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| Infection |
Notice to Readers: Fourth
Decennial International Conference on Nosocomial and Healthcare-Associated
Infections.
MMWR, February 25, 2000 / 49(07);138.
This article reports that every year in the U.S., approximately 2,000,000 patients develop hospital-acquired infections and 88,000 die from them. The cost of hospital-acquired infections has been estimated at $4.6 billion. These estimates are conservative, because they do not take into account nosocomial infections occurring in patients in nursing homes, outpatient clinics, dialysis centers and other health care centers.
Mortality associated with
nosocomial infections: analysis of multiple cause-of-death data.
White MC.
J Clin Epidemiol 1993 Jan;46(1):95-100.
This article emphasizes that hospital-acquired infections are among the 10 leading cause of death in the U.S.
The nationwide nosocomial
infection rate. A new need for vital statistics.
Haley RW, Culver DH, White JW, Morgan WM,
Emori TG.
Am J Epidemiol 1985 Feb;121(2):159-67.
The results of this study indicate that in 1985, the incidence of hospital-acquired infections in the U.S. was 5.7 per 100 patients. Extrapolation of these data to the 6,449 acute-care hospitals revealed that every year, in the U.S., approximately 2 million infections occur in hospitalized patients. However, after adjustment for accuracy of detection methods, trend toward a nationwide increase in infection rates, and number of infections in nursing home patients, the estimated number of yearly nosocomial infections increased to 4 millions. The authors emphasizes that these data greatly exceed previous evaluations, and call for correct statistics to properly address the problem.
Trends in infectious disease
hospitalizations in the United States, 1980-1994.
Simonsen L, Conn LA, Pinner RW, Teutsch S.
Arch Intern Med 1998 Sep 28;158(17):1923-8.
The results of this study show that from 1980 to 1994, mortality rates in individuals hospitalized for infectious disease doubled, from 1.9% to 4.0%.
Trends in infectious diseases
mortality in the Unites States.
Pinner RW, et al.
JAMA 1996 Jan 17;275(3):189-93.
The results of this study show that from 1980 to 1992, death due to infectious diseases in the U.S. increased 58%, from 41 to 65 deaths per 100,000 population. Of note, death due to infectious diseases increased 6.3 times in individuals aged 25- to 44-years-old, from 6 to 38 deaths per 100,000 population. These data indicate that despite previsions of a decline in rates of infectious diseases in the U.S., mortality rates from infectious diseases have actually been progressively increasing in recent years.
Nosocomial bloodstream
infections. Secular trends in rates, mortality, and contribution to total
hospital deaths.
Pittet D, Wenzel RP.
Arch Intern Med 1995 Jun 12;155(11):1177-84.
The results of this study show that the incidence of hospital-acquired bloodstream infections increased threefold in the period from 1980 to 1992, from a rate of 6.7 to 18.4 infections per 1,000 discharges. Population-attributable risk of death from this complication also rose during this period, from 3.55 to 6.22 deaths per 1,000 discharges.
Nosocomial enterococci resistant
to vancomycin--United States, 1989-1993.
MMWR Morb Mortal Wkly Rep 1993 Aug 6;42(30):597-9.
This article reports that from 1989 to 1993, the rate of enterococci responsible for hospital-acquired infections that acquired resistance to the antibiotic vancomycin increased by more than 20 folds. The majority of these bacteria are resistant to all available antibiotics. In the intensive care units, the percentage of vancomycin-resistant enterococci strains increased from 0.4% in 1989 to 13.6% in 1993.
Emerging and reemerging
microbial threats. Nosocomial fungal infections.
Henderson VJ, Hirvela ER.
Arch Surg 1996 Mar;131(3):330-7.
This article shows that the rate of fungal hospital-acquired infections increased steadily in the past 25 years, from a rate of 2.0 infections per 1000 discharges to as high as 6.6 infections per 1000 discharges.
Hospital-acquired candidemia.
The attributable mortality and excess length of stay.
Wey SB, Mori M, Pfaller MA, Woolson RF,
Wenzel RP.
Arch Intern Med 1988 Dec;148(12):2642-5.
The results of this study show that from 1977 to 1984, the incidence of hospital-acquired bloodstream infections caused by Candida species in the U.S. tripled. Patients with fungemia have a 3-fold increased risk of dying, compared to uninfected, closely matched patients. Hospital length of stay in patients who survived the bloodstream infection was 70 days, as compared to 40 days in matched controls. Candida infections were responsible for 10% of all bloodstream infections.
Secular trends in the
epidemiology of nosocomial fungal infections in the United States,
1980-1990.
National Nosocomial Infections Surveillance
System.
Beck-Sague C, Jarvis WR.
J Infect Dis 1993 May;167(5):1247-51.
