Beruflich Dokumente
Kultur Dokumente
To the
CRBSI SYMPOSIUM
Dr. Victor Rosenthal’s
Summarized CV
Dr. Rosenthal is a specialist in Internal Medicine and Infectious Diseases in Buenos Aires. He holds
an Infectious Diseases fellowship at the University of Wisconsin. He is a graduate in Clinical
Effectiveness, from Harvard University. He is certified on Infection Control and Hospital Epidemiology.
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 Infections collaborating with more than 2,000 researchers in more than 500 cities in more
than 50 countries.
He is Coauthor of JCI guidelines to prevent CR-BSI. He was a Task Force Member and Reviewer of
the Infection Control Guidelines for the World Health Organization (WHO) for Hand Hygiene and
Bacterial Rersistance. He has collaborated with Center for Diseases Control and Prevention (CDC)
and with Microbiology Lab of US Army (NAMRU) on international infection control programs. He has
collaborated with edition of the Infection Control Guidelines of Argentina, Brazil, Colombia, Peru,
Hong Kong, Taiwan, China and several other countries.
He is an editorial board member and scientific reviewer of more than 100 international peer reviewed
journals, such as “Lancet”, “Lancet ID”, “American Journal of Infection Control (AJIC)”, “Infection
Control and Hospital Epidemiology”(ICHE), and several others.
Being an author of more than 400 scientific publications and book chapters worldwide, Dr. Rosenthal
has received several awards granted at different international scientific meetings, including SHEA,
APIC, IFIC, Pan American Meetings, and others. Dr. Rosenthal was a speaker in more than 5,000
conferences and symposiums in more than 100 countries, at the five continents, during last 28 years.
South East Asia
January 30th to February 17th, 2017
Benedetta Allegranzi et al. Report on the Burden of Endemic Health Care-Associated Infection
Worldwide. A systematic review of the literature. © World Health Organization 2011
T h e B u r d e n O f E n d e mic H e a l t h C a r e - a s soci at ed
I n f e cti on I n L ow - A n d M i d d le- inco me C o u n tr ie s
Benedetta Allegranzi et al. Report on the Burden of Endemic Health Care-Associated Infection
Worldwide. A systematic review of the literature. © World Health Organization 2011
Sc ope of INICC
HAI Rates
Mortality, LOS, Costs
Training of HAIs
Microorganism
profile and bacterial
Guidelines
resistance
Publications HH Compliance
Compliance with
Cost-effectiveness Bundles of Care
Analysis (BSI, UTI, VAP, SSI)
Reports and
Surveillance of NSIs
Benchmarking
Antimicrobial
consumption
www.INICC.org
2- CUBA 3- DOMINICAN REPUBLIC
1- MEXICO
4- PUERTO RICO
6- GUATEMALA
7- EL SALVADOR
5- HONDURAS
8- NICARAGUA
9- COSTA RICA
10- PANAMA 11- VENEZUELA
12- COLOMBIA
13- ECUADOR
16- BOLIVIA
LATIN AMERICA
19- ARGENTINA
20- URUGUAY
1- MONGOLIA
2- NEPAL
3- CHINA
4- BANGLADESH
5- INDIA
6- THAILAND 8- PHILIPPINES
9- VIETNAM
11- SINGAPORE
SOUTH EAST ASIA
&
WESTERN PACIFIC
12- INDONESIA
13- PAPUA NEW GUINEA
13 COUNTRIES
4- IRAN
1- LEBANON
5- PAKISTAN
2- MOROCCO 6- JORDAN
7- KUWAIT
3- EGYPT
9- SAUDI ARABIA 8- BAHRAIN
10 COUNTRIES
EASTERN EUROPE
8 COUNTRIES
1- RUSSIA
2- POLAND
3- SERBIA
4- KOSOVO
6- BULGARIA
5- MACEDONIA
7- TURKEY
8- GREECE
Systematic Review of CRBSI in Limited Resources Countries Published at “Clinical
Infectious Diseases”, Official Peer Review Journal Indexed in Pubmed of the
Infectious Diseases Society of America, in 2009
Limited Resource Intensive Care Units (ICUs) With Outdated
Technology
(1) Crowded ICUs; (2) three-way stop-cock, open intravenous connector; (3) open glass intravenous container with air
filter; (4) ICU with 42 beds and neither sinks nor alcohol hand rub; (5) central line insertion with no maximal barrier;
(6) open, semi-rigid, plastic intravenous container with inserted needle; (7) sinks at a neonatal ICU with no antiseptic
soaps; (8) wet cloth towel; (9) open burette intravenous container with air filter.
