Healthcare-associated infections

 

Healthcare-associated infections (HAIs) are infections people get while they are receiving health care for another condition.
HAIs can happen in any health care facility, including hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities.
Bacteria, fungi, viruses, or other, less common pathogens can cause HAIs.
HAIs are a significant cause of illness and death — and they can have serious emotional, financial, and medical consequences.
At any given time, about 1 in 31 inpatients have an infection related to hospital care.
These infections lead to tens of thousands of deaths and cost the U.S. health care system billions of dollars each year.

 

Role of the INICC Foundation in Healthcare-Associated Infections Research and Prevention in Low- and Middle-Income Countries 

 

Fifty years ago, the U.S. CDC began a comprehensive national healthcare-associated infection (HAI) surveillance and prevention program1, 2. According to the WHO, infectious diseases claim the lives of 17 million people each year3. Most of those infectious diseases are acquired inside healthcare institutions, positioning HAIs among the world’s most common and primary causes of mortality. HAIs lead to sepsis, which causes an estimated 1.7 million illnesses and 270,000 deaths annually in the U.S.4. Because of globalization and the quick migration of multi-drug resistant organisms (MDRO) from low and middle income countries (LMICs) to the rest of the globe, including the U.S., bacterial resistance has increased in the U.S. Additionally, it is possible for people who visit LMICs on business, for pleasure, or as soldiers to experience a health issue that forces them to be admitted to hospitals in these nations, where they acquire a HAI, develop MDRO, and pass away5-8.

The World Bank recognizes 217 economies worldwide, of which 28 are low-income countries, 54 are lower-middle-income countries, 54 are upper-middle-income countries, and 81 are high-income countries. Thus, the 136 LMICs represent 63% of all countries, and with an estimated population of 3.36 billion, they are home to 43% of the world’s 7.8 billion people9.

Dr. Rosenthal started measuring HAIs at his home country in 199310, 11.  He found that in his country, the HAI rates were more than 10 times higher than the U.S. CDC/NHSN rates1, 2, and their clinical outcomes11-20, extra mortality21-24, hospital stay11-17, 21-23, 25-28, costs21-24, microorganism profile12, 15-17, 29, 30, and bacterial resistance12, 15-17, 29-31 were extremely high.

So, Dr. Rosenthal made a computerized online system to perform surveillance of HAIs and clinical outcomes and to track and improve healthcare workers (HCW) compliance with hand hygiene (HH) and the other almost 80 evidence-based interventions to reduce HAI rates 32, 33.

Applying a system consisting in surveillance of HAIs, monitoring compliance of HCWs with infection prevention practices and performance feedback32, it was improved the compliance of HCWs with HH34-36 and infection prevention interventions in Dr. Rosenthal’s home country37-40, and as a consequence, HAI rates were reduced significantly10, 11, 21, 23, 34, 35, 37, 39-41. ThenDr. Rosenthal drafted papers and published them in the American Journal of Infection Control and in other U.S. journals indexed in Pubmed10, 11, 21, 23, 34, 35, 37, 39-41.

From 2002 to 2023, Dr. Rosenthal was asked to talk about this topic in 71 countries across 5 continents. He found that in LMICs, an awareness or knowledge of HAI surveillance and rates, their clinical outcomes, or how they could be prevented was absent.

Dr. Rosenthal performed research to understand if there were international or even national bodies that were working on the global health issue of HAIs. He checked with various international organizations. All of them told him that they were not working in that field.

That is why in 2002 Dr. Rosenthal founded and have been the Chief Scientific Officer of the International Nosocomial Infection Control Consortium (INICC), which provides education, training, software, an  INICC Multidimensional Approach (IMA) for infection prevention, data analysis, publications, advice, and consultancy, all pro bono, for LMICs. With them, he published the previously unknown rates of HAIs and clinical outcomes with data from hospitals in 51 countries10-16, 18-21, 24, 29, 42-63.

