Shona Cairns

Health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the European Centre for Disease Prevention and Control point-prevalence survey.

BACKGROUND In 2011-12, the European Centre for Disease Prevention and Control (ECDC) held the first Europe-wide point-prevalence survey of health-care-associated infections in acute care hospitals. We analysed paediatric data from this survey, aiming to calculate the prevalence and type of health-care-associated infections in children and adolescents in Europe and to determine risk factors for infection in this population. METHODS Point-prevalence surveys took place from May, 2011, to November, 2012, in 1149 hospitals in EU Member States, Iceland, Norway, and Croatia. Patients present on the ward at 0800 h on the day of the survey and who were not discharged at the time of the survey were included. Data were collected by locally trained health-care workers according to patient-based or unit-based protocols. We extracted data from the ECDC database for all paediatric patients (age 0-18 years). We report adjusted prevalence for health-care-associated infections by clustering at the hospital and country level. We also calculated risk factors for development of health-care-associated infections with use of a generalised linear mixed-effects model. FINDINGS We analysed data for 17 273 children and adolescents from 29 countries. 770 health-care-associated infections were reported in 726 children and adolescents, corresponding to a prevalence of 4·2% (95% CI 3·7-4·8). Bloodstream infections were the most common type of infection (343 [45%] infections), followed by lower respiratory tract infections (171 [22%]), gastrointestinal infections (64 [8%]), eye, ear, nose, and throat infections (55 [7%]), urinary tract infections (37 [5%]), and surgical-site infections (34 [4%]). The prevalence of infections was highest in paediatric intensive care units (15·5%, 95% CI 11·6-20·3) and neonatal intensive care units (10·7%, 9·0-12·7). Independent risk factors for infection were age younger than 12 months, fatal disease (via ultimately and rapidly fatal McCabe scores), prolonged length of stay, and the use of invasive medical devices. 392 microorganisms were reported for 342 health-care-associated infections, with Enterobacteriaceae being the most frequently found (113 [15%]). INTERPRETATION Infection prevention and control strategies in children should focus on prevention of bloodstream infections, particularly among neonates and infants. FUNDING None.

From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals

BackgroundIn 2008, the Scottish Antimicrobial Prescribing Group (SAPG) was established to coordinate a national antimicrobial stewardship programme. In 2009 SAPG led participation in a European point prevalence survey (PPS) of hospital antibiotic use. We describe how SAPG used this baseline PPS as the foundation for implementation of measures for improvement in antibiotic prescribing.MethodsIn 2009 data for the baseline PPS were collected in accordance with the European Surveillance of Antimicrobial Consumption [ESAC] protocol. This informed the development of two quality prescribing indicators: compliance with antibiotic policy in acute admission units and duration of surgical prophylaxis. From December 2009 clinicians collected these data on a monthly basis. The prescribing indicators were reviewed and further modified in March 2011. Data for the follow up PPS in September 2011 were collected as part of a national PPS of healthcare associated infection and antimicrobial use developed using ECDC protocols.ResultsIn the baseline PPS data were collected in 22 (56%) acute hospitals. The frequency of recording the reason for treatment in medical notes was similar in Scotland (75.9%) and Europe (75.7%). Compliance with policy (81.0%) was also similar to Europe (82.5%) but duration of surgical prophylaxis <24hr (68.6%), was higher than in Europe (48.1%, OR: 0.41, p<0.001). Following the development and implementation of the prescribing indicators monthly measurement and data feedback in admission units illustrated improvement in indication documented of ≥90% and compliance with antibiotic prescribing policy increasing from 76% to 90%. The initial prescribing indicator in surgical prophylaxis was less successful in providing consistent national data as there was local discretion on which procedures to include. Following a review and a focus on colorectal surgery the mean proportion receiving single dose prophylaxis exceeded the target of 95% and the mean proportion compliant with policy was 83%. In the follow up PPS of 2011 indication documented (86.8%) and policy compliant (82.8%) were higher than in baseline PPS.ConclusionsThe baseline PPS identified priorities for quality improvement. SAPG has demonstrated that implementation of regularly reviewed national prescribing indicators, acceptable to clinicians, implemented through regular systematic measurement can drive improvement in quality of antibiotic use in key clinical areas. However, our data also show that the ESAC PPS method may underestimate the proportion of surgical prophylaxis with duration <24hr.