This article reports on the increase in the incidence of hospital-acquired fungal infections in U.S. hospitals, as determined by evaluation of data submitted to the National Nosocomial Infections Surveillance System. The rate of this complication increased from 2.0 per 1000 discharges in 1980 to 3.8 per 1000 discharges in 1990, an almost two-fold increase. Candida species accounted for three-quarters of infections. Patients with a central intravascular catheter had a 3-fold increased risk of developing a fungal bloodstream infection, compared to those without it. Thirty percent of patients with hospital-acquired fungemia died, compared to 17% of those with bloodstream infections due to other microorganisms.
Accuracy of reporting nosocomial
infections in intensive-care-unit patients to the National Nosocomial
Infections Surveillance System: a pilot study.
Emori TG, et al.
Infect Control Hosp Epidemiol 1998 May;19(5):308-16.
The results of this study indicate that the National Nosocomial Infections Surveillance (NNIS) System is not a reliable indicator of the true incidence of nosocomial infections in hospital settings. This system was instituted under the sponsorship of the Centers for Disease Control (CDC) to monitor rates of hospital-acquired infections through voluntarily reporting of this complication by participating hospitals. The accuracy of the system in reflecting the rate of nosocomial infections was evaluated by reviewing the charts of 1,136 patients admitted to the intensive care units of 9 hospitals. There were 611 reports of hospital-acquired infections submitted to the NNIS system for this cohort. However, when some trained epidemiologists evaluated retrospectively the charts of the patients, they identified 340 extra infections that had not been previously reported. These data indicate that the voluntary system of reporting of hospital-acquired infections is significantly underestimating the true incidence of nosocomial infections in U.S. hospitals, and, as a consequence, all studies that utilize data from the NNIS system are misrepresenting the real magnitude of the problem.
Influence of nosocomial
infection on mortality rate in an intensive care unit.
Bueno-Cavanillas A, et al.
Crit Care Med 1994 Jan;22(1):55-60.
The results of this study show that patients who develop hospital-acquired infections have a twofold increased risk of death, compared to uninfected patients. The increased risk of death persists even after adjustment for several confounding factors, and is particularly high in younger patients with less severe disease.
A survey of nosocomial
infections and their influence on hospital mortality rates.
Dinkel RH, Lebok U.
J Hosp Infect 1994 Dec;28(4):297-304.
The results of this study show that even after controlling for possible confounders, patients who develop a hospital-acquired infection have a two-fold increased risk of death, compared to patients without this complication. The risk of death increases by three-folds in patients hospitalized for trauma who develop a hospital-acquired infection.
Nosocomial infections in elderly
patients in the United States, 1986-1990.
National Nosocomial Infections Surveillance
System.
Emori TG, et al.
Am J Med 1991 Sep 16;91(3B):289S-293S.
This study reports that from 1986 to 1990, 89 hospitals submitted to the National Nosocomial Infections Surveillance (NNIS) system a total of 101,479 reports of hospital-acquired infections occurring in 75,398 adult patients. In 12% of the infections the patients died. In 54% of elderly patients that died an in 59% of younger patients that died the infection was judged to be related to their death. Bloodstream infections and pneumonias were associated with the highest mortality rates.
The impact of surgical-site
infections in the 1990s: attributable mortality, excess length of
hospitalization, and extra costs.
Kirkland KB, Briggs JP, Trivette SL,
Wilkinson WE, Sexton DJ.
Infect Control Hosp Epidemiol 1999 Nov;20(11):725-30.
The results of this study, conducted on 255 pairs of matched surgical patients with and without surgical site infection, indicate that infected patients have a 2.2-fold increased risk of dying, a 60% increased risk of being admitted to an intensive care unit, and a twofold increased hospital length of stay, compared to uninfected patients. In addition, patients who survive a surgical site infection are approximately 6 times more likely to be readmitted to the hospital in the 30-days following discharge, compared to uninfected patients. The study estimated that, after the inclusion of the second hospital admission, each surgical site infection was associated with an excess hospital stay of 12 days and with an excess cost of $5,038 per patient. The authors highlight that the implementation of measures designed to reduce the rates of surgical site infections will likely result in a significant reduction of infection-related morbidity, mortality and health care costs.
Nosocomial infections in surgical patients in the United States, January 1986-June 1992.
National Nosocomial Infections Surveillance (NNIS) System.
Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR.
Infect Control Hosp Epidemiol 1993 Feb;14(2):73-80.
This study reports that from 1986 to 1992, 106 hospitals reported to the National Nosocomial Infections Surveillance System a total of 59,351 hospital-acquired infections occurring in 48,168 surgical patients. The probability that these infections were related to the death of the patients ranged from 22% for urinary tract infections, to 90% for organ/space surgical site infections.
Infection in surgical patients:
effects on mortality, hospitalization, and postdischarge care.
