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

17 October 2006 | Volume 145 Issue 8 | Pages 582-591

Background: Health care–associated infections from invasive medical devices in the intensive care unit (ICU) are a major threat to patient safety. Most published studies of ICU-acquired infections have come from industrialized western countries. In a Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) System report, the U.S. pooled mean rates of central venous catheter (CVC)–related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections were 4.0 per 1000 CVC days, 5.4 per 1000 mechanical ventilator days, and 3.9 per Foley catheter days, respectively.

Objective: To ascertain the incidence of device-associated infections in the ICUs of developing countries.

Design: Multicenter, prospective cohort surveillance of device-associated infection by using the CDC NNIS System definitions.

Setting: 55 ICUs of 46 hospitals in Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey that are members of the International Nosocomial Infection Control Consortium (INICC).

Measurements: Rates of device-associated infection per 100 patients and per 1000 device days.

Results: During 2002–2005, 21 069 patients who were hospitalized in ICUs for an aggregate 137 740 days acquired 3095 device-associated infections for an overall rate of 14.7% or 22.5 infections per 1000 ICU days. Ventilator-associated pneumonia posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by CVC-related bloodstream infections (30% of all device-associated infections or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days). Notably, 84% of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were resistant to ceftriaxone, and 59% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones. The crude mortality rate for patients with device-associated infections ranged from 35.2% (for CVC-associated bloodstream infection) to 44.9% (for ventilator-associated pneumonia).

Limitations: These initial data are not adequate to represent any entire country, and likely variations in the efficiency of surveillance and institutional resources may have affected the rates that were detected.

Conclusions: Device-associated infections in the ICUs of these developing countries pose greater threats to patient safety than in U.S. ICUs. Active infection control programs that perform surveillance of infection and implement guidelines for prevention can improve patient safety and must become a priority in every country.

*For a list of members of the International Nosocomial Infection Control Consortium, see the Appendix.

Editors' Notes Context We know little about medical device–associated infections in developing countries. Contribution Prospective surveillance of 21 069 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 catheter–related 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 device–associated infections pose major risks in developing countries. —The Editors

 

Author and Article Information

From the Medical College of Buenos Aires, Buenos Aires, Argentina; University of Wisconsin Medical School, Madison, Wisconsin; Santa Marcelina Hospital, São Paulo, Brazil; San Ignacio Hospital, Pontificia Javeriana University, Bogota, Colombia; Escorts Heart Institute and Research Centre, New Delhi, India; General Hospital, Mexico City, Mexico; Institute of Neoplastic Diseases, Lima, Peru; Ankara University School of Medicine, Ibni Sina Hospital, Ankara, Turkey; Ibn Sina Hospital, Rabat, Morocco; and Ondokuz Mayis University Medical School, Samsun, Turkey.

Acknowledgments: The authors thank the many professionals at each member hospital who assisted with the conduct of the surveillance study, including the surveillance nurses, clinical microbiology laboratory personnel, and the physicians and nurses providing care for the patients during the study, without whose cooperation and generous assistance the study would not have been possible.

Potential Financial Conflicts of Interest: During the past 5 years, Dr. Rosenthal has presented at scientific meetings sponsored by Baxter Healthcare International, Wyeth Colombia, and Tyco Healthcare Latin America.

Requests for Single Reprints: Victor D. Rosenthal, MD, Arengreen 1366, (1405) Buenos Aires, Argentina; e-mail, victor_rosenthal{at}inicc.org.

Current Author Addresses: Dr. Rosenthal: Arengreen 1366, (1405) Buenos Aires, Argentina.

Dr. Maki: H4/574, University of Wisconsin Hospital and Clinics, Madison, WI 53792.

Dr. Salomao: Rua Santa Marcelina, 177 Itaquera, São Paulo SP, Cep 08270-070, Brazil.

Dr. Álvarez-Moreno: Calle 122A No. 14-71, Apto. 412, Bogota, Colombia.

Dr. Mehta: Department of Anesthesiology and Critical Care, Escorts Heart Institute & Research Centre, Okhla Road, New Delhi 110 025, India.

Dr. Higuera: Dr. Balmis No. 148, Col. Doctores, C.P. 06726 Mexico, D.F. Mexico.

Dr. Cuellar: Calle Alonso de Molina 1566, Santiago de Surco, Lima, Peru.

Dr. Arikan: Angora Evleri, Sancak sok B2-2A, Ümitköy, Ankara, Turkey.

Dr. Abouqal: Service de Réanimation Médicale, Hopital Ibn Sina, CHU Ibn Sina, 10000-Rabat, Morocco.

Dr. Leblebicioglu: Department of Clinical Microbiology and Infectious Diseases, Ondokuz Mayis University Medical School, Samsun 55139, Turkey.

Author Contributions: Conception and design: V.D. Rosenthal, D.G. Maki.

Analysis and interpretation of the data: V.D. Rosenthal.

Drafting of the article: V.D. Rosenthal, D.G. Maki.

Critical revision of the article for important intellectual content: V.D. Rosenthal, D.G. Maki, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Final approval of the article: V.D. Rosenthal, D.G. Maki, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Provision of study materials or patients: V.D. Rosenthal, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Statistical expertise: V.D. Rosenthal.

Administrative, technical, or logistic support: V.D. Rosenthal.

Collection and assembly of data: V.D. Rosenthal, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

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