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

Victor D. Rosenthal, MD; Dennis G. Maki, MD; Reinaldo Salomao, MD; Carlos Álvarez Moreno, MD; Yatin Mehta, MD; Francisco Higuera, MD; Luis E. Cuellar, MD; Özay Akan Arikan, MD; Rédouane Abouqal, MD; Hakan Leblebicioglu, MD, International Nosocomial Infection Control Consortium*
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From the Medical College of Buenos Aires, Buenos Aires, Argentina; University of Wisconsin Medical School, Madison, Wisconsin; Santa Marcelina Hospital, São Paulo, Brazil; San Ignacio Hospital, Pontificia Javeriana University, Bogota, Colombia; Escorts Heart Institute and Research Centre, New Delhi, India; General Hospital, Mexico City, Mexico; Institute of Neoplastic Diseases, Lima, Peru; Ankara University School of Medicine, Ibni Sina Hospital, Ankara, Turkey; Ibn Sina Hospital, Rabat, Morocco; and Ondokuz Mayis University Medical School, Samsun, Turkey.

Acknowledgments: The authors thank the many professionals at each member hospital who assisted with the conduct of the surveillance study, including the surveillance nurses, clinical microbiology laboratory personnel, and the physicians and nurses providing care for the patients during the study, without whose cooperation and generous assistance the study would not have been possible.

Potential Financial Conflicts of Interest: During the past 5 years, Dr. Rosenthal has presented at scientific meetings sponsored by Baxter Healthcare International, Wyeth Colombia, and Tyco Healthcare Latin America.

Requests for Single Reprints: Victor D. Rosenthal, MD, Arengreen 1366, (1405) Buenos Aires, Argentina; e-mail, victor_rosenthal@inicc.org.

Current Author Addresses: Dr. Rosenthal: Arengreen 1366, (1405) Buenos Aires, Argentina.

Dr. Maki: H4/574, University of Wisconsin Hospital and Clinics, Madison, WI 53792.

Dr. Salomao: Rua Santa Marcelina, 177 Itaquera, São Paulo SP, Cep 08270-070, Brazil.

Dr. Álvarez-Moreno: Calle 122A No. 14-71, Apto. 412, Bogota, Colombia.

Dr. Mehta: Department of Anesthesiology and Critical Care, Escorts Heart Institute & Research Centre, Okhla Road, New Delhi 110 025, India.

Dr. Higuera: Dr. Balmis No. 148, Col. Doctores, C.P. 06726 Mexico, D.F. Mexico.

Dr. Cuellar: Calle Alonso de Molina 1566, Santiago de Surco, Lima, Peru.

Dr. Arikan: Angora Evleri, Sancak sok B2-2A, Ümitköy, Ankara, Turkey.

Dr. Abouqal: Service de Réanimation Médicale, Hopital Ibn Sina, CHU Ibn Sina, 10000-Rabat, Morocco.

Dr. Leblebicioglu: Department of Clinical Microbiology and Infectious Diseases, Ondokuz Mayis University Medical School, Samsun 55139, Turkey.

Author Contributions: Conception and design: V.D. Rosenthal, D.G. Maki.

Analysis and interpretation of the data: V.D. Rosenthal.

Drafting of the article: V.D. Rosenthal, D.G. Maki.

Critical revision of the article for important intellectual content: V.D. Rosenthal, D.G. Maki, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Final approval of the article: V.D. Rosenthal, D.G. Maki, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Provision of study materials or patients: V.D. Rosenthal, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Statistical expertise: V.D. Rosenthal.

Administrative, technical, or logistic support: V.D. Rosenthal.

Collection and assembly of data: V.D. Rosenthal, R. Salomao, C. Álvarez-Moreno, Y. Mehta, F. Higuera, L.E. Cuellar, Ö.A. Arikan, R. Abouqal, H. Leblebicioglu.

Ann Intern Med. 2006;145(8):582-591. doi:10.7326/0003-4819-145-8-200610170-00007
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Health care–acquired infections have been associated with substantial morbidity and attributable mortality (89, 3844), as well as greatly increased health care costs (6, 13, 17, 39, 42, 45). Studies done in U.S. hospitals 30 years ago showed that an integrated infection control program that includes surveillance of health care–associated infections can reduce the incidence of infection by as much as 30% and can lead to reduced health care costs (3).

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Submit a Comment/Letter
Comparison of Device-Related Infection Rates Between Developing Countries and the United States
Posted on November 12, 2006
Rodrigo A Ribeiro
Hospital de Clinicas de Porto Alegre
Conflict of Interest: None Declared

We read with great interest the article by Rosenthal and colleagues about intensive care unit (ICU)-acquired infections in developing countries(1). The results are of great concern, since high overall rates of device-related nosocomial infections were found in participating ICUs (24.1 ventilator-associated pneumonia (VAP) per 1000 mechanical ventilator days, 12.5 central venous catheter (CVC)-related bloodstream infections per 1000 CVC days, and 8.9 catheter-associated urinary tract infections (UTI) per 1000 Foley catheter days). Furthermore, the authors found that these were far higher than those reported by National Nosocomial Infection Surveillance (NNIS) System in the Unites States(2).

However, this comparison has some significant drawbacks. The comparator rates from NNIS presented(1) (4.0 CVC-related bloodstream infections, 5.4 VAP, and 3.9 catheter-associated UTIs per 1000 device days) are, in fact, only from the medical-surgical ICUs of major teaching hospitals(2). This subgroup of ICUs represents only about 16% of total NNIS ICUs, and accounted for less than 18% of total infections. Moreover, these ICUs are likely to be centers of excellence in infection control. The rates from these ICUs, for example, underestimated the weighted arithmetic mean of all ICUs from NNIS (4.85 per 1000 CVC days, 7.5 per 1000 mechanical ventilator days, and 4.9 per 1000 urinary catheter days). Although it is possible to compare the overall incidence of these infections, a wide range of infection rates among different ICU settings requires individual comparisons as done in NNIS report, where no pooled mean was calculated.

The study by Rosenthal and colleagues gathered data from medical- surgical units (58%), coronary care units (12%), combined medical-surgical and coronary units (25%), and other types of adult ICUs (10%). We believe that it would be more appropriate to compare infection rates according to these strata, since they may result from different rates of device usage, different infection control practices and patients with different degrees of susceptibility to infections.

Although the overall results described by Rosenthal and colleagues indicate higher incidence of device-associated nosocomial infections in developing countries, it might be overestimated. It called to our attention a wide range of rates among countries, especially regarding VAP, which ranged from 10.0 to 52.7 per 1000 mechanical ventilator days. We believe that the overall pooled mean rates are not well-suited to represent developing countries, since striking variations among countries may actually indicate differences in infection control measures, distinct practices and distinct care of patients in developing countries.


1. Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F, Cuellar LE, Arikan OA, Abouqal R, Leblebicioglu H. International Nosocomial Infection Control Consortium. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries.Ann Intern Med. 2006;145:582-91.

2. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-85.

Conflict of Interest:

None declared

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