Healthcare-associated Infections Definitions Research Articles

International Nosocomial Infection Control Consortium (INICC) resources: INICC multidimensional approach and INICC surveillance online system

The International Nosocomial Infection Control Consortium (INICC) is an international, nonprofit, multicentric health care-associated infection (HAI) cohort surveillance network with a methodology based on the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN). The INICC was founded in 1998 to promote evidence-based infection control in limited-resource countries through the analysis of surveillance data collected by their affiliated hospitals. The INICC is comprised of >3,000-affiliated infection control professionals from 1,000 hospitals in 67 countries and is the only source of aggregate standardized international data on HAI epidemiology. Having published reports on device-associated (DA) HAI (HAI) and surgical site infections (SSIs) from 43 countries and several reports per individual country, the INICC showed DA HAI and SSI rates in limited-resources countries are 3-5 times higher than in high-income countries. The INICC developed the INICC Multidimensional Approach (IMA) for HAI prevention with 6 components, bundles with 7-13 elements, and the INICC Surveillance Online System (ISOS) with 15 modules. In this article the IMA, the ISOS for outcome surveillance of HAIs and process surveillance of bundles to prevent HAIs, and the use of surveillance data feedback are described. Remarkable features of the IMA and ISOS are INICC's applying of the latest published CDC-NHSN HAI definitions, including their updates and revisions in 2008, 2013, 2015 and 2016; INICC's informatics system to check accuracy of fulfillment of CDC-NHSN HAI criteria; and INICC's system to check compliance with each bundle element.

The Current Definitions of Health-Care Associated Infections in Intensive Care Units

The incidence of nosocomial infections is higher than other sites of the hospitals at intensive care units (ICUs) because of high frequency of invasive interventions and multidrug resistant microorganism’s prevalence. The most frequent nosocomial infections in ICUs’ are ventilator-related pneumoniae, urinary tract infections, catheter-related bacteremia and surgical site infections. The definitions of health care associated infections and the diagnosis criteria were updated at 2008 by CDC/NHSN (Centers for Disease Control and Prevention/National Healthcare Safety Network). After this period, Public Health Agency of Turkey translated this guideline to Turkish and publicated it. The aim of this study to discuss the definitions of health care associated infections in the lightening of current guidelines.

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Introduction: ECMO cannulation typically occurs in the operating room (OR), however emergent situations may warrant cannulation outside of the OR, where sterility and aseptic technique may be compromised. Although no consensus guideline recommendations exist for antibiotic prophylaxis, patients typically receive cefazolin and vancomycin for peri-operative prophylaxis for 48 hours at our institution. This study aims to compare the incidence of infection between emergent (EC) and non-emergent cannulation (NEC). Secondary aims included examining predominant microorganisms and time to infection. Methods: This retrospective, single-center, cohort study included patients > 18 years of age who received initial ECMO between January 1, 2009 and June 30, 2012. Patients were excluded if initial cannulation was at an outside hospital or if ECMO duration was < 24 hours. EC was defined as taking place outside the OR and NEC was defined as taking place inside the OR. Infections were defined according to the CDC/NHSN health-care associated infection definitions and were evaluated during two timeframes: pre-ECMO (72 hours pre-cannulation up until time of cannulation) and post-ECMO (time of cannulation to 72 hours post-decannulation). Results: Seventy-three patients were included in the study; 39 received EC and 34 received NEC. There were no differences between groups in terms of demographics or ECMO characteristics. The prevalence of infection at the time of cannulation was similar between groups, EC 8/39 (21%) vs. NEC 5/34 (15%), p=0.58. The incidence of infection after cannulation was similar between groups, EC 8/39 (21%) vs. NEC 7/34 (21%), p=0.99. Eleven (73%) infections occurred within the first 7 days on ECMO. Gram (-) bacteria were the most common pathogens, accounting for 67% (n=10) of the infections. Importantly, most gram (-) isolates observed would not have been covered by our standard antibiotic prophylaxis. Specific isolates include: Enterobacter spp. (n=3), Pseudomonas spp. (n=2), Acinetobacter spp. (n=2), and other enteric gram (-) (n=3). Conclusions: The urgency of cannulation did not affect infection risk. Infections occurred early and were predominantly gram negative. These data may have important implications for the design of antibiotic prophylaxis regimens in the future.

