Device-associated nosocomial infection in general hospitals, Kingdom of Saudi Arabia, 2013-2016

Ten-year incidence and impact of coronavirus infections on incidence, etiology, and antimicrobial resistance of healthcare-associated infections in a critical care unit in Western Qatar

BACKGROUND

Healthcare-associated infections (HAI) in critical patients affect the quality and safety of patient care as they impact morbidity and mortality. During the COVID-19 pandemic, an increase in the incidence rate was reported worldwide. We aim to describe the incidence of HAI in the intensive care unit (ICU) during a 10-year follow-up period and compare the incidence during the pre-COVID-19 and COVID-19 periods.

METHODS

A retrospective observational study of HAI in the medical-surgical ICU at The Cuban Hospital was conducted. The data collected include the annual incidence of HAI, its etiology, and antimicrobial resistance, using the Centers for Disease Control and Prevention definitions, except for other respiratory tract infections (RTIs).

RESULTS

A total of 155 patients had HAI, of which 130 (85.5%) were identified during COVID-19. The frequency of device-associated infections (DAI) and non-DAI was higher during COVID-19, except for Clostridium difficile infections. Etiology was frequently related to species of Enterobacter, Klebsiella, and Pseudomonas in both periods, and a higher frequency of Acinetobacter, Enterococcus, Candida, Escherichia coli, Serratia marcescens, and Stenotrophomonas maltophilia was noted during the COVID-19 period. Device utilization ratio increased by 10.7% for central lines and 12.9% for ventilators, while a reduction of 15% in urinary catheter utilization ratio was observed. DAI incidence was higher during the COVID-19, with a 2.79 higher risk of infection (95% CI: 0.93-11.21; p < 0.0050), 15.31 (2.53-625.48), and 3.25 (0.68-31.08) for CLABSI, VAP, and CAUTI, respectively.

CONCLUSION

The incidence of DAI increased during the pandemic period as compared to the pre-pandemic period, and limited evidence of the impact on antimicrobial resistance was observed. The infection control program should evaluate strategies to minimize the impact of pandemics on HAI.

Clean hands, safe care: how knowledge, attitude, and practice impact hand hygiene among nurses in Najran, Saudi Arabia

Introduction

Healthcare-acquired infections are infections that patients acquire while receiving treatment for a medical or surgical condition and can occur in all care facilities. Hospital-acquired infections and the spread of antimicrobial resistance can be reduced by implementing proper preventive measures, including hand hygiene.

Aim

This study aimed to assess nurses' knowledge and attitudes toward hand hygiene guidelines in Najran city, determine compliance levels, identify factors contributing to non-compliance, and provide recommendations for interventions to improve hand hygiene practices and reduce healthcare-associated infections risk.

Subject and methods

This cross-sectional study was conducted among nurses working in the selected government hospitals in Najran City, Saudi Arabia. A self-administered questionnaire was distributed among the targeted nurses using an online survey. The questionnaire includes socio-demographic characteristics such as age, gender, and marital status. The questionnaire had 25 items to measure knowledge, 10 to measure attitude, 6 to measure practices, and 4 to measure the impact of COVID-19 on hand hygiene practices.

Results

Among the 386 nurses recruited, 88.3% were females, and 25.6% were aged between 31 to 35 years old. Overall, good knowledge, positive attitude, and good practice levels were found in 42.5, 48.4, and 94%, respectively. The common factor influencing hand hygiene practice was the prevention of cross-infection (88.1%). The total knowledge score mean was 18 ± 3.4 (highest possible score: 25). The total attitude score mean was 37.5 ± 6.1 (highest possible score: 50). The total practice score mean was 26.9 ± 2.8 (highest possible score: 30). A higher score indicates higher KAP of hand hygiene. Factors associated with increased KAP were being older in age (Z = 6.446; p < 0.001), gender female (Z = 9.869; p < 0.001), being a Filipino nurse (H = 117.8; p < 0.001), working in a surgery department (H = 28.37; p < 0.001), having more than 10 years of experience (Z = 6.903; p < 0.001), living in shared accommodation (H = 87.22; p < 0.001), having associated chronic disease (Z = 4.495; p < 0.001), and receiving formal training in hand hygiene (Z = 2.381; p = 0.017). There was a positive highly statistically significant correlation between knowledge score and attitude score (r = 0.556), between knowledge score and practices score (r = 0.303), and between attitude score and practices score (r = 0.481).

