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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 45-50

An epidemiological study of health-care-associated infections and their antimicrobial sensitivity pattern in the Al-Qassim region of Kingdom of Saudi Arabia


Infection Prevention and control Department, Al Rass General Hospital, Al Qassim, Saudi Arabia

Date of Web Publication28-Aug-2018

Correspondence Address:
Dr. Sanjay Kumar Gupta
Al Rass General Hospital, Al Qassim
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cai.cai_11_17

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  Abstract 


Background: In the USA, up to 2 million health-care-associated infections (HAIs) per year are reported, of which 80,000 are lethal. Materials and Methods: This was a hospital-based observational (retrospective) study. Results: Hospital-wide rate of HAI ranges from 0.35 to 1.96 per thousand patients per day. The most common organism observed in the last 5 years is Acenatobacter (88 [27%]) followed by Pseudomonas aeruginosa (73 [22%]). Significant cases in these 5 years were reported from Intensive Care Unit (157 [48%]) followed by medical wards (males and females) (106 [32%]). The common site reported in the present study is catheter-associated urinary tract infection which was significantly higher (CA-UTI) (152 [46%]) followed by ventilator-associated pneumonia (VAP) (66 [20%]). The common organisms reported to cause UTI are P. aeruginosa (22%) followed by Escherichia coli (19%), and the most common microbial agent associated with VAP is Acenatobacter baumannii (48 [72%]) which was found to be significantly higher. The antibiogram of microorganism responsible for HAI was observed, and 56% isolates of Acinetobacter baumannii were sensitive to aztreonam followed by imipenem 54%, ceftazidime 47%, and amikacin 36%. Another common organism reported was P. aeruginosa, and the majority of isolates of this were sensitive to imipenem 79% followed by amikacin 68%, ceftazidime 53%, aztreonam, and ciprofloxacin 49% and least sensitive to meropenem 9%. Most of the Klebsiella pneumoniae strains during the same period were found to be sensitive to imipenem 94% followed by piperacillin/tazobactam 71%, amikacin 69%, cefepime 59%, and ceftriaxone 56% and least sensitive to nitrofurantoin 11% only. Conclusion: HAI is a big threat for patients' safety and prolongs patients' stay and cost of health care, so effective utilization of hospital data is crucial for prevention and control.

Keywords: Contributing areas, health-care-associated infection, hospital, Intensive Care Unit, microorganism, sensitivity pattern, site of infection


How to cite this article:
Gupta SK, Al Khaleefah FK, Al Harbi IS. An epidemiological study of health-care-associated infections and their antimicrobial sensitivity pattern in the Al-Qassim region of Kingdom of Saudi Arabia. Community Acquir Infect 2017;4:45-50

How to cite this URL:
Gupta SK, Al Khaleefah FK, Al Harbi IS. An epidemiological study of health-care-associated infections and their antimicrobial sensitivity pattern in the Al-Qassim region of Kingdom of Saudi Arabia. Community Acquir Infect [serial online] 2017 [cited 2019 Jul 16];4:45-50. Available from: http://www.caijournal.com/text.asp?2017/4/3/45/240007