After founding the INICC and counting with data from several countries, Dr. Rosenthal published them in the Annals of Internal Medicine42, Lancet64, American Journal of Infection Control, and in other journals indexed in Pubmed10-16, 18-21, 23, 24, 29, 34, 35, 37, 39-63, 65-73. We revealed unknown rates of central line-associated bloodstream infections (CLABSI) 18, 42-48, ventilator-associated pneumonia (VAP) 18, 42-48, catheter-associated urinary tract infections (CAUTI) 18, 42-48 in 50 LMICs and by specific countries10-16, 19-21, 24, 29, 49-63, 72, 73, and of surgical site infection (SSI) 71 in 30 LMICs and by specific countries63, 65-70. We found that all those HAI (CLABSI, VAP, CAUTI, and SSI) rates in LMICs are significantly higher than those in the U.S. We also conducted reviews, communicating that HAIs in LMICs are several times higher than those in high-income countries64, 74-76.

Applying the IMA33, HH compliance was improved at hospitals in 19 countries77, and by specific countries34-36, 78-83. Applying the IMA33, compliance with interventions to prevent CLABSI in adult ICUs of 15 countries84, in pediatric ICUs (PICUs) at 5 countries85, in neonatal ICUs (NICU) at 4 countries86, and also by specific countries37, 38, 87-91, were improved;compliance with interventions to prevent VAP39, 92-100, in adult ICU of 14 countries92, in PICUs of 5 countries93, in NICUs of 10 countries94, in specific countries39, 95-100, were improved; and compliance with interventions to prevent CAUTI,  in adult ICU of 15 countries101, in PICUs of 6 countries102, and in specific countries40, 103-105, were also improved.

With INICC research, we also found that closed IV fluid systems compared with open IV fluid system, needle-free connectors compared with three way stop cock, single use flushing compared with manual admixture, and peripherally inserted central catheters compared with other insertion sites are the safest devices to prevent CLABSI. We also identified the safest mechanical ventilator systems, the safest urinary catheters, and more discoveries and success stories, as described on our references.

Being aware of the previously unknown and now revealed burden of HAIs in LMICs by INICC, by 2008, WHO published a secondary analysis and review of HAI rates in LMICs compared with high-income countries, and they used as the source of information, the primary data published by INICC106; and by 2011, WHO published another secondary analysis and review of HAI rates in LMICs compared with high-income countries, and again, they used as the source of information, the primary data published by INICC107.

During the last 20 years, Dr. Rosenthal have been receiving several invitations to collaborate with infection prevention worldwide: WHO invited me to review guidelines for HH108; the International Society of Infectious Diseases invited him to draft and coauthor several infection prevention guidelines and recommendations, such as those to prevent CLABSI109, SSIs110, infections by Clostridium difficile111, and the spread of COVID-19112; Oxford University team have been publishing with him regarding the growing challenge of bacterial resistance31; and the governments of Argentina, Brazil, Colombia, Hong Kong, Taiwan, and several others have invited him to be their advisor and to draft their infection prevention guidelines.

Understanding that HAIs are associated with extra-attributable mortality, we conducted studies to identify independent risk factors (RF) for mortality, and we found that CLABSI, VAP, and CAUTI are independent RFs for mortality, worldwide113 and also stratified per region in Latin America114, Asia115, and the Middle East116. This data allowed us to focus on an independent risk factor that can be easily modified, namely the HAIs.

When we confirmed that HAIs are an independent RF for mortality, we analyzed our collected data to identify the RF for CLABSI globally72 and stratified per region in Latin America117 and Asia; we also analyzed our collected data to identify the RF for VAP globally118 and stratified per region in Latin America114 and Asia 119. Through these investigations to identify the RFs for HAIs, we have been able to clearly identify which actions, strategies, and devices must be continued and which ones must be stopped.

In short, INICC was the first organization and the pioneer to find and report that HAIs were a problem in LMICs in Latin America, Asia, Africa, Eastern Europe, and the Middle East, that their rates were much higher than in high-income countries, and that they were linked to high mortality rates, longer hospital stays, higher costs, and MDROs. It was our initial discovery, published by country since 2003 and pooling several countries since 2006, that made people and organizations pay attention to this problem. Aware of that, we also developed an online platform to measure and reduce these rates and clinical outcomes.

Before INICC research and publications, the data relating to HAI rates and their impact on mortality, extra hospital stays, extra costs, and the burden of MDROs in LMICs were unknown.

