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. 2025 Sep 24.
doi: 10.1097/CCM.0000000000006881. Online ahead of print.

Institutional Risk Factors Associated With Healthcare-Associated Infections in Brazilian ICUs: A Nested Cohort Within the IMPACTO-MR Platform

Bruno Adler Maccagnan Pinheiro Besen  1   2 , Camila Dietrich  1 , Carla Cristina Gomes Pinheiro  1 , Débora Patrício Silva  1 , Renata Rodrigues de Mattos  1 , Clayse Carla da Silva Spadoni  1 , Luiz Fernando Lima Reis  3 , Pedro Aniceto Nunes Neto  4 , Luis Eduardo Miranda Paciência  5 , Eliana Bernadete Caser  6 , Caio Cesar Ferreira Fernandes  7 , Vanildes de Fátima Fernandes  8 , Bianca Ramos Ferronato  9 , Hugo Corrêa de Andrade Urbano  10 , Cintia Magalhães Carvalho Grion  2   11 , Elisangela Maria de Lima Medeiros  12 , Antônio Carlos da Silva  13 , Nicole Alberti Golin  14 , Valéria Paes Lima  15 , Emerson Boschi  16 , André Sant'Ana Machado  17 , Rafael Botelho Foernges  18 , Lúcio Couto de Oliveira Junior  19 , Everton Macêdo Silva  20 , Francielle Constantino Pereira  21 , Thiago Costa Lisboa  2   22 , Antônio Paulo Nassar Jr  2   23 , Adriano José Pereira  2   24 , Viviane Cordeiro Veiga  2   25 , Beatriz Arns  26 , Giovanna Marsola  27 , Flávia Ribeiro Machado  2   28 , Alexandre Biasi Cavalcanti  2   29 , Luciano César Pontes Azevedo  1   2 , Bruno Martins Tomazini  1   2 ; Impact of Infections by Antimicrobial-Resistant Microorganisms in Patients Admitted to Adult ICUs in Brazil: Platform of Projects to Support the National Action Plan for the Prevention and Control of Antimicrobial Resistance (IMPACTO-MR) investigators and Brazilian Research in Intensive Care Network (BRICNet)
Collaborators, Affiliations

Institutional Risk Factors Associated With Healthcare-Associated Infections in Brazilian ICUs: A Nested Cohort Within the IMPACTO-MR Platform

Bruno Adler Maccagnan Pinheiro Besen et al. Crit Care Med. .

Abstract

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.

Keywords: bloodstream infection; healthcare-associated infection; intensive care unit; processes of care; ventilator-associated pneumonia.

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Conflict of interest statement

Drs. Besen’s, Nassar’s, Reis', Pereira’s and Tomazini’s institutions received funding from the Brazilian Ministry of Health. Drs. Besen, Foernges, and Nassar received support for article research from the Brazilian Ministry of Health. Drs. Spadoni, Paciência, and Boschi received support for article research from the National Institutes of Health. Drs. Spadoni, Paciência, and Neto disclosed government work. Dr. Paciência disclosed off-label use of antibiotics resistance. Dr. Neto received support for article research from the Brazilian Government. Dr. Azevedo received funding from Baxter, Merck Sharp Dome (MSD), and Nestlé. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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