  Introduction Top


Health-care-associated infections (HAIs) are the infections that patients acquire during receiving treatment for medical or surgical problems and are the most frequent adverse event that can occur during care delivery process.[1] HAI is a major concern for patient safety and can lead to prolonged hospital stay, long-term disability, increased resistance of microorganisms, an extra financial burden to the health-care system, more costs for patients and their families, and increased mortality.[2],[3] HAI is defined as: “An infection occurred in a patient during the process of care in a hospital or other health-care institution which was not present or incubating at the time of admission.” This includes infections acquired in the hospital, but appearing after discharge.[4] Many international agencies such as Centers for Disease Control and Prevention (CDC) and WHO work to monitor and prevent these infections because they are a big threat to patient safety and outcome. In India, it has been estimated that around 10%–30% of patients admitted to the hospitals and various nursing homes acquire a nosocomial infection. Surveys were conducted in 183 hospitals in the USA and 4% of HAIs are reported. The most common types were pneumonia (21.8%), followed by surgical-site infections (21.8%) and gastrointestinal infections (17.1%).[5] The study conducted by Horen et al. in 2004 about surveillance of nosocomial infections at a Saudi Arabian military hospital observed 32.3% of respiratory tract infection (RTI), 25.7% of urinary tract infection (UTI), and 18.6% of bloodstream infection (BSI).[6] Device-associated infections (i.e., central catheter-associated BSI, catheter-associated-UTI [CA-UTI], and ventilator-associated pneumonia [VAP]), which have traditionally been the focus of programs to prevent HAIs, accounted for 25.6% of such infections. We estimated that there were 648,000 patients with 721,800 HAIs in the U.S. acute care hospitals in 2011; of the 33,848 pathogens reported, 87% were bacteria and 13% were fungi.[6] Over 15% of infections were polymicrobial.[7] The most commonly isolated pathogens were coagulase-negative staphylococci (CoNS), Staphylococcus aureus, Enterococcus species, Candida species,  Escherichia More Details coli, and Pseudomonas aeruginosa. In Europe, 5 million HAI cases per year are reported, of which 50,000 (1%) are lethal and contribute to death in 135,000 cases (2.7%).[8],[9] This study was carried out to find the epidemiology of HAI, and with the study findings, we can develop effective intervention/infection control program in our hospital to prevent and control the HAIs.

Objectives

  1. To know the epidemiology of HAIs
  2. To find the antimicrobial sensitivity pattern of various common microorganisms responsible for HAIs in the hospital.



  Materials and Methods Top


The present retrospective study was carried out by Infection Prevention and Control Department of the Al Rass General Hospital, having a capacity of 250 beds with 10 separate beds for Intensive Care Unit (ICU); all types of patients are treated here such as road traffic accident, internal medicine, surgery, orthopedics, neurosurgery, obstetrics, and gynecology, and pediatrics. This hospital-based retrospective observational study was carried out in ICU and various wards of the hospital. All patients admitted in ICU and other wards during the study period for any reasons and develop HAI were taken as a sample and data were collected from laboratory on a daily basis about culture and sensitivity reporting. This study collected data from January 2012 to December 2016, and the data were compiled and analyzed in the period of 3 months from October to December 2016. HAI data were collected by infection control department from ICU and various other departments during surveillance, then according to HAI definition, the collected data were categorized and compiled and monthly submitted to higher authority.

Sample size

All patients admitted during the study period and acquired any types of HAI were taken as a sample. During the study period from 2012 to 2016, a total of 331 cases of HAI were reported. Sampling method: No sampling method was applied and all cases those who develop HAI were taken as sample. Data collection tool: A predesigned and pretested pro forma was used as the data collection tool. Study variables: age, gender, hospital-wide rate, VAP, CLABSI, CA-UTI, SSI, contributing areas, sites of HAI, type of microorganisms, and antibiotic sensitivity patterns.

Data analysis

SPSS version 20 developed by IBM (Armonk, New York, United States) was used for statistical analysis. Statistical tests such as Chi-square test, means, and standard deviation were used. P ≤ 0.05 was considered statistically significant.

Ethical clearance was obtained from Institutional Review Board, informed written consent was not obtained because there was no direct human subject involvement in the study or intervention, and only secondary data were analyzed from medical records.

Inclusion criteria

HAI cases presented during the study period and fall under CDC definition were included in the study.

Exclusion criteria

Cases that do not fall under CDC definition and not reported during the study periods were excluded from the study.


  Results Top


[Figure 1] shows that health care associated infection were in increasing trend from 2012-15, somewhat downtrends reported in 2016 only 54 cases were reported showing a slight decreasing trend for the first time in the last 5 years. Hospital-wide rate of HAI ranged from 0.35 to 1.96 per thousand patients per day in this period. [Table 1] shows the common organism observed in the last 5 years: Acinetobacter baumannii (88 [27%]) followed by P. aeruginosa (73 [22%]), E. coli (38 [11%]), Klebsiella pneumoniae (34 [10%]), and Candida (28 [9%]), and the combined infection rate due to these five organisms was 80%.
Figure 1: Year-wise number of health-care-associated infection cases reported (2012–2016) in the hospital

