring the financial impact of complications and the cost-effectiveness of interventions.


  • Studies related to improved antibiotic usage and management of antibiotic resistance.


  • Development, edition, promotion, and distribution of guidelines to prevent and control HAIs (DA-HAIs and SSIs).


  • Improving compliance with practices known to be beneficial, especially HH, appropriate staffing in healthcare institutions, and other components for HAI control and prevention programs.


  • Improving compliance with specific interventions proven effective for prevention and control of each specific DA-HAI.


  • Preventing occupational transmission of bloodborne pathogens.


  • Establishment of worldwide, national, regional, and local networks to provide support and information, improve practices, and reduce the steep learning curve more efficiently and economically.


  • Surveillance and reduction of healthcare-associated transmission of epidemic respiratory diseases, such as influenza.


MISSION, VISION, AND GOALS OF INTERNATIONAL ORGANIZATIONS DEDICATED TO SURVEILLANCE, PREVENTION, AND CONTROL OF HEALTHCARE-ASSOCIATED INFECTIONS AND SAFETY IN LIMITED-RESOURCE COUNTRIES


INTERNATIONAL NOSOCOMIAL INFECTION CONTROL CONSORTIUM (INICC)



  • Mission: We are an international scientific community that works interactively through a network aiming at reducing healthcare-associated infections.


  • Vision: A society that recognizes the legitimate right of a hospitalized patient to be delivered safe healthcare. A society in which the scientific and medical community works for the safeguard of good infection control and surveillance practices. A society with the minimum incidence of HAIs.


WORLD HEALTH ORGANIZATION: FIRST GLOBAL PATIENT SAFETY CHALLENGE: CLEAN CARE IS SAFER CARE



  • The goal of Clean Care is Safer Care is to ensure that infection control is acknowledged universally as a solid and essential basis toward patient safety and supports the reduction of HAIs and their consequences.


  • As a global campaign to improve HH among healthcare workers (HCWs), Save Lives: Clean Your Hands is a major component of Clean Care is Safer Care. It advocates the need to improve and sustain HH practices of HCWs at the right times and in the right way to help reduce the spread of potentially life-threatening infections in healthcare facilities.


JOINT COMMISSION INTERNATIONAL



  • Mission: To continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.


  • Vision: All people always experience the safest, highest quality, best-value healthcare across all settings.


  • As the international arm of JCI has been working with healthcare organizations, ministries of health, and global organizations in more than 80 countries since 1994.


  • Our focus is on improving the safety of patient care through the provision of accreditation and certification services as well as through advisory and educational services aimed at helping organizations implement practical and sustainable solutions.


INTERNATIONAL HEALTHCARE WORKER SAFETY CENTER



  • Mission: Protecting HCWs. Millions of HCWs around the globe face a daily risk of contracting life-threatening occupational infections, such as HIV, hepatitis B, and hepatitis C, from occupational exposures to patients’ blood and body fluids. The International Healthcare Worker Safety Center at the University of Virginia is dedicated to reducing this serious risk.


INTERNATIONAL FEDERATION OF INFECTION CONTROL



  • Vision: To become the leading worldwide network facilitator between organizations and individuals active in the prevention and control of HAIs.


  • Mission: To facilitate international networking in order to improve the prevention and control of HAIs worldwide.



THE INICC PROGRAM

The INICC (www.INICC.org) is a nonprofit, open, multicenter, international, collaborative program modeled on the U.S. CDC-NNIS/NHSN system. Founded in Argentina in 1998, it is the first international research network that includes prospective, targeted, outcome and process surveillance designed to identify and reduce HAI rates and their consequences in the participating facilities (31,32,33,34,35).

Its objectives are the following: To create a global network using standardized HAI surveillance definitions and methodology in order to reduce HAIs, their attributable mortality, bacterial resistance, length of hospital stay, and extra cost. To collaborate in the development, adaptation, promotion, and edition of local guidelines for the control and prevention of HAIs. To enhance safety and quality of healthcare in every healthcare facility. To optimize antimicrobial use for prophylaxis or treatment. To stimulate, support, guide, and advice on the development of research projects aimed at reducing HAIs. To train HCWs in order to improve their skills for scientific research. To foster relevant scientific evidence-based literature for the surveillance, prevention, and control of HAIs by designing, coordinating, and publishing scientific research studies on the clinical and cost-effectiveness of proved or new infection control interventions.

INICC does the following activities with hospitals of limited-resource countries: (a) provides tools for and training for outcome HAI surveillance, (b) provides tools for and training for HAI process surveillance, (c) develops and provides charts and tables for feedback of HAI rates, (e) develops and provides charts and tables for performance feedback, (f) provides an infection control bundle with targeted interventions guided by risk-factor analysis and cost-effective interventions guided by cost analysis, (g) provides education and training in infection control guidelines application, (h) provides secretarial and administrative support in entering data, (i) develops and sends charts, scientific data analysis, and data interpretation to guide actions, (j) analyzes, edits, and shares data at scientific meetings and publishing in peer-reviewed journals, and (k) cooperates with hospitals and organizations worldwide in order to improve surveillance and control of HAIs.








