International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - vol 05 issue 19, October, 2013

Pages: 26-40

Date of Publication: 19-Oct-2013


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PROSPECTIVE EVALUATION AND MORTALITY OUTCOME OF NOSOCOMIAL INFECTIONS IN MEDICAL INTENSIVE CARE UNIT AT TERTIARY CARE TEACHING CENTRE IN MUMBAI

Author: Bhadade Rakesh R., deSouza Rosemarie A, Harde Minal J. , Prarthana Patil

Category: Healthcare

Abstract:Background: Hospital acquired infections are a worldwide phenomenon and infection rates in ICU's have been documented to be ranging from 12% to 45%. Methods and Material: To study epidemiology of nosocomial infections and its clinical outcome. Study Design and Setting: It is a prospective observational study; carried out in the Medical intensive care unit (MICU) of a tertiary care teaching hospital. Results and Conclusion: 205 patients developed nosocomial infection. The commonest nosocomial infections developing in MICU were ventilator associated pneumonia (VAP); hospital acquired pneumonia followed by urinary tract infection. 94.1% isolates were gram-negative and gram-positive contributing to 2.5%, of which most common organisms isolated were Klebsiella, Acinetobacter and E. coli. 93.4% of blood stream infections were associated with intravenous lines, 68.1% of pneumonia with intubation, 91.7 % of UTIs were associated with urinary catheter. As number of risk factors increase, like duration of mechanical ventilation, prolonged ICU stay (60.0%), increasing age, and number of organs failed, mortality increased significantly. Sensitivity of E.coli isolates to carbapenams, polymyxin was 100%. Klebsiella and Acinetobacter showed a maximum sensitivity to carbepenem, polymyxin followed by piperacillin-tazobactum. 75.1% of patients with nosocomial infections improved and mortality in current study was 30.3%.v

Keywords: Critical illness, Nosocomial infection, Antibiotics.

Full Text:

INTRODUCTION

A nosocomial infection also called “Hospital acquired infection” can be defined as: “An infection occurring in a patient, in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge and also occupational infections among staff of the facility”. [1]

The term “Healthcare associated infection” is now widely used instead of the traditional “nosocomial infection” and is defined by the centre for disease control and prevention (CDC) “as a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting”. [2]

The most frequent nosocomial infections are blood stream infections, urinary tract infections, lower respiratory tract infections and infections of surgical wounds. The WHO studies, and others, have shown that the highest prevalence of nosocomial infections occurs in intensive care units and in acute surgical and orthopaedic wards. Infection rates are higher among patients with increased susceptibility because of old age, underlying disease, or chemotherapy. In the USA the most frequent type of infection, hospital wide is urinary tract infection (36%), followed by surgical site infection (20%), bloodstream infection (BSI), and pneumonia (both 11%).[3] In France , the most common infection sites are urinary tract infections (30.3 %), pneumonia (14.7 %), infections of surgery sites (14.2 %). infections of the skin and mucous membrane (10.2 %), other respiratory infections (6.8%) and bacterial infections / blood stream infections (6.4 %).[4]

A prevalence survey conducted under the auspices of WHO in 55 hospitals of 14 countries representing 4 WHO Regions (Europe, Eastern Mediterranean, South-East Asia and Western Pacific) showed an average of 8.7% of hospital pts had nosocomial infections. At any time, over 1.4 million people worldwide suffer from infectious complications acquired in hospital. [5].The highest frequencies of nosocomial infections were reported from hospitals in the Eastern Mediterranean and South-East Asia Regions (11.8 and 10.0% respectively), with a prevalence of 7.7 and 9.0% respectively in the European and Western Pacific Regions. [6]International comparisons of nosocomial infection rates in various countries are as follows United States (10%), France (21.6%), Italy (6.7%), United Kingdom (10%), Finland (8.5%), and India (19.7%) [3] [7-11]

A 6-year surveillance study from 2002-2007 involving intensive care units (ICUs) in Latin America, Asia, Africa, and Europe, using CDC's NNIS definitions (National nosocomial infection surveillance), revealed higher rates of central-line associated blood stream infections (BSI), ventilator associated pneumonias (VAP), and catheter-associated urinary tract infections than those of comparable United States ICUs.[12]  In 2005, the National Healthcare Safety Network (NHSN) was established by CDC with the purpose of integrating and succeeding previous surveillance systems at the Centres for Disease Control and Prevention. [13] Percentage of most frequently isolated nosocomial organisms as per CDC, National nosocomial infection surveillance (NNIS) system (January1990-March1996) and the top 3 pathogens in various nosocomial infections are shown in [Table 1,2] [13-17]