Limited Resource Intensive Care Units (ICUs) With Outdated
Technology
(1) Cotton balls already impregnated with contaminated antiseptic; (2) central line in place with no dressing; (3) open
semi-rigid intravenous container with administration set and 3-way stopcock for intravenous preparation; (4) Single-dose
vials used multiple times and covered with contaminated tape; (5) peripheral line in a newborn with no sterile dressing; (6)
multi-use vials used with an inserted needle; (7) single-dose vials used multiple times and open to the air; (8) peripheral
line in an adult patient with no sterile dressing; (9) semi-rigid plastic container used for intravenous preparation.
S i x I N I C C i n t e r na t iona l r e p o r t s
( o n e ev e r y s e c o nd ye a r, f ro m 2 0 0 6 t o 2 0 1 6 )
Number of 8 18 25 36 43 50
Countries
15
S i x ( 6 ) I N I C C i n t e r na t iona l r e p o r t s,
p u b lishe d f ro m 2 0 0 6 t o 2 0 1 6
INICC 2002- INICC 2002- INICC 2003- INICC 2004- INICC 2007- INICC 2010-
2005 2007 2008 2009 2012 2015
(Published in (Published in (Published in (Published in (Published in (Published in
2006) 2008) 2010) 2012) 2014) 2016)
Pooled Mean Pooled Mean Pooled Mean Pooled Mean Pooled Mean Pooled Mean
Countries, n 8 18 25 36 43 50
• Countries included: Argentina, Bolivia, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba,
Dominican Republic, Ecuador, Egypt, Greece, India, Iran, Jordan, Kosovo, Lebanon, Lithuania,
Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Poland, Puerto Rico,
Romania, El Salvador, Saudi Arabia, Serbia, Singapore, Slovakia, Sri Lanka, Sudan, Thailand, Tunisia,
Turkey, United Arab Emirates, Uruguay, Venezuela,Vietnam
• ICUs: 703
• Patients: 861,284
• Bed days: 3,506,562
• Central Line days: 2,011,406
• Ventilator days: 1,246,455
• Urinary catheter days: 2,254,329
• CR-BSI (n): 8,428
• VAP (n): 15.173
• CAUTI (n): 10,868
• Total IAD: 34,469
Rosenthal, VD et al. “International Nosocomial Infection Control Consortium (INICC) Report, data summary of
50 countries, for 2010-2015”. American Journal of Infection Control. December 2016.
HA I rates INICC vs CDC -NHSN (USA )
Medical-surgical ICU
CR-BSI 4.11 (4.0-4.2) 0.8 (0.8-0.9)
CAUTI 5.07 (4.9-5.2) 1.7 (1.6-1.8)
VAP 13.1 (12.9-13.4) 0.9 (0.8-1.0)
Rosenthal, VD et al. “International Nosocomial Infection Control Consortium (INICC) Report, data summary of
50 countries, for 2010-2015”. American Journal of Infection Control. December 2016.
HA I rates INICC vs CDC -NHSN (USA )
NICU CR-BSI
Rate
<750 20.90 (16.8-25.7) 2.1 (1.9-2.3)
750-1000 8.74 (6.9-11.0) 1.3 (1.2-1.5)
1001-1500 19.70 (16.9-22.8) 0.8 (0.7-0.9)
1501-2500 20.86 (18.6-23.3) 0.6 (0.5-0.7)
>2500 10.53 (8.6-12.8) 0.7 (0.6-0.9)
Rosenthal, VD et al. “International Nosocomial Infection Control Consortium (INICC) Report, data summary of
50 countries, for 2010-2015”. American Journal of Infection Control. December 2016.
CR-BSI rate in India, Malaysia, Philippines
Infection risks associated with peripheral vascular catheters. Li Zhang, Siyu Cao, Nicole Marsh,
Journal of Infection Prevention 2016
I n f ec t io n R i s ks A s so c i ated W i t h Pe r i p h er al Va sc ul ar
C a t h et ers
Infection risks associated with peripheral vascular catheters. Li Zhang, Siyu Cao, Nicole Marsh,
Journal of Infection Prevention 2016
A n t i mi crobia l r e s is ta nce r a t e s r e l a t ed t o C R - BS I
Rosenthal, VD et al. “International Nosocomial Infection Control Consortium (INICC) Report, data summary of
50 countries, for 2010-2015”. American Journal of Infection Control. December 2016.
Length of Stay with and without CR-BSI
Infants at level III neonatal intensive care units, with CR-BSI 37.82 (37.10-38.60)
Infants at level III neonatal intensive care units, with VAP 36.16 (34.80-37.60)
Rosenthal, VD et al. “International Nosocomial Infection Control Consortium (INICC) Report, data summary of
50 countries, for 2010-2015”. American Journal of Infection Control. December 2016.
