, Volume 38, Issue 3, pp 165–171 | Cite as

Device-associated infections in the intensive care units of Cyprus: results of the first national incidence study

  • A. Gikas
  • M. Roumbelaki
  • D. Bagatzouni-Pieridou
  • M. Alexandrou
  • V. Zinieri
  • I. Dimitriadis
  • E. I. Kritsotakis
Clinical and Epidemiological Study



Surveillance of healthcare-associated infections (HCAIs) has become an integral part of infection control programs in several countries, especially in the intensive care unit (ICU) setting. In contrast, surveillance data on the epidemiology of ICU-acquired infections in Cyprus are limited. The aim of this study was to assess the risk of ICU-acquired infections and to identify areas for improvement in Cypriot hospitals by comparing observed incidence rates with international benchmarks and by specifying the microbiological and antibiotic resistance profiles of infecting organisms.

Materials and methods

An active surveillance protocol was introduced in the ICUs of the four major public hospitals in Cyprus, based on the methodology of the US National Nosocomial Infections Surveillance system.


During February to December 2007, 2,692 patients who were hospitalized in ICUs for a mean length of stay of 5 days acquired 214 infections for an overall incidence rate of 15.8 infections per 1,000 patient-days [95% confidence interval (CI): 13.8–18.1]. Bloodstream infections, pneumonias and urinary tract infections accounted for 80.4% of all infections; of these, 87.8% were device-related. Central line-associated bloodstream infection (CL-BSI) posed the greatest risk (18.6 cases per 1,000 central line-days; 95% CI 14.9–22.9), followed by ventilator-associated pneumonia (VAP) (6.4 cases per 1,000 ventilator-days; 95% CI 4.5–8.8) and catheter-associated urinary tract infection (2.8 cases per 1,000 urinary catheter-days; 95% CI 1.9–4.1). Most frequently isolated pathogens included Pseudomonas aeruginosa (21.6% of all isolates), coagulase-negative Staphylococcus (11.7%), Enterococcus spp. (11.3%) and Staphylococcus aureus (9.2%). Overall, 29.8% of P. aeruginosa isolates were imipenem-resistant and 68.2% of S. aureus were methicillin-resistant. The crude excess mortality rate associated with ICU-acquired infections was 33.2% (95% CI 24.9–41.9%) and the mean post-infection stay in the ICUs was 21.6 days (95% CI 17.0–26.2).


In comparison to international benchmarks, the markedly high rate of CL-BSI, the high rate of VAP and the resistance patterns of major infecting pathogens identified in this study emphasize the need to improve current practices for appropriate use and management of invasive devices in Cypriot ICUs.


Healthcare associated infection Device associated infection Surveillance Incidence rate Intensive care unit Cyprus 



We thank the following infection control nurses and physicians for their cooperation and generous assistance in conducting this surveillance study: M. Kontou, P. Panagiotou and L. Haladjian from Nicosia General Hospital; E. Vounou, M. Pavlou and A. Aristodemou from Limassol General Hospital; T. Aristeidou, M. Demeriou and M. Hinis from Larnaca General Hospital; and P. Papakyriakou, C. Panagiotou and M. Kapnisi-Andreou from Pafos General Hospital. This study was supported by the European Regional Development Funds through the initiative “INTERREG III Greece-Cyprus 2000–2006” and national funds.

