Mortality Attributable to Nosocomial Infection: A Cohort of Patients With and Without Nosocomial Infection in a French University Hospital

Clinical and economic burden of healthcare-associated infections: A prospective cohort study

INTRODUCTION

Healthcare-associated infections (HAIs) have become a serious public health problem. Despite the fact that implementing evidence-based infection control strategies could prevent HAIs and save billions of dollars, Ethiopia lacks national surveillance studies on the rate, economic, and clinical burden of HAIs.

OBJECTIVE

To assess the clinical and economic burden of HAIs in hospitalized patients at Ayder comprehensive specialized hospital.

MATERIALS AND METHODS

A prospective cohort study design was conducted in patients with and without HAIs. A review of medical records, interviews, and patient bills was used to extract necessary information. The patients in the two arms were matched based on age, sex, Charlson comorbidity index, and ward type. Measurable factors were compared between infected and uninfected patients using the paired ttest or McNemar's test, as appropriate. Logistic regression was used to identify predictors of in-hospital mortality. Stata 14.1 was used to conduct all analyses.

RESULTS

A total of 408 patients, 204 with HAIs and 204 without HAIs were included in the study. In-hospital mortality was higher in patients with HAI (14.7% vs 7.8%, P = 0.028). Patients with HAI stayed an average of 8.3 days longer than controls (18.85 vs 10.59, P<0.001). The average direct medical costs for patients with HAI were 3033 Ethiopian birrs (ETB) higher than controls (4826 vs 1793, P<0.001). The presence of HAIs (AOR: 2.22, 95% CI: 1.13-4.39) and admission to intensive care units (AOR: 3.39, 95% CI: 1.55-7.40) were significant predictors of in-hospital mortality.

CONCLUSION

HAIs have a significant impact on in-hospital mortality, the length of extra hospital stays, and extra costs for medical care. Patients admitted to intensive care units and those with HAIs were found to be significant predictors of in-hospital mortality. Interventions must be implemented to prevent HAIs, especially in patients admitted to intensive care units.

Economic evaluation of preoperative shower with antiseptic soap to prevent surgical site infections

Preoperative shower is recommended before surgery to prevent surgical site infections (SSIs). We modelled the occurrence of SSIs and the potential savings for the patients undergoing antimicrobial soap (AS) shower prior to surgery at a French University Hospital level. AS shower prevented 209 SSIs, generating a potential saving of €632,210 per year. Results grouped by type of surgery showed annual savings of €26,537, €20,520 and €14,377 for orthopaedic, gynaecologic and obstetric and digestive surgery, respectively. Despite the lack of published data surrounding the efficacy of AS in preventing SSIs, we demonstrated the potential savings and benefits of generalizing AS before surgical interventions.

Individual decontamination measures reduce by two the incidence of surgical site infections in spinal surgery

BACKGROUND

In spinal surgery, incidence of surgical site infections (SSI) is estimated between 1 and 10%. It results in increased morbidity, mortality and cost of management. Individual Staphylococcus aureus (SA) decolonization has already proved efficiency to prevent those events in various surgical domains. The aim of this study was to evaluate a strategy of prevention of SSI and in particular the decolonization of the nasal carriage of SA by a protocol with Mupirocin application.

METHODS

We conducted a bicentric observational study on 5314 spinal surgery patients over a seven-year period. In both center, we compared periods before and after implementation of two measures: modification of antibioprophylaxis and staphylococcus decolonization. Homogeneity of the different samples of patients was assessed through measure of individual and surgical variables. We measured monthly incidence of SSI and evaluated its evolution in order to assess efficiency of these interventions.

RESULTS

The incidence of SSI decreased by half, from 7.3% to 3% at the Beaujon Hospital and from 8.3% to 3.9% at the Georges-Pompidou European Hospital (GPEH). We do not observe any significant decrease of SA rate in these SSI.

CONCLUSION

We believe that Staphylococcus aureus decolonization should be recommended in spinal surgery, and should be combined with an overall improvement of the quality of care.

Factors associated with in-hospital death in patients with nosocomial infections: a registry-based study using community data in western Iran

OBJECTIVES

Determining the predictors of in-hospital death related to nosocomial infections is an essential part of efforts made in the overall health system to improve the delivery of health care to patients. Therefore, this study investigated the predictors of in-hospital death related to nosocomial infections.

