- Received June 30, 2022
- Accepted July 18, 2022
- Publication September 06, 2022
- Visibility 3 Views
- Downloads 0 Downloads
- DOI 10.18231/j.ijmmtd.2022.042
-
CrossMark
- Citation
Reducing hospital-acquired infections and improving the rational use of antibiotics in a tertiary care hospital in Bangalore
- Author Details:
-
Mahesh Babu Kothapalli
-
Girish Narayanaswamy *
-
Leela Rani
-
Uma Maheshwar
-
Ravi Babu
-
Sanjay Paruchuri
-
Shashidhar Karpuranath
-
Rama Mishra
-
Shailaja Alapaty
Introduction
Even in settings with limited resources, prevention of hospital-acquired infections (HAIs) is central to providing high quality and safe health-care. The two important preventable factors involved in many HAIs are transmission of infectious agents between patients by health workers and irrational use of antibiotics.[1], [2], [3] HAIs are among the most significant causes of morbidity and mortality in healthcare settings throughout the world. [4] In developed countries, many studies have shown that infection control programme, including campaigns to improve hand hygiene, are effective in reducing HAIs.[5], [6], [7] In developing countries, studies on the effectiveness of interventions to reduce HAIs are limited.
This study aimed to develop and evaluate the effectiveness of a multifaceted infection control programme on rates of HAIs, including rational use of antibiotics and hand hygiene compliance throughout the wards and ICUs of a tertiary care hospital in Bangalore.
Materials and Methods
The study was conducted at the Vydehi Hospital, Bangalore in ICUs and general wards. The total bed strength of the hospital is 1600.
Design
The research design was a retrospective study consisting of two periods: The intervention (6 months, June 2021 to November 2021) and the post-intervention (5 months, December 2021 to April 2022).
Sample size
Calculation of sample size was done using the formula (a difference between intervention and post-intervention groups with proportional comparison using the power of 80%, type 1 error of 5%). The study included 2,342 ICU patients admitted in Vydehi hospital from June 2021 to April 2022 (11 months). Study also included 1,398 patients admitted in the wards. A total of 5,524 post surgery patients during the same period were included for the calculation of SSI.
Inclusion criteria
Patients who remained in the ICU or wards for more than 48 h and post-surgery patients were included in the study.
Outcome measures and data collection
Hospital-acquired infection
Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network[8], [9] definition for HAI was followed in the study. Investigations of the causes of fever and other signs of infection were at the discretion of the treating clinical staff. If clinical criteria for suspected HAIs were fulfilled and the patient had not been investigated by the treating doctors, the clinical staff was advised by the HICC team, so they could collect a culture of blood, urine or other sterile sites, as appropriate, on the same day.
The rational use of antibiotics
During the intervention period, the antibiotic policy was revised as per hospital antibiogram from microbiology laboratory and periodic monitoring by HICC team with emphasis on antibiotic stewardship was done. Medical record of each patient for daily antibiotic use was checked during this period. Inappropriate antibiotic use was classified according to the spectrum, dose and duration. [10], [11]
Hand hygiene compliance
Hand hygiene compliance was defined as for each of WHO’s five moments for hand hygiene, hand washing with antiseptic soap and water or alcohol-based hand rubs by the health worker. [12], [13] When there was an indication for hand hygiene whether the hand hygiene compliance was achieved by the health worker and performed it correctly. Health care workers (doctors, nurses, ward boys, house keeping staff and technicians) were systematically observed over a fixed time period (20±10 min each). During these periods of observation, the actions of the first health worker who was involved in the care of the patient was recorded by the Infection control nurses. [14] Direct hand hygiene observation began when the healthcare worker entered the patient’s room or bed area and was observed during activities that involved contact with the patient or their environment, and the observation ended when the healthcare worker completed the activity and left the bed space.
Bacterial culture
According to CLSI guidelines, bacterial isolation and antibiotic susceptibility testing were performed.[15] Vitek-2 (Bio-Mereuix) was used for all specimens except blood for which the BACTEC 9120 (BD Diagnostics, Sparks, Maryland, USA) was used. For each positive culture result, isolated organism, time taken for culture positivity, number of positive culture sites, the presence of focal or generalized clinical signs of infection and an overall assessment of illness were recorded. This enabled an assessment of whether the isolate was a true pathogen or a contaminant
Intervention period
Engaging the target group prior to the commencement of the intervention, HICC team reviewed the pre-intervention data and to provide feedback about the educational tools to be used and the implementation processes.
