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Institutional Risk Factors Associated With Healthcare-Associated Infections in Brazilian ICUs: A Nested Cohort Within
Bruno Adler Maccagnan Pinheiro Besen1,2, Camila Dietrich1, Carla Cristina Gomes Pinheiro1
1Diretoria de Compromisso Social, Hospital Sírio-Libanês, São Paulo, Brazil.
Objectives:
Healthcare-associated infections are common and potentially preventable, especially in low- and middle-income countries (LMICs), due to substandard staffing, structure, and process-of-care. We evaluated institutional risk factors associated with ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI) rates.
Design:
Multicenter cohort study.
Setting:
Fifty Brazilian ICUs.
Patients:
All patients admitted from September 2019 to December 2021 to the participating ICUs, exposed to at least 2 days of invasive mechanical ventilation (MV) or central venous catheter (CVC).
Interventions:
None.
Measurements And Main Results:
Individual patient data were prospectively collected, and cross-sectional hospital-level data were collected at baseline. VAP and CLABSI were reported in accordance with Brazilian regulatory agency guidance. Negative binomial or Poisson multiple regression were used to model risk factors, adjusted for individual-level covariates. Of 75,164 ICU admissions, there were 19,108 at-risk (≥ 48 hr of MV) patients with a total of 244,059 MV-days for a VAP incidence rate of 6.03 (95% CI, 5.73-6.35) per 1,000 MV-days. There were 26,560 patients with a total of 375,078 CVC-days for a CLABSI incidence rate of 1.63 per 1,000 CVC-days (95% CI, 1.51-1.77 per 1,000 CVC-days). The median rate ratios of hospital random-effects were 4.39 (95% CI, 2.72-6.06) for VAP and 3.53 (95% CI, 2.30-4.76) for CLABSI. Hospital-level fixed effects explained 39.9% (95% CI, 33.6-46.1%) of the between-hospital variability for VAP and 44.7% (95% CI, 35.0-54.5%) for CLABSI. Prevention protocols, flexible family visitation policies, and hand hygiene training were associated with reduced rates of VAP and CLABSI. Nursing staffing ratios, single-use gowns, and alcohol availability were associated with a lower CLABSI rate. Sedation titration by nurses, weaning by respiratory therapists, and dentist availability were associated with a lower rate of VAP.
Conclusions:
Processes-of-care and ICU structure measures are associated with the burden of VAP and CLABSI in LMICs.
Insights
Healthcare-associated infections like ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI) are linked to ICU structure and care processes in low-income countries. Improving these factors can reduce infection rates.
Area of Science:
- Infection Control and Hospital Epidemiology
- Intensive Care Medicine
- Global Health
Background:
- Healthcare-associated infections (HAIs), including ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI), pose significant risks, particularly in low- and middle-income countries (LMICs).
- Substandard staffing, infrastructure, and care processes contribute to the high burden of HAIs in these settings.
- Identifying institutional risk factors is crucial for developing targeted prevention strategies.
Purpose of the Study:
- To evaluate institutional risk factors associated with ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI) rates in Brazilian intensive care units (ICUs).
- To determine the impact of specific processes of care and ICU structural elements on VAP and CLABSI incidence.
Main Methods:
- A multicenter cohort study was conducted across 50 Brazilian ICUs from September 2019 to December 2021.
- Data included individual patient information and cross-sectional hospital-level data. Patients exposed to invasive mechanical ventilation (MV) or central venous catheter (CVC) for at least 48 hours were included.
- Negative binomial or Poisson regression models were used to analyze risk factors, adjusted for individual-level covariates.
Main Results:
- The study analyzed 75,164 ICU admissions, identifying VAP incidence at 6.03 per 1,000 MV-days and CLABSI incidence at 1.63 per 1,000 CVC-days.
- Significant between-hospital variability was observed, with hospital-level factors explaining substantial portions of this variation for both VAP (39.9%) and CLABSI (44.7%).
- Prevention protocols, flexible visitation, hand hygiene training, nursing staffing, single-use gowns, alcohol availability, nurse-led sedation titration, respiratory therapist-led weaning, and dentist availability were associated with reduced infection rates.
Conclusions:
- Processes of care and ICU structural measures are significantly associated with the burden of VAP and CLABSI in LMICs.
- Targeted interventions focusing on these modifiable factors can effectively reduce HAI rates in resource-limited settings.
- The findings underscore the importance of a systems-based approach to infection prevention in ICUs.
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