A Web-Based, Hospital-Wide Health Care-Associated Bloodstream Infection Surveillance and Classification System: Development and Evaluation

Impact of coronavirus disease 2019 (COVID-19) on antimicrobial resistance among major pathogens causing healthcare-associated infection

BACKGROUND

Coronavirus disease 2019 (COVID-19) has caused great impact on healthcare systems, including antibiotic usage and multi-drug resistant (MDR) bacterial infections at hospitals. We aim to investigate the trends of antimicrobial resistance among the major pathogens causing healthcare-associated infection (HAI) at intensive care units (ICU).

MATERIAL AND METHODS

The demographic characteristics of hospitalization, usage of antimicrobial agents, counted by half-an-year DID (defined daily dose per 1000 patient-days), and HAI density of five major MDR bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Klebsiella pneumoniae (CRKP), and carbapenem-resistant Pseudomonas aeruginosa (CRPA), of ICU patients at a medical center in Taiwan during January 2017 to December 2021 were collected and analyzed.

RESULTS

The total antibiotic usage, counted by DID, had a significant increasing trend, before COVID-19 occurrence in 2017-2019, but no further increase during the pandemic period in 2020-2021. However, comparing the two time periods, antibiotics consumption was significantly increased during pandemic period. There was no significant change of HAI density in MRSA, VRE, CRAB, CRKP, and CRPA, comparing the pandemic to the pre-pandemic period. Although, CRKP and CRPA infection rates were increasing during the pre-pandemic period, there was no further increase of CRKP and CRPA HAI rates during the pandemic period.

CONCLUSION

During COVID-19 pandemic, there was no significant increase in HAI density of five major MDR bacteria at ICU in Taiwan, despite increased antibiotic usage. Strict infection prevention measures for COVID-19 precautions and sustained antimicrobial stewardship probably bring these effects.

Diagnostic accuracy of electronic surveillance tool for catheter-associated urinary tract infections in tertiary care hospitals: A meta-analysis

BACKGROUND

Automated systems have been developed to reduce labor-intensive manual recordings during nosocomial infection surveillance. The diagnostic accuracies of these systems have differed in various settings.

METHODS

We designed this meta-analysis to evaluate the diagnostic accuracy of an electronic surveillance tool for catheter-associated urinary tract infections (CAUTIs) in tertiary care hospitals. We systematically searched databases such as Medline, Scopus, Cochrane library and Embase (from inception until November 2019) for relevant studies. We assessed the quality of trials using the diagnostic accuracy studies-2 tool, and performed a meta-analysis to obtain a pooled sensitivity and specificity for electronic surveillance. We included 6 studies with 16,492 patients in the analysis.

RESULTS

We found a pooled sensitivity of electronic diagnostic surveillance for CAUTIs of 97.5% (95% confidence interval [CI], 67.6-99.9%) and a pooled specificity of 92.6% (95% CI, 55.2-99.2%). The diagnostic odds ratio was 494 (95% CI, 89-2747). The positive likelihood ratio was 13.1 (95% CI, 1.63-105.8) and the negative likelihood ratio 0.02 (95% CI, 0.001-0.40). A bivariate box plot indicated the possibility of heterogeneity between the included studies.

CONCLUSION

Our review suggests that electronic surveillance is useful for diagnosing CAUTIs among hospitalized patients in tertiary care hospitals due to its high sensitivity and specificity.

Chlorhexidine Bathing to Prevent Central Line-Associated Bloodstream Infections in Hematology Units: A Prospective, Controlled Cohort Study

BACKGROUND

Chlorhexidine (CHG) bathing decreases the incidence of bloodstream infections in intensive care units, but its effect has been understudied in patients with hematological malignancies in noncritical care units.

METHODS

Adults with hematological malignancies hospitalized for cytotoxic chemotherapy in noncritical care units were offered daily 2% CHG bathing. We compared outcomes of patients who chose CHG bathing (CHG group) with outcomes of those who did not choose CHG bathing (usual-care group). The primary outcome was gram-positive cocci-related, skin flora-related, or central line-associated bloodstream infection. The negative control outcome was gut-origin bacteremia.

