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Multinational prospective study of incidence and risk factors for central-line–associated bloodstream infections in 728 intensive care units of 41 Asian, African, Eastern European, Latin American, and Middle Eastern countries over 24 years

Published online by Cambridge University Press:  28 April 2023

Victor Daniel Rosenthal*
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States INICC Foundation, International Nosocomial Infection Control Consortium, Miami, Florida, United States
Ruijie Yin
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States
Sheila Nainan Myatra
Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
Ziad A. Memish
King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
Camilla Rodrigues
Pd Hinduja National Hospital And Medical Research Centre, Mumbai, India
Mohit Kharbanda
Desun Hospital, Kolkata, India
Sandra Liliana Valderrama-Beltran
Pontificia Universidad Javeriana Hospital Universitario San Ignacio, Bogota, Colombia
Yatin Mehta
Medanta The Medicity, Haryana, India
Majeda Afeef Al-Ruzzieh
King Hussein Cancer Center, Amman, Jordan
Guadalupe Aguirre-Avalos
Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
Ertugrul Guclu
Sakarya University Training and Research Hospital, Sakarya, Turkey
Chin Seng Gan
University Malaya Medical Centre, Kuala Lumpur, Malaysia
Luisa Fernanda Jiménez Alvarez
Clinica Universitaria Colombia, Bogota, Colombia
Rajesh Chawla
Indraprastha Apollo Hospitals, New Delhi, India
Sona Hlinkova
Faculty of Health, Catholic University in Ruzomberok, Ruzomberok, Slovakia Central Military Hospital Ruzomberok, Ruzomberok, Slovakia
Rajalakshmi Arjun
Kerala Institute of Med Sciences Health, Trivandrum, India
Hala Mounir Agha
Cairo University Specialized Pediatric Hospital, Cairo, Egypt
Maria Adelia Zuniga Chavarria
Hospital Clinica Biblica, San Jose de Costa Rica, Costa Rica
Narangarav Davaadagva
Intermed Hospital, Ulaanbaatar, Ulaanbaatar, Mongolia
Yin Hoong Lai
International Islamic University Malaysia, Kuantan Pahang, Malaysia
Katherine Gomez
Clinica Sebastian de Belalcazar, Cali, Colombia
Daisy Aguilar-de-Moros
Hospital del Niño Dr José Renán Esquivel, Panama City, Panama
Chian-Wern Tai
Universiti Kebangsaan Malaysia Specialist Children’s Hospital, Kuala Lumpur, Malaysia
Alejandro Sassoe Gonzalez
Hospital Regional de Alta Especialidad Ixtapaluca, Ixtapaluca, Mexico
Lina Alejandra Aguilar Moreno
Clinica Infantil Santa María del Lago, Bogota, Colombia
Kavita Sandhu
Max Super Speciality Hospital Saket Delhi, New Delhi, India
Jarosław Janc
Department of Anesthesiology and Intensive Therapy, 4th Clinical Military Hospital with Polyclinic, Wroclaw, Poland
Mary Cruz Aleman Bocanegra
Hospital San Jose TecSalud, Monterrey, Nuevo León, México
Dincer Yildizdas
Cukurova University. Balcali Hospital, Adana, Turkey
Yuliana Andrea Cano Medina
Instituto Del Corazon De Bucaramanga Sede Bogota, Bogota, Colombia
Maria Isabel Villegas Mota
Instituto Nacional de Perinatología, México DF, México
Abeer Aly Omar
Infection Control Directorate. Ministry of Health, Kuwait City, Kuwait
Wieslawa Duszynska
Wroclaw Medical University. Department of Anesthesiology and Intensive Therapy, Wroclaw, Poland
Amani Ali El-Kholy
Dar Alfouad Hospital, 6th of October City, Egypt
Safaa Abdulaziz Alkhawaja
Salmaniya Medical Center, Manama, Bahrain
George Horhat Florin
University of Medicine and Pharmacy Victor Babes, Timisoara, Romania Timisoara Emergency Clinical County Hospital Romania, Timisoara, Romania
Eduardo Alexandrino Medeiros
Hospital Sao Paulo, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
Lili Tao
Zhongshan Hospital, Fudan University, Shanghai, China
Nellie Tumu
Port Moresby General Hospital, Port Moresby, Papua, New Guinea
May Gamar Elanbya
National Infection control Program, Khartoum, Sudan
Reshma Dongol
Grande International Hospital, Kathmandu, Nepal
Vesna Mioljević
Clinical Center of Serbia, Belgrade, Serbia
Lul Raka
National Institute For Public Health, Prishtina, Kosovo
Lourdes Dueñas
Hospital Nacional de Niños Benjamin Bloom, San Salvador, El Salvador
Nilton Yhuri Carreazo
Universidad Peruana de Ciencias Aplicadas, Lima, Peru Hospital de Emergencias Pediatricas, Lima, Peru
Tarek Dendane
Hôpital Ibn Sina, Rabat, Morocco
Aamer Ikram
National Institutes of Health, Islamabad, Pakistan
Tala Kardas
American University of Beirut Medical Center, Beirut, Lebanon
Michael M. Petrov
Department of Microbiology, Faculty of Pharmacy, Medical University of Plovdiv, Plovdiv, Bulgaria
Asma Bouziri
Hôpital d’enfants, Tunis, Tunisia
Nguyen Viet-Hung
Bach Mai Hospital, Hanoi, Vietnam
Vladislav Belskiy
Privolzhskiy District Medical Center, Nizhniy Novgorod, Russia
Naheed Elahi
Dubai Hospital, Dubai, United Arab Emirates
Estuardo Salgado
Hospital de Especialidades, Alianza Del Ecuador, Ecuador
Zhilin Jin
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States
Corresponding author: Victor D. Rosenthal, MD, Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, Floor 9, Office 912, Miami, FL 33136, USA. E-mail:,



