INICC Update and Current Recommendations - St. Luke's ...

Dr. Victor Rosenthal’s s Summarized CV:Dr. Rosenthal is a Medical Doctor graduated from the University of Buenos Aires. He completed fellowshipprograms on Internal Medicine and Infectious Diseases in Buenos Aires; and he holds an Infectious Diseasesfellowship at the University of Wisconsin. He is a graduate in Clinical Effectiveness, from Harvard Universityand the University of Buenos Aires; and obtained a certificate in Infection Control (IC) and HospitalEpidemiology from the Chilean Society of IC.Dr. Rosenthal is the founder and chairman of the International Nosocomial Infection Control Consortium(INICC), a nonprofit international research center which focuses on Healthcare-Associated Infectionscollaborating with more than 1000 researchers in more than 150 cities in 39 countries. He is the chairman ofan Infection Control and Hospital Epidemiology Course at the Medical College of Buenos Aires. He is aVisiting professor at University of Wisconsin, USA, and a speaker at several International Scientific Meetingsworldwide (Latin America, Asia, Africa, Europe and Oceania).He is a task force member and reviewer of the Infection Control Guidelines for the World Health Organization(WHO), and an editorial board member and scientific reviewer of several international peer reviewed journals,such as “Lancet”, “American Journal of Infection Control (AJIC)”; “Infection Control and HospitalEpidemiology” (ICHE); “Critical Care Medicine”; “Emerging Infectious Diseases (CDC)”; “Epidemiology andInfection”; and several others. He has advised the governments of Colombia and Mexico, and hascollaborated with edition of the Infection Control Guidelines of Argentina, Brazil, Colombia, Peru, Hong Kong,Taiwan.Being an author of more than 350 scientific publications, Dr. Rosenthal has received several awards grantedat different international scientific meetings, including APIC, IFIC, Pan American Meetings, and others.

.1 st St Luke’s International Conference on Infection ControlManila, PhilippinesSeptember 14th and 15th, 2011.INICC Update and CurrentRecommendationsDr. Victor D. Rosenthal, MD, MSC, CICINICC Founder and Chairmanvictor_rosenthal@inicc.org

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• DAI Rates in Developed Countries• DAI rates comparing Developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAP)

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• DAI Rates in Developed Countries• DAI rates comparing Developed and Developing Countries• Special Conditions of Developing Countries.INICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAP)

CAUTI RatesCDC- NHSN Report6

VAP RatesCDC- NHSN Report7

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• DAI Rates in Developed Countries• DAI rates comparing Developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAP)

American Journal of Infection Control, October 2008

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing Countries• Special Conditions of Developing Countries.INICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAP)

Tuesday, 30 de August de 2011Follow us on:» HomeWELCOME TO INICC WEBSITEMethodsINICC, International Nosocomial Infection Control Consortium, evolves from itinerant information workand training that started in the late 90s.A group of Latin American hospitals were pioneers of the application of this new methodology: thesystematic collection of outcome and process surveillance data.Such was the origin of the current international data base, from which there appeared the possibility ofestablishing standards developed by INICC for countries with limited resources.The cosmopolitan nature of INICC is reflected in its structure: Country Coordination, conducted bychairmen and board members of local scientific organizations, and an advisory Board of InternationalExperts, who accompany the Chairman, composing a true scientific community.At present, more than 600 researchers participate actively, reporting their measures from over 140healthcare centers in 108 cities, from 36 countries of 4 continents.Data collected at each of these healthcare centers are sent on a monthly basis to the INICCHeadquarters in Buenos Aires, Argentina. There the data are analyzed, and a detailed report isprepared, containing tables and graphics that reflect the following:Global healthcare-associated infection rates per percentage and per 1000 bed days, as indicators ofoutcome surveillance.Specific healthcare-associated infection rates per 1000 device days.Reports on microbiological profile and bacterial resistance.Extra mortality attributable to healthcare-associated infections.Extra length of hospital stay for each type of healthcare-associated infection.Extra cost analysis for each type of healthcare-associated infection.Studies on cost-effectiveness of interventions and bio medical supplies.Hand hygiene compliance, as an indicator of process surveillance.Vascular and urinary catheter care.Nosocomial pneumonia prevention.www.INICC.org 16

List of 40 Countries Participating in INICCLatin America1. Argentina2. Brazil3. Chile4. Colombia5. Costa Rica6. Cuba7. Dominican Republic8. Ecuador9. El Salvador10. Guatemala.11. MéxicoAsia1. Arabia2. China3. India4. Jordan5. Lebanon6. Malaysia7. Pakistan8. Philippines9. Singapore10. Sri Lanka11. TaiwanEurope1. Bulgaria2. Greece3. Kosovo4. Lithuania5. Macedonia6. Poland7. Czech Republic8. Romania9. Turkey10. UkraineÁfrica1. Egypt2. Morocco3. Niger4. Tunisia5. Sudan12. Panamá12. Thailand13. Peru13. Vietnam14. Puerto Rico15. Venezuela16. Uruguay

Rosenthal VD, Maki DG, Graves N. The International Nosocomial Infection Control Consortium (INICC):Goals and objectives, description of surveillance methods, and operational activities.Am J Infect Control 2008;36:e1-e12.

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAP)

INICC Monthly ReportPeriod: xxxxHospital: xxxICU: xxxCity: xxxCountry: xxxPrincipal Investigator: xxxxSecodary Investigators: xxxxGlobal Coordination: xxxxx

Outcome SurveillanceMicroorganismsProportion of NosocomialInfections by Type – Mix ICUMicroorganisms- Ventilator AsociatedPneumoniaEnterococcus;3,2%Klebsiella; 1,6%VentilatorAssociatedPneumonia;45,0%Providencia; 1,6%StaphylococcusAureus; 3,2%Pseudomonas;21,0%Proteus; 6,5%Acinetobacter;62,9%BloodStreamInfection;10,0%Urinary TractInfection;45,0%Microorganisms - Catheter AssociatedBloodstream InfectionStenotrophomonas;4,0%Staph.Coag.Negative; 28,0%Pseudomonas;8,0%StaphylococcusAureus; 12,0%Serratia; 4,0%Acinetobacter;20,0%Enterococcus;8,0%Klebsiella; 4,0%Providencia; 8,0%Enterobacter; 4,0%Pseudomonas;13,7%Microorganisms- Catheter Associated UrinaryTract InfectionStreptococcus;Staph.Coag.Neg;2,7%2,7% Enterobacter; 2,7%StaphylococcusAureus; 1,4%Proteus; 4,1%Klebsiella; 17,8%MicroorganismsE.Coli; 26,0%Acinetobacter;8,2%Candida; 20,5%

Global Nosocomial Infection RatesPercentage of Nosocomial Infections by DischargeMix ICUpercentage100,0%90,0%80,0%70,0%60,0%50,0%40,0%30,0%20,0%10,0%0,0%30,0% 25,0% 22,0% 18,0% 15,0% 10,0%Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08MonthNosocomial Infection Rate per 1000 patient daysMix ICUrate per 1000 patientdays100,080,060,040,020,00,0Jun-0840,0 35,0 30,0 26,0 21,0 15,0Jul-08Aug-08Sep-08Oct-08Nov-08Month

