Hospitalization in double-occupancy rooms and the risk of hospital-acquired influenza: a prospective cohort study

Accepted Manuscript Hospitalisation in double-occupancy rooms and the risk of hospital-acquired influenza: a prospective cohort study Elodie Munier, MD, MSc, Thomas Bénet, MD, MPH, Corinne Régis, RN, Bruno Lina, MD, PhD, Florence Morfin, Pharm, PhD, Philippe Vanhems, MD, PhD PII:

S1198-743X(16)00026-4

DOI:

10.1016/j.cmi.2016.01.010

Reference:

CMI 503

To appear in:

Clinical Microbiology and Infection

Received Date: 12 November 2015 Revised Date:

23 December 2015

Accepted Date: 11 January 2016

Please cite this article as: Munier E, Bénet T, Régis C, Lina B, Morfin F, Vanhems P, Hospitalisation in double-occupancy rooms and the risk of hospital-acquired influenza: a prospective cohort study, Clinical Microbiology and Infection (2016), doi: 10.1016/j.cmi.2016.01.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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ACCEPTED MANUSCRIPT Hospitalisation in double-occupancy rooms and the risk of hospital-acquired

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influenza: a prospective cohort study

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Elodie Munier, MD, MSc1 ; Thomas Bénet, MD, MPH1,2 ; Corinne Régis, RN1 ; Bruno Lina,

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MD, PhD3 ; Florence Morfin, Pharm, PhD3 ; Philippe Vanhems, MD, PhD1,2

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Lyon, 69003 Lyon, France

Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de

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Infectiologie (CIRI) Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, 69007 Lyon,

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France

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Emerging Pathogens Laboratory - Fondation Mérieux, Centre International de Recherche en

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Influenza, Hospices Civils de Lyon, 69500 Bron, France and VIRPATH Laboratory, EA

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4610, Claude Bernard University of Lyon, René-Théophile-Hyacinthe Laennec School of

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Medicine, University of Lyon 1, 69003 Lyon, France

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Running title: Nosocomial influenza and double-occupancy room

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National Reference Center for Influenzae Viruses, Virology Reference Laboratory of

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Corresponding author: Philippe Vanhems, MD, PhD

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Service d’Hygiène, Epidémiologie et Prévention, Hôpital Edouard Herriot, Hospices Civils de

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Lyon, 5 place d'Arsonval, 69437 Lyon cedex 03, France

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Telephone: +33 4 72 11 07 21

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Fax: +33 4 72 11 07 26

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E-mail: [email protected]

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Text word count: 1 000

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Abstract

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Hospitalisation in double-occupancy rooms and the risk of hospital-acquired influenza (HAI)

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were assessed prospectively. The incidence was 2.0 for 100 patient-days in double versus 0.7

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in single-occupancy rooms (p=0.028). The adjusted HR of HAI was 2.67 (95%CI: 1.05-6.76)

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in patients hospitalised in double compared to single-occupancy rooms.

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Keywords: double-occupancy room; hospital-acquired infection; influenza; epidemiology;

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cohort

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BACKGROUND

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With attack rates reaching 60%, hospital-acquired influenza (HAI) and influenza-like illness

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(HA-ILI) are anything but rare [1]. Hospitalised patients exposed to infected cases or

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healthcare workers (HCWs) are at high risk of HA-ILI [1].

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Close contacts among patients sharing rooms offer opportunities for pathogen transmission by

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HCWs, visitors and patients themselves. Indeed, more contacts can be counted among

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patients hospitalised in double-occupancy rooms than those in single-occupancy rooms [2].

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Nosocomial bacterial acquisition has been associated with the number of roommate exposures

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per day [3].

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The impact of double-occupancy rooms on HAI in nursing homes has been described in

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retrospective studies [4,5], but this risk has not been quantified in acute care settings

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prospectively with systematic virological sampling.

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The objective was to assess the relationship between hospitalisation in double-occupancy

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rooms and HAI risk in a hospital-based cohort.

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METHODS

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Prospective ILI surveillance was implemented between October and April from 2004-2005 to

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2011-2012 and in 2013-2014 at Edouard Herriot University Hospital (Lyon, France) counting

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for 1,000 beds. This surveillance has been described elsewhere [1]. ILI was defined as fever

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>37.8°C (in the absence of antipyretics) and/or cough or sore throat. Eligible patients

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presented ILI ≥48 hours after admission (incident ILI) with available data on room type,

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virological results on influenza and length of stay in the unit. No specific infection control

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measures were implemented because of the study. Standard procedures were followed with

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droplet precaution in case of ILI.