Public Reporting of Health Care–Associated Surveillance Data: Recommendations From the Healthcare Infection Control Practices Advisory Committee

Health care-associated infection (HAI) rates are used as measures of a health care facility's quality of patient care. Recently, these outcomes have been used to publicly rank quality efforts and determine facility reimbursement. The value of comparing HAI rates among health care facilities is limited by many factors inherent to HAI surveillance, and incentives that reward low HAI rates can lead to unintended consequences that can compromise medical care surveillance efforts, such as the use of clinical adjudication panels to veto events that meet HAI surveillance definitions.The Healthcare Infection Control Practices Advisory Committee, a federal advisory committee that provides advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services about strategies for surveillance, prevention, and control of HAIs, assessed the challenges associated with using HAI surveillance data for external quality reporting, including the unintended consequences of clinician veto and clinical adjudication panels. Discussions with stakeholder liaisons and committee members were then used to formulate recommended standards for the use of HAI surveillance data for external facility assessment to ensure valid comparisons and to provide as level a playing field as possible.The final recommendations advocate for consistent, objective, and independent application of CDC HAI definitions with concomitant validation of HAIs and surveillance processes. The use of clinician veto and adjudication is discouraged.

Variations in Identification of Healthcare-Associated Infections

Little is known about whether those performing healthcare-associated infection (HAI) surveillance vary in their interpretations of HAI definitions developed by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Our primary objective was to characterize variations in these interpretations using clinical vignettes. We also describe predictors of variation in responses. Cross-sectional study. United States. A sample of US-based members of the Society for Healthcare Epidemiology of America (SHEA) Research Network. Respondents assessed whether each of 6 clinical vignettes met criteria for an NHSN-defined HAI. Individual- and institutional-level data were also gathered. Surveys were distributed to 143 SHEA Research Network members from 126 hospitals. In total, 113 responses were obtained, representing at least 61 unique hospitals (30 respondents did not identify a hospital); 79.2% (84 of 106 nonmissing responses) were infection preventionists, and 79.4% (81 of 102 nonmissing responses) worked at academic hospitals. Among the 6 vignettes, the proportion of respondents correctly characterizing the vignettes was as low as 27.3%. Combining all 6 vignettes, the mean percentage of correct responses was 61.1% (95% confidence interval, 57.7%-63.8%). Percentage of correct responses was associated with presence of a clinical background (ie, nursing or physician degrees) but not with hospital size or infection prevention and control department characteristics. Substantial heterogeneity exists in the application of HAI definitions in this survey of infection preventionists and hospital epidemiologists. Our data suggest a need to better clarify these definitions, especially when comparing HAI rates across institutions.

A Comparative Assessment of Surgeons' Tracking Methods for Surgical Site Infections

The incidence of surgical site infections (SSI) is considered increasingly to be an indicator of quality of care. We conducted a study in which daily inspection of the surgical incision was performed by an independent, trained team to monitor the incidence of SSI using U.S. Centers for Disease Control and Prevention (CDC) definitions, as a gold-standard measure of care. In the department of surgery, two registration systems for SSI were used routinely by the surgeon: An electronic and a plenary tracking system. The results of the independent team were compared with the outcomes provided by two registration systems for SSI, so as to evaluate the reliability of these systems as a possible alternative for indicating quality of care. The study was an incidence study conducted from May 2007 to January 2009 that included 1,000 adult patients scheduled to undergo open abdominal surgery in an academic teaching hospital. Surgical incisions were inspected daily to check for SSI according to definitions of health care-associated infections established by the CDC. Follow-up after discharge was done at the outpatient clinic of the hospital by telephone or letter in combination with patient diaries and reviews of patient charts, discharge letters, electronic files, and reported complications. Univariate and multivariable analyses were done to identify putative risk factors for missing registrations. Of the 1,000 patients in the study, 33 were not evaluated. Surgical site infections were diagnosed in 26.8% of the 967 remaining patients, of which 18.0% were superficial incisional infections, 5.4% were deep incisional infections, and 3.4% were organ/space infections. More than 60% of SSIs were unreported in either of the department's two tracking systems for such infections. For these two systems, independent major risk factors for missing registrations were (1) the lack of occurrence of an SSI, (2) transplantation surgery, and (3) admission to non-surgical departments. Most SSIs were not tracked with the department's two systems. These systems proved poor alternatives to the gold-standard method of quantifying the incidence of Surgical Site Infection SSI and, therefore, the quality of care. Both protocolized wound assessment and on-site documentation are mandatory for realistic quantification of the incidence of SSI.

