Healthcare-associated infections in Brazilian ICUs
Abstract:
Objectives: Healthcare-associated infections are common and potentially preventable, especially in low- and middle-income countries (LMICs), due to substandard staffing, structure, and process-of-care. We evaluated institutional risk factors associated with ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI) rates.
Design: Multicenter cohort study.
Setting: Fifty Brazilian ICUs.
Patients: All patients admitted from September 2019 to December 2021 to the participating ICUs, exposed to at least 2 days of invasive mechanical ventilation (MV) or central venous catheter (CVC).
Interventions: None.
Measurements and main results: Individual patient data were prospectively collected, and cross-sectional hospital-level data were collected at baseline. VAP and CLABSI were reported in accordance with Brazilian regulatory agency guidance. Negative binomial or Poisson multiple regression were used to model risk factors, adjusted for individual-level covariates. Of 75,164 ICU admissions, there were 19,108 at-risk (≥ 48 hr of MV) patients with a total of 244,059 MV-days for a VAP incidence rate of 6.03 (95% CI, 5.73-6.35) per 1,000 MV-days. There were 26,560 patients with a total of 375,078 CVC-days for a CLABSI incidence rate of 1.63 per 1,000 CVC-days (95% CI, 1.51-1.77 per 1,000 CVC-days). The median rate ratios of hospital random-effects were 4.39 (95% CI, 2.72-6.06) for VAP and 3.53 (95% CI, 2.30-4.76) for CLABSI. Hospital-level fixed effects explained 39.9% (95% CI, 33.6-46.1%) of the between-hospital variability for VAP and 44.7% (95% CI, 35.0-54.5%) for CLABSI. Prevention protocols, flexible family visitation policies, and hand hygiene training were associated with reduced rates of VAP and CLABSI. Nursing staffing ratios, single-use gowns, and alcohol availability were associated with a lower CLABSI rate. Sedation titration by nurses, weaning by respiratory therapists, and dentist availability were associated with a lower rate of VAP.
Conclusions: Processes-of-care and ICU structure measures are associated with the burden of VAP and CLABSI in LMICs.
Reference:
Besen BAMP, Dietrich C, Pinheiro CCG, Silva DP, de Mattos RR, Spadoni CCDS, Reis LFL, Nunes Neto PA, Paciência LEM, Caser EB, Ferreira Fernandes CC, Fernandes VF, Ferronato BR, Urbano HCA, Grion CMC, Medeiros EML, Silva ACD, Golin NA, Lima VP, Boschi E, Machado AS, Foernges RB, de Oliveira Junior LC, Silva EM, Pereira FC, Lisboa TC, Nassar AP Jr, Pereira AJ, Veiga VC, Arns B, Marsola G, Machado FR, Cavalcanti AB, Azevedo LCP, Tomazini BM; Impact of Infections by Antimicrobial-Resistant Microorganisms in Patients Admitted to Adult ICUs in Brazil: Platform of Projects to Support the National Action Plan for the Prevention and Control of Antimicrobial Resistance (IMPACTO-MR) investigators and Brazilian Research in Intensive Care Network (BRICNet). Institutional Risk Factors Associated With Healthcare-Associated Infections in Brazilian ICUs: A Nested Cohort Within the IMPACTO-MR Platform. Crit Care Med. 2025 Sep 24. doi: 10.1097/CCM.0000000000006881. Epub ahead of print. PMID: 40990605.