Prevalence of healthcare-associated infections and antimicrobial use in China: Results from the 2018 point prevalence survey in 189 hospitals in Guangdong Province

Journal Pre-proof Prevalence of healthcare-associated infections and antimicrobial use in China: results from the 2018 point prevalence survey in 189 hospitals in Guangdong province Yu Zhang, Zhen-Feng Zhong, Shu-Xian Chen, Dian-Rong Zhou, Zheng-Kang Li, Yue Meng, Jing-Fang Zhou, Tie-Ying Hou

PII:

S1201-9712(19)30383-2

DOI:

https://doi.org/10.1016/j.ijid.2019.09.021

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International Journal of Infectious Diseases

Received Date:

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Revised Date:

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Accepted Date:

25 September 2019

Please cite this article as: Zhang Y, Zhong Z-Feng, Chen S-Xian, Zhou D-Rong, Li Z-Kang, Meng Y, Zhou J-Fang, Hou T-Ying, Prevalence of healthcare-associated infections and antimicrobial use in China: results from the 2018 point prevalence survey in 189 hospitals in Guangdong province, International Journal of Infectious Diseases (2019), doi: https://doi.org/10.1016/j.ijid.2019.09.021

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Prevalence of healthcare-associated infections and antimicrobial use in China: results from the 2018 point prevalence survey in 189 hospitals in Guangdong province Yu Zhang1, 4; Zhen-Feng Zhong2, 4; Shu-Xian Chen3, 4; Dian-Rong Zhou1, 4; Zheng-Kang Li1;Yue Meng1;Jing-Fang Zhou1; Tie-Ying Hou1, 4. Authors’ affiliations:

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1. Department of Laboratory, Guangdong Provincial People’s Hospital & Guangdong Academy of Medicine Sciences, Guangzhou, China.

2. Department of Infection Prevention and Control, Guangdong Zhongshan City

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People's Hospital, Zhongshan, China.

Hospital, Guangzhou, China.

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3. Department of Infection Prevention and Control, Guangzhou First People's

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4. Guangdong Nosocomial Infection Control and Quality Improvement Centre,

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China Corresponding author:

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Tie-Ying Hou, MPH, Laboratory Department, Guangdong Provincial People’s Hospital & Guangdong Academy of Medicine Sciences, Guangzhou 510000, China.

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(No.106, 2nd Zhongshan Road, Yuexiu District, Guangzhou, 510000, China; Phone: +86-20-83827812, Fax: +86-20-83852765, E-mail: [email protected])

Highlights  A low prevalence of HAI but high antimicrobial using was observed in Guangdong, China.  The overall VAP rate was more than 2-fold higher than that reported in the USA. 1

 

The pooled rate of CAUTI was nearly 2 times higher than that reported from the USA. The rate of inpatients antibiotic prescribing was significantly higher than Europe.

Running head: Prevalence of healthcare-associated infections and antimicrobial use in Guangdong, China.

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Abstract Background: Few data about healthcare-associated infection (HAI) is available from

the developing world, thus we conducted a point prevalence survey (PPS) to

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determine the prevalence of HAI and antimicrobial use (AMU) in Guangdong province, China. Methods: A standardized methodology for PPS on HAIs and AMU

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has been developed by Chinese Nosocomial Infection Control and Quality

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Improvement Centre. Prevalence of HAI, AMU and baseline hospital-level variables were collected in 189 hospitals from June 2017 to May 2018. Results: Of 5,868,147

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patients, 72,976 had one or more HAIs (1.24%) with distinct 82,700 HAIs. The prevalence of device-associated infections, including ventilator-associated pneumonia,

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catheter-associated urinary tract infection and central-line-associated bloodstream

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infection were 7.92, 2.06 and 0.63 per 1,000 catheter days, respectively. 10,591(0.18%)

HAIs

caused

by

MDROs

were

identified.

Carbapenem

nonsusceptibility rates were highest in Acinetobacter species (53.86%) and P. aeruginosa (21.60%). 46.22% (2,712,258/5,868,147) of inpatients were receiving at least one antimicrobial during this survey. Conclusions: Our survey indicated the relatively lower prevalence of HAI but higher antimicrobial using in Guangdong 2

province compared with other mid-low income and high-income countries. Further studies are warranted to elucidate which HAI-related indicators are the best measures of HAI performance and thus allow improvements leading to better patient outcomes.

