- Email: [email protected]
Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India
Journal of Hospital Infection 86 (2014) 272e274 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India A. Kumar a, M. Biswal b, *, N. Dhaliwal a, R. Mahesh a, S.B. Appannanavar b, V. Gautam b, P. Ray b, A.K. Gupta a, N. Taneja b a b
Department of Hospital Administration, Postgraduate Institute of Medical Education and Research, Chandigarh, India Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
A R T I C L E
I N F O
Article history: Received 18 May 2012 Accepted 29 December 2013 Available online 18 February 2014 Keywords: Point prevalence Nosocomial infection Device use Antibiotic usage India
S U M M A R Y
Few hospitals in India perform regular surveillance for healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials. The aim of this study was to conduct two one-day point prevalence surveys of HAIs and use of indwelling devices and antimicrobials in a large 1800-bed tertiary care hospital in India. The overall prevalence of HAIs was 7%, and surgical site infections were the most common (33%). Indwelling devices were present in 497 (27%) patients, and 915 (50%) patients were receiving antimicrobials. This study helped to generate robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital. ª 2014 Published by Elsevier Ltd on behalf of the Healthcare Infection Society.
Introduction Surveillance of healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials is an important strategy to help reduce the incidence of HAIs and to promote appropriate device use and antimicrobial prescribing. The study hospital was a tertiary care hospital in north India, catering for six states and serving a population of approximately five million people. One-day point prevalence surveys were conducted in 2008 and 2011 to assess trends in the
* Corresponding author. Address: Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel.: þ91 172 2755151. E-mail address: [email protected] (M. Biswal).
prevalence of HAIs and to determine usage of indwelling devices and antimicrobials in the study hospital. To the authors’ knowledge, this is the first hospital-wide point prevalence study of HAIs from India.
Methods The hospital consists of five buildings housing the main hospital, the cardiac centre, the paediatric centre, the ophthalmology centre and the trauma centre with 1089, 208, 196, 243 and 100 beds, respectively. All adult (age >18 years) patients hospitalized for more than 48 h at 08.00 am on the survey days (09/05/2008 and 23/09/2011) were included in the study.
0195-6701/$ e see front matter ª 2014 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. http://dx.doi.org/10.1016/j.jhin.2013.12.010
Results In total, 1834 patients over 18 years of age (790 in 2008 and 1044 in 2011), admitted to 11 intensive care units (ICUs), six emergency wards and 26 general wards, were surveyed. Of these, 744, 558, 176, 182 and 174 patients had been admitted under surgical, medical, obstetrics and gynaecology, ICU and emergency services, respectively. Nine hundred and eighty (53%) patients were male. In total, 129 HAIs were identified in 125 patients, giving an overall prevalence of seven HAIs per 100 patients. Overall, SSIs (N ¼ 42, 33%) were the most common HAIs, followed by UTIs (N ¼ 34, 26%), pneumonia (N ¼ 31, 24%) and BSIs (N ¼ 22, 17%). Eighty-three (66%) of these patients were male. Overall, the prevalence of HAIs did not show a significant change (P > 0.05) between the two surveys. The HAI rate in ICUs increased from 17% to 32% over the three-year study period. Patients admitted to emergency wards (P < 0.05), ICUs (P < 0.05) and surgical wards (P < 0.05) were more likely to have an HAI than patients admitted to other wards. Table I shows the prevalence of various HAIs in 2008 and 2011.
273
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100 90 80 70 60 50 40 30 20 10 0
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The surveys were conducted by four teams, each of which comprised an infection control nurse, a senior doctor from hospital administration and a microbiologist. The team members visited patients and recorded the presence and types of HAIs using the standard definitions of the Centers for Disease Control and Prevention.1 Information on the following variables was collected for each patient: sex, current diagnosis, number of days of hospital stay, presence and number of indwelling devices, presence and site of HAI, microbiology culture report, antibiotics prescribed and reason for prescription. The following categories of HAIs were included in the study: surgical site infections (SSIs), hospital-acquired pneumonia, urinary tract infections (UTIs) and bloodstream infections (BSIs). Device-associated infections were measured, including ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTIs) and central-line-associated bloodstream infections (CLABSIs). All clinical specimens sent for microbiological culture were processed, and organisms were identified using standard methodologies.2 Statistical analyses were performed using Statistical Package for the Social Sciences Version 19.0 (SPSS Inc., Chicago, IL, USA). The prevalence of HAI was defined as the number of patients with HAI divided by the total number of patients surveyed. Chi-squared test with Yates’ correction was used to calculate differences between categorical variables. Continuous variables were summarized as medians and compared using the ManneWhitney U-test. A two-tailed P-value of <0.05 was considered to indicate statistical significance.
