Victor D. Rosenthal

Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries

Context We know little about medical deviceassociated infections in developing countries. Contribution Prospective surveillance of 21069 patients who were hospitalized in 55 intensive care units in 46 hospitals in Central and South America, India, Morocco, and Turkey showed high rates (22.5 infections per 1000 intensive care unit days) of device-associated infections. Infections included ventilator-associated pneumonia (24.1 cases/1000 ventilator days), central venous catheterrelated bloodstream infections (12.5 cases/1000 catheter days), and catheter-associated urinary tract infections (8.9 cases/1000 catheter days). Eighty-four percent of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were ceftriaxone-resistant, and 59% of Pseudomonas aeruginosa isolates were fluoroquinolone-resistant. Implications Medical deviceassociated infections pose major risks in developing countries. The Editors Surveillance of health careassociated infections, especially in high-risk hospital settings, such as the intensive care unit (ICU) (1, 2), has become an integral feature of infection control and quality assurance in all U.S. hospitals. The Centers for Disease Control and Prevention (CDC) Study of the Efficacy of Nosocomial Infection Control (SENIC) Project (3) showed that surveillance can help prevent health careassociated infections. Standards for institutional surveillance have been adopted in the United States (1), the United Kingdom (4), Australia (5), Canada (6), and Germany (7). A growing body of literature has shown that health careassociated infections are a major cause of patient illness and death in developed countries (8, 9). Device-associated infections, particularly ventilator-associated pneumonia (1012), central venous catheter (CVC)associated bloodstream infections (1315), and catheter-associated urinary tract infections (16, 17), pose the greatest threat to patient safety in the ICU (18). Surveillance of health careassociated infection has been standardized by the CDCs National Nosocomial Infection Surveillance (NNIS) System by providing simple unambiguous definitions, especially for device-associated infections (1921). Targeted surveillance and calculation of device-associated infection rates per 1000 device days allows benchmarking with similar other hospitals and detection of unique institutional problems that need redress. Most published studies of ICU-acquired infections have come from hospitals in industrialized western countries (1, 8, 1019, 22, 23). Relatively few data have been reported from developing countries (9, 2427), especially rates of device-associated infections by using standardized definitions. We report the initial findings of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2002 through December 2005. The consortium was established by Dr. Rosenthal in 1998 when selected hospitals in Latin America began collecting surveillance data on health careassociated infections for inclusion in a regional database. Consortium hospitals provide general medical and surgical inpatient services to adults and children who require short-term care. All data from the participating hospitals were collected by using standardized NNIS System protocols and definitions (1921). The consortium has initially focused on surveillance and prevention of device-associated infections in adult and pediatric ICUs and high-risk nurseries. Methods Setting Most current participating hospitals and ICUs joined the consortium since 2002 after hearing Dr. Rosenthal (the INICC chairman) speak in their country or after learning about the INICC from its Web site (www.inicc.org), but some hospitals were actively solicited. Study data were collected between 2002 and 2005 in 55 ICUs in 46 hospitals from 8 developing countries: Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey. The consortium requires each member hospital to have an infection control team, comprising a physician and an infection control practitioner, and a microbiology laboratory that can isolate and identify aerobic pathogens from clinical cultures and perform in vitro susceptibility testing by using standardized methods (28). The person responsible for surveillance in each institution must have had at least 3 years of infection control experience (Table 1). In most of the hospitals, the team had access to electronic patient data. Table 1. Features of the International Nosocomial Infection Control Consortium Hospitals and Intensive Care Units* The institutional review board at each hospital approved the study protocol. Patient confidentiality is protected by coding the recorded information, with patient identities available only to the individual hospitals infection control team. Infection Control Practices at the Study Sites Hand hygiene adherence varies in the different countries and ICUs, ranging from 20% to 70% (2932). A recent study in all participating