INICC has been doing this work for more than 20 years in a completely selfless, philanthropic, generous, and empathetic way, with very high humanistic values and the noble goal of preventing so many millions of deaths and helping to stop the spread of the terrible, still unbeatable bacterial resistance that is killing more and more people around the world.

Our objective is to continue investigating the causes and how to prevent HAIs, making specific interventions to prevent HAIs, publishing our findings in peer-reviewed scientific journals, generating recommendations and guidelines, distributing our scientific material and recommendations, educating and training doctors and nurses in more than 50 countries, going ahead to collaborate with even more countries, updating our INICC-specific software for the surveillance and prevention of HAIs, and providing said materials to healthcare workers. In short, we will keep working together to stop HAIs and the deaths, costs, and bacterial resistance they cause.

We count on your generous and selfless contribution to this noble global cause.

 

References:

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  3. Infectious diseases kill over 17 million people a year: WHO warns of global crisis.
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  13. Kubler A, Duszynska W, Rosenthal VD, Fleischer M, Kaiser T, Szewczyk E, et al. Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial Infection Control Consortium’s (INICC) findings. J Crit Care. 2012;27:105 e5-10.
  14. Hu B, Tao L, Rosenthal VD, Liu K, Yun Y, Suo Y, et al. Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings. Am J Infect Control. 2013;41:301-6.
  15. Al-Mousa HH, Omar AA, Rosenthal VD, Salama MF, Aly NY, El-Dossoky Noweir M, et al. Device-associated infection rates, bacterial resistance, length of stay, and mortality in Kuwait: International Nosocomial Infection Consortium findings. Am J Infect Control. 2016;44:444-9.
  16. Salgado Yepez E, Bovera MM, Rosenthal VD, Gonzalez Flores HA, Pazmino L, Valencia F, et al. Device-associated infection rates, mortality, length of stay and bacterial resistance in intensive care units in Ecuador: International Nosocomial Infection Control Consortium’s findings. World J Biol Chem. 2017;8:95-101.
  17. Viet Hung N, Hang PT, Rosenthal VD, Thi Anh Thu L, Thi Thu Nguyet L, Quy Chau N, et al. Multicenter Study of Device-Associated Infection Rates, Bacterial Resistance, Length of Stay, and Mortality in Intensive Care Units of 2 Cities of Vietnam: International Nosocomial Infection Control Consortium Findings. J Patient Saf. 2021;17:e222-e7.
  18. Rosenthal VD, Duszynska W, Ider BE, Gurskis V, Al-Ruzzieh MA, Myatra SN, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module. Am J Infect Control. 2021;49:1267-74.
  19. Moreno CA, Rosenthal VD, Olarte N, Gomez WV, Sussmann O, Agudelo JG, et al. Device-associated infection rate and mortality in intensive care units of 9 Colombian hospitals: findings of the International Nosocomial Infection Control Consortium. Infect Control Hosp Epidemiol. 2006;27:349-56.
  20. Cuellar LE, Fernandez-Maldonado E, Rosenthal VD, Castaneda-Sabogal A, Rosales R, Mayorga-Espichan MJ, et al. Device-associated infection rates and mortality in intensive care units of Peruvian hospitals: findings of the International Nosocomial Infection Control Consortium. Rev Panam Salud Publica. 2008;24:16-24.
  21. Rosenthal VD, Guzman S, Migone O, Crnich CJ. The attributable cost, length of hospital stay, and mortality of central line-associated bloodstream infection in intensive care departments in Argentina: A prospective, matched analysis. Am J Infect Control. 2003;31:475-80.
  22. Higuera F, Rangel-Frausto MS, Rosenthal VD, Soto JM, Castanon J, Franco G, et al. Attributable cost and length of stay for patients with central venous catheter-associated bloodstream infection in Mexico City intensive care units: a prospective, matched analysis. Infect Control Hosp Epidemiol. 2007;28:31-5.
