Point prevalence survey on healthcare-associated infections and antimicrobial use in Ukrainian acute care hospitals: results of the pilot survey in 2021

doi:10.21203/rs.3.rs-4953962/v1

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Point prevalence survey on healthcare-associated infections and antimicrobial use in Ukrainian acute care hospitals: results of the pilot survey in 2021

https://doi.org/10.21203/rs.3.rs-4953962/v1

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Background

According to official statistics, 2611 cases of health care associated infections (HAI) were reported in 2019 in Ukraine, however true burden of HAI remains unknown. The pilot point prevalence survey (PPS) of HAI and antimicrobial use was organized in Ukrainian acute care hospitals in 2021 to assess prevalence of HAI and antimicrobial use.

Methods

Five acute healthcare facilities participated in the point prevalence survey applying European Centre’s for Disease Prevention and Control (ECDC) protocol “Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals” (version 5.3). Hospital and patient data were collected during March-April 2021. In total, 1,373 patients were included. Analysis of data was conducted using HelicsWin.Net (HWN).

Results

The HAI prevalence among the five hospitals was 5,7% (95% CI: 4,5% – 6,9%). 93% of HAI were detected during the period of hospitalization, and 7% were present on admission and were associated with another hospital. HAI prevalence was 16,7% in intensive care units, and 7,6% in surgical units. HAIs were less prevalent in medical and obstetrics/gynecology units − 3,0% and 1,9% respectively. Surgical site infections were the most prevalent type of HAI – 33,7%. Antimicrobial (AM) prescription prevalence was 36.9% (CI 95% 34.5–39.5%).

Conclusions

The PPS was instrumental to raise awareness regarding HAI and antimicrobial use. The pilot PPS results indicate that current official statistics may not quantify the actual HAI burden in the country. A nationwide PPS is highly recommended to further understand the extent of the HAI burden in Ukraine, and to support implementation of tailored infection prevention and control measures.

Ukraine

point prevalence survey

healthcare associated infection

According to the World Health Organization’s (WHO) data, on average, every tenth patient gets infected while receiving inpatient care, and this frequency varies depending on the level of income per capita in the country. While in high-income countries, the healthcare-associated infections (HAI) prevalence in inpatient healthcare facilities (HCFs) is 3–5%, in low-income countries it is 10–15% and every tenth patient dies from HAI [1]. Every HAI case on average leads to over seven additional days of hospital stay increasing consumption of HCF’s limited resources, both financial and human, equipment, causing additional expenditures for consumables and utilities [2].

In Ukraine, according to unpublished official data, the HAI incidence was 0.04% in 2018, and 0.035% in 2019. These data are based on HCFs self-reports on complications and adverse events during treatment, which suggests the lack of proper epidemiological surveillance of HAIs at inpatient HCFs.

According to existing legislation [16], a framework for both routine and sentinel epidemiological surveillance was established in 2021, but, due to full-scale invasion of Russian federation in 2022, implementation of these procedures has not been implemented completely. Until now, 1,518 healthcare facilities were damaged and 195 were totally destroyed due to Russian Federation aggression, according to official communique by the Ministry of Health of Ukraine [17]. It decreased accessibility of healthcare for Ukrainians, with disproportionate effect on Southern and Eastern parts of the country. Healthcare institutions across Europe accepted significant number of Ukrainian refugees and medically evacuated patients, and this coincided with detection of unusual cases of extensively-drug resistant pathogens, including Acinetobacter baumanii, Klebsiella pneumoniae and Providencia stuartii [18, 19, 20]. Ukrainian government prioritized efforts on surveillance on HAI’s and drug-resistant pathogens despite numerous other urgent healthcare needs.

In 2021, a limited-scale pilot point prevalence survey was performed to test the methodology and procedures, required for performing full-scale nationwide PPS and is prone to significant limitations, but due to subsequent war and related disruption of medical services, it contains valuable data regarding “baseline” HAI occurrence and antimicrobial use before the invasion started. We expect a more wide-scale and reliable study on HAI and multi-drug resistant pathogens prevalence to be completed and published in the upcoming year.

A descriptive cross-sectional survey using the ECDC protocol “Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals” (version 5.3) [4] was conducted in five randomly selected acute HCFs. The survey took place during 3 weeks in March-April 2021. Study protocol was previously translated in Ukrainian.