Mortality with and without CR-BSI
Infants at level III neonatal intensive care units, with CR-BSI 29.7% (24.2-35.6)
Infants at level III neonatal intensive care units, with VAP 28.4% (18.5-40.0)
Rosenthal, VD et al. “International Nosocomial Infection Control Consortium (INICC) Report, data summary of
50 countries, for 2010-2015”. American Journal of Infection Control. December 2016.
Extra
Costs
and
Length
of Stay
of HAIs
28
T h e a t t r i b u t a bl e c o s t , l e n g t h o f h o s p i t a l s t a y, a n d m o r t a l i t y o f
c e n t r a l l i n e - a s s o c i a t e d C R - B S I i n i n t e n s i v e c a r e d e p a r t m e nt s i n
a r g e n t i n a : A p r o s p e c t i ve , m a t c h e d a n a l y s i s .
29
Rosenthal VD, et al. Am J Infect Control 2003;31(8):475-80.
T h e a t t r i b u t a bl e c o s t , l e n g t h o f h o s p i t a l s t a y, a n d m o r t a l i t y o f
c e n t r a l l i n e - a s s o c i a t e d C R - B S I i n i n t e n s i v e c a r e d e p a r t m e nt s i n
a r g e n t i n a : A p r o s p e c t i ve , m a t c h e d a n a l y s i s .
Length of Stay (days) 30.58 + 20.41 6.95 + 4.89 23.6 4.40 4.08 – 4.75 0.0000
Reinaldo Salomao, Victor D. Rosenthal, et al. APIC Meeting. Tampa, USA. June 2006.
31
T h e a t t r i b u t a bl e c o s t , a n d l e n g t h o f h o s p i t a l s t a y o f c e n t r a l
l i n e a s s o c i a t ed C R - B S I i n i n t e n s i v e c a r e u n i t s i n m e x i c o . A
pr os pe c tiv e , ma t c he d a na ly s is .
Higuera F, Rangel-Frausto M, Rosenthal VD, Graves N, et al. Infection Control and Hospital Epidemiology.
32 January 2007.
“IF WE HAVE HIGH RATES OF CR-BSI”,
WE HAVE 2 OPTIONS
CLAB rate
Reduction by 54%
CLAB per
1000 CL
days
Rosenthal, V. D., D. G. Maki, et al. (2010). "Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central
line-associated bloodstream infection rates in the intensive care units of 15 developing countries." Infection control and hospital
epidemiology : the official journal of the Society of Hospital Epidemiologists of America 31(12): 1264-1272.
D e a t h s i n p a t i e nt s w i t h c e n t ra l l i n e -a sso cia te d
b l o o dst rea m i n f ecti on d u r i n g b a s e li ne a n d
i n t e r ve nti on p e r i o ds.
No. Deaths of CLAB- RR* (95%
patients at patients with associated CI)
Cohort ICUs, n risk CLAB, n deaths per P-value
100 patients
(%)
Months 1-3 86 7,376 77 1.04 - -
(Baseline)
1. Victor D. Rosenthal, Founder and Chairman of the International 14. Adeeba Kamarulzaman, Dean, Faculty of Medicine University of Malaya.
Nosocomial Infection Control Consortium (INICC), Argentina; University Malaya Medical Centre, Malaysia;
2. Souha S. Kanj, Professor of Medicine at American University of Beirut, 15. Maria Isabel Villegas Mota. Director of Strategic Planning of Hospital
Head, Division of Infectious Diseases and Chair, Infection Control and Juarez de Mexico;
Prevention Program, Lebanon;
16. Roxana Trejo, President of the Hospital Infection Society of Mexico;
3. Javier Desse, Professor Infectious Diseases, Buenos Aires University;
Professor of Microbiology, Maimonides University;; Founding Member of 17. Ider Bat-Erdene, Board Member of Society of Infection Control
the Infectious Diseases Society of Argentina; Professionals of Mongolia;
4. Safaa AlKhawaja, Head of Infection Control Department of Ministry of 18. Hernan Diosnel Rodriguez Enciso, Former President of the Infectious
Health, Bahrain; Diseases Society of Paraguay;
5. Sergio Cimerman, President of the Infectious Diseases Society of Brazil; 19. Sofia Del Carmen González Collantes, President of the Infectious
Diseases Society of Peru;
6. Alfonso J Rodriguez Morales, President of the Colombian Association of
Infectious Diseases Coffee-Triangle Chapter, Senior Researcher and 20. Melecia A. Velmonte, Founder and Former President of the infection
Professor at the Universidad Tecnológica de Pereira, Colombia; Control Society of Philippines;
7. Amani El Kholy, President of the Egyptian African Society for Clinical 21. Wieslawa Duszynska, Assistant Professor at Wroclaw Medical University,
Microbiology Infectious Diseases and Infection Control, Cairo University Poland;
Hospital, Egypt;
22. Paul Tambyah, Secretary-General of the Asia Pacific Society of Clinical
