Care Bundels Stop Infections - DR - Rosenthal

WELCOME
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
Epidemiology and Prevention of

Catheter Related Blood Stream Infections
(CRBSIs)
INICC Care Bundles
Dr.Victor D. Rosenthal, MD, MSC, CIC

INICC Founder and Chairman
victor_rosenthal@inicc.org
T h e Bu 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 H i g h - 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
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
14- PERU 15- BRAZIL
16- BOLIVIA
LATIN AMERICA
20 COUNTRIES 17- PARAGUAY

18- CHILE
19- ARGENTINA
20- URUGUAY
1- MONGOLIA
2- NEPAL
3- CHINA
4- BANGLADESH
5- INDIA
6- THAILAND 8- PHILIPPINES
9- VIETNAM
7- SRI LANKA 10- MALAYSIA
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- UNITED ARAB EMIRATES

EASTERN
MEDITERRNEAN
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 )
Publication 2006 2008 2010 2012 2014 2016

year
Number of 8 18 25 36 43 50
Countries
Peer Review Annals of Internal American American American American American

Journal Medicine Journal of Journal of Journal of Journal of Journal of
Infection Infection Infection Infection Infection
Control Control Control Control Control
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
ICUs, n 55 98 173 422 503 703
CLABSI, 12.5 9.2 7.6 6.8 4.8 4.1

rate (per 1000
CL- days)
CAUTI, rate 8.9 6.5 6.3 6.3 5.3 4.82

(per 1000 UC
days)
VAP, 24.1 19.5 13.6 15.8 14.7 12.2

Rate (per 1000
MV days)
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.
I N I C C r e p o r t – 5 0 c o u n tr ie s - “ 2 01 0 t o 2 0 1 5 ”.
• 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
HA I rates INICC vs CDC -NHSN (USA )
INICC 2010-2015 U.S. NHSN 2013

Pooled Mean (95% CI) Pooled Mean (95% CI)
Medical Cardiac ICU

CR_BSI 3.81 (3.4-4.2) 1.0 (0.9-1.1)
CAUTI 4.49 (4.1-4.9) 2.3 (2.2-2.4)
VAP 13.7 (12.7-14.9) 1.0 (0.8-1.1)
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)
HA I rates INICC vs CDC -NHSN (USA )
INICC 2010–2015 U.S. NHSN 2013

Pooled Mean (95% CI) Pooled Mean
PICU
CR-BSI Rate 8.46 (7.9-9.0) 1.2 (1.1-1.3)
CAUTI Rate 5.50 (5.0-6.0) 2.5 (2.2-2.7)
VAP Rate 8.2 (7.7-8.8) 0.7 (0.6-0.8)
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)
CR-BSI rate in India, Malaysia, Philippines
Mehta, Jaggi,Rosenthal, et al. ICHE 2015
Rai, Gan, Rosenthal, et al. CJIC. 2016
Novoa, Berba, Galapia, Rosenthal, et al. AJIC 2011

CR-BSI rate in India, Malaysia, Philippines
India Malaysia Philippines INICC CDC- NHSN

50 countries
2005- 2013 2009-2015 2005- 2009 2010- 2015 2013
CLAB rate 5.1 9.4 4.6 4.1 0.8

per 1000
CL-Days
Mehta, Jaggi,Rosenthal, et al. ICHE 2015

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
• Peripheral vascular catheters (PVC) are the most

frequently used invasive medical devices in
hospitals, with 330 million sold each year in the
USA alone.
• It is estimated that 30–80% of hospitalised
patients receive at least one PVC during their
hospital stay.
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
• While the incidence of PVC-related infection (0.2–0.7

episodes per 1000 calendar days) is reportedly lower
than for CVCs, the far greater number of PVCs in use
means that the absolute infection rates for PVCs
approach the absolute infection rates for CVCs ( Lolom
et al., 2009; Maki et al., 2006)
• PVC thrombophlebitis is a frequent PVC complication,
with rates in the range of 2–80% (Malach et al., 2006;
Uslusoy and Mete, 2008).
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
Resistance percentage at INICC ICUs Resistance percentage at CDC NSHN ICUs