Device-Associated Nosocomial Infection RatesNI per 1000 device daysNI per 1000 device-days25201510509 per 1,000 CVCdaysINICC Benchmark20 per 1,000 MVdays7 per 1,000 UCdaysIVD-BSI VAP CAUTIrate per 1000 urinarycatheter days1009080706050403020100Infección del Tracto Urinario (ITU) por 1000días de catéter urinario – UCI MixtaINICC: 9,8NHSN 3,0Jun-0810,0 9,0 8,0 7,0 7,0 6,0Jul-08Aug-08Sep-08Oct-08Nov-08mesCentral Vascular Catheter- Associated BloodstreamInfection per 1000 CVC days – Mix ICUVentilator-Associated Pneumonia Rate per 1000ventilator days Mix ICUB lo o d s tre a m In fe c tio n p e r1 0 0 0 C V C d a y s100,090,080,070,060,050,040,030,020,010,00,0INICC: 13,0NHSN: 3,020,0 18,0Jun-08Jul-0816,0 13,0Aug-08Sep-08Month/Year11,0Oct-087,0Nov-08ra te p e r 1 0 0 0 ve n tila to r d a ys1009080706050403020100INICC: 24,8NHSS: 4,035,0Jun-0820,0 19,0Jul-08Aug-0818,0 17,0 15,0Sep-08Oct-08Nov-08Victor D. Rosenthal,a Dennis G. Maki, Ajita Mehta, et al. International Nosocomial Infection Control Consortium (INICC) Report, Data Summary for 2002-2007, American Journal of Infection Control- In Press, 2008ITS-CVC: Infección del torrente sanguíneo asociada a catéter vascular central, NAV: Neumonía asociada a ventilador. ITU-SV: Infección del tractourinario asociada a sonda vesical

Extra Length of StayPercentage of Deaths by NosocomialInfectionsType of patientAverageLength ofStayExtraLength ofStayPatients without HAI 4.5 -Patients with CLABSI 15.0 11.5Patients with VAP 22.0 15.5Patients with CAUTI 17.0 13.5-Patients with severalHAI 22.0 17.5Type ofpatientPercentage ofDeathsExtraMortalityPatientswithout HAI 15.0% -Patients withCLABSI 35.0% 20%Patients withVAP 50.0% 35.0%Patients withCAUTI 20.0% 5.0%Patients withseveral HAI 60.0% 45.0%

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAP)

!Original ArticleDevice-associated infection rates in intensive care units in El Salvador:International Nosocomial Infection Control Consortium (INICC) FindingsLourdes Dueñas 1 , Ana C. Bran de Casares 1 , Victor D. Rosenthal 2 , Lilian Jesús Machuca 11 Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador2 International Nosocomial Infection Control Consortium, Buenos Aires, ArgentinaAbstractIntroduction: This study aimed to determine the rate of device-associated, health care-associated infection (DA-HAI), the excess in length ofstay, the mortality, and the hand hygiene compliance in a pediatric intensive care unit (PICU) and a neonatal ICU (NICU) in a hospitalmember of the International Infection Control Consortium (INICC) in El Salvador.Methodology: A prospective cohort, active DA-HAI surveillance study was conducted on patients admitted in the pediatric and neonatalICUs from January 2007 to November 2009. The protocol and methodology implemented were developed by INICC. Data were collected inthe participating ICUs, and analyzed at INICC headquarters by proprietary software. DA-HAI rates were recorded by applying the definitionsof the Centers for Disease Control and Prevention National Healthcare Safety Network.Results: Of 1,145 patients hospitalized in the PICU for 9,517 days, 177 acquired DA-HAIs (overall rate 15.5%), and 18.6 DA-HAIs per1,000 ICU-days. Furthermore, 1,270 patients hospitalized in the NICU for 30,663 days acquired 302 DA-HAIs (overall rate 23.8%), and 9.8DA-HAIs per 1,000 ICU-days. The central line-associated bloodstream infection (CLA-BSI) rates in the NICU and PICU were 9.9 and 10.0per 1,000 catheter-days respectively. The ventilator-associated pneumonia (VAP) rate was 16.1 per 1,000 ventilator-days in the NICU and12.1 in the PICU.The catheter-associated urinary tract infection (CAUTI) rate was 5.8 per 1,000 catheter-days in the PICU.Conclusions: DA-HAI rates in the PICU and NICU of our hospital were higher than international standards; infection control programsincluding surveillance and antibiotic policies must be a priority in El Salvador.27

Display Settings:AbstractJournal of Critical Care (2011) xx, xxx–xxxInt J Infect Dis. 2011 Aug 14. [Epub ahead of print]Device-associated infection rates in 398 intensive care units in Shanghai, China:International Nosocomial Infection Control Consortium (INICC) findings.Tao L, Hu B, Rosenthal VD, Gao X, He L.Department of Respiratory Medicine, Huadong Hospital, Fudan University, Shanghai, China.AbstractOBJECTIVES: To determine device-associated healthcare-associated infection (DA-HAI) rates and themicroorganism profile in 398 intensive care units (ICUs) of 70 hospitals in Shanghai, China.METHODS: An open-label, prospective, cohort, active DA-HAI surveillance study was conducted on patients admittedto 398 tertiary-care ICUs in China from September 2004 to December 2009, implementing the methodologydeveloped by the International Nosocomial Infection Control Consortium (INICC). The data were collected in theparticipating ICUs, and uploaded and analyzed at the INICC headquarters on proprietary software. DA-HAI rates wereregistered by applying the definitions of the US Centers for Disease Control and Prevention (CDC) NationalHealthcare Safety Network (NHSN). We analyzed the rates of DAI-HAI, ventilator-associated pneumonia (VAP),central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI), andtheir microorganism profiles.RESULTS: During the 5 years and 4 months of the study, 391 527 patients hospitalized in an ICU for an aggregate of3 245 244 days, acquired 20 866 DA-HAIs, an overall rate of 5.3% (95% confidence interval (CI) 5.3-5.4) and 6.4(95% CI 6.3-6.5) infections per 1000 ICU-days. VAP posed the greatest risk (20.8 per 1000 ventilator-days, 95% CI20.4-21.1), followed by CAUTI (6.4 per 1000 catheter-days, 95% CI 6.3-6.6) and CLABSI (3.1 per 1000 catheter-days,95% CI 3.0-3.2). The most common isolated microorganism was Acinetobacter baumannii (19.1%), followed byPseudomonas aeruginosa (17.2%), Klebsiella pneumoniae (11.9%), and Staphylococcus aureus (11.9%).CONCLUSIONS: DA-HAIs in the ICUs of Shanghai pose a far greater threat to patient safety than in ICUs in the USA.This is particularly the case for the VAP rate, which is much higher than the rates found in developed countries. Activeinfection control programs that carry out infection surveillance and implement prevention guidelines can improvepatient safety and must become a priority.Copyright © 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.Device-associated infection rates and extra length of stay inan intensive care unit of a university hospital in Wroclaw,Poland: International Nosocomial Infection ControlConsortium's (INICC) findingsAndrzej Kübler a , Wieslawa Duszynska a , Victor DRosenthal b, , Malgorzata Fleischer a ,Teresa Kaiser a , Ewa Szewczyk a , Barbara Barteczko-Grajek a28a Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Polandb International Nosocomial Infection Control Consortium, Buenos Aires, Argentina