8. Japheth A. Opintan, Professor of Microbiology of college of health of Microbiology and Infection, Republic of Singapore;
university of Ghana medical school, Ghana;
23. Kushlani Jayatilleke, Member of the IPC Guideline Development Group,
9. Gertrude Sika Avortri, Deputy Director, Clinical Information and WHO, Geneva, 2016, Consultant Microbiologist, Sri Jayewardenapura
Monitoring Department, National Infection Prevention and Control General Hospital, Sri Lanka;
Coordinator, Ghana Health Service, Ghana;
24. Anucha Apisarnthanarak, Executive Committee Asia Pacific Society of
10. Sanjeev Singh, Chair of Research Committee at National Accreditation Infection Control, Thailand;
Board for hospitals, India;
25. Najiba M Abdulrazzaq, General Director, General Directorate of Infection
11. Yatin Mehta, President Elect, Indian Society of Critical Care Medicine, Prevention and Control, Ministry of Health, United Arab Emirates;
India;
26. Nguyen Viet Hung, Vice President and General Secretary of the Hanoi
12. Toshihiro Mitsuda, Associate Professor, Director of the Department of Society of Infection Control, Vietnam;
Infection Prevention and Control Yokohama City University Hospital,
Japan; 27. Hakan Leblebicioglu, Former President of Infectious Diseases and Clinical
Microbiology Specialty Society of Turkey, Ondokuz Mayis University
13. Hail M Al-Abdely, General Director, General Directorate of Infection Medical School, Turkey.
Prevention and Control, Ministry of Health, Kingdom of Saudi Arabia;
Bu n d le o f t h e i n t e r na ti ona l n o s o com ia l i n f e cti on
c o n t rol c o n s or t ium ( I N I C C ) t o p r event c e n t r a l a n d
p e r i phe ra l l i n e - re la te d b l o o dstr ea m i n f ecti ons
1. Adapted bundles,
2. Education and training of healthcare
personnel
3. Outcome surveillance.
4. Process surveillance,
5. Feedback on outcome surveillance,
6. Performance feedback.4, 82-86, 104, 154, 155, 169, 172,
176, 179-182
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
1. Bu n d le
• Outcome Surveillance included rates of HAI per 1000 device-days, use of invasive
devices (CL, mechanical ventilator, and urinary catheter), severity illness score,
underlying diseases, use of antibiotics, culture taken, microorganism profile,
bacterial resistance, length of stay, mortality in their ICUs.
• HAI definitions and surveillance methods were performed applying the definitions
for healthcare-associated infection (HAI) developed by the U.S. Centers for
Disease Control and Prevention (CDC) for the National Healthcare Safety
Network (NHSN) program.
• Additionally, INICC methods were adapted to the limited-resource setting of
developing countries, due to their different socioeconomic status.
• ASIS score was used instead of APACHE II score due to budget limitations of
participating ICUs from this limited-resource country. Thus, we decided to use
ASIS score, as historically used by the CDC NNIS .
4 . P ro c e s s s u r vei lla nce
• Upon processing the hospitals’ outcome surveillance data on a monthly basis, the INICC
Research Team, at INICC Headquarters located in Buenos Aires, prepares and sends to each ICT
a final report on the results of outcome surveillance rates; that is, monthly DA-HAI rates, length
of stay, bacterial profile and resistance, and mortality.
• Feedback of DA-HAI rates is provided to HCWs working in the AICU by communicating the
outcomes of the patients.
• The resulting rates are reviewed by the ICT at monthly meetings, where charts are analyzed, and
statistical graphs and visuals are posted inside the ICU, to provide an overview of rates of DA-
HAIs.
• This infection control tool is key to increase awareness about outcomes of patients at their ICU,
enable the ICT and ICU staff to focus on the necessary issues and apply specific strategies for
improvement of high DA-HAI rates.
6 . Pe r f o r m ance f e e dba ck
• Upon processing the hospitals’ process surveillance data on a monthly basis, the
INICC Research Team, at INICC Headquarters located in Buenos Aires, prepares
and sends to each ICT a final report on the results of process surveillance rates,
including compliance with hand hygiene, and care of CL.
• Performance feedback is provided to HCWs working in the AICU by
communicating the assessment of practices routinely performed by them.