RESULTS

The CHG group (n = 485) had a crude incidence rate of the primary outcome that was 60% lower than the rate for the usual-care group (n = 408; 3.4 vs 8.4 per 1000 patient-days, P = .02) but had a similar crude incidence rate of the negative control outcome (4.5 vs 3.2 per 1000 patient-days; P = .10). In multivariable analyses, CHG bathing was associated with a 60% decrease in the primary outcome (adjusted hazard ratio [HR], 0.4; P < .001). In contrast, CHG bathing had no effect on the negative control outcome (adjusted HR, 1.1; P = .781). CHG bathing was well tolerated by participants in the CHG group.

CONCLUSIONS

CHG bathing could be a highly effective approach for preventing gram-positive cocci-related, skin flora-related, or central line-associated bacteremia in patients with hematological malignancies who are hospitalized for cytotoxic chemotherapy in noncritical care units.

Unpacking Prevalence and Dichotomy in Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Parameters: Observational Data-Driven Approach Backed by Sepsis Pathophysiology

BACKGROUND

Considering morbidity, mortality, and annual treatment costs, the dramatic rise in the incidence of sepsis and septic shock among intensive care unit (ICU) admissions in US hospitals is an increasing concern. Recent changes in the sepsis definition (sepsis-3), based on the quick Sequential Organ Failure Assessment (qSOFA), have motivated the international medical informatics research community to investigate score recalculation and information retrieval, and to study the intersection between sepsis-3 and the previous definition (sepsis-2) based on systemic inflammatory response syndrome (SIRS) parameters.

OBJECTIVE

The objective of this study was three-fold. First, we aimed to unpack the most prevalent criterion for sepsis (for both sepsis-3 and sepsis-2 predictors). Second, we intended to determine the most prevalent sepsis scenario in the ICU among 4 possible scenarios for qSOFA and 11 possible scenarios for SIRS. Third, we investigated the multicollinearity or dichotomy among qSOFA and SIRS predictors.

METHODS

This observational study was conducted according to the most recent update of Medical Information Mart for Intensive Care (MIMIC-III, Version 1.4), the critical care database developed by MIT. The qSOFA (sepsis-3) and SIRS (sepsis-2) parameters were analyzed for patients admitted to critical care units from 2001 to 2012 in Beth Israel Deaconess Medical Center (Boston, MA, USA) to determine the prevalence and underlying relation between these parameters among patients undergoing sepsis screening. We adopted a multiblind Delphi method to seek a rationale for decisions in several stages of the research design regarding handling missing data and outlier values, statistical imputations and biases, and generalizability of the study.

RESULTS

Altered mental status in the Glasgow Coma Scale (59.28%, 38,854/65,545 observations) was the most prevalent sepsis-3 (qSOFA) criterion and the white blood cell count (53.12%, 17,163/32,311 observations) was the most prevalent sepsis-2 (SIRS) criterion confronted in the ICU. In addition, the two-factored sepsis criterion of high respiratory rate (≥22 breaths/minute) and altered mental status (28.19%, among four possible qSOFA scenarios besides no sepsis) was the most prevalent sepsis-3 (qSOFA) scenario, and the three-factored sepsis criterion of tachypnea, high heart rate, and high white blood cell count (12.32%, among 11 possible scenarios besides no sepsis) was the most prevalent sepsis-2 (SIRS) scenario in the ICU. Moreover, the absolute Pearson correlation coefficients were not significant, thereby nullifying the likelihood of any linear correlation among the critical parameters and assuring the lack of multicollinearity between the parameters. Although this further bolsters evidence for their dichotomy, the absence of multicollinearity cannot guarantee that two random variables are statistically independent.

CONCLUSIONS

Quantifying the prevalence of the qSOFA criteria of sepsis-3 in comparison with the SIRS criteria of sepsis-2, and understanding the underlying dichotomy among these parameters provides significant inferences for sepsis treatment initiatives in the ICU and informing hospital resource allocation. These data-driven results further offer design implications for multiparameter intelligent sepsis prediction in the ICU.

Chlorhexidine bathing to prevent healthcare-associated vancomycin-resistant Enterococcus infections: A cluster quasi-experimental controlled study at intensive care units

BACKGROUND/PURPOSE

Vancomycin-resistant Enterococcus (VRE), a multidrug-resistant, difficult-to-treat pathogen of healthcare-associated infections (HAIs), is now endemic at many intensive care units (ICUs). Chlorhexidine (CHG) bathing is a simple and highly effective intervention to decrease VRE acquisition, but its effect on VRE-HAIs has not been assessed in prospective studies at ICUs.