Intervention phase
Educational seminars, reminders, audit and performance feedback on all aspects of infection control were the tools used in the intervention aimed to reach all doctors, nurses and allied workers at the wards and ICUs. Seminars were conducted at least twice for each topic for approximately 1 h to cover all the health workers on different shifts. Topics of the seminars and other interventions were related to HAIs, hand hygiene practices, isolation of MDRO patients, water and air quality analysis, improving the rational use of antibiotics based on antibiotic policy and measures to prevent central line associated bloodstream infections, ventilator associated pneumonia, catheter associated urinary tract infections, and surgical site infections.
The HICC team consisting of doctors and the infection control nurses provided the seminars and feedback to the health workers. During the intervention period, the audit data were also collected and feed back to the health workers individually were given, and were presented at the monthly HICC meetings.
A bottle of alcohol hand rub had already been made available in every patient care room and another bottle was placed at the entrance of each room. There was a water sink and antiseptic soap in every ward.
Post-intervention period
In the, intervention and post-intervention periods, an identical method was used to collect data. While the main educational push was in the 6-months intervention period, ongoing education was provided where needed. This was the rationale for including the intervention period in the analysis of effectiveness.
Outcome measures
The primary outcome was the proportion of patients with a HAI, between the intervention and post-intervention periods. Secondary outcomes were the proportions of patients who were exposed to inappropriate antibiotic use, healthcare workers ‘compliance with hand hygiene.
Data analysis
When comparing proportions from both time periods, the Chi-sqauare test was used to analyse the results . For comparison of means student t test was used. The statistical significance was set at p<0.05. To compare the effect of the interventions between both periods, the relative risk (RR) was also calculated. To quantify the relationship between the HAI and the multifaceted intervention allowing for statistical control of potential con-founders Regression analyses were used. Vydehi Institutional Ethics Committee approved the study.
Results
Study population
A total of 2,342 ICU patients, 1,398 ward patients and 5,524 post- surgery patients were enrolled between 1ST June 2021 and 30th April 2022 (11 months).
The effectiveness of the multifaceted intervention on HAIs
The number of patients developing HAI decreased from 89% (198/222) in the intervention period to 10.8% (24/222) in the post-intervention period (relative risk (RR) (95% CI) 0.48 (0.31 to 0.56) ([Table 1]).
|
Month &Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
HAI |
89 (40%) |
34 (15%) |
26 (12%) |
23 (10%) |
13(6%) |
13 (6%) |
10 (5%) |
6 (3%) |
6 (3%) |
0 (0%) |
2 (1%) |
222 (100%) |
The reduction was observed gradually and consistently during the post-intervention period as the analyses of HAI incidence every 4 months showed. (December 2021 to April 2022) ([Table 1]).
|
Month & Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
Total no of ICU patients |
123 (5.3%) |
149 (6.4%) |
199 (8.5%) |
293 (13%) |
279 (12%) |
304 (13%) |
136 (6%) |
234 (10%) |
231 (9.9%) |
274 (11.7%) |
120(5%) |
2,342 (100%) |
|
Total no with catheter |
102 (7.7%) |
112 (8.4%) |
133 (10%) |
149 (11%) |
163 (12%) |
149 (11%) |
73 (5.5%) |
137 (10%) |
123 (9%) |
132 (9.9%) |
57(4.3%) |
1,330 (100%) |
|
No of catheter days |
387 (8%) |
426 (9%) |
501 (10.6%) |
510 (11%) |
470 (10%) |
568 (12%) |
275 (5.8%) |
529 (11%) |
385 (8%) |
459 (9.7%) |
210(4.4%) |
4,720 (100%) |
|
No. of cultures sent |
51 (16%) |
40 (12%) |
46 (14%) |
22 (6.8%) |
35 (11%) |
41 (13%0 |
17 (5.3%) |
23 (7%) |
19 (6%) |
18 (5.6%) |
10 (3%) |
322 (100%) |
|
Isolates |
20 (27%) |
11 (15%) |
11 (15%) |
7 (9%) |
6 (8%) |
9 (12%) |
5 (7%) |
2 (3%) |
2 (3%) |
0 |
2 (3%) |
75 (100%) |
|
CAUTI |
15 (32%) |
10 (21%) |
7 (15%) |
6 (13%) |
1 (2%) |
1(2%) |
2 (4.3%) |
1 (2%) |
2 (4.3%) |
0 |
2 (4.3%) |
47 (100%) |
|
Colonizer |
2 (18%) |
3 (27%) |
1 (9%) |
0 |
3 (27%) |
2 (18%) |
0 |
0 |
0 |
0 |
0 |
11 (100%) |
|
Community aquired |
4 (14%) |
8 (28%) |
6 (21) |
7 (25%) |
2 (7%) |
1 (4%) |
0 |
0 |
0 |
0 |
0 |
28 (100%) |
The use of urinary catheters in ICUs (catheter days) decreased significantly from 60.6% (2862/4720) to 39% (1858/4720) in the post-intervention period (p=0.01). Consequently, from 32% in the beginning of intervention period to 4.3% in the post-intervention period CAUTI dropped significantly ([Table 2]), showing the effectiveness of the intervention with RR=0.24(95% CI 0.11-0.49).