METHODS

This registry-based, longitudinal study analyzed data on 8,895 hospital-acquired infections (HAIs) in Hamadan Province, Iran from March 2017 to December 2019. The medical records of all patients who had been admitted to the hospitals were extracted from the Iranian Nosocomial Infections Surveillance Software. The effects of the type and site of infection, as well as age group, on in-hospital death were estimated using univariate and multivariable Cox regression models.

RESULTS

In total, 4,232 (47.8%) patients with HAIs were males, and their mean age was 48.25±26.22 years. In both sexes, most nosocomial infections involved Gram-negative bacteria and the most common site of infection was the urinary tract. Older patients had a higher risk of in-hospital death (adjusted hazard ratio [aHR], 2.26; 95% confidence interval [CI], 1.38 to 3.69 for males; aHR, 2.44; 95% CI, 1.29 to 4.62 for females). In both sexes, compared with urinary tract infections, an increased risk of in-hospital death was found for ventilator-associated events (VAEs) (by 95% for males and 93% for females) and bloodstream infections (BSIs) (by 67% for males and 82% for females).

CONCLUSION

We found that VAEs, BSIs, and fungal infections were independently and strongly associated with increased mortality.

Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data

OBJECTIVES

Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis.

DESIGN

Retrospective cohort study.

SETTING

136 U.S. hospitals in the Cerner HealthFacts dataset.

PATIENTS

Adults hospitalized in 2009-2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) (p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0-2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9-3.2).

CONCLUSIONS

Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.

Prevalence of health care-associated infections and antimicrobial resistance of the responsible pathogens in Ukraine: Results of a multicenter study (2014-2016)

BACKGROUND

The aim of this study was to obtain the first national estimates of the current prevalence and incidence and death of health care-associated infections (HAIs) of all types in acute care hospitals in Ukraine.

METHODS

Prospective surveillance was conducted from January 2014 to December 2016 in 17 hospitals. Surveillance case definitions were derived from the Centers for Disease Control and Prevention's National Healthcare Safety Network HAI case definitions. The identification and antimicrobial susceptibility of cultures were determined using a automated microbiology analyzer. Some antimicrobial susceptibility tests used Kirby-Bauer antibiotic testing.

RESULTS

Of 97,340 patients, 10,986 (11.3%) HAIs were observed. The most frequently reported HAI types were surgical site infections (60%), respiratory tract infections (pneumonia and lower respiratory tract, 18.4%), bloodstream infections (10.2%), and urinary tract infections (9.5%). Death during hospitalization was reported in 9.7% of HAI cases. The most common organism reported was Escherichia coli, accounting for 21.8% of all organisms, followed by Staphylococcus aureus (18.4%), Enterococcus spp (15.7%), and Pseudomonas aeruginosa (12.4%). Antimicrobial resistance among the isolates associated with HAIs showed that 42.1% and 3.6% of coagulase-negative Staphylococcus spp isolates were β-lactam (oxacillin)- and glycopeptide (teicoplanin)-resistant, respectively. Meticillin resistance was reported in 39.2% of S aureus isolates.

CONCLUSIONS

HAIs and increasing antimicrobial resistance present a significant burden to the Ukraine hospital system. Infection control priorities in hospitals should include preventing surgical site infections, respiratory tract infections (which also include PNEU and LRTI), bloodstream infections, and urinary tract infections, as well preventing infections due to antimicrobial-resistant pathogens.

Prevalence of healthcare-associated infections and antimicrobial resistance in acute care hospitals in Kyiv, Ukraine

BACKGROUND

Healthcare-associated infections (HAIs) are among the most common adverse events in patient care, and account for substantial morbidity and mortality.

AIM

To obtain the first estimates of the current prevalence of HAIs and antimicrobial resistance in acute care hospitals in Kyiv, Ukraine.

METHODS

Prospective surveillance was conducted from January 2014 to December 2016 in five acute care hospitals in Kyiv. Definitions of HAIs were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network.