Percentage
A. Kumar et al. / Journal of Hospital Infection 86 (2014) 272e274
Figure 1. Device use in wards. Blue bars, obstetrics and gynaecology wards; purple bars, surgical wards; green bars, medical wards; red bars, intensive care units; orange bars, emergency wards.
Seven hundred and seventy-four indwelling devices were present in 497 (27%) patients (Figure 1). Device use was associated with the development of HAI (P < 0.05). Of the 129 HAIs, 40 (35%) matched the criteria for device-associated infection: 18 were VAP (18% of ventilated patients), 15 were CAUTIs (4% of patients with a urinary catheter) and nine were CLABSIs (15% of patients with a central venous catheter). A few ventilators were available for use in some of the general wards in addition to those in the ICUs. Sixty-seven (52%) of the 129 HAIs were confirmed microbiologically. Acinetobacter calcobaumannii (ACB) complex (N ¼ 16, 24%), Pseudomonas aeruginosa (N ¼ 10, 15%), Klebsiella pneumoniae (N ¼ 10, 15%), Escherichia coli (N ¼ 8, 12%) and Staphylococcus aureus (N ¼ 6, 9%) were the most common isolates. All six S. aureus isolates were resistant to meticillin. Resistance to three or more classes of drugs (multi-drug resistance) was exhibited by 93%, 83% and 50% strains of ACB complex, K. pneumoniae and P. aeruginosa, respectively. Nine hundred and fifteen (50%) patients surveyed were receiving 1359 antimicrobials. Antibiotic use increased significantly from 47% in 2008 to 52% in 2011(P < 0.05). Table I shows antibiotic use in the clinical specialties. The use of piperacillintazobactam, carbapenems and colistin increased significantly from 7% to 24%, from 3% to 7%, and from 0% to 2%, respectively (P < 0.05).
Discussion The overall prevalence of HAIs in the study hospital (7%) is similar to rates reported for other developing countries.3e5 Further surveys are being conducted in the study hospital in order to provide more robust data over time.
Table I Prevalence of healthcare-associated infections and antibiotic usage in 2008 and 2011 Total number of antibiotics (mean SD per patient)
No. (%) of infections Pneumonia
UTI
SSI
BSI
Emergency
ICU
Medical
O&G
Surgical
2008 18 (38.2) 8 (17) 21 (44.7) 4 (8.5) 52 (1.4 0.5) 64 (1.6 1.1) 131 (1.3 0.5) 55 (1.3 0.6) 205 (1.4 0.5) 2011 13 (16.7) 26 (33.3) 21 (27) 18 (23) 96 (1e3) 1.5 0.71 168 (1.7 0.8) 187 (1.5 0.6) 65 (1.5 0.6) 332 (1.6 0.6) P-value 0.09 0.02 0.46 <0.05 0.37 0.001 <0.001 <0.001 <0.001 UTI, urinary tract infection; SSI, surgical site infection; BSI, bloodstream infection; ICU, intensive care unit; O&G, obstetrics and gynaecology; SD, standard deviation.
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A. Kumar et al. / Journal of Hospital Infection 86 (2014) 272e274
Similar to reports from other developing countries, SSIs, UTIs and pneumonia were found to be the most common HAIs in the study hospital.3,6 As reported in other studies, the prevalence of HAIs in ICU patients (26%) was higher than the overall prevalence (7%).7 The HAI rate in ICUs almost doubled over the three-year study period, and this requires further investigation. Similar to studies from other developing countries, more multi-drug-resistant Gram-negative bacteria were reported from cultures than Gram-positive organisms.4,5 Approximately 75% of central lines were used in emergency wards and ICUs, while nearly 40% of all urinary catheters were present in surgical patients. Therefore, device usage and the management of devices should be further investigated in these patients as a future strategy. The increased use of piperacillintazobactam, carbapenems and glycopeptides in the study hospital resembles the situation in other healthcare settings worldwide.4,8 This study has a number of limitations. Firstly, only patients over 18 years of age were included. Studies on the prevalence of HAIs in paediatric hospitals have reported higher rates.9 Also, microbiological confirmation of HAI episodes was achieved in 52% of patients. In studies from other developing countries with a higher prevalence of HAIs, microbiological culture results were available for 70e80% of patients.10 Distinguishing between infection and colonization is not always straightforward, even when accepted definitions of HAI are used. Clinical samples from patients were not processed for the presence of viral pathogens. Finally, the two surveys were conducted in different months, and seasonal variation could have influenced the results of the surveys. Only two such surveys have been conducted to date, and the long-term and seasonal trends of HAI in the study hospital need to be investigated further. Despite these limitations, the current study provides robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital. Infection prevention bundles for indwelling devices and SSIs, bi-annual hand hygiene awareness programmes and antibiotic stewardship policies have been implemented in critical care areas to
address the problems highlighted by this study. The information generated by the point prevalence surveys has helped to formulate targeted infection prevention and control programmes for the study hospital. Conflict of interest statement None declared. Funding sources None.