Healthcare-associated infection prevention in pediatric intensive care units: a review

The objective of this review was to summarize the current knowledge base on the prevention of nosocomial infections in pediatric intensive care units (PICUs). Healthcare-associated infections (HAIs) are a crucial problem in PICUs because of their impact on patient outcome, length of hospital stay, and costs. Studies published between 1998 and 2011 were identified using the MEDLINE and Cochrane databases. Randomized, cohort, case-control studies, and meta-analyses concerning global strategies of prevention, general organization of the wards, general recommendations on antibiotic management, and measures for the prevention of ventilator-associated pneumonia (VAP), bloodstream infections (BSIs), urinary tract infections (UTIs), and surgical site infections (SSIs) were incorporated. Limits of age from 1 month to 18 years were used. When recommendations could not be supported by the pediatric literature, adult studies were also reviewed. This review excludes the neonate population. Specific pediatric data are often lacking so as to establish specific evidence-based pediatric recommendations. This review underlines the absolute necessity of pediatric studies and to harmonize the definitions of HAIs.

Concordance between European and US case definitions of healthcare-associated infections

BackgroundSurveillance of healthcare-associated infections (HAI) is a valuable measure to decrease infection rates. Across Europe, inter-country comparisons of HAI rates seem limited because some countries use US definitions from the US Centers for Disease Control and Prevention (CDC/NHSN) while other countries use European definitions from the Hospitals in Europe Link for Infection Control through Surveillance (HELICS/IPSE) project. In this study, we analyzed the concordance between US and European definitions of HAI.MethodsAn international working group of experts from seven European countries was set up to identify differences between US and European definitions and then conduct surveillance using both sets of definitions during a three-month period (March 1st -May 31st, 2010). Concordance between case definitions was estimated with Cohen’s kappa statistic (κ).ResultsDifferences in HAI definitions were found for bloodstream infection (BSI), pneumonia (PN), urinary tract infection (UTI) and the two key terms “intensive care unit (ICU)-acquired infection” and “mechanical ventilation”. Concordance was analyzed for these definitions and key terms with the exception of UTI. Surveillance was performed in 47 ICUs and 6,506 patients were assessed. One hundred and eighty PN and 123 BSI cases were identified. When all PN cases were considered, concordance for PN was κ = 0.99 [CI 95%: 0.98-1.00]. When PN cases were divided into subgroups, concordance was κ = 0.90 (CI 95%: 0.86-0.94) for clinically defined PN and κ = 0.72 (CI 95%: 0.63-0.82) for microbiologically defined PN. Concordance for BSI was κ = 0.73 [CI 95%: 0.66-0.80]. However, BSI cases secondary to another infection site (42% of all BSI cases) are excluded when using US definitions and concordance for BSI was κ = 1.00 when only primary BSI cases, i.e. Europe-defined BSI with ”catheter” or “unknown” origin and US-defined laboratory-confirmed BSI (LCBI), were considered.ConclusionsOur study showed an excellent concordance between US and European definitions of PN and primary BSI. PN and primary BSI rates of countries using either US or European definitions can be compared if the points highlighted in this study are taken into account.

Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries. This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology. During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P= .02), demonstrating a 31% reduction in VAP rate. Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.