  23. Rosenthal VD, Guzman S, Migone O, Safdar N. The attributable cost and length of hospital stay because of nosocomial pneumonia in intensive care units in 3 hospitals in Argentina: a prospective, matched analysis. Am J Infect Control. 2005;33:157-61.
  24. Duszynska W, Rosenthal VD, Szczesny A, Zajaczkowska K, Fulek M, Tomaszewski J. Device associated -health care associated infections monitoring, prevention and cost assessment at intensive care unit of University Hospital in Poland (2015-2017). BMC Infect Dis. 2020;20:761.
  25. Barnett AG, Graves N, Rosenthal VD, Salomao R, Rangel-Frausto MS. Excess length of stay due to central line-associated bloodstream infection in intensive care units in Argentina, Brazil, and Mexico. Infect Control Hosp Epidemiol. 2010;31:1106-14.
  26. Barnett AG, Beyersmann J, Allignol A, Rosenthal VD, Graves N, Wolkewitz M. The time-dependent bias and its effect on extra length of stay due to nosocomial infection. Value Health. 2011;14:381-6.
  27. Rosenthal VD, Dwivedy A, Calderon ME, Esen S, Hernandez HT, Abouqal R, et al. Time-dependent analysis of length of stay and mortality due to urinary tract infections in ten developing countries: INICC findings. J Infect. 2011;62:136-41.
  28. Rosenthal VD, Udwadia FE, Munoz HJ, Erben N, Higuera F, Abidi K, et al. Time-dependent analysis of extra length of stay and mortality due to ventilator-associated pneumonia in intensive-care units of ten limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC). Epidemiol Infect. 2011;139:1757-63.
  29. Empaire GD, Guzman Siritt ME, Rosenthal VD, Perez F, Ruiz Y, Diaz C, et al. Multicenter prospective study on device-associated infection rates and bacterial resistance in intensive care units of Venezuela: International Nosocomial Infection Control Consortium (INICC) findings. Int Health. 2017;9:44-9.
  30. Pawar M, Mehta Y, Purohit A, Trehan N, Rosenthal VD. Resistance in gram-negative bacilli in a cardiac intensive care unit in India: risk factors and outcome. Ann Card Anaesth. 2008;11:20-6.
  31. Antimicrobial Resistance C. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399:629-55.
  32. Rosenthal VD, Maki DG, Graves N. The International Nosocomial Infection Control Consortium (INICC): goals and objectives, description of surveillance methods, and operational activities. Am J Infect Control. 2008;36:e1-12.
  33. Rosenthal VD. International Nosocomial Infection Control Consortium (INICC) resources: INICC multidimensional approach and INICC surveillance online system. Am J Infect Control. 2016;44:e81-90.
  34. Rosenthal VD, McCormick RD, Guzman S, Villamayor C, Orellano PW. Effect of education and performance feedback on handwashing: the benefit of administrative support in Argentinean hospitals. Am J Infect Control. 2003;31:85-92.
  35. Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Am J Infect Control. 2005;33:392-7.
  36. Rosenthal VD, Viegas M, Sztokhamer D, Benchetrit G, Santoro B, Lastra CE, et al. Impact of INICC Multidimensional Hand Hygiene Approach in ICUs in Four Cities in Argentina. J Nurs Care Qual. 2015;30:E17-25.
  37. Rosenthal VD, Guzman S, Pezzotto SM, Crnich CJ. Effect of an infection control program using education and performance feedback on rates of intravascular device-associated bloodstream infections in intensive care units in Argentina. Am J Infect Control. 2003;31:405-9.
  38. Rosenthal VD, Desse J, Maurizi DM, Chaparro GJ, Orellano PW, Chediack V, et al. Impact of the International Nosocomial Infection Control Consortium (INICC)’s Multidimensional Approach on Rates of Central Line-Associated Bloodstream Infection in 14 Intensive Care Units in 11 Hospitals of 5 Cities in Argentina. Infect Control Hosp Epidemiol. 2018;12:1-7.
  39. Rosenthal VD, Guzman S, Crnich C. Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals. Am J Infect Control. 2006;34:58-63.
  40. Rosenthal VD, Guzman S, Safdar N. Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol. 2004;25:47-50.
  41. Rosenthal VD, Maki DG. Prospective study of the impact of open and closed infusion systems on rates of central venous catheter-associated bacteremia. Am J Infect Control. 2004;32:135-41.
