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

















Only gold members can continue reading. Log In or Register to continue

Jun 16, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Epidemiology and Control of Healthcare-Acquired Infections in Limited-Resource Settings
Premium Wordpress Themes by UFO Themes

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