Keywords: Healthcare-associated infection; Point-prevalence survey; Antimicrobial use;

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Multidrug-resistant organism; China

Introduction

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Healthcare-associated infection (HAI) is recognized as the most frequent adverse

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event threatening patients’ safety worldwide and could result in prolonged hospital stay, increased costs for patients and excess deaths [1]. Of additional concern, HAIs

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caused by multidrug resistant organisms (MDROs) deserve special attention in

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healthcare facilities because the antimicrobial drugs were extremely limited and the high risk of death was observed among patients with these infections[2]. It has been

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demonstrated that increasing antimicrobial resistance was associated with inappropriate antimicrobial consumption, suggesting that restricting inappropriate

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antimicrobial prescribes may curb the development of antimicrobial resistance[3,4]. The establishment of priorities and strategies for HAIs prevention depends on a comprehensive understanding of the epidemiology of HAIs. The surveillance of such infections has been proved, increasingly, to be effective for both estimate the burden and prioritize strategies for the prevention of HAIs[5-7]. A variety of surveillance 3

strategies exist for enumerating HAIs and to evaluate the impact of control interventions. Prospective longitudinal surveillance is considered the gold standard method, but such studies are resource-intensive and require a significant number of trained personnel[8]. Point prevalence surveys (PPSs), meanwhile, are a practical alternative which need fewer resources and can provide a valuable in-depth snapshot of the burden and epidemiological information of HAIs[9]. The Chinese National

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Healthcare Associated Infection Surveillance System (NHAISS) has conducted

regular HAI PPSs since 2001 using standardized national HAI definitions to allow geographical and prospective comparisons[10]. In addition, local and regional PPSs

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peer-reviewed journals and in English[11-14].

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were also performed in China; however, quite a few of them have been published in

It is difficult to interpret the rates of HAIs due to the huge discrepancy in the

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socio-economy or the Gross Domestic Product (GDP) between different provinces or

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regions in China. Guangdong, one of the largest provinces in China, is located in the southernmost part of the country, whose economy reaches the top spot in China and

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reach the level of middle-income countries[15]. Notably, the Chinese government has made huge efforts to the management of AMU in recent years. In 2011, coupled with

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new healthcare reforms, the National Health Commission of the People’s Republic of China (NHCPC; formerly the Chinese Ministry of Health) changed strategy and launched a special campaign to promote the rational use of antimicrobials in healthcare settings. This mainly consisted of establishing mandatory management strategies, such as target setting, taskforce organization, and the development of audit 4

and inspection systems[16]. Besides, ‘Guidelines for clinical application of antibiotics’ was issued by NHCPC in 2005, and thoroughly explained the basic principles of antibacterial drug use and preventive use, respectively[17]. These measures had positive effect on reducing irrational use of antimicrobial agent which had be described through some previous studies[16,18,19]. However, accurate estimates of the burden of HAIs and antimicrobial use (AMU) in Guangdong province are not

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available to date.

To clarify the knowledge gap in the local epidemiology of HAIs and establish

priorities and strategies for HAI prevention and appropriate antimicrobial use,

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Guangdong Nosocomial Infection Control and Quality Improvement Centre (GNICC)

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has conducted yearly PPS in all secondary and tertiary care hospitals of the province since 2017. The objectives of this report are to determine the (1) prevalence of HAI,

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(2) prevalence of AMU among inpatients, (3) prevalence of HAIs caused by MDROs

Methods

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and antimicrobial resistance in Guangdong province.