Conflict of interest statement



  1. 1.
    Vincent JL. Nosocomial infections in adult intensive-care units. Lancet. 2003;361:2068–77.CrossRefPubMedGoogle Scholar
  2. 2.
    Horan TC, Gaynes RP. Surveillance of nosocomial infections. In: Mayhall CG, editor. Hospital epidemiology and infection control. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 1659–702.Google Scholar
  3. 3.
    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.CrossRefGoogle Scholar
  4. 4.
    Gaynes R, Culver DH, Banerjee S, Edwards JR, Henderson TS. Meaningful interhospital comparisons of infection rates in intensive care units. Am J Infect Control. 1993;21:43–4.CrossRefPubMedGoogle Scholar
  5. 5.
    Gastmeier P, Sohr D, Geffers C, Nassauer A, Daschner F, Rüden H. Are nosocomial infection rates in intensive care units useful benchmark parameters? Infection. 2000;28:346–50.CrossRefPubMedGoogle Scholar
  6. 6.
    Gaynes R, Richards C, Edwards J, Emori TG, Horan T, Alonso-Echanove J, et al. Feeding back surveillance data to prevent hospital-acquired infections. Emerg Infect Dis. 2001;7:295–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Gastmeier P, Geffers C, Brandt C, Zuschneid I, Sohr D, Schwab F, et al. Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect. 2006;64:16–22.CrossRefPubMedGoogle Scholar
  8. 8.
    L’Hériteau F, Olivier M, Maugat S, Joly C, Merrer J, Thaler F, et al. Impact of a five-year surveillance of central venous catheter infections in the REACAT intensive care unit network in France. J Hosp Infect. 2007;66:123–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Kritsotakis EI, Dimitriadis I, Roumbelaki M, Vounou E, Kontou M, Papakyriakou P, et al. Case-mix adjustment approach to benchmarking prevalence rates of nosocomial infection in hospitals in Cyprus and Greece. Infect Control Hosp Epidemiol. 2008;29:685–92.CrossRefPubMedGoogle Scholar
  10. 10.
    Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA. 1995;274:639–44.CrossRefPubMedGoogle Scholar
  11. 11.
    The French Prevalence Survey Study Group. Prevalence of nosocomial infections in France: results of the nationwide survey in 1996. J Hosp Infect. 2000;46:186–93.CrossRefGoogle Scholar
  12. 12.
    Smyth ET, McIlvenny G, Enstone JE, Emmerson AM, Humphreys H, Fitzpatrick F, et al. Four country healthcare associated infection prevalence survey 2006: overview of the results. J Hosp Infect. 2008;69:230–48.CrossRefPubMedGoogle Scholar
  13. 13.
    Vaqué J, Rosselló J, Arribas JL. Prevalence of nosocomial infections in Spain: EPINE study 1990–1997. EPINE Working Group. J Hosp Infect. 1999;43:s105–11.CrossRefPubMedGoogle Scholar
  14. 14.
    National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing: 14th informational supplement. NCCLS document M100-S14, Wayne, PA; 2004.Google Scholar
  15. 15.
    Abramson JH. WINPEPI (PEPI-for-Windows): computer programs for epidemiologists. Epidemiol Perspect Innov. 2004;1:6.CrossRefPubMedGoogle Scholar
  16. 16.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical–surgical intensive care units in the United States. Infect Control Hosp Epidemiol. 2000;21:510–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Dima S, Kritsotakis EI, Roumbelaki M, Metalidis S, Karabinis A, Maguina N, et al. Device-associated nosocomial infection rates in intensive care units in Greece. Infect Control Hosp Epidemiol. 2007;28:602–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Legras A, Malvy D, Quinioux AI, Villers D, Bouachour G, Robert R, et al. Nosocomial infections: prospective survey of incidence in five French intensive care units. Intensive Care Med. 1998;24:1040–6.CrossRefPubMedGoogle Scholar
  19. 19.
    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.CrossRefPubMedGoogle Scholar
  20. 20.
    Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC, et al. National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control. 2008;36:609–26.CrossRefPubMedGoogle Scholar
  21. 21.
    Gastmeier P, Geffers C, Sohr D, Dettenkofer M, Daschner F, Rüden H. Five years working with the German nosocomial infection surveillance system (Krankenhaus Infektions Surveillance System). Am J Infect Control. 2003;31:316–21.CrossRefPubMedGoogle Scholar
  22. 22.
    van der Kooi TI, de Boer AS, Manniën J, Wille JC, Beaumont MT, Mooi BW, et al. Incidence and risk factors of device-associated infections and associated mortality at the intensive care in the Dutch surveillance system. Intensive Care Med. 2007;33:271–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Malacarne P, Langer M, Nascimben E, Moro ML, Giudici D, Lampati L, et al. Building a continuous multicenter infection surveillance system in the intensive care unit: findings from the initial data set of 9,493 patients from 71 Italian intensive care units. Crit Care Med. 2008;36:1105–13.CrossRefPubMedGoogle Scholar
  24. 24.
    Wójkowska-Mach J, Bulanda M, Rózańska A, Kochan P, Heczko PB. Hospital-acquired pneumonia in the intensive care units of Polish hospitals. Infect Control Hosp Epidemiol. 2006;27:784–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Suetens C, Morales I, Savey A, Palomar M, Hiesmayr M, Lepape A, et al. European surveillance of ICU-acquired infections (HELICS-ICU): methods and main results. J Hosp Infect. 2007;65(Suppl 2):171–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Turgut H, Sacar S, Okke D, Kavas ST, Asan A, Kutlu SS. Evaluation of device associated infection rates in intensive care units of Pamukkale University Hospital. Infection. 2008;36:262–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Borg MA, de Kraker M, Scicluna E, van de Sande-Bruinsma N, Tiemersma E, Monen J, et al. Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in invasive isolates from southern and eastern Mediterranean countries. J Antimicrob Chemother. 2007;60:1310–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol. 2008;29:996–1011.CrossRefPubMedGoogle Scholar
  29. 29.
    Centers for Disease Control, Prevention (CDC). Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR Morb Mortal Wkly Rep. 2009;58:256–60.Google Scholar

Copyright information

© Urban & Vogel 2010

Authors and Affiliations

  • A. Gikas
    • 1
  • M. Roumbelaki
    • 1
  • D. Bagatzouni-Pieridou
    • 2
  • M. Alexandrou
    • 3
  • V. Zinieri
    • 4
  • I. Dimitriadis
    • 5
  • E. I. Kritsotakis
    • 6
  1. 1.Infection Control UnitUniversity Hospital of HeraklionCreteGreece
  2. 2.Microbiology DepartmentNicosia General HospitalNicosiaCyprus
  3. 3.Microbiology LaboratoryLimassol General HospitalLimassolCyprus
  4. 4.Microbiology LaboratoryPafos General HospitalPafosCyprus
  5. 5.Department of PneumonologyLarnaca General HospitalLarnacaCyprus
  6. 6.Laboratory of Infectious Diseases, School of Health SciencesUniversity of CreteCreteGreece

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