FINDINGS

Among 53,884 patients, 3753 (7%) HAIs were observed. The most frequently reported HAIs were respiratory tract infections (pneumonia 19.4%, lower respiratory tract infections 4.1%), surgical site infections (19.6%), urinary tract infections (17.5%) and bloodstream infections (10.6%). Death during hospitalization was reported in 7.2% cases of HAI. The micro-organisms most frequently isolated from HAIs were Escherichia coli (15.9%), Staphylococcus aureus (14.8%), Enterococcus spp. (10.2%), Pseudomonas aeruginosa (8.9%) and Klebsiella spp. (8.9%). Meticillin resistance was reported in 28.2% of S. aureus, and 14.2% of enterococci were resistant to vancomycin. Overall, 35.1% of all Enterobacteriaceae were resistant to third-generation cephalosporins, with the highest resistance rates seen in K. pneumoniae (53.8%) and E. coli (32.1%).

CONCLUSIONS

Infection control priorities in hospitals should include prevention of surgical site infections, pneumonia, bloodstream infections and urinary tract infections. These results may help to delineate the requirements for infection prevention and control in acute care hospitals.

Prevalence, incidence burden, and clinical impact of healthcare-associated infections and antimicrobial resistance: a national prevalent cohort study in acute care hospitals in Greece

BACKGROUND

Assessing the overall burden of healthcare-associated infections (HAIs) is challenging, but imperative in evaluating the cost-effectiveness of infection control programs. This study aimed to estimate the point prevalence and annual incidence of HAIs in Greece and assess the excess length of stay (LOS) and mortality attributable to HAIs, overall and for main infection sites and tracer antimicrobial resistance (AMR) phenotypes and pathogens.

PATIENTS AND METHODS

This prevalent cohort study used a nationally representative cross-section of 8,247 inpatients in 37 acute care hospitals to record active HAIs of all types at baseline and overall LOS and in-hospital mortality up to 90 days following hospital admission. HAI incidence was estimated using prevalence-to-incidence conversion methods. Excess mortality and LOS were assessed by Cox regression and multistate models correcting for confounding and time-dependent biases.

RESULTS

HAIs were encountered with daily prevalence of 9.1% (95% confidence interval [CI] 7.8%-10.6%). The estimated annual HAI incidence was 5.2% (95% CI 4.4%-5.3%), corresponding to approximately 121,000 (95% CI 103,500-123,700) affected patients each year in the country. Ninety-day mortality risk was increased by 80% in patients with HAI compared to those without HAI (adjusted hazard ratio 1.8; 95% CI 1.3-2.6). Lower respiratory tract infections, bloodstream infections, and multiple concurrent HAIs doubled the risk of death, whereas surgical site and urinary tract infections were not associated with increased mortality. AMR had significant impact on the daily risk of 90-day mortality, which was increased by 90%-110% in patients infected by carbapenem-resistant gram-negative pathogens. HAIs increased LOS for an average of 4.3 (95% CI 2.4-6.2) additional days. Mean excess LOS exceeded 20 days in infections caused by major carbapenem-resistant gram-negative pathogens.

CONCLUSION

HAIs, alongside with increasing AMR, pose significant burden to the hospital system. Burden estimates obtained in this study will be valuable in future evaluations of infection prevention programs.

Prevalence of antimicrobial resistant pathogens from blood cultures: results from a laboratory based nationwide surveillance in Ghana

Background

Blood stream infections (BSI) are critical medical conditions with high morbidity and mortality. There is paucity of information on BSI from surveillance studies in Ghana.

Aim

This study sought to demonstrate how useful BSI data can be gleaned from population-based surveillance, especially from resource-limited settings.

Methods

Data from a nationwide surveillance of antimicrobial drug resistance (AMR) in Ghana were extracted and analyzed. Secondly, we revived archived Staphylococcus aureus isolates from blood cultures that were cefoxitin resistant (CRSA), and screened these for protein A (spa) and mec A genes.

Results

Overall blood culture positivity was 11.2% (714/6351). All together, participating laboratories submitted 100 multidrug resistant blood culture isolates (Gram-negative = 49 and Gram-positive = 51). Prevalence of some Gram-negative isolates was as follows; Escherichia coli (20.4%), Pseudomonas aeruginosa (16.3%), Enterobacter spp. (14.3%), Salmonella serotype Typhi (8.2%) and Non-typhoidal Salmonella [NTS] (8.2%). Gram-positive pathogens included Staphylococcus aureus (66.7%), coagulase negative S. aureus [CoNS] (17.6%) and Streptococcus pneumoniae (11.8%). No methicillin resistance was confirmed in our CRSA isolates. Most blood stream associated infections were from inpatients (75%) and cultured bacteria were resistant to common and cheaper antimicrobials.