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Study design and hospital selection A single-day cross sectional design was used in our study. According to ‘Hospital

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Grading Management Regulations’ issued by Chinese Ministry of Health in 1989, the medical institutions in China were categorized into primary hospitals, secondary or second class hospitals and tertiary or third class hospitals by size, medical facilities, technology, service quality, and scientific research level, which primary and secondary hospitals were expected to provide basic healthcare services, while tertiary 5

hospitals are referral centers for specialist care with medical teaching and research. All of the 244 secondary and tertiary hospitals in Guangdong province, including private and public settings that were expected to participate in this survey, and finally 189 hospitals (77.5%) submitted data to our center between March 2018 and May 2018. The rest hospitals failed to enroll in this survey due to various reasons, such as unable to obtain sufficient administrative support, yet to carry out the surveillance or

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conflict with other surveillance programs. Patients’ selection and definitions

Inpatients of any age in participating hospitals were eligible for inclusion, and the

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survey included all inpatients at the hospital at 0:00 h on the survey date and patients

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who were discharged on the same day. Patients in outpatient areas, emergency departments, and psychiatry, and rehabilitation units, and those who were admitted for

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census on the survey date.

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less than 48h were excluded. All the eligible patients were obtained from the morning

The definitions employed in the PPS were based on the definition criteria established

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by NHCPC in 2001[20], which is a modified translation of the US Center for Disease Control and Prevention (CDC) definitions for HAIs[21]. Infections were categorized

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into respiratory tract infection (RTI), urinary tract infection (UTI), bloodstream infection (BSI), surgical site infection (SSI), gastrointestinal tract infection (GTI), skin and soft tissue infection (STI) and other infections including parotitis, chickenpox, nervous system infections and deep organ infections[20] . In addition, device-associated HAIs (DA-HAIs), i.e. catheter-associated urinary tract infection 6

(CAUTI),

central-line-associated

bloodstream

infection

(CLABSI),

ventilator-associated pneumonia (VAP), and surgical site infection (SSI) were particularly evaluated in this survey. AMU was defined as (1) the presence of any systemic antibiotic or antifungal surgical prophylaxis within a 24-hour period before the survey date, or (2) the presence of any systemic antibiotic or antifungal medication on the survey date.

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Training and data collection

Patient information was collected on standardized case-related forms provided by “Quality Control Indicators of Hospital Infection Management (2015 edition)”issued

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by NHCPC[22]. A web-based software system for data collection has been developed

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before the initiation of the survey. All the data collectors from the participating hospitals were trained in data collection and using of the software though a video

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describing the survey methods and the process of submitting data precisely. The

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hospitals submitted summary data to the GNICC and to the National Clinical Improvement System (CLIS). GNICC is affiliated to Guangdong provincial people's

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hospital and managed by the Guangdong Provincial Health Commission. The mission of GNICC is to monitor and improve the quality control of nosocomial infection

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across the whole province, including nosocomial infection surveillance, training and outbreak investigation and treatment, etc. The National Clinical Improvement System (CLIS), which was developed by NHCPC and aimed to improve the quality of clinical services in China, has proposed in 2016 that the total burden of HAIs should be measured regularly and in a standardized manner throughout the country. In addition, 7

antimicrobial use was documented for the survey day. For antimicrobial use, the rates of inpatients antibiotic prescribing, antibiotic prophylaxis in Class I wound surgery and microbiological culture before use of antimicrobial drugs for treatment purpose should be collected respectively to monitor the quality of antibiotic management according to the ‘National Program of Antimicrobial Drug Clinical Application Special Rectification Activities’ proposed by NHCPC in 2013[23]. Hand hygiene (HH)

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compliance was assessed by measuring the frequency on which HH was performed according to the World Health Organization (WHO) “Five Moments for Hand

Hygiene”[24]. Direct observation was performed by health care workers (HCWs)

Enterococcus

Staphylococcus

faecium,

aureus

(MRSA),

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methicillin-resistant

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after training and consensus development. Seven types of MDRO HAIs, including

vancomycin-resistant

vancomycin-resistant

Enterococcus

faecalis,

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Carbapenem-resistant Escherichia coli, Carbapenem-resistant Klebsiella pneumoniae,

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multidrug-resistant Acinetobacter baumannii and multidrug-resistant Pseudomonas aeruginosa, were assessed in this survey. This survey was part of a mandated quality

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improvement initiative and did not require ethical approval. Data analysis