Display Settings:AbstractInt J Infect Dis. 2011 Aug 14. [Epub ahead of print]Device-associated infection rates in 398 intensive care units in Shanghai, China:International Nosocomial Infection Control Consortium (INICC) findings.Tao L, Hu B, Rosenthal VD, Gao X, He L.Department of Respiratory Medicine, Huadong Hospital, Fudan University, Shanghai, China.AbstractOBJECTIVES: To determine device-associated healthcare-associated infection (DA-HAI) rates and themicroorganism profile in 398 intensive care units (ICUs) of 70 hospitals in Shanghai, China.METHODS: An open-label, prospective, cohort, active DA-HAI surveillance study was conducted on patients admittedto 398 tertiary-care ICUs in China from September 2004 to December 2009, implementing the methodologydeveloped by the International Nosocomial Infection Control Consortium (INICC). The data were collected in theparticipating ICUs, and uploaded and analyzed at the INICC headquarters on proprietary software. DA-HAI rates wereregistered by applying the definitions of the US Centers for Disease Control and Prevention (CDC) NationalHealthcare Safety Network (NHSN). We analyzed the rates of DAI-HAI, ventilator-associated pneumonia (VAP),central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI), andtheir microorganism profiles.RESULTS: During the 5 years and 4 months of the study, 391 527 patients hospitalized in an ICU for an aggregate of3 245 244 days, acquired 20 866 DA-HAIs, an overall rate of 5.3% (95% confidence interval (CI) 5.3-5.4) and 6.4(95% CI 6.3-6.5) infections per 1000 ICU-days. VAP posed the greatest risk (20.8 per 1000 ventilator-days, 95% CI20.4-21.1), followed by CAUTI (6.4 per 1000 catheter-days, 95% CI 6.3-6.6) and CLABSI (3.1 per 1000 catheter-days,95% CI 3.0-3.2). The most common isolated microorganism was Acinetobacter baumannii (19.1%), followed byPseudomonas aeruginosa (17.2%), Klebsiella pneumoniae (11.9%), and Staphylococcus aureus (11.9%).CONCLUSIONS: DA-HAIs in the ICUs of Shanghai pose a far greater threat to patient safety than in ICUs in the USA.This is particularly the case for the VAP rate, which is much higher than the rates found in developed countries. Activeinfection control programs that carry out infection surveillance and implement prevention guidelines can improvepatient safety and must become a priority.Copyright © 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Table 2. Pooled means and 95% CI of the distribution of central line-associated blood stream infectionrates (per 1000 central line-days) and central line utilization ratios by type of adult and pediatric ICUs:Type of ICUNo of No of No of CLdaysPooled 95% CIICUs patients CLABSImeanCLABSI rateBurn ICU 8 169 0 351 0.0 -Cardiothoracic ICU 48 61189 332 166943 2.0 1.8 - 2.2Coronary Care ICU 59 88287 190 59337 3.2 2.7 - 3.7General ICU 47 64707 719 198871 3.6 3.4 - 3.9Medical ICU 53 24664 164 38207 4.3 3.7 - 5.0Neuro-Surgical ICU 43 26944 145 64521 2.2 1.9 - 2.6Pediatric ICU 19 17365 68 19462 3.5 2.7 - 4.4Respiratory ICU 48 10668 84 30598 2.7 2.2 - 3.4Surgical ICU 64 95491 870 251631 3.5 3.2 - 3.7Trauma ICU 9 2043 6 5394 1.1 0.4 - 2.4Overall 398 391,527 2,578 835,313 3.1 3.0 – 3.2ICU, Intensive Care Unit; CLABSI, Central line-associated blood stream infection; CL, central line; CI,Confidence Interval.

Table 3. Pooled means and 95% CI of the distribution of Ventilator Associated Pneumonia rates (per1000 mechanical ventilator-days) and mechanical ventilator utilization ratios by type of adult andpediatric ICUs:Type of ICUNo ofICUsNo ofpatientsNo ofVAPMVdaysPooledmeanVAP rate95% CIBurn ICU 8 169 1 134 7.5 0.1 - 40.9Cardiothoracic ICU 48 61189 975 78901 12.4 11.6 - 13.1Coronary Care ICU 59 88287 437 25507 17.1 16.0 - 18.8General ICU 47 64707 4103 165007 24.9 24.1 - 25.6Medical ICU 53 24664 535 25219 21.2 19.5 - 23.1Neuro-Surgical ICU 43 26944 1487 63360 23.5 22.3 - 24.7Pediatric ICU 19 17365 220 20806 10.6 9.2 - 12.1Respiratory ICU 48 10668 676 31186 21.7 20.0 - 23.4Surgical ICU 64 95491 2626 126230 20.8 20.2 - 21.6Trauma ICU 9 2043 164 4186 39.2 33.5 - 45.5Overall 398 391,527 11,224 540,535 20.8 20.4 - 21.1ICU, Intensive Care Unit; VAP, Ventilator Associated Pneumonia; MV, mechanical ventilator; CI,Confidence Interval.

Table 4. Pooled means and 95% CI of the distribution of catheter-associated urinary tract infection rates(per 1000 urinary catheter -days) and urinary catheter utilization ratios by type of adult and pediatricICUs:Type of ICUNo ofICUsNo ofpatientsNo ofCAUTIUC-daysPooledmeanCAUTI rate95% CIBurn ICU 8 169 0 452 0.0 -Cardiothoracic ICU 48 61189 206 144694 1.4 1.2 - 1.6Coronary Care ICU 59 88287 1050 82220 12.8 12.0 - 13.6General ICU 47 64707 2596 297760 8.7 8.4 - 9.1Medical ICU 53 24664 637 67243 9.5 8.7 - 10.2Neuro-Surgical ICU 43 26944 585 129187 4.5 4.2 - 4.9Pediatric ICU 19 17365 39 14742 2.6 1.9 - 3.6Respiratory ICU 48 10668 331 41392 8.0 7.2 - 8.9Surgical ICU 64 95491 1550 312618 5.0 4.7 - 5.2Trauma ICU 9 2043 70 7707 9.1 7.1 - 11.5Overall 398 391,527 7,064 1,098,013 6.4 6.3 - 6.6ICU, Intensive Care Unit; CAUTI, catheter-associated urinary tract infection; UC, urinary catheter; CI,Confidence Interval.

American Journal of Infection Control, 2011.

American Journal of Infection Control, 2011.

INICC report 2004- 2009.AJIC 2011Period: January 2004 to December 2009 (6 years)Countries: 36 (Argentina, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba,Dominican Republic, Ecuador, Egypt, Greece, India, Jordan, Kosovo, Lebanon,Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru,Philippines, Puerto Rico, El Salvador, Saudi Arabia, Singapore, Sri Lanka, Sudan,Thailand, Tunisia, Turkey, Venezuela, Vietnam, Uruguay)ICUs: 422Patients: 313,008Bed days: 2,194,897Central Line days: 1,078,448Ventilator days: 796,847Urinary catheter days: 1,049,541BSI (n): 7,603VAP (n): 12,395CAUTI (n): 6,595Total IAD: 20,657

DAI RATESINICC vs CDC-NHSN (USA)American Journal of Infection Control, 2011.

