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Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections

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Abstract

Purpose

To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators.

Methods

Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance.

Results

Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p < 0.0001). When adjusted for patient and CVC characteristics all three interventions significantly reduced CRBSI incidence density. When additionally adjusted for the baseline decreasing trend, the HHi and COMBi arms were still effective. CVC insertion scores and HH compliance increased significantly with all three interventions.

Conclusions

This study demonstrates that multimodal prevention strategies aiming at improving CVC insertion practice and HH reduce CRBSI in diverse European ICUs. Compliance explained CRBSI reduction and future quality improvement studies should encourage measuring process indicators.

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Acknowledgements

We thank Sylvie Touveneau, Marie-Noëlle Chraïti and Benedetta Allegranzi, who devoted themselves to the training of the on-site investigators and study nurses in the workshops, both at the University Medical Center Groningen and the HUG. We thank Lauren Clack for editing. Our gratitude extends also to the participating centres for collaborating in this study, especially the on-site investigators and study nurses, physicians, (auxiliary) nurses and other healthcare professionals that responded positively to the challenge to improve their hand hygiene and CVC insertion practices and thus contributed to the increased safety of the patients in their care. Martin Wolkewitz has been funded by the German Research Foundation (Deutsche Forschungsgemeinschaft; Grant No WO 1746/1-1).

PROHIBIT Consortium: PROHIBIT Study Group: Pittet D (principaI investigator), Zingg W (coordinator), Ahmad R, Allegranzi B, Cookson B, Dettenkofer M, Gastmeier P, Grundmann H, Hansen S, Heczko PB, Holmes A, Kyratsis Y, Magiorakos A, Martin M, Richet H, Sax H, Szilágyi E, van Benthem B, van der Kooi T, Wu AW.

Author information

Authors and Affiliations

  1. RIVM National Institute for Public Health and the Environment, 3720 BA, Bilthoven, The Netherlands

    Tjallie van der Kooi, Jaap van Dissel, Birgit van Benthem, Sabine de Greeff, Hendriek Boshuizen & Jan van de Kassteele

  2. Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland

    Hugo Sax & Lauren Clack

  3. Infection Control and World Health Organization Collaborating Center on Patient Safety, The University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211, Geneva, Switzerland

    Hugo Sax, Didier Pittet & Walter Zingg

  4. Division of Anaesthesiology, University of Geneva Hospitals, Rue Gabrielle Perret-Gentil 4, 1211, Geneva, Switzerland

    Bernhard Walder, Vanessa Cartier & Hajo Grundmann

  5. Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, 79085, Freiburg, Germany

    Martin Wolkewitz & Stefanie Hieke

  6. AZ Sint-Lucas Hospital, 9000, Ghent, Belgium

    Annemie Van den Abeele & Kris Leleu

  7. University Hospital Galway, Galway, H91 YR71, Ireland

    Teck Wee Boo

  8. Medical University of Vienna, 1090, Vienna, Austria

    Magda Diab-Elschahawi

  9. Pauls Stradins Clinical University Hospital, University of Latvia, Riga, 1002, Latvia

    Uga Dumpis

  10. Department of Infection Control, Institute for Emergency Cardiovascular Diseases “Prof. C.C. Iliescu”, 022328, Bucharest, Romania

    Camelia Ghita

  11. St. Vincent’s University Hospital, Dublin, D04 T6F4, Ireland

    Susan FitzGerald

  12. University Medical Center Ljubljana, 1000, Ljubljana, Slovenia

    Tatjana Lejko

  13. Arnau de Vilanova University Hospital, 25198, Lleida and Vall d’Hebron University Hospital and Universitat Autónoma, 08035, Barcelona, Spain

    Mercedes Palomar Martinez

  14. Evanggelismos Hospital, 106 76, Athens, Greece

    Olga Paniara

  15. Bács-Kiskun County Teaching Hospital, Kecskemét, 6000, Hungary

    Márta Patyi

  16. Hospital of Silesia, 43-400, Cieszyn, Poland

    Paweł Schab

  17. Papa Giovanni XXIII Hospital, 24127, Bergamo, Italy

    Annibale Raglio

  18. Office of the Chief Medical Officer and Szent János Hospital, Budapest, 1125, Hungary

    Emese Szilágyi

  19. John Paul II Hospital and Dept of Anesthesiology and Intensive Care, Jagielonian University, Medical College, 30-001, Kraków, Poland

    Mirosław Ziętkiewicz

  20. John Hopkins University Bloomberg School of Public Health, Baltimore, MD, 21205, USA

    Albert W. Wu

  21. Institute for Infection Prevention and Hospital Epidemiology, Medical Center, University of Freiburg, 79085, Freiburg, Germany

    Hajo Grundmann

  22. Imperial College London, London, SW7 2AZ, UK

    Walter Zingg

Authors
  1. Tjallie van der Kooi
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  2. Hugo Sax
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  3. Didier Pittet
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  4. Jaap van Dissel
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  5. Birgit van Benthem
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  6. Bernhard Walder
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  7. Vanessa Cartier
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  8. Lauren Clack
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  9. Sabine de Greeff
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  10. Martin Wolkewitz
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  12. Hendriek Boshuizen
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  14. Annemie Van den Abeele
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  18. Camelia Ghita
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  22. Mercedes Palomar Martinez
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  27. Emese Szilágyi
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  28. Mirosław Ziętkiewicz
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  29. Albert W. Wu
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  30. Hajo Grundmann
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  31. Walter Zingg
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Consortia

On behalf of the PROHIBIT consortium

Contributions

DP, HG, AW, WZ and HS conceived the study. HG, WZ, HS, BB and TK further designed the study and developed the study protocol. BW, LC and VC trained the on-site investigators and study nurses. ME, AB, KL, MPM, OP, MP, ES, TW, SF, AR, UD, PS, MZ, CG and TL were responsible for the local study coordination, data collection and implementation of the interventions. TK was responsible for random allocation of interventions to hospitals, data management and, together with MW, SH, JK and HB, for statistical analyses. TK and WZ wrote the initial draft of the manuscript, with contributions of HS, HG, JD, and LC, which was revised and approved by all authors. The guarantor is TK.

Corresponding author

Correspondence to Walter Zingg.

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Conflicts of interest

The authors declare that they have no interests to disclose.

Data sharing

The data are stored with the RIVM. Applications to use the data for further research can be sent to Dr. Walter Zingg (e-mail, Walter.Zingg@hcuge.ch).

Additional information

Hajo Grundmann and Walter Zingg contributed equally to this work.

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van der Kooi, T., Sax, H., Pittet, D. et al. Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections. Intensive Care Med 44, 48–60 (2018). https://doi.org/10.1007/s00134-017-5007-6

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