• The resulting rates are reviewed by the ICT at monthly meetings, where charts
are analyzed, and statistical graphs and visuals are posted inside the ICU, to
provide an overview of rates measuring compliance with infection control
practices.
• This infection control tool is key to enable the ICT and ICU staff to focus on the
necessary strategies for improvement of low compliance rates.
Bu n d le o f t h e i n t e r na ti ona l n o s o com ia l i n f e cti on
c o n t rol c o n s or t ium ( I N I C C ) t o p r event c e n t r a l a n d
p e r i phe ra l l i n e - re la te d b l o o dstr ea m i n f ecti ons
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
C h a r a c t er ist ics o f t h e p a r t i c i pat ing h o s pi ta ls
( f ro m A p r il 1 9 9 9 t o D e c e m ber 2 0 1 2 )
ICUs, n Number of observations
Country
Argentina 11 21998
Brazil 4 4837
China 5 2079
Colombia 11 13512
Costa Rica 1 303
Cuba 1 434
Greece 1 2315
El Salvador 3 1691
India 18 32869
Lebanon 1 1728
Lithuania 1 1565
Macedonia 1 3418
Mexico 10 13201
Pakistan 3 1830
Panama 1 551
Peru 5 6610
Philippines 9 17844
Poland 1 102
Turkey 12 22840
All countries 99 149,727
Type of ICU, n
Adult 80 (81%) 131882
Pediatric 9 (9%) 9081
New Born 10 (10%) 8764
All ICUs 99 (100%) 149,727
Type of hospital, n (%)
Academic Teaching 27 (42%) 50515
Public Hospital 16 (25%) 40530
Private Community 22 (34%) 58682
All hospitals 65 (100%) 149,727
H a n d hy g i e ne c o m p lia nce by t y p e o f v a r i a b le .
L o g i st ic r e g r e ssion, m u l t i va r ia te a n a l y sis
85.0
86.0
81.2
75.0
71.4
65.0 69.4 69.1
67.2
Hand
Hygie 61.2
ne
Comp
55.0
liance
45.0 48.3
35.0
Month 1 to 3 Months 4 to 6 Months 7 to 9 Months 9 to 12 Second Year Third Year Fourth and Sixth and
Fifth Year Seventh Year
Central lines
Wear Maximal Sterile Barrier Precautions During
Insertion and Removal of a Central Line (quality
of evidence: II)1-4, 104, 185-191
• During central line (CL) insertion, both the inserter
and the assistant need to wear sterile gloves and
gown, cap and mask, and use a full-patient body
sterile drape.1
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
M a x i m a l s t e r i le b a r r i er p r e c a utio ns
4 5
3.5 4.5
3.5 4 4.51
3
3.5
2.5 3
2 2.5 2.92
CLAB
% of 1.5 per 1000 2
CLAB CL days 1.5
1
1
0.5 0.5
0.6
0 0
Baseline Maximal
Control MSB Barriers
Strattegy: Maximal Steriel Barrier Precautions Strategy: Standardize CL insertion with MSB precautions,
educational program for first postgraduate year
Raad, II, D. C. Hohn, et al. (1994). "Prevention of central venous Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B,
catheter-related infections by using maximal sterile barrier Flynn L, Hayes S, Strong S, Cruz J, Bowton DL, Hulgan T, Haponik EF.
precautions during insertion." Infection control and hospital Education of physicians-in-training can decrease the risk for vascular
epidemiology : 15(4 Pt 1): 231-238. catheter infection. Ann Intern Med. 2000 Apr 18;132(8):641–648.
Bu n d le o f t h e i n t e r na ti ona l n o s o com ia l i n f e cti on
c o n t rol c o n s or t ium ( I N I C C ) t o p r event c e n t r a l a n d
p e r i phe ra l l i n e - re la te d b l o o dstr ea m i n f ecti ons
Peripheral lines
Use Appropriate Personal Protective Equipment and Aseptic Technique
During Insertion of Peripheral Lines (quality of evidence: II) 175
• Use a new pair of disposable, nonsterile gloves in conjunction with a “no-
touch” technique for peripheral line (PL) insertion, meaning that the insertion
site is not palpated after skin antisepsis.
• Maintain aseptic technique for the insertion and care of PLs. Consider
labelling PL inserted under suboptimal aseptic conditions. e.g. “Emergent.
Remove and insert a new PL as soon as possible, preferably within 24 to
48 hours”.
