Epidemiology of healthcare acquired infection An Indian perspective on surgical site infection and catheter related blood stream infection

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Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P Epidemiology of healthcare acquired infection An Indian perspective on surgical site infection and catheter
Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P Epidemiology of healthcare acquired infection An Indian perspective on surgical site infection and catheter related blood stream infection V Ramasubramanian 1, Vivek Iyer 2*, Sandeep Sewlikar 3 and Anish Desai 4 1 Sr Consultant Infectious Diseases, HIV & Tropical Medicine, Apollo hospitals, Chennai Adjunct Professor of Infectious Diseases & Consultant, Sri Ramachandra Medical College & Research Institute (DU). Adjunct Associate Professor of Infectious Diseases, University of Queensland. Adjunct Associate Professor of Infectious Diseases, MGR Medical University 2 Infection Prevention Specialist, Johnson and Johnson Limited, Mumbai 3 Manager Clinical Affairs, Johnson and Johnson Limited, Mumbai 4 Director Medical Affairs and Clinical Operations, Johnson and Johnson Limited, Mumbai * Corresponding Author: Dr. Vivek Iyer ; Date of submission: 08 June 2014 ; Date of Publication: 15 September 2014 ABSTRACT Healthcare acquired infections or hospital acquired infections (HAIs) are amongst the most common complications of hospital care, leading to high morbidity and mortality. While WHO estimates about 7-12% HAI burden in hospitalized patients globally, the figures from India are alarming, with an incidence rate varying from 11% to 83% for different kinds of HAIs. The article reviews literature and data for HAIs from India, with particular focus on surgical site infections (SSIs) and catheter related blood stream infection (CRBSI). The profile of SSIs and CRBSIs in India with a relative context to the relevant global data has been discussed. Key words: Hospital acquired infection, Surgical site infection, Catheter related blood stream infection, pathogens INTRODUCTION Healthcare acquired infection, alternatively also called hospital acquired infection (HAI), or nosocomial infection refers to the infection occurring in patients after admission at the hospital for a reason other than that infection; an infection that was neither present nor incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility (1, 2, 3). As a general timeline, infections occurring more than 48 hours after admission are usually considered hospital acquired. The Hospital Infection Society of India (HISI) finds the latter justified in the Indian scenario, as most of the time it is difficult to make out whether an infection was acquired outside the hospital or inside a specific healthcare set up (4). The current clinical review highlights published literature on epidemiology of HAI, surgical site infection (SSI) and catheter related blood stream infection (CRBSI) in India. The literature search was performed using Medline database, PubMed website and general search engines. The citations published in last two decades, highlighting incidence rate, prevalence rate and economic burden were considered for the review. Total 18 studies were shortlisted for the review. Most of them were prospective observational studies and one study was single day point prevalence study. 46 Indian Journal of Basic and Applied Medical Research; September 2014: Vol.-3, Issue- 4, P HAIs are likely to be the most common complication of hospital care. World Health Organization (WHO) developing countries including India revealed an overall rate of 14.7% HAI corresponding to 22.5 estimates these infections to occur among 7-12% of infections per 1000 ICU days (7). In 2007, the the hospitalized patients globally, with more than 1.4 INICC conducted a prospective surveillance in 7 million people suffering from infectious Indian cities to determine the rate of HAI, complications acquired in the hospital at any time (1, 2, 5). A survey amongst 55 hospitals of 14 countries representing the 4 WHO regions (Europe, Eastern Mediterranean, South-East Asia and Western Pacific) showed that 8.7% of hospital patients had nosocomial infections (1). HAIs have highest prevalence in intensive care units (ICUs), and in acute surgical and orthopaedic wards (1). Moreover, the burden of HAIs is higher in developing countries (6). The estimated prevalence of HAIs in the United States (US) is 4.5% corresponding to 9.3 infections per 1000 patientdays; while that in Europe is reported to be 7.1% corresponding to a cumulative incidence of 17.0 episodes per 1000 patient-days (3). A Multicenter, prospective cohort surveillance of device-associated infection by the International Nosocomial Infection Control Consortium (INICC) in 55 ICUs of 8 microbiological profile, and related aspects in India. Data for a total of 10,835 patients hospitalized for a total of 52,518 days from 12 ICUs at 7 different hospitals were evaluated. This study benchmarks HAI rates in Indian ICUs