To ensure consistency in data collection, two trainings were organized for all specialists involved in data collection before the survey and additional training for the validation team. The survey personnel training was arranged by the WHO Country Office in Ukraine. The national coordinators, regional coordinators and responsible officers of the HCFs received online training on data collection methods, approaches for completing data collection forms, criteria for inclusion/exclusion, approaches of completing digital forms, and ethical standards applicable to the survey. The first 5-day training took place in December 2020, and the second 4-day training was arranged in February 2021. The regional coordinators received data validation training in February 2021. Each of the specialists was tested for the basic knowledge of the methods of survey for the estimation of the point prevalence of HAIs and received a certificate “Estimation of point prevalence of healthcare-associated infections and antimicrobial use” issued by State Institute (SI) “Public Health Center of the MoH of Ukraine”.

Each HCF has capacity of at least 400 beds that were not dedicated for providing care to COVID-19 patients at the moment of the survey. The list of oblasts and HCFs is not be disclosed in line with the survey protocol. Each facility was assigned a unique HCF code for recording the information in the data collection forms.

The organization of the survey at the national-level was supported by the survey’s national coordinators, the staff of the antimicrobial resistance and infection control department of the SI “Public Health Center of the MoH of Ukraine”.

At each of the HCFs, a responsible representative of the HCF and a group of up to five HCF workers were appointed for arranging the data collection.

To ensure data quality control, the national coordinators collected the data and completed the paper-based data collection forms (W – the ward data collection form, A – the patient form) independently from the regional coordinators. The methods were based on the ECDC PPS validation protocol version 3.1.2. [11]

The validation survey lasted 5 days in each of the HCFs in line with the previously established schedules. The data were collected in the same ward and following the planning of original PPS (PPSDAY method) without purposive sampling, until the required number of validation records per hospital was obtained.

The survey protocol and tools were approved by the Bioethics Commission of the PHC of the MoH of Ukraine. Planning, conduct and reporting of the study was in line with the Declaration of Helsinki, as revised in 2013. All the survey personnel signed non-disclosure agreements concerning confidential information.

The collected data contain no personal data of patients and medical personnel, as well as no names of the HCF where the survey took place. Also the study was of purely observational nature, within the frame of usual care, so signing an individual informed consent form was not required by the study protocol.

The total number of wards included in the survey was 90, including 41 surgery departments, nine intensive care units (ICUs), 33 internal medicine, five obstetrics and gynaecology and two neonatal departments. Four wards (internal medicine, surgery and ICU) were excluded from the survey due to repurposing them for COVID-19 care. The total number of rooms included was 850, of which 21% were single-bed rooms (134 single rooms, 47 single rooms with individual toilet). The total number of beds at the participating HCFs was 3,293, including 177 ICU beds. The survey included 2,997 beds, of which 103 were ICU beds.

At the time of the survey, the wards accommodated 1,450 patients, of which 1,373 were included in the survey. The information on a part of the patients staying in the ward could not be obtained due to reasons like undergoing a surgery, an additional examination at another HCF, or absence due to other reasons. For the validation survey (VS), data on 433 patients were collected.

Healthcare -associated infections

Among the patients included in the survey, there were 57% women and 43% men. The patients’ age median was 54 years (range from 0 to 92 years). The median age of the patients with HAIs was 59 years (range from 0 to 89 years). Among the patients included in the survey, 40.4% underwent surgery during their inpatient stay. Among the patients who had surgery, HAIs were reported for 10%. At the time of the survey, 31.6% of patients had a peripheral venous catheter (PVC), 4.4% had a central venous catheter (CVC), 9.0% had an indwelling urinary catheter, and 2.6% of patients were intubated. Among all of the HAI cases, 26.7% of patients had invasive devices placed.

The number of unique patients with HAIs was 78, the number of HAI cases detected was 86. Based on the results of the main survey, the HAI prevalence was 5.7% (CI 95% 4.5–6.9%). The average number of HAIs per infected with HAIs was 1.10. The majority of HAIs (93%) occurred during hospitalization, while 7% of HAIs were present on admission. 75% of registered HAIs were associated with the ward where survey took place. The prevalence of HAI by specialty is summarized in the Table 1.

Table 1

Crude prevalence of HAIs.
Ward specialty	No. of patients	No. of patients with at least one HAI	Crude prevalence (%)	95% CI
All wards	1373	78	5.7	4.5–6.9
Surgery	660	50	7.6	5.7–9.9
Medicine	528	16	3.0	1.7–4.9
Intensive care	60	10	16.7	8.3–28.5
Obstetrics and gynaecology	105	2	1.9	0.2–6.7

The most prevalent type HAI was surgical site infections – 33,7% (29 cases); pneumonia – 25,6% (22 cases); urinary tract infections – 14% (12 cases); treated unidentified severe infection in adults and children − 12,8% (11 cases); bloodstream infections – 2,3% (2 cases).