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bu n d le o f t h e i n t e r na ti ona l n o s o com ia l i n f e cti on
c o n t rol c o n s or t ium ( I N I C C ) t o p r event c e n t r a l a n d
p e r i phe ra l l i n e - re la te d b l o o dstr ea m i n f ecti ons
• Skin Antisepsis with Single Use Application or Sterile Single Use Applicator
of 2% Chlorhexidine Gluconate in 70% Isopropyl Alcohol at Insertion Site
Prior to Insertion and Prior to Changing Dressing of a VAD (quality of evidence:
I)1-4, 104, 185, 186, 192-199
• During 30 seconds for dry sites, non-groin areas, and 2 minutes for groin areas, and allow to dry:
• Prior to the insertion of a VAD,
• Prior to dressing changes at VAD insertion site,
• No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2
months.1
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
S k i n p r e pa r at io n
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
I n s e r t io n s i t e s e l e ctio n
Data derived from several observational studies of CVC insertions suggest that the
• greatest risk of infection in adults is associated with use of the femoral vein as the
insertion site,
• the lowest risk is associated with subclavian site insertions,
• an intermediate level of risk associated with internal jugular vein insertions for nontunneled
CVCs
I n s e r t io n s i t e s e l e ctio n
Colonization CLAB
60.0 12
Goetz, A. M., M. M. Wagener, et al. (1998). "Risk of infection due to central venous catheters: effect of site of placement and catheter
type." Infection Control & Hospital Epidemiology 19(11): 842-845.
Bundle of the International Nosocomial Infection Control Consortium
(INICC) to Prevent Central and Peripheral Line-Related Bloodstream
Infections
In paediatric patients:
• For inserting a PL, the upper, or lower extremity,
and the scalp (in young infants) can be used.1-4,
185, 223, 224
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
Peripheral Arterial Lines:
• For adults,
• The radial artery is the most appropriate access for percutaneous cannulation,
• the brachial artery
• followed by the dorsalis pedis as alternative sites.
• For paediatric patients,
• Use the radial,
• posterior tibial,
• and dorsalis pedis arteries.
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
• Remove PLs when Not Needed (quality of evidence: II)1-4, 75, 104, 185, 235-238
• PLs should be removed when complications occur or as soon as it is no longer
required.75, 238
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
• Do Not Routinely Replace CLs (quality of evidence: II)1-4, 75, 185, 235-237
• PLs should be removed when complications occur or as soon as it is no longer required
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
• Do Not Routinely Replace PLs (quality of evidence: II)1-4, 75, 185, 235-237
• PLs should be re-sited when clinically indicated and not routinely.
• PLs insertion sites should be inspected at a minimum during each shift, and a Visual Infusion
Phlebitis (VIP) score should be recorded.
• The catheter should be removed if signs of inflammation, infiltration or blockage are
present.75, 238
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
Peripheral
catheter
integrated extension
and needleless
access ports
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
• Use Sterile Dressings to Cover the VAD Insertion Site (quality of evidence: I)1-4, 185, 245-248
• Sterile transparent, semi-permeable polyurethane dressings (with or without chlorhexidine)
should be routinely changed every 7 days, or sooner, if they are no longer intact or if moisture
collects under the dressing.1-4, 185
• Use sterile gauze if a patient has profuse perspiration or if the VAD insertion site is bleeding or
leaking, and change when inspection of the insertion site is necessary or when the dressing
becomes damp, loosened or soiled.
• Replace sterile gauze with a transparent semi-permeable dressing as soon as possible.4
• Sterile gauze dressings should be routinely changed every 2 days, or sooner, if they are no longer
intact or if moisture collects under the dressing.1-4, 185
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
C H G i m p r egna t ed d r e ssi ngs
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
S t u d y ov e r view
Objective:
To compare the clinical impact and cost-effectiveness of
CLABSI prevention
• Needle Less Connector (NCs) + Single-Use Prefilled Flush devices (SUFs)
Vs.
• Three-Way Stopcocks (3WSCs) + Multiple Use Container (MUC)
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
P ro d u ct s ov e r v iew: N C + S U F v s . 3 W S C
Study Design:
• A Randomized controlled trial (RCT)
• 5 ICUs of 2 centers, 2 Cities in India;
Outcomes:
• Clinical impact and cost effectiveness analysis
Patient Groups:
• 1,096 ICU adult patients those needed a central line
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
Pa t i e n t c h a r a ct er ist ics: c o m pa r iso n b e t we en n e e d le
l e s s c o n ne cto r a n d t h r e e -way s t o p cock g ro u p s
Patients’ co-morbodities and characteristics were similar in both comparison groups, showing that the CLAB and cost effectiveness difference
between the use of NC+SUF vs. 3WSC + MUC was attributable only to CLABSI and devices compared.
