Özay Arıkan Akan

Impact of a multidimensional infection control approach on central line-associated bloodstream infections rates in adult intensive care units of 8 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

BackgroundCentral line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey.MethodsWe conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention.ResultsDuring baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 – 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB.ConclusionsThe implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Investigation of Panton-Valentine Leukocidin Genes and SCCmec Types in Clinical Staphylococcus aureus Isolates from Turkey

Panton-Valentine leukocidin (PVL) is an important virulence determinant of Staphylococcus aureus. The aim of this study was to investigate the prevalence of PVL genes in clinical S. aureus isolates and to determine the staphylococcal chromosomal cassette mec (SCCmec) types of methicillin-resistant S. aureus (MRSA) strains obtained from inpatients and outpatients of two hospitals in Turkey. Of the 304 S. aureus strains (230 hospital acquired [HA] and 74 community-onset [CO]), 261 were MRSA and 43 were methicillin-sensitive S. aureus (MSSA). PVL positivity was determined in 12 (1 HA and 11 community acquired) strains. Eight were MRSA, and four were MSSA. Seven of the PVL-positive strains were isolated from wound specimens, four from urine, and one from synovial fluid. SCCmec type III (93.78%) was more prevalent among HA-MRSA strains, and SCCmec type IIIB (41.18%) was more prevalent among CO-MRSA strains. Pulsed-field gel electrophoresis patterns of the PVL-positive isolates were different. Our results indicate that PVL-positive strains are able to cause infection in nearly every system without the need for additional risk factors. Our PVL-positive CO-MRSA strains carry SCCmec types other than types IV and V. Due to the presence of PVL-positive strains in the hospitals, it is important to establish appropriate infection control measures to prevent their spread in the community and in hospitals.

International Nosocomial Infection Control Consortium (INICC) national report on device-associated infection rates in 19 cities of Turkey, data summary for 2003–2012

BackgroundDevice-associated healthcare-acquired infections (DA-HAI) pose a threat to patient safety, particularly in the intensive care unit (ICU). We report the results of the International Infection Control Consortium (INICC) study conducted in Turkey from August 2003 through October 2012.MethodsA DA-HAI surveillance study in 63 adult, paediatric ICUs and neonatal ICUs (NICUs) from 29 hospitals, in 19 cities using the methods and definitions of the U.S. NHSN and INICC methods.ResultsWe collected prospective data from 94,498 ICU patients for 647,316 bed days. Pooled DA-HAI rates for adult and paediatric ICUs were 11.1 central line-associated bloodstream infections (CLABSIs) per 1000 central line (CL)-days, 21.4 ventilator-associated pneumonias (VAPs) per 1000 mechanical ventilator (MV)-days and 7.5 catheter-associated urinary tract infections (CAUTIs) per 1000 urinary catheter-days. Pooled DA-HAI rates for NICUs were 30 CLABSIs per 1000 CL-days, and 15.8 VAPs per 1000 MV-days. Extra length of stay (LOS) in adult and paediatric ICUs was 19.4 for CLABSI, 8.7 for VAP and 10.1 for CAUTI. Extra LOS in NICUs was 13.1 for patients with CLABSI and 16.2 for patients with VAP. Extra crude mortality was 12% for CLABSI, 19.4% for VAP and 10.5% for CAUTI in ICUs, and 15.4% for CLABSI and 10.5% for VAP in NICUs. Pooled device use (DU) ratios for adult and paediatric ICUs were 0.54 for MV, 0.65 for CL and 0.88 for UC, and 0.12 for MV, and 0.09 for CL in NICUs. The CLABSI rate was 8.5 per 1,000 CL days in the Medical Surgical ICUs included in this study, which is higher than the INICC report rate of 4.9, and more than eight times higher than the NHSN rate of 0.9. Similarly, the VAP and CAUTI rates were higher compared with U.S. NHSN (22.3 vs. 1.1 for VAP; 7.9 vs. 1.2 for CAUTI) and with the INICC report (22.3 vs. 16.5 in VAP; 7.9 vs. 5.3 in CAUTI).ConclusionsDA-HAI rates and DU ratios in our ICUs were higher than those reported in the INICC global report and in the US NHSN report.

