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Abstract

Background and Aims:

In the realm of healthcare, device-associated hospital-acquired infections (DA-HAIs) pose significant challenges. These infections occur due to invasive medical devices and can lead to serious complications for patients. This study intends to assess the trends in device-associated infections over time in order to improve patient safety and quality through measurements and improvements in device-associated infections.

Methods:

The Department of Microbiology conducted a routine surveillance using a specific infection surveillance proforma for various healthcare-associated infections, including ventilator-associated events (VAEs), central line–associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). The data were examined at the end of each month, and the infection rate was determined using CDC guidelines.

Results:

The overall rate of HAI was found to be 1.69 HAI cases per 1,000 patient days. The cumulative DAI rates for the years 2021 and 2022 were CAUTI 6.14/1,000 urinary catheter days, CLABSI 4.5/1,000 central line catheter days and VAE 16.3/1,000 ventilator days.

Discussion:

It was observed that the CAUTI and CLABSI rates in our institution were comparable to or slightly higher than the national standard benchmark and INICC report and were significantly higher compared to the CDC/NHSN benchmark. The VAE rate was comparable to INICC report but was significantly higher compared to the NSB and the CDC/NHSN reports.

Conclusion:

Individual hospitals should make efforts to generate and evaluate their DAI trends and overall HAI rates and implement and improve their infection control programme to collectively achieve the target in our country in bringing down HAIs.

Keywords

Catheter-associated urinary tract infections central line–associated bloodstream infections device-associated infections quality indicators ventilator-associated events

Introduction

Device-associated hospital-acquired infections (DA-HAIs), also known as device-associated infections (DAIs), are defined as infections acquired in a hospital by a patient who was admitted for a reason unrelated to the infection.^[1] These devices include ventilators; central venous catheters (CVCs), otherwise termed central line (CL); and urinary catheters (UCs). One of the biggest risks to patient safety is DAI, which increase expenses, lengthen hospital stays and cause patient morbidity and mortality, especially in critical care settings in low-resource nations.^[2] Robust surveillance systems play a crucial role in identifying, managing and preventing HAIs, thus contributing to quality improvement by ensuring patient safety, reducing morbidity and enhancing overall healthcare outcomes.

Quality indicators are quantifiable measures that evaluate various aspects of healthcare delivery. They serve as benchmarks to assess the effectiveness, safety and efficiency of medical practices. By leveraging these metrics, healthcare institutions can enhance patient safety, optimize clinical practices and ultimately improve overall healthcare delivery. The quality of care delivered by the healthcare system can be tracked through the calculation of a number of quality indicators.^[3] Ventilator-associated events (VAEs), central line–associated blood stream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) are the most commonly encountered DAIs.^[4]

VAEs occur in patients who require mechanical ventilation. These events encompass a range of conditions, including ventilator-associated pneumonia (VAP) and ventilator-associated conditions (VACs). Prolonged mechanical ventilation, immune suppression and underlying lung diseases increase the risk. Strict infection control measures, proper hand hygiene and regular assessment of ventilator settings are crucial. CLABSI result from CVCs or other central lines. Bacteria enter the bloodstream through the catheter. Prolonged catheter use, poor insertion technique and inadequate maintenance contribute to CLABSI risk. Aseptic insertion, daily assessment for catheter necessity and prompt removal when no longer needed might prevent CLABSI. CAUTI occur due to indwelling urinary catheters. Bacteria ascend the catheter and infect the urinary tract. Prolonged catheterization, female gender and older age increase susceptibility. Proper catheter insertion, regular hygiene and timely removal are essential to reduce the risk.

Intensive care units (ICU) in high-income countries report HAI rates of about 5%-10%. The incidence of HAIs can be 2-10 times greater in lower and middle-income countries.^[5] The incidence of HAI varies by hospital, by ICU within a hospital, with teaching hospitals having the highest rates.^[6] These DA-HAIs not only jeopardize patient well-being but also strain healthcare resources. Vigilance, evidence-based practices and interdisciplinary collaboration are vital in preventing and managing these infections. As healthcare providers, we must remain committed to minimizing risks and ensuring patient safety. This study intends to assess the trends in DAIs over time in order to improve patient safety and quality through measurements and improvements in DAIs.