Pathogen, antimicrobial
Staphylococcus aureus
OXA 65.4% 54.6%
Enterococcus faecalis
VAN 8.6% 9.5%
Pseudomonas aeruginosa
FQs 32.0% 30.5%
PIP or TZP 36.1% 17.4%
AMK 29.8% 10.0%
IPM or MEM 44.4% 26.1%
FEP 46.3% 26.1%
Klebsiella pneumonia
CRO or CAZ 73.2% 28.8%
IPM, MEM or ETP 43.2% 12.8%
Acinetobacter baumanii
IPM or MEM 90.2% 62.6%
Escherichia Coli
CRO or CAZ 66.0% 19.0%
IPM, MEM or ETP 12.8% 1.9%
FQs 62.0% 41.8%
Length of Stay with and without CR-BSI
ADULTS Pooled average LOS,

days, (95% CI)
Adult and Pediatric patients, without DA-HAI 7.08 (7.06-7.10)
Adult and Pediatric patients, with CR-BSI 17.36 (17.16-17.55)
Adult and Pediatric patients, with VAP 16.98 (16.83-17.12)
Adult and Pediatric patients, with CAUTI 10.30 (10.09-10.53)
NEONATES Pooled average LOS,

days, (95% CI)
Infants at level III neonatal intensive care units, without DA-HAI 17.46 (17.30-17.60)
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)
Mortality with and without CR-BSI
ADULTS Pooled crude

mortality, % (95% CI)
Adult and Pediatric patients, without DA-HAI 14.7% (14.5-15.0)
Adult and Pediatric patients, with CR-BSI 38.4% (36.1-40.8)
Adult and Pediatric patients, with VAP 35.9% (34.2-37.6)
Adult and Pediatric patients, with CAUTI 25.4% (23.1-27.9)
NEONATES Pooled crude

mortality, % (95% CI)
Infants at level III neonatal intensive care units, without DA-HAI 19.0% (18.6-20.4)
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)
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 .
Case (N= 142) Control (N= 142) Extra Expenditures

Total days 3,322 1,632 1690
Average length of stay in ICU 23.39 (SE 1.49) 11.49 (SE 0.68) 11.90
Total fixed cost $830,500 $408,000 $422,500
Mean fixed cost $5,848 (SE 372.89) $2,873 (SE 171.07) $2,975
Antibiotic utilization
Total antibiotics (in DDD*) 4,568 1,356 3,212
Mean antibiotic use per patient ( 32.16 (SE 2.81) 9.54 (SE 1.05) 22.62
DDD*)
Total cost of antibiotics $301,488 $29,832 $271,656
Mean costs of antibiotics per patient $2,123 (SE 186.06) $210 (SE 23.09) $1,913
Aggregate costs $1,131,988 $437,832 $694,156
Mean aggregate costs per patient $7,971.74 $3,083.32 $4,888.42
Average mortality 77/142 (54.2%) 42/142 (29.6%) 24.6%
Rosenthal VD, et al. Am J Infect Control 2003;31(8):475-80. 30

The Attributable Cost, And Length Of Hospital Stay Of Central Line
Associated CR-BSIIn Intensive Care Units In Brazil. A Prospective,
Matched Analysis
BSI Controls Extra RR 95 % CI P-value
Total patients (n) 70 140
Total Antibiotic DDD, (DDD) 4243 2124
Antibiotic DDD per patient, (DDD) 60.61 15.17 45.44
Total Antibiotic cost (US$) 312,225.54 99,930.12
Antibiotic cost per patient, (US$) 4,460.36 713.78 3,746.58
Length of Stay (days) 30.58 + 20.41 6.95 + 4.89 23.6 4.40 4.08 – 4.75 0.0000
Cost (US$) 9,843.35 1,937.18 7,906
Total deaths (n) 23 45
Crude mortality (%) 32.9% 32.1% 1.02 0.62 – 1.69 0.9316
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 .
Control Case Overall Attributable

