Infection Control Challenges in a Middle-Income Country Intensive Care Unit

Background:

Infection control (IC) in an intensive care unit (ICU) is a difficult task; in middle income countries chronic shortage of skilled nurses makes IC even more challenging. Because of overcrowding, it was decided to expand our unit; 5 more beds were added to our 15-bed ICU during the period August 2009 to December 2009 (construction period). Central line-associated bloodstream infection (CLABSI) bundle has been implemented since 2006; bundles for urinary tract infection (UTI) and ventilator-associated pneumonia (VAP) have been partially implemented.

Objective:

To describe IC results in an ICU with limited resources before, during and after construction.

Methods:

Hospital São Francisco ICU is a tertiary unit that admits surgical and clinical patients (pt) ; up to 2009 it had  a monthly mean of 390 pt-days and in 2010  the mean went up to  490 pt-days. The shortage of skilled nurses was calculated to be 15-20% in 2009 and 2010. Active surveillance for nosocomial infections (NI) using CDC definitions and pt-days as denominators was done by the IC team. Compliance with CLABSI bundle was verified by central line insertion forms (CLIF) using the formula: # of CLIF /# inserted central lines x 100. Noticing an increase of resistant Acinetobacter baumanii  (RAB)infections , a routine of collecting weekly rectal swabs and / or tracheal aspirates in all ICU pts looking for  RAB was implemented. Cohorting of infected or colonized pts until discharge from ICU was established .  Contact precautions were implemented for all RAB colonized/infected pts. RAB colonization/infection  rate was expressed as # colonized/infected pts/1,000 pt-days. The study period went from January 2009 to September 2010.

Results: Results can be seen at table.

	TOTAL INFECTION RATE/1,000 PT-DAYS	CLABSI /1,000 PT-DAYS	UTI/1,000 PT-DAYS	VAP/1,000 PT-DAYS	RAB COLONIZATION/1,000 PT-DAYS	RAB INFECTION/1,000 PT-DAYS
JANUARY-JULY 2009	24.6	5.8	10.2	0.35	14.3	0.7
AUGUST- DECEMBER 2009	17.5	2.3	6.5	3.3	24	5
JANUARY-SEPTEMBER 2010	11.6	3	3.2	2.8	17.8	4
JULY-AUGUST-SEPTEMBER 2010					12.2	1.3

Of note, there was a substantial decrease of total infections, comparing before, during and after construction. The greatest impact was in UTI, followed by CLABSI, which had a small increase in 2010. VAP increased in an impressive way; RAB colonization and infection rates were higher during construction, and just in the last three months they start to decrease to pre-construction levels. % of completed CLIF  went up from 80% (184/229) to 99% (260/261).

Conclusions:

Expanding the ICU had a positive impact in total rate  of infections, but RAB became much more prevalent. UTI and CLABSI  rates decreased but VAP is much higher now. Compliance with CLABSI bundle may explain the decrease of CLABSI rates; VAP bundle is the next one to implement and follow.