References 1. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control 1988;16: 128e140. 2. Collee JG, Marr W. Culture of bacteria. In: Collee JG, Fraser GF, Marmion BP, Simmons A, editors. Mackie and McCartney practical medical microbiology. London: Churchill Livingstone; 2003. 3. Razine RA, Azzouzi A, Barkat I, et al. Prevalence of hospitalacquired infections in the university medical center of Rabat, Morocco. Int Arch Med 2012;5:26. 4. Thu TA, Hung NV, Quang NN, et al. A point-prevalence study on healthcare-associated infections in Vietnam: public health implications. Infect Control Hosp Epidemiol 2011;32:1039e1041. 5. Xie DS, Xiong W, Xiang LL, et al. Point prevalence surveys of healthcare-associated infection in 13 hospitals in Hubei Province, China, 2007e2008. J Hosp Infect 2010;76:150e155. 6. Greco D, Magombe I. 2011. Hospital acquired infections in a large north Ugandan hospital. J Prev Med Hyg 2011;52:55e58. 7. Gravel D, Taylor G, Ofner M, et al. Point prevalence survey for healthcare-associated infections within Canadian adult acute-care hospitals. J Hosp Infect 2007;66:243e248. 8. Robert JY, Pean E, Varon J, et al. Point prevalence survey of antibiotic use in French hospitals in 2009. J Antimicrob Chemother 2012;67:1020e1026. 9. Signorelli C, D’Alessandro D, Collina D, Fara GM. Prevalence survey of nosocomial infections in a paediatric hospital. J Hosp Infect 1991;18:139e143. 10. Nicholls TM, Morris AJ. Nosocomial infection in Auckland healthcare hospitals. N Z Med J 1997;110:314e316.
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India A. Kumar a, M. Biswal b, *, N. Dhaliwal a, R. Mahesh a, S.B. Appannanavar b, V. Gautam b, P. Ray b, A.K. Gupta a, N. Taneja b a b
Department of Hospital Administration, Postgraduate Institute of Medical Education and Research, Chandigarh, India Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
A R T I C L E
I N F O
Article history: Received 18 May 2012 Accepted 29 December 2013 Available online 18 February 2014 Keywords: Point prevalence Nosocomial infection Device use Antibiotic usage India
S U M M A R Y
Few hospitals in India perform regular surveillance for healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials. The aim of this study was to conduct two one-day point prevalence surveys of HAIs and use of indwelling devices and antimicrobials in a large 1800-bed tertiary care hospital in India. The overall prevalence of HAIs was 7%, and surgical site infections were the most common (33%). Indwelling devices were present in 497 (27%) patients, and 915 (50%) patients were receiving antimicrobials. This study helped to generate robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital. ª 2014 Published by Elsevier Ltd on behalf of the Healthcare Infection Society.
Introduction Surveillance of healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials is an important strategy to help reduce the incidence of HAIs and to promote appropriate device use and antimicrobial prescribing. The study hospital was a tertiary care hospital in north India, catering for six states and serving a population of approximately five million people. One-day point prevalence surveys were conducted in 2008 and 2011 to assess trends in the
* Corresponding author. Address: Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel.: þ91 172 2755151. E-mail address: [email protected] (M. Biswal).
prevalence of HAIs and to determine usage of indwelling devices and antimicrobials in the study hospital. To the authors’ knowledge, this is the first hospital-wide point prevalence study of HAIs from India.
Methods The hospital consists of five buildings housing the main hospital, the cardiac centre, the paediatric centre, the ophthalmology centre and the trauma centre with 1089, 208, 196, 243 and 100 beds, respectively. All adult (age >18 years) patients hospitalized for more than 48 h at 08.00 am on the survey days (09/05/2008 and 23/09/2011) were included in the study.
