Longitudinal trends in all healthcare-associated infections through comprehensive hospital-wide surveillance and infection control measures over the past 12 years: substantial burden of healthcare-associated infections outside of intensive care units and "other" types of infection

Vaccines for healthcare associated infections without vaccine prevention to date

In spite of the widespread implementation of preventive strategies, the prevalence of healthcare-associated infections (HAIs) remains high. The prevalence of multidrug resistant organisms is high in HAIs. In 2019, the World Health Organization retained antimicrobial resistance as one of the ten issues for global health. The development of vaccines may contribute to the fight against antimicrobial resistance to reduce the burden of HAIs. Staphylococcus aureus, Gram negative bacteria and Clostridium difficile are the most frequent pathogens reported in HAIs. Consequently, the development of vaccines against these pathogens is crucial. At this stage, the goal of obtaining effective vaccines against S.aureus and Gram negative bacteria has not yet been achieved. However, we can expect in the near future availability of a vaccine against C. difficile. In addition, identifying populations who may benefit from these vaccines is complex, as at-risk patients are not great responders to vaccines, or as vaccination may occur too late, when they are already confronted to the risk. Vaccinating healthcare workers (HCWs) against these pathogens may have an impact only if HCWs play a role in the transmission and in the pathogens acquisition in patients, if the vaccine is effective to reduce pathogens carriage and if vaccine coverage is sufficient to protect patients. Acceptance of these potential vaccines should be evaluated and addressed in patients and in HCWs.

A scoping review of registry captured indicators for evaluating quality of critical care in ICU

BACKGROUND

Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation.

METHOD

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance.

RESULTS

The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).

CONCLUSIONS

Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.

Burden of Clostridioides difficile infection (CDI) - a systematic review of the epidemiology of primary and recurrent CDI

BACKGROUND

Clostridioides difficile is a Gram-positive anaerobic bacterium, which causes Clostridioides difficile infection (CDI). It has been recognised as a leading cause of healthcare-associated infections and a considerable threat to public health globally. This systematic literature review (SLR) summarises the current evidence on the epidemiology and clinical burden of CDI.

METHODS

A SLR was conducted to identify CDI and recurrent CDI (rCDI) epidemiology studies, to evaluate patient and disease characteristics, incidence rates, epidemiological findings and risk factors. Embase, MEDLINE and the Cochrane Library databases were searched for English articles from 2009 to 2019. Included territories were the United Kingdom, France, Germany, Italy, Spain, Poland, US, Canada, Australia, Japan and China.

RESULTS

Of 11,243 studies identified, 165 fulfilled the selection criteria. An additional 20 studies were identified through targeted review of grey literature. The most widely reported findings were incidence and risk factors for CDI and rCDI. Among key studies reporting both healthcare-associated (HA-CDI) and community-associated CDI (CA-CDI) incidence rates for each country of interest, incidence rates per 10,000 patient days in the US were 8.00 and 2.00 for HA-CDI and CA-CDI, respectively. The highest incidence in Europe was reported in Poland (HA-CDI: 6.18 per 10,000 patient days, CA-CDI: 1.4 per 10,000 patient days), the lowest from the UK, at 1.99 per 10,000 patient days and 0.56 per 10,000 patient days for HA-CDI and CA-CDI, respectively. No clear trend for incidence over time emerged, with most countries reporting stable rates but some either a decrease or increase. Rates of recurrent CDI varied based on geographical setting. The rate of recurrence was lower in community-associated disease compared to healthcare-associated disease. Independent CDI risk factors identified common to both initial CDI and recurrent CDI included increasing age, antibiotic use, recent hospitalisation, and proton pump inhibitor (PPI) use. In addition, leukocyte count, length of hospital stays, and Charlson comorbidity index score featured as statistically significant risk factors for recurrent CDI, but these are not reported among the most common statistically significant risk factors for initial CDI.

CONCLUSIONS

Despite considerable heterogeneity, evidence suggests substantial incidence of recurrent and primary CDI, even after considerable efforts in the last decade.