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Table 1: Distribution of health-care-associated infection cases according to types of organism isolated from 2012 to 2016

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[Table 2] shows the major contributor of HAI cases in these 5 years in the present study was ICU (159 [48%]) followed by medical wards (males and females) (106 [32%]); if we combined these two areas of our hospital they are the most common contributor of HAI cases in the hospital (265 [80%]), and a highly significant difference was observed (χ2 = 40.6, P < 0001) between ICU and the male medical ward. [Table 3] shows that the common site/type reported in the present study was CA-UTI (153 [46%]) followed by VAP and BSI, respectively (66 [20%] and 62 [19%]). Differences between CA-UTI and VAP cases were highly significant (χ2 = 25.7, P < 0.0001). The mean VAP rate in ICU (per 1000 ventilator days) was reported from 2012 to 2016 in range of 2.14-5.1.
Table 2: Distribution of health-care-associated infection cases according to department/wards from 2012 to 2016

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Table 3: Distribution of health-care-associated infection cases according to site of infection or system involved from 2012 to 2016

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[Table 4] shows that common organisms reported in UTI were P. aeruginosa (22%) followed by E. coli (19%), but the difference was not statistically significant, and the most common microbial agent associated with VAP is A. baumannii (72%); in other words, Acinetobacter B was significantly associated with VAP cases in comparison to any other organism and the common microbial agents associated with BSI are Staphylococcus species (26%) followed by P. aeruginosa (22.5%) and A. baumannii (21%), but difference was not statistically significant. [Figure 2] shows that most common contributing area of HAI in the hospital was ICU followed by medical ward.
Table 4: Distribution of health-care-associated infection cases according to site of infection or system involved and types of microorganism from 2012 to 2016

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Figure 2: Comparative Distribution of health-care-associated infection cases from the hospital (2012–2016) in the Intensive Care Unit, Neonatal Intensive Care Unit, and medical ward

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The antibiogram of microorganism commonly responsible for HAI was observed, 56% of isolates of A. baumannii were sensitive to aztreonam followed by imipenem 54%, ceftazidime 47%, ciprofloxacin 47%, gentamicin 42%, meropenem 40%, and amikacin 36%. The second common organism reported was P. aeruginosa, the majority of isolates of this were sensitive to imipenem 79% followed by amikacin 68%, ceftazidime 53%, aztreonam, and ciprofloxacin 49% and least sensitive to meropenem 9%. Most of the K. pneumoniae strains during the same period were sensitive to imipenem 94% followed by Pipaeracillin/Tazobactam 71%. The S. aureus observed during the study period was most sensitive to Vancomycin 100% followed by gentamicin 75% and least sensitive to penicillin. E. coli isolates were most sensitive to nitrofurantoin 100%, followed by imipenem 94%, amikacin 90%, aztreonam 88%, gentamycin, and cefoxitin 78% and least sensitive to cephalothin.


  Discussion Top


The present study was carried out in the Al Rass General Hospital of Al Qassim region of Saudi Arabia to know the pattern of various HAIs and their sensitivity pattern (antibiogram) was studied. The study conducted by Moataz et al. in 2004 about the surveillance of nosocomial infections at a Saudi Arabian military hospital observed 32.3% RTI, 25.7% UTI, and 18.6% BSI. In the present study, CA-UTI observed more than above study 46.3%, the difference may be due to different setting.[10] According to the type of organism reported in the study, E. coli 22.3% was the most common organism followed by P. aeruginosa 17.6% and K. pneumoniae 9.9%. In the present study, the most common Gram-negative organism was A. baumannii (27%) followed by P. aeruginosa (22%).[10] In a study done by Mahmoud Abu Saud regarding the prevalence of nosocomial infection in Saudi Arabian teaching hospitals, the most common site observed was UTI followed by wound and umbilical cord (133, 48, and 18, respectively). In the present study also, the common site reported was UTI.[11] A study done by Al Tawfiq et al. in Saudi Arabia regarding HAI perspectives and fatality rate and fatality reported in the range of 2.3 to 14.4%, in the present study we not calculated fatality rate due to HAIs.[12] The another study conducted by Abdraboh SN about role of hand hygiene in control of HAIs and concluded hand hygiene improvement is affordable measure to control HAIs.[13] Klevens et al. in 2002 who conducted a study in America about estimating HAI and deaths found an estimated number of HAI 1.7 million and 98,987 deaths; in the present study, we estimated the total number of HAI in our hospital was 331 and deaths were not calculated, and the difference in number may be due to the sample size.[14] The systemic review done by Buhl et al regarding P. aeruginosa and its microbial resistance pattern, in the present study we also found second most common organism in our hospital environment with drug resistance.[15]