Conclusion

E. coli and S. aureus are common pathogens associated with BSI in Ghana and they are resistant to several antimicrobials. Active and continuous AMR surveillance can serve multiple purposes, including data generation for BSI.

Predictors of Clostridium difficile infection-related mortality among older adults

BACKGROUND

Over 90% of annual deaths caused by Clostridium difficile infection (CDI) occur in persons aged ≥65 years. However, no large-scale studies have been conducted to investigate predictors of CDI-related mortality among older adults.

METHODS

This case-control study included 540 CDI patients aged ≥60 years admitted to a tertiary care hospital in Detroit, Michigan, between January 2005 and December 2012. Cases were CDI patients who died within 30 days of CDI date. Controls were CDI patients who survived >30 days after CDI date. Cases were matched to controls on a 1:3 ratio based on age and hospital acquisition of CDI.

RESULTS

One-hundred and thirty cases (25%) were compared with 405 controls (75%). Independent predictors of CDI-related mortality included admission from another acute hospital (odds ratio [OR], 8.25; P = .001) or a long-term care facility (OR, 13.12; P = .012), McCabe score ≥2 (OR, 12.19; P < .001), and high serum creatinine (≥1.7 mg/dL) (OR, 3.43; P = .021). The regression model was adjusted for the confounding effect of limited activity of daily living score, total number of antibiotic days prior to CDI, ileus on abdominal radiograph, low albumin (≤2.5 g/dL), elevated white blood cell count (>15 × 1,000/mm³), and admission to intensive care unit because of CDI.

CONCLUSIONS

Predictors of CDI-related mortality reported in this study could be applied to the development of a bedside scoring system for older adults with CDI.

Mortality related to hospital-associated infections in a tertiary hospital; repeated cross-sectional studies between 2004-2011

BACKGROUND

Hospital-associated infections (HAIs) are reported to increase patient mortality and incur longer hospital stays. Most studies to date have focused on specific groups of hospitalised patients with a rather short follow-up period. In this repeated cross-sectional study, with prospective follow-up of 19,468 hospitalized patients, we aimed to analyze the impact of HAIs on mortality 30 days and 1 year after the prevalence survey date.

METHODS

The study was conducted at Haukeland University Hospital, Norway, a large combined emergency and referral teaching hospital, from 2004 to 2011 with follow-up until November 2012. Prevalence of all types of HAIs including urinary tract infections (UTI), lower respiratory tract infections (LRTI), surgical site infections (SSI) and blood stream infections (BSI) were recorded four times every year. Information on the date of birth, admission and discharge from the hospital, number of diagnoses (ICD-10 codes) and patient's mortality was retrieved from the patient administrative data system. The data were analysed by Kaplan-Meier survival analysis and by multiple Cox regression analysis, adjusted for year of registration, time period, sex, type of admission, Charlson comorbidity index, surgical operation, use of urinary tract catheter and time from admission to the prevalence survey date.

RESULTS

The overall prevalence of HAIs was 8.5 % (95 % CI: 8.1, 8.9). Patients with HAIs had an adjusted hazard ratio (HR) of 1.5 (95 % CI: 1.3, 1.8,) and 1.4 (95 % CI: 1.2, 1.5) for death within 30-days and 1 year, relative to those without HAIs. Subgroup analyses revealed that patients with BSI, LRTI or more than one simultaneous infection had an increased risk of death.

CONCLUSIONS

In this long time follow-up study, we found that HAIs have severe consequences for the patients. BSI, LRTI and more than one simultaneous infection were independently and strongly associated with increased mortality 30 days and 1 year after inclusion in the study.

[Adverse events and associated factors in patients who died in a university hospital]

OBJECTIVE

This study aims to associate adverse events related to health care with another indicator of quality of care such as hospital mortality, and determining the proportion of adverse events (AEs) and associated factors in deceased patients.

METHODS

First a descriptive study of hospital-based mortality was performed, followed by a case-control study in deceased patients. We studied the presence of AEs, the probability which they could be predicted and prevented, and their association with several factors.

RESULTS

The proportion of AEs found was 19.8% (82/414), and the proportion of deceased patients who suffered an AE was 15.5% (64/414). The AE ratio per person was 1.28. The most common AE was nosocomial infection, and 48.8% of all AEs were preventable. No difference was found with the presence of an AE by age or sex. Factors associated with the presence of AEs were surgery, length of stay and hospital unit to which patients were admitted.