Conclusion

In light of the results, we can say that the nurses' knowledge, attitude, and practice in regards to hand hygiene were deemed acceptable. We noticed that female nurses who were older and had more experience, as well as those who had received formal hand hygiene training, displayed better KAP compared to their counterparts. Moreover, we found a significant and positive correlation between the scores for knowledge, attitude, and practice. Nonetheless, additional research is necessary to establish the extent of KAP concerning hand hygiene.

Narrative Review of the Epidemiology of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia in Gulf Cooperation Council Countries

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are the most common healthcare-associated infections, with rates varying between countries. Antimicrobial resistance (AMR) among common HAP/VAP pathogens has been reported, and multidrug resistance (MDR) is of further concern across Middle Eastern countries. This narrative review summarizes the incidence and pathogens associated with HAP/VAP in hospitals across Gulf Cooperation Council (GCC) countries. A PubMed literature search was limited to available data on HAP or VAP in patients of any age published within the past 10 years. Reviews, non-English language articles, and studies not reporting HAP/VAP data specific to a GCC country were excluded. Overall, 41 articles, a majority of which focused on VAP, were selected for inclusion after full-text screening. Studies conducted over multiple years showed a general reduction in VAP rates over time, with Gram-negative bacteria the most commonly reported pathogens. Gram-negative isolates reported across GCC countries included Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Rates of AMR varied widely among studies, and MDR among A. baumannii, K. pneumoniae, Escherichia coli, P. aeruginosa, and Staphylococcus aureus isolates was commonly reported. In Saudi Arabia, between 2015 and 2019, rates of carbapenem resistance among Gram-negative bacteria were 19-25%; another study (2004-2009) reported antimicrobial resistance rates in Acinetobacter species (60-89%), P. aeruginosa (13-31%), and Klebsiella species (100% ampicillin, 0-13% other antimicrobials). Although limited genotype data were reported, OXA-48 was found in ≥ 68% of patients in Saudi Arabia with carbapenem-resistant Enterobacteriaceae infections. Ventilator utilization ratios varied across studies, with rates up to 0.9 reported in patients admitted to adult medical/surgical intensive care units in both Kuwait and Saudi Arabia. VAP remains a burden across GCC countries albeit with decreases in rates over time. Evaluation of prevention and treatment measures and implementation of a surveillance program could be useful for the management of HAP and VAP.

Surveillance of device associated infections in intensive care units at a Saudi Arabian Hospital, 2017-2020

BACKGROUND

Device-associated infections (DAIs) are important components of healthcare associated infection and are associated with increased morbidity and mortality. This study describes DAIs across different intensive care units (ICUs) in a hospital in Saudi Arabia.

METHODS

The study was conducted between 2017 and 2020 and followed the definitions of National Healthcare Safety Network (NHSN) for DAIs. The calculated the rates of ventilator-associated events (VAE), catheter-associated urinary tract infections (CAUTI) and central line-associated blood stream infections (CLABSI) followed NHSN definitions.

RESULTS

During the study period, there were 82 DAIs in adult ICUs and of these 16 (19.5%) were CLABSI, 26 (31.7%) were CAUTI and 40 (48.7%) were VAE. The overall rates for adult ICUs were 1.6, 1.9, 3.8 per 1000 device-days for CAUTI, CLABSI and VAE, respectively. The device-utilization ratio was 0.5, 0.6, and 0.48 for urinary catheters, central lines, and ventilators, respectively. VAE rates for medical and surgical ICU were about 2.8 times the rate in the coronary care unit and the rates were high in 2020 corresponding with the COVID-19 pandemic. Of the adult ICUS, medical ICU had a CLABSI rate of 2.13/1000 device-days and was about double the rate in surgical and cardiac ICU. For CAUTI, the rates per 1000 device-days were 2.19, 1.73, and 1.65 for medical, surgical, and coronary ICUs, respectively. The rate of CLABSI per 1000 device-days for pediatric and neonatal ICUs were 3.38 and 2.28, respectively.

CONCLUSIONS

CAUTI was the most common infections among adult ICUs and medical ICU had higher rates than other adult ICUs. VAE rate was higher in the first year of the COVID-19 pandemic, indicating increased device-use, change in patients characteristics as well as possible change in practices across the ICUs.