A positive microbiological result was reported for 26 HAI cases (30,2%). 44 microorganisms were isolated, among them Pseudomonas aeruginosa (N = 9; 20,5%); Escherichia coli (N = 7; 15,9%); Klebsiella spp. (N = 6; 13,6%); Staphylococcus aureus (N = 6; 13,6%).

Antimicrobial use

Antimicrobials (AMs) were prescribed for 507 patients (36.9% [CI 95% 34.5–39.5%]). In total, there were 719 AM prescriptions with, on average, 1.42 AM prescriptions per patient. The reason for prescribing AMs was documented in the medical record only in 38.4% of cases. The summary of AM prescription data is provided in Table 2.

Table 2

AM prescription
Description	%
Administration route
Parenteral	85.8
Oral	13.8
Inhalation/rectal	0.0
Unknown	0.4
Reason in medical record	38.4
Change in antimicrobial treatment
No change	75.0
Escalation	7.9
De-escalation	1.7
Switch from parenteral to oral route	0.6
Due to side effects	0.1
Changes for other/unknown reasons	1.5
No data	0.4
Dose of AM recorded	97.9

The prevalence of AM use differed depending on the ward specialty. The prevalence of AM use in different departments is provided in Table 3.

Table 3

Prevalence of antimicrobial use.
Ward specialty	No. of patients	No. of patients with at least one antimicrobial prescribed	Crude prevalence (%)	95% CI
All wards	1373	507	36.9	34.5–39.5
Surgery	660	316	47.9	44.0–51.8
Medicine	528	98	18.6	15.3–22.1
Intensive care	60	58	96.7	88.4–99.6
Obstetrics and gynaecology	105	35	33,3	24.4–43.2

The review of the AM prescription indications showed that, treatment takes 39.1% of AMs were prescribed for treatment, including 8.7% for the treatment of HAIs. Perioperative antimicrobial prophylaxis was the indication in 27.1% of prescriptions, including single-dose or single-day prophylaxis in 1.9% and 2.5%, respectively (Table 4).

Table 4

Indications of prescription of AM to patients included in survey
Prescription indication		N	%
CI	Treatment of community-acquired infectious diseases	220	30.60
HI	Treatment of HAIs	70	9.70
LI	Long-term treatment using AMs	3	0.40
MP	Any AM prophylaxis except surgical prescriptions	179	24.90
O	Other substantiated reasons	5	0.70
SP1	Surgical prophylaxis: administration of a single dose	10	1.40
SP2	Surgical prophylaxis during 24 h	17	2.40
SP3	Surgical prophylaxis for more than 24 h	171	23.80
UI	Unknown indication	44	6.10
Total		719	100.00

Among all of the AM prescriptions, the most frequently used agents were Ceftriaxone (26.0%), Levofloxacin (17.9%), Metronidazole (7.9%), Cefepime (4.7%), and Fluconazole (4.7%). Among the AMs prescribed for treatment, the AMs were most frequently prescribed for pneumonia (98 cases), upper urinary tract infections (36 cases), ENT infections (26 cases), surgical site infections (22 cases).

At present, no reliable data are available on prevalence of HAIs in Ukraine. Previous official reports were never published, and data in them are of questionable reliability. This is the first study to assess the prevalence of HAIs in a standardized way with an independent team. The study was planned to be a pilot project to test procedures and instruments for a more wide-scale PPS, but, due to full-scale invasion of Russian federation, implementation of the project was delayed. So, we cannot compare the results with previous (or comparable) studies from Ukraine and the only option remaining is to compare them with available data from similar studies from another countries.

For example, HAI prevalence estimates showed realistic figures, but still lower, than in many other studies. In the latest pan-European 2023 PPS [5], out of the total of 293 581 patients included, 20 869 patients (7.1%) were reported to have at least one HAI. Of those, 19 042 (91.2%) patients had one HAI, 1 725 (8.3%) had two HAIs and 102 (0.5%) had three or more HAIs on the day of the PPS. A total of 22 806 HAIs (1.09 HAI per infected patient) were reported. The most frequently reported types of HAI were pneumonia and lower respiratory tract infection (29.3%). The second most frequently reported type of HAI was urinary tract infection (19.2%), followed by surgical site infection (16.1%), bloodstream infection (11.9%) and gastro-intestinal infection (9.5%), with C. difficile infections (CDIs) accounting for 62.1% of the latter or 5.9% of all HAIs. Systemic infections (4.2% of total) included clinical sepsis in neonates (n = 109) and treated infections of unknown origin in adults and children (SYS-CSEP, n = 625). Skin and soft tissue infections represented 3.7% of the total.