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
A g e g ro u p w i s e s e x d i s t r ibut ion
Patient Type
Age Group Total
Male Female
up to 15 1 (0.1) 1 (0.3) 2(.2)
16-25 35(4.8) 8(2.2) 43(.4)
26-35 56(7.7) 23(6.4) 79(7.3)
36-45 72(9.9) 25(6.9) 97(8.9)
46-55 106(14.6) 47(13.0) 153(14.1)
56-65 171(23.6) 75(20.7) 246(22.7)
66-75 153(21.1) 106(29.3) 259(23.8)
above 76 130(18.0) 77(21.3) 207(19.1)
Total 724 362 1086(100)
Mean Age 62.59 (+-16.16) 59.10(+/-17.57) 60.27(+/-17.18)
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
A g e d i s t r ibut io n o f p a t i e nts i n c a s e a n d c o n t ro l g ro u p
Patient Type
Age Group Total
NC + SUF 3-WSC + MUC
up to 15 1(0.2) 1 (.2) 2(.2)
16-25 21(3.8) 22(4) 43(.4)
26-35 41(7.6) 38(7) 79(7.3)
36-45 53(9.8) 44(8.1) 97(8.9)
46-55 83(15.3) 70(12.8) 153(14.1)
56-65 105(19.4) 141(25.9) 246(22.7)
66-75 115(21.3) 144(26.4) 259(23.8)
above 76 122(22.6) 85(15.6) 207(19.1)
Total 541(100) 545(100) 1086(100)
Mean 60.2+/-17.7 60.3+/-16.7 60.27(+/-17.18)
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
D i s e a se d i s t ri buti on
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
C L A BS I r a t e
CLABSI Rate per 1000 CL-days CLABSI Rate per 100 patients, %
7.00 5 4.7
6.40
4.5
6.00
4
CLABSI x 1000 CL-days
3.00 2
2.21 1.5
1.5
2.00
1
1.00 0.5
0
0.00 SS+SUF Group 3 WSC Group
SS+SUF group 3WSC group
CLABSIs per 1000 CL-
CLABSI rate per 100
2.21 6.40 1.5 4.7
days, n patients, %
CLABSI incidence rate is significantly lower in NC + SUF group than in 3WSC + MUC group
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
R e s u lt s
c o s t - effect ivenes s a n a l y sis
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
R e s u lt s – c o s t -e ffe ctive ness a n a l ys is
i m p a c t on cos t b y u s i n g NC +S U F i n s t e a d of 3 W S C
Per patient
average saving
Additional
investment
per device
$402.88
3.24
$124
saved for each extra dollar
invested in NC+SUF
Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-
way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International
Nosocomial Infection Control Consortium (INICC). Am J Infect Control 2015;43:1040-5
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
• Scrub and Disinfect Catheter Hub, Ports and Needleless Connectors (quality
of evidence: II)1-4, 185, 253-266
• A single-use application 70 % isopropyl alcohol alone or with 2 % chlorhexidine gluconate (or
povidone iodine in alcohol for patients with sensitivity to chlorhexidine) should be used to
decontaminate the access port, catheter hub, and needleless connectors.
• The access port, catheter hub, and needleless connectors should be cleaned for a minimum of
15 seconds and allowed to dry before accessing the system.
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-
Related Bloodstream Infections
• Replacement of IV administration Sets (quality of evidence: II)1-4, 82-86, 154, 155, 169, 176, 185
• Administration sets in continuous use do not need to be replaced more frequently than every 96
hours, unless they become disconnected or the VAD is replaced. 1-4, 185
• For blood and blood components, the set should be changed when the transfusion episode is
complete or with 24 hours (whichever is sooner).1-4, 185
• When used for lipid containing parenteral nutrition, the set should be changed within 24
hours of initiating the infusion.1-4, 185
• Replace tubing used to administer propofol infusions every 6 or 12 hours or when the vial is
changed (whichever is sooner).1-4
• Label date and hour of intravenous administration sets.82-86, 154, 155, 169, 176
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
S i n g le u s e f l u shing d ev i ce
• INS:
• Flushing is an important element of intermittent I.V
.therapy. Flushing with preservative-free 0.9 % sodium
chloride (USP) or other flush solutions shall be
performed before and after the administration of
incompatible medications and solutions
• Single-use flushing systems shall be used.
1- Rosenthal, K., Impacts On Adverse Events In 25 Sub-acute Care Units After a Change In Central Venous Catheter
Irrigation Techniques, JVAD, 1999
S i n g le u s e f l u shing d ev i ce
1- Calop J, Bosson J, Croize J, Laurent P. Maintenance of peripheral and central intravenous infusion devices by 0.9%
sodium chloride with or without heparin as a potential source of catheter microbial contamination. J Hosp Infect.2000;
46:161-162
2- Trautmann M, Zauser B,Wiedeck H. Bacterial colonisation and endotoxin contamination of intravenous infusion
fluids. J Hosp Inf 1997;37:225-236.