MATERIAL AND METHODS

It is a prospective observational study done in the Medical Intensive Care Unit (MICU) of a tertiary care teaching public hospital and, we aimed, to study  rates of nosocomial infections (as per CDC definitions of nosocomial infections in adults) [18-21] ,  sites of infections and risk factors involved, empirical antibiotics used in treatment and its effectiveness by studying culture sensitivity of various body fluids/ secretions, time of initiation of antibiotics, effects of antibiogram on clinical outcome. We included all adult patients (pts), who have been admitted in critical care unit for more than 48 hours. Patients, who already have an infection and were on antibiotics within less than 48 hours, were followed for superadded infections. We excluded surgical, immunocompromised pts, and those below 12 years of age. Institutes Ethics committee approval was taken. After valid written informed consent, all patients were assessed, investigated, and treated as per the existing practices without disturbing their routine care appropriate for the disease condition till either the patient was discharged from MICU or expired. All hospital infection control practices were strictly adhered too. All the routine investigations done in MICU patients were taken into consideration. We noted all the haemodynamic parameters Type and class of antimicrobial drugs used, route of administration, dosage and its frequency, duration of antimicrobial drug used, reason for selection of drug, reason for change of drug were noted. Resistance and sensitivity of various organisms isolated in present study to the drugs used to treat patients in current study were those that were supplied under government schedule.

Study Design and Setting: It is a prospective observational study; and was carried out in the MICU of a tertiary care, teaching, public hospital in India over a period of 2 years.

Statistical analysis: Outcome of each nosocomial infection was classified as either survived (improved) or expired. Data thus obtained was statistically analysed, using Pearson Chi-square test and logistic regression analysis using SPSS software.

RESULTS

Out of 2935 patients admitted to MICU during the study period, 205 patients developed nosocomial infections, with an incidence rate of 14.31% during study period. Results are noted in [Tables 3, 4, 5.]

DISCUSSION

Nosocomial infection rates in ICU’s have been documented to be highest of all hospital acquired infections, ranges from 12% to 45%. The data from various studies shows variable results of nosocomial infection in MICU statistics, Ak O et al reported 25.6% mortality, Ustan C et al reported 45.4%, Madani N et al reported 14.5%, Sax H et al reported 29.7%, Habibi S et al reported 34.1%, Rizwi MF et al reported 39.7%, and Present study had 14.31% mortality rate. [22-27]

In present study, majority of patients (85 pts) developing nosocomial infections were between age group of 21 – 40 years (41.5%) and 29.8% (61 pts) patients were between age group of 41-60 years which may be explained by the higher incidence of patients in age group of 21-40 years getting admitted with complications. The mean age of patients was 44.29 years in present study. Dahmash MS et al, included patients with age ranging from 14 to 100 years with median age being 54 years. [28] In another study done by Gagneja D et al, it was found that 21.61% of patients were in age group of less than 17 years, 42.15% in 18-64 years and 36.38% were of more than 65 years of age. [29]  The present study showed higher mortality rate in age group of > 80 years (50%) followed by second peak in the age group between 41-60 years (36.1%) which was not statistically significant.

In current study, 63.4 % (130 pts) of MICU patients developing nosocomial infections were males while females (75 pts) contributed to 36.6% of total cases. In study done by Dahmash MS et al, 51.4% were males while 48.6% were females. [28] Most frequently identified nosocomial infections in current study were pneumonia (65.9%) (VAP responsible for 44.9% of cases), urinary tract infections (UTI) (17.6%) followed by wound infections (9.3%). Habibi S et al showed that 77% had pneumonia, 24% had urinary tract infection, and 9% had blood stream infection which is comparable to our study. [26] Ak O et al and Moreno CA et al showed that blood stream infection was most common infection followed by VAP and UTI. [22] [31]   While, Lyytikainen O et al showed Surgical Site Infection (SSI) (29%) being most common followed by UTI (19%). [10]

