Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries

Context We know little about medical deviceassociated infections in developing countries. Contribution Prospective surveillance of 21069 patients who were hospitalized in 55 intensive care units in 46 hospitals in Central and South America, India, Morocco, and Turkey showed high rates (22.5 infections per 1000 intensive care unit days) of device-associated infections. Infections included ventilator-associated pneumonia (24.1 cases/1000 ventilator days), central venous catheterrelated bloodstream infections (12.5 cases/1000 catheter days), and catheter-associated urinary tract infections (8.9 cases/1000 catheter days). Eighty-four percent of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were ceftriaxone-resistant, and 59% of Pseudomonas aeruginosa isolates were fluoroquinolone-resistant. Implications Medical deviceassociated infections pose major risks in developing countries. The Editors Surveillance of health careassociated infections, especially in high-risk hospital settings, such as the intensive care unit (ICU) (1, 2), has become an integral feature of infection control and quality assurance in all U.S. hospitals. The Centers for Disease Control and Prevention (CDC) Study of the Efficacy of Nosocomial Infection Control (SENIC) Project (3) showed that surveillance can help prevent health careassociated infections. Standards for institutional surveillance have been adopted in the United States (1), the United Kingdom (4), Australia (5), Canada (6), and Germany (7). A growing body of literature has shown that health careassociated infections are a major cause of patient illness and death in developed countries (8, 9). Device-associated infections, particularly ventilator-associated pneumonia (1012), central venous catheter (CVC)associated bloodstream infections (1315), and catheter-associated urinary tract infections (16, 17), pose the greatest threat to patient safety in the ICU (18). Surveillance of health careassociated infection has been standardized by the CDC's National Nosocomial Infection Surveillance (NNIS) System by providing simple unambiguous definitions, especially for device-associated infections (1921). Targeted surveillance and calculation of device-associated infection rates per 1000 device days allows benchmarking with similar other hospitals and detection of unique institutional problems that need redress. Most published studies of ICU-acquired infections have come from hospitals in industrialized western countries (1, 8, 1019, 22, 23). Relatively few data have been reported from developing countries (9, 2427), especially rates of device-associated infections by using standardized definitions. We report the initial findings of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2002 through December 2005. The consortium was established by Dr. Rosenthal in 1998 when selected hospitals in Latin America began collecting surveillance data on health careassociated infections for inclusion in a regional database. Consortium hospitals provide general medical and surgical inpatient services to adults and children who require short-term care. All data from the participating hospitals were collected by using standardized NNIS System protocols and definitions (1921). The consortium has initially focused on surveillance and prevention of device-associated infections in adult and pediatric ICUs and high-risk nurseries. Methods Setting Most current participating hospitals and ICUs joined the consortium since 2002 after hearing Dr. Rosenthal (the INICC chairman) speak in their country or after learning about the INICC from its Web site (www.inicc.org), but some hospitals were actively solicited. Study data were collected between 2002 and 2005 in 55 ICUs in 46 hospitals from 8 developing countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey. The consortium requires each member hospital to have an infection control team, comprising a physician and an infection control practitioner, and a microbiology laboratory that can isolate and identify aerobic pathogens from clinical cultures and perform in vitro susceptibility testing by using standardized methods (28). The person responsible for surveillance in each institution must have had at least 3 years of infection control experience (Table 1). In most of the hospitals, the team had access to electronic patient data. Table 1. Features of the International Nosocomial Infection Control Consortium Hospitals and Intensive Care Units* The institutional review board at each hospital approved the study protocol. Patient confidentiality is protected by coding the recorded information, with patient identities available only to the individual hospital's infection control team. Infection Control Practices at the Study Sites Hand hygiene adherence varies in the different countries and ICUs, ranging from 20% to 70% (2932). A recent study in all participating ICUs