Use of multistate models to assess prolongation of intensive care unit stay due to nosocomial infection

Background. Reliable data on the costs attributable to nosocomial infection (NI) are crucial to demonstrating the real cost-effectiveness of infection control measures. Several studies investigating this issue with regard to intensive care unit (ICU) patients have probably overestimated, as a result of inappropriate study methods, the part played by NIs in prolonging the length of stay. Methods. Data from a prospective study of the incidence of NI in 5 ICUs over a period of 18 months formed the basis of this analysis. For describing the temporal dynamics of the data, a multistate model was used. Thus, ICU patients were counted as case patients as soon as an NI was ascertained on any particular day. All patients were then regarded as control subjects as long as they remained free of NI (time-to-event data analysis technique). Results. Admitted patients (n = 1,876) were observed for the development of NI over a period of 28,498 patient-days. In total, 431 NIs were ascertained during the study period (incidence density, 15.1 NIs per 1,000 patient-days). The influence of NI as a time-dependent covariate in a proportional hazards model was highly significant (P < .0001, Wald test). NI significantly reduced the discharge hazard (hazard P < .0001 ratio, 0.72 [95% confidence interval, 0.63- 0.82]) - that is, it prolonged the ICU stay. The mean prolongation of ICU length of stay due to NI (+/- standard error) was estimated to be 5.3 +/- 1.6 days. Conclusions. Further studies are required to enable comparison of data on prolongation of ICU length of stay with the results of various study methods.