3.- Stucki C et al. Am J Health Syst Pharm 2009;56:2032-6.
4- Widell A, et al. Epidemiologic and molecular investigation of outbreaks of hepatitic C virus infection on a pediatric
oncology service. Ann Int Med 1999; 130:130-134.
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Bundle of the International Nosocomial Infection Control
Consortium (INICC) to Prevent Central and Peripheral Line-Related
Bloodstream Infections
JANUARY 1 st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
C AR E BU N D LES HAV E T WO (2 ) C O MP ONENTS
BEHAVIOR TECHNOLOGY
1. Hand hygiene 7. Don’t Replace of 1. Clorhexidine skin antisepsis
CL at fixed
2. Maximal barrier intervals 2. Use single use device for
precautions upon flushing
insertion 8. Don’t Replace of
PL at fixed 3. Sterile chlorhexidine
3. Optimal catheter intervals impregnated dressing at
site selection, with insertion site
avoidance of the 9. Scrub and disinfect
femoral vein for catheter hub, ports 4. Needleless connectors as IV
CV access in adult and needleless connection devices
patients connectors
5. PL with integrated extension
4. Sterile dressings to10. Replace IV and needleless access ports
cover the VAD administration sets
insertion site every 96 hs 6. Closed IV fluid containers
5. Remove CL when 11. Don’t use of multi- 7. Daily bath with 2%
is not needed dose vials as chlorhexidine-impregnated
source for flushing wash cloth in patients with CL
6. Remove PL when and locking
is not needed
C o m po n ent s o f b u n d l e t o p r even t C L A B
IHI INICC
1. Hand hygiene 1. Hand hygiene
2. Maximal barrier precautions upon insertion 2. Maximal barrier precautions upon insertion
3. Clorhexidine skin antisepsis 3. Clorhexidine skin antisepsis
4. Optimal catheter site slection, with avoidance of 4. Optimal catheter site slection, with avoidance of
the femoral vein for CV access in adult patients the femoral vein for CV access in adult patients
5. Remove CL when is not needed 5. Remove CL when is not needed
6. Remove PL when is not needed
7. Don’t Replace of CL at fixed intervals
8. Don’t Replace of PL at fixed intervals
9. Scrub and disinfect catheter hub, ports and needleless
connectors
10. Replace IV administration sets every 96 hs
11. Don’t use of multi-dose vials as source for flushing and
locking
12. Use single use device for flushing
13. Sterile dressings to cover the VAD insertion site
14. Sterile chlorhexidine impregnated dressing at insertion
site
15. Needleless connectors as IV connection devices
16. PL with integrated extension and needleless access
ports
17. Closed IV fluid containers
18. Daily bath with 2% chlorhexidine-impregnated wash
cloth in patients with CL
W i t h I N I C C s u r v e i l l a n c e o n l i n e s y s t e m ( I S O S ) , I N I C C m e m b e r s w o r l w i de h a v e b e e n
c o n d uct ing:
A g r egated B a s ic S u r veil lanc e A n d / O r A d v a nced C o h or t S u r veil lance O f :
“ H A I s I n I C U ” , “ H A I s I n I n p a t i e n t W a r d s A n d S t e p D o w n U n i t s ” , “ S SI s ” ,
“ B e n c hmar k Wi th C D C N S H N A n d W ith I N ICC”
“ H a n d H i g ien e C o mpl iance”,
“ C o m p l i a n c e O f B u n d l e s To P r e v e n t C L A B , V A P, C A U T I , A n d S S I ” ,
“ M i c roorgan ism P r o f il e A n d B a c ter ial R e s is tence”,
“ E x t ra M o r t ali ty O f H A I s”, “ E xtr a L e nght O f S t ay O f H A I s”, “ R isk F a c t ors O f H A I s ”,
“ R o b o t To M a k e D i a g n o s i s O f H A I A c c o r di n g W i t h C D C N H S N R e c e n t C r i e t r i a ” ;
“ M a k i n g R e p o r t I n F o u r ( 4 ) S e c o n ds ” , A n d “ M u c h M o r e . “
INICC Surveillance Online System (ISOS)
All necessary Modules for Infection Control
INICC Surveillance Online System (ISOS)
Surveillance of HAIs
INICC Surveillance Online System (ISOS)
co nta ct u s b y ema i l :
o nl i ne@inicc.or g
co nta ct us i n o ur web pa g e:
w w w.INICC .org
f o l low us :