ICUs found a 50% overall rate of hand hygiene adherence (32), similar to that of recent studies in the United States and Europe (33). Use of sterile dressings on CVC insertion sites also ranges widely (29, 34, 35). Open infusion systems (rigid or semirigid containers that must admit air to empty) rather than closed systems (fully collapsible containers that do not require any external vent to empty the solution; the container residue after administration does not exceed 5% of the nominal volume) or combinations of open and closed systems are universally used to deliver intravenous fluids and medications in the study hospitals (35). Surveillance and Case Report Forms Each center established an augmented infection control program, with the initial major emphasis on active surveillance of health careassociated infections and process surveillance of hand hygiene adherence and invasive device care. During the study, we determined the rates of ventilator-associated pneumonia, CVC-associated bloodstream infection, and catheter-associated urinary tract infection monthly by using current CDC NNIS System definitions (1921). Designated surveillance forms were used for all patients in the study ICUs, both patients with and those without health careassociated infection. The following data were to be recorded daily on the forms for each patient: temperature and blood pressure, invasive devices, all cultures done, imaging studies, and antibiotic use. Previous studies have shown that fever, hypotension, cultures, and initiation of antimicrobial therapy are powerful markers for the presence of a health careassociated infection (36). A mean average severity of illness score was also recorded for each patient at ICU admission by using the CDC NNIS System criteria (19). Points were totaled, with 1 point for surgical patients who require routine postoperative observation only, 2 points for physiologically stable nonsurgical patients who require overnight observation, 3 points for patients who need continuous nursing care and monitoring, 4 points for physiologically unstable patients who require intensive nursing and medical care and need frequent reassessment and adjustment of therapy, and 5 points for physiologically unstable patients who are in a coma or in shock and require cardiopulmonary resuscitation or intensive medical and nursing care with frequent reassessment. If a patient was determined to have acquired a health careassociated infection, the date of onset, site of infection, infecting microorganisms, and antimicrobial susceptibilities were also recorded. Definitions Ventilator-Associated Pneumonia Ventilator-associated pneumonia is indicated in a mechanically ventilated patient with a chest radiograph that shows new or progressive infiltrates, consolidation, cavitation, or pleural effusion. The patient must also have at least 1 of the following criteria: new onset of purulent sputum or change in character of sputum; organism cultured from blood; or isolation of an etiologic agent from a specimen obtained by tracheal aspirate, bronchial brushing or bronchoalveolar lavage, or biopsy. Laboratory-Confirmed CVC-Associated Bloodstream Infection Central venous catheterassociated bloodstream infection is laboratory-confirmed when a patient with a CVC has a recognized pathogen that is isolated from 1 or more percutaneous blood cultures after 48 hours of vascular catheterization and is not related to an infection at another site. The patient also has at least 1 of the following signs or symptoms: fever (temperature 38C), chills, or hypotension. With skin commensals (for example, diphtheroids, Bacillus spp., Propionibacterium spp., coagulase-negative staphylococci, or micrococci), the organism is cultured from 2 or more blood cultures. Clinically Suspected CVC-Associated Bloodstream Infection Central venous catheterassociated bloodstream infection is clinically suspected when a patient with a CVC has at least 1 of the following clinical signs with no other identified cause: fever (temperature 38C), hypotension (systolic blood pressure 90 mm Hg), or oliguria (urine output 20 mL/h) with blood cultures not obtained or no organisms recovered from blood cultures, infections not apparent at another site, and antimicrobial therapy instituted by the physician. Catheter-Associated Urinary Tract Infection For the diagnosis of catheter-associated urinary tract infection, the patient must meet 1 of 2 criteria. The first criterion is when a patient with a urinary catheter has 1 or more of the following symptoms with no other recognized cause: fever (temperature 38C), urgency, or suprapubic tenderness when the urine culture is positive for 105 colony-forming units per mL or more, with no more than 2 microorganisms isolated. The second criterion is when a patient with a urinary catheter has at least 2 of the following criteria with no other recognized cause: positive dipstick analysis for leukocyte esterase or nitr