Urinary Tract Infections in the Kingdom of Saudi Arabia, a Review

Urinary tract infections (UTIs) are among the most common infections and are associated with an increased rate of antimicrobial resistance in Saudi Arabia. Better knowledge of the most common pathogens and their antimicrobial resistance patterns will be useful for creating new treatment guidelines. PubMed, Web of Science, Scopus, and Google Scholar were searched using suitable keywords to identify UTI publications until November 2022. Eligible studies were selected and analyzed. A total of 110 records were found, but only 58 articles were analyzed. Most studies were retrospective, and just a few were cross-sectional or prospective. The majority of the studies were conducted in the central region followed by the Eastern region. Escherichia coli and Klebsiella spp. were the most common pathogens. There was a significant resistance rate against co-trimoxazole and ciprofloxacin. On the other hand, amikacin was one of the most effective antibiotics. Overall, only a few studies have been published on UTIs in Saudi Arabia. Moreover, not all regions have been represented, so the full scope of the issue is unknown. UTIs are still a major problem, and resistance has developed against commonly used antibiotics. Thus, large epidemiological studies are needed to battle the rapid emergence of antimicrobial resistance.

Assessment of potassium ion channel during electric signalling in biofilm formation of Acinetobacter baumannii for finding antibiofilm molecule

Acinetobacter baumannii is an opportunistic ESKAPE pathogen which causes nosocomial infections and can produce biofilms that act as resistant determinants. The role of quorum sensing (chemical signaling) in biofilm establishment has already been studied extensively, but the existence of electrochemical signaling during biofilm formation by A. baumannii has not yet been investigated. The current study evaluated the presence of electrical signaling, types of ion channels involved, and their role in biofilm formation using spectroscopic and microbiological methods. The findings suggest that the potassium ion channel has a significant role in the electrical signaling during the biofilm formation by A. baumannii. Further, in-silico screening, molecular mechanics, and molecular dynamic simulation studies identify a potential lead, ZINC12496555(a specific inhibitor), which targets the potassium ion channel protein of A. baumannii. Mutational analysis of the interacting residues showed alterations in the unfolding rate of this protein after the selected mutation, which shows its role in the stability of this protein. It was also observed that identified lead has high antibiofilm activity, no human off-targets, and non-cytotoxicity to cell lines. Thus, identified lead against the potassium channel of A baumannii may be used as an effective therapeutic for the treatment of A. baumannii infections after further experimental validation.

Epidemiology of Healthcare-Associated Infections and Adherence to the HAI Prevention Strategies

Healthcare-associated infections are widely considered one of the most common unfavorable outcomes of healthcare delivery. Ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections are examples of healthcare-associated infections. The current study was a retrospective study conducted at a public hospital in Unaizah, Saudi Arabia, to investigate the frequency of healthcare-associated illnesses and adherence to healthcare-associated infection prevention techniques in the year 2021. Surgical site infections occurred at a rate of 0.1%. The average number of catheter-associated urinary tract infections per 1000 catheter days was 0.76. The average number of central line-associated bloodstream infections per 1000 central line days was 2.6. The rate of ventilator-associated pneumonia was 1.1 per 1000 ventilator days on average. The average number of infections caused by multidrug-resistant organisms per 1000 patient days was 2.8. Compliance rates were 94%, 100%, 99%, and 76% for ventilator-associated pneumonia, central line-associated bloodstream infections, catheter-associated urinary tract infections, and hand hygiene bundles, respectively. It is critical to participate in more educational events and workshops, particularly those that emphasize hand cleanliness and personal safety equipment.

Impact of the COVID-19 pandemic on the incidence, etiology, and antimicrobial resistance of healthcare-associated infections in a critical care unit in Western Qatar

BACKGROUND

Healthcare-associated infections (HAIs) in critical patients affect the quality and safety of patient care and increase patient morbidity and mortality. During the COVID-19 pandemic, an increase in the incidence of HAIs, particularly device-associated infections (DAIs), was reported worldwide. In this study, we aimed to estimate the incidence of HAIs in an intensive care unit (ICU) during a 10-year period and compare HAI incidence during the preCOVID-19 and COVID-19 periods.

METHODS

A retrospective, observational study of HAIs in the medical-surgical ICU at The Cuban Hospital was conducted. DAIs included central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP). Data included the annual incidence of HAIs, etiology, and antimicrobial resistance, using definitions provided by the Centers for Disease Control and Prevention, except for other respiratory tract infections (RTIs).