(N= 55) (N= 55) Attributable Extra
Extra Expenditures
Expenditures per patient
Average length of stay in ICU 406 739 333 6.05
(days)
Antibiotics (US$) 13,354.35 46,265.96 32,911.61 598.39
Other medicaments (US$) 128,415.14 129,832.44 1,417.30 25.77
Disposables (US$) 219,345.82 308,808.79 89,462.97 1,626.60
Cultures (US$) 1,171.40 2,111.85 940.45 17.10
Other lab tests (US$) 37,441.19 61,174.01 23,732.82 431.51
X ray, Scan, etc (US$) 15,198.40 19,556.44 4,358.04 79.24
Other costs (US$) 44,395.46 71,105.56 26,710.09 485.64
Hospitalization (fixed costs) 496,326.78 954,294.33 457,967.55 8326.68
(US$)
Total cost (US$) 955,648.55 1,593,149.38 637,500.83 11,590.92
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
Diagnose and Treat a Prevent

CR-BSI CR-BSI
• Increase length of stay • Reduced length of stay
• Increase mortality • Reduced mortality
• Increase cost • Reduced costs
• Reduce bed availability • Increased bed availability
• Increase bacterial resistance • Reduce bacterial resistance
• Increase antibiotic use • Reduce antibiotic use
34
M o n i t or ing i n t e r vent io ns
C h a r a c t er ist ics o f p a t i e nt s i n b o t h p e r i o ds
R e d u cti on o f C L A B . 8 6 I C U s o f 1 5 c o u nt r ies
CLAB rate
Reduction by 54%
CLAB per
1000 CL
days
RR= 0.67 95%

CI=(0.58 - 0.77)
P= 0.0001
RR= 0.46
33% BSI rate reduction
95% CI= (0.33 - 0.63)
P= 0.0001
54% BSI rate reduction
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)
Months 5-7 86 7,522 46 0.61 0.59 0.004

(0.41-0.84)
Months 11- 68 4,718 22 0.47 0.45 0.001

13 (0.28-0.72)
Months 17- 43 3,527 16 0.45 0.43 0.002

19 (0.25-0.74)
Months 23- 28 2,264 10 0.44 0.42 0.008

25 (0.22-0.82)
Mortality reduction by 58%
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 31(12): 1264-1272.
INICC Bundle
to Prevent CR-BSI
(2017)
http://www.inicc.org
B u n d le p r a c t ice c o m m it t ee
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
Use a Multidimensional Approach:
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
The Institute for Healthcare Improvement (IHI)

describes a “Bundle” as “Group of best
practices that individually improve care, but when
applied Together result in substantially
Greater improvement.”
2 . E d u c a tio n
Monthly sessions of education provided by

ICP to the HCWs in charge of the
insertion, care, and maintenance of CLs for
HAI prevention based on INICC, CDC,
WHO, APIC, SHEA, IDSA, and or IHI
guidelines and or Bundles to prevent HAI.
3 . O u t c o me s u r vei lla nce
• 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
Process surveillance was designed to assess compliance

with easily measurable key infection control practices, such
as surveillance of compliance rates for hand hygiene
practices and specific measures for the prevention of HAI.
5 . Fe e d b a ck o f DA - H AI r a t e s
• 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.
Hand Hygiene Before Insertion and

Manipulation of a VAD (quality of evidence:
II)1-4, 104, 128, 184-186
• Alcohol-based hand rub should be made
available at the point of care in all healthcare
facilities.
• Perform hand rub, with 70% alcohol, or
alcohol plus 2% chlorhexidine if hands are
free of dirt and organic material.1
• Perform hand hygiene with 2% chlorhexidine
or wash them with soap and water if hands
are soiled or potentially contaminated with
blood or body fluids.
• Regular audits should be undertaken on
health care workers’ (HCW) adherence to
hand hygiene guidelines, whose results
should be fed back to HCWs to improve and
sustain high levels of compliance.
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
Variable Adjusted OR 95% CI P. value

Gender (baseline: Female) 1.0
Women
Male better than 0.91 0.89 – 0.93 < 0.001
men: 9%
Type of professional (baseline: nurses) 1.0

Physicians Nurses better than 0.68 0.66 – 0.70 < 0.001
Doctors: 32%
Ancillary Staff 0.52 0.51 – 0.54 < 0.001
Type of contact (baseline: invasive) 1.0

Non-invasive 0.95 0.93 – 0.98 < 0.001
Type of ICU (baseline: New Born) 1.0

Adult ICU Neonatal better than 0.49 0.47 – 0.52 < 0.001
Adult ICU: 51%
Pediatric ICU 0.58 0.54 – 0.62 < 0.001
Work Shift (baseline: Night) 1.0