We cannot definitely say if the difference is due to lower occurrence of HAIs in Ukraine, or to under-diagnosis and under-reporting by the study team.

The prevalence of AM use (36,9%) was comparable to data from other European studies. For example, in abovementioned pan-European PPS study, the prevalence of patients receiving at least one antimicrobial in the EU/EEA sample was 35.5%. 72.6% of the patients received one antimicrobial, 22.4% received two, and 5.4% received three or more. The weighted prevalence of antimicrobial use in the EU/EEA, accounting for the number of occupied acute care beds by country, was 32.4% (95% CI: 29.7–35.1%).

Antimicrobials were administered parenterally for 80.3% of antimicrobials, and the reason for antimicrobial use was documented in the patient’s medical record for 82.7% of antimicrobials.

The prevalence of antimicrobial use was the lowest in psychiatric patients (2.8%) and the highest in intensive care patients (59.5%). Antimicrobials were the most frequently prescribed for treatment of an infection (70.2%): of a community-acquired infection (49.3%), of a hospital-acquired infection (18.4%) and an infection acquired in a long-term care facility (2.5%). Surgical prophylaxis was the indication for 14.9% of the prescriptions and was prolonged for more than one day for 48.3% of surgical prophylaxis prescriptions.

The most frequently prescribed antibiotic, ceftriaxone (ATC code J01DD04), accounted for 10.4% of all antimicrobial agents.

Information about change of antimicrobials during the treatment of an infection was reported for 83.0% of prescriptions. Most prescriptions (81.7%) were not changed from the initiation of treatment to the date of the PPS. Escalation, de-escalation and switch from intravenous to oral use were reported for 10.9%, 3.9%, and 1.9% antimicrobial prescriptions, respectively.

In a study from Austria [8], a team of researchers described an overall HAI prevalence of 6.2% (268/4321) with the highest prevalence in intensive care departments (20.9%; 49/234). In medical and surgical departments the HAI prevalence was 5.4% (95/1745) and 6.6% (105/1586), respectively. The most frequent HAIs were urinary tract infections (21.3%; 61/287) followed by pneumonia (20.6%; 59/287) and surgical site infections (17.4%; 50/287).

To compare our results to data from outside Europe, we can refer to a study from Pacific region [9]. Of the 5415 patients surveyed, there were 646 patients (11.9%; 95% confidence interval [CI], 11.1–12.8%) with 727 distinct HAIs, of which 331 (45.5%) were culture positive. The most common HAIs were unspecified clinical sepsis (25.5%) and pneumonia (24.8%). Staphylococcus aureus (12.9%) and Pseudomonas aeruginosa (11.5%) were the most common pathogens implicated in HAIs.

Speaking about national PPS from countries with comparable to Ukrainian economic and social development, we can address a study from Kosovo [10]. Despite having only 915 patients included in PPS, it contains valuable reference points. Countrywide prevalence of HAIs was 4.9%. The highest prevalence was noticed in tertiary care level in University Clinical Centre of Kosovo (UCCK) (7.2%). The most common type of HAI was surgical site infection, representing 35.5% of all reported HAIs. Prevalence of HAIs was highest in surgical departments (46.6%).

Regarding ICU-acquired infections, in a study from Brazil, by Braga et al. [12] including303 patients, 155 (51.2%) patients had an infection and 123 (79.4%) had at least one ICU-acquired infection. The most common ICU-acquired infections were pneumonia (53.0%) and bloodstream infection (27.6%). One hundred and nineteen bacterial isolates were cultured; the most common were A. baumannii (27.1%), P. aeruginosa (27.1%) and S. aureus (39.0%).

Comparing with countries of high economic development, in a Belgian study, based on earlier version of the ECDC protocol [13],the crude prevalence of patients receiving at least one antimicrobial was 27.1% (95% confidence interval (CI) 26.5–27.6%). The most frequently reported indications were pneumonia (23.2%), urinary tract infections (15.2%) and skin and soft tissue infections (11.9%). The reason for antimicrobial use was recorded for 81.9% of the prescriptions

Regarding overseas data, a large-scale study from Australia [14] has shown the prevalence of patients with a HAI was 9.9% (95%CI: 8.8–11.0). Hospital prevalence rates ranged from 5.7% (95%CI:2.9–11.0) to 17.0% (95%CI:10.7–26.1). The most common HAIs were surgical site infection, pneumonia and urinary tract infection, comprising 64% of all HAIs identified.