Three-year prevalence of healthcare-associated infections in Dutch nursing homes

From November 2007 for a period of three years (2007-2009), we conducted an annual one-day prevalence study of healthcare-associated infections (HAIs) among nursing home residents in the Nijmegen region of The Netherlands. In the absence of national HAI definitions applicable to the nursing home setting, we used modified definitions based on US Centers for Disease Control and Prevention criteria for bloodstream infection, lower respiratory tract infection, bacterial conjunctivitis, and gastroenteritis. For the surveillance of urinary tract infection (UTI), criteria established by the Dutch Association of Elderly Care Physicians were used. Resident characteristics were recorded and data collection was performed by the attending elderly care physicians. For the three-year period, 1275, 1323, and 1772 nursing home residents were included, resulting in a prevalence of HAIs of 6.7%, 7.6% and 7.6%, in 2007, 2008 and 2009, respectively. The demographics with respect to age (mean 81 years) and sex (31% men, 69% women) were almost identical in all three years. UTI was the most prevalent HAI with 3.5%, 4.2%, and 4.1% respectively. Most HAIs occurred among residents of rehabilitation units. The prevalence of HAIs varied by nursing home (range: 0.0-32.4%). We present the results of the first prevalence study of HAIs in Dutch nursing homes. Point prevalence studies of HAIs, as part of a quality improvement cycle, are an important cornerstone of infection control programmes in nursing homes, allowing us to further increase patient safety efforts in this setting.

Reimbursement Policy for HAI: A Research Agenda

Background: Annually in the United States there are nearly 2 million patients stricken with a healthcare associated infection (HAI), which translates to more than 5 percent of all hospitalized patients. Nearly 100,000 of the patients with HAIs are estimated to die. The annual cost of HAIs in the US is estimated to be greater than 25 billion dollars. With the pervasiveness of HAIs that are largely preventable and the associated costs, it is not surprising that these infections were targeted for nonpayment. As part of the Deficit Reduction Act effective October 2008, Medicare no longer pays for many potentially preventable types of HAI.Purpose: To develop a research agenda to evaluate the impact of the new HAI non-reimbursement policy.Methodology: A daylong invitational conference was convened with a group of 39 national experts who discussed the issues and generated a research agenda. Participants' interdisciplinary expertise included nursing, quality, epidemiology, economics, health services research and policy.Findings: All agreed that there will be intended (eg, hospitals invest in infection prevention and HAIs are reduced) and unintended consequences (eg, poor patient care such as overtreatment with antibiotics or change in coding practices with no change in patient care) The research agenda that emerged included applicable conceptual frameworks (eg, behavioral change and organizational theory), methodologic issues (eg, HAI definitions and measurement, risk-adjustment, process measures, interdisciplinary teams, and mixed methodologies) and specific research topics (eg, identifying best practices, monitoring coding practices and examining financial impact).Summary Concluding Statement: Payment reform is happening and must be evaluated. Nursing leadership should play a key role in all phases of reform (planning, implementation and evaluation) This research agenda developed is likely to be applicable to reform related many different clinical issues. Background: Annually in the United States there are nearly 2 million patients stricken with a healthcare associated infection (HAI), which translates to more than 5 percent of all hospitalized patients. Nearly 100,000 of the patients with HAIs are estimated to die. The annual cost of HAIs in the US is estimated to be greater than 25 billion dollars. With the pervasiveness of HAIs that are largely preventable and the associated costs, it is not surprising that these infections were targeted for nonpayment. As part of the Deficit Reduction Act effective October 2008, Medicare no longer pays for many potentially preventable types of HAI. Purpose: To develop a research agenda to evaluate the impact of the new HAI non-reimbursement policy. Methodology: A daylong invitational conference was convened with a group of 39 national experts who discussed the issues and generated a research agenda. Participants' interdisciplinary expertise included nursing, quality, epidemiology, economics, health services research and policy. Findings: All agreed that there will be intended (eg, hospitals invest in infection prevention and HAIs are reduced) and unintended consequences (eg, poor patient care such as overtreatment with antibiotics or change in coding practices with no change in patient care) The research agenda that emerged included applicable conceptual frameworks (eg, behavioral change and organizational theory), methodologic issues (eg, HAI definitions and measurement, risk-adjustment, process measures, interdisciplinary teams, and mixed methodologies) and specific research topics (eg, identifying best practices, monitoring coding practices and examining financial impact). Summary Concluding Statement: Payment reform is happening and must be evaluated. Nursing leadership should play a key role in all phases of reform (planning, implementation and evaluation) This research agenda developed is likely to be applicable to reform related many different clinical issues.