TABLE 18.1 Overall Healthcare-Associated Infection Rates in Facilities Reported by Hospitals from Economies Defined as Low-, Lower-Middle, and Upper-Middle Income by the World Bank Reported as Crude Rates: Proportion Infected over Patients Discharged or Admitted to the Units and Reported as Proportion Infected per 1,000 Patient-Days in the Unit or Hospital

















































































































































































































































































































































































































































































































































































































































































Country

Type of Study/Unit

Type of HAI

HAI Rate (%)

Year

Ref


Argentina (INICC Study)

Multicenter adult ICU

Overall

27.0

2003

(37)


Brazil

Multicenter newborn ICU

Overall

28.1

2004

(194)


Brazil (INICC Study)

Multicenter adult ICU

Overall

29.6

2006

(195)


Brazil

Newborn ICU

Overall

50.7

2002

(79)


Chile

Hospitalwide

Overall

14.0

2001

(81)


China

Hospitalwide

Overall

3.04

2005

(80)


Colombia

Newborn ICU

Overall

5.3

2005

(196)


Colombia (INICC Study)

Multicenter adult ICU

Overall

12.2

2006

(40)


Croatia (INICC Study)

Adult ICU

Overall

7.0

2006

(197)


Costa Rica (INICC Study)

Adult ICU

Overall

4.8

2009

(198)


Cuba (INICC Study)

Multicenter adult ICU

Overall

22.4

2011

(49)


Egypt

Pediatric ICU

Overall

23.0

2005

(199)


India (INICC Study)

Multicenter adult ICU

Overall

12.3

2005

(200)


Mexico

Hospitalwide

Overall

21.0

2002

(201)


Mexico

Multicenter adult ICU

Overall

23.2

2000

(82)


Mexico (INICC Study)

Multicenter adult ICU

Overall

24.4

2006

(42)


Morocco (INICC Study)

Adult medical ICU

Overall

19.3

2005

(202)


Peru (INICC Study)

Multicenter adult ICU

Overall

11.2

2005

(203)


Philippines (INICC Study)

Adult ICU

Overall

19.1

2006

(204)


Saudi Arabia

Multicenter hospitalwide

Overall

2.8

2004

(205)


Saudi Arabia

Hospitalwide, maternity hospital

Overall

4.0

2002

(206)


Saudi Arabia

Hospitalwide

Overall

8.5

2002

(207)


Saudi Arabia

Adult ICU

Overall

19.8

2002

(207)


Saudi Arabia

Newborn ICU

Overall

35.8

2002

(207)


Tanzania

Multicenter hospitalwide

Overall

14.8

2003

(208)


Tanzania

Adult medical ICU

Overall

40.0

2003

(208)


Turkey

Adult ICU

Overall

12.5

2000

(84)


Turkey

Adult ICU

Overall

33.0

2003

(209)


Turkey

Adult ICU

Overall

51.8

2003

(210)


Turkey (INICC Study)

Multicenter adult ICU

Overall

20.5

2005

(211)


Turkey

Multicenter adult ICU

Overall

48.7

2004

(212)


Turkey

Neurology ICU

Overall

88.9

2005

(213)


INICC 8 countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey (INICC Study)

Multicenter adult ICU

Overall

14.7

2005

(32)


Kuwait

Adult MS ICU

Overall

10.6

2008

(214)


China

Newborn ICU

Overall

11.6

2007

(215)


Turkey

General pediatric wards

Overall

3.02

2012

(216)


India

Pediatric ICU

Overall

19.3

2011

(217)


Turkey

Adult ICU

Overall

25.6

2011

(218)


Turkey

Adult ICU

Overall

20.1

2011

(219)


Turkey

Newborn ICU

Overall

Range: 14.1-29.7

2010

(220)


Turkey

Adult ICU

Overall

16.6

2005

(221)


Macedonia (INICC Study)

Adult ICU

Overall

2.1

2010

(222)


Tunisia (INICC Study)

Newborn and pediatric ICU

Overall

4.1

2010

(223)


Bangladesh

Adult ICU

Overall

30

2011

(224)


Albania

Adult ICU

Overall

31.6

2008

(225)


Albania

Surgical ICU

Overall

22.0

2008

(225)


Pakistan

Adult ICU

Overall

39.7

2007

(226)


Lebanon (INICC Study)

Adult ICU

Overall

9.8

2012

(52)


Poland (INICC Study)

Adult ICU

Overall

24.3

2012

(53)


Egypt (INICC Study)

Adult ICU

Overall

32.8

2012

(227)


Egypt (INICC Study)

Pediatric ICU

Overall

24.5

2012

(227)