 In current study, most frequently isolated organisms were Klebsiella pneumoniae (35.1%), Acinetobacter baumannii (24.9%) and E. coli (16.5%). Kallel H et al showed multidrug-resistant P. aeruginosa (44.7%) and A. baumannii (21.3%) being most frequently isolated organisms. [30] Ak O et al reported that 68.8% of the isolates were gram-negative, 27.6% were gram-positive. [22] While present study showed 94.6% isolates being gram-negative with gram-positive organisms contributing to only 1.5% isolates. Ak O et al reported that 3.6% of the isolates were fungi, which is comparable with our study which showed 3.9% of the isolates being fungi. [22]

In current study, 66.7% isolates of Acinetobacter baumannii, 73.6% isolates of Klebsiella pneumoniae and 64.7% isolates of E.coli were ESBL (Extended spectrum beta lactamases). Most common infection caused by ESBL organisms was pneumonia (71.6%) with VAP contributing to 52.3% of cases followed by UTI (15.6%). Isolate from pts with VAP caused by ESBL organisms was Acinetobacter baumannii (49.1%) followed by Klebsiella pneumoniae (40.4%). While most common isolate patients with UTI caused by ESBL organisms was Klebsiella pneumoniae (70.6%).In present study, no significant difference in mortality was found among the patients with nosocomial infections caused by non-ESBL organisms (42.1%) and those caused by ESBL organisms (43.1%).The mortality was higher in cases with non-ESBL strains of Acinetobacter baumannii (70.6%) as compared to ESBL strains (55.9%).While in case of Klebsiella pneumoniae ESBL strains (39.6%) were associated with higher mortality as compared to non-ESBL strains (10.5%). In case of E.coli, mortality was almost equal in both ESBL (31.8%) and non-ESBL (33.3%) strains. Fagon JY et al showed that pneumonias occurring in ventilated patients were especially those due to Pseudomonas or Acinetobacter species and were associated with considerable mortality(71.3%) in excess of that resulting from the underlying disease alone, and significantly prolong the length of stay in the MICU. [32]

In present study, organism’s isolated from patients with UTI were E. coli (55.5%), Klebsiella pneumoniae (25.0%) and Pseudomonas aeruginosa (16.7%). Bagshaw S et al reported their findings as E .coli, Pseudomonas, Enterococcus and Candida. [33] In similar study done by Laupland K B et al, the most common UTI aetiologies were found to be Enterococcus species (24%), Candida albicans (21%), and Escherichia coli (15%). [34] There were no Candida species isolated from patients with nosocomial UTI in our study which is in contrast to other studies mentioned above. [33-34]

In the current study, organism’s isolated from patients with nosocomial pneumonia were Klebsiella pneumoniae (37.8%), Acinetobacter baumannii (32.6%) and Pseudomonas aeruginosa (12.6%). A 5 years (2004-2009) study done by Gagneja D et al reported Pseudomonas aeruginosa (30-50%) as most common organism followed by Klebsiella species, they also reported that the rate of isolation of Acinetobacter species increased from 11.78% (2004-2005) to 25% (2008-2009) becoming the second most common isolate. [29] Trivedi TH et al showed enteric gram-negative organisms were commonest isolates (61.9%), followed by Staph aureus (29.8%). [35] While in present study, 94.8% of isolates causing nosocomial pneumonia were gram-negative organisms.

In present study, 42.4% of isolates causing VAP were Acinetobacter baumannii followed by Klebsiella pneumoniae (29.3%), Pseudomonas aeruginosa (10.9%). Chatre J et al showed that Staphylococcus aureus, Pseudomonas and Enterobacteriaceae were most common among isolates causing VAP. [36] Richard MJ et al reported their findings as Pseudomonas and Acinetobacter being most common organisms causing VAP. [37] In another study done by Japoni A et al, most commonly isolated organisms were Acinetobacter, MRSA (methacillin resistant staphylococcus aurous), Pseudomonas and MSSA (methacillin sensitive staphylococcus aurous). [38] While Esperatti M et al showed that non-fermenter, enteric gram negative bacilli and MSSA were most commonly isolated from patients with VAP. [39]

In current study, most common bloodstream infection isolates were Klebsiella pneumoniae (40.0%), Acinetobacter baumannii (33.3%) and Coagulase Negative Staphylococci (CONS) (20.0%). Edmond MB et al found that gram-positive organisms accounted for 64% of cases, gram-negative organisms accounted for 27%, and 8% were caused by fungi with most common organisms being CONS (32%), Staphylococcus aureus (16%), and Enterococci (11%).[40] Laupland KB et al showed Staphylococcus aureus (18%),CONS (11%), and Enterococcus faecalis (8%) being most common bloodstream infection isolates. [41] Thus Edmond MB et al differs from our study where gram-negative organisms were most common bloodstream infection isolates (80.0%) demonstrating the changing trends of the isolates. [40]