|
Month & Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
Total no of ICU patients |
123 (5.3%) |
149 (6.4%) |
199 (8.5%) |
293 (13%) |
279 (12%) |
304 (13%) |
136 (6%) |
234 (10%) |
231 (9.9%) |
274 (12%) |
120 (5%) |
2,342 (100%) |
|
Total no of Cental line patients |
21 (5.4%) |
18 (5%) |
23 (6%) |
46 (12%) |
42 (11%) |
41 (10.%) |
30 (7.8%) |
34 (8.8%) |
40 (10%) |
71 (18%) |
22 (5.7%) |
388 (100%) |
|
No of Central line day |
97 (7.8%) |
151 (12%) |
88 (7%) |
168 (14%) |
211 (17%) |
87 (7%) |
117 (9%) |
68 (6%) |
67 (5.4%) |
75 (6%) |
105 (8.5%) |
1,234 (100%) |
|
No. of cultures sent |
8 (27%) |
5 (17%) |
4 (13%) |
3 (10%) |
1(3%) |
1 (3%) |
1 (3%) |
1 (3%) |
2 (7%) |
4 (13%) |
0 |
30 (100%) |
|
CLABSI |
8 (31%) |
5 (19%) |
4 (15%) |
3 (12%) |
1 (4%) |
1 (4%) |
1 (4%) |
1 (4%) |
2 (8%) |
0 |
0 |
26 (100%) |
The use of invasive devices in ICUs and HAIs related to invasive devices was varied in the post-intervention period. The use of central line catheters increased from 14.2% (191/1,347) to 19.8% (197/995) in the post-intervention period ( p=0.007).The Central line catheter days decreased from 65% (802/1234) in the intervention period to 35% (432/1,234) in the post-intervention period (p =0.10). CLABSI decreased significantly from 31% during the beginning of intervention period to nil in the post-intervention period RR 0.45 (95% CI 0.33 - 0.62) ([Table 3]).
|
Month & Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
Total no of ICU patients |
123 (5.3%) |
149 (6.4%) |
199 (8.5%) |
293 (13%) |
279 (12%) |
304 (13%) |
136 (6%) |
234 (10%) |
231 (9.9%) |
274 (12%) |
120 (5%) |
2,342 (100%) |
|
Total no of patients on ventilator |
58 (6%) |
47 (5%) |
58 (6%) |
149 (16%) |
163 (17%) |
149 (16%) |
107 (11%) |
68 (7%) |
58 (6%) |
71 (7.3%) |
32 (3%) |
960 (100%) |
|
No of ventilator days |
163 (6%) |
136 (5%) |
138 (5%) |
510 (19%) |
470 (17%) |
568 (21%) |
347 (13%) |
140 (5%) |
68 (2.5%) |
75 (3%) |
51 (2%) |
2,666 (100%) |
|
No. of ET culture send |
17 (10%) |
8 (5%) |
13 (8%) |
22 (13%) |
35 (21%) |
41 (25%) |
18 (11%) |
2 (1%) |
3 (2%) |
4 (2.5%) |
0 |
163 (100%) |
|
No of isolates |
17 (28%) |
5 (8%) |
8 (13%) |
7 (12%) |
6 (10%) |
9 (15%) |
5 (8%) |
2 (3%) |
1 (2%) |
0 |
0 |
60 (100%) |
|
No of HAI VAP |
15 (45%) |
5 (15%) |
4 (12%) |
3 (9%) |
1 (3%) |
1 (3%) |
1 (3%) |
2 (6%) |
1 (3%) |
0 |
0 |
33 (100%) |
|
Community acquired VAP patients |
10 (37%) |
3 (11%) |
7 (26%) |
0 |
3 (11%) |
2 (7%) |
1 (4%) |
1 (4%) |
0 |
0 |
0 |
27 (100%) |
The use and the duration of mechanical ventilation (ventilator days) decreased from 74.5% (1,985/ 2666) in the intervention period to 25.5% (681/2,666) in the post-intervention period (p=0.12). Consequently, the risk of developing ventilator-associated pneumonia decreased significantly from 45% during the beginning of intervention period to nil in the post-intervention period ([Table 4]) showing the effectiveness of the intervention with RR-0.13(95% CI 0.05-0.31).