Bulgaria

Newborn ICU

Overall

1.9

2011

(228)


Kosovo

Adult ICU

Overall

64.3

2008

(229)


Kosovo

Adult and newborn ICU

Overall

17.4

2006

(230)


Serbia

Adult ICU

Overall

1.5-40.8

2006

(231)


Argentina (INICC Study)

Multicenter adult ICU

Overall

90.0 per 1,000 patient-days

2003

(37)


Brazil

Multicenter adult ICU

Overall

30.6 per 1,000 patient-days

2006

(195)


Brazil

Multicenter newborn ICU

Overall

24.9 per 1,000 patient-days

2004

(194)


Brazil

Newborn ICU

Overall

62.0 per 1,000 patient-days

2002

(79)


Colombia (INICC Study)

Newborn ICU

Overall

6.2 per 1,000 patient-days

2005

(196)


Colombia (INICC Study)

Multicenter adult ICU

Overall

18.2 per 1,000 patient-days

2006

(40)


Croatia (INICC Study)

Adult ICU

Overall

25.6 per 1,000 patient-days

2006

(297)


Costa Rica (INICC Study)

Adult ICU

Overall

13.9 per 1,000 patient-days

2009

(232)


Egypt

Pediatric ICU

Overall

40.0 per 1,000 patient-days

2005

(199)


India (INICC Study)

Multicenter adult ICU

Overall

21.4 per 1,000 patient-days

2005

(200)


India

Hospitalwide

Overall

36.2 per 1,000 patient-days

2004

(233)


Mexico (INICC Study)

Multicenter adult ICU

Overall

39.0 per 1,000 patient-days

2006

(42)


Morocco (INICC Study)

Adult medical ICU

Overall

20.4 per 1,000 patient-days

2005

(202)


Peru (INICC Study)

Multicenter adult ICU

Overall

25.3 per 1,000 patient-days

2005

(203)


Philippines (INICC Study)

Adult ICU

Overall

27.5 per 1,000 patient-days

2006

(204)


Turkey (INICC Study)

Multicenter adult ICU

Overall

48.4 per 1,000 patient-days

2005

(43)


Turkey (INICC Study)

Neurology ICU

Overall

84.2 per 1,000 patient-days

2005

(211)


Cuba (INICC Study)

Multicenter adult ICU

Overall

30.6 per 1,000 patient-days

2011

(49)


INICC (INICC Study)

Multicenter adult ICU

Overall

22.5 per 1,000 patient-days

2005

(32)


Turkey

Burn ICU

Overall

18.2 per 1,000 patient-days

2009

(234)


Lithuania

5 pediatric ICUs

Overall

24.5 per 1,000 patient-days

2009

(235)


Kuwait

Adult MS ICU

Overall

20.6 per 1,000 patient-days

2008

(214)


China

Newborn ICU

Overall

14.9 per 1,000 patient-days

2007

(215)


Turkey

General pediatric wards

Overall

3.17 per 1,000 patient-days

2012

(216)


India

Pediatric ICU

Overall

21 per 1,000 patient-days

2011

(217)


Turkey

ICU

Overall

21.6 per 1,000 patient-days

2011

(218)


Egypt

Pediatric ICU

Overall

8.6 per 1,000 patient-days

2011

(236)


Egypt

Multicenter ICU

Overall

20.5 per 1,000 patient-days

2012

(237)


Egypt (INICC Study)

Adult ICU

Overall

52.9 per 1,000 patient-days

2012

(227)


Egypt (INICC Study)

Pediatric ICU

Overall

22.8 per 1,000 patient-days

2012

(227)


Turkey

Newborn ICU

Overall

Range: 10.9-17.3 per 1,000 patient-days

2010

(220)


Lebanon (INICC Study)

Adult ICU

Overall

11.85 per 1,000 patient-days

2012

(52)


Turkey

Adult ICU

Overall

30.2 per 1,000 patient-days

2012

(238)


Poland (INICC Study)

Adult ICU

Overall

21.9 per 1,000 patient-days

2012

(53)


Serbia

Adult ICU

Overall

1.5-65.6 per 1,000 patient-days

2006

(231)


Macedonia (INICC Study)

Adult ICU

Overall

4.5 per 1,000 patient-days

2010

(222)


Tunisia (INICC Study)

Pediatric and

newborn ICU

Overall

6.88 per 1,000 bed-days

2010

(223)


INICC, International Nosocomial Infection Control Consortium; ICU, intensive care unit; MS, medical surgical; Ref, reference.


INICC sends a protocol to INICC members, who review it with their research committees and agree to full participation by signing a commitment letter and sending it to the INICC central office in Buenos Aires, which then processes data, and provides analyses and reports on a monthly basis, answers questions, and augments the tutorial with personal instructions when needed.

