The Use of Prevalence Surveys for Healthcare-Associated Infection Surveillance



The Use of Prevalence Surveys for Healthcare-Associated Infection Surveillance


Bruno P. Coignard



INTRODUCTION

A point-prevalence survey often is the first step to be implemented for healthcare-associated infection (HAI) surveillance in healthcare facilities. Its objectives are to give an estimate of the total burden of HAIs, to describe patients’ characteristics (i.e., specialties, risk factors including exposure to invasive devices or procedures), infections (i.e., sites, microorganisms including markers of antimicrobial resistance), and/or antimicrobial treatments they are exposed to.

Point-prevalence surveys have been extensively used at local, regional, or national levels since the early 1960s. Among the first published surveys were those conducted in the United States at Boston City Hospital from 1964 to 1973, which documented at 3-year intervals the prevalence of HAIs and of antimicrobial use, of 12.0% and 33.0% in 1970, respectively (1,2). From 1969 to 1973, the Centers for Disease Control and Prevention (CDC) also conducted surveillance in 8 hospitals in the Comprehensive Hospital Infection Project (CHIP), which was based on prevalence studies performed every 4 months (3). The Study of the Efficacy of Nosocomial Infection Control (SENIC) Project (from 1974 to 1983) and the National Nosocomial Infections Surveillance (NNIS) System (from 1970 to 2004) then advocated for continuous, prospective incidence surveillance components (4). In an effort to allow for interhospital comparison of rates and benchmarking of healthcare facilities, targeted, risk-adjusted surveillance components, now incorporated into the National Healthcare Safety Network (NHSN, from 2005 till present), were developed and have produced estimates of selected HAIs for many years (5). However, hospital-wide surveillance, which was mandated in the early days of the NNIS system, was discontinued in 1996, and incidence surveillance was focused on intensive care unit (ICU), high-risk nursery, or surgical patients. Reinforced with U.S. state-mandated HAI reporting, this long-lasting trend narrowed the focus of HAI surveillance, limiting its ability to identify emerging infections or even estimate the true magnitude of hospital-wide HAIs and leading CDC to recently reconsider the value of HAI prevalence surveys (6).

Although other countries also replicated the NNIS model (7,8), they also have been using hospital-wide point-prevalence surveys as a tool for HAI surveillance for a long time. From the first HAI point-prevalence survey implemented in the 1970s in Sweden (9) to the most recent one coordinated by the European Center for Disease Prevention and Control (ECDC) among 30 countries in 2011 and 2012 (10), numerous point-prevalence surveys on HAIs and/or antimicrobial use and resistant pathogens were conducted in Europe (Table 7.1) or elsewhere in the world (Table 7.2), with a prevalence of patients with one or more HAIs ranging from 3.5% to 16.8%. Some surveys also were targeted on specific infection sites, pathogens, or specialty populations, providing a quick and useful focus on undocumented HAIs of public health importance, such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile infections, HAIs in neonatal or pediatric patients or in long-term care facility residents (Table 7.3).


THE PROS AND CONS OF PREVALENCE SURVEYS

Point-prevalence surveys have numerous advantages over incidence surveys. They are unique in their ability to quickly get an overall picture of the magnitude and scope of all HAIs. Hospital-wide point-prevalence surveys not only describe the full spectrum of infection sites and pathogens affecting hospitalized patients, but first and foremost their main characteristics, risk factors, invasive devices, procedures, or antimicrobial treatments they are exposed to. In France in 2006, the median age of the patients was 69 years, 1 out of 10 patients was immunosuppressed, 1 out of 3 had an ultimately or rapidly fatal disease (McCabe score 1 or 2), 1 out of 5 had surgery within the past 30 days, 1 out of 4 had a vascular catheter, and 1 out of 10 had a urinary catheter; 5.0% had one or more HAIs (urinary tract, lower respiratory tract, and surgical site infections accounting for 60% of infections) and 15.5% received an antimicrobial therapy (11). Such point-prevalence surveys provide a sound basis for identifying and setting-up future priorities for



infection surveillance and control, including incidence surveys and targeted prevention programs in identified high-risk patients or areas. They also can provide more detailed data on patients and their exposures than can usually be collected in on-going incidence surveillance systems.








TABLE 7.1 Selected Point-Prevalence Surveys in Europe, from 1975 to 2012
































































































































































































































































































































































































Country

Year of Survey

Hospitals (No)

Patients (No)

Type of Care

Type of Wards

Types of Infections

CDC def. for HAI

Prev. of Patients with ≥1 HAI / of HAI (%)

Infections Documented by Microbiology (%)

Prev. of Patients with Antimicrobials (%)

Ref.