|
Month & Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
Total no of surgeries |
266 (5%) |
438 (8%) |
512 (9%) |
682 (12%) |
598 (11%) |
625 (11%) |
(7%) 553(10%) |
396 |
191 (3.5%) |
663 (12%) |
600 (11%) |
5,524 (100%) |
|
SSI in Clean surgeries |
19 (39%) |
8 (16%) |
6 (12%) |
5 (10%) |
4 (8%) |
4 (8%) |
2(4%) |
1 (2%) |
0 |
0 |
0 |
49 (100%) |
|
SSI in Clean contaminated surgeries |
25 (45%) |
5 (9%) |
4 (7%) |
6 (11%) |
6 (11%) |
6 (11%) |
4 (7%) |
1 (1.8%) |
1 (1.8%) |
0 |
0 |
56 (100%) |
SSI in clean surgeries decreased from 93.8% (46/49) in the intervention period to 6.1% (3/49) in the post intervention period. Similarly SSI in clean contaminated surgeries decreased from 92.8% (52/56) to 10.7% (6/56) ([Table 5]), showing the effectiveness of intervention.
|
Month & Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
Total no. of patients with catheter |
65 (5%) |
70 (5%) |
69 (5%) |
90 (7%) |
79 (6%) |
163 (12%) |
237 (17%) |
151(11%) |
102 (7%) |
233 (17%) |
106 (8%) |
1,365 (100%) |
|
No of catheter days |
150 (4%) |
165 (4%) |
173 (4.4%) |
368 (9%) |
248 (6.3%) |
454 (12%) |
643 (16%) |
462(12%) |
250 (6.4%) |
635 (16%) |
364 (9.2%) |
3,912 (100%) |
|
CAUTI |
7 (78%) |
1 (11%) |
1 (11%) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
9 (100%) |
|
Colonizer |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
The use of urinary catheters in wards (catheter days) increased significantly from 39.8% (1,558/3912) to 60% (2354/3912) in the post-intervention period. However, CAUTI dropped significantly from 100% in the intervention period to nil in the post-intervention period ([Table 6]), showing the effectiveness of the intervention.
|
Month & Year |
Jun 2021 |
Jul 2021 |
Aug 2021 |
Sep 2021 |
Oct 2021 |
Nov 2021 |
Dec 2021 |
Jan 2022 |
Feb 2022 |
Mar 2022 |
Apr 2022 |
Total |
|
Total no of Central line patients |
2 (6%) |
5 (15%) |
0 |
3 (9%) |
0 |
0 |
5 (15%) |
4 (12%) |
3 (9%) |
6 (18%) |
5 (15%) |
33 (100%) |
|
No of central line days |
55 (14%) |
106 (27%) |
0 |
35 (9%) |
0 |
0 |
58 (14.5%) |
60 (15%) |
21 (5%) |
38 (10%) |
25 (6%) |
398 (100%) |
|
CLABSI |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
The central line catheter days increased from 49% (196/398) in the intervention period to 50.8% (202/398) in the post-intervention period, though CLABSI was not detected in any of the patients in both the periods ([Table 7]).