  42. Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med. 2006;145:582-91.
  43. Rosenthal VD, Maki DG, Mehta A, Alvarez-Moreno C, Leblebicioglu H, Higuera F, et al. International Nosocomial Infection Control Consortium report, data summary for 2002-2007, issued January 2008. Am J Infect Control. 2008;36:627-37.
  44. Rosenthal VD, Maki DG, Jamulitrat S, Medeiros EA, Todi SK, Gomez DY, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009. Am J Infect Control. 2010;38:95-104 e2.
  45. Rosenthal VD, Bijie H, Maki DG, Mehta Y, Apisarnthanarak A, Medeiros EA, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009. Am J Infect Control. 2012;40:396-407.
  46. Rosenthal VD, Maki DG, Mehta Y, Leblebicioglu H, Memish ZA, Al-Mousa HH, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module. Am J Infect Control. 2014;42:942-56.
  47. Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SAA, Leblebicioglu H, Mehta Y, et al. International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control. 2016;44:1495-504.
  48. Rosenthal VD, Bat-Erdene I, Gupta D, Belkebir S, Rajhans P, Zand F, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module. Am J Infect Control. 2020;48:423-32.
  49. Salomao R, Rosenthal VD, Grimberg G, Nouer S, Blecher S, Buchner-Ferreira S, et al. Device-associated infection rates in intensive care units of Brazilian hospitals: findings of the International Nosocomial Infection Control Consortium. Rev Panam Salud Publica. 2008;24:195-202.
  50. Tao L, Hu B, Rosenthal VD, Gao X, He L. Device-associated infection rates in 398 intensive care units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis. 2011;15:e774-80.
  51. Guanche-Garcell H, Requejo-Pino O, Rosenthal VD, Morales-Perez C, Delgado-Gonzalez O, Fernandez-Gonzalez D. Device-associated infection rates in adult intensive care units of Cuban university hospitals: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis. 2011;15:e357-62.
  52. Rasslan O, Seliem ZS, Ghazi IA, El Sabour MA, El Kholy AA, Sadeq FM, et al. Device-associated infection rates in adult and pediatric intensive care units of hospitals in Egypt. International Nosocomial Infection Control Consortium (INICC) findings. J Infect Public Health. 2012;5:394-402.
  53. Duenas L, Bran de Casares A, Rosenthal VD, Jesus Machuca L. Device-associated infections rates in pediatrics and neonatal intensive care units in El Salvador: findings of the INICC. J Infect Dev Ctries. 2011;5:445-51.
  54. Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect. 2007;67:168-74.
  55. Mehta Y, Jaggi N, Rosenthal VD, Kavathekar M, Sakle A, Munshi N, et al. Device-Associated Infection Rates in 20 Cities of India, Data Summary for 2004-2013: Findings of the International Nosocomial Infection Control Consortium. Infect Control Hosp Epidemiol. 2016;37:172-81.
  56. Kanj S, Kanafani Z, Sidani N, Alamuddin L, Zahreddine N, Rosenthal V. International nosocomial infection control consortium findings of device-associated infections rate in an intensive care unit of a lebanese university hospital. J Glob Infect Dis. 2012;4:15-21.
  57. Ramirez Barba EJ, Rosenthal VD, Higuera F, Oropeza MS, Hernandez HT, Lopez MS, et al. Device-associated nosocomial infection rates in intensive care units in four Mexican public hospitals. Am J Infect Control. 2006;34:244-7.
  58. Ider BE, Baatar O, Rosenthal VD, Khuderchuluun C, Baasanjav B, Donkhim C, et al. Multicenter study of device-associated infection rates in hospitals of Mongolia: Findings of the International Nosocomial Infection Control Consortium (INICC). Am J Infect Control. 2016;44:327-31.
  59. Navoa-Ng JA, Berba R, Galapia YA, Rosenthal VD, Villanueva VD, Tolentino MC, et al. Device-associated infections rates in adult, pediatric, and neonatal intensive care units of hospitals in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings. Am J Infect Control. 2011;39:548-54.
  60. Duszynska W, Rosenthal VD, Szczesny A, Woznica E, Ulfik K, Ostrowska E, et al. Urinary tract infections in intensive care unit patients – a single-centre, 3-year observational study according to the INICC project. Anaesthesiol Intensive Ther. 2016;48:1-6.