Hospital Infection Society Prevalence Survey of Healthcare Associated Infection 2006: comparison of results between Northern Ireland and the Republic of Ireland

As part of the Third Healthcare Associated Infection (HCAI) Prevalence Survey of the United Kingdom and Ireland, HCAI point prevalence surveys were carried out in Northern Ireland (NI) and the Republic of Ireland (RoI). Here we explore the potential benefits of comparing results from two countries with different healthcare systems, which employed similar methodologies and identical HCAI definitions. Forty-four acute adult hospitals in the RoI and 15 in NI participated with a total of 11 185 patients surveyed (NI 3644 patients and RoI 7541). The overall HCAI prevalence was 5.4 and 4.9 in NI and the RoI, respectively. There was no significant difference in prevalence rates of HCAI, device-related HCAI or HCAI associated with bloodstream infection but there was a difference in meticillin-resistant Staphylococcus aureus-related HCAI (P = 0.02) between the two countries. There were significantly more urinary tract infections and Clostridium difficile infections recorded in NI (P = 0.002 and P < 0.001). HCAIs were more prevalent in patients aged >65 years and in the intensive care unit in both countries. HCAIs were also more prevalent if patients were mechanically ventilated, had had recent non-implant surgery (RoI) or had more recorded HCAI risk factors. This is the first time that HCAI prevalence rates have been directly compared between NI and the RoI. By closely examining similarities and differences between HCAI prevalence rates in both countries it is hoped that this will influence healthcare planning and at the same time reassure the public that HCAI is important and that measures are being taken to combat it.

Mandatory reporting of healthcare-associated infections: A long way to go

BACKGROUND: In 2004, the Pennsylvania Health Care Cost Containment Council (PHC4) mandated that acute care hospitals in Pennsylvania report all healthcare-associated infections (HAIs) in hospitalized patients. The goal of PHC4 is to reduce the cost and improve the quality of healthcare through public reporting of healthcare outcomes, including HAIs. PHC4 requires the use of CDC definitions of HAI but does not specify a methodology to obtain this data. PHC4 utilizes both administrative and active surveillance data sources supplied by hospitals to assess the quality of HAI data submitted. Preliminary reports from PHC4 revealed significant discrepancies between data from these two sources. Objective: To determine the concordance between HAIs in hospitalized patients identified using administrative data to HAIs identified by active surveillance conducted by infection control professionals (ICPs). METHODS: This retrospective study was performed at a large children's hospital that conducts active surveillance of high-risk patient units. Using selected ICD-9 billing codes in predetermined positions on hospital discharge reports, PHC4 classifies four types of presumed HAI: 1) surgical site infections, 2) ventilator-associated pneumonia, 3) catheter-associated urinary tract infections, and 4) central line–associated bloodstream infections (CLABSIs). We compared HAIs identified by active surveillance to HAIs identified by PHC4 from hospital administrative data. Discrepancies were resolved by further chart review by ICPs. RESULTS: Active surveillance of targeted units over 9 months in 2004 identified 239 HAIs; administrative data identified 943 patients with presumed HAIs during the same period. 131 infections identified by active surveillance were not captured from administrative data; 842 presumed HAIs captured from administrative data were not identified by active surveillance. Upon further review, we found that 70% of HAIs identified by active surveillance alone were CLABSIs. We are conducting an audit of randomly selected records to resolve discrepancies and identify sources of error in this reporting mechanism. CONCLUSIONS: Public reporting of adverse healthcare events might reduce costs and improve patient outcomes. However, additional study is needed to define the optimal strategy for conducting surveillance for HAIs so that accurate and meaningful data are available to consumers.