Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys.

BACKGROUND: Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs). AIM: To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016. METHODS: In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals. FINDINGS: PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)). CONCLUSION: Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

Post-discharge surveillance (PDS) for surgical site infections: a good method is more important than a long duration.

Post-discharge surveillance (PDS) for surgical site infections (SSIs) normally lasts 30 days, or one year after implant surgery, causing delayed feedback to healthcare professionals. We investigated the effect of shortened PDS durations on SSI incidence to determine whether shorter PDS durations are justified. We also studied the impact of two national PDS methods (those mandatory since 2009 ('mandatory') and other methods acceptable before 2009 ('other')) on SSI incidence. From Dutch surveillance (PREZIES) data (1999-2008), four implant-free surgeries (breast amputation, Caesarean section, laparoscopic cholecystectomy and colectomy) and two implant surgeries (knee replacement and total hip replacement) were selected. We studied the impact of PDS duration and method on SSI incidences by survival and Cox regression analyses. We included 105,607 operations. Shortened PDS duration for implant surgery from one year to 90 days resulted in 6­14% of all SSIs being missed. For implant-free procedures, PDS reduction from 30 to 21 days caused similar levels of missed SSIs. In contrast, up to 62% of SSIs (for cholecystectomy) were missed if other instead of mandatory PDS methods were used. Inferior methods of PDS, rather than shortened PDS durations, may lead to greater underestimation of SSI incidence. Our data validate international recommendations to limit the maximum PDS duration (for implant surgeries) to 90 days for surveillance purposes, as this provides robust insight into trends.

Catheter application, insertion vein and length of ICU stay prior to insertion affect the risk of catheter-related bloodstream infection.

BACKGROUND: The Dutch PREZIES surveillance scheme for catheter-related bloodstream infection (CR-BSI) collects data on infection rates and related risk factors. AIM: To evaluate risk factors for CR-BSI. METHODS: Hospitals collected data for intensive care units (ICU) or for the entire hospital. All short-term central venous catheters (CVC), including Swan-Ganz catheters, present for ≥48h were surveyed, except in cases when bacteraemia was present at insertion. CVCs were monitored until infection, removal or death for up to 28 days. Data were collected on 3750 CVCs and 29,003 CVC-days. FINDINGS: Of the CVCs surveyed, 1.6% [95% confidence interval (CI) 1.2-2.0] resulted in CR-BSI, representing 2.0/1000 CVC-days (95% CI 1.6-2.6). Multi-variate analysis revealed that the length of ICU stay prior to CVC insertion, insertion in the jugular or femoral vein, and use of the CVC to deliver total parenteral nutrition increased the risk of CR-BSI, whereas use of the CVC to deliver antibiotics decreased the risk of CR-BSI. CONCLUSION: Attention to these risks has the potential to reduce the incidence of CR-BSI.

Prevalence of nosocomial infections in The Netherlands, 2007-2008: results of the first four national studies.

The PREZIES national network for the surveillance of nosocomial infections (NI) in The Netherlands has organised a national prevalence study twice a year since 2007. This paper presents the results of the first four surveys. Of 95 hospitals in The Netherlands, 41 participated in 92 surveys and 26 937 patients were included. On the survey day 6.2% had an NI (prevalence of infections 7.2%). The prevalence of infections varied from 1.4% to 16.5% between hospitals. The prevalence of surgical site infections was 4.8%, pneumonia 1.1%, primary bloodstream infection 0.5% and symptomatic urinary tract infection 1.7%. On admission to hospital, 3.3% of patients had an NI. On the day of the survey, 30.9% of the patients were receiving antibiotics. The use of antibiotics as well as medical devices differed considerably between hospitals. Both the prevalence of NI in The Netherlands and the use of antibiotics and devices were comparable to other European countries.

Comparison of the National Surgical Site Infection surveillance data between The Netherlands and Germany: PREZIES versus KISS.

As there has been increasing interest in comparing surgical site infection (SSI) rates between countries, we compared the SSI surveillance data for The Netherlands ('PREZIES') and Germany ('KISS'). Both surveillance systems have comparable protocols with many similar risk factors, including SSI definitions developed by the Centers for Disease Control and Prevention and optional postdischarge surveillance. Nine surgical procedure categories from several specialities were included, the reporting of which were similar, with respect to content and with enough data for proper comparison. Differences for the SSI data were found between PREZIES and KISS for duration of surgery, wound contamination class, American Society of Anesthesiologists physical status classification and the postoperative duration of hospitalization. A significantly higher superficial SSI rate was found for seven surgical procedures according to PREZIES and a higher deep SSI rate for five procedures. When considering only deep SSI during hospitalization, the differences in SSI rates were much smaller. Differences in intensity of postdischarge surveillance led to 34% of SSI being detected after discharge for PREZIES and 21% for KISS. In conclusion, even though similar infection surveillance protocols are used in The Netherlands and Germany, differences occurred in the implementation. Comparisons between countries are most reliable if only deep SSIs during hospitalization are taken into account, since these SSI are not affected by postdischarge surveillance and the diagnostic sensitivity for deep SSI is probably more alike between countries than for superficial SSI.