|
Month & Year |
No. of doctors |
No.of nurses |
No.of ward boys and house keeping staff |
No. of technicians |
No.of opportunities |
Missed opportunites |
Compliance (%) |
|
Jun 2021 |
520 (8%) |
870 (8%) |
333 (7%) |
70 (4.6%) |
1793 (7.6%) |
0 |
100 |
|
Jul 2021 |
544 (8.4%) |
865 (8%) |
453(9.7%) |
88 (5.7%) |
1950 (8.3%) |
0 |
100 |
|
Aug 2021 |
588 (9%) |
984 (9%) |
321 (7%) |
96 (6.3%) |
1989 (8.5%) |
0 |
100 |
|
Sep 2021 |
555 (8.6%) |
854 (8%) |
328 (7%) |
110 (7.2%) |
1847 (7.9%) |
0 |
100 |
|
Oct 2021 |
540 (8.4%) |
792 (7%) |
418 (9%) |
178 (11.6%) |
1928 (8.2%) |
0 |
100 |
|
Nov 2021 |
657 (10%) |
890 (8%) |
469 (10%) |
150 (9.8%) |
2166 (9.2%) |
0 |
100 |
|
Dec 2021 |
672 (10.4%) |
817 (8%) |
352 (7.5%) |
114 (7.4%) |
1955 (8.3%) |
1 |
99.95 |
|
Jan 2022 |
323 (5%) |
678 (6.3%) |
323 (7%) |
124 (8%) |
1448 (6.2%) |
0 |
100 |
|
Feb 2022 |
1059 (16.4%) |
1925 (17.8%) |
920 (19.6%) |
288 (18.8%) |
4192 (17.8%) |
0 |
100 |
|
Mar 2022 |
538 (8.3%) |
1110 (10.3%) |
401 (8.6%) |
178 (11.6%) |
2227 (9.5%) |
0 |
100 |
|
Apr 2022 |
468 (7.2%) |
1022 (9.5%) |
365 (8%) |
137 (9%) |
1992 (8.5%) |
0 |
100 |
|
Total |
6,464 (100%) |
10,807 (100%) |
4,683 (100%) |
1,533 (100%) |
23,487 (100%) |
1 (100%) |
100 |
Hand hygiene compliance among Doctors, Nurses, ward boys, house keeping staffs and technicians was 100% during the intervention period in ICU and the general wards ([Table 8]). Overall, hand hygiene compliance among the health- care workers was maintained at 100% during both the periods.
|
Month & Year |
No. of IV cannula audited |
Undated IV cannula |
Over dated IV cannula |
No. of IV set audited |
Undated IV sets |
Over dated IV sets |
No.of Central line audited |
Undated Central line |
No.of Foley's catheter |
Undated Foley's catheter |
|
Jun 2021 |
220 (9.4%) |
20 (17%) |
9 (23%) |
130 (7.3%) |
14 (20%) |
8 (17%) |
22 (11.6%) |
2 (100%) |
55 (9.4%) |
9 (21%) |
|
Jul 2021 |
231 (9.9%) |
18 (15.4%) |
6 (15.4%) |
140 (7.8%) |
11 (15.7%) |
9 (19%) |
18 (9.5%) |
0 |
60 (10%) |
8 (18.6%) |
|
Aug 2021 |
222 (9.5%) |
16 (13.7%) |
8 (20.5%) |
155 (8.7%) |
13 (18.6%) |
7 (14.9%) |
25 (13.2%) |
0 |
52 (8.9%) |
7(16.3%) |
|
Sep 2021 |
214 (9%) |
19 (16.2%) |
4 (10.3%) |
162 (9%) |
11 (15.7%) |
6 (12.8%) |
24 (12.7%) |
0 |
56 (9.6%) |
6 (14%) |
|
Oct 2021 |
217 (9.3%) |
21 (18%) |
7 (18%) |
198 (11%) |
12 (17%) |
9 (19%) |
26 (13.8%) |
0 |
58 (9.9%) |
7 (16.3%) |
|
Nov 2021 |
238 (10%) |
22 (18.8%) |
3 (7.7%) |
177 (9.9%) |
7 (10%) |
4 (8.5%) |
11 (5.8%) |
0 |
56 (9.6%) |
6 (14%) |
|
Dec 2021 |
246 (10.5%) |
0 |
0 |
219 (12%) |
0 |
0 |
19 (10%) |
0 |
70 (12%) |
0 |
|
Jan 2022 |
201 (8.6%) |
0 |
0 |
158 (8.8%) |
0 |
0 |
12 (6.3%) |
0 |
54 (9.2%) |
0 |
|
Feb 2022 |
209 (8.9%) |
1 (0.85%) |
1 (2.6%) |
142 (7.9%) |
1 (1.4%) |
2 (4.3%) |
13 (6.9%) |
0 |
38 (6.5%) |
0 |
|
Mar 2022 |
205 (8.8%) |
0 |
1 (2.6%) |
168 (9.4%) |
1 (1.4%) |
2 (4.3%) |
13 (6.9%) |
0 |
46 (7.9%) |
0 |
|
Apr 2022 |
138 (5.9%) |
0 |
0 |
142 (7.9%) |
0 |
0 |
6 (3.2%) |
0 |
41 (7%) |
0 |
|
Total |
2,341 (100%) |
117 (100%) |
39 (100%) |
1,791 (100%) |
70 (100%) |
47 (100%) |
189 (100%) |
2 (100%) |
586 (100%) |
43 (100%) |
The number of IV cannula audited in the intervention period was 57.3% (1342/2341) and in post intervention period, 42.7% (999/2341). The number of undated IV cannula decreased from 99% (116/117) in the intervention period to 0.85% (1/117) in the post intervention period. Similarly the number of over dated IV cannula decreased from 95% (37/39) to 5% (2/39) in the post-intermention period.