against international standards. An overall HAI incidence rate of 4.4% corresponding to 9.06 infections per 1000 ICU-days was reported (9). Lately, there are increasing reports from different parts of the country revealing varying HAI incidence rates across various healthcare setups. In India, major health services are given by government hospitals. Unfortunately, very limited HAI data is available from government hospitals to assess the actual burden of HAI in India. Data on HAI prevalence in India over the last few years has been summarized in Table 1. The table also reflects an increasing trend in HAI incidence across India over the last decade. Table 1: Incidence of Hospital acquired infections in India Source Total Patients (N) Patients with HAI (n) HAI number of episodes HAI rate # Infections per 1000 patient days Mehta 2007 (9) 10,835 ns % 9.06 Taneja 2004 (14) % 36.2 Habibi 2008 (15) % 28.6 Kamat 2008 (16) % Shalini 2010(13) ns 27.4% Ns Datta 2010 * (17) % Ns Sood 2011 * (18) 435 Ns % 6.16 Ramana 2012 * (19) ns 41% Ns 47 N = total number of patients in the study, n = number of patients with HAI, ns = not specified in the source, # where episodes of HAI are unavailable, this column presents HAI percentage, * only device associated infections included. Figure 1: HAI rate reported in various Indian publications % 4.40% 52.20% 34% 27.40% 29.13% 4.36% 41% HAI Rate HAIs account for major causes of death, functional disability, emotional suffering and economic burden among the hospitalized patients (2, 3). The crude mortality rate in the INICC survey across developing countries including India ranged from 35.2% to 44.9% (7). The increased length of stay for infected patients is the greatest contributor to cost. It is suggested that the increased length of stay varies from 3 days for gynaecological procedures to 19.8 days for orthopaedic procedures. The increased use of drugs, the need for isolation, and the use of additional laboratory and other diagnostic studies also contribute to costs. There are also indirect costs due to loss of work (1, 3). In India, the extravagant use of antibiotics and antibiotic resistance adds to the expenditure as well as mortality following HAI (10). Additionally, In India, infections due to multi drug resistant organisms increase mortality and also warrant the use of high end antibiotics like Carbapenems and new generation Tetracyclines which increase the health care expenditure. In the US, assuming an incidence of 2 million nosocomial infections per year, the estimated added healthcare expenditure is in excess of $2 billion per year; while the direct medical cost of HAI ranged from $28-45 billion (3). In the UK, a patient with HAI spends 2.5 times longer in hospital, incurring additional costs of 3000 more than an uninfected patient (11). A retrospective case-control, cost utility analysis in a tertiary care Indian hospital reported a significantly longer total hospital stay averaging to 22.9 days in patients with bacteraemia, accompanied with significantly longer ICU stay of 11.3 days and a significantly higher attributable mortality of 54%; all these costing significantly more (average US $14,818) than the controls (12). An integrated infection control program can reduce the incidence of infection by as much as 30% and reduce the health care costs (13). CLASSIFICATION OF HAIs AND INDIAN RELEVANCE The most frequent and important HAIs are: 1) catheter associated urinary tract infection (CAUTI), 2) surgical site infection (SSI), 3) ventilator- 48 associated pneumonia (VAP), and 4) intravascular device or catheter related bloodstream infections (CRBSI). Different organisms cause HAI, and the infecting organisms vary among different patient populations, health care settings, facilities, and countries. HAI can also be classified into organism specific (1). Grampositive organisms commonly reported include Staphylococcus aureus, Coagulase-Negative Staphylococci (CoNS), Enterococci; while commonly reported gram-negative organisms include Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinobacter baumanii, and Escherichia coli (1, 16, 20, 21, 22, 23, 24). Clostridium difficile is the major cause of nosocomial colitis in adults in developed countries (1). The implications of hospital acquired methicillinresistant Staphylococcus aureus (MRSA) infections in nosocomial sepsis are an escalating concern in most of the hospitals globally as well as in India. In the INICC study, 87.5% of all S. aureus infections were caused by MRSA, revealing a high burden of MRSA in Indian ICUs (9). Additionally, there are increasing reports of community-acquired MRSA in India (25, 26). Apart from bacteria, fungi, especially Candida species is being recognized as an important cause of nosocomial blood stream infections in India (27). In India, the challenges such as poor medical infrastructure, un-controlled use of antibiotics increased the risk of development of HAIs. SSIs and CRBSIs are considered to be the commonly reported HAIs in India. Hence, we decided to