The study conducted by Bonelli RR about antimicrobial resistance among Enterobacteriaceae and another study done by Yasmin et al about epidemiology of BSIs caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York found that the resistance rate of S. aureus to most drugs, including oxacillin, tetracycline, erythromycin, clindamycin, gentamicin, and ciprofloxacin, showed a tendency to decrease and there were no S. aureus strains resistant to linezolid and vancomycin; in the present we also observed same.[16],[17] The study conducted by Moreira et al. regarding antimicrobial use, incidence, etiology, and resistance patterns in bacteria causing VAP, we also observed same.[18] Another research done by Joseph et al. regarding the relationship between antimicrobial consumption and the incidence of antimicrobial resistance in E. coli and K. pneumoniae isolates observed that E. coli isolates showed high resistance for increased use of gentamicin and ciprofloxacin.[19] The study conducted by Tao et al., about device-associated infection rates, overall rate of HAI to be 5.3% and 6.4 infections per 1000 ICU days and the same type of finding was also reported in the present study.[20] Study done by Xie and Xiong regarding point prevalence survey the most common type (64.7%) of HAIs, was RTI followed by UTIs (12.6%) and BSIs (5.4%), in the present study CAUTI was most common.[21],[22] HAI occurrences were significantly associated with male sex and age over 85 years. Gram-negative bacteria were found to be the most common (67.1%), with Gram-positive bacteria and fungi reported for 20.3% and 10.5%, respectively. In the present study, we observed little lower prevalence than the above study and the most common type of HAI was CA-UTI in our setting, and the difference may be due to the change of area.[21],[22] The study conducted by Ghabrah and Madani et al during Haze, they observed for the prevention of RTIs it is important to encourage personal hygiene, cough etiquette, and hand hygiene among pilgrims, in the present study we were not observed such findings.[23] The study done in Egypt by Maha Talaat and Mona Al shokry observed that 30% were BSIs, 29% SSIs, 26% pneumonia, and 15% UTIs. VAP had the highest incidence of device-associated infections (4.3/1000 ventilator days). The most common pathogens reported were Klebsiella spp. (28.7%) followed by Acinetobacter spp. (13.7%). In the present study, all HAIs reported lower prevalence rate than the above study such as BSI 19%, SSI only 9%, and VAP 20%, which may be due to better implementation of infection control practices, policies, and procedure than that of the study conducted in Egypt.[24]


  Conclusion Top


HAI is a big threat for patients' safety and increases patients' morbidity, mortality, stay, and cost of health care. So effective utilization of hospital data about the pattern of occurrence of HAI, their sensitivity pattern (antibiogram), common site of occurrence, and contributing factors or areas is very important indicators, on the basis of which we can plane effective intervention for prevention and control of HAI in own setting.

Acknowledgment

We are very thankful to the ICU staffs and laboratory for providing help and support for conduction of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK, Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. Global priorities for patient safety research. BMJ 2009;338:b1775.  Back to cited text no. 1
    
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Burke JP. Infection control – A problem for patient safety. N Engl J Med 2003;348:651-6.  Back to cited text no. 2
    
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Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet 2011;377:228-41.  Back to cited text no. 3
    
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Prevention of hospital-acquired infections A practical guide 2nd ed. World Health Organization Department of Communicable Disease; 2002. p. 64.  Back to cited text no. 4
    
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Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.  Back to cited text no. 5
    
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Horan TC, Gaynes RP. Surveillance of nosocomial infections. In: Mayhall CG, editor. Hospital Epidemiology and Infection Control. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 1659-702.  Back to cited text no. 6
    
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Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198-208.  Back to cited text no. 7
    
