Here we report on the first comprehensive cross-sectional study that describes the impacts of HAI among Libyan hospitals including the four largest referral hospitals in the country. HAI prevalence varied from one hospital to another with a mean prevalence of (13.7%). The highest prevalence was reported in Benghazi Medical Centre which was 17.9%, followed by Sebha Medical Centre (14.8%), Tripoli Central Hospital (14.2%), and Tripoli Medical Centre (9.4%). However, HAI prevalence varied greatly from one country to another. In developed countries such as Ireland and Germany, it was found to be 3.5% though, in developing countries and Sub-Saharan countries, it reached up to 21.7%. (21, 22, 23). Our data is in concordance with other data reported from north African countries such as Tunisia, Morocco, and Algeria as they have rates as high as 18%. Therefore, efforts at national and regional levels should be combined to reduce the burden of HAI in these countries (24, 25).
The burden of HAI in Libyan hospitals was influenced by gender, age, and ward of admission. A higher prevalence was reported among female patients with a proportion of 1.25: 1( F: M) ratio. This has been supported by other studies done in other African countries. Hospitalized patients aged 51 y and above had a higher burden than patients at a younger age. This result was in line with the other studies done in Russia and Ethiopia. This discrepancy was probably due that our study had relatively more adult-aged patients. (26, 27). Gram negative bacilli particularly E coli and Klebsiella spp., and Gram positive cocci mainly S. aureus were the most commonly isolated HAI-causing pathogens in the present study. This however is concordance with other studies reported from other African countries (22, 23).
In our study patients admitted to ICU have the highest prevalence of HAI (29.8%) followed by those admitted at Pediatric (14.7%), Surgery (13.7% ), Medical (11.8%), and Obstetrics & gynecology(11.3%). This is similar to those results reported previously in Tunisia and Ethiopia though it was lower than that reported by the studies conducted in Morocco (28, 29).
The most common type of HAI encountered in our study was SSI (31.28%). Our finding was higher compared to studies done in USA and France while it was lower than the studies done in Nigeria. (30–34). The differences in these results could be contributed to the inclusion criteria where patients with contaminated and dirty wounds were included in these studies. However, the higher SSI in our study could be due to the difference in the operation theater in each hospital in addition to the lack of guidelines and lack antimicrobial stewardship in Libya could also contribute to the higher prevalence. Therefore, further studies are needed on the association between HAI and the type of surgical operation and implementation of guidelines on antimicrobial use(35).
Pneumonia is the second HAI in our study reported in (29.34%) of the studied patients. Our findings are lower than these studies carried out in countries in the MENA region, including Iran and Saudi Arabia where pneumonia accounted for 28,9% and 70% respectively. Such discrepancy could be contributed that studies in other countries were carried out mainly in ICU patients(36, 37).
The third common HAI in our study was UTI reported in (26.84%) of the patients studied. This finding was comparable with the study done in Lithuania (28.5%), Tanzania (31.1%), and Ethiopia (19.8%) (RR-RR). This could be contributed to the improper use of cauterization. However different studies have indicated that 79.3% of UTIs can be prevented if catheterization was not performed in hospitals (38–40). Bloodstream infection was the less reported HAI accounting for only (12.55%). This, however, is in agreement with other studies carried out in North and Sub-Saharan African countries. Probably due to a lack of good Microbiological techniques for blood specimens. Therefore, improving such techniques is needed (41–43).
Hospital-acquired Infections have a substantial impact on morbidity and mortality. They extend hospitalization, the requirement for ICU admission, and additional diagnostic and therapeutic interventions. In our study, 34% of the patients needed ICU admission and over 90% needed excess antimicrobials. This extended the hospital stay resulting in overcrowding (particularly in ICU) and not allowing new patients to be admitted. Furthermore, they may act as a potential reservoir for patients with transmissible resistant pathogens. This is in concordance with other studies carried out in South African hospitals. These factors reflect the consequences of HAI and may act as predictors of hospital mortality However, further studies are needed to improve this concept (44–46).
Surgical intervention, respiratory support, and device removal were intervened management of HAI events. Interestingly they vary from one hospital to another. The highest inappropriate management of HAI in our study was seen by BMC followed by SMC and then Tripoli hospitals(TCH&TMC). This however contrary to other studies carried out in developed countries. This, however, could be contributed to a lack of proper management, monitoring, and efficient safety procedures in our study settings (47, 48).
Strengths And Limitations
A major strength of this study is that it provides a clear perspective analysis of HAI in a large vast country like Libya. To our knowledge, this is the largest study characterizing the epidemiological manifestations of HAI in the MENA region. The potential of our data is to alert the decision-makers to the fact that healthcare-associated infection is endemic and represents a hidden and serious burden for the Libyan healthcare system. Hence then health authorities and decision-makers should be alerted to take the needed actions to fulfill the requirements of the pledge of WHO's First Global Patient Safety Challenge(49–51). Several limitations need to be considered when interpreting the results of this study. There could be misreporting of some surveillance data that may not reflect the real situation in the participating hospitals. Another limitation of this study was the inability to follow up with every patient particularly after SSIs as they were considered high when they were proactively followed up. In comparison with other studies, we were unable to investigate the treatment and the clinical outcomes of HAIs due to differences in the hospitals studied (52, 53).
The scope of this study was principally limited by data availability. Prevalence of antimicrobial resistance among Gram-negative bacilli and Gram positive particularly MRSA causing HAI is alarmingly high, and resistant infections may be more expensive to treat ]; however, data limitations prevented us to determine burden of antimicrobial resistance in the studied hospitals.
Despite these limitations, our study gives good insights into HAI in Libyan hospitals particularly as the country is enfolded in a major conflict since 2011. The results could be used as a reference for future studies and to plan HAI prevention strategies and research (54–55). The problem of HAI in Libya is more serious as there are no national programs for HAI prevention or mandatory public reporting data in the health care settings. Unfortunately, lack of awareness and low levels of staff preparedness and knowledge are the main factors leading to poor infection control in Libya. Furthermore, the collection of surveillance data for HAIs is lacking and not seen as a priority in Libyan hospitals even in ICU settings. Therefore, education and comprehensive training programs for hospital staff should be provided. A national guideline has to be implemented. Doctors and nurses in particular should be obliged to follow and fulfill the needed requirements for HAI prevention and control.