International Nosocomial Infection Control Consortium report, data summary for 2002-2007, issued January 2008

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from 2002 through 2007 in 98 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study, using Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance System (NNIS) definitions for device-associated health care-associated infection, we collected prospective data from 43,114 patients hospitalized in the Consortiums hospital ICUs for an aggregate of 272,279 days. Although device utilization in the INICC ICUs was remarkably similar to that reported from US ICUs in the CDCs National Healthcare Safety Network, rates of device-associated nosocomial infection were markedly higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infections (CLABs) in the INICC ICUs, 9.2 per 1000 CL-days, is nearly 3-fold higher than the 2.4-5.3 per 1000 CL-days reported from comparable US ICUs, and the overall rate of ventilator-associated pneumonia was also far higher, 19.5 vs 1.1-3.6 per 1000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 6.5 versus 3.4-5.2 per 1000 catheter-days. Most strikingly, the frequencies of resistance of Staphylococcus aureus isolates to methicillin (MRSA) (80.8% vs 48.1%), Enterobacter species to ceftriaxone (50.8% vs 17.8%), and Pseudomonas aeruginosa to fluoroquinolones (52.4% vs 29.1%) were also far higher in the Consortiums ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 14.3% (CLABs) to 27.5% (ventilator-associated pneumonia).

EFFECT OF EDUCATION AND PERFORMANCE FEEDBACK ON RATES OF CATHETER-ASSOCIATED URINARY TRACT INFECTION IN INTENSIVE CARE UNITS IN ARGENTINA

OBJECTIVE To evaluate the effect of education and performance feedback regarding compliance with catheter care and handwashing on rates of catheter-associated urinary tract infection (UTI) in intensive care units (ICUs). SETTING Two level III adult ICUs in a private healthcare facility in Argentina. PATIENTS All adult patients admitted to the study units who had a urinary catheter in place for at least 24 hours. METHODS A prospective, open trial in which rates of catheter-associated UTI determined during a baseline period of active surveillance without education and performance feedback were compared with rates of catheter-associated UTI after implementing education and performance feedback. RESULTS There were 1,779 catheter-days during the baseline period and 5,568 catheter-days during the intervention period. Compliance regarding prevention of compression of the tubing by a leg improved (from 83% to 96%; relative risk [RR], 1.15; 95% confidence interval [CI95], 1.03 to 1.28; P = .01) and so did compliance with handwashing (from 23.1% to 65.2%; RR, 2.82; CI95, 2.49 to 3.20; P < .0001). Catheter-associated UTI rates decreased significantly from 21.3 to 12.39 per 1,000 catheter-days (RR, 0.58; CI%, 0.39 to 0.86; P = .006). CONCLUSION Implementing education and performance feedback regarding catheter care measures and handwashing compliance was associated with a significant reduction in catheter-associated UTI rates. Similar programs may help reduce catheter-associated UTI rates in other Latin American hospitals.

Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium.

OBJECTIVE To perform active targeted prospective surveillance to measure device-associated infection (DAI) rates, attributable mortality due to DAI, and the microbiological and antibiotic resistance profiles of infecting pathogens at 10 intensive care units (ICUs) in 9 hospitals in Colombia, all of which are members of the International Infection Control Consortium. METHODS We conducted prospective surveillance of healthcare-associated infection in 9 hospitals by using the definitions of the US Centers for Disease Control and Prevention National Nosocomial Surveillance System (NNIS). DAI rates were calculated as the number of infections per 100 ICU patients and per 1,000 device-days. RESULTS During the 3-year study, 2,172 patients hospitalized in an ICU for an aggregate duration of 14,603 days acquired 266 DAIs, for an overall DAI rate of 12.2%, or 18.2 DAIs per 1,000 patient-days. Central venous catheter (CVC)-related bloodstream infection (BSI) (47.4% of DAIs; 11.3 cases per 1,000 catheter-days) was the most common DAI, followed by ventilator-associated pneumonia (VAP) (32.3% of DAIs; 10.0 cases per 1,000 ventilator-days) and catheter-associated urinary tract infection (CAUTI) (20.3% of DAIs; 4.3 cases per 1,000 catheter-days). Overall, 65.4% of all Staphylococcus aureus infections were caused by methicillin-resistant strains; 40.0% of Enterobacteriaceae isolates were resistant to ceftriaxone and 28.3% were resistant to ceftazidime; and 40.0% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.0% were resistant to ceftazidime, 33.3% were resistant to piperacillin-tazobactam, and 19.0% were resistant to imipenem. The crude unadjusted attributable mortality was 16.9% among patients with VAP (relative risk [RR], 1.93; 95% confidence interval [CI], 1.24-3.00; P=.002); 18.5 among those with CVC-associated BSI (RR, 2.02; 95% CI, 1.42-2.87; P<.001); and 10.5% among those with CAUTI (RR, 1.58; 95% CI, 0.78-3.18; P=.19). CONCLUSION The rates of DAI in the Colombian ICUs were lower than those published in some reports from other Latin American countries and were higher than those reported in US ICUs by the NNIS. These data show the need for more-effective infection control interventions in Colombia.