The number of IV sets audited in the intervention period was 53.7% (962/1,791) and in post intervention period, 46.2% (829/1,791). The number of undated IV sets decreased from 97% (68/70) in the intervention period to 3% (2/70) in the post intervention period. Similarly the number of over dated IV sets decreased from 91.5% (43/47) to 8.5% (4/47) in the post intervention period.
The number of central lines audited in the intervention period was 66.6% (126/189) and in post intervention period, 33.3% (63/189). The number of undated central lines decreased from 100% (2/2) in the beginning of the intervention period to nil in the post intervention period
The number of Foley’s catheter audited in the intervention period was 57.5% (337/586) and in post intervention period, 42.5% (249/586). The number of undated Foley’s catheter decreased from 100% (43/43) in the intervention period to nil in the post intervention period
Adjustment for potential confounding
We performed a multi-variable analysis to adjust for factors that might be different between the two time periods, including factors that might reflect different disease severity among patients or which might interact with the intervention. We adjusted for patient characteristics, independent risk factors of HAI and independent risk factors of mortality derived from this study. After adjusting with those factors, we found that none of those patient characteristics, independent risk factors for HAI or independent risk factors of mortality significantly changed the effect of the multifaceted intervention in reducing HAIs in the post-intervention period: adjusted OR 0.28 (95% CI 0.21 to 0.38) (p<0.001)
The effectiveness of a multifaceted intervention on irrational antibiotic use
The overall use of antibiotics in the ICUs decreased from intervention to post-intervention periods; these were prescribed for 58% (780/1347) and 44% (442/995) of all patients in the ICUs, respectively (RR 0.44 (0.40 to 0.55) (p=0.43).
Discussion
HAIs are a universal healthcare problem. The largest burden is in developing countries where surveillance is rarely performed and intervention research is limited. However, it is in these settings where basic infection control interventions may have the greatest impact.
Infection control programme should integrate two fundamental strategies in order to reduce HAIs: reducing transmission of pathogens between patients and reducing the emergence and spread of antibiotic resistance. Despite financial constraints in settings with limited resources, we have shown that simple infection control measures, principally, hand hygiene and the more rational use of antibiotics, are feasible and effective. To our knowledge, this is the first quality improvement study that has evaluated the effectiveness of an infection control and antibiotic stewardship programme among hospitalized patients in a tertiary care hospital in southern India.
Patients in the intervention and post-intervention periods of this study had similar characteristics, including gender, age and underlying diseases, and could be expected to have similar intrinsic infection risks in both periods. However, there are a number of other sources of potential bias in any before-and-after study, including ascertainment bias. We addressed this in several ways. First, there was no difference in the proportion of cultures collected when patients had signs and symptoms of infection between the two time periods (data not shown). Second, there were no changes to laboratory procedures between the intervention and post-intervention periods that might lead to more false-positive cultures in the intervention period, or false-negative cultures in the post-intervention period.