Afternoon 0.79 0.76 – 0.81 < 0.001
Morning 0.83 0.81 – 0.86 < 0.001
H a n d hy g i e ne c o m p lia nce
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
Infection Control and Hospital Epidemiology. April 2013

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
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
Several studies have demonstrated the benefit, either alone or as part of

multimodal CLABSI prevention strategies, of using MSB precautions during CVC
placement to reduce the risk of CLABSIs
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.
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”.
• 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
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
Insertion Site Selection for CL (quality of

evidence: I)
• To reduce risk of CRBSI with a non-tunnelled VAD
in adult patients, the subclavian vein is favoured,
rather than the jugular or femoral veins. 1-4, 104,
173, 175, 185, 187, 200-216
• Avoid areas of wounds or infections
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
50.0 54.0 There was a trend for association

10
10.2
with femoral location by Cox
40.0 regression (hazard, 4.7; CI95, 0.82- 8
26; P=.08).
30.0 6
CLAB per
Colonization 20.0 1000 CL…
4
per 1000 days 4.6
10.0 2
2.4
0.0 4.8 4.7 0
Femoral / Jugular / Subclavian Femoral / Jugular / Subclavian
Single Single / Single Single Single / Triple
Lumen Lumen Lumen lumen Lumen Lumen
Strattegy: Femoral vs Jugular, vs Subclavian
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
Insertion Site Selection for PLs (quality of evidence: I) 175

• Avoid the use of veins in the following sites:
• Ventral surface of the wrist,
• areas of flexion and areas of pain on palpation;
• upper extremity on the side of breast surgery with axillary node
dissection,
• with lymphedema,
• with AV fistula / graft,
• after radiation therapy to that side of the body,
• affected extremity from a CVA
•For adult patients:

•To minimize the risk of CRBSI and phlebitis, it is preferable to use an upper extremity site
for inserting a PL in adults.1-4, 185
•use the forearm to increase dwell time, decrease pain during dwell time, promote self-
care, and prevent accidental removal and occlusions.
•Consider veins found on the dorsal and ventral surfaces of the upper extremities,
including the metacarpal, cephalic, basilic, and median veins.1, 106, 200, 203, 217-221
•Do not use veins of the lower extremities unless necessary due to risk of tissue damage,
thrombophlebitis, and ulceration.1, 219, 222
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
• Considering veins in the hands, forearms, and

upper arms below the axilla.
• Consider that in paediatric patients, femoral
catheters have a low incidence of mechanical
complications and might have an equivalent
infection rate to that of non-femoral catheters.2
• Avoid the ante-cubital area, which has a higher
failure rate.
For infants and toddlers:

•Consider veins of the scalp,
•and if the patient is not walking, then veins of the feet could also be
considered.
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.

• For adults and children,
• Avoid femoral or axillary.
• For Pediatric population,
• Avoid Brachial artery in paediatric patients

• Use ultrasound in arterial identification and selection to increase first-
attempt success.172, 233, 234
• Consider use of local

anesthetic agents (quality
of evidence: II)175
• Consider local anesthetic agents
for painful VAD placement or
access including, but not limited
to topical vapocoolant sprays,
topical transdermal agents,
intradermal lidocaine, and
pressure accelerated
lidocaine.226-228
• Consider use of visualization technology for patients with difficult to find

veins (quality of evidence: II)175
• For CL, use ultrasound for vein identification and selection to decrease risks of cannulation
failure, arterial puncture, hematoma, and hemo-thorax.221, 222, 225
• For PL use special vein finder machines with light or infrared technology for patient
with weak veins, particularly kids or overweight patients, if technology is available. 221, 222, 225
• Remove CL When Not Needed (quality of evidence:

II)1-4, 75, 104, 185, 235-238
• CLs should be removed when complications occur or
as soon as it is no longer required. 1-4, 75, 104, 185, 235-238
• Criteria for justification of continued use of
a CVAD include but are not limited to:
• Hemodynamic monitoring.
• Clinical instability of the patient.
• Prescribed continuous infusion therapy,
such as parenteral nutrition.
• Documented history of difficult
peripheral venous access.229-232
• 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
• 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
• 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
• Identify and select appropriate short PL device

type and gauge175
• The VAD selected is of the smallest outer diameter
with the fewest number of lumens and is the least
invasive device needed for the prescribed therapy.
• Safety-engineered devices shall be selected
• Use VAD systems that minimize manipulations and

reduce components (PLs with integrated extension and
needleless access ports)
Peripheral
catheter
integrated extension
and needleless
access ports
• 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
C H G i m p r egna t ed d r e ssi ngs
• Consider the use of a chlorhexidine impregnated sponge

dressing or chlorhexidine-impregnated transparent dressing
in adult patients.1-4, 75, 185, 249-251
• Randomized controlled trials evaluating the efficacy of a
chlorhexidine-impregnated dressing compared with
conventional dressings for prevention of catheter
colonization and catheter-related bloodstream infection.
• Use of a chlorhexidine-impregnated dressing resulted in a
reduced prevalence of catheter-related bloodstream
infection (random effects relative risk, 0.60; 95% CI, 0.41-
0.88, p = 0.009).
• The prevalence of catheter colonization was also markedly
reduced in the chlorhexidine-impregnated dressing group
(random effects relative risk, 0.52; 95% CI, 0.43-0.64; p <
0.001).
Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-

analysis*. Safdar et al. Crit Care Med. 2014 Jul;42(7):1703-13
Consortium (INICC) to Prevent Central and Peripheral Line-
Related Bloodstream Infections
• Integration of Needleless Connectors as IV Connection Devices (quality of

evidence: II)2, 79, 80, 87, 105-108, 185, 240-244
• Use needleless connectors (NC) as IV connection devices.2, 87, 105-108, 185, 240-243
• Avoid three way-stop cocks as IV connection devices.2, 87, 185, 240-243, 252
• Disinfect NC prior to each entry into the device.
• Use aseptic no-touch technique to change NC connectors.
• Access NC connectors only with a sterile device.2, 87, 185, 240-243, 252
• Consider the use of an extension set between the line and needleless connector to reduce line
manipulation.239
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
Closed IV system Open IV system

NEEDLE LESS CONNECTOR (NCS) • Three-Way Stopcocks (3WSC)
• Simple needleless • A valve or tuning plug that
connector with a pre- controls the flow of fluid from a
pierced septum that container through a tube. Open
can be of a blunt to the air when the cover is not
cannula or luer-lock in place
design
Single-use Prefilled Flushing Devices Multiple use container (MUC)
(SUF)
• A prefilled • A 100 to 500 ml
single use vial container as a
for IV lines common source of
when drugs are fluids
not compatible
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
S t u d y ov e r view
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
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
Variable NC + SUF (%) 3WSC + MUC (%) P
Gender (male), n (%) 358 (65%) 375 (68%) 0.56
Surgical admission, n (%) 280 (51%) 299 (54%) 0.46
Age (years), mean ± SD 60,2 ± 17.7 60,3 ± 16.7 0.98
ASIS score, mean ± SD 3,14 ± 0.7 3,22 ± 0.8 0.13
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.
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)
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)
D i s e a se d i s t ri buti on
Sn Disease NC + SUF 3 WSC + MUC Total P-value
1 Endocrine 197 (36) 198 (36) 395 .56

2 Heart fail 250 (46) 262 (48) 512 .62
3 Coronary failure 121 (22) 125 (23) 246 .82
4 Respiratory failure 49 (9) 49 (9) 98 .99
5 Renal failure 52 (10) 61 (11) 113 .41
6 Liver failure 6 (1) 6 (1) 14 .59
7 Cardiac surgery 50 (9) 52 (9) 102 .86
8 Abdominal surgery 29 (5) 38 (7) 67 .28
9 Thoracic surgery 10 (2) 5 (1) 15 .19
10 Stroke coma 68 (12) 62 (11) 130 .58
11 Cancer 35 (6) 32 (4) 57 .08
12 Previous Infection 69 (13) 68 (12) 137 .92
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
5.00 RR: 0.35 3.5 RR: 0.31
CLABSI Rate (%)

Cost Effectivennes Analysis:
P value: 0.006 P value: 0.002
For each US$ 1 invested 3
4.00
US$ 124 were saved 2.5
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
R e s u lt s
c o s t - effect ivenes s a n a l y sis
Variable NC+SUF Group 3WSC Group