Forms and software designed to record data and direct infection control activities are used for both control patients without HAI and patients with HAIs. These forms include age, gender, underlying diseases, and severity of illness score at the time of entrance to the ICU. On a daily basis, information regarding temperature, blood pressure, device-days, cultures taken, presence of clinical pneumonia, antibiotic use, and characteristics of any surrogate of infection is collected both for cases and controls. Thus, it is also possible to validate received data and analyze cases and controls in a prospective cohort nested study (36,37,40,42,43,44,45,46,47,48,49,50,51,52,53).

At the same time, process surveillance and performance feedback are done for HH compliance, vascular and urinary catheter care, mechanical ventilator care, and measures to prevent SSIs. Data collected for process surveillance purposes include HH compliance and key interventions to prevent CLA-BSI, CA-UTI, VAP, and SSI, such as practices for insertion of the central line, skin antisepsis, placement of gauze on intravascular (IV) access insertion sites, marking the date on the IV administration set, condition of the gauze, position of the urinary catheter regarding the leg and position of urine bag regarding the bed, among many others.

INICC has reported HAI rates by country (Tables 18.1 and 18.2), and in international global reports (Table 18.2), mortality rates (Tables 18.3, 18.4 and 18.5), as well as extra LOS (Tables 18.6, 18.7 and 18.8), and extra cost (Tables 18.9 and 18.10) from several participating hospitals that applied the INICC methodology (31).











TABLE 18.2 Device-Associated Infections per 1,000 Device-Days Reported by Hospitals from Economies Defined as Low-, or Lower-Middle, or Upper-Middle Income by the World Bank











































































































































































































































































































































































































































































































Country

ICU Type

Number of patients

CLA-BSI per 1,000 CL-days

VAP per 1,000 device-days

CA-UTI per 1,000 device-days

Year

Ref


Argentina (INICC Study)

Adult

3,319

30.3

46.3

18.5

2004

(239)


Argentina (INICC Study)

Adult

2,525

2.7

—

—

2004

(52)


Argentina

Adult

—

11.4

—

—

2002

(240)


Albania

Adult, PICU, NICU

968

—

40.0

41.0


(86)


Brazil (INICC Study)

Adult

1,031

9.1

20.9

9.6

2008

(36)


Brazil

NICU

1,443

17.3

3.2

—

2010

(87)


Brazil (INICC Study)

Adult, PICU

320

34.0

26.0

—

2003

(57)


Brazil

PICU

515

10.2

18.7

1.8

2003

(88)


Brazil (INICC Study)

NICU

6,243

3.1

4.3

—

2007

(195)


China (INICC Study)

Adult

391,527

3.1

20.8

6.4

2011

(51)


China (INICC Study)

Adult

2,631

7.66

10.46

1.3

2012

(146)


Colombia (INICC Study)

Adult

2,172

11.3

10.1

4.3

2006

(40)


Cuba (INICC Study)

Adult

1,982

2.0

52.5

8.1

2011

(49)


Egypt (INICC Study)

Adult

473

22.5

73.4

34.2

2011

(227)


Egypt (INICC Study)

PICU

143

18.8

31.8

—

2011

(227)


El Salvador (INICC Study)

PICU

1,145

10.1

12.1

5.8

2011

(48)


El Salvador (INICC Study)

NICU

1,270

16.1

9.9

—

2011

(48)


India (INICC Study)

Adult

10,835

7.9

10.4

1.4

2007

(44)


India

Adult, PICU, NICU

—

0.48

21.9

0.6

2010

(89)


India

NICU

—

27.0

—

—

2011

(90)


Iran

Adult

106

147.3

275

137.5

2004

(91)


Mexico (INICC Study)

Adult

1,055

23.1

21.8

13.4

2006

(42)


Morocco (INICC Study)

Adult

1,731

15.7

43.2

11.7

2009

(47)


Peru (INICC Study)

Adult

1,920

7.7

31.3

5.1

2008

(45)


Peru

PICU

414

18.1

7.9

5.1

2010

(92)


Philippines (INICC Study)

Adult

2,887

4.6

16.7

4.2

2011

(50)


Philippines (INICC Study)

PICU

252

8.23

12.8

0.0

2011

(50)


Philippines (INICC Study)

NICU

1,813

20.8

0.44

—

2011

(50)


Poland (INICC Study)

Adult

847

4.01

18.2

4.8

2011

(53)


Saudi Arabia

NICU

—

8.2

—

—

2009

(93)


Tunisia

Adult

340

15.3

4.4

—

2006

(94)


Tunisia

Adult

647

14.8

—

—

2007

(95)


Turkey (INICC Study)

Adult

3,288

17.6

26.5

8.3

2007

(43)


Turkey

Adult

509

11.8

27.1

9.6

2010

(96)


Turkey

Adult

6,005

2.8

21.2

11.9

2011

(97)


Lebanon (INICC Study)

Adult

666

5.2

8.1

4.1

2011

(52)


Kuwait

Adult

1,173

5.5

9.1

2.3

2008

(214)


China

NICU

638

18 (per 1,000 umbilical-days)