INICC report 2004- 2009

HAI rates published by INICCPublication year 2006200820102011Number of Countries 8182536Peer Review JournalAnnals of InternalMedicineAmerican Journalof Infection ControlAmerican Journal ofInfection ControlAmerican Journal ofInfection ControlCLABSI rate per 1000CL days12.59.27.66.8VAP rate per 1000device days24.119.513.615.8CAUTI per 1000 devicedays8.96.56.36.342

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Ventilator Associated Pneumonia (VAP• Catheter Associated Urinary Tract Infections (CAUTI)• Central Line Associated Blood Stream Infections (CLABSI)Impact of Closed Systems on CLABSI

SOCIOECONOMICSITUATION IMPACT ONHAI RATES

InfectionDOI 10.1007/s15010-011-0136-2CL I NI CA L A ND EPI DEM I OL OGI CA L STUDYSocioeconomic impact on device-associated infectionsin limited-resource neonatal intensive care units:findings of the INICCV. D. Rosenthal • P. Lynch • W. R. Jarvis • I. A. Khader • R. Richtmann • N. B. Jaballah •C. Aygun • W. V. Gómez • L. Dueñas • T. A. Espinoza • J. A. Navoa-Ng • M. Pawar •M. S. Oropeza • A. Barkat • N. Mejía • C. Y. Meng • A. Apisarnthanarak • INICC membersReceived: 30 September 2010/ Accepted: 9 June 2011Ó Springer-Verlag 2011

World Bank classification of Countries Economic Strata.According to 2007 gross national income (GNI) per capita.The World Bank classifies countries into four economic strata according to 2007gross national income (GNI) per capita.These groups are:• low income, $935 or less;• lower middle income, $936–3,705;• upper middle income, $3,706–11,455;• high income, $11,456 or more.• These economies represent 144 of 209 countries of the world (68.8%) andmore than 75% of the world population.There is very limited information regarding association between socio economiclevel of the country (Low income, mid low income, and mid high income) and DAIrates, as well as association between type of hospital (Public, Academic, andPrivate) and DAI rates.The goal of this study is to show DAIs rates stratified by socio economic level ofthe country and type of hospital and to find statistical associations among them.

Central line-associated BSI rates and central line device utilization ratios,Neonatal Intensive Care Units.Stratified by country socioeconomic level, International Nosocomial InfectionControl Consortium, September 2003-February 2010SocioeconomiclevelPooledmean CLA-BSI rates95%ConfidenceIntervals(CIs)ComparisonsRR (95%CI)P valueLowincome37.0 16.0 – 71.8LowIncome vsLower MiddleIncome3.12(1.55 -6.28)0.0008Lowermiddleincome11.9 10.7 – 13.2Lowermiddleincome vsUpper middleincome0.67(0.57-0.80)0.0001Uppermiddleincome17.6 15.3 – 20.2Lowincome vsUpper middleincome2.10(1.04-4.26)0.0349

Central line-associated bloodstream infection rates and central line device utilizationratios, Neonatal Intensive Care Units.Stratified by hospital type, International Nosocomial Infection Control Consortium(INICC), September 2003-February 2010HospitalCLA-BSI95% CI Vs RRP valueTyperate(95% CI)Academic 14.3 12.9-15.7Academic vsPublic0.98(0.73-1.2)0.8620Public 14.6 11.0 -19.1Public vsPrivate1.35(0.95 -1.92)0.0881Private 10.8 8.5-13.5Academic vsPrivate1.32(1.03 -1.69)0.0260

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Ventilator Associated Pneumonia (VAP• Catheter Associated Urinary Tract Infections (CAUTI)• Central Line Associated Blood Stream Infections (CLABSI)Impact of Closed Systems on CLABSI

EXTRA MORTALITY

EXTRA MORTALITY RATES in ADULT ICUsAmerican Journal of Infection Control, 2011.

EXTRA MORTALITY RATES in NICUsAmerican Journal of Infection Control, 2011.

EXTRA LENGTH OF STAY

Extra Length of Stay Rate of Central-LineAssociated Bloodstream InfectionAmerican Journal of Infection Control, 2011.

New INICC Analysis forLength of Stay andMortality55

New INICC Analysis

EXTRA COST

ExtraCostsandLengthof Stayof HAIs58

BACTERIAL RESISTANCE

BACTERIAL RESISTANCEINICC vs CDC-NHSNINICC. American Journal of Infection Control, 2011

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Ventilator Associated Pneumonia (VAP• Catheter Associated Urinary Tract Infections (CAUTI)• Central Line Associated Blood Stream Infections (CLABSI)Impact of Closed Systems on CLABSI

INTERNATIONAL NOSOCOMIALINFECTION CONTROL CONSORTIUMANALYSIS OF 88,661 HAND HYGIENE OPPORTUNITIESDURING 11 YEARS IN 77 ICUS, OF 34 CITIES, OF 14COUNTRIES. FINDINGS OF INICC.Dr. Victor D. Rosenthal, MD, MSc, CICwww.INICC.org62

IMPROVEMENT OF HAND HYGIENE53 ICUsHandHygienepercentage100%90%80%70%60%50%40%30%20%10%0%35%Baseline period60%RR = 1.7395% CI = 1.68-1.78,P 0.0001Intervention period63

Impact on HAI rates (%)

HAND HYGIENE COMPARISON PER STRATUMHand Hygiene Compliance per stratum100.0%90.0%80.0%70.0%60.0%50.0%40.0%30.0%20.0%10.0%Gender HCW56.9% 58.3%50.3%49.1%44.9%ProcedureUnitWork Shift64.6%60.1% 56.9%51.9% 54.2% 54.9% 53.3% 56.4%0.0%FemaleMaleNursesPhysiciansAncillaryStaffNoninvasiveInvasiveAdult ICUPediatric ICUNewBorn ICUMorningAfternoonNight65

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing CountriesINICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Central Line Associated Blood Stream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Ventilator Associated Pneumonia (VAPImpact of Closed Systems on CLABSI

The INICC CLABSI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Feedback of CLABSI rates,5- Process surveillance,6- Performance feedback of infection controlpractices

INICC Bundle to Reduce CLABSI Rate1. Performance of active surveillance forCLABSI.2. Education of healthcare personnel involved inthe insertion, care, and maintenance of CVCsabout CLABSI prevention.3. Use of an all-inclusive catheter cart or kit.4. Use of a catheter checklist to ensureadherence to infection prevention practices at thetime of CVC insertion.5. Performance of hand hygiene before catheterinsertion or manipulation.

INICC Bundle to Reduce CLABSI Rate6. Use a chlorhexidine-based antiseptic forskin preparation.7. Use of maximal sterile barrierprecautions during CVC insertion.8. Disinfection of catheter hubs, needlelessconnectors, and infection ports beforeaccessing the catheter.9. Removal of nonessential catheters.

The INICC CLABSI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Feedback of CLABSI rates,5- Process surveillance,6- Performance feedback of infection controlpractices

EDUCATION71

The INICC CLABSI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Feedback of CLABSI rates,5- Process surveillance,6- Performance feedback of infection controlpractices

Device Associated Infection Rates.Central Line Associated Blood Stream Infection per 1000 Device Days.XX University Hospital, Reanimation ICUSeptember 2008 - October2009/November 2010 - January2011CL Days 3546Number of CLAB 54Pooled CLAB Ratex 1000 CL Days 15,2

Extra Length of StayUpdated on a quarterly basisMersin University Hospital, Adult ICUsType of patientAverage Length ofStayExtra length of stayPatients without HAI 5,3 -Patients with CLABSI 13,7 8,3Patients with VAP 13,2 7,9Patients with CAUTI 8,7 3,3Patients with several HAI 18,8 13,5References: HAI: Health Care Associated Infection; CLABSI: Central Vascular Catheter AssociatedBlood Stream Infection; VAP: Ventilator Asscciated Pneumonia; CAUTI: Catheter Associated UrinaryTract Infection.

Percentage of Deaths by HAIUpdated on a Quarterly BasisMersin University Hospital, Adult ICUsType of patient Percentage of Deaths Extra MortalityPatients without HAI 21,0% -Patients with CLABSI 75,0% 54,0%Patients with VAP 55,0% 34,0%Patients with CAUTI 55,6% 34,6%Patients with several HAI 52,4% 31,4%References: HAI: Health Care Associated Infection; CLABSI: Central Vascular Catheter AssociatedBlood Stream Infection; VAP: Ventilator Asscciated Pneumonia; CAUTI: Catheter Associated UrinaryTract Infection.