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The primary endpoint was confirmed HAI defined as virologically-confirmed influenza

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occurring ≥48h after admission in acute-stay units. The main exposure of interest was

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hospitalisation in double-occupancy compared with single-occupancy room.

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The following variables were recorded at ILI diagnosis: admission and discharge dates,

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underlying diseases, gender, age at admission, influenza vaccination status, room type (single

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or double-occupancy). Rooms with more than 2 beds did not exist in this hospital.

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Nasal swabs, tested by the National Reference Center for Influenzae Viruses in Lyon, were

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collected for each patient included by research nurses. Other respiratory viruses were also

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tested.

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Categorical variables were compared by the chi2 test or Fisher’s exact test, and continuous

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variables, by the Mann-Whitney U-test. Incidence was expressed per 100 patient-days of

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hospitalisation at risk. Data were censored at patient discharge, death or at 50 days of follow-

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up. HAI probability according to type of room was described by the Kaplan-Meier method,

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and survival curves were compared by the log-rank test. Univariate and multivariate Cox

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proportional hazard models were fitted to assess relationship between type of room and risk of

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HAI, hazard ratios and 95% confidence interval (95% CI) were calculated. Covariates with

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p<0.20 after univariate analysis were entered in the multivariate model. All tests were 2-

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tailed. P<0.05 was considered significant. The data were analysed by Stata software 11.1.

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The protocol design was approved by the ethic board of the hospital. All patients received

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study information and gave signed informed consent.

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RESULTS

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Overall, 93 patients, accounting for 1,775 patient-days at risk, were analysed and among

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them, 20 (21.5%) had confirmed HAI. Among the 73 patients without HAI, 7 had other viral

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infections: 3 by respiratory syncytial virus, 2 by picornavirus, 1 by metapneumovirus and 1 by

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herpes simplex virus 1. 4

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Patients’ characteristics and HAI incidence are presented on Table 1. The mean age of all

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patients included was 74.2 years. The HAI incidence rate was 0.7 for 100 patient-days in

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patients hospitalised in single-occupancy rooms (N=9) and 2.0 for 100 patient-days in patients

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hospitalised in double-occupancy rooms (N=11) (p=0.028). Influenza vaccination coverage

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was not different between patients in single and double-occupancy rooms (47% vs 62%;

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p=0.16).

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The HAI probability was higher among patients hospitalised in double-occupancy rooms

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compared to those in single-occupancy rooms (Figure 1). Univariate analysis indicated that

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hospitalisation in double-occupancy rooms increased HAI risk by 2.69 (95% CI: 1.07-6.79).

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Female gender (crude hazard ratio [cHR]=2.39, 95% CI: 0.86-6.64), age (cHR=1.00 per 1

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year, 95% CI: 0.98-1.02), being hospitalised outside a geriatric unit (cHR=1.59, 95% CI:

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0.64-3.93), influenza vaccination (cHR=0.81, 95% CI: 0.32-2.09), cardiac and/or respiratory

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underlying disease (cHR=0.62, 95% CI: 0.24-1.59) were not significantly associated with

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HAI risk. After adjustment for gender, the relative risk of HAI in patients was 2.67 (95% CI:

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1.05-6.76; p=0.039) in case of hospitalisation in double compared to single-occupancy rooms.

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DISCUSSION

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Higher HAI risk was detected among patients hospitalised in double-occupancy rooms

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compared to those in single-occupancy rooms, confirming that double-occupancy rooms

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contribute to the transmission of influenza, in acute-care hospitals. A previous study analysing

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contact patterns between individuals in Edouard Herriot Hospital [6] reported more frequent

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and longer contacts for patients hospitalised in double-occupancy rooms. This association was

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noted in other settings and for other micro-organisms, mostly transmitted by contact and

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relative risks of bacterial HA infections have been reported to be reduced by 58 to 82%

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among patients in single-occupancy rooms compared to those in multiple-occupancy rooms

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[7]. The added values of the study were a standardised prospective design carried out during

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9 influenza seasons and virological analysis conducted by the National Reference Center for

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Influenzae Viruses. The primary end-point was very specific to prevent misclassification bias.

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Moreover, HAI risk was ascertained by survival analysis that took duration of exposure into

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account [8].