Adjustment for characteristics of the patient populations was done to make a reliable estimation of the effect of the intervention and reduce confounding. [16], [17], [18] Such differences included patient demographic and illness severity characteristics, intrinsic infection risk factors and other risks and treatment differences. [17], [18] None of these significantly changed the effectiveness of the intervention for reducing HAIs; the impact of such an intervention on decreasing the rates of HAIs was greater than 75%.
Previous studies involving hand hygiene campaigns to reduce HAIs in developing countries provided effect sizes ranging from 12.7% to 100%. [19] However, those studies were mostly undertaken in neonates and adults. Two previous developing country studies involving adult populations were solely in ICUs. [20], [21]
The number of patients developing HAI decreased from 89% (198/222) in the intervention period to 10.8% (24/222) in the post-intervention period (relative risk (RR) (95% CI) 0.48 (0.31 to 0.56). The most common causes of HAIs in both periods were Gram-negative bacteria. A similar finding was also observed in the previous review conducted in developing countries.[1] Hand hygiene has been shown to be effective in preventing transmission of Gram-negative bacteria.[22], [23]
Hand hygiene is inexpensive and fundamental to infection prevention programme, and our data provide strong evidence of its value in developing countries. Overall, hand hygiene compliance among the health-care workers was maintained at 100% during both the periods, which is more than of other studies with post-intervention hand hygiene compliance rates reported between 40% and 60%.[24], [25]
The overall use of antibiotics in the ICUs decreased from intervention to post-intervention periods; these were prescribed for 58% (780/1347) and 44% (442/995) of all patients in the ICUs, respectively ( p=0.43). More rational prescribing was achieved, particularly, de-escalation of antibiotics. In a developing country, referral hospitals where infectious diseases remain the major cause of hospital admissions and where bacterial infection rates are high, antibiotic prescribing at this level is understandable. The greatest gains in reducing antibiotic prescribing may not be in limiting the initiation of antibiotic treatment, but in earlier cessation or scaling down when serious bacterial infection is unlikely. [26]
Inappropriate use of antibiotics is a universal problem. It has been described well in developed countries, but a renewed focus is needed in developing countries, where the major burden of antibiotic resistance may exist.[26]
Although the multifaceted intervention was not primarily aimed at reducing overall hospital mortality, we observed a significant reduction in deaths. After adjustment for several high- risk patient characteristics, types of treatments and the severity of illness, the multifaceted intervention was associated with a risk of in-hospital mortality that was at least 6% lower in the post-intervention period.
While it is difficult to isolate the most effective components of the intervention we used, such an effectiveness study reflects the complexity of clinical practice. [27] A before-and-after study design is a practical choice for the evaluation of the effective- ness of a complex quality improvement intervention, and it is commonly used for implementation of best practice guidelines when a randomized controlled trial is not feasible or ethical. The 11-month period before and after the intervention was chosen so as to reduce any effect of seasonal variation of HAIs [27] or other infections, and an identical method of data collection before and after the intervention was used to minimise bias. [27]
Conclusions
A multifaceted infection control and antibiotic stewardship programme were effective in reducing HAIs and improving healthcare outcomes, including reducing in-hospital mortality. Even in resource-limited settings, HAIs and their consequences are not inevitable events.
Conflict of Interest
The authors declare no relevant conflicts of interest.
Source of Funding
None.