DISCUSSION

The proportion of AEs found between patients who died, the percentage of preventable AEs, the most common AE (nosocomial infection) and the association of their presence with stay and the surgery should make us focus on the development of measures to reduce hospital stay and the dissemination of information on prevention and control of nosocomial infection.

A prospective study of nosocomial-infection-related mortality assessed through mortality reviews in 14 hospitals in Northern France

AIM

To determine the number of deaths associated with nosocomial infection (NI) occurring in French hospitals, and to evaluate the role of hospital mortality reviews in assessing the preventability of NI-associated death.

METHODS

The study considered 13,537 consecutive deaths occurring in 14 French hospitals in 2007 and 2008. An expert commission including attending physicians and nurses determined the likelihood that deaths could be attributed to NI, and the preventability of NI and death.

FINDINGS

Medical records of the 2355 eligible patients with a McCabe score of 0 or 1 who died more than 48 h after admission were reviewed. Among them, 33% had at least one NI. Death was attributable to NI in 182 patients, and was considered preventable in 35 cases. Among these, 10 deaths were unexpected.

CONCLUSION

Extrapolating these figures nationally, approximately 3500 [95% confidence interval (CI) 2605-4036] deaths attributable to NI occur in France annually. Among these, approximately 1300 NIs (95% CI 357-2196) and 800 deaths (95% CI 51-1481) can be considered preventable. Hospital mortality review commissions can help to improve the quality of health care by identifying circumstances associated with NI contributing to death, and targeting specific preventative measures. Such hospital commissions should involve all healthcare personnel.

Trends among pathogens reported as causing bacteraemia in England, 2004-2008

The Health Protection Agency in England operates a voluntary surveillance system that collects data on bacteraemias reported by over 90% of laboratories in England. Trends in causative microorganisms reported between 2004 and 2008 were analyzed using a generalized linear model with a log link function for Poisson distribution. In 2008, 101,276 episodes of bacteraemia were reported; a rate of 189 per 100,000 population. More than one-half occurred in those aged over 65 years and males. The most common organisms reported were Escherichia coli (23%), coagulase-negative staphylococci (CNS) (16.9%) and Staphylococcus aureus (11.4%). Between 2004 and 2008, E. coli bacteraemia increased by 33% (p < 0.001); the species now accounts for more than 30% of bacteraemia in those aged over 75 years. There also were significant increases in bacteraemia caused by other Gram-negative pathogens and marked seasonal variation. Bacteraemia caused by S. aureus increased until 2005, with a decline after 2006 (p < 0.001) entirely due to methicillin-resistant strains. CNS bacteraemia have declined significantly since 2007. The renewed dominance of Gram-negative pathogens as major causes of bacteraemia in England is of particular concern because they are associated with a high morbidity and increasing resistance to antibiotics. Further investigation of the underlying causes and prevention strategies is a public health priority. Recent declines in methicillin-resistant S. aureus bacteraemia have not been reflected in other pathogens, including methicillin-susceptible S. aureus.

Identifying possible deaths associated with nosocomial infection in a hospital by data mining

BACKGROUND

Nosocomial infection (NI) is a cause of patient morbidity and mortality. Conducting an audit of deaths due to NI is a potentially useful approach to improving professional standards. In France, these deaths are required to be reported, but the reporting is left to clinicians, who often do not comply. The aim of the present study was to assess whether linking the microbiological database with the hospital mortality database might be a suitable surveillance approach for identifying patients who died with an NI.

METHODS

A total of 1,726 deaths were recorded in the mortality database of a French university hospital between September 1, 2006, and September 16, 2007. During this same period, 6,290 potential NIs (PNIs) were identified by bacteriological examination. These PNIs were generated using a computer algorithm specific to the bacteriology database. PNI information request forms were sent to the senior doctor of the unit where the samples had been obtained to determine whether the PNI was an NI, colonization, or a non-nosocomial infection. A total of 364 cases were common to both databases; from these, a sample of 135 cases was selected for further analysis. To establish the strength of evidence for NI as the cause of death, the 135 cases were analyzed using the patient record by an investigator from the hospital hygiene team.