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Statistical analysis was performed by SPSS, version 19.0 (IBM, USA). The prevalence of HAIs and AMU was reported as the percentage of patients with at least one HAI or receiving at least one antimicrobial agent among the total number of patients, respectively. The prevalence of SSI was described as the number of SSIs per 100 inpatients who underwent a surgical procedure. However, we did not record 8

aspects of the surgical procedure due to lack of resources. Differences in prevalence of HAI in different hospitals were determined. Significance was established at P < 0.05 (two-tailed). Results Hospitals and patients 189 hospitals with 5,868,147 patients were finally enrolled in this survey. In total, 27

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secondary private hospitals, 85secondary public hospitals, 13 tertiary private hospitals

and 64 tertiary public hospitals assessed a total of 147,934, 1,719,656, 302,986and

3,697,571patients, respectively. A large proportion (63.01%) of patients were

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distributed in tertiary public hospitals, disproportion with the ratio of corresponding

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hospitals (33.86%) included (Table S1). Prevalence of HAIs

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Table 1 summarizes the overall HAIs prevalence among different hospitals classified

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by grade and size. In the 5,868,147 patients, 82,700 HAIs were reported from72,976 patients. The pooled HAIs prevalence was 1.24% (72,976/5,868,147) and the overall

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frequency of HAIs was 1.41% (82,700/5,868,147). Tertiary public hospitals (1.51%, 55,932/3,697,571) had the highest rate, and the HAIs prevalence in tertiary private

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care, secondary public care and secondary private care were 0.97% (2,943/302,986), 0.79% (13,617/1,719,656) and 0.33% (484/147,934), respectively, which differed significantly from each other (2 = 6231.835, P = 0.000). There was an increasing trend of HAIs prevalence, in general, with the increase of beds. The rate of HAIs in hospitals with more than 1000 beds was 1.58%, which was 9

higher than that in hospitals with 501-1000 beds (1.08%), hospitals with less than 300 beds (0.63%), and hospitals with 301-500 beds (0.59%). Table 2 summarizes the incidence of class I wound surgical site infection (SSI) and the prevalence of device-associated HAIs. The pooled incidence of SSI in Class I wound surgery was 0.33 per 100 patients, and no obvious variation was observed among

hospitals.

The

rates

of

device-associated

infections,

including

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Ventilator-associated pneumonia (VAP), Catheter-associated urinary tract infection

(CAUTI) and Central-line–associated bloodstream infection (CLABSI) were 7.92, 2.06 and 0.63 per 1,000 catheter days, respectively.

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Hand hygiene (HH) compliance and antimicrobial use

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Table 3 summarizes the HH compliance and the use of antimicrobial drugs. The overall HH compliance was 74.60%. In general, the public hospitals had higher rates

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of HH compliance (78.87% in secondary public care and 74.48% in tertiary public

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care, respectively) than the private hospitals (45.01% in secondary public care and 56.88% in tertiary public care, respectively).

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Three indicators, including the rate of inpatients antibiotic prescribing, rate of antibiotic prophylaxis in Class I wound surgery and submission rate of the specimen

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before therapeutic use of antibiotics, were applied to monitor the quality of antibiotic management[22]. Approximately 46.22% of patients (2,712,258/5,868,147)were receiving at least one antimicrobial agent during the survey. Moreover, of the 2,712,258 patients on antimicrobials for therapeutic purposes, a total of 1,216,176 (44.84%) patients conducted microbiology testing before using antimicrobial agents. 10

The overall rate of antibiotic prophylaxis in Class I wound surgery was 33.90%, and the tertiary private hospitals had the lowest rate of antibiotic prophylaxis in Class I wound surgery comparing with the others. Prevalence of MDRO infections and Antimicrobial Resistance A total of 10,591 MDRO HAIs were identified in 5,868,147 patients, and the pooled prevalence of MDROs was 0.18%. Prevalence of MDROs varies by healthcare setting

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(Table 4). Carbapenem-resistant Acinetobacter baumannii was the most prevalent

MDRO, causing 3862 HAIs (0.066%), followed by Carbapenem-resistant Pseudomonas aeruginosa (2421 HAIs, 0.041%), MRSA (2397 HAIs, 0.041%), Klebsiella

pneumoniae

(887

HAIs,

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Carbapenem-resistant

0.015%),

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Carbapenem-resistant Escherichia coli (810 HAIs, 0.014%), vancomycin-resistant Enterococcus faecium (136 HAIs, 0.002%) and vancomycin-resistant Enterococcus

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faecalis (78 HAIs, 0.001%).