0195-6701/$ e see front matter ª 2014 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. http://dx.doi.org/10.1016/j.jhin.2013.12.010
Results In total, 1834 patients over 18 years of age (790 in 2008 and 1044 in 2011), admitted to 11 intensive care units (ICUs), six emergency wards and 26 general wards, were surveyed. Of these, 744, 558, 176, 182 and 174 patients had been admitted under surgical, medical, obstetrics and gynaecology, ICU and emergency services, respectively. Nine hundred and eighty (53%) patients were male. In total, 129 HAIs were identified in 125 patients, giving an overall prevalence of seven HAIs per 100 patients. Overall, SSIs (N ¼ 42, 33%) were the most common HAIs, followed by UTIs (N ¼ 34, 26%), pneumonia (N ¼ 31, 24%) and BSIs (N ¼ 22, 17%). Eighty-three (66%) of these patients were male. Overall, the prevalence of HAIs did not show a significant change (P > 0.05) between the two surveys. The HAI rate in ICUs increased from 17% to 32% over the three-year study period. Patients admitted to emergency wards (P < 0.05), ICUs (P < 0.05) and surgical wards (P < 0.05) were more likely to have an HAI than patients admitted to other wards. Table I shows the prevalence of various HAIs in 2008 and 2011.
273
e
e
as
in ll ra
N
as
og
nt
tri
ea ch tra
do En
Ce
ct
ub lt
et th ca y ar
ub
e
er
100 90 80 70 60 50 40 30 20 10 0
rin U
The surveys were conducted by four teams, each of which comprised an infection control nurse, a senior doctor from hospital administration and a microbiologist. The team members visited patients and recorded the presence and types of HAIs using the standard definitions of the Centers for Disease Control and Prevention.1 Information on the following variables was collected for each patient: sex, current diagnosis, number of days of hospital stay, presence and number of indwelling devices, presence and site of HAI, microbiology culture report, antibiotics prescribed and reason for prescription. The following categories of HAIs were included in the study: surgical site infections (SSIs), hospital-acquired pneumonia, urinary tract infections (UTIs) and bloodstream infections (BSIs). Device-associated infections were measured, including ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTIs) and central-line-associated bloodstream infections (CLABSIs). All clinical specimens sent for microbiological culture were processed, and organisms were identified using standard methodologies.2 Statistical analyses were performed using Statistical Package for the Social Sciences Version 19.0 (SPSS Inc., Chicago, IL, USA). The prevalence of HAI was defined as the number of patients with HAI divided by the total number of patients surveyed. Chi-squared test with Yates’ correction was used to calculate differences between categorical variables. Continuous variables were summarized as medians and compared using the ManneWhitney U-test. A two-tailed P-value of <0.05 was considered to indicate statistical significance.
Percentage
A. Kumar et al. / Journal of Hospital Infection 86 (2014) 272e274
Figure 1. Device use in wards. Blue bars, obstetrics and gynaecology wards; purple bars, surgical wards; green bars, medical wards; red bars, intensive care units; orange bars, emergency wards.
Seven hundred and seventy-four indwelling devices were present in 497 (27%) patients (Figure 1). Device use was associated with the development of HAI (P < 0.05). Of the 129 HAIs, 40 (35%) matched the criteria for device-associated infection: 18 were VAP (18% of ventilated patients), 15 were CAUTIs (4% of patients with a urinary catheter) and nine were CLABSIs (15% of patients with a central venous catheter). A few ventilators were available for use in some of the general wards in addition to those in the ICUs. Sixty-seven (52%) of the 129 HAIs were confirmed microbiologically. Acinetobacter calcobaumannii (ACB) complex (N ¼ 16, 24%), Pseudomonas aeruginosa (N ¼ 10, 15%), Klebsiella pneumoniae (N ¼ 10, 15%), Escherichia coli (N ¼ 8, 12%) and Staphylococcus aureus (N ¼ 6, 9%) were the most common isolates. All six S. aureus isolates were resistant to meticillin. Resistance to three or more classes of drugs (multi-drug resistance) was exhibited by 93%, 83% and 50% strains of ACB complex, K. pneumoniae and P. aeruginosa, respectively. Nine hundred and fifteen (50%) patients surveyed were receiving 1359 antimicrobials. Antibiotic use increased significantly from 47% in 2008 to 52% in 2011(P < 0.05). Table I shows antibiotic use in the clinical specialties. The use of piperacillintazobactam, carbapenems and colistin increased significantly from 7% to 24%, from 3% to 7%, and from 0% to 2%, respectively (P < 0.05).
Discussion The overall prevalence of HAIs in the study hospital (7%) is similar to rates reported for other developing countries.3e5 Further surveys are being conducted in the study hospital in order to provide more robust data over time.