Humidification policies for mechanically ventilated intensive care patients and prevention of ventilator-associated pneumonia: a systematic review of randomized controlled trials.

The Dutch Working Party on Infection Prevention (WIP) aimed to determine whether certain humidification policies are better than others in terms of prevention of ventilator-associated pneumonia (VAP) in mechanically ventilated intensive care unit (ICU) patients. Publications were retrieved by a systematic search of Medline and the Cochrane Library up to February 2006. All (quasi-) randomized trials and systematic reviews/meta-analyses comparing humidification methods in ventilated ICU patients were selected. Two reviewers independently assessed trial quality and extracted data. If the data was incomplete, clarification was sought from original authors and used to calculate the relative risk of VAP. Data for VAP were combined in the analysis, where appropriate, using a random-effects model. Ten trials were included in the review. In general, the quality of the trials and the way they were reported were unsatisfactory. The results did not show any benefit from specific humidification techniques in terms of reducing VAP. WIP do not recommend either passive or active humidifiers to prevent VAP, nor the type of passive humidifiers to be used. Regarding active humidification, WIP recommends using heated wire circuits. This is due to the theoretical consideration that less condensate reduces colonization and subsequent risk of spread throughout an ICU when condensate is removed.

Validation of surgical site infection surveillance in the Netherlands.

OBJECTIVES: To describe how continuous validation of data on surgical site infection (SSI) is being performed in the Dutch National Nosocomial Infection Surveillance System (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]), to assess the quality and accuracy of the PREZIES data, and to present the corresponding outcomes of the assessment. DESIGN: Mandatory, 1-day on-site validation visit to participating hospitals every 3 years. The process of surveillance, including the quality of the method of data collection, is validated by means of a structured interview. The use of SSI criteria is validated by review of medical records, with the judgment of the validation team as the criterion standard. SETTING: Hospitals participating in PREZIES. RESULTS: During 1999-2004, the validation team visited 40 hospitals and reviewed 859 medical charts. There was no deviation between reports of SSI by infection control professionals and findings by the PREZIES validation team at 30 hospitals and 1 deviation in each of 10 hospitals; the positive predictive value was 0.97, and the negative predictive value was 0.99. The validation team often gave advice to the hospital, aimed at perfecting the process of surveillance. On 2 occasions, data were removed from the PREZIES database after the validation visit revealed deviations from the SSI surveillance protocol that could have resulted in nonrepresentative SSI rate data. CONCLUSIONS: PREZIES is confident that the assembled Dutch SSI surveillance data are reliable and robust and are sufficiently accurate to be used as a reference for interhospital comparison. PREZIES will continue performing on-site validation visits, to improve the process of surveillance and ensure the reliability of the surveillance data.

Random effect modelling of patient-related risk factors in orthopaedic procedures: results from the Dutch nosocomial infection surveillance network 'PREZIES'.

In the Dutch surveillance for surgical site infections (SSIs), data from 70277 orthopaedic procedures with 1895 SSIs were collected between 1996 and 2003. The aims of this study were: (1) to analyse the trends in SSIs associated with Gram-positive and Gram-negative bacteria; (2) to estimate patient-related risk factors for deep and superficial SSIs after all orthopaedic procedures, with special attention to primary total hip arthroplasty (THA); and (3) to analyse inherent differences in infection risk between hospitals. A random effect model was used to estimate the odds ratios of patient-related risk factors for developing an SSI, and to describe the distribution of the most widespread bacterial species responsible for SSIs among hospitals. Gram-positive organisms, mainly staphylococci, were the main cause of both deep (84.0%) and superficial SSIs (69.1%) after orthopaedic procedures. The percentage of SSIs after THA caused by coagulase-negative staphylococci decreased over the surveillance period, while the contribution of Staphylococcus aureus increased. Temporary elevations in the incidence of the most widespread pathogen species were observed within hospitals. Patient-related factors such as the National Nosocomial Infections Surveillance System risk index or age had little effect on the predictive power of the random effect models. This study underlines the usefulness of a random effect model, which adjusts risk estimates for random variation between hospitals, in a multicentre study on risk factors for SSIs.