The Impact of Clostridium Difficile Infections on In-Hospital Outcomes of Venous Thromboembolism (Deep Vein Thrombosis or Pulmonary Embolism) Hospitalizations

Background

Clostridium difficile infection (CDI) is associated with high mortality. Studies have shown an increased rate of venous thromboembolism (VTE) in patients with CDI. However, literature regarding the impact of CDI on outcomes of VTE-related hospitalizations is scarce. Our study aimed to assess the impact of CDI on in-hospital outcomes among VTE hospitalizations.

Methods

The 2016 National Inpatient Sample (NIS) was used to identify all adult hospitalizations in the United States with a primary discharge diagnosis of acute VTE. Hospitalizations with deep vein thrombosis (DVT) or pulmonary embolism (PE) were included under VTE. The sample was stratified based on the presence or absence of active CDI. Chi-square test and weighted Student’s t-test were used to analyze categorical and continuous variables, respectively. The adjusted odds ratio (OR) for clinical outcomes were calculated using multivariate logistic regression analysis. Subgroup analyses for DVT and PE hospitalizations were performed. All analyses were completed in SAS (SAS Institute Inc., Cary, NC), and a p-value of <0.05 was considered statistically significant.

Results

We identified 382,585 weighted hospitalizations for VTE. Among them, 0.8% had concomitant CDI. The presence of CDI was associated with a statistically significant increase in in-hospital mortality (6% vs. 3%), hospitalization cost ($147,356.5 vs. $55,193), and length of stay (13.7 vs. 5.4 days). There were more incidents of bleeding and acute respiratory failure requiring prolonged ventilation in patients with CDI. The odds of stroke were significantly higher in patients with CDI and DVT.

Conclusion

CDI independently increased in-hospital mortality in VTE. Preventing CDI in the VTE population may mitigate complications, improve in-hospital outcomes, and reduce treatment costs.

Healthcare-associated bloodstream infection trends under a provincial surveillance program

OBJECTIVE

BACTOT, Quebec's healthcare-associated bloodstream infection (HABSI) surveillance program has been operating since 2007. In this study, we evaluated the changes in HABSI rates across 10 years of BACTOT surveillance under a Bayesian framework.

DESIGN

A retrospective, cohort study of eligible hospitals having participated in BACTOT for at least 3 years, regardless of their entry date. Multilevel Poisson regressions were fitted independently for cases of HABSI, catheter-associated bloodstream infections (CA-BSIs), non-catheter-associated primary BSIs (NCA-BSIs), and BSIs secondary to urinary tract infections (BSI-UTIs) as the outcome and log of patient days as the offset. The log of the mean Poisson rate was decomposed as the sum of a surveillance year effect, period effect, and hospital effect. The main estimate of interest was the cohort-level rate in years 2-10 of surveillance relative to year 1.

RESULTS

Overall, 17,479 cases and 33,029,870 patient days were recorded for the cohort of 77 hospitals. The pooled 10-year HABSI rate was 5.20 per 10,000 patient days (95% CI, 5.12-5.28). For HABSI, CA-BSI, and BSI-UTI, there was no difference between the estimated posterior rates of years 2-10 compared to year 1. The posterior means of the NCA-BSI rate ratios increased from the seventh year until the tenth year, when the rate was 29% (95% confidence interval, 1%-89%) higher than the first year rate.

CONCLUSIONS

HABSI rates and those of the most frequent subtypes remained stable over the surveillance period. To achieve reductions in incidence, we recommend that more effort be expended in active interventions against HABSI alongside surveillance.

Incidence and risk factors of non-device-associated pneumonia in an acute-care hospital

OBJECTIVE

To update current estimates of non-device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.

DESIGN

Cohort study.

SETTING

Academic teaching hospital.

PATIENTS

All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non-device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.

RESULTS

From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40-3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07-2.05), or paralysis (HR, 1.72; 95% CI, 1.09-2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18-2.00) or in the ICU (HR, 1.49; 95% CI, 1.06-2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.

CONCLUSION

The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non-device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.

Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys

BACKGROUND

Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs).

AIM

To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016.

METHODS

In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals.

FINDINGS

PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)).

CONCLUSION

Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

Incidence and risk factors of non-device-associated urinary tract infections in an acute-care hospital

OBJECTIVE

To update current estimates of non-device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.