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

BACKGROUND The International Nosocomial Infection Control Consortium (INICC) was established in 15 developing countries to reduce infection rates in resource-limited hospitals by focusing on education and feedback of outcome surveillance (infection rates) and process surveillance (adherence to infection control measures). We report a time-sequence analysis of the effectiveness of this approach in reducing rates of central line-associated bloodstream infection (CLABSI) and associated deaths in 86 intensive care units with a minimum of 6-month INICC membership. METHODS Pooled CLABSI rates during the first 3 months (baseline) were compared with rates at 6-month intervals during the first 24 months in 53,719 patients (190,905 central line-days). Process surveillance results at baseline were compared with intervention period data. RESULTS During the first 6 months, CLABSI incidence decreased by 33% (from 14.5 to 9.7 CLABSIs per 1,000 central line-days). Over the first 24 months there was a cumulative reduction from baseline of 54% (from 16.0 to 7.4 CLABSIs per 1,000 central line-days; relative risk, 0.46 [95% confidence interval, 0.33-0.63]; P < .001). The number of deaths in patients with CLABSI decreased by 58%. During the intervention period, hand hygiene adherence improved from 50% to 60% (P < .001); the percentage of intensive care units that used maximal sterile barriers at insertion increased from 45% to 85% (P < .001), that adopted chlorhexidine for antisepsis increased from 7% to 27% (P < .001), and that sought to remove unneeded catheters increased from 37% to 83% (P < .001); and the duration of central line placement decreased from 4.1 to 3.5 days (P < .001). CONCLUSIONS Education, performance feedback, and outcome and process surveillance of CLABSI rates significantly improved infection control adherence, reducing the CLABSI incidence by 54% and the number of CLABSI-associated deaths by 58% in INICC hospitals during the first 2 years.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in adult intensive care units from 14 developing countries of four continents: Findings of the International Nosocomial Infection Control Consortium

Objectives:The aim of this study was to analyze the effect of the International Nosocomial Infection Control Consortium’s multidimensional approach on the reduction of ventilator-associated pneumonia in patients hospitalized in intensive care units. Design:A prospective active surveillance before–after study. The study was divided into two phases. During phase 1, the infection control team at each intensive care unit conducted active prospective surveillance of ventilator-associated pneumonia by applying the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the methodology of International Nosocomial Infection Control Consortium. During phase 2, the multidimensional approach for ventilator-associated pneumonia was implemented at each intensive care unit, in addition to the active surveillance. Setting:Forty-four adult intensive care units in 38 hospitals, members of the International Nosocomial Infection Control Consortium, from 31 cities of the following 14 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, and Turkey. Patients:A total of 55,507 adult patients admitted to 44 intensive care units in 38 hospitals. Interventions:The International Nosocomial Infection Control Consortium ventilator-associated pneumonia multidimensional approach included the following measures: 1) bundle of infection-control interventions; 2) education; 3) outcome surveillance; 4) process surveillance; 5) feedback of ventilator-associated pneumonia rates; and 6) performance feedback of infection-control practices. Measurements:The ventilator-associated pneumonia rates obtained in phase 1 were compared with the rates obtained in phase 2. We performed a time-series analysis to analyze the impact of our intervention. Main Result:During phase 1, we recorded 10,292 mechanical ventilator days, and during phase 2, with the implementation of the multidimensional approach, we recorded 127,374 mechanical ventilator days. The rate of ventilator-associated pneumonia was 22.0 per 1,000 mechanical ventilator days during phase 1, and 17.2 per 1,000 mechanical ventilator days during phase 2.The adjusted model of linear trend shows a 55.83% reduction in the rate of ventilator-associated pneumonia at the end of the study period; that is, the ventilator-associated pneumonia rate was 55.83% lower than it was at the beginning of the study. Conclusion:The implementation the International Nosocomial Infection Control Consortium multidimensional approach for ventilator-associated pneumonia was associated with a significant reduction in the ventilator-associated pneumonia rate in the adult intensive care units setting of developing countries.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part II: Impact of a multidimensional strategy to reduce ventilator-associated pneumonia in neonatal intensive care units in 10 developing countries.