In present study, most common isolates from wound infection were Klebsiella pneumoniae (31.6%) followed by Pseudomonas aeruginosa (21.0%). Peromet M et al showed that most common organisms isolated from pressure ulcers were Proteus mirabilis, group D streptococci, Escherichia coli, Staphylococcus species, Pseudomonas species, and Corynebacterium organisms. [42]

In present study, 93.4% of blood stream infections were associated with central lines, 68.1% of pneumonia with intubation, 91.7 % of UTI,s were associated with urinary catheter. Rosenthal VD reported that VAP posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by central venous catheter (CVC)-related bloodstream infections (30% of all device-associated infections (DAI) or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days).[43]

In current study, patients with 1-2 risk factors (100%) had better survival than those with 3 or more risk factors (60.1%). Majority of patients in present study (85.5%) stayed for more than 7 days in MICU, mortality rate was high in patients with prolonged ICU stay (60.0%) followed by second peak in patients with ICU stay of less than 7 days (47.2%), most of these patients were referred from other hospitals in moribund condition. Wong DT et al showed that the mortality for long-stay patients approached 50% which is comparable with our finding. [44] Similar finding was observed in the study done by Laupland KB et al. [45] While Williams T A et al showed that an increase in length of stay was not independently associated with an increased risk of hospital mortality with most of hospital deaths occurring  within the first 10 days in ICU. [46]

The patients on mechanical ventilation (56.0%) had higher mortality as compared to non-ventilated patients (11.2%), and as duration of mechanical ventilation increases, mortality also increased significantly. The risk factors such as Diabetes mellitus, hypertension, COAD and duration of mechanical ventilation were found to be associated with development of VAP, but association was not statistically significant. [Table 6] This is in contrast to the study done by Craven DE et al which showed that host factors, oropharyngeal and gastric colonization, cross-infection, and complications from the use of antibiotics and nasogastric and endotracheal tubes increased the risk of bacterial VAP. [47]

In current study, increasing age was associated with higher risk, whereas Diabetes Mellitus, female sex, foley’s catheter were not statistically associated with risk of developing ICU-acquired UTI in logistic regression analysis.[Table 7] In a study done by Bagshaw S M et al it was found that indwelling urinary catheters, increased duration of urinary catheterization, female sex, length of stay in a ICU, and preceding systemic antimicrobial therapy were associated with risk of developing ICU-acquired UTI.[33] No differences in vital signs on admission, routine blood tests, APACHE II and TISS  scores (therapeutic intervention scoring system), or overall hospital mortality rate were observed among patients who developed an ICU-acquired UTI as compared with those who did not.

In present study, it was found that 88.21% isolates of Enterobacteriaceae, 93.75% isolates of Acinetobacter baumannii, 89.4% isolates of Klebsiella pneumoniae, and 81.5% cases of E. coli were resistant to ceftriaxone. But this finding is in contrast to studies done by Moreno CA  et al, Rosenthal VD et al,  Cuellar LE et al in western world which showed resistance of Enterobacteriaceae to ceftriaxone was between 40-50%.[31][43][48] In current study, 48.9% isolates of Acinetobacter baumannii, 25.4% isolates of Klebsiella pneumoniae, and 4.3% cases of E. coli were resistant to piperacillin-tazobactum and it was found that about 37.5% isolates of Pseudomonas aeruginosa were resistant to ciprofloxacin, whereas studies done by Rosenthal VD et al, Cuellar LE et al found resistance between 40%-70% [43][48] Further, 84.2% isolates were sensitive to meropenem, while 93.8% isolates were sensitive to imipenem. Resistance of Pseudomonas aeruginosa to imipenem was found to be low (6.2%) which is in contrast to other studies done by Moreno CA  et al,  Cuellar LE et al which reported resistance in the range of 13-38%.[31] [48] In present study, sensitivity of Staphylococcus aureus and CONS to methicillin was not tested. In studies done by Rosenthal VD et al ,Cuellar LE et al it was found that methicillin resistant Staphylococcus aureus were in range of 75-95%.[43][48] Emerging drug resistance may be explained by the indiscriminate use of antibiotics in developing countries like India.