Surveillance of healthcare-associated infections in Indonesian hospitals.

A cross-sectional surveillance of healthcare-associated infections (HAIs) and exposure to risk factors was undertaken in two Indonesian teaching hospitals (Hospitals A and B). Patients from internal medicine, surgery, obstetrics and gynaecology, paediatrics, a class department and intensive care were included. Patient demographics, antibiotic use, culture results, presence of HAI [phlebitis, surgical site infection (SSI), urinary tract infection (UTI) and septicaemia] and risk factors were recorded. To check for interobserver variation, a validation study was performed in Hospital B. In Hospitals A and B, 1,334 and 888 patients were included, respectively. Exposure to invasive devices and surgery was 59%. In Hospital A, 2.8% of all patients had phlebitis, 1.7% had SSI, 0.9% had UTI and 0.8% had septicaemia. In Hospital B, 3.8% had phlebitis, 1.8% had SSI, 1.1% had UTI and 0.8% had septicaemia. In the validation study, the prevalence as recorded by the first team was 2.6% phlebitis, 1.8% SSI, 0.9% UTI and no septicaemia, and that recorded by the second team was 2.2% phlebitis, 2.6% SSI, 3.5% UTI and 0.9% septicaemia. This study is the first to report on HAI in Indonesia. Prevalence rates are comparable to those in other countries. The reliability of the surveillance was insufficient as a considerable difference in prevalence rates was found in the validation study. The surveillance method used is a feasible tool for hospitals in countries with limited healthcare resources to estimate their level of HAI and make improvements in infection control. Efficiency can be improved by restricting the surveillance to include only those patients with invasive procedures. This can help to detect 90% of all infections while screening only 60% of patients.

Hair removal policies in clean surgery: systematic review of randomized, controlled trials.

OBJECTIVE: To determine whether certain hair removal policies are better than others to prevent surgical-site infections in patients undergoing clean surgery. METHODS: Publications were retrieved by a systematic search of Medline, the Cochrane Library, and EMBASE up to February 2005. Additionally, the reference lists of all identified trials were examined. All randomized trials, quasi-randomized trials, and systematic reviews or meta-analyses of randomized or quasi-randomized trials comparing hair removal policies in clean surgery were selected. Trials involving patients undergoing cranial neurosurgery were excluded. Two reviewers independently assessed trial quality and extracted data. Disagreements were resolved by discussion with a third reviewer. Data from the original publications were used to calculate the relative risk or risk difference of surgical-site infection. Data for similar outcomes were combined in the analysis, where appropriate, with the use of a random effects model. RESULTS: Four trials were included in the review. No eligible systematic review or meta-analysis of randomized or quasi-randomized trials was found. The quality of the trials and how they were reported were generally unsatisfactory. Evidence regarding whether preoperative hair removal has any effect was inconclusive. When hair removal was considered necessary, evidence about the best time for removal was inconclusive. There was some evidence that hair removal by clipper is superior to removal by razor. CONCLUSIONS: Because of insufficient evidence as a basis for recommendations, the practical consequences for ward management were essential when the Dutch Working Party on Infection Prevention formulated its recommendations for hair removal policies. Large randomized, controlled trials are needed to determine the optimal policy for preoperative hair removal.

Surveillance as a starting point to reduce surgical-site infection rates in elective orthopaedic surgery.

A surveillance programme was started after a period of high infection rates in an orthopaedic surgical department. The programme was aimed at reducing infection rates in elective hip and knee replacement procedures, and at creating awareness of infection control practices in an acute hospital. Possible causes of the initial high infection rates were analysed and discussed with healthcare workers involved in orthopaedic surgery. No specific cause could be found but substantial logistic improvements were achieved by studying for five years that may have contributed to the reduction of postoperative infections. Surveillance is an important part of any hospital-acquired infection surveillance programme. Its success depends on the ability of the infection control practitioner (ICP) to form a partnership with the surgical staff. Creating a sense of ownership of the surveillance initiative amongst the surgical staff enhances co-operation and ensures that the best use is made of the information generated. It is not possible to eliminate surgical-site infections (SSI) completely, but by a process of sharing information we have been able to influence behaviour to reduce the incidence of SSI.

[Hospital infections and risk factors in the intensive care units of 16 Dutch hospitals, results of surveillance of quality assurance indicators]. / Ziekenhuisinfecties en risicofactoren op de intensive-careafdelingen van 16 Nederlandse ziekenhuizen; resultaten van surveillance als indicator voor zorgkwaliteit.