RESULTS

155 patients with HAI infections were reported, from which 130 (85.5%) were identified during the COVID-19 period. The frequencies of DAIs and non-DAIs were higher during the COVID-19 period, except for Clostridium difficile infections. Species under Enterobacter, Klebsiella, and Pseudomonas dominated in both periods, and higher frequencies of Acinetobacter, Enterococcus, Candida, Escherichia coli, Serratia marcescens, and Stenotrophoma maltophila were noted during COVID-19 period. Device utilization ratio increased to 10.7% for central lines and 12.9% for ventilators, while a reduction of 15% in urinary catheter utilization ratio was observed. DAI incidence was higher during the COVID-19 pandemic, with risks for CLABSI, VAP, and CAUTI increased by 2.79 (95% confidence interval, 0.93-11.21; p < 0.0050), 15.31 (2.53-625.48), and 3.25 (0.68-31.08), respectively.

CONCLUSION

The incidence of DAIs increased during the pandemic period, with limited evidence of antimicrobial resistance observed. The infection control program should evaluate strategies to minimize the impact of the pandemic on HAIs.

Reducing Central-Line-Associated Bloodstream Infections (CLABSI): An Improvement Project in a Specialized Tertiary Hospital

Introduction

Central-line-associated bloodstream infections (CLABSI) are preventable hospital-acquired infections that harm and prolong a patient's hospital stay and increase unnecessary hospital expenditure. In collaboration with infection control and hospital epidemiology, the quality management department initiated a performance improvement project to address 144 CLABSI events in 2017.

Methods

The performance improvement project team used brainstorming to create change ideas presented in a driver diagram. The team then applied plan-do-study-act (PDSA) cycles to implement and monitor the improvements. Finally, the team applied a bundle of interventions that included the following: (a) policies and procedures for central line insertion, maintenance and removal processes standardization, (b) physicians training for line insertion by simulation, (c) an awareness campaign that included recognizing healthcare workers and enhancing patient engagement, (d) performing root cause analysis for the CLABSI events, and (e) automation of central line insertion, and (f) maintenance bundles documentation in the hospital information system.

Results

The CLABSI rate per 1000 patient days dropped from 1.5 per 1000 device days to 1.03 per 1000 device days. In addition, CLABSI events reduction was 24% by 2018. Then further reduction of 15% occurred by the end of 2019. Thus, the overall decrease in CLABSI events was 35% from the baseline number of events (i.e., 144 events) in 2017. Another achievement of the project is that 10 units reported zero CLABSI events in 2018 and 2019, of which four units had a high central line utilization rate, more than 40%.

Conclusion

The implemented interventions effectively reduced the CLABSI events in the hospital. The project team will continue implementing more interventions with monitoring, aiming to achieve zero CLABSIs over time in all the hospital units.

Incidence of Healthcare-Associated Infections (HAIs) and the adherence to the HAIs' prevention strategies in a military hospital in Alkharj

Background

Healthcare-associated infections (HAI) are considered one of the most common adverse events in health care service provision. In order to prevent the occurrence of HAIs, it is important to implement several prevention strategies.

Objectives

This study aims to determine the incidence of healthcare-associated infections in a military hospital in Alkharj and the adherence to the HAIs' prevention strategies.

Methods

This study included exporting data for all infected cases confirmed by the infection disease specialists in 2019. The data were collected from the reports that were written by infection control unit and infectious disease department.

Results

The rate of healthcare associated infections (HAIs) in 2019 was 0.43% of total patient admissions. The rate of central line associated bloodstream infections in 2019 was 1.15 per 1000 central line days. The rate of catheter associated urinary tract infections in 2019 was 1.00 per 1000 catheter days. The rate of ventilator associated pneumonia in 2019 was 2.11 per 1000 ventilator days and the rate of surgical site infections in 2019 was 0.41 %.

Conclusion

The rate of overall healthcare-associated infections (HAI) was low. The compliance rate of health care workers to preventive measures that control HAIs was generally high but there was a need for more awareness particularly regarding personal protective equipment and hand hygiene. So it is important to attend more awareness activities and workshops particularly regarding personal protective equipment and hand hygiene. Furthermore, infection control unit and infectious disease department in the hospital should support the robust HAI prevention programs.