The INICC CLABSI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Feedback of CLABSI rates,5- Process surveillance,6- Performance feedback of infection controlpractices

Process SurveillancePerformance of direct observation of:•hand hygiene compliance;•placement of sterile gauze or sterile polyurethane dressing on theinsertion site•condition of sterile gauze or sterile polyurethane dressing on theinsertion site;•recording of the date of catheter insertion and last administration setchange;•gauze dressing replacement every 48 hours•and replacement of transparent semi-permeable membranedressings, at least, every 7 days,•with the recording of the date and time of the dressing replacementusing structured observation tools at regularly scheduled intervals

The INICC CLABSI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Feedback of CLABSI rates,5- Process surveillance,6- Performance feedback of infection controlpractices

MONITORING79

Process Analysis.Hand washing Compliance.Global Monthly Compliance.Sunway Medical Centre Berhad – Global RatesHand washing Compliance. Global Monthly Compliance.Sunway Medical Centre Berhad - Global Percentages100%90%80%70%60%50%40%30%20%10%0%30%14%21% 22%0%23%Aug-10Sep-10Oct-10Nov-10Dec-10Jan-11Feb-11month

RESULTSREDUCTION OF CLAB86 ICUs of 15 CountriesCLAB per1000 CLdaysRR= 0.67 95%CI=(0.58 - 0.77)P= 0.000133% BSI rate reductionRR= 0.4695% CI= (0.33 - 0.63)P= 0.000154% BSI rate reductionRosenthal VD, Maki DG, et al. Infection Control and Hospital Epidemiology. 2010

Mortality Rate Reduction58% mortality reduction

Impact of a Multidimensional Infection Control Strategy on Central Line-AssociatedBloodstream Infections Rates and Mortality in Pediatric Intensive Care Units of 6Developing Countries: Findings of the International Nosocomial Infection ControlConsortium (INICC)Victor Daniel Rosenthal, 1 Bala Ramachandran, 2 Wilmer Villamil-Gómez, 3Alberto Armas Ruiz, 4 Josephine Anne Navoa-Ng, 5 Gulden Ersoz, 6 Lorena Matta-Cortés, 7 Mandakini Pawar, 8 A.Nevzat-Yalcin, 9 Marena Rodríguez-Ferrer, 10 10 Cheong Yuet-Meng, 11,12 R Dinçer Yıldızdaş, 13 13 Antonio Menco, 3Roberto Campuzano, 4 Victoria D. Villanueva, 5 Ali Kaya, 6 Luis Fernando Rendon-Campo, 7 Amit Gupta, 8 OzgeTurhan, 9 Nayide Barahona-Guzmán, 10 10 Jegathesan Manikavasagam, 11 11 Ozden Ozgur Horoz, 13 13 Patrick Arrieta, 3Jorge Mena Brito, 4 María Corazon V. Tolentino, 5 Necdet Kuyucu, 6 Yamileth Astudillo, 7 Narinder Saini, 8 SevimKeskin, 9 Guillermo Sarmiento-Villa, 10 10 Lian Huat-Tan, 11 11 Hybeth Dabua, 7 Eylul Gumus, 9 Alfredo Lagares-Guzmán, 10 10Kerinjeet Kaur, 11 11 Oguz Dursun, 9 Joelene Lim. 11 11International Nosocomial Infection Control Consortium, Buenos Aires, Argentina;KK Childs Trust Hospital, Chennai, India;Clínica Santa María, Sucre, Colombia;Centro Médico La Raza IMSS, Mexico City, Mexico;St. Luke's Medical Center, Quezon City, Philippines;Mersin University, Faculty of Medicine, Mersin; Turkey;Corporación Comfenalco Valle- Universidad Libre, Santiago de Cali, Colombia;Pushpanjali Crosslay Hospital, Ghaziabad, India;Akdeniz University, Antalya, Turkey;Universidad Simón Bolivar, Barranquilla, Colombia;Sunway Medical Centre Berhad, Petaling Jaya, Malaysia;Monash University Sunway Campus, Petaling Jaya, Malaysia;Çukurova University, Balcali Hospital, Adana, Turkey.Rosenthal et al. Infection. In Press 2011

Characteristics of Patients Hospitalized in Pediatric Intensive Care Unitsin Phase 1 (Baseline Period) and in Phase 2 (Intervention Period)No. patients 438 2,414Baseline Intervention RR 95% CI P ValueCentral line duration,2.81 ± 5.3 2.44 ± 5.8 - - 0.209mean ± SDSex, n (%)Male 256 (58%) 1380 (57%) 0.98 0.86 – 1.12 0.7446Female 182 (42%) 1034 (43%)Age, mean ± SD 4.50 ± 5.7 4.75 ± 6.4 - - 0.456Abdominal Surgery, n (%) 5 (1%) 14 (1%) 0.51 0.18 – 1.41 0.1852Thoracic Surgery, n (%) 3 (1%) 15 (1%) 0.91 0.26 – 3.13 0.8775Previous Infection, n (%) 29 (7%) 190 (8%) 1.19 0.80 – 1.76 0.3851Rosenthal et al. Infection. In Press 2011

Hand Hygiene Improvement in Phase 1 (BaselinePeriod) and in Phase 2 (Intervention Period)Phase 1Phase 2RRP Value(months 1-(95% CI)3)No. of Hand Hygiene512 2,180observationsHand Hygienecompliance % (n)56% 79% 1.42(1.25 – 1.61)0.0001Rosenthal et al. Infection. In Press 2011

Catheter Care Improvement in Phase 1 (BaselinePeriod) and Phase 2 (Intervention Period)Phase 1Phase 2 RR (95% CI) P Value(months 1-3)No. of inserted887 2,686catheters% of catheters withSterile Gauze83.9% 93.9% 1.12 (1.03 –1.21)0.0068% of catheters withSterile Gauze inGood Conditions84.0% 97.2% 1.16 (1.07 –1.26)0.0004Rosenthal et al. Infection. In Press 2011

Rates of Patients Hospitalized in the Pediatric Intensive Care Unitsin Phase 1 (Baseline Period) and in Phase 2 (Intervention Period)Phase 1 (months 1-3) Phase 2 RR (95% CI) P ValueNo. of CLAB 16 40No. of CL days 1,229 5,841CL use, mean 0.39 0.36 0.93 (0.87 – 0.99) 0.0198CLAB Rate per13.0 6.9 0.53 (0.29 – 0.94) 0.02711000 CL daysRR, relative risk; CI, confidence interval; CLAB, central line-associatedbloodstream infection; CL, central line.Rosenthal et al. Infection. In Press 2011

Overall Mortality Reduction in Phase 1 (BaselinePeriod) and Phase 2 (Intervention Period)Baseline periodInterventionRR (95% CI)P Value(months 1-3)periodNo. of Patients 1,272 3,067No. of deaths 145 253Percentage of10.3% 7.0% 0.69 (0.49 – 0.95) 0.0234deathsRR, relative risk; CI, confidence interval.Rosenthal et al. Infection. In Press 2011