In present study, sensitivity of E.coli isolates to Carbapenems and Polymixin was 100%. While Klebsiella pneumoniae and Acinetobacter baumannii showed a maximum sensitivity to carbepenem, polymyxin followed by piperacillin-tazobactum. Pseudomonas aeruginosa showed a maximum sensitivity to piperacillin-tazobactum followed by Imipenem. In current study 100% isolates of ESBL organisms were resistant to amoxicillin-clavunate and ceftriaxone. 60.0% isolates of ESBL Acinetobacter baumannii, 74.5% isolates of ESBL Klebsiella pneumoniae and 94.1% isolates of ESBL E.coli were sensitive to piperacillin-tazobactum. While 75.0% isolates of ESBL Acinetobacter baumannii, 88.6% isolates of ESBL Klebsiella pneumoniae and 100.0% isolates of ESBL E.coli were sensitive to meropenem. 100% isolates of ESBL organisms were sensitive to Carbapenems. While79.2 % isolates of ESBL Acinetobacter baumannii, 95.6% isolates of ESBL Klebsiella pneumoniae and 100.0% isolates of ESBL E.coli were sensitive to Imipenem. Gunserena F et al showed that amikacin, ciprofloxacin and imipenem were effective against, respectively, 41.3%, 48.2% and 92.0% of the ESBL producers, however, only 12.5% of these were susceptible to piperacillin-tazobactum and Cefepime was found to be active against 35.5% of these problem pathogens. [49] Thus our observations found that there is changing trend of organisms causing nosocomial infection and also change in the sensitivity patterns of these organisms to various antibiotics.

Resistance of gram-negative organisms isolated from patients with lower respiratory tract infections to various antibiotics in current study is ceftriaxone 86.0%, ceftazidime 85.7%, piperacillin-tazobactum 18.4%, gentamicin 73.3%, amikacin 57.8%, netlimycin 53.6%, ciprofloxacin 71.4%, meropenam 31.9% and imipenam 34.8%. Gagneja D et al showed increasing trend of resistance of gram negative organisms to third generation cephalosporins, amoxicillin/clavulanic acid and piperacillin-tazobactum and declining trend of resistance to aminoglycosides, they also showed increasing trend of resistance to carbapenems. [29] Thus, judicious use of older/newer antimicrobial agents is essential to prevent the emergence of multidrug-resistant bacteria in the ICU.

 In our study, 3 out of 10 patients with swine flu were females while 7 were males and most common nosocomial infection was lower respiratory tract infection (70%) with HAP contributing to 50% of cases. The most common organism isolated was Klebsiella pneumoniae (80%) with ESBL strains contributing to 50% cases followed by Acinetobacter baumannii (20%). Out of 10 patients, 4 required mechanical ventilation. 3 patients had 1-2 risk factors while remaining 6 had 3 or > 3 risk factors. Piperacillin-tazobactum was used in 70% cases; mostly in combination with levofloxacin (50%). The mortality in patients on mechanical ventilation was 50% and those without ventilation, was 16.7% .70% patients of swine flu with nosocomial infection survived while 30% died.

In current study, antibiotics were started empirically in 19% cases, while in 79.5% patients antibiotics were started empirically and modified according to culture sensitivity report. Antibiotics started after culture sensitivity report in only 1.5% cases. In present study, ceftriaxone, Piperacillin-tazobactum, Meropenem was started empirically in 51.3%, 35.9%, 5.1% cases and after culture sensitivity reports in 38%, 67.5%, 17.8% cases respectively. The mortality was significantly higher (56.4%) in patients in whom antibiotics started empirically as culture sensitivity report were not made available before the patient had died, as compared to those in whom antibiotics were started empirically and modified according to culture sensitivity report or antibiotics started after culture sensitivity report (32.6%). No significant difference in mortality was found between, in those with antibiotics started empirically and modified according to culture sensitivity report and antibiotics started only after culture sensitivity report.