Preventive Measures and Management of Catheter-Associated Urinary Tract Infection in Adult Intensive Care Units in Saudi Arabia

Catheter-associated Urinary Tract Infection (CAUTI) has been studied worldwide as part of device-related healthcare infection. CAUTI is one of the most commonly reported infections in the literature, which occurs during clinical practice in Intensive Care Units (ICUs) and non-ICU departments. Many studies have covered the CAUTI rate in Saudi Arabia mainly in the ICU covering single or multiple hospitals as surveillance for device-related infections in the ICU. Few studies have conducted an interventional approach that examined the implementation of infection control protocols and then compared them to international practice as a standard. This review aims to explore the literature to provide insight into the infection control practices that have been reported in Saudi Arabia during the last two decades on the preventive measures and clinical consequences of CAUTIs. Very few studies have recorded the pattern of resistant microorganisms that burdens clinical practice in ICUs concerning CAUTIs. Only one study compared the type of catheter materials and discussed the effect of these materials on reducing CAUTIs. It is essential to cover catheter utilization and to understand how a sufficient infection control protocol with educational programs for healthcare personnel can transform practice, for the better, regarding CAUTI rates in Saudi hospitals. There is a demand for more interventional and epidemiological studies on the causes and factors affecting the rate of CAUTI in the area. Studies may help reduce the CAUTI incidence rate, which consequently reduces the costs and morbidity associated with this type of infection and other healthcare-related infections.

Critical care nurses' compliance and barriers toward ventilator-associated pneumonia prevention guidelines: cross-sectional survey

OBJECTIVES

This study aims to determine the compliance of critical care nurses with the ventilator-associated pneumonia prevention guidelines and the factors that affect their compliance. We also explored the barriers faced by the nurses in the implementation of these guidelines.

METHODS

A cross-sectional descriptive survey was conducted using a self-administered questionnaire containing 17 recommended strategies to prevent ventilator-associated pneumonia and 15 possible barriers. All critical care nurses of varying qualifications, levels of experience, and nationalities working in adult ICUs were invited. Between January and March 2018, the questionnaire was distributed to 283 nurses at eight ICUs in five public hospitals in Almadinah Almunawwarah, KSA.

RESULTS

A total of 229 invitees responded to the questionnaire. The mean compliance score was 85.9%. More than half (54%) of the sample had a high or acceptable compliance level. The lowest compliance rate was reported for the suctioning of subglottic secretions. The main reported barriers were the shortage of nursing staff, forgetfulness, and hospital cost control policies. Working in general ICUs with the capacity of 10-15 beds or prior education related to ventilator-associated pneumonia prevention influenced the nurses' compliance.

CONCLUSION

In our study, the overall compliance of the critical care nurses with the ventilator-associated pneumonia prevention guidelines is acceptable. Shortage of nursing staff, forgetfulness, and cost control policies were the main reported barriers to compliance.

Sustained Low Incidence Rates of Central Line-Associated Blood Stream Infections in the Intensive Care Unit

Background

Central line-associated bloodstream infection (CLABSI) is an important cause of increased morbidity and mortality in ICUs. The occurrence of CLABSI in significantly higher in developing countries and contributes to the burden of healthcare-associated infections.

Methods

This prospective study was carried out from January 2016 to December 2019 in the intensive care unit at King Faisal Medical Complex in Taif, Saudi Arabia. The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) recommendations were introduced and implemented during 2017–2019. In the post-intervention period, observation of hand hygiene, CLABSI bundle compliance, and benchmarking of CLABSI rates were carried out.

Results

The CLABSI incidence rate was 1.12/1,000 central-line days, with a 0.51 utilization ratio in the pre-intervention period. This dropped to 0.46/1,000 central line days with a 0.44 utilization ratio in the post-intervention period. This reduction was also confirmed in benchmarking with National Healthcare Safety Network (NHSN) (50th–75th) percentile pre-intervention vs (25th–50th) percentile post-intervention. Institutional risk assessment revealed a formal educational program as a potential need for improvement. The CLABSIs were caused predominantly by multidrug-resistant Klebsiella pneumoniae.

Conclusion

We observed a reduction and sustained low incidence rate of CLABSI benchmarking to NHSN for 3 years after implementation of the basic SHEA/IDSA recommendations.

Length of Stay in Patients With Central Line-Associated Bloodstream Infection at a Tertiary Hospital in the Kingdom of Saudi Arabia

Objective

To examine the impact of central line-associated bloodstream infection (CLABSI) on hospital length of stay (LOS) and to identify the factors associated with prolonged LOS.

Methods

The research setting was King Saud University Medical City (KSUMC) in Riyadh, Kingdom of Saudi Arabia. A retrospective cohort design was applied with a sample of adult CLABSI patients. Patients developed CLABSI following central line insertion at KSUMC between March 2016 and February 2018.

Results

The CLABSI-related prolongation of LOS was 13.13 ± 9.53 days for a total of 283 patients. This figure rose for