With more target on HAI and their types, a study from Pakistan [15], based on the same ECDC protocol, shown that out of 1,553 hospitalized patients, 130 (8.4%) had symptoms of HAIs. The most common HAI was surgical site infection (40.0%), followed by bloodstream infection (21.5%), and lower respiratory tract infection (14.6%).

Our study was subject to significant limitations. The sample size was limited to 1,500 patients and 5 healthcare facilities, which is not representative for Ukraine. This survey was planned as a pilot one aimed at preparing Ukraine to participation in the Pan-European survey of point prevalence of healthcare-associated infections in 2022. The nationwide survey was postponed in 2022 due to full scale invasion of Russian Federation.

Wards that provided care to COVID-19 patients were excluded from the survey.

The pilot project did not include direct examinations of patients by the survey teams. Given that the information was collected from medical records, opportunities for detecting device-associated HAIs were limited and dependent on overall quality of medical documentation and practice in participating hospitals, i.e. if a case of HAI was missed (or purposefully hidden) by clinical team, it would be missed by survey team as well.

According to the survey results the HAI prevalence is 5.7% which drastically exceeds the data obtained from the official statistics in 2019. This highlights the need for improving the hospital surveillance system for HAIs. The largest HAI burden falls to the ICUs (16.7% of all patients in the unit, within the range of European country averages) which in combination with the highest frequency of AMs use (96.7% of all patients in the unit, almost twice the average European rate) demands more thorough monitoring of AM prescription practices with particular focus to ICU.

High SSI prevalence in surgical wards combined with the high AM use prevalence, including for surgical prophylaxis lasting over 24 hours, suggests low efficiency of the current surgical prophylaxis approach and the need in reviewing the measures for SSI prevention and antimicrobial stewardship interventions.

The low level of AM treatment de-escalation or switching from parenteral to oral administration route (used in only 1.7% and 0.6% of cases, respectively) confirms the necessity of introduction of antimicrobial stewardship interventions.

The number of bacteriologically confirmed HAI cases (30.2%), including the number of blood culture tests (2 per 100 patient admissions), confirms a low level of awareness of doctors on HAIs, including bloodstream infections and underutilization of blood cultures

It was impossible to confirm diseases caused by C. difficile due to the lack of capacity of HCF laboratories to perform relevant tests.

The PPS was instrumental to raise awareness regarding HAI and antimicrobial use. Full-scale invasion of Russian Federation disrupted Ukrainian medical network and delayed implementation of nationwide HAI and AMR surveillance system. The pilot PPS results indicate that current official statistics may not reflect the actual HAI burden in the country; also, it is the only available data on HAI and AMR prevalence in Ukraine before the war. A nationwide PPS is highly recommended to further understand the extent of the HAI burden in Ukraine, and to support implementation of tailored infection prevention and control measures.

AM: antimicrobials

AMR: antimicrobial resistance

ATC: Anatomical Therapeutical Chemical classification system

CI: confidence interval

ECDC: European Centre’s for Disease Prevention and Control

HAI: healthcare associated infection

HCF: healthcare facility

ICU: intensive care unit

PHC: Public health centre of the Ministry of Health of Ukraine

PPS: point prevalence survey

WHO: World Health Organization

Ethical approval: Study was approved by Bioethics Commission of the Public health center of the Ministry of Health of Ukraine. Planning, conduct and reporting of the study was in line with the Declaration of Helsinki, as revised in 2013.

Consent for publication:

Not applicable

Competing interests:

The authors declare no competing interests.

Funding:

Study was co-funded by WHO Ukraine Country office and government of Ukraine through PHC.

Authors` contributions:

AV designed the trial, managed data collector’s training, performed data analysis and provided general oversight, ED contributed to Background and Discussion chapters and final manuscript formatting and preparation, RK contributed to protocol creation and was responsible for clinical sites recruiting and data processing, MP was responsible for protocol adherence at clinical sites and data verification, AC contributed to protocol creation and data review as well as Results section, RV provided interpretation of data, contributed to Discussion and final preparation of the manuscript.

Acknowledgments

Authors want to acknowledge team of data collectors, involved in this study, particularly Yekateryna Soiak, consultant (IPC and AMR) WHO Country Office in Ukraine, Tetiana Nesterovska, head of the department of antibiotic resistance and infection control, Vita Postolnyk, epidemiologist, Olha Andrieieva, nurse, Olena Stankevych, infectious disease specialist, Tetiana Yatskovych, epidemiologist.

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No competing interests reported.

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Point prevalence survey on healthcare-associated infections and antimicrobial use in Ukrainian acute care hospitals: results of the pilot survey in 2021

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Introduction

Methods

Results

Healthcare -associated infections

Antimicrobial use

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1