Design. Before-after prospective surveillance study to assess the efficacy of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control program to reduce the rate of occurrence of ventilator-associated pneumonia (VAP). Setting. Neonatal intensive care units (NICUs) of INICC member hospitals from 15 cities in the following 10 developing countries: Argentina, Colombia, El Salvador, India, Mexico, Morocco, Peru, Philippines, Tunisia, and Turkey. Patients. NICU inpatients. Methods. VAP rates were determined during a first period of active surveillance without the implementation of the multidimensional approach (phase 1) to be then compared with VAP rates after implementation of the INICC multidimensional infection control program (phase 2), which included the following practices: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices. This study was conducted by infection control professionals who applied National Health Safety Network (NHSN) definitions for healthcare-associated infections and INICC surveillance methodology. Results. During phase 1, we recorded 3,153 mechanical ventilation (MV)-days, and during phase 2, after the implementation of the bundle of interventions, we recorded 15,981 MV-days. The VAP rate was 17.8 cases per 1,000 MV-days during phase 1 and 12.0 cases per 1,000 MV-days during phase 2 (relative risk, 0.67 [95% confidence interval, 0.50-0.91]; [Formula: see text]), indicating a 33% reduction in VAP rate. Conclusions. Our results demonstrate that an implementation of the INICC multidimensional infection control program was associated with a significant reduction in VAP rate in NICUs in developing countries.

Device-associated nosocomial infection rates in intensive care units of Argentina

BACKGROUND Nosocomial infections are an important public health problem in many developing countries, particularly in the intensive care unit (ICU) setting. No previous data are available on the incidence of device-associated nosocomial infections in different types of ICUs in Argentina. METHODS We performed a prospective nosocomial infection surveillance study during the first year of an infection control program in six Argentinean ICUs. Nosocomial infections were identified using the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System definitions, and site-specific nosocomial infection rates were calculated. RESULTS The rate of catheter-associated bloodstream infections in medical-surgical ICUs was 30.3 per 1,000 device-days; it was 14.2 per 1,000 device-days in coronary care units (CCUs). The rate of ventilator-associated pneumonia in medical-surgical ICUs was 46.3 per 1,000 device-days; it was 45.5 per 1,000 device-days in CCUs. The rate of symptomatic catheter-associated urinary tract infections in medical-surgical ICUs was 18.5 per 1,000 device-days; it was 12.1 per 1,000 device-days in CCUs. CONCLUSION The high rate of nosocomial infections in Argentinean ICUs found during our surveillance suggests that ongoing targeted surveillance and implementation of proven infection control strategies is needed in developing countries such as Argentina.

Device-associated infection rates in intensive care units of Brazilian hospitals: datos de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS: Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8% or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7% of cases, resistant to ceftazidime in 79.3% of cases, and resistant to piperacillin-tazobactam in 85.7% of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3% of cases, resistant to ceftazidime in 75.5% of cases, and resistant to imipenem in 27.7% of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3% (RR 1.79, P = 0.0149) for VAP, 27.8% (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7% (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION: The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an active infection control program comprising surveillance of DAIs and infection prevention guidelines. These actions should become a priority in every country.OBJECTIVES To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8% or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7% of cases, resistant to ceftazidime in 79.3% of cases, and resistant to piperacillin-tazobactam in 85.7% of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3% of cases, resistant to ceftazidime in 75.5% of cases, and resistant to imipenem in 27.7% of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3% (RR 1.79, P = 0.0149) for VAP, 27.8% (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7% (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an active infection control program comprising surveillance of DAIs and infection prevention guidelines. These actions should become a priority in every country.

Device-associated nosocomial infections in limited-resources countries: Findings of the International Nosocomial Infection Control Consortium (INICC)

NEED The rates of health care-associated infections (HAIs) and bacterial resistance in developing countries are 3 to 5 times higher than international standards. HAIs increase length of stay (10 days), costs (US