DiPiro JT, Martindale RG, Bakst A, Vacani PF,
Watson P, Miller MT.
Am J Health Syst Pharm 1998 Apr 15;55(8):777-81.
The results of this study show that 12% of patients who undergo moderate to high-risk surgical procedures develop hospital-acquired infections. Mortality rates in infected patients are 14.5%, as compared to 1.8% in uninfected patients. In addition, hospital length of stay more than triples in infected versus uninfected patients (14 days vs. 4 days), and so does the number of patients who require health care assistance after hospital discharge (24% of infected patients versus 7% of uninfected ones).
Nosocomial infection, indices of
intrinsic infection risk, and in-hospital mortality in general surgery.
Delgado-Rodriguez M, et al.
J Hosp Infect 1999 Mar;41(3):203-11.
The results of this study show that patients who develop a surgical site infection or a bloodstream infection have a 4.5-fold and 17.3-fold increased risk of dying, respectively, compared to uninfected patients.
Nosocomial infection in surgery
wards: a controlled study of increased duration of hospital stays and direct
cost of hospitalization.
Vegas AA, Jodra VM, Garcia ML.
Eur J Epidemiol 1993 Sep;9(5):504-10.
The results of this study show that hospital-length of stay increases by an average of 14 days in patients who develop hospital-acquired wound infections. The study was conducted on a sample of patients from a general and digestive surgical ward, to assess the effect that hospital-acquired infections had on the length of their hospital stay. Infected and uninfected patients were matched for age, diagnosis, surgical procedure, and, when possible, underlying conditions, elective or emergency surgery, and invasive devises. Length of hospital stay increased by l2.6 days in patients who developed superficial wound infection, compared to those without infection. Wound infections, either superficial or deep, and other infections were associated with an extra 14.3 and 7.3 days of hospital stay, respectively.
Selected aspects of the
socioeconomic impact of nosocomial infections: morbidity, mortality, cost,
and prevention.
Jarvis WR.
Infect Control Hosp Epidemiol 1996 Aug;17(8):552-7.
This study shows that in the U.S., every year, approximately 2 million infections occur in hospital patients, leading to substantial increase in morbidity, mortality, and health care costs. Hospital length of stay increases by 1 to 4 days in patients who contract urinary tract infections, by 7-8 days in those with surgical site infections, by 7 to 21 days in those with bloodstream infections, and by 7 to 30 days in those with pneumonia. Costs associated with these infections have been estimated at $550-$600 for each urinary tract infection, $2,700 for each surgical site infection, $3,000 to $40,000 for each bloodstream infection, and $5,000 for each pneumonia.
Nosocomial pneumonia and
mortality among patients in intensive care units.
Fagon JY, Chastre J, Vuagnat A, Trouillet JL,
Novara A, Gibert C.
JAMA 1996 Mar 20;275(11):866-9.
The results of this study show that 16.6% of patients admitted to an intensive care unit in France develop hospital-acquired pneumonia. The study, conducted on 1978 consecutive patients, also showed that patients who developed pneumonia while in the hospital had a twofold increased rate of death, compared to those without pneumonia, and this increase was unrelated to the severity of underlying diseases.
Hospital-acquired pneumonia.
Attributable mortality and morbidity.
Leu HS, Kaiser DL, Mori M, Woolson RF, Wenzel
RP.
Am J Epidemiol 1989 Jun;129(6):1258-67.
The results of this study show that 30% of patients who develop hospital-acquired pneumonia die. In one third of patients the infection is judged to be directly responsible for the death of the patient.
Nosocomial pneumonia in
ventilated patients: a cohort study evaluating attributable mortality and
hospital stay.
Fagon JY, Chastre J, Hance AJ, Montravers P,
Novara A, Gibert C.
Am J Med 1993 Mar;94(3):281-8.
The results of this study show that the development of hospital-acquired
pneumonia is associated with a two-fold increased risk of death in
mechanically ventilated patients, and with a significant prolongation of
hospital length of stay, from a median of 21 days to a median of 34 days.
The increase in death rates is independent from underlying diseases.
Guidelines for Prevention of
Nosocomial Pneumonia.
MMWR January 03, 1997 / 46(RR-1);1-79.
This article reports that pneumonia accounts for 15% of all hospital-acquired infections (HAIs), and is the second most frequent HAI after urinary tract infections. The incidence of nosocomial pneumonia has been estimated at approximately 6 per 1000 hospitalized patients, and is significantly higher in university hospitals, compared to non-teaching hospitals. Reported mortality rates range from 20% to 50%, and in 30% to 33% of cases the death is directly attributed to the infection contracted in the hospital. Conservative estimates place the total costs of this complication at $1.2 billion per year. Bacteria responsible for the infections are found everywhere in the hospital and are frequently spread from patient to patient through contaminated hands of health care workers. The risk of spreading the infection could be considerably reduced by adhesion to simple hand-washing practices. However, doctors rarely comply with this practice, and as a consequence the use of gloves has been promoted in order to reduce cross-contamination. Unfortunately, transmission of infection has been reported even with use of gloves, and is attributable to either breaks in the glove, or to the omission by health care workers to change their gloves between contacts with different patients.