  61. Al-Abdely HM, Alshehri AD, Rosenthal VD, Mohammed YK, Banjar W, Orellano PW, et al. Prospective multicentre study in intensive care units in five cities from the Kingdom of Saudi Arabia: Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on rates of central line-associated bloodstream infection. J Infect Prev. 2017;18:25-34.
  62. Leblebicioglu H, Rosenthal VD, Arikan OA, Ozgultekin A, Yalcin AN, Koksal I, et al. Device-associated hospital-acquired infection rates in Turkish intensive care units. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect. 2007;65:251-7.
  63. Viet Hung N, Anh Thu T, Rosenthal VD, Tat Thanh D, Quoc Anh N, Le Bao Tien N, et al. Surgical Site Infection Rates in Seven Cities in Vietnam: Findings of the International Nosocomial Infection Control Consortium. Surg Infect (Larchmt). 2016;17:243-9.
  64. Rosenthal VD. Health-care-associated infections in developing countries. Lancet. 2011;377:186-8.
  65. Alvarez-Moreno C, Perez-Fernandez AM, Rosenthal VD, Quintero J, Chapeta-Parada E, Linares C, et al. Surgical site infection rates in 4 cities in Colombia: findings of the International Nosocomial Infection Control Consortium (INICC). Am J Infect Control. 2014;42:1089-92.
  66. Portillo-Gallo JH, Miranda-Novales MG, Rosenthal VD, Sanchez M, Ayala-Gaytan JJ, Ortiz-Juarez VR, et al. Surgical site infection rates in four Mexican cities: findings of the International Nosocomial Infection Control Consortium (INICC). J Infect Public Health. 2014;7:465-71.
  67. Leblebicioglu H, Erben N, Rosenthal VD, Sener A, Uzun C, Senol G, et al. Surgical site infection rates in 16 cities in Turkey: findings of the International Nosocomial Infection Control Consortium (INICC). Am J Infect Control. 2015;43:48-52.
  68. Ramirez-Wong FM, Atencio-Espinoza T, Rosenthal VD, Ramirez E, Torres-Zegarra SL, Diaz Tavera ZR, et al. Surgical Site Infections Rates in More Than 13,000 Surgical Procedures in Three Cities in Peru: Findings of the International Nosocomial Infection Control Consortium. Surg Infect (Larchmt). 2015;16:572-6.
  69. Singh S, Chakravarthy M, Rosenthal VD, Myatra SN, Dwivedy A, Bagasrawala I, et al. Surgical site infection rates in six cities of India: findings of the International Nosocomial Infection Control Consortium (INICC). Int Health. 2015;7:354-9.
  70. Richtmann R, Siliprandi EM, Rosenthal VD, Sanchez TE, Moreira M, Rodrigues T, et al. Surgical Site Infection Rates in Four Cities in Brazil: Findings of the International Nosocomial Infection Control Consortium. Surg Infect (Larchmt). 2016;17:53-7.
  71. Rosenthal VD, Richtmann R, Singh S, Apisarnthanarak A, Kubler A, Viet-Hung N, et al. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010. Infect Control Hosp Epidemiol. 2013;34:597-604.
  72. Rosenthal V, Yin R, Myatra S, al. e. Multinational prospective study of incidence and risk factors for central line-associated bloodstream infections in 728 ICUs of 41 Asian, African, Eastern European, Latin American and Middle Eastern countries over 24 years. Infection Control and Hospital Epidemiology. 2023;In Press.
  73. Rosenthal VD, Jin Z, Memish ZA, Rodrigues C, Myatra SN, Kharbanda M, et al. Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC). Antimicrob Steward Healthc Epidemiol. 2023;3:e6.
  74. Rosenthal VD. Central line-associated bloodstream infections in limited-resource countries: a review of the literature. Clin Infect Dis. 2009;49:1899-907.
  75. Rosenthal VD. Device-associated nosocomial infections in limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC). Am J Infect Control. 2008;36:S171 e7-12.
  76. Rosenthal VD. The need for international benchmark for health care-associated infections. Am J Infect Control. 2009;37:432-4.
  77. Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villamil-Gomez W, Armas-Ruiz A, et al. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol. 2013;34:415-23.
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