Table I Prevalence of healthcare-associated infections and antibiotic usage in 2008 and 2011 Total number of antibiotics (mean SD per patient)
No. (%) of infections Pneumonia
UTI
SSI
BSI
Emergency
ICU
Medical
O&G
Surgical
2008 18 (38.2) 8 (17) 21 (44.7) 4 (8.5) 52 (1.4 0.5) 64 (1.6 1.1) 131 (1.3 0.5) 55 (1.3 0.6) 205 (1.4 0.5) 2011 13 (16.7) 26 (33.3) 21 (27) 18 (23) 96 (1e3) 1.5 0.71 168 (1.7 0.8) 187 (1.5 0.6) 65 (1.5 0.6) 332 (1.6 0.6) P-value 0.09 0.02 0.46 <0.05 0.37 0.001 <0.001 <0.001 <0.001 UTI, urinary tract infection; SSI, surgical site infection; BSI, bloodstream infection; ICU, intensive care unit; O&G, obstetrics and gynaecology; SD, standard deviation.
274
A. Kumar et al. / Journal of Hospital Infection 86 (2014) 272e274
Similar to reports from other developing countries, SSIs, UTIs and pneumonia were found to be the most common HAIs in the study hospital.3,6 As reported in other studies, the prevalence of HAIs in ICU patients (26%) was higher than the overall prevalence (7%).7 The HAI rate in ICUs almost doubled over the three-year study period, and this requires further investigation. Similar to studies from other developing countries, more multi-drug-resistant Gram-negative bacteria were reported from cultures than Gram-positive organisms.4,5 Approximately 75% of central lines were used in emergency wards and ICUs, while nearly 40% of all urinary catheters were present in surgical patients. Therefore, device usage and the management of devices should be further investigated in these patients as a future strategy. The increased use of piperacillintazobactam, carbapenems and glycopeptides in the study hospital resembles the situation in other healthcare settings worldwide.4,8 This study has a number of limitations. Firstly, only patients over 18 years of age were included. Studies on the prevalence of HAIs in paediatric hospitals have reported higher rates.9 Also, microbiological confirmation of HAI episodes was achieved in 52% of patients. In studies from other developing countries with a higher prevalence of HAIs, microbiological culture results were available for 70e80% of patients.10 Distinguishing between infection and colonization is not always straightforward, even when accepted definitions of HAI are used. Clinical samples from patients were not processed for the presence of viral pathogens. Finally, the two surveys were conducted in different months, and seasonal variation could have influenced the results of the surveys. Only two such surveys have been conducted to date, and the long-term and seasonal trends of HAI in the study hospital need to be investigated further. Despite these limitations, the current study provides robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital. Infection prevention bundles for indwelling devices and SSIs, bi-annual hand hygiene awareness programmes and antibiotic stewardship policies have been implemented in critical care areas to
address the problems highlighted by this study. The information generated by the point prevalence surveys has helped to formulate targeted infection prevention and control programmes for the study hospital. Conflict of interest statement None declared. Funding sources None.
References 1. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control 1988;16: 128e140. 2. Collee JG, Marr W. Culture of bacteria. In: Collee JG, Fraser GF, Marmion BP, Simmons A, editors. Mackie and McCartney practical medical microbiology. London: Churchill Livingstone; 2003. 3. Razine RA, Azzouzi A, Barkat I, et al. Prevalence of hospitalacquired infections in the university medical center of Rabat, Morocco. Int Arch Med 2012;5:26. 4. Thu TA, Hung NV, Quang NN, et al. A point-prevalence study on healthcare-associated infections in Vietnam: public health implications. Infect Control Hosp Epidemiol 2011;32:1039e1041. 5. Xie DS, Xiong W, Xiang LL, et al. Point prevalence surveys of healthcare-associated infection in 13 hospitals in Hubei Province, China, 2007e2008. J Hosp Infect 2010;76:150e155. 6. Greco D, Magombe I. 2011. Hospital acquired infections in a large north Ugandan hospital. J Prev Med Hyg 2011;52:55e58. 7. Gravel D, Taylor G, Ofner M, et al. Point prevalence survey for healthcare-associated infections within Canadian adult acute-care hospitals. J Hosp Infect 2007;66:243e248. 8. Robert JY, Pean E, Varon J, et al. Point prevalence survey of antibiotic use in French hospitals in 2009. J Antimicrob Chemother 2012;67:1020e1026. 9. Signorelli C, D’Alessandro D, Collina D, Fara GM. Prevalence survey of nosocomial infections in a paediatric hospital. J Hosp Infect 1991;18:139e143. 10. Nicholls TM, Morris AJ. Nosocomial infection in Auckland healthcare hospitals. N Z Med J 1997;110:314e316.