DESIGN

Cohort study.

SETTING

Academic teaching hospital.

PATIENTS

All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.

RESULTS

From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non-device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50-2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04-4.86), immunosuppression (HR, 1.48; 95% CI, 1.15-1.91), trauma admissions (HR, 1.36; 95% CI, 1.02-1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35-2.94) and opioid use (HR, 1.62; 95% CI, 1.10-2.32). Urinary retention (HR, 1.41; 95% CI, 0.96-2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88-5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83-4.93) may also increase risk, but estimates were imprecise.

CONCLUSION

Greater than 70% of UTIs are now non-device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.

Incidence of healthcare-associated infections in a tertiary hospital in Beijing, China: results from a real-time surveillance system

Background

To quantify the five year incidence trend of all healthcare-associated infections (HAI) using a real-time HAI electronic surveillance system in a tertiary hospital in Beijing, China.

Methods

The real-time surveillance system scans the hospital’s electronic databases related to HAI (e.g. microbiological reports and antibiotics administration) to identify HAI cases. We conducted retrospective secondary analyses of the data exported from the surveillance system for inpatients with all types of HAIs from January 1st 2013 to December 31st 2017. Incidence of HAI is defined as the number of HAIs per 1000 patient-days. We modeled the incidence data using negative binomial regression.

Results

In total, 23361 HAI cases were identified from 633990 patients, spanning 6242375 patient-days during the 5-year period. Overall, the adjusted five-year HAI incidence rate had a marginal reduction from 2013 (4.10 per 1000 patient days) to 2017 (3.62 per 1000 patient days). The incidence of respiratory tract infection decreased significantly. However, the incidence rate of bloodstream infections and surgical site infection increased significantly. Respiratory tract infection (43.80%) accounted for the most substantial proportion of HAIs, followed by bloodstream infections (15.74%), and urinary tract infection (12.69%). A summer peak in HAIs was detected among adult and elderly patients.

Conclusions

This study shows how continuous electronic incidence surveillance based on existing hospital electronic databases can provide a practical means of measuring hospital-wide HAI incidence. The estimated incidence trends demonstrate the necessity for improved infection control measures related to bloodstream infections, ventilator-associated pneumonia, non-intensive care patients, and non-device-associated HAIs, especially during summer months.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0582-7) contains supplementary material, which is available to authorized users.

Global burden of Clostridium difficile infections: a systematic review and meta-analysis

Background

Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates.

Methods

Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model.

Results

229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups.

Conclusions

Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.

A ten-year review of healthcare-associated bloodstream infections from forty hospitals in Québec, Canada

OBJECTIVE

Healthcare-associated bloodstream infections (HABSI) are a significant cause of morbidity and mortality worldwide. In Québec, Canada, HABSI arising from acute-care hospitals have been monitored since April 2007 through the Surveillance des bactériémies nosocomiales panhospitalières (BACTOT) program, but this is the first detailed description of HABSI epidemiology.

METHODS

This retrospective, descriptive study was conducted using BACTOT surveillance data from hospitals that participated continuously between April 1, 2007, and March 31, 2017. HABSI cases and rates were stratified by hospital type and/or infection source. Temporal trends of rates were analyzed by fitting generalized estimating equation Poisson models, and they were stratified by infection source.

RESULTS

For 40 hospitals, 13,024 HABSI cases and 23,313,959 patient days were recorded, for an overall rate of 5.59 per 10,000 patient days (95% CI, 5.54-5.63). The most common infection sources were catheter-associated BSIs (23.0%), BSIs secondary to a urinary focus (21.5%), and non-catheter-associated primary BSIs (18.1%). Teaching hospitals and nonteaching hospitals with ICUs often had rates higher than nonteaching hospitals without ICUs. Annual HABSI rates did not exhibit statistically significant changes from year to year. Non-catheter-associated primary BSIs were the only HABSI type that exhibited a sustained change across the 10 years, increasing from 0.69 per 10,000 patient days (95% CI, 0.59-0.80) in 2007-2008 to 1.42 per 10,000 patient days (95% CI, 1.27-1.58) in 2016-2017.