METHODS

This is a cluster quasi-experimental controlled study. Under active VRE surveillance and contact isolation of all identified VRE carriers, four ICUs were assigned to provide 2% CHG bathing for all patients on a daily basis (CHG group) during the intervention period, while another four ICUs were assigned to provide standard care without CHG bathing for all patients (standard care group) during the same period.

RESULTS

The CHG group (n = 1501) had a 62% lower crude incidence of VRE-HAIs during the intervention period, compared with the baseline period (1.0 vs. 2.6 per thousand patient-days, P = 0.009), while VRE-HAIs incidence did not change in standard care group (n = 3299) (1.1 vs. 0.5 per thousand patient-days, P = 0.139). In multivariable analyses, CHG bathing was independently associated with a 70% lower risk of VRE-HAIs (adjusted odds ratio [OR] 0.3, 95% confidence interval [CI], 0.2 to 0.7, P = 0.006). In contrast, standard care during the same period had no effect on the risk of VRE-HAIs (adjusted OR 1.8, 95% CI: 0.7 to 4.7, P = 0.259).

CONCLUSION

CHG bathing is a highly effective approach to prevent VRE-HAIs at ICUs, in the context of active VRE surveillance with contact isolation.

Electronically assisted surveillance systems of healthcare-associated infections: a systematic review

Background

Surveillance of healthcare-associated infections (HAI) is the basis of each infection control programme and, in case of acute care hospitals, should ideally include all hospital wards, medical specialties as well as all types of HAI. Traditional surveillance is labour intensive and electronically assisted surveillance systems (EASS) hold the promise to increase efficiency.

Objectives

To give insight in the performance characteristics of different approaches to EASS and the quality of the studies designed to evaluate them.

Methods

In this systematic review, online databases were searched and studies that compared an EASS with a traditional surveillance method were included. Two different indicators were extracted from each study, one regarding the quality of design (including reporting efficiency) and one based on the performance (e.g. specificity and sensitivity) of the EASS presented.

Results

A total of 78 studies were included. The majority of EASS (n = 72) consisted of an algorithm-based selection step followed by confirmatory assessment. The algorithms used different sets of variables. Only a minority (n = 7) of EASS were hospital-wide and designed to detect all types of HAI. Sensitivity of EASS was generally high (> 0.8), but specificity varied (0.37–1). Less than 20% (n = 14) of the studies presented data on the efficiency gains achieved.

Conclusions

Electronically assisted surveillance of HAI has yet to reach a mature stage and to be used routinely in healthcare settings. We recommend that future studies on the development and implementation of EASS of HAI focus on thorough validation, reproducibility, standardised datasets and detailed information on efficiency.

Healthcare-associated infections in intensive care units in Taiwan, South Korea, and Japan: recent trends based on national surveillance reports

Background

Sustainable systematic interventions are important for infection prevention and control (IPC). Data from surveillance of healthcare-associated infections (HAI) provides feedback for implementation of IPC programs. To address the paucity of such data in Asia, we searched for national HAI surveillance and IPC programs in this region.

Methods

Data were analysed from open access national surveillance reports of three Asian countries: Taiwan, South Korea and Japan from 2008 to 2015. National IPC programs were identified.

Results

There were differences among the countries in surveillance protocols, hospital coverage rates, and national IPC policies and programs. Nevertheless, there was a 53.0% reduction in overall HAI over the 8-year period. This consisted of a decrease from 9.34 to 5.03 infections per 1000 patient-days in Taiwan, from 7.56 to 2.76 in Korea, and from 4.41 to 2.74 in Japan (Poisson regression, all p < 0.05). Across the three countries, Escherichia coli and Candida albicans were the major pathogens for urinary tract infection. Staphylococcus aureus, Acinetobacter baumannii and Enterococcus faecium were common bloodstream pathogens. For pneumonia, S. aureus, A. baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the predominant pathogens, with considerable country differences. There was a 64.6% decrease in the number of isolates of methicillin-resistant S. aureus, 38.4% decrease in carbapenem-resistant P. aeruginosa and 49.2% decrease in carbapenem-resistant A. baumannii (CRAB) in Taiwan (all p < 0.05), and similarly in Korea with the exception of CRAB (30.5 and 50.4% reduction, respectively, both p < 0.05).

Conclusion

We found a significant decrease in HAI across the three countries in association with sequential multifaceted interventions such as hand hygiene, care bundles, and antimicrobial stewardships. Further regional collaboration could be forged to develop joint strategies to prevent HAI.