RESULTS

During the study period, no deaths associated with NI were reported spontaneously. Of the 135 cases analyzed, NI was considered the main cause of death in 6 (4.4%) and a contributory factor in 51 (37.8%). Thus, NI was estimated to be the main cause of death in 0.9% of all patients who died in the hospital during the study period and a contributory cause in another 8.0% of these patients.

CONCLUSION

Linking databases from bacteriology with those containing hospital mortality records is a simple, reproducible tool for identifying the number of deaths attributable to NI. This may provide a powerful approach to help reduce the burden of disease due to NI through the auditing of such identified deaths.

Influence of a hygiene promotion programme on infection control in an intensive-care unit

The objectives of this study were to determine the risk factors associated with nosocomial infection (NI) in the intensive-care unit and to assess the influence of a hand-washing promotion programme on the NI rate. Over a 6-month study period (P1), a prospective study of NI cases was performed, and risk factors for NI were analysed. Data were compared with those corresponding to a second period (P2), during which a health workers' hand-washing promotion programme was carried out; alcohol-based solution was also placed at the patients' headboard. Eight hundred and six patients were included (395 patients in P1 and 411 in P2). The mean APACHE II score was 11.41; there were no statistically significant differences in epidemiological or clinical variables between P1 and P2, and there were no differences in risk factors for NI. The rate of infection in P1 was 26%, and that in P2 was 16% (p <0.05). The hand-washing rate was higher in P2 than in P1 (before patient care, 45% and 35%, respectively; after contact with the patient, 63% and 51%, respectively). In the multivariate analysis, only central venous catheterization (>5 days) and tracheostomy were statistically significant risk factors for NI; having been included in the study during P1 or P2 was not statistically associated with NI. In conclusion, there was a significant increase in hand-washing frequency in P2; the incidence of NI during P1 was significantly higher than during P2, but having been included in the study in P1 was not significantly associated with a higher rate of NI; only central venous catheterization (>5 days) and tracheostomy were significantly associated with NI.

Risk factors for infections caused by multidrug-resistant bacteria in patients with solid tumours

OBJECTIVES

We aimed to determine the risk factors for healthcare-associated infections (HCAI) caused by multidrug-resistant (MDR) bacteria in patients with solid tumours.

METHODS

This retrospective study was performed in the Department of Clinical Microbiology and Infectious Diseases, Mersin Teaching and Research Medical Centre, between January 2004 and December 2008. SPSS version 11.5 program package was used for the statistical analyses.

RESULTS

A total of 145 patients who had an HCAI were analyzed; 62% of the patients were male and their median age was 57.7 ± 16 y and median Charlson co-morbidity score was 4.94 ± 1.2. During the study period, 83 MDR bacteria were isolated from HCAIs that developed in 70 (48.3%) patients. In multiple binary logistic regression analysis, duration of hospital stay (odds ratio (OR) 1.041, 95% confidence interval (CI) 1.007-1.077; p = 0.019), surgery (OR 3.115, 95% CI 1.288-7.535; p = 0.012), use of glycopeptides (OR 5.394, 95% CI 1.960-14.850; p = 0.001), and use of third-generation cephalosporins (OR 5.521, 95% CI 2.017-15.110; p = 0.001) were found to be independent risk factors for the development of an MDR infection.

CONCLUSIONS

Among hospitalized patients with a solid tumour, HCAIs caused by MDR bacteria occurred more frequently in patients undergoing surgery, receiving third-generation cephalosporins and glycopeptide antibiotics, and having a prolonged hospital stay.

Estimating attributable mortality due to nosocomial infections acquired in intensive care units

BACKGROUND

The strength of the association between intensive care unit (ICU)-acquired nosocomial infections (NIs) and mortality might differ according to the methodological approach taken.

OBJECTIVE

To assess the association between ICU-acquired NIs and mortality using the concept of population-attributable fraction (PAF) for patient deaths caused by ICU-acquired NIs in a large cohort of critically ill patients.

SETTING

Eleven ICUs of a French university hospital.

DESIGN

We analyzed surveillance data on ICU-acquired NIs collected prospectively during the period from 1995 through 2003. The primary outcome was mortality from ICU-acquired NI stratified by site of infection. A matched-pair, case-control study was performed. Each patient who died before ICU discharge was defined as a case patient, and each patient who survived to ICU discharge was defined as a control patient. The PAF was calculated after adjustment for confounders by use of conditional logistic regression analysis.