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CDC Practical Guide for the Prevention of Health Care Associated Infections. Available from: https://www.cdc.gov/hai/prevent/prevention.html. [Last accessed on 2014 Sep 09].  Back to cited text no. 8
    
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Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA, et al. NHSN annual update: Antimicrobial-resistant pathogens associated with healthcare-associated infections: Annual summary of data reported to the national healthcare safety network at the centers for disease control and prevention, 2006-2007. Infect Control Hosp Epidemiol 2008;29:996-1011.  Back to cited text no. 9
    
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Abdel-Fattah MM. Surveillance of nosocomial infections at a Saudi Arabian military hospital for a one-year period. Ger Med Sci 2005;3:Doc06.  Back to cited text no. 10
    
11.
Abussaud MJ. Prevalence of nosocomial infections in a Saudi Arabian teaching hospital. J Hosp Infect 1991;17:235-8.  Back to cited text no. 11
    
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Al-Tawfiq JA, Tambyah PA. Healthcare associated infections (HAI) perspectives. J Infect Public Health 2014;7:339-44.  Back to cited text no. 12
    
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Abdraboh SN, Milaat W, Ramadan IK, Al-Sayes FM, Bahy KM. Hand hygiene and health care associated infection: An intervention study. Am J Med Med Sci 2016;6:7-15.  Back to cited text no. 13
    
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Klevens RM, Edwards JR, Richards CL Jr., Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. Hospitals, 2002. Public Health Rep 2007;122:160-6.  Back to cited text no. 14
    
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Buhl M, Peter S, Willmann M. Prevalence and risk factors associated with colonization and infection of extensively drug-resistant Pseudomonas aeruginosa: A systematic review. Expert Rev Anti Infect Ther 2015;13:1159-70.  Back to cited text no. 15
    
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Bonelli RR, Moreira BM, Picão RC. Antimicrobial resistance among Enterobacteriaceae in South America: History, current dissemination status and associated socioeconomic factors. Drug Resist Updat 2014;17:24-36.  Back to cited text no. 16
    
17.
Yasmin M, El Hage H, Obeid R, El Haddad H, Zaarour M, Khalil A, et al. Epidemiology of bloodstream infections caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York. Am J Infect Control 2016;44:41-6.  Back to cited text no. 17
    
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Moreira MR, Guimarães MP, Rodrigues AA, Gontijo Filho PP. Antimicrobial use, incidence, etiology and resistance patterns in bacteria causing ventilator-associated pneumonia in a clinical-surgical Intensive Care Unit. Rev Soc Bras Med Trop 2013;46:39-44.  Back to cited text no. 18
    
19.
Joseph NM, Bhanupriya B, Shewade DG, Harish BN. Relationship between antimicrobial consumption and the incidence of antimicrobial resistance in Escherichia coli and Klebsiella pneumoniae isolates. J Clin Diagn Res 2015;9:DC08-12.  Back to cited text no. 19
    
20.
Tao L, Hu B, Rosenthal VD, Gao X, He L. Device-associated infection rates in 398 Intensive Care Units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis 2011;15:e774-80.  Back to cited text no. 20
    
21.
Xie DS, Xiong W, Xiang LL, Fu XY, Yu YH, Liu L, et al. Point prevalence surveys of healthcare-associated infection in 13 hospitals in Hubei province, China, 2007-2008. J Hosp Infect 2010;76:150-5.  Back to cited text no. 21
    
22.
WHO. The Burden of Health Care-Associated Infection Worldwide. WHO; 2011.  Back to cited text no. 22
    
23.
Ghabrah TM, Madani TA, Albarrak AM, Alhazmi MA, Alazraqi TA, Alhudaithi MA, et al. Assessment of infection control knowledge, attitude and practice among healthcare workers during the Hajj period of the Islamic year 1423 (2003). Scand J Infect Dis 2007;39:1018-24.  Back to cited text no. 23
    
24.
Talaat M, El-Shokry M, El-Kholy J, Ismail G, Kotb S, Hafez S, et al. National surveillance of health care-associated infections in Egypt: Developing a sustainable program in a resource-limited country. Am J Infect Control 2016;44:1296-301.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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