The Prevalence of Health Care–Associated Infection in Older People in Acute Care Hospitals

OBJECTIVE To determine the prevalence of health care-associated infection (HAI) in older people in acute care hospitals, detailing the specific types of HAI and specialties in which these are most prevalent. DESIGN Secondary analysis of the Scottish National Healthcare Associated Infection Prevalence Survey data set. PATIENTS AND SETTING All inpatients in acute care (n = 11,090) in all acute care hospitals in Scotland (n = 45). RESULTS The study found a linear relationship between prevalence of HAI and increasing age (P<.0001) in hospital inpatients in Scotland. Urinary tract infections and gastrointestinal infections represented the largest burden of HAI in the 75-84- and over-85-year age groups, and surgical-site infections represented the largest burden in inpatients under 75 years of age. The prevalence of urinary catheterization was higher in each of the over-65 age groups (P<.0001). Importantly, this study reveals that a high prevalence of HAI in inpatients over the age of 65 years is found across a range of specialties within acute hospital care. An increased prevalence of HAI was observed in medical, orthopedic, and surgical specialties. CONCLUSIONS HAI is an important outcome indicator of acute inpatient hospital care, and our analysis demonstrates that HAI prevalence increases linearly with increasing age (P<.0001). Focusing interventions on preventing urinary tract infection and gastrointestinal infections would have the biggest public health benefit. To ensure patient safety, the importance of age as a risk factor for HAI cannot be overemphasized to those working in all areas of acute care.

Prevalence of healthcare-associated infection in Scottish intensive care units.

A national point prevalence survey of healthcare-associated infection (HCAI) in all acute hospitals, including intensive care units (ICUs), was carried out in Scotland from October 2005 to October 2006. The survey measured the prevalence of HCAIs to determine the burden on ICU resources. HCAI prevalence in ICUs was compared with HCAI prevalence in patients outside ICU. The prevalence of HCAI in ICU patients was 27.1%, significantly higher than HCAI prevalence in patients outside ICU, which was 9.3%. The prevalence of specific infections, namely pneumonia and lower respiratory tract, bloodstream and surgical site infections, was also significantly higher in ICU patients compared with non-ICU patients. These results highlight the burden on ICU resources from all HCAIs, regardless of site of infection. High HCAI prevalence in Scottish ICUs has major implications for patient safety and ICU resources and emphasises the need for continuing strong collaboration between intensivists and infection control teams.

Results from the second Scottish national prevalence survey: the changing epidemiology of healthcare-associated infection in Scotland

BACKGROUND Healthcare-associated infections (HAIs) are a recognized public health problem worldwide. Point prevalence surveys (PPSs) can be used to measure the burden of all HAI types. AIM To measure the prevalence of HAI and determine any changes in the epidemiology of HAI since the first Scottish national PPS. METHODS A national rolling PPS in National Health Service (NHS) acute, NHS non-acute, NHS paediatric and independent hospitals was carried out during September and October 2011 using the European Centre for Disease Prevention and Control protocol designed for the European PPS. The prevalence of HAI and distribution of HAI types were measured and the results compared with the first Scottish national HAI point prevalence survey of 2005/2006. RESULTS The prevalence of HAI was 4.9%, 2.5%, 6.1% and 1.2% in acute, non-acute, paediatric and independent hospitals respectively. The prevalence of HAI was significantly higher in acute hospitals compared with non-acute hospitals. There were no significant differences between the prevalence in the other hospital types. The prevalence of HAI in acute and non-acute hospitals was lower than the first survey by approximately one-third. The proportion of HAIs that were urinary tract infection, surgical site infection and bloodstream infection was higher and the proportion that were gastrointestinal including Clostridium difficile infection was lower in acute hospitals compared with the previous survey. CONCLUSIONS The epidemiology of HAI has changed in Scotland since the first national survey in 2005/2006, thus infection prevention and control measures require to be refocused in this regard. The lower prevalence and changing epidemiology of HAI in acute and non-acute care suggest that there may be a temporal relationship with the implementation of the national programme of targeted HAI interventions in the intervening period.