RESULTS

Among 8,068 ICU patients, a total of 1,725 deceased patients were successfully matched with 1,725 control patients. The adjusted PAF due to ICU-acquired NI for patients who died before ICU discharge was 14.6% (95% confidence interval [CI], 14.4%-14.8%). Stratified by the type of infection, the PAF was 6.1% (95% CI, 5.7%-6.5%) for pulmonary infection, 3.2% (95% CI, 2.8%-3.5%) for central venous catheter infection, 1.7% (95% CI, 0.9%-2.5%) for bloodstream infection, and 0.0% (95% CI, -0.4% to 0.4%) for urinary tract infection.

CONCLUSIONS

ICU-acquired NI had an important effect on mortality. However, the statistical association between ICU-acquired NI and mortality tended to be less pronounced in findings based on the PAF than in study findings based on estimates of relative risk. Therefore, the choice of methods does matter when the burden of NI needs to be assessed.

Prevalence of nosocomial infections in The Netherlands, 2007-2008: results of the first four national studies

The PREZIES national network for the surveillance of nosocomial infections (NI) in The Netherlands has organised a national prevalence study twice a year since 2007. This paper presents the results of the first four surveys. Of 95 hospitals in The Netherlands, 41 participated in 92 surveys and 26 937 patients were included. On the survey day 6.2% had an NI (prevalence of infections 7.2%). The prevalence of infections varied from 1.4% to 16.5% between hospitals. The prevalence of surgical site infections was 4.8%, pneumonia 1.1%, primary bloodstream infection 0.5% and symptomatic urinary tract infection 1.7%. On admission to hospital, 3.3% of patients had an NI. On the day of the survey, 30.9% of the patients were receiving antibiotics. The use of antibiotics as well as medical devices differed considerably between hospitals. Both the prevalence of NI in The Netherlands and the use of antibiotics and devices were comparable to other European countries.

Risk factors for increased mortality from hospital-acquired versus community-acquired infections in febrile medical patients

BACKGROUND

Risk factors for hospital-acquired infection and attributable mortality in surgical and critically ill patients are well-known. We sought to identify factors associated with increased mortality from hospital-acquired infections as compared with community-acquired infections in patients with new-onset fever and a presumed infectious focus (n = 212), in a department of internal medicine.

METHODS

Demographic, clinical, and laboratory variables were studied for 2 days after inclusion. Septic shock and outcome were monitored for up to 7 and 28 days after inclusion, respectively.

RESULTS

Of the 212 patients, 54 had hospital-acquired and 158 community-acquired infection, with septic shock rates of 15% and 4% and mortality rates of 24% and 6% (P = .001), respectively. Prior neurologic disease was associated with death. Patients with hospital-acquired infection had more often (intravascular) devices and underwent more often interventions, had a different distribution of infectious foci, and had more often bacteremia. Bacteremia-associated septic shock was associated with nonsurvival in both infection groups. The causative agents were not associated with outcome, and the clinical and laboratory host response associated with nonsurvival generally did not differ among infection groups.

CONCLUSION

Our data suggest that hospital-acquired infections carry a higher crude mortality rate than community-acquired infection in febrile medical patients, mainly because of more frequent use of devices and hospital interventions and resultant bacteremia and septic shock, rather than by differences in underlying diseases, causative agents, and clinical and laboratory host responses. The observations thus emphasize the continued importance of preventive measures on medical wards of our hospital and can be used for comparison with future studies.

Mortality attributable to hospital-acquired infections among surgical patients

We performed a multicenter prospective matched cohort study to evaluate the mortality attributable to hospital-acquired infections among 12,791 patients admitted to surgical departments. We were able to match 731 patients with 1 or more hospital-acquired infections (ie, case patients) with 731 patients without a hospital-acquired infection (ie, control patients) at a 1:1 ratio. Of the 731 case patients, 42 (5.7%) died; of the 731 control patients, 23 (3.1%) died--a significant difference of 2.6%.

