patients, both device‐assisted and not, were considered, developing nosocomial sepsis or two or more nosocomial infections independently increased mortality (data not shown). Pros and cons of this surveillance based study The patient‐based surveillance of ICU‐acquired infections in 19 hospitals, taking into account duration of device use, resulted in an extensive, detailed database. Surveillance using a standard protocol with standardized infection definitions for prospective surveillance on a daily basis has been shown to present the greatest sensitivity and specificity for the identification of nosocomial infections [39]. A drawback of observational studies is that not all confounding variables can be taken into account. Furthermore, we included the use of all three devices in our analyses, but we did not adjust for the occurrence of a possible earlier infection of another type. Data on antibiotic resistance of the cultured micro‐organisms were not collected. However, mean resistance levels in Dutch hospitals and ICUs are known to be low [40]. CONCLUSIONS Duration of device use was an important risk factor for VAP, CR‐BSI, and CA‐UTI. The risk for VAP increased until day 5 and remained fairly constant until day 10. Device‐ associated infections were not independently associated with mortality, but (duration of) ventilation and (duration of) CVC use were. When investigating which patient groups in an institution would benefit most of infection prevention strategies, factors such as device use, time at risk, APACHE II score, intravenous antibiotics at admission, immunity, sex, acute admission must be considered. These risk factors are also of importance when stratifying for device‐associated infection risks for interhospital comparison. The protocol that we used was designed for comparing the incidence of different types of ICU‐ acquired infections and therefore included a broad range of risk factors. The surveillance results formed a good basis to develop more specified protocols. Now Dutch hospitals can use specific surveillance protocols for CR‐BSI and VAP which take more treatment specific risk factors into account and may better support infection prevention policy on the ICU. 2 33 Device-associated infections and associated mortality in the ICU
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