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Overall, 32.74% of all Staphylococcus aureus were not susceptible to methicillin. Nonsusceptibility to carbapenems was present in 2.87% of all Escherichia coli, 5.15%

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of all Klebsiella pneumoniae, 53.86% of all Acinetobacter baumannii and 21.60% of all Pseudomonas aeruginosa, respectively. The rates of vancomycin resistance for

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Enterococcus faecalis and Enterococcus faecium were 0.52% and 3.68%, respectively (Table 5).

Discussion This study described the 2017-2018 point prevalence estimates for HAIs and antimicrobial use, which is one of the largest HAI PPS in the People’s Republic of 11

China. In our survey, 1.24% of inpatients in Guangdong had at least one HAI. The overall prevalence of HAIs was lower than previous Chinese reports from Hubei province (3.88%) conducted in 2007-2008[13], Guizhou province (2.41%) in 2014[25] and Beijing city (2.10%) in 2014[12]. It is arduous to draw conclusions from these comparisons considering the disparities in case mix, including severity, comorbidities and length of stay. The survey period could be another reason, because the later the

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study was conducted, the lower the prevalence of HAIs could be due to a series of

management and intervention measures that have been carried out in China. The differences in data collection could also contribute to the disparities in the prevalence

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of HAIs. Moreover, the imbalance of socio-economic development between provinces

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and even the cities within the province could also impact the differences in the prevalence of HAIs. Since Guangdong province is one of the most developed regions

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in China, the prevalence of HAIs in this survey was lower than other less developed

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areas reported from previous studies due to the relatively high investment in healthcare resources[15,26]. Besides, our study found the HAIs prevalence of tertiary

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care settings, including private and public hospitals, was higher than that of secondary private and public care settings respectively, similar to the findings from the other two

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surveys in China[11,25]. The factors attributed to the variation of HAIs rates between different hospitals were complicated. In China, tertiary hospitals, especially the public care settings, have better medical circumstances and armamentariums than the secondary hospitals, and the staffs in the tertiary hospitals, in general, have higher educational qualifications and better skills, which provided advantages in preventing 12

HAIs. Whereas, the patients admitted to tertiary hospitals were usually more severe, by other words more susceptible to healthcare-associated infections, than secondary hospitals, which could result in high HAIs rate in tertiary hospitals. Moreover, the low level of information-based surveillance of nosocomial infections in secondary hospitals, to some extent, could also lead to low reporting rate of HAIs. Therefore, it is necessary for the government to invest more funds for the secondary or primary and improve the abilities in

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hospitals, to upgrade the armamentariums information-based HAIs surveillance.

Device-associated healthcare associated infections (DA-HAIs) have long been a

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major focus of HAIs prevention in developing countries as they are mainly considered

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preventable[27]. In this survey, the overall VAP rate was more than 2-fold higher than that reported in the U.S. (7.92 vs. 1.1/1,000 catheter days). Similarly, the pooled rate

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of CAUTI (2.06/1,000 catheter days) was nearly 2 times higher than that 1.30/1,000

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catheter days reported from the USA. In contrast, the overall CLABSI rate (0.63/1,000 catheter days) was lower than the rate reported from the USA (0.90/1,000

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catheter days)[28]. Previous studies have implied that a country‘s higher socioeconomic level (defined as low income, mid-low income and high income) was

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correlated with lower infection risk[29]. Our high VAP and CAUTI rates compared with the U.S. could be explained, to a great extent, by the fact that China was like most mid-low income countries with limited-resource invested in healthcare settings[30]. It has been reported that low nurse-to-patients staffing ratios were closely related to high HAIs rates because of hospital overcrowding, lack of medical 13

supplies and an insufficient number of experienced nurses or trained health care works[31,32]. Besides, there are still no legally enforceable regulations for the implementation of infection control programs in China, and even though there were infection control programs conducted by the academic organization, only a small amount of hospitals are involved. Noticeably, the device use ratio is an extrinsic risk factor for DA-HAI and also a marker for the severity of illness of patients and patients’

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susceptibility to DA-HAI[33], nevertheless, which was not available in our survey. In the other hand, the extremely low rate of CLABSI in this study was due to the low

portion of hospitals initiating CLABSI surveillance, 49 of 189 participated hospitals

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reported rate of CLABSI as 0.00%.