To identify central-line (CL)–associated bloodstream infection (CLABSI) incidence and risk factors in low- and middle-income countries (LMICs).


From July 1, 1998, to February 12, 2022, we conducted a multinational multicenter prospective cohort study using online standardized surveillance system and unified forms.


The study included 728 ICUs of 286 hospitals in 147 cities in 41 African, Asian, Eastern European, Latin American, and Middle Eastern countries.


In total, 278,241 patients followed during 1,815,043 patient days acquired 3,537 CLABSIs.


For the CLABSI rate, we used CL days as the denominator and the number of CLABSIs as the numerator. Using multiple logistic regression, outcomes are shown as adjusted odds ratios (aORs).


The pooled CLABSI rate was 4.82 CLABSIs per 1,000 CL days, which is significantly higher than that reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN). We analyzed 11 variables, and the following variables were independently and significantly associated with CLABSI: length of stay (LOS), risk increasing 3% daily (aOR, 1.03; 95% CI, 1.03–1.04; P < .0001), number of CL days, risk increasing 4% per CL day (aOR, 1.04; 95% CI, 1.03–1.04; P < .0001), surgical hospitalization (aOR, 1.12; 95% CI, 1.03–1.21; P < .0001), tracheostomy use (aOR, 1.52; 95% CI, 1.23–1.88; P < .0001), hospitalization at a publicly owned facility (aOR, 3.04; 95% CI, 2.31–4.01; P <.0001) or at a teaching hospital (aOR, 2.91; 95% CI, 2.22–3.83; P < .0001), hospitalization in a middle-income country (aOR, 2.41; 95% CI, 2.09–2.77; P < .0001). The ICU type with highest risk was adult oncology (aOR, 4.35; 95% CI, 3.11–6.09; P < .0001), followed by pediatric oncology (aOR, 2.51;95% CI, 1.57–3.99; P < .0001), and pediatric (aOR, 2.34; 95% CI, 1.81–3.01; P < .0001). The CL type with the highest risk was internal-jugular (aOR, 3.01; 95% CI, 2.71–3.33; P < .0001), followed by femoral (aOR, 2.29; 95% CI, 1.96–2.68; P < .0001). Peripherally inserted central catheter (PICC) was the CL with the lowest CLABSI risk (aOR, 1.48; 95% CI, 1.02–2.18; P = .04).


The following CLABSI risk factors are unlikely to change: country income level, facility ownership, hospitalization type, and ICU type. These findings suggest a focus on reducing LOS, CL days, and tracheostomy; using PICC instead of internal-jugular or femoral CL; and implementing evidence-based CLABSI prevention recommendations.

Original Article
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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