Materials and Methods

This study does not directly involve human subjects and hence institutional review board clearance is not required. This study is a retrospective analysis and comparison of the routine HAI surveillance conducted as part of the existing hospital infection control (HIC) programme in the institution, Mamata Academy of Medical Sciences (MAMS), to evaluate the HAI trends over a period of two years. This retrospective analysis was carried out in a teaching hospital with 750 beds that had a multidisciplinary intensive care unit (ICU) with six sections, each with five beds.

The Department of Microbiology conducted routine surveillance using a specific infection surveillance proforma for various healthcare-associated infections, including VAEs, CLABSI and CAUTI. The infection control nurse (ICN) along with the infection control officer (ICO) and critical care physician filled up these forms during routine hospital infection control rounds. The data were examined at the end of each month, and the infection rate was determined using CDC guidelines^[1] and presented along with other matters, at a quarterly infection control meeting.

The patients who were included in the diagnosis of CAUTI either had symptoms that started 48 hours after catheterisation or had an indwelling catheter removed within seven days of the onset of symptoms. Both catheter-associated symptomatic UTI (CA-SUTI) and asymptomatic bacteremic UTI (CA-ABUTI) were taken as CAUTI. CLABSI was considered if more than blood cultures, drawn on different occasions, were positive for common skin contaminant or one positive blood culture with a recognised pathogen and a central line in place for 48 hours prior to the onset of signs and symptoms. VAE was identified using a combination of radiologic, clinical and laboratory criteria. The formulae used for calculation of various DAI rates are shown in Table 1.

Table 1.

Formulae for Calculation of Various DAI Rates

HAI Indicator	Formula
CAUTI (per 1,000 urinary catheter days)	Number of CAUTI cases/number of urinary catheter days × 1,000
CLABSI(per 1,000 central line catheter days)	Number of CLABSI cases/number of central line days × 1,000
VAE(per 1,000 ventilator days)	Number of VAE cases/number of mechanical ventilation days × 1,000

Results

HAI surveillance included a total of 4,761 patients, including surgical site infections (SSIs). Over the course of their hospitalization, these patients accumulated a total of 58,420 patient days. The overall rate of HAI was 1.69 HAI cases per 1,000 patient days, as shown in Table 2. In 2021, the HAI rate was 1.61 HAI cases per 1,000 patient days. In 2022, the HAI rate increased slightly to 1.73 HAI cases per 1,000 patient days. The individual DAI rates, namely CAUTI, CLABSI and VAE rates for the years 2021 and 2022, and the cumulative rates are shown in Table 3.

Table 2.

HAI (Including SSI) Rate for the Years 2021 and 2022

Indicators	Year 2021	Year 2022	Cumulative2021–2022
Total HAI (including SSI)	33	66	99
Total patients admitted	1,647	3,114	4,761
Total patient bed days	20,422	37,998	58,420
HAI rate (per 1,000 patient bed days)	1.61	1.73	1.69

Table 3.

Details of Various DAIs for the Years 2021 and 2022

Indicators	Year 2021	Year 2022	Cumulative2021–2022
Catheter patients	747	684	1,431
Catheter days	2,496	3,686	6,182
CAUTI	15	24	38
CAUTI Rate (per 1,000 urinary catheter days)	6	6.5	6.14
Central line patients	54	26	80
Central line days	405	252	657
CLABSI	2	1	3
CLABSI rate (per 1,000 central line catheter days)	4.9	3.9	4.5
Ventilator patients	66	80	146
Ventilator days	309	548	857
VAE	4	10	14
VAE rate (per 1,000 ventilator days)	12.9	18.2	16.3

Discussion

Developing and impoverished nations use the International Nosocomial Infection Control Collaboration (INICC) data for HAI rates for comparison. It is a global, nonprofit healthcare safety network based on the National Healthcare Safety Network of the U.S. Centers for Disease Control and Prevention (CDC-NHSN). HAI rates reported by the CDC-NHSN are widely regarded as the benchmark for healthcare-associated infections.