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The “Standards for nosocomial infection management” and “Management of clinical application of antibiotics”, which were issued by NHCPC, stated that the rate of SSI

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in Class I wound surgery should be less than 1% for hospitals with <100 beds, and

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less than 0.5% for those with ≥100 beds[34]; the inpatients antibiotic prescribing rate and antibiotic prophylaxis in Class I wound surgery rate should not exceed 60% and

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30%, respective, while the rate of microbiology testing before therapeutic use of antibiotics should not less than 30%[35]. In this survey, the rates of SSI in Class I

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wound surgery in different types of hospitals were all underneath that benchmark. The pooled rate of inpatients antibiotic prescribing (46.22%) was significantly higher compared to Europe (34.6%)[36], though it was in agreement with the standard in China. Moreover, we found the rates of inpatients antibiotic prescribing in tertiary and secondary private care settings were both higher than public hospitals, which may 14

warrant increased attention because the Chinese government paid more attention to the public care settings than private hospitals in the current situation[35], while it was necessary to monitor all kinds of hospitals to restrict inappropriate antimicrobial use and ultimately curb the development of antimicrobial resistance. All hospitals together and different types of hospitals, except for tertiary private care settings, were observed slight higher rates of antibiotic prophylaxis in Class I wound surgery than expected,

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which were similar to previous reports from China[25,37,38]. 44.84% of patients on

antimicrobials had microbiological testing in the context of its use, which was far more reached the expectation. In addition, we found the rates of microbiology testing

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before therapeutic use of antibiotics in secondary or tertiary public hospitals were

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higher than that in private settings, respectively. This is discouraging for private care

microbiological findings.

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settings because it allows potential adaptation of appropriate antimicrobials based on

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In our survey, more than 30% of all Staphylococcus aureus were non-susceptible to methicillin, which appeared to be decreasing locally in the past 5 years[39]. Likewise,

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the prevalence of carbapenems resistant Acinetobacter baumannii was 53.86%, showed a decreasing trend in the past 5 years. Notably, resistance to carbapenems

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among Enterobacteriaceae and resistance to vancomycin among Enterococci were both appeared to significantly increase during the past 5 years. To fight against these increasing resistance rates, hospital infection control and management of clinical use of antimicrobial agents in our local setting should be implemented[40]. There were several limitations should be acknowledged. First, infections not 15

associated with devices or operative procedures including Clostridium difficile infections and non-ventilator associated pneumonia, which have been reported accounting for a large part of all HAIs in the current studies[10,36,41] were not evaluated in this survey. Argue about which HAI-related indicators were the best measures of performance and thus the most appropriate for public reporting has been continued in these years[42,43]. Relevant examples include device associated

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infections, surgical prophylaxis and surgical site infections[44-46]. Nevertheless, expanding surveillance on other HAIs should also be taken into consideration as the

declination of device- and procedure-associated HAIs has been reported[41]. Second,

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we were unable to validate the collected data across the 189 hospitals which might

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deteriorate the quality of this study. Third, we had no access to collecting the information about whether the hospitals were using any approaches (Bundles) or

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antibiotic stewardship program for the prevention of HAIs or MDROs, and the patient

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nurse ratio, patient doctor ratio across hospitals, which were crucial for the comparison of HAIs prevalence between different hospitals.

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As far as we know, this survey is to date one of the largest PPSs from China. Our survey provided an insight into the burden of HAIs and antimicrobial use in

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Guangdong province and could serve as benchmarks for future PPSs. However, repeated PPSs are needed to better understand the trends in the epidemiology of HAIs and highlight the priority areas and targets for quality improvement. In addition, there is also a need for further studies concerning which performance indicators should be chosen to be assessed to improve the quality of health care and to facilitate 16

benchmarking among regions or countries.

Funding: Science and Technology Planning Project of Guangdong Province (2016A010103019)

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Conflict of interest: All authors report no conflicts of interest relevant to this article.