OBJECTIVE: To gain insight into the incidence of nosocomial infections and associated risk factors in Intensive Care Units (ICUs). DESIGN: Prospective. METHOD: From July 1997 to December 1999, standardised surveillance of nosocomial infections was implemented in ICUs in 16 hospitals in the Netherlands. Surveillance was performed in patients with an ICU stay of > or = 48 hrs; data were collected from admission until discharge from ICU. Data-collection included demographic data and patient- and treatment-related risk factors. The data were aggregated in a national database. RESULTS: In the research period, hospitals sent good quality data for aggregation in the national database on 2795 patients (61% male) and 27,922 ICU patient days. The median length of stay was six days, the median 'Acute physiology and chronic health evaluation' (APACHE) II score was 17 and the median age was 67 years. A total number of 749 infected patients were found with 1,177 nosocomial infections (27% of patients, 42 infections/1000 patient days), consisting of 43% pneumonia, 20% sepsis, 21% urinary tract infections, 16% other types of infections. Out of all the patients, 62% was on mechanical ventilation, 64% had a central venous line and 89% had a urinary catheter in situ. Selective decontamination of the gastrointestinal tract was used for 12% of the patients, and systemic antibiotics for 68%. Micro-organisms most frequently isolated were Pseudomonas aeruginosa in patients with pneumonia, Staphylococcus epidermidis in catheter-related bloodstream infections and Escherichia coli in patients with urinary tract infections. Large differences in device use and incidence of infections were observed between the ICUs. CONCLUSION: The aggregated data gave insight into the incidence of nosocomial infections and associated risk factors in ICUs. The data are meant as references to support decision- and policy-making in local infection control programs.

Nosocomial catheter-associated bacteriuria: a clinical trial comparing two closed urinary drainage systems.

We compared the time of onset and incidence of nosocomial bacteriuria between two different closed urinary drainage systems: a simple closed drainage system containing an antireflux valve ('Urias A-4') and a complex closed drainage system ('Curity Infection Control System') incorporating: (1) a preconnected, coated catheter, (2) a tamper discouraging seal at the catheter-drainage tubing junction, (3) a drip chamber, (4) an antireflux valve, (5) a hydrophobic drainage bag vent and (6) a povidone-iodine releasing cartridge in line with the outlet tube of the urine collection bag. 181 non-bacteriuric patients, requiring catheter drainage for more than 48 h, were assigned by chance to either of the two systems. Bacteriological monitoring of bladder urines of the enrolled patients was performed every 24 h by establishing viable counts and identification of all microorganisms. No differences in the onset and incidence of nosocomial bacteriuria between the two urine drainage system groups were noted. We conclude that additional complex features aimed at preventing intraluminal spread of bacteria did not reduce the risk of urinary tract infection, compared to a simple closed urinary drainage system.

A comparison of two transparent film-type dressings in central venous therapy.

A prospective randomized clinical trial has been conducted to compare the clinical performance, with prolonged use, of two film-type transparent dressings used over subclavian and jugular single-lumen venous catheters. 'OpSite', a traditional dressing with a moderate moisture vapour permeability was compared with a new dressing of high moisture vapour permeability, 'OpSite IV3000'. Information was collected daily to assess the nature and incidence of complications, dressing durability and the ease of application and removal. One hundred and one patients provided two well-matched populations receiving a total of 153 dressings for a total of 780 catheter-days. No differences between the two dressings were noted with respect to the incidence of complications, such as moisture accumulation or lifting, and dressing durability. The low incidence of catheter-related sepsis ('OpSite' group three episodes and 'OpSite IV3000' group one episode) suggests that transparent dressings do not increase this risk. This clinical study demonstrated the new 'OpSite IV3000' to be easier to handle, leading to better application, improved catheter fixation and easy removal.

A comparison of four film-type dressings by their anti-microbial effect on the flora of the skin.

Two polyurethane dressings ('Tegaderm' and 'OpSite') were compared with their respective povidone iodine and chlorhexidine acetate-impregnated dressings ('Tegaderm Plus' and 'OpSite CH') for their effectiveness in reducing recolonization of skin after application of the dressings. After 7 days the average number of cfu on undamaged skin, covered with the four dressings, was significantly lower than the number of cfu on skin which had not been covered. The number of cfu on the skin covered with OpSite CH was significantly lower than with all other dressings tested. OpSite CH possesses most anti-microbial activity in relation to the flora of the skin.