CONCLUSIONS

Despite ongoing surveillance, overall HABSI rates have not decreased. The effect of BACTOT participation should be more closely investigated, and targeted interventions along alternative surveillance modalities should be considered, prioritizing high-burden and potentially preventable BSI types.

Epidemiologic characteristics of health care-associated outbreaks and lessons learned from multiple outbreak investigations with a focus on the usefulness of routine molecular analysis

BACKGROUND

Single outbreaks have often been reported in health care settings, but the frequency of outbreaks at a hospital over time has not been described. We examined epidemiologic features of all health care-associated outbreak investigations at an academic hospital during a 5-year period.

METHODS

Health care-associated outbreak investigations at an academic hospital (2012-2016) were retrospectively reviewed through data on comprehensive hospital-wide surveillance and pulsed-field gel electrophoresis (PFGE) analysis.

RESULTS

Fifty-one health care-associated outbreaks (annual range, 8-15), including 26 (51%) outbreaks in intensive care units (ICUs), and 263 infected-colonized patients involved in these outbreaks were identified. The frequency of pathogens varied by affected location, specifically multidrug-resistant organisms (20/26 outbreaks, 77% in ICUs vs 2/25 outbreaks, 8% in non-ICUs; P < .0001) and gastroenteritis because of Clostridium difficile, norovirus, or adenovirus (1/26 outbreaks, 4% in ICUs vs 17/25 outbreaks, 68% in non-ICUs; P < .0001). Outbreaks occurred in approximately one-third of all units (37%) with some repeated instances of the same pathogens. Of 16 outbreaks caused by a bacterial pathogen evaluated by PFGE, 12 (75%) included some indistinguishable strains, suggesting person-to-person transmission or a common source.

CONCLUSIONS

This study demonstrated epidemiologic characteristics of multiple outbreaks between ICUs and non-ICUs and the value of molecular typing in understanding the epidemiology of health care-associated outbreaks.

Burden of Healthcare-Associated Viral Respiratory Infections in Children's Hospitals

OBJECTIVE

Although healthcare-associated (HA) viral respiratory infections (VRIs) are common in pediatrics, no benchmark for comparison exists. We aimed to determine, compare, and assess determinants of unit-specific HA-VRI incidence rates in 2 children's hospitals.

METHODS

This study was a retrospective comparison of prospective cohorts. The Montreal Children's Hospital and the Cohen Children's Medical Center of New York perform prospective surveillance for HA-VRI using standardized definitions that require the presence of symptoms compatible with VRI and virus detection. Cases detected between April 1, 2010, and March 31, 2013, were identified using surveillance databases. Annual incidence rates were calculated, and a generalized estimating equation model was used to assess determinants of HA-VRI rates.

RESULTS

The overall HA-VRI rate during the 3-year study period was significantly higher at Montreal Children's Hospital than that at Cohen Children's Medical Center of New York (1.91 vs 0.80 per 1000 patient-days, respectively; P < .0001). Overall, the HA-VRI incidence rate was lowest in the neonatal intensive care unit. Rates in the pediatric intensive care, oncology, and medical/surgical units were similar. The most common etiology of HA-VRI at both institutions was rhinovirus (49% of cases), followed by parainfluenza virus and respiratory syncytial virus. Hospitals with less than 50% single rooms had HA-VRI rates 1.33 (95% confidence interval, 1.29-1.37) times higher than hospitals with more than 50% single rooms for a given unit type.

CONCLUSIONS

HA-VRI rates were substantial but different among 2 children's hospitals. Future studies should examine the effect of HA-VRI and evaluate best practices for preventing such infections.

Comparing knowledge and self-reported hand hygiene practices with direct observation among Iranian hospital nurses

We compared knowledge and self-reported hand hygiene practices with direct observations among Shiraz Nemazee Hospital nurses. Overall hand hygiene compliance was low (39.6%). Use and appreciation for alcohol-based handrubs were suboptimal. Some reluctance was due to religious concerns. Most nurses self-reported performing proper hand hygiene more than 75% of the time, whereas direct observation indicated much lower levels of compliance. It appears that additional training and improved monitoring are needed.