found a 50% overall rate of hand hygiene adherence (32), similar to that of recent studies in the United States and Europe (33). Use of sterile dressings on CVC insertion sites also ranges widely (29, 34, 35). Open infusion systems (rigid or semirigid containers that must admit air to empty) rather than closed systems (fully collapsible containers that do not require any external vent to empty the solution; the container residue after administration does not exceed 5% of the nominal volume) or combinations of open and closed systems are universally used to deliver intravenous fluids and medications in the study hospitals (35). Surveillance and Case Report Forms Each center established an augmented infection control program, with the initial major emphasis on active surveillance of health careassociated infections and process surveillance of hand hygiene adherence and invasive device care. During the study, we determined the rates of ventilator-associated pneumonia, CVC-associated bloodstream infection, and catheter-associated urinary tract infection monthly by using current CDC NNIS System definitions (1921). Designated surveillance forms were used for all patients in the study ICUs, both patients with and those without health careassociated infection. The following data were to be recorded daily on the forms for each patient: temperature and blood pressure, invasive devices, all cultures done, imaging studies, and antibiotic use. Previous studies have shown that fever, hypotension, cultures, and initiation of antimicrobial therapy are powerful markers for the presence of a health careassociated infection (36). A mean average severity of illness score was also recorded for each patient at ICU admission by using the CDC NNIS System criteria (19). Points were totaled, with 1 point for surgical patients who require routine postoperative observation only, 2 points for physiologically stable nonsurgical patients who require overnight observation, 3 points for patients who need continuous nursing care and monitoring, 4 points for physiologically unstable patients who require intensive nursing and medical care and need frequent reassessment and adjustment of therapy, and 5 points for physiologically unstable patients who are in a coma or in shock and require cardiopulmonary resuscitation or intensive medical and nursing care with frequent reassessment. If a patient was determined to have acquired a health careassociated infection, the date of onset, site of infection, infecting microorganisms, and antimicrobial susceptibilities were also recorded. Definitions Ventilator-Associated Pneumonia Ventilator-associated pneumonia is indicated in a mechanically ventilated patient with a chest radiograph that shows new or progressive infiltrates, consolidation, cavitation, or pleural effusion. The patient must also have at least 1 of the following criteria: new onset of purulent sputum or change in character of sputum; organism cultured from blood; or isolation of an etiologic agent from a specimen obtained by tracheal aspirate, bronchial brushing or bronchoalveolar lavage, or biopsy. Laboratory-Confirmed CVC-Associated Bloodstream Infection Central venous catheterassociated bloodstream infection is laboratory-confirmed when a patient with a CVC has a recognized pathogen that is isolated from 1 or more percutaneous blood cultures after 48 hours of vascular catheterization and is not related to an infection at another site. The patient also has at least 1 of the following signs or symptoms: fever (temperature 38C), chills, or hypotension. With skin commensals (for example, diphtheroids, Bacillus spp., Propionibacterium spp., coagulase-negative staphylococci, or micrococci), the organism is cultured from 2 or more blood cultures. Clinically Suspected CVC-Associated Bloodstream Infection Central venous catheterassociated bloodstream infection is clinically suspected when a patient with a CVC has at least 1 of the following clinical signs with no other identified cause: fever (temperature 38C), hypotension (systolic blood pressure 90 mm Hg), or oliguria (urine output 20 mL/h) with blood cultures not obtained or no organisms recovered from blood cultures, infections not apparent at another site, and antimicrobial therapy instituted by the physician. Catheter-Associated Urinary Tract Infection For the diagnosis of catheter-associated urinary tract infection, the patient must meet 1 of 2 criteria. The first criterion is when a patient with a urinary catheter has 1 or more of the following symptoms with no other recognized cause: fever (temperature 38C), urgency, or suprapubic tenderness when the urine culture is positive for 105 colony-forming units per mL or more, with no more than 2 microorganisms isolated. The second criterion is when a patient with a urinary catheter has at least 2 of the following criteria with no other recognized cause: positive dipstick analysis for leukocyte esterase or nitr