conduct systematic review of epidemiology SSIs and CRBSIs in India, which could help to ascertain the clinical and economic burden due to these HAIs in India and also to implement new or change of current patient management plan by adopting appropriate preventive measures, thus reducing morbidity, mortality and the extra cost. 1) SURGICAL SITE INFECTIONS Before the mid-19 th century, surgical patients commonly developed post-operative irritative fever, followed by purulent drainage from their incisions, overwhelming sepsis, and often death. Post 1860s, introduction of the antisepsis principles substantially decreased the postoperative infectious morbidity. Nevertheless, SSI remained as one of the major nosocomial infections amongst hospitalized patients (28). WHO defines SSI clinically as: a purulent discharge around the wound or the insertion site of the drain, or spreading cellulitis from the wound. Infections of the surgical wound (whether above or below the aponeurosis), and deep infections of organs or organ spaces are identified separately. The US Centre of Disease Control and Prevention s (CDC) National Nosocomial Infections Surveillance (NNIS) system classifies SSIs as being either incisional or organ/space, occurred within 30 days after the operation. Incisional SSIs are further divided into those involving only skin and subcutaneous tissue (superficial incisional SSI) and those involving deeper soft tissues of the incision (deep incisional SSI). Organ/space SSIs involve any part of the anatomy (e.g. organ or space) other than incised body wall layers that was opened or manipulated during an operation. The global data suggests the SSI incidence rate varies from 0.5 to 20% depending upon the type of operation and underlying patient status (28, 29). A recent surveillance by INICC across 82 hospitals of 66 cities in 30 limited-resource countries including India revealed an overall SSI rate of 2.9 as compared with the incidence rate of 2.0 for the US hospitals (30). For India, the overall incidence rate of SSI varies from 2 to 21% across recent reports. The 49 profile of SSI in India from various studies over the last decade has been summarized in the Table 2. For an SSI, microbial contamination of the surgical site is a prerequisite. The risk of SSI is markedly increased when a surgical site is contaminated with 10 5 microorganisms per gram. Table 2: Profile of Surgical site infections (SSIs) in India Source SSI Microorganisms * Surgery Incidence (n/n) Gram-positive Gram-negative Type (%SSI) Bhatia % (116/615) S. Epidermis (42.24%) Total (12.06%) CABG (ns) (51) MMSE (26.72%), MRSE (15.5%) S.aureus (15.55%) MRSA (12.06%), MSSA (3.2%) E. coli, P.aeruginosa Agarwal % (40/2558) S. aureus (57.5%) P. aeruginosa (10%) Neurosurgeries (1.6%) (53) MRSA 35%, MSSA 22.5% E.coli (15%) Pawar 2005 (52) 5.1% (7/136) Staphylococcus sp. (10%) - Cardiac surgery with intraaortic balloon pulsation (5.1%) Lilani 2005 (34) 8.95% (17/190) S. aureus (35.3%) MRSA (33%) P. aeruginosa (4/17) E.coli (2/17) Thoracotomy (44.44%) Gastrointestinal surgeries (variable upto 100%) Sharma % (786/31927) Staphylococcus sp. - Neurosurgeries (2.5%) (54) Joyce 2009 (35) 12% (135/1125) S.aureus (33.3%) MRSA (14.0%) E faecalis (33.3%) VRE (1.4%) P. Aeruginosa (24.4%), E.coli (7.4%), Klebsiella spp(1.4%) Gastrectomy (36.4%), Cholecystectomy (15.4%), Prostatectomy (15.2%), Hysterectomy (10.4%), Appendicectomy (3.4%) Patel 2011 (2) 12.72% (7/55) S. aureus (42.86%) Klebsiella sp. (ESBL) (57.14%) Colon surgery (29.41%), Amputation (50%) Sarma 2011 (36) 21% (14/66) S. aureus MRSA 67% MSSA 33% E.faecalis E coli ESBL (43%), ESBL+ Amp-C hyperproducers (29%) Amp-C hyperproducers (14%) NDM-1 producer (14%) (ns) Post-operative patients 50 K. Pneumoniae ESBL (67%), NDM-1 (33%) Enterobacter cloacae - NDM-1 producer (100%) Reddy % (27/743) Enterococcus species klebsiella sp., general surgery; surgical (55) CoN S. epidermis E.coli gasteroenterology S. aureus (MRSA) Enterobacter sp. SSI in bowel resection (50%) beta-hemolytic Elective open hernia ( 1%) Streptococci Patel S % (32/200) CoNS (14.3%) E. coli (35.7%) Appendicetomy (0-40%) (32) S. aureus (7.1%) Klebsiella sp. (21.4%) Laparotomy ( %) P. aeruginosa (14.3%) Amputation (10-60%) Proteus mirabilis (7.1%) Cholecystectomy ( %) Nephrectomy ( %) N = total number of patients in the study, n = number of patients with SSI, ns = not specified in the source, * percentage of isolates specified in ( ) if available from the source However, when foreign material is already present at the site (i.e. 100 Staphylococci per gram of tissue introduced on silk sutures), the dose of contaminating microorganisms required to produce infection may be much lower. The endogenous flora of the patient s skin, mucous membranes, or hollow viscera is the source of pathogens for most SSIs. When mucous membrane or skin is incised, the exposed tissues are at risk for contamination with endogenous flora. Usually, these are aerobic gram-positive cocci (e.g. Staphylococci), but when incisions are made near