References
- B Allegranzi, S B Nejad, C Combescure, W Graafmans, H Attar, L Donaldson. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet 2011. [Google Scholar] [Crossref]
- RM Klevens, JR Edwards, CL Richards, TC Horan, RP Gaynes, DA Pollock. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2002. [Google Scholar] [Crossref]
- . European Centre for Disease Prevention. Annual epidemiological report on communicable diseases in Europe. ECDC, European Centre for Disease Prevention and Control. 2008. [Google Scholar]
- B Allegranzi, D Pittet. Role of hand hygiene in healthcare-associated infection prevention. J Hospital Infect 2009. [Google Scholar] [Crossref]
- GL Darmstadt, ASM Nawshad Uddin Ahmed, SK Saha, MAK Azad Chowdhury, MA Alam, M Khatun. Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh. J Perinatol 2005. [Google Scholar] [Crossref]
- C J Gill, J B Mantaring, W B Macleod, M Mendoza, S Mendoza, W C Huskins. Impact of enhanced infection control at 2 neonatal intensive care units in the Philippines. Clin Infect Dis 2009. [Google Scholar]
- J B Carlin, L W Doyle. Sample size. J Paediatr Child Health 2002. [Google Scholar] [Crossref]
- T C Horan, M Andrus, M A Dudeck. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008. [Google Scholar]
- J S Garner, W R Jarvis, T G Emori, T C Horan, J M Hughes. CDC definitions for nosocomial infections. Am J iInfect Control 1988. [Google Scholar]
- . WHO. Pocket book of hospital care for children: Guidelines for the management of common illnesses with limited resources. 1st edn. World Health Organization. (accessed 25 April 2022). 2005. [Google Scholar]
- ME Levison, JH Levison. Pharmacokinetics and pharmacodynamics of antibacterial agents. Infect Dis Clin 2009. [Google Scholar]
- . WHO Guidelines on Hand Hygiene in Health Care: a Summary. World Health Organization . 2009. [Google Scholar]
- H Sax, B Allegranzi, I Uckay, E Larson, J Boyce, D Pittet. My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007. [Google Scholar] [Crossref]
- H Sax, B Allegranzi, M N Chraïti, J Boyce, E Larson, D Pittet. The World Health Organization hand hygiene observation method. Am J Infect Control 2009. [Google Scholar]
- . CLSI performance standards for antimicrobial susceptibility tsting-seventeenth informational supplement. CLSI document M100-S17 2007:27. . [Google Scholar]
- S Blot, P Depuydt, K Vandewoude, D De Bacquer. Measuring the impact of multidrug resistance in nosocomial infection. Curr Opin Infect Dis 2007. [Google Scholar] [Crossref]
- S Blot. Limiting the attributable mortality of nosocomial infection and multidrug resistance in intensive care units. Clin Microbiol Infect 2008. [Google Scholar] [Crossref]
- I Murni, T Duke, R Triasih, S Kinney, A J Daley, Y Soenarto. Prevention of nosocomial infections in developing countries, a systematic review. Paediatr Int Child Health 2013. [Google Scholar]
- V D Rosenthal, C Álvarez-Moreno, W Villamil-Gómez, S Singh, B Ramachandran, J A Navoa-Ng. 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. Am J Infect Control 2012. [Google Scholar]
- L Barrera, W Zingg, F Mendez, D Pittet. Effectiveness of a hand hygiene promotion strategy using alcohol-based handrub in 6 intensive care units in Colombia. Am J Infect Control 2011. [Google Scholar]
- J M Jefferies, T Cooper, T Yam, S C Clarke. Pseudomonas aeruginosa outbreaks in the neonatal intensive care unit-a systematic review of risk factors and environmental sources. J Med Microbiol 2012. [Google Scholar]
- S Jones. Hand hygiene and transmission of Pseudomonas aeruginosa on hands in a hospital environment. J Infect Prev 2011. [Google Scholar]
- J M Boyce. CDC guideline for hand hygiene in health-care setting. MMWR 2002. [Google Scholar]
- B Allegranzi, A Gayet-Ageron, N Damani, L Bengaly, M L Mclaws, M L Moro. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis 2013. [Google Scholar]
- . World Health Organization. WHO global strategy for containment of antimicrobial resistance. World Health Organization. (Accessed 20 April 2022).. 2001. [Google Scholar]
- R Grol, M Wensing, M Eccles. Improving patient care: the implementation of change in clinical practice. 2005. [Google Scholar]
- G Cable. Enhancing causal interpretations of quality improvement interventions. Qual Health Care 2001. [Google Scholar] [Crossref]
- Introduction
- Materials and Methods
- Design
- Sample size
- Inclusion criteria
- Outcome measures and data collection
- Hospital-acquired infection
- The rational use of antibiotics
- Hand hygiene compliance
- Bacterial culture
- Intervention period
- Intervention phase
- Post-intervention period
- Outcome measures
- Data analysis
- Results
- Study population
- The effectiveness of the multifaceted intervention on HAIs
- Adjustment for potential confounding
- The effectiveness of a multifaceted intervention on irrational antibiotic use
- Discussion
- Conclusions
- Conflict of Interest
- Source of Funding