63.3

—

2007

(215)


Turkey

NICU

600

3.8

13.76

—

2012

(241)


Turkey

Adult

204

—

—

19.02

2012

(242)


Lithuania

PICU

1,239

7.7

28.8

3.4

2009

(235)


Croatia (INICC Study)

Adult

369

8.3

47.8

6.0

2006

(197)


Costa Rica (INICC Study)

Adult

125

4.65

29.9

—

2009

(198)


Macedonia (INICC Study)

Adult

1,558

1.47

6.58

0.45

2010

(222)


Tunisia (INICC Study)

PICU, NICU

367

8.65

5.56

0.0

2010

(223)


INICC 8 countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU, NICU

21,069

18.5

24.1

8.9

2006

(32)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

Adult, PICU

43,114

9.2

19.5

6.5

2008

(33)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

NICU

1,323

14.8

7.5

—

2008

(33)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

Adult, PICU

144,323

7.6

13.6

6.3

2010

(34)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

NICU

9,156

13.9

9.5

—

2010

(34)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

Adult, PICU

295,264

6.8

15.8

6.3

2011

(35)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

NICU

15,420

12.2

9.0

—

2011

(35)


INICC 15 countries: Argentina, Brazil, Colombia, Dominican Republic, India, Jordan, Malaysia, Mexico, Morocco, Peru, Philippines, El Salvador, Thailand, Tunisia, and Turkey (INICC Study)

NICU

13,251

13.7

9.7

—

2011

(167)


CLA-BSI, central line-associated bloodstream infection; VAP, ventilator-associated pneumonia; CA-UTI, catheter-associated urinary tract infection; Ref, reference; ICU, intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; CL, central line; INICC, International Nosocomial Infection Control Consortium.











TABLE 18.3 Extra Mortality of Central Line-Associated Bloodstream Infection Reported by Hospitals from Economies Defined as Low-, Lower-Middle, and Upper-Middle Income by the World Bank
























































































































































































































































































Country

ICU Type

Mortality without HAI (%)

Mortality with CLA-BSI (%)

Extra Mortality (%)

RR

95% CI

P

Year

Ref


Argentina (INICC Study)

Adult

29.6

54.2

24.6

—

—

—

2003

(144)


Brazil (INICC Study)

Adult

19.2

47.1

27.8

2.44

1.46-4.09

0.0001

2008

(36)


Colombia (INICC Study)

Adult

18.1

36.6

18.5

2.02

1.42-2.87

0.0001

2006

(40)


Cuba (INICC Study)

Adult

33.0

50.0

17.0

1.52

0.4-6.1

0.5552

2011

(49)


El Salvador (INICC Study)

PICU

13.6

25.0

11.4

1.84

0.97-3.50

0.0586

2011

(48)


El Salvador (INICC Study)

NICU

12.3

38.0

25.7

3.09

2.17-4.42

0.001

2011

(48)


Macedonia (INICC Study)

Adult

2.4

30.0

28

6.80

5.25-8.81

0.0001

2010

(222)


Tunisia (INICC Study)

PICU, NICU

8.2

14.7

6

1.79

0.69-4.62

0.2226

2010

(223)


India (INICC Study)

Adult

6.6

10.6

4.0

1.60

1.08-2.37

0.0001

2007

(44)


Mexico (INICC Study)

Adult

21.8

41.8

20

1.92

0.95-3.85

0.06

2007

(150)


Morocco (INICC Study)

Adult

24.9

100

75.1

4.02

1.50-0.77

0.0027

2009

(47)


Peru (INICC Study)

Adult

14.0

29.0

15.0

2.07

1.07-4.04

0.0280

2008

(45)


Philippines (INICC Study)

Adult

6.8

10.0

3.2

1.48

0.21-10.56

0.695

2011

(50)


Philippines (INICC Study)

PICU

3.8

50.0

46.3

13.3

2.88-61.7

0.0001

2011

(50)


Philippines (INICC Study)

NICU

5.6

25.0

19.4

4.46

0.62-32.3

0.1033

2011

(50)


Lebanon (INICC Study)

Adult

19.1

60.0

40.9

3.14

1.38-7.13

0.0039

2011

(52)


INICC 8 countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU, NICU

17.1

35.2

18.0

—

—

—

2006

(243)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

Adult, PICU

15.3

29.6

14.3

—

—

—

2008

(33)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

NICU

14.3

39.7

25.4

—

—

—

2008

(33)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

Adult, PICU

14.4

38.1

23.6

—

21.6-25.7

—

2009

(34)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

NICU

8.8

34.5

25.7

—

26.7-42.9

—

2010

(34)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

Adult, PICU

10.0

24.7

14.7


12.8-16.6

—

2010

(35)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

NICU

9.1

35.3

26.2

—

20.3-32.4

—

2010

(35)


INICC 15 countries: Argentina, Brazil, Colombia, Dominican Republic, India, Jordan, Malaysia, Mexico, Morocco, Peru, Philippines, El Salvador, Thailand, Tunisia, and Turkey (INICC Study)

NICU

9.4

37.1

27.7


21.1-34.5

—

2011

(167)


HAI, healthcare-associated infection; CLA-BSI, central line-associated bloodstream infection; Ref, reference; ICU, intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; RR, relative risk; CI, confidence interval; INICC, International Nosocomial Infection Control Consortium.