Evidence-based infection control planning based on national healthcare-associated infection prevalence data.

This study identifies factors associated with a high prevalence of healthcare-associated infection (HAI) in the Scottish inpatient population, on the basis of the Scotland National HAI Prevalence Survey data set. The multivariate models developed can be used to predict HAI prevalence in specific patient groups to help with planning and policy in infection control.

A pilot validation in 10 European Union Member States of a point prevalence survey of healthcare-associated infections and antimicrobial use in acute hospitals in Europe, 2011.

We present a pilot validation study performed on 10 European Union (EU) Member States, of a point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in Europe in 2011 involving 29 EU/European Economic Area (EEA) countries and Croatia. A total of 20 acute hospitals and 1,950 patient records were included in the pilot study, which consisted of validation and inter-rater reliability (IRR) testing using an in-hospital observation approach. In the validation, a sensitivity of 83% (95% confidence interval (CI): 79–87%) and a specificity of 98% (95% CI: 98–99%) were found for HAIs. The level of agreement between the primary PPS and validation results were very good for HAIs overall (Cohen’s κappa (κ):0.81) and across all the types of HAIs (range: 0.83 for bloodstream infections to 1.00 for lower respiratory tract infections). Antimicrobial use had a sensitivity of 94% (95% CI: 93–95%) and specificity of 97% (95% CI: 96–98%) with a very good level of agreement (κ:0.91). Agreement on other demographic items ranged from moderate to very good (κ: 0.57–0.95): age (κ:0.95), sex (κ: 0.93), specialty of physician (κ: 0.87) and McCabe score (κ: 0.57). IRR showed a very good level of agreement (κ: 0.92) for both the presence of HAIs and antimicrobial use. This pilot study suggested valid and reliable reporting of HAIs and antimicrobial use in the PPS dataset. The lower level of sensitivity with respect to reporting of HAIs reinforces the importance of training data collectors and including validation studies as part of a PPS in order for the burden of HAIs to be better estimated.

The reliability of the McCabe score as a marker of co-morbidity in healthcare-associated infection point prevalence studies

This study aimed to ascertain the reliability of the McCabe score in a healthcare-associated infection point prevalence survey.   A 10 European Union Member States survey in 20 hospitals (n = 1912) indicated that there was a moderate level of agreement (κ = 0.57) with the score. The reliability of the application of the score could be increased by training data collectors, particularly with reference to the ultimately fatal criteria. This is important if the score is to be used to risk adjust data to drive infection prevention and control interventions.

A pilot study of surveillance of intensive care unit associated infections in Scotland

Healthcare associated infections (HCAI) are a significant problem in healthcare settings worldwide. H The risk of HCAI is higher in patients undergoing multiple invasive procedures such as those requiring intensive care. A pilot study was undertaken to determine the incidence of intensive care unit (ICU) acquired infection in Scotland and to test the feasibility of the implementation of a surveillance system to measure ICU acquired infection in Scottish hospitals. The overall incidence of ICU acquired infection, namely pneumonia, bloodstream infection and central venous catheter related infection, was 30.5 infections per 1000 patient days with the majority being pneumonia. Implementation of the surveillance system was found to feasible and as such may have an important role in the monitoring of ICU acquired infection.

Healthcare associated infection in care homes for older people in Scotland: results from a pilot survey

The prevalence of infection in Scottish care homes is currently unknown. The aim of this survey was to estimate the prevalence of infection within a small sample of care homes for older people and to develop and test a methodology for point prevalence surveys which would allow local care home staff to monitor infection in care homes for older people that employ trained nurses. The pilot survey was undertaken by Health Protection Scotland (HPS) in collaboration with the Care Commission and two volunteer service providers. Data collection within 18 volunteer care homes was undertaken between 6 April 2009 and 1 May 2009. A total of 922 residents from 18 care homes were included. On the day of survey, 87 infections were identified in 86 residents. The prevalence of infection was 9.3%. The most common infections types were urinary tract infections and respiratory tract infections. The results from this small survey of volunteer care homes have provided valuable insight into the previously unmeasured prevalence of infection in Scottish care homes for older people. It is hoped that the rollout of a larger scale survey that includes a representative sample of all Scottish care homes can be implemented.