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A lack of a standardised HAI definition might be discussed [9,10]. We undertook sensitivity

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analysis with different time interval between admission and symptoms onset. The association

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remained consistent for time interval of 24 and 72 hours, respectively (data not shown).

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Study limitations included possible residual confounding due to limited sample size and

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misclassification bias related to possible intra-unit room transfers preceding onset. Linkage

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between hospital architecture (including bed management) and the HA infection rate is not

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obvious because of their multifactorial nature [11]. Then, environmental factors including

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patient repartition in the unit should be considered.

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We observed higher HAI risk among patients hospitalised in double-occupancy rooms than

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those in single-occupancy rooms. In addition to being more appropriate for global patient care

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regarding privacy, rest, familial support, costs and confidentiality, single-occupancy rooms

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are reducing the risk of HA infections, including HA influenza [12,13].

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Author contributions

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Dr Vanhems had full access to all the data in the study and takes responsibility for the

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integrity of the data and the accuracy of the data analysis. Study concept and design:

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Vanhems, Lina. Acquisition of data: Munier, Regis, Morfin, Lina. Analysis and interpretation

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of data: Munier, Bénet, Vanhems. Drafting of the manuscript: Munier, Bénet, Vanhems.

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Critical revision of the manuscript for important intellectual content: Munier, Bénet, Regis,

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Lina, Morfin, Vanhems. Statistical analysis: Munier, Bénet. Obtained funding: Vanhems,

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Lina. Administrative, technical, and material support: Vanhems, Regis. Study supervision:

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Vanhems.

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Potential conflicts of interest

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Dr Vanhems received research grants from Sanofi MSD, Biomerieux, and ANIOS and

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consulting fees from GSK, and Biomerieux. Dr Lina belongs to the scientific council of the

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French Influenza Clinical Information Network (Groupe d’Expertise et d’Information sur la

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Grippe) and the European Scientific Working group on Influenza, he received congress and

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travel fees from Biomerieux. Munier, Bénet and Morfin had no conflict of interest.

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Funding

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This work was supported by a “Programme Hospitalier de Recherche Clinique (PHRC)

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Regional” from the French Ministry of Health and Sanofi Pasteur.

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Acknowledgements

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We would like to thank the healthcare workers from the participating units of Edouard Herriot

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Hospital.

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References

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11. Dettenkofer M, Seegers S, Antes G, Motschall E, Schumacher M, Daschner FD. Does the architecture of hospital facilities influence nosocomial infection rates? A systematic

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13. Glind I van de, Roode S de, Goossensen A. Do patients in hospitals benefit from single rooms? A literature review. Health Policy Amst Neth. 2007; 84(2-3):153–161.

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12. Detsky ME, Etchells E. Single-patient rooms for safe patient-centered hospitals. JAMA.

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Table 1. Patients’ characteristics and HAI incidence by stay in a single or double-

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occupancy room (2004-2014), Edouard Herriot University Hospital (Lyon, France) Patients in single

Patients in double

Total

room (N=51)

room (N=42)

32 (64%)

25 (60%)

0.66

57 (62%)

73.5 (21.8)

76.1 (17.7)

0.97

74.2 (19.9)

P (N=93)

Gender, female

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Patients’ characteristics

Medium (standard deviation)

0.57

31 (61%)

Medical

15 (29%)

10 (24%)

25 (27%)

Surgical

5 (10%)

7 (17%)

12 (13%)

36 (71%)

28 (67%)

0.68

64 (69%)

21 (47%)

23 (62%)

0.16

44 (54%)

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11

20

1 227

548

1 775

0.7 (0.4-1.4)

2.0 (1.1-3.6)

Cardiac and/or respiratory underlying diseases Influenza vaccination Confirmed HAIa

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Number

25 (60%)

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Geriatric

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Unit type

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Age, years

Cumulative patient-days at risk

56 (60%)

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Incidence rate (95% CI), for

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1.1 (0.7-1.7)

100 patient-days at risk 196

HAI: Hospital-acquired influenza

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a

Onset ≥48h and virologic confirmation

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Figure Legend.

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Figure 1. Probability of hospital-acquired influenza at Edouard Herriot University Hospital

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(Lyon, France) by stay in a single or double-occupancy room (2004-2014) (Kaplan-Meier

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survival curves).

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HAI: Hospital-acquired Influenza

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At admission (T0), no patient has influenza. The event is influenza acquisition confirmed

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virologically during hospital stay. Data are censored at patient discharge, death or at 50 days

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of follow-up. Survival curves were compared by the log-rank test.

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