The observed DAI rates were compared with the national and international benchmark rates as shown in Table 4 and Figure 1. It was observed that the CAUTI and CLABSI rates in our institution (MAMS) were comparable to or slightly higher than the National standard benchmark and INICC report, and were significantly higher compared to the CDC-NHSN benchmark. The VAE rate was comparable to that in the INICC report but was significantly higher compared to the NSB and the CDC-NHSN report.

Table 4.

Mapping of the DAI Rate with National and International Benchmark Rates

HAI	Observed Rates(MAMS)	National Standard Benchmark (NSB)	INICC Report⁷ (2007–2012)	CDC-NHSN Report⁸(2013)
CAUTI	6.14	4.02	5.3	1.3
CLABSI	4.5	2.79	4.9	0.8
VAP	16.3	5	16.5	1.1

Figure 1.

Mapping of the DAI Rate with National and International Benchmark Rates

In our study, it was observed that the overall CLABSI rate had marginally improved for the year 2022 as opposed to 2021. However, the CAUTI rate had increased slightly and the VAE rate had increased significantly for the year 2022 compared to 2021. This could be probably due to the increased number of admissions for the year 2022 compared to the less number of admissions for the year 2021. Also, the rampant use of personal protective equipment together with strict adherence to hand hygiene practices due to the COVID-19 pandemic, better staff-to-patient ratio owing to less number of admissions and restriction of the number of visitors attending the hospital during the COVID-19 pandemic in 2021 probably explain the lower HAI rates for the year 2021 compared to the HAI rates for the year 2022. Nevertheless, strict adherence to infection control practices was reinforced among the healthcare workers by conducting frequent trainings and audits and ensuring compliance to Bundle care (CAUTI, CLABSI and VAE bundle). The bundle care surveillance proforma is given in online Appendix A.

In a study conducted by Habibi et al, the DAI rates were 11.3/1,000 UC days for CAUTI, 3.4/1,000 CL days for CLABSI and 31.4/1,000 ventilator days for VAE.^[9] In the ICUs of seven Indian cities that were members of the INICC, the rates were 1.41/1,000, 7.92/1,000 and 10.46/1,000 for CAUTI, CLABSI and VAP, respectively.^[10] In a study conducted in 55 ICUs in developing countries by Rosenthal et al, the rates were CAUTI 8.9/1,000 UC days, CLABSI 12.8/1,000 CL days and VAP 24/1,000 ventilator days.^[11] All these rates vary significantly from the rates observed in our institution.

Conclusion

While there has been progress in the efforts in reducing HAI, HAI rates still remain higher compared to the benchmark set by CDC. Apart from regular HAI surveillance, indicators such as device utilization ratio (DUR) and standardized utilization ratio (SUR) can be calculated for each device (central line, ventilator and urinary catheter) and targets can be set by individual hospitals and incorporated into their HIC policy manual to minimise the use or reduce the duration of these devices in individual patients to bring down the DAI rates. Individual hospitals should make efforts in generating and evaluating their DAI trends and overall HAI rates and should implement and improve their infection control programme to collectively achieve the target in our country in bringing down the HAIs.

Supplemental material

Supplemental material for this article is available online.

Supplemental material

Supplemental material for this article is available online.

Footnotes

Acknowledgements

I sincerely thank Dr M. Chandra Shekar, medical director and medical superintendent, for his constant encouragement and support in implementing and improvising hospital infection control practices; I gratefully acknowledge the sincere efforts by the infection control nurse, Ms Swetha Vangapalli, in conducting the HAI surveillance.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author received no financial support for the research, authorship and/or publication of this article.

Ethical approval and informed consent

This study does not directly involve human subjects and hence institutional review board clearance and informed consent are not required.

Credit author statement

Conception of the study, analysis of the records and writing of the manuscript were solely done by the author.

Data availability

HAI surveillance records are maintained at Apollo Institute of Medical Sciences and Research, Hyderabad.

Use of artificial intelligence

None

References

CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. ScienceDirect. https://www.sciencedirect.com/science/article/abs/pii/S0196655308001673. Accessed March 20, 2023.

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5th Edition Hospital Std April 2020.pdf. Accessed March 21, 2023. https://www.nabh.co/images/Standards/1.%205th%20Edition%20Hospital%20Std%20April%202020.pdf

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Supplementary Material

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