TABLE 18.4 Extra Mortality of Ventilator-Associated Pneumonia Reported by Hospitals from Economies Defined as Low-, Lower-Middle, and Upper-Middle Income by the World Bank

























































































































































































































































































































Country

ICU Type

Mortality without HAI (%)

Mortality with VAP (%)

Extra Mortality (%)

RR

95% CI

P

Year

Ref


Argentina (INICC Study)

Adult

37.2

71.4

34.2

—

—

—

2003

(100)


Argentina (INICC Study)

Adult

33.2

63.5

30.3

—

—

0.0001

2005

(145)


Brazil (INICC Study)

Adult

19.2

34.5

15.3

2.91

2.72-3.13

0.0001

2008

(36)


Colombia (INICC Study)

Adult

18.1

35.0

16.9

1.93

1.24-3.00

0.003

2006

(40)


Cuba (INICC Study)

Adult

33

80

47

2.42

0.9-6.5

0.0693

2011

(49)


El Salvador (INICC Study)

PICU

13.6

19.0

5.5

1.4

0.78-2.53

0.2592

2011

(48)


El Salvador (INICC Study)

NICU

12.3

23.0

10.7

1.88

1.20-2.93

0.0050

2011

(48)


India (INICC Study)

Adult

6.6

25.6

19.0

3.87

2.70-5.54

0.0001

2007

(44)


Macedonia (INICC Study)

Adult

2.4

45.5

43

19.05

5.25-8.81

0.0001

2010

(222)


Tunisia (INICC Study)

PICU, NICU

8.2

100

92

12.17

3.71-39.96

0.0001

2010

(223)


Costa Rica (INICC Study)

Adult

5.0

20.0

15.0

3.97

0.45-32.95

0.1678

2009

(198)


Croatia (INICC Study)

Adult

—

—

17.4

7.56

0.96-59.64

0.0236

2006

(244)


Morocco (INICC Study)

Adult

24.9

81.6

56.7

3.28

2.51-4.29

0.0001

2009

(47)


Peru (INICC Study)

Adult

14.0

38.5

24.5

2.75

2.00-3.78

0.0001

2008

(45)


Philippines (INICC Study)

Adult

6.8

9.7

3.0

1.44

0.67-3.06

0.3454

2011

(50)


Philippines (INICC Study)

PICU

3.8

0.0

-3.8

Undef

Undef

0.7373

2011

(50)


Philippines (INICC Study)

NICU

5.6

—

—

—

—

—

2011

(50)


Lebanon (INICC Study)

Adult

19.1

15.0

—

0.78

0.25-2.47

0.6780

2011

(52)


INICC 10 countries: Argentina, Brazil, Colombia, Greece, India, Lebanon, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU, NICU

—

14.0

—

—

2-27

—

2011

(173)


INICC 8 countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU, NICU

17.1

44.9

27.8

—

—

—

2006

(243)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

Adult, PICU, NICU

15.3

42.8

27.5

—

—

—

2008

(33)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

NICU

14.3

46.5

32.2

—

—

—

2008

(33)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

Adult, PICU

14.4

43.7

29.3

—

27.1-31.4

—

2009

(34)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

NICU

9.4

27.3

17.9

—

11.0-25.8

—

2010

(34)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

Adult, PICU

10.0

25.2

15.2

—

—

—

2010

(35)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

NICU

9.1

24.0

14.9

—

8.9-21.1

—

2010

(35)


INICC 15 countries: Argentina, Brazil, Colombia, Dominican Republic, India, Jordan, Malaysia, Mexico, Morocco, Peru, Philippines, El Salvador, Thailand, Tunisia, and Turkey (INICC Study)

NICU

9.4

27.3

17.9

—

—

—

2011

(167)


HAI, healthcare-associated infection; VAP, ventilator-associated pneumonia; ICU, intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; RR, relative risk; CI, confidence interval; INICC, International Nosocomial Infection Control Consortium; Ref, reference.