In our study, we found the statistically significant association between types of nosocomial infections and final outcome. In study done by Esperatti M et al, it was found that the type of isolates and outcomes are similar regardless of whether pneumonia is acquired or not during ventilation, indicating they may depend on patients' underlying severity rather than previous intubation. [39] It was seen that patients with Glasgow coma score < 10 at the time of admission had significantly high mortality as compared to patients with > 10. Knaus WA et al showed that the mortality was 40.0% in patients with single organ failure as against 98% in three or more organ failure which was consistent with our findings.[50] The commonest procedure performed was insertion of central venous lines in almost 96.58% of patients. It was done especially in cases of circulatory shock, acute renal failure and pulmonary edema for fluid management purpose. Intubations were performed 106 patients (51.7%) mostly for ventilatory support but also for prophylactic purposes to secure the airway. Tracheostomies were performed in 11.2% of the total patients who required prolonged ventilatory support. Amongst the 21 patients who received dialysis, 12 survived, while 9 died. Described by Knaus WA et al, the mean APACHE II score at time of admission in our study was 16.85; we found that as APACHE II score increases, mortality also increased significantly. [50]

In present study, need of mechanical ventilation and elevated APACHE II score at the time of admission were associated with higher mortality while length of MICU stay between 16-30 days were associated with less mortality in a logistic regression analysis. No statistical significance between factors such as number of risk factors, age, gender and final outcome was found in our study by logistic regression analysis. [Table 8] Yologlu S et al showed that extrinsic risk factors such as urinary catheter, mechanical ventilation, total parenteral nutrition, intubations, antimicrobial treatment prior to nosocomial infections, nasogastric catheter and central catheter were associated with nosocomial infections. [51]  

CONCLUSION

From the experience of the present study, we put forth the following:

Thus in current study of 205 critically ill patients who developed nosocomial infection in MICU, 130 (63.4%) patients improved, and mortality in our study was 36.6% (75 patients). The commonest nosocomial infections developing in MICU were VAP; HAP followed by urinary tract infection. 94.1% isolates were gram-negative with gram-positive organisms contributing to only 2.5% of isolates, of which most common organisms isolated were Klebsiella pneumoniae, Acinetobacter and E.coli. Most common isolates from cases of UTI were E.coli followed by Klebsiella pneumoniae, from nosocomial pneumonia were Klebsiella pneumonia followed by Acinetobacter baumannii, from wound infection were Klebsiella, and from bloodstream infection, isolates were Klebsiella pneumoniae, Acinetobacter baumannii and CONS, thus demonstrating the changing trends in the isolates. Nosocomial infection seen in patients with swine flu was lower respiratory tract infection; organism isolated was Klebsiella pneumoniae (80%) with ESBL strains contributing to 50% cases. The mortality was significantly higher in patients, in whom antibiotics were started empirically, as compared to those in whom antibiotics were started empirically and modified according to culture sensitivity report or antibiotics started after culture sensitivity report, emphasizing the importance of culture sensitivity report in treatment of infections. Thus our observations found that there is changing trend of organisms causing nosocomial infection as compared to the western world, and also change in the sensitivity patterns of these organisms to various antibiotics.

High APACHE II score on admission was associated with significantly high mortality and thus can be used as effective tool to determine outcome and accordingly modify treatment strategy in these patients. Association between types of nosocomial infection and its outcome as well as between types of nosocomial infections and final outcome was statistically significant. Thus, early recognition of all the discussed co-morbid factors in patients with nosocomial infections going downhill before one or multiple systems start failing is important as is the importance of good intensive care once this does occur.

 

B-         Coefficient for the constant in the null model (also called the "intercept")

S.E.  -   Standard error around the coefficient for the constant.

Wald - Wald chi-square test

df -       Degree of freedom

Sig-       Significance

Exp (B) -Exponentiation of the B coefficient

VAP-   Ventilator associated Pneumonia

Dependent Variable Encoding- For VAP yes, it’s 1

 

B-         Coefficient for the constant in the null model (also called the "intercept")

S.E.  -   Standard error around the coefficient for the constant.

Wald - Wald chi-square test

df -       Degree of freedom

Sig-       Significance

Exp (B) -Exponentiation of the B coefficient

UTI-Urinary tract Infection

Dependent Variable Encoding- For UTI yes, it’s 1

B-         Coefficient for the constant in the null model (also called the "intercept")

S.E.  -   Standard error around the coefficient for the constant.

Wald - Wald chi-square test

df -       Degree of freedom

Sig-       Significance

Exp (B) -Exponentiation of the B coefficient

*         - Multiplication

Dependent Variable Encoding- For Expired yes, it’s 1

 

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Research Incentive Schemes

Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
Late to bed everyday? You may die early, get depression
Egg a day tied to lower risk of heart disease
88 Percent Of Delhi Population Has Vitamin D Deficiency: ASSOCHAM Report

List of Awardees

Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19


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International Journal of Current Research and Review (JICRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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