ALOS 7.5 9
CL Days 5.0 7.4
Cost of Per day CL Days 521 521
Per device cost $3.59 $0.35
Cost per patients with CLABSI
$3443.96 $3846.84
(Hospitalization+ Device)
Total cost saving per patient: $402.88 -
Cost Per Patient with CLABSI (Hospitalization + Device)
• NC+SUF: Mean (Cl days*521)+ $3.59 (device cost) = $3443.96
• 3WSC+MA: Mean (Cl days*521)+ $0.35 (device cost) = $3846.84
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
• 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.
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
• Use Closed IV Fluid Containers (quality of evidence: II)122-126

• Use plastic, flexible, collapsible, non-vented, closed IV fluid containers.122-126
• Avoid use of plastic, semi rigid, vented, open IV fluid containers. 122-126
• Avoid use of glass, vented, open IV fluid containers. 122-126
• Avoid inserting needles to vent the IV fluid containers. 122-126
• Avoid use of an air filter to vent the IV fluid containers.122-126
• Flushing and Locking of VADs

• Use single-dose systems (eg, single-dose vials or prefilled labeled
syringes) for all VAD flushing and locking.
• Do not use intravenous (III) solution containers (eg, bags or bottles) as a
source for obtaining flush solutions.5, 106, 175, 200,201 (III)
• Prefilled syringes may reduce the risk of CR-BSI and save staff time for
syringe preparation.5, 106, 267, 268 (III)
• Perform disinfection of connection

surfaces (ie, needleless connectors,
injection ports) before flushing and
locking procedures.
• Flush all VADs with preservative-free
0.9% sodium chloride (USP).
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.
* CDC: Based on recent HCV outbreak,

* CDC “strongly encourages” use of pre-fills or single dose
vials.
* JCAHO: Sentinel Events Alert identifies

* “ single-use IV flush vials” as important strategy to
reduce the risk of nosocomial infections.
• Infusion Nurse Society Standard. 2011

• CDC 2011
• JCAHO Sentinel events
With multi-dose vials , 10 steps required to

aseptically flush CVC vs. 4 steps with a pre-filled
syringe. 1
• 126 patients studied, 62 flushed with pre-fills, 64 with
multi-dose vials and/or cartridge system Pre-fills were
associated with:
• Significantly fewer catheter related blood stream
infections, 1 with pre-fills vs. 10 with other flush
systems
• Significantly longer median time to catheter related
complication, pre-fills at 104 days, other at 42 days
• Fewer CVCs removed as result of adverse event, pre-
fills at 3% vs. 28% for other.
1- Rosenthal, K., Impacts On Adverse Events In 25 Sub-acute Care Units After a Change In Central Venous Catheter
Irrigation Techniques, JVAD, 1999
• Contamination rates when saline is drawn up manually

• 8% (Calop1)
• 7.8% (Trautmann2)
• 6-16% (Slucki3)
• Hepatitis C in the (multi-dose) vial. A report from a
children’s cancer ward in Malmo, Sweden 3
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.
• Lock short peripheral catheters immediately following

each use.
• In adults, use preservative-free 0.9% sodium chloride
(USP) for locking. 5, 85, 160, 172, 217, 232, 233 (I)
• In neonates and pediatrics, use heparin 0.5 units
to 10 units per mL or preservative-free 0.9%
sodium chloride (USP).
• For short peripheral catheters not being used for intermittent
infusion, consider locking once every 24 hours.5, 275
27 (III)
Perform Daily Bath with 2% Chlorhexidine-Impregnated

Wash Cloth in patients with CL (quality of evidence: I)1, 3, 4,
185, 302
• Consider daily cleansing with chlorhexidine in adult patients

with CL.1, 3, 4, 185, 302
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
Surveillance of HAIs
Compliance with HH and Bundles of Care

Uploading Monitoring Compliance with Bundles of Care of CRBSI
Ask for the Report of Monitoring Compliance with Bundles of Care of CRBSI
Watch the Report of Monitoring Compliance with Bundles of Care of CRBSI
Surveillance of Microorganism Profile and Bacterial Resistance