TABLE 18.5 Extra Mortality of Catheter-Associated Urinary Tract Infection Reported by Hospitals from Economies Defined As Low-, Lower-Middle, and Upper-Middle Income by the World Bank





















































































































































































Country

ICU Type

Mortality without HAI (%)

Mortality with CA-UTI (%)

Extra Mortality (%)

RR

95% CI

P

Year

Ref


Argentina (INICC Study)

Adult

37.2

42.9

5.7

—

—

—

2003

(100)


Brazil (INICC Study)

Adult

19.2

30.0

10.7

1.56

0.69-3.52

0.2875

2008

(36)


Colombia (INICC Study)

Adult

18.1

28.6

10.5

1.58

0.78-3.18

0.199

2006

(40)


Cuba (INICC Study)

Adult

40.0

50.0

10.0

1.25

0.40-3.93

0.7018

2008

(49)


El Salvador (INICC Study)

PICU

13.6

18.2

4.6

1.34

0.33-5.41

0.681

2011

(48)


India (INICC Study)

Adult

6.6

18.2

11.6

2.83

2.57-3.12

0.0001

2007

(44)


Morocco (INICC Study)

Adult

24.9

43.6

18.7

1.75

1.08-2.85

0.0218

2009

(47)


Peru (INICC Study)

Adult

14.0

18.2

4.2

1.30

0.49-3.49

0.6028

2008

(45)


Philippines (INICC Study)

Adult

6.8

3.8

-2.9

0.57

0.08-4.06

0.5683

2011

(50)


Lebanon (INICC Study)

Adult

19.1

12.5

—

0.65

0.16-2.65

0.5487

2011

(52)


INICC 10 countries: Argentina, Brazil, Colombia, Greece, India, Lebanon, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU, NICU

—

15.0

—

—

3-28

—

2011

(151)


INICC 8 countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU

17.1

38.4

21.3

—

—

—

2006

(243)


INICC 18 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, Philippines, El Salvador, Turkey, and Uruguay (INICC Study)

Adult, PICU

15.3

35.8

20.5

—

—

—

2008

(33)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

Adult, PICU

14.4

32.9

18.5

—

15.1-22.1

—

2009

(34)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

Adult, PICU

10.0

17.3

7.3

—

5.7-9.1

—

2010

(35)


HAI, healthcare-associated infection; CA-UTI, catheter-associated urinary tract infection; ICU, intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; RR, relative risk; CI, confidence interval; INICC, International Nosocomial Infection Control Consortium; Ref, reference.











TABLE 18.6 Extra Length of Stay of Central Line-Associated Bloodstream Infection Reported by Hospitals from Economies Defined as Low-, Lower-Middle, and Upper-Middle Income by the World Bank
























































































































































































































































































Country

ICU Type

LOS without HAI (days)

LOS with CLA-BSI (days)

Extra LOS (days)

RR

95% CI

P

Year

Ref


Argentina (INICC Study)

Adult

12.14

26.08

13.9

—

—

—

2003

(100)


Argentina (INICC Study)

Adult

11.5

23.3

11.9

—

—

—

2003

(144)


Brazil (INICC Study)

Adult

5.8

13.0

7.3

2.26

2.05-2.49

0.0001

2008

(36)


Cuba (INICC Study)

Adult

4.9

23.3

18.3

4.7

9.4-85.8

—

2011

(48)


El Salvador (INICC Study)

PICU

6.2

19.1

12.9

2.08

14.1-26.5

—

2011

(48)


El Salvador (INICC Study)

NICU

16.7

37.7

21.0

—

31.3-45.9

—

2011

(48)


India (INICC Study)

Adult

4.4

9.4

5.0

2.15

2.06-2.24

0.0001

2007

(44)


Macedonia (INICC Study)

Adult

4.3

22.2

17.9

—

—

—

2010

(222)


Tunisia (INICC Study)

PICU, NICU

5.5

6.8

1.3

—

—

—

2010

(223)


Croatia (INICC Study)

Adult

2.1

11.0

8.9

5.34

2.95-9.69

0.001

2006

(244)


Mexico (INICC Study)

Adult

7.34

13.4

6.05

—

—

—

2007

(150)


Morocco (INICC Study)

Adult

5.3

10.0

4.7

—

—

0.0004

2007

(150)


Peru (INICC Study)

Adult

4.0

13.1

9.1

3.27

2.96-3.61

0.0001

2008

(45)


Philippines (INICC Study)

Adult

4.3

16.2

11.9

3.79

9.0-33.5

—

2011

(50)


Philippines (INICC Study)

PICU

5.6

17.0

11.4

3.03

6.9-62.5

—

2011

(50)


Philippines (INICC Study)

NICU

12.6

28.0

15.4

2.21

11.2-104.2

—

2011

(50)


Poland (INICC Study)

Adult

6.9

10.0

3.1

1.4

3.2-87.7

—

2011

(53)


Lebanon (INICC Study)

Adult

7.3

13.8

6.5

1.88

7.7-28.4

—

2011

(52)


Algeria

NICU

15.1

24.3

9.2

—

—

—

2008

(245)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

Adult, PICU

5.0

17.14

12.1

—

—

—

2009

(34)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

NICU

11.1

33.3

22.2

—

17.9-27.5

—

2009

(34)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

Adult, PICU

6.2

17.1

10.9

—

—

—

2011

(35)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

NICU

9.1

35.3

26.2

—

20.3-32.4

—

2011

(35)


INICC 15 countries: Argentina, Brazil, Colombia, Dominican Republic, India, Jordan, Malaysia, Mexico, Morocco, Peru, Philippines, El Salvador, Thailand, Tunisia, and Turkey (INICC Study)

NICU

11.4

29.8

18.4

—

—

—

2011

(167)


LOS, length of stay; HAI, healthcare-associated infection; CLA-BSI, central line-associated bloodstream infection; Ref, reference; ICU, intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; RR, relative risk; CI, confidence interval; INICC, International Nosocomial Infection Control Consortium.