Hand washing. A modest measure
with big effects.
Handwashing Liaison Group.
BMJ 1999;318:686-686 ( 13 March ).
This article highlights that hand washing, a simple preventive measure effective in reducing the spread of in-hospital infections, is frequently disregarded as such by health care workers, who often fail to perform it. The incidence of in-hospital infections is significantly high, with an estimated 9% of patients acquiring an infection while being in the hospital. Hands are an important vehicle of transfer of pathogenic bacteria from one patient to the other. The majority of physicians, however, fail to decontaminate their hands after contact with patients. One study documented hand washing in only 9% of physicians, and another documented senior physicians washing their hands only twice during a 21-hour ward shift. Failure of physicians to recognize the risks associated with non-compliance reflects a system of belief that is deeply ingrained and of difficult solution. The authors emphasize how physicians need to recognize that hand contamination is an important mean of transfer of pathogenic bacteria before hand washing practices can be integrated as part of normal duty care.
Current guidelines for the treatment and
prevention of nosocomial infections.
Bergogne-Berezin E.
Drugs 1999 Jul;58(1):51-67.
This article highlights that in the U.S., 5% to 10% of patients admitted to the hospital develop a hospital-acquired infection. The incidence of this complication is particularly high in the intensive care units, where it occurs in as many as 28% of patients. There are preventive measures that could reduce the incidence of hospital-acquired infections, and they include improvement in nursing practices, decreased rates of antibiotic prescribing, and shortened hospital stay. These measures could significantly lower health care costs and infection-related morbidity and mortality.
Nosocomial Hepatitis B Virus
Infection Associated with Reusable Fingerstick Blood Sampling Devices --
Ohio and New York City, 1996.
MMWR. March 14, 1997 / 46(10);217-221.
This article reports on two outbreaks of hepatitis B virus infection that
occurred in diabetic patients from an Ohio nursing home and a New York City
hospital. In both instances, an epidemiologic investigation revealed that
patients became infected because the health-care personnel did not change
fingerstick devices for blood-glucose monitoring between patients.
Nosocomial transmission of
hepatitis B virus associated with the use of a spring-loaded finger-stick
device.
Polish LB, et al.
N Engl J Med 1992 Mar 12;326(11):721-5.
This article reports on the case of 26 diabetic patients who developed hepatitis B virus infection in a California hospital. Epidemiologic investigation revealed that the virus was spread from one infected patient to the others due to nursing practices of utilizing the same blood glucose monitoring fingerstick device for several patients.
Hospital infection rates in
England out of control. News.
Kmietowicz, Z.
BMJ 2000;320:534 ( 26 February ).
This letter explains that in England, every year, at least 100,000 patients develop hospital-acquired infections and 5,000 of them die from the complication. Hospital-acquired infections affect approximately 1 every 10 hospitalized patients, for an annual cost of £1bn ($1.6 billion). Very little effort is put in the prevention of infections, as shown by the scant participation of clinicians and hospital chief executives to the problem. In some areas, for example, 1 infection control nurse is in charge of 1,000 beds, and only 1 of 5 hospitals surveyed has the minimum number of infection control doctors recommended by the Royal College of Pathologists -1 physician per 1,000 beds. These resources are obviously insufficient to guarantee an effective control of the spread of pathogens among hospitalized patients, a negligence that results not only in excess length of hospital stay and health care costs, but also in significant morbidity and mortality.
Nosocomial bloodstream infection
in critically ill patients. Excess length of stay, extra costs, and
attributable mortality.
Pittet D, Tarara D, Wenzel RP.
JAMA 1994 May 25;271(20):1598-601.
The results of this study show that patients who develop hospital-acquired bloodstream infections have an over three-fold increased risk of dying and an almost two-fold increase in hospital length of stay, compared to uninfected ones. The study was conducted on 86 pairs of patients from a surgical intensive care unit (SICU), with and without bloodstream infection, who were matched for age, sex, length of hospital stay and number of discharge diagnoses. Fifty percent of patients with bloodstream infection died, compared to 15% of those without this complication. In addition, patients who survived the infection spent an additional 24 days in the hospital and an additional 8 days in the SICU, compared to controls (54 vs. 30 days and 15 vs. 7 days, respectively). Health care costs attributable to the bloodstream infection were estimated at $40,000 per patient.
Part 2|
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