Effectiveness of Multi-Faceted Infection Control Program to Reduce CentralLine-Associated Bloodstream Infections in Neonatal Intensive Care Units of 11Developing Countries: Findings of the International Nosocomial InfectionControl Consortium (INICC)Victor Daniel Rosenthal, 1 Regina Berba, 2 Lourdes Dueñas, 3 Canan Aygun, 4 Martha Sobreyra-Oropeza, 5 Amina Barkat, 6 Mandakini Pawar, 7 Khaldi Ammar, 8 María Eugenia Rodríguez-Calderón, 9 Teodora Atencio-Espinoza, 10 Cheong Yuet-Meng, 11 Gulden Ersoz, 12 Tanu Singhal, 13Josephine Anne Navoa-Ng, 14 Davut Ozdemir, 15 Marena Rodríguez-Ferrer. 16International Nosocomial Infection Control Consortium, Buenos Aires, Argentina;Philippine General Hospital, Manila, Philippines;Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador;Ondokuz Mayis University Medical School, Samsun,Turkey;Hospital de la Mujer, Mexico City, Mexico;Children Hôspital of Rabat, Rabat, Morocco;Pushpanjali Crosslay Hospital, Ghaziabad, India;Hôpital d'Enfants, Tunis, Tunisia;Hospital La Victoria, Bogota, ColombiaHospital Regional de Pucallpa, Pucallpa, Peru;Sunway Medical Centre Berhad and Monash University Sunway Campus, Petaling Jaya,Malaysia;Mersin University, Faculty of Medicine, Mersin; Turkey;Kokilaben Dhirubhai Ambani Hospital, Mumbai, India;St. Luke's Medical Center, Quezon City, Philippines;Duzce University, Duzce Medical School, Duzce, Turkey;Universidad Simón Bolivar, Barranquilla, Colombia;Rosenthal et al. Submitted to American Journal Infection Control.

Characteristics of Patients Hospitalized in Neonatal Intensive Care Unitsin Phase 1 (Baseline Period) and in Phase 2 (Intervention Period)BaselineperiodInterventionperiodRR 95% CI P. valueNo. ofpatientsSex %(male)Weight,mean ± SDGestationalAge, mean±SD1,248 5,71260% 58% 0.97 0.90 – 1.05 0.47042.48 ± 1.15 2.35 + 0.87 1.06 - 0.00334.6 ± 5.8 35.2 ± 4.84 1.02 - 0.024Rosenthal et al. Submitted to American Journal Infection Control.

Hand Hygiene Improvement in Phase 1 (Baseline Period)and in Phase 2 (Intervention Period)Phase 1(months 1-3)Phase 2 RR (95% CI) P. valueNo. of HandHygieneobservationsHandHygienecompliance% (n)1,451 5,17563% 79% 1.26 (1.18 – 1.36) 0.0001Rosenthal et al. Submitted to American Journal Infection Control.

Catheter Care Improvement in Phase 1 (Baseline Period) andPhase 2 (Intervention Period)Phase 1(months 1-3)Phase 2 RR (95% CI) P. valueNo. ofinsertedcatheters% ofcatheterswith SterileDressing% ofcatheterswith SterileDressingin GoodConditions3,631 25,70549% 78% 1.61 (1.53 – 1.70) 0.000157% 81% 1.43 (1.36 – 1.49) 0.0001Rosenthal et al. Submitted to American Journal Infection Control.

Rates of Patients Hospitalized in the Neonatal Intensive Care Units inPhase 1 (Baseline Period) and in Phase 2 (Intervention Period)Phase 1(months 1-3)Phase 2 RR (95% CI) P. valueNo. of CLAB 60 272No. of CL days 3,314 22,460CL use, mean 0.20 0.30 1.53(1.48 – 1.59)0.001CLAB Rateper 1000 CLdays18.1 12.1 0.67(0.51 – 0.88)0.0045RR, relative risk; CI, confidence interval; CLAB, central line-associatedbloodstream infection; CL, central line.Rosenthal et al. Submitted to American Journal Infection Control.

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing Countries• Special Conditions of Developing Countries.INICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Ventilator Associated Pneumonia (VAP• Catheter Associated Urinary Tract Infections (CAUTI)• Central Line Associated Blood Stream Infections (CLABSI)Impact of Closed Systems on CLABSI

The INICC CAUTI Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Process surveillance,5- Feedback of VAP rates,6- Performance feedback of infection controlpractices

INICC Bundle to Reduce CAUTI Rate1. Education and training on insertion, care, maintenance, alternatives to indwellingcatheters, procedures for catheter insertion, management, insertion, andremoval.2. Insertion urinary catheters only when needed and remove them when notnecessary.3. Use of indwelling urethral catheters for perioperative and for selected surgicalprocedures; urine output monitoring in critically ill patients; management of acuteurinary retention and urinary obstruction; assistance in pressure ulcer healing forincontinent residents.4. To consider other methods for management, including condom catheters or inand-outcatheterization, when appropriate.5. Hand hygiene before insertion and manipulation of the catheter.6. To use as small a catheter as possible.7. Use of gloves, a drape, and sponges; a sterile or antiseptic solution for cleaningthe urethral meatus; and a single-use packet of sterile lubricant jelly for insertion.

INICC Bundle to Reduce CAUTI Rate8. To insert catheters by use of aseptic technique and sterile equipment.9. Appropriate management of indwelling catheters: to properly secureindwelling catheters to prevent movement; to maintain a sterile,continuously closed drainage system; Not to disconnect the catheter anddrainage tube; to replace the collecting system by use of aseptictechnique and after disinfecting the catheter-tubing junction when breaksin aseptic technique, disconnection, or leakage occur.10.To maintain unobstructed urine flow.11.To keep the collecting bag below the level of the bladder at all times.12.To empty the collecting bag regularly; and to avoid allowing the drainingspigot to touch the collecting container.13.Cleaning of the meatal area as part of routine hygiene.14.Surveillance of CAUTI; using standardized criteria to identify patientswith CAUTI; to collect catheter-days as denominator.

Effectiveness of a Multidimensional Infection Control Approach on Catheter-Associated Urinary Tract Infections Rates in Pediatric Intensive Care Units of 7Developing Countries: Findings of the International Nosocomial Infection ControlConsortium (INICC)Victor Daniel Rosenthal, 1 Bala Ramachandran, 2 Lourdes Dueñas, 3Carlos Álvarez-Moreno, 4 Josephine Anne Navoa-Ng, 5 Alberto Armas-Ruiz, 6 Gulden Ersoz, 7 Lorena Matta-Cortés, 8Mandakini Pawar, 9 Ata Nevzat-Yalcin, 10 10 Marena Rodríguez-Ferrer, 11 11 Cheong Yuet-Meng, 12,13 R Dinçer Yıldızdaş, 14 14 AnaConcepción Bran de Casares, 3 Claudia Linares, 4 Victoria D. Villanueva, 5 Roberto Campuzano, 6 Ali Kaya, 7 LuisFernando Rendon-Campo, 8 Amit Gupta, 9 Ozge Turhan, 10 10 Nayide Barahona-Guzmán, 11 11 Jegathesan Manikavasagam, 12 12Ozden Ozgur Horoz, 14 14 Lilian de Jesús-Machuca, 3 María Corazon V. Tolentino, 5 Jorge Mena-Brito, 6 Necdet Kuyucu, 7Yamileth Astudillo, 8 Narinder Saini, 9 Nurgul Gunay, 10 10 Guillermo Sarmiento-Villa, 11 11 Lian Huat-Tan, 12 12 Eylul Gumus, 10 10Alfredo Lagares-Guzmán, 11 11 Joelene Lim, 12 12 Oguz Dursun. 10 10International Nosocomial Infection Control Consortium, Buenos Aires, Argentina;KK Childs Trust Hospital, Chennai, India;Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador;Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogota, Colombia;St. Luke's Medical Center, Quezon City, Philippines;Centro Médico La Raza IMSS, Mexico City, Mexico;Mersin University, Faculty of Medicine, Mersin, Turkey;Corporación Comfenalco Valle- Universidad Libre, Santiago de Cali, Colombia;Pushpanjali Crosslay Hospital, Ghaziabad, India;Akdeniz University, Antalya, Turkey;Universidad Simón Bolivar, Barranquilla, Colombia;Sunway Medical Centre Berhad, Petaling Jaya, Malaysia;Monash University Sunway Campus, Petaling Jaya, Malaysia;Çukurova University, Balcali Hospital, Adana, Turkey.Rosenthal et al. Infection Control and Hospital Epidemiology. In Press 2011