TABLE 18.7 Extra Length of Stay of Ventilator-Associated Pneumonia in Hospitals Reported by Hospitals from Economies Defined as Low-, Lower-Middle, and Upper-Middle Income by the World Bank














































































































































































































































































Country

ICU Type

LOS without HAI (days)

LOS with VAP (days)

Extra LOS (days)

RR

95% CI

P

Year

Ref


Argentina (INICC Study)

Adult

12.14

22.14

10.0

—

—

—

2003

(100)


Argentina (INICC Study))

Adult

10.73

19.3

8.95

—

—

—

2005

(145)


Brazil (INICC Study)

Adult

5.8

16.8

11.0

2.91

2.72-3.13

0.0001

2008

(36)


Cuba (INICC Study)

Adult

4.9

23.8

18.9

4.9

10.5-73.3

—

2011

(49)


El Salvador (INICC Study)

PICU

6.2

18.6

12.4

—

11.8-24.0

—

2011

(48)


El Salvador (INICC Study)

NICU

16.7

42.3

25.5

—

34.8-51.9

—

2011

(48)


India (INICC Study)

Adult

4.4

15.3

11.0

3.50

3.34-3.67

0.0001

2007

(44)


Morocco (INICC Study)

Adult

5.3

10.8

5.5

—

—

0.0001

2007

(150)


Macedonia (INICC Study)

Adult

4.3

23.0

4.1

—

—

—

2010

(222)


Tunisia (INICC Study)

PICU, NICU

5.5

20.0

14.5

—

—

—

2010

(223)


Croatia (INICC Study)

Adult

2.1

14.2

12.1

6.90

5.40-8.80

0.001

2006

(244)


Peru (INICC Study)

Adult

4.0

13.4

9.4

3.35

3.17-3.54

0.0001

2008

(45)


Philippines (INICC Study)

Adult

4.3

12.4

8.2

2.91

9.9-15.8

—

2011

(50)


Philippines (INICC Study)

PICU

5.6

10.7

5.1

1.90

4.0-52.1

—

2011

(50)


Poland (INICC Study)

NICU

6.9

15.5

8.6

2.2

6.4-56.9

—

2011

(53)


Turkey (INICC Study)

Adult

6.6

16.1

—

—

—

0.0001

2007

—


Lebanon (INICC Study)

Adult

7.3

18.8

11.4

2.56

12.3-30.5

—

2011

(52)


INICC 10 countries: Argentina, Brazil, Colombia, Greece, India, Lebanon, Mexico, Morocco, Peru, and Turkey (INICC Study)

Adult, PICU, NICU

—

2.03

—

—

1.52-2.54

—

2011

(173)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

Adult, PICU

5.0

15.58

10.58

—

—

—

2009

(34)


INICC 25 countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, El Salvador, Thailand, Tunisia, Turkey, Venezuela, and Vietnam (INICC Study)

NICU

11.1

27.3

16.2

—

22.6-33.3

—

2009

(34)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam

(INICC Study)

Adult, PICU

6.2

18.0

11.7

—

—

—

2011

(35)


INICC 36 countries: Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosova, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sudan, Sri Lanka, Thailand, Tunisia, Turkey, Uruguay, Venezuela, and Vietnam (INICC Study)

NICU

9.1

24.0

14.9

—

8.9-21.1

—

2011

(35)


INICC 15 countries: Argentina, Brazil, Colombia, Dominican Republic, India, Jordan, Malaysia, Mexico, Morocco, Peru, Philippines, El Salvador, Thailand, Tunisia, and Turkey (INICC Study)

NICU

11.4

37.0

25.6

—

—

—

2011

(167)


LOS, length of stay; HAI, healthcare-associated infection; VAP, ventilator-associated pneumonia; Ref, reference; ICU, intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; RR, relative risk; CI, confidence interval; INICC, International Nosocomial Infection Control Consortium.










TABLE 18.8 Extra Length of Stay of Catheter-Associated Urinary Tract Infection Reported by Hospitals from Economies Defined as Low-, Lower-Middle, and Upper-Middle Income by the World Bank

















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Country

ICU Type

LOS without HAI (days)

LOS with CA-UTI (days)

Extra LOS (days)

RR

95% CI

P

Year

Ref


Argentina (INICC Study)

Adult

12.14