Surveillance of hospital-acquired infections in Liguria, Italy: results from a regional prevalence study in adult and paediatric acute-care hospitals

A multi-hospital prevalence study of hospital-acquired infections (HAIs) was carried out between 19 March and 6 April 2007 in Liguria, Italy, being the first to be performed in this region. Of the 29 existing public acute hospitals, 25 took part in the investigation (86.2%). In total, 3176 patients were enrolled in the study, representing a regional average bed-occupancy rate of nearly 70%. Three-hundred and ten HAIs were diagnosed from 283 patients, with an overall prevalence of infections and cases of 9.8% and 8.9%, respectively. Prevalence varied considerably between hospitals, ranging from 0 to 24.4% [95% confidence interval (CI): 15.53-33.27]. Urinary tract infections (UTIs) (30.0%) and respiratory tract infections (RTIs) (26.1%) presented the highest relative frequency, followed by bloodstream infections (BSIs) (14.8%), surgical site infections (11.6%) and gastrointestinal infections (6.5%). Intensive care units (ICUs) and haemato-oncological units showed the highest specific prevalence of HAI, respectively 42.5% (95% CI: 34.48-50.52) and 13.3% (6.28-20.32), with RTI and BSI as the predominant infections. Spinal units (33.3%; 13.14-53.46) and functional-rehabilitation units (18.9%; 17.75-24.06) demonstrated a high rate of urinary tract infections. Uni- and multivariate analyses were performed to assess the main risk factors and conditions associated with HAI, both overall and by site. Our study provides an overall picture of the epidemiology of HAI in Liguria, which may be usefully employed as a starting point to plan and organise future surveillance and control programmes.

The role of the innate immune response in hospital- versus community-acquired infection in febrile medical patients

OBJECTIVES

To study the role of the innate immune response in the higher mortality of hospital- than of community-acquired infections, in febrile medical patients.

METHODS

We studied presumably immunocompetent patients with new-onset fever and a clinically presumed focus of infection (N=212) at a university department of internal medicine. Clinical and microbiological data were collected for 2 days from inclusion, and circulating complement activation product C3a, secretory phospholipase A(2), interleukin (IL)-6, procalcitonin, and elastase-alpha(1)-antitrypsin were measured. Patients were followed for septic shock and outcome, up to a maximum of 7 and 28 days after inclusion, respectively. Infection was considered hospital-acquired if it developed at least 72h after admission.

RESULTS

Fifty-four patients had hospital-acquired infections and 158 had community-acquired infections, with septic shock and mortality rates of 15% and 24%, and 4% and 6% (p=0.001), respectively. Bloodstream infection predisposed to septic shock and the latter predisposed to death. Bloodstream infection was relatively more common in septic shock originating from community-acquired infection and was associated with an innate immune response in both hospital- and community-acquired infection, as judged from circulating immune variables. In contrast, circulating C3a, IL-6, and procalcitonin were more elevated when septic shock developed following hospital- than community-acquired infection, independent of infectious focus. The levels of C3a, secretory phospholipase A(2), IL-6, and elastase-alpha(1)-antitrypsin were more elevated in ultimate non-survivors than in survivors in both infection groups.

CONCLUSIONS

The data suggest that rates of septic shock and mortality from hospital- vs. community-acquired infections in febrile medical patients are not increased by impaired innate immunity. In contrast, proinflammatory factors may be particularly useful to predict a downhill course in hospital-acquired infections.

Additional direct medical costs of nosocomial infections: an estimation from a cohort of patients in a French university hospital

We estimated the direct additional medical costs of nosocomial infections (NI) using a cohort study in acute and longer-term care at Nîmes University Hospital in France. Patients hospitalised between May 2001 and January 2003 with NI were considered as exposed; all others were eligible as non-exposed. Thirty patients were randomly chosen for each site of infection: respiratory tract, bloodstream, surgical site, urinary tract and other sites for a total of 150 exposed patients. Each exposed patient was matched with a non-exposed patient according to gender, age, severity of the underlying disease, diagnosis according to hospital discharge records, ward type and length of hospitalisation before inclusion. Additional direct medical costs for the exposed patients compared to the non-exposed and the difference between actual costs and the diagnosis-related group rate were measured. Costs resulting from laboratory tests, radiology, surgery and exploratory examinations, and antimicrobial agents were estimated to be Euro2421 for a respiratory tract infection, Euro1814 for a surgical site infection, Euro953 for a bloodstream infection and Euro574 for a urinary tract infection. Total additional costs of NI (direct medical costs and costs of extra length of stay) in acute care were estimated to be up to Euro3.2 million per year (95% confidence interval: 2,275,063-4,132,157). In conclusion, both prevention of avoidable NI and better estimation of the actual costs of NI should be priorities for all healthcare facilities.