Characteristics of Patients Hospitalized in Pediatric Intensive Care Units in Phase1 (Baseline Period) and in Phase 2 (Intervention Period)No. patients 612 3,278Baseline Intervention RR 95% CI P- ValueStudy period, mean± SD (range)Urinary catheter duration,3 13.6 ± SD 10.4(range 4-34)2.51 ± 4.6 2.16 ± 5.71 - - 0.161mean ± SDMale 352 (58%) 1873 (57%) 0.99 0.89 – 1.11 0.9096Female 256 (42%) 1390 (42%)Surgical Stay, n (%) 120 (20%) 607 (19%) 0.94 0.78 – 1.15 0.5667Endocrine diseases, n (%) 14 (2%) 50 (2%) 0.67 0.37 – 1.21 0.1771COPD, n (%) 129 (21%) 767 (23%) 1.11 0.92 – 1.34 0.2723Abdominal Surgery, n (%) 11 (2%) 47 (1%) 0.80 0.41 – 1.54 0.4989Rosenthal et al. Infection Control and Hospital Epidemiology. In Press 2011

Rates of Patients Hospitalized in the Pediatric Intensive Care Unitsin Phase 1 (Baseline Period) and in Phase 2 (Intervention Period)Phase 1 (months 1-3) Phase 2 RR (95% CI) P ValueNo. of CAUTI 9 19No. of UC days 1,534 7,050UC use, mean 0.32 0.31 0.96 (0.91 – 1.01) 0.1267CAUTI Rate per5.9 2.7 0.46 (0.21 – 1.0) 0.04861000 UC daysCAUTI, Catheter-associated urinary tract infection; UC, urinary catheter; RR,relative risk; CI, confidence interval.Rosenthal et al. Infection Control and Hospital Epidemiology. In Press 2011

AgendaDevice Associated Infections (DAI) in Intensive Care Units (ICU)• Rates: Percentage vs Incidence Density.• DAI Rates in Developed Countries• DAI rates comparing developed and Developing Countries• Special Conditions of Developing Countries.INICC• Goals and Methods.• Monthly Report• DAI rates in Developing Countries.• Impact of Economy on DAI rates.Consecquences of DAI• Extra Mortality• Extra lenght of stay (LOS)• Extra Cost• Bacterial Resistance.Experience of INICC with Prevention of DAI• Hand Hygiene• Ventilator Associated Pneumonia (VAP)• Catheter Associated Urinary Tract Infections (CAUTI)• Central Line Associated Blood Stream Infections (CLABSI)Impact of Closed Systems on CLABSI

The INICC VAP Multi Faceted PreventionModel Included the Following Measures:1- Bundle of infection control interventions,2- Education,3- Outcome surveillance,4- Process surveillance,5- Feedback of VAP rates,6- Performance feedback of infection controlpractices

INICC Bundle to reduce VAP rate1. Conduction of active surveillance for VAP;2. Adherence to hand-hygiene guidelines;3. Maintenance of patients in a semi recumbent position (30-45° elevation of the head of the bed);4. Performance of daily assessments of readiness to wean anduse of weaning protocols;5. Performance of regular oral care with an antiseptic solution;6. Use of noninvasive ventilation whenever possible andminimization of the duration of ventilation;7. Preferable use of orotracheal instead to nasotrachealintubation;

INICC Bundle to reduce VAP rate8. Maintenance of an endotracheal cuff pressure of at least 20 cm H2O;9. Removal of the condensate from ventilator circuits; and keeping theventilator circuit closed during condensate removal;10.Change of the ventilator circuit only when visibly soiled or malfunctioning;11.Avoidance of gastric overdistention;12.Avoidance of histamine receptor 2 (H2)–blocking agents and protonpump inhibitors;13.Use of sterile water to rinse reusable respiratory equipment.14.We perform direct observation of hand hygiene compliance, duration ofthe ventilation, and ventilation ratio use, using a structured observationtools at regularly scheduled intervals.

Effectiveness of a Multi-faceted Prevention Model for Ventilator-AssociatedPneumonia in Adult Intensive Care Units from 16 Developing Countries:Findings of the International Nosocomial Infection Control Consortium (INICC).Victor D. Rosenthal; 1 Subhash Kumar Todi; 2 Carlos Álvarez-Moreno; 3 Rédouane Abouqal; 4 Zan Mitrev; 5Yeguxiang; 6 Josephine Anne Navoa-Ng; 7 Reinaldo Salomao; 8 Fatma Ulger; 9 Humberto Guanche-Garcell; 10 10 SSKanj; 11 11 Luis E. Cuéllar; 12 12 Francisco Higuera; 13 13 Cheong Yuet-Meng; 14 14 Trudell Mapp; 15 15 Rosalía Fernández-Hidalgo. 16 16International Nosocomial Infection Control Consortium, Buenos Aires, Argentina.Amri Hospitals, Kolkata, India.Hospital Universitario San Ignacio, Universidad Pontificia Javeriana, Bogotá, Colombia.Ibn Sina- Medical ICU, Rabat, Morocco.Filip II II Special Hospital for Surgery, Skopje, Macedonia.Yangpu Hospital, Shanghai, China.St. Luke's Medical Center, Quezon City, Philippines.Hospital Santa Marcelina, São Paulo, Brazil.Ondokuz Mayis University Medical School, Samsun, Turkey.Hospital Docente Clínico Quirúrgico “Joaquín Albarrán Domínguez”, Havana, Cuba.American University of Beirut Medical Center, Beirut, Lebanon.Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Perú.Hospital General de México, Mexico City, Mexico.Sunway Medical Centre Berhad and Monash University Sunway Campus, Petaling Jaya, Malaysia.Clínica Hospital San Fernando, Panama City, Panama.Hospital Clínica Bíblica, San José, Costa Rica.Rosenthal et al. Critical Care Medicine- In Press 2011

Patient characteristics at Phase 1 (baselineperiod) and Phase 2 (Intervention period).Variables Phase 1 Phase 2 RR 95% CI P- ValueNo. patients 5,579 76,441Male 62% 60% 0.98 0.94 – 1.010.1579Cardiac Surgery, n (%) 4% 3% 0.88 0.77 – 1.010.0684Rosenthal et al. Critical Care Medicine- In Press 2011

Ventilator-Associated Pneumonia Rates in the participatingAICUsPhase 1Baseline period(months 1-3)Phase 2InterventionperiodRR (95% CI)95% CINo. of VAP 277 2811No. of MV days 13344 170610MV use, mean 0.37 0.37 1.00 -VAP Rate per1000 MV days20.8 16.5 0.79 (0.70 –0.90)0.0002AICU, adult intensive care unit; RR, relative risk; CI, confidence interval; VAP, ventilator-associatedpneumonia; MV, mechanical ventilator; MV use ratio: MV use ratios were calculated by dividing the totalnumber of MV-days by the total number of patient-days. MV-days: the total number of days of exposure tomechanical ventilation by all of the patients in the selected population during the selected time period. Patientdays:the total number of days that patients are in the ICU during the selected time period.Rosenthal et al. Critical Care Medicine- In Press 2011