Surveillance of Needle Stick Injuries

Generation of Reports, with Tables, Columns, Cost Analysis, and Benchmark

Other Examples of
Impact of INICC
Reducing BSI rates
worldwide
C o n c lusi ons
1. INICC cohort surveillance was successful in measuring and reducing:

• HAI rates
• Mortality
• Extra length of stay
• Costs
2. Increase compliance to “Bundles of Care”
3. Bundles are a combination of:

• Practices
• Technology
4. While incorporating new technology, evaluate:

• Clinical outcomes
• Cost effectiveness
Tha nk yo u ver y much
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 :
- in f a cebo i n “ I NI CC - I nter national No s o comia l

I nf ection Co ntrol Co ns or tium”
- i n tw i tter i n i n “ @ i ni cc_o rg”

Care Bundels Stop Infections - DR - Rosenthal

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WELCOME

Epidemiology and Prevention of

Dr.Victor D. Rosenthal, MD, MSC, CIC

14- PERU 15- BRAZIL

20 COUNTRIES 17- PARAGUAY

7- SRI LANKA 10- MALAYSIA

10- UNITED ARAB EMIRATES

Publication 2006 2008 2010 2012 2014 2016

Peer Review Annals of Internal American American American American American

ICUs, n 55 98 173 422 503 703

CLABSI, 12.5 9.2 7.6 6.8 4.8 4.1

CAUTI, rate 8.9 6.5 6.3 6.3 5.3 4.82

VAP, 24.1 19.5 13.6 15.8 14.7 12.2

INICC 2010-2015 U.S. NHSN 2013

Medical Cardiac ICU

INICC 2010–2015 U.S. NHSN 2013

Mehta, Jaggi,Rosenthal, et al. ICHE 2015

Rai, Gan, Rosenthal, et al. CJIC. 2016

Novoa, Berba, Galapia, Rosenthal, et al. AJIC 2011

India Malaysia Philippines INICC CDC- NHSN

CLAB rate 5.1 9.4 4.6 4.1 0.8

Mehta, Jaggi,Rosenthal, et al. ICHE 2015

• Peripheral vascular catheters (PVC) are the most

• While the incidence of PVC-related infection (0.2–0.7

Resistance percentage at INICC ICUs Resistance percentage at CDC NSHN ICUs

ADULTS Pooled average LOS,

NEONATES Pooled average LOS,

ADULTS Pooled crude

NEONATES Pooled crude

Case (N= 142) Control (N= 142) Extra Expenditures

Rosenthal VD, et al. Am J Infect Control 2003;31(8):475-80. 30

BSI Controls Extra RR 95 % CI P-value

Total patients (n) 70 140

Total Antibiotic DDD, (DDD) 4243 2124

Antibiotic DDD per patient, (DDD) 60.61 15.17 45.44

Total Antibiotic cost (US$) 312,225.54 99,930.12

Antibiotic cost per patient, (US$) 4,460.36 713.78 3,746.58

Cost (US$) 9,843.35 1,937.18 7,906

Total deaths (n) 23 45

Crude mortality (%) 32.9% 32.1% 1.02 0.62 – 1.69 0.9316

Control Case Overall Attributable

Diagnose and Treat a Prevent

RR= 0.67 95%

Months 5-7 86 7,522 46 0.61 0.59 0.004

Months 11- 68 4,718 22 0.47 0.45 0.001

Months 17- 43 3,527 16 0.45 0.43 0.002

Months 23- 28 2,264 10 0.44 0.42 0.008

Use a Multidimensional Approach:

The Institute for Healthcare Improvement (IHI)

Monthly sessions of education provided by

Process surveillance was designed to assess compliance

Hand Hygiene Before Insertion and

Variable Adjusted OR 95% CI P. value

Type of professional (baseline: nurses) 1.0

Type of contact (baseline: invasive) 1.0

Type of ICU (baseline: New Born) 1.0

Work Shift (baseline: Night) 1.0

Infection Control and Hospital Epidemiology. April 2013

Several studies have demonstrated the benefit, either alone or as part of

Insertion Site Selection for CL (quality of

• Avoid areas of wounds or infections

50.0 54.0 There was a trend for association

Strattegy: Femoral vs Jugular, vs Subclavian