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Acknowledgements

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Table 1 Prevalence of all types of HAIs in Guangdong Province in 2018, by hospital grades Secondary private care

Secondary public care

pr

All hospitals

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Pr

e-

Prevalence of infected patients/100 1.24 0.33 patients, % Prevalence of HAIs/100 patients, % 1.41 0.34 Prevalence of HAIs by hospital size, % ≤300 beds 0.63 0.32 301-500 beds 0.59 0.38 501-1000 beds 1.08 0.26 ﹥1000 beds 1.58 NA Abbreviations: HAIs: healthcare-associated infections; NA: not available

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Tertiary private care

Tertiary public care

0.79

0.97

1.51

0.85

1.27

1.72

0.88 0.61 0.94 0.88

0.50 0.49 0.70 1.27

0.39 0.62 1.30 1.62

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Table 2 Rates of SSI in Class I wound surgery and device-associated HAIs in different hospitals.

0.33

0.40

2.06 0.63 7.92

1.25 0.94 0.92

Secondary public care

pr

Secondary private care

e-

Rate of SSI in Class I wound surgery, % Device-associated HAIs rate, ‰ CAUTI/1000 catheter days CLABSI /1000 catheter days VAP/1000 catheter days

All hospitals

Tertiary private care

Tertiary public care

0.30

0.33

0.34

2.41 0.64 9.82

3.60 0.87 15.09

1.96 0.61 7.52

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na l

Pr

Abbreviations: SSI: surgical site infection; CAUTI: catheter-associated urinary tract infection; CLABSI: central-line-associated bloodstream infection; VAP: ventilator-associated pneumonia

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Table 3 HH compliance and antibiotic management in different grades of hospital.

Tertiary private care 56.88 49.04

Tertiary public care 74.48 46.67

33.47

32.25

26.77

34.88

38.48

44.41

39.70

45.79

e-

pr

Secondary public care 78.87 44.42

44.84

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Abbreviations: HH: hand hygiene

33.90

Secondary private care 45.01 51.50

Pr

HH compliance, % Rate of inpatients antibiotic prescribing, % Rate of antibiotic prophylaxis in Class I wound surgery, % Rate of microbiology testing before therapeutic use of antibiotics, %

All hospitals 74.60 46.22

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Table 4 Targeted MDRO infection rates in different grades of hospital All patients(N = 5,868,147)

Secondary private care(N = 147,934)

Secondary public care(N = 1,719,656)

Tertiary private care(N = 302,986)

Tertiary public care(N = 3,697,571)

methicillin-resistant Staphylococcus aureus vancomycin-resistant Enterococcus faecalis vancomycin-resistant Enterococcus faecium Carbapenem-resistant Escherichia coli Carbapenem-resistant Klebsiella pneumoniae Carbapenem-resistant Acinetobacter baumannii Carbapenem-resistant Pseudomonas aeruginosa Total

2397(0.041%) 78(0.001%) 136(0.002%) 810(0.014%) 887(0.015%) 3862(0.066%) 2421(0.041%) 10591(0.180%)

80(0.054%) 2(0.001%) 2(0.001%) 15(0.010%) 7(0.005%) 6(0.004%) 3(0.002%) 115(0.078%)

378(0.022%) 29(0.002%) 76(0.004%) 155(0.009%) 143(0.008%) 217(0.013%) 145(0.008%) 1143(0.066%)

116(0.038%) 2(0.001%) 0(0.000%) 5(0.002%) 10(0.003%) 195(0.064%) 126(0.042%) 454(0.150%)

1823(0.049%) 45(0.001%) 58(0.002%) 635(0.017%) 727(0.020%) 3444(0.093%) 2147(0.058%) 8879(0.240%)

na l

Pr

e-

pr

MDRO

Jo ur

Abbreviations: MDRO: Multidrug resistant organism

28

Table 5 Rates of multidrug-resistant microorganisms of each bacterium All strains 29319 29808 5272 65819 32796 25633 38153

No. of multidrug-resistant strains (%) 9599 (32.74) 155 (0.52) 194 (3.68) 1889(2.87) 1689 (5.15) 13806(53.86) 8241(21.60)

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ur

na

lP

re

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ro of

Pathogen Staphylococcus aureus Enterococcus faecalis Enterococcus faecium Escherichia coli Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa

29