Effectiveness of a Multidimensional Approach to Reduce Ventilator-Associated Pneumonia in Pediatric Intensive Care Units of 5 DevelopingCountries: International Nosocomial Infection Control Consortium (INICC)Findings.Victor D Rosenthal 1 ; Carlos Álvarez-Moreno 2 ; Wilmer Villamil-Gómez 3 ; Sanjeev Singh 4 ; BalaRamachandran 5 ; Josephine A Navoa-Ng 6 ; Lourdes Dueñas 7 ; Ata N Yalcin 8 ; Gulden Ersoz 9 ; AntonioMenco 3 ; Patrick Arrieta 3 ; Ana C Bran-de-Casares 7 ; Lilian de-Jesus-Machuca 7 ; Kavitha Radhakrishnan 4 ;Victoria D Villanueva 6 ; Maria C V Tolentino 6 ; Ozge Turhan 8 ; Sevim Keskin 8 ; Eylul Gumus 8 ; OguzDursun 8 ; Ali Kaya 9 , Necdet Kuyucu 9International Nosocomial Infection Control Consortium, Buenos Aires, Argentina.Hospital Universitario San Ignacio, Universidad Pontificia Javeriana, Bogota, Colombia.Clinica Santa Maria, Sucre, Colombia.Amrita Institute of Medical Sciences & Research Center, Kochi, India.KK Childs Trust Hospital, Ghaziabad, IndiaSt. Luke’s Medical Center, Quezon City, Philippines.Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador.Akdeniz University, Antalya, TurkeyMersin University, Faculty of Medicine, Mersin, Turkey.Rosenthal et al. American Journal of Infeciton Control In Press 2011

Characteristics of Patients at Baseline andduring Intervention PeriodBaseline Intervention RR 95% CI PNo. months 7 21.1 (range 7-52, SD 15.1)No. patients 1,272 3,0675,212 9,894No. mechanical ventilatordaysNo. Bed days 9,113 20,096Sex, n (%)Male 710 (56%) 1802 (59%) 1.05 0.97 – 1.15 0.2471Female Rosenthal et al. 548 American (43%) Journal 1260 (41%) of Infeciton Control In Press 2011

Characteristics of Patients at Baseline andduring Intervention PeriodBaseline Intervention RR 95% CI PUnderlying Diseases 15 (1%) 29 (1%) 0.80 0.43 – 1.50 0.4865Renal Failure, n(%) 15 (1%) 29 (1%) 0.80 0.43 – 1.50 0.4865Hepatic Failure, n (%) 7 (1%) 6 (0.2%) 0.36 0.12 – 1.06 0.0520Cardiac Surgery, n (%) 35 (3%) 58 (2%) 0.69 0.45 – 1.05 0.0780Abdominal Surgery, n (%) 21 (2%) 33 (1%) 0.65 0.38 – 1.13 0.1222Thoracic Surgery, n (%) 8 (1%) 19 (1%) 0.99 0.43 – 2.25 0.9713Trauma, n (%) 33 (3%) 53 (2%) 0.67 0.43 – 1.03 0.0650Previous Infection, n (%) 109 (9%) 260 (8%) 0.99 0.79 – 1.24 0.9247Rosenthal et al. American Journal of Infeciton Control In Press 2011

Outcome Surveillance. VentilatorAssociated Pneumonia RatesBaseline period(months 1-7)InterventionperiodRR (95% CI)P valueNo. of VAP 61 80No. of MV days 5,212 9,894VAP Rate per1000 MV days11.7 8.1 0.69 (0.50 –0.96)0.0286RR, relative risk; CI, confidence interval; VAP, ventilator associated pneumonia;MV, mechanical ventilatorRosenthal et al. American Journal of Infection Control In Press 2011

Impact of a Multidimensional Strategy to Reduce Ventilator-AssociatedPneumonia in Neonatal Intensive Care Units in 11 DevelopingCountries: Findings of the International Nosocomial Infection ControlConsortium (INICC).Victor D. Rosenthal; 1 Maria E Rodríguez-Calderón; 2 Marena Rodríguez-Ferrer; 3 Tanu Singhal; 4Mandakini Pawar; 5 Cheong Yuet-Men; 6 Martha Sobreyra-Oropeza; 7 Amina Barkat; 8 TeodoraAtencio-Espinoza; 9 Regina Berba; 10 Josephine A Navoa-Ng; 11 Lourdes Dueñas; 12 Nejla Ben-Jaballah; 13 Davut Ozdemir; 14 Gulden Ersoz; 15 Canan Aygun. 16International Nosocomial Infection Control Consortium, Buenos Aires, ArgentinaHospital La Victoria, Bogotá, Colombia.Universidad Simón Bolívar, Barranquilla, Colombia.Kokilaben Dhirubhai Ambani Hospital, Mumbai, India.Pushpanjali Crosslay Hospital, Ghaziabad, India.Sunway Medical Centre Berhad and Monash, University Sunway Campus, Petaling Jaya,Malaysia.Hospital de la Mujer, México D.F., México.Children Hospital of Rabat, Rabat, Morocco.Hospital Regional de Pucallpa, Pucallpa, Perú.Philippine General Hospital, Manila, Philippines.St. Luke’s Medical Center, Quezon City, Philippines.Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador.Hospital d’Enfants, Tunis, Tunisia.Duzce University Medical School Infectious Diseases and Clinical Microbiology, Duzce, Turkey.Mersin University, Faculty of Medicine, Mersin, Turkey.Ondokuz Mayis University Medical School, Samsun, Turkey.Rosenthal et al. Infection Control and Hospital Epidemiology. In Press 2011

Characteristics of patients in baseline and interventionperiodsBaseline Intervention P valueNo. months 3 14.5 (range 3-35; SD, 9.1)No. patients 1,240 5,6075,212 9,894No. mechanical ventilatordaysMV use ratio, mean (95% CI) 0.19 (0.18 – 0.20) 0.22 (0.21 – 0.23) 0.0001MV duration, mean ± SD 2.55 ± 7.3 2.85 ± 6.6 0.144No. bed days 9,113 20,096Sex, n (%)Male 59% (733) 58% (3,271) 0.7467Female 41% (507) 42% (2336)Weight, mean ± SD 2. 43 ± 1.14 2.36 ± 0.87 0.090Rosenthal et al. Infection Control and Hospital Epidemiology. In Press 2011

Ventilator-associated pneumonia inbaseline and intervention periodsBaseline periodInterventionRR (95% CI)P value(months 1-3)periodNo. of VAP 56 191No. of MV days 3,303 15,850VAP Rate per17.0 12.1 0.71 (0.53 – 0.96) 0.02341000 MV daysRR, relative risk; CI, confidence interval; VAP, ventilator associated pneumonia; MV,mechanical ventilatorRosenthal et al. Infection Control and Hospital Epidemiology. In Press 2011

ConclusionsHAIS rates in limited resources countries are higher than in USAand Europe.INICC trained health care workers of 40 limited resources countriessince 1998 to conduct outcome and process surveilance and to useincidence density of HAI rates.INICC hospitals generated a useful benchmark to compare HAIrates between hospitals and countries.INICC hospitals measured adverse consequences of HAI (mortality,extra length of stay, cost, bacterial resistance)INICC “Multidimensional Approach” including a bundle, education,outcome surveillance, feedback of HAI rates, process surveillance,and performance feedback was useful to significantly increasecompliance with infection control guidelines, to significantly reduceHAI rates, and to significantly reduce mortality.

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