Initial Candida dubliniensis isolate in Candida spp. positive haemocultures in Turkey between 2001 and 2004

Candida dubliniensis which was first recognized in 1995 can be easily misidentified because of its phenotypic similarities with Candida albicans. In this study blood samples of patients from various departments of Ankara University Medical Faculty between January 2001–June 2004 were investigated for the distribution of Candida spp. and the presence of C. dubliniensis. Culture positive 67 fungi were included to the study. Phenotypic tests such as chlamydospore formation, colony morphology on Staib agar, growth at 45 °C, carbohydrate assimilation profiles were investigated for identification and differentiation of C. dubliniensis from C. albicans. To confirm the results polymerase chain reaction were used for suspected C. albicans and C. dubliniensis isolates. Among 38 germ tube and chlamydospore forming isolates, 37 of them were found as C. albicans and one as C. dubliniensis. The incidence of C. dubliniensis in our hospital is still low, this is the first C. dubliniensis isolate as an agent of candidaemia reported from Turkey.

Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach, over 8 years, in 11 cities of Turkey

Aims: To evaluate the effectiveness of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach in Turkey and analyse predictors of poor hand hygiene compliance. Design: An observational, prospective, interventional, before-and-after study was conducted from August 2003 to August 2011 in 12 intensive care units (ICU) of 12 hospitals in 11 cities. The study was divided into a baseline and a follow-up period and included random 30-minute observations for hand hygiene compliance in ICU. The hand hygiene approach included administrative support, supplies availability, education and training, reminders in the workplace, process surveillance, and performance feedback. Results: We observed 21,145 opportunities for hand hygiene. Overall hand hygiene compliance increased from 28.8% to 91% (95% CI 87.6–93.0, p 0.0001). Multivariate and univariate analyses showed that several variables were significantly associated with poor hand hygiene compliance: males vs. females (39% vs. 48%; 95% CI 0.79–0.84, p 0.0001), ancillary staff vs. physicians (35% vs. 46%, 95% CI 0.73–0.78, p 0.0001), and adult vs. pediatric ICUs (42% vs. 74%, 95% CI 0.54–0.60, p 0.0001). Conclusions: Adherence to hand hygiene was significantly increased with the INICC Hand Hygiene Approach. Specific programmes should be directed to improve hand hygiene in variables found to be predictors of poor hand hygiene compliance.

Epidemiological and molecular characteristics of meticillin-resistant Staphylococcus aureus in Turkey: A multicentre study

The aim of this study was to investigate the epidemiological and molecular features of clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates in Turkey. MRSA isolates were collected from six regions of Turkey. The mecA and nuc genes were detected by PCR. Antimicrobial susceptibilities were determined by the disk diffusion method. Staphylococcal cassette chromosome mec (SCCmec) and staphylococcal protein A (spa) typing were performed by the sequencing method for 270 randomly selected MRSA isolates. The US Centers for Disease Control and Prevention (CDC) definition was used for epidemiological diagnosis of community-associated MRSA (CA-MRSA). Resistance rates of MRSA to ciprofloxacin, gentamicin, clindamycin, erythromycin, rifampicin, trimethoprim/sulfamethoxazole and tetracycline were 93.4%, 81.2%, 38.5%, 57.8%, 93.9%, 1.1% and 93.1%, respectively. The most frequent SCCmec type was SCCmec III (91.1%). SCCmec type IV was found in 5.2% of the isolates. The most frequent spa type was t030 (81.1%). Five isolates were CA-MRSA if only the epidemiological definition was used (5/725; 0.7%). Two isolates were defined as CA-MRSA both by epidemiological features and SCCmec typing (2/270; 0.7%). Of 14 SCCmec type IV isolates, 12 were not defined as CA-MRSA by epidemiological features. In conclusion, this is the most comprehensive multicentre study in Turkey investigating MRSA using both epidemiological and genotypic features. The CA-MRSA rate is low in Turkey. Combined use of epidemiological and genotypic methods is the most accurate approach for the diagnosis of CA-MRSA.

Evaluation of Preanalytic Errors in Clinical Laboratory Practice

Preanalytic errors are important factors that affect laboratory test results, but they are generally underestimated in routine practice. As a part of a quality management program, preanalytic errors were observed in the Central Laboratory Clinical Biochemistry Unit at Ankara University Ibni Sina Hospital. Closed monitoring of preanalytic errors for hospitalized patients during a randomly selected 1-month period was performed separately for 2 different working hours [morning (08:00–16:30) and night shifts (16:30–08:00) plus weekends]. The most common preanalytic error was incorrect patient information being entered into the hospital information system (16.5% and 23.5% for the morning and night shift, respectively). The second most common preanalytic error was discordance between test requests on the forms and what was entered into the hospital information system (10.1% and 7.1% for the morning and night shift, respectively) Inadequate volume of blood (3.2% and 2.9% for the morning and night shift, respectively) was the next most common preanalytic error. The statistical differences between morning and night shifts were significant ( P <0.001) for hospital information system patient errors, discordance of test requests, and hemolysis or coagulation of blood for complete blood count. Hospital information system corrections were taken into consideration as a first step in quality management of our hospital laboratory.