the perineum or groin, these may also include faecal flora (e.g. anaerobic bacteria and gram-negative aerobes). Gram-negative bacilli (e.g. Escherichia coli), grampositive organisms (e.g. Enterococci), and sometimes anaerobes (e.g. Bacillus fragilis) are the typical SSI isolates when a gastrointestinal organ is operated and is the source of pathogens. Apart from these endogenous sources, exogenous sources of SSI pathogens include surgical personnel (especially members of the surgical team), the operating room environment (including air), and all tools, instruments, and materials brought to the sterile field during an operation. Exogenous flora are primarily aerobes, especially gram-positive organisms (e.g. Staphylococci and Streptococci). Rarely, fungi from endogenous and exogenous sources are reported as causative organisms for SSIs (28). Globally, S. aureus continues to top the list of pathogens isolated from SSI, followed by CoNS, Enterococcus sp, E.coli, P. aeruginosa, and Enterobacter sp. Other pathogens involved include Proteus mirabilis, K. pneumoniae, C. albicans, and other Streptococcus sp. (28). Indian studies over the last decade also find S. aureus to be the most common gram-positive pathogen followed by CoNS and E. faecalis; while E.coli, P. aeruginosa and K. pneumoniae remain the commonest gram-negative culprits (Table 2). The infecting microorganisms are variable, depending on the type and location of surgery, and antimicrobials received by the patient. Other organisms like Proteas mirabilis, 51 Enterobacter, and Mycobacterium fortuitum are also identified in discrete reports (31, 32). A report also identified Mycobacterium chelonae as a causative pathogen from a series of laparoscopic port site infections (33). The gradual increase in the emergence of antibiotic resistant microorganisms in surgical patients in India further complicates the management of SSIs (2, 34, 35) Upfront and indiscriminate use of antimicrobials as prophylaxis is a routine in India partly contributing to this resistance (2, 10). As expected, majority of the S. aureus isolated in Indian patients were found to be MRSA (Table 2). Moreover, 100% resistance of S. aureus to penicillin has been documented in one study, while resistance to oxacillin, cloxacillin, clindamycin, cephalosporins, ciprofloxacin, ampicillin, amoxicillin, tetracycline, and cotrimoxazole has also been found in other studies (2, 35). S. aureus strains positive for beta-lactamase have also been reported from Indian patients (34). E. faecalis strains were found to be resistant to penicillin, cloxacillin and clindamycin, cotrimoxazole, amikacin, gentamicin, and ciprofloxacin in varying extent (35). Among the gram-negative organisms, P. aeruginosa has exhibited 100% resistance to gentamycin (33), which was also one of the antibiotics used for antimicrobial prophylaxis in those patients. Resistance to third generation cephalosporins, cotrimoxazole, ciprofloxacin, gentamicin and amikacin has also been observed with P. aeruginosa, E. coli, as well as Klebsiella sp. (35). ESBL producers and Amp-C hyperproducers isolated from Enterobacteriaceae infections were resistant to multiple classes of antimicrobials - ampicillin, piperacillin, piperacillintazobactam, third generation cephalosporins, amikacin, gentamicin, tobramycin, ciprofloxacin. Metallo-β lactamase (MBL) producers were resistant to all antimicrobials except colistin and tigecycline heralding an era of untreatable infections. Carbapenems are usually the choice of antimicrobials in infections caused by ESBL and Amp C producing enterobacteriaceae. However, there are increasing reports of carbapenem resistant strains across the globe. The New Delhi metallo-β-lactamase-1 (NDM- 1) containing strains a type of carbapenemase producer, has been isolated from different locations in India since 2006 (36, 37, 38, 39, 36). All these multidrug resistant strains have raised concerns about increasing carbapenem resistance amongst gramnegative bacteria in various infections over the last decade in India (40, 41, 42). The incidence of SSI also varies more widely between surgical procedures suggesting the type of surgery to be an important determinant. The INICC comparison revealed that the SSI rates amongst hospitals in limited-resource countries including India were significantly higher after abdominal surgeries, cardiothoracic surgeries, and ventricular shunt when compared to those in the US hospitals (30). Reports exclusively from India also suggest a higher incidence for gastrointestinal and cardiothoracic surgeries; while a relatively lower one with neurosurgical procedures (Table 2). Moreover, while laparoscopic procedures are associated with lesser infections as compared to open surgeries, port site infections are a growing concern in patients undergoing laparoscopic procedures (43, 44, 45). Port-site mycobacterial infection following laparoscopy is also on a rise over last decade in India (46, 47, 48, 49). In most of thes
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