Sweden

1975

5

4,246

AC, LTC

All

All sites

N

—/17.0



9.


Norway

1979

15

7,833

AC

All

All sites

N

—/9.0



38.


United Kingdom

1980

43

18,163

AC

All

All sites

N (HIS)

—/9.2



39.


Italy

1983

130

34,577

AC

All

All sites

N

6.8/—


35.5

40.


Belgium

1984

106

8,723

AC

All

UTI, SSI, BSI

N

9.3/—



41.


Czechoslovakia

1984

23

12,260

AC

All

All sites

N

—/6.1



42.


Spain

1990

123

38,489

AC

All

All sites

Y

8.5/9.9


33.8

43.


France

1990

39

11,599

AC

All

UTI, SSI, LRTI, BSI, CAT

Y

6.7/7.4

81.2

29.5

44.


Norway

1991

76

14,977

AC

All

All sites

N

—/6.3



45.


UK & Republic of Ireland

1993-1994

157

37,111

AC

All

All sites

N (HIS)

—/9.0



46.


Germany

1994

72

14,996

AC

All

All sites

Y

3.5/3.6

56.5


36.


Switzerland

1996

4

1,349

AC

All

All sites

Y

11.6/13.0

65.0


47.


France

1996

830

236,334

AC, LTC, RH, PSY

All

All sites

Y, mod. (+McGeer)

6.7+1.3a/7.6



48.


Greece

1999

14

3,925

AC

All

All sites

Y

8.6/9.3

51.5

51.4

49.


France

2001

1,533

305,656

AC, LTC, RH, PSY

All

All sites

Y, mod. (+McGeer)

6.9/7.5

72.0

15.9

50.


Italy

2001

15

2,165

AC

All but ≤14 yo

All sites

Y

7.5/8.3



51.


Slovenia

2001

19

6,695

AC

All

All sites

Y

4.6/5.0

55.8


52.


Latvia

2001

2

1,291

AC

All

All sites

N (HIS)

5.1/5.7

29.0

22.0

53.


Italy

2002-2004

51

9,609

AC

All but ≤14 yo

All sites

Y

6.1/6.7

68.4

45.3

54.


Albania

2003

1

968

AC

All

All sites

Y, mod.

16.8/19.1

71.4

46.9

55.


Finland

2005

30

8,234

AC

All

All sites

Y

8.5/9.1

53.0

39.0

35.


Scotland

2005

45

11,608

AC

All but ≤16 yo

All sites

Y, mod.

9.5/10.7



56.


France

2006

2,337

358,353

AC, LTC, RH, PSY

All

All sites

Y, mod. (+McGeer)

5.0/5.4

70.0

15.5

11.


UK & Republic of Ireland

2006

270

75,694

AC

All but children

All sites

Y

7.6


33.1

57.


Belgium

2007

63

17,343

AC

All

All sites

Y

6.2/7.1



58.


The Netherlands

2007-2008

41

26,937

AC

All

All sites

Y, mod.

6.2/7.2


30.9

59.


Lithuania

2007

30

6,288

AC

All

All sites

Y

3.4

28.6

32.1

60.


Scotland

2011

52

11,902

AC

All

All sites

N (ECDC)

4.9/5.2



61.


a Only HAI acquired in the reporting facility were described; 1.3% of patients had a HAI at their admission


HAI, healthcare-associated infection; AC, acute care; LTC, long-term care; RH, rehabilitation; PSY, psychiatrics; UTI, urinary tract infection; SSI, surgical site infection; LRTI, lower respiratory tract infection; BSI, bloodstream infection; CAT, catheter-associated infection; Y, yes; mod, modified; HIS, Hospital Infection Society; ECDC, European Centre for Disease Prevention and Control; yo, year-old









TABLE 7.2 Selected Point-Prevalence Surveys in the World Outside the United States or Europe, from 1984 to 2008


































































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Country

Year of Survey

Hospitals (No)

Patients (No)

Type of Care

Type of Wards

Types of Infections

CDC def. for HAI

Prev. of Patients with ≥1 HAI / of HAI (%)

Infections Documented by Microbiology (%)

Prev. of Patients with Antimicrobials (%)

Ref.


Australia

1984


28,643

AC

All

All sites


6.3/8.1



62.


Hong-Kong

1987

10

9,848





8.6/—



63.


Lebanon

1997

14

834

AC

All

All sites

Y

6.8/8.5

39.4


64.


Indonesia

2001-2002

2

2,222

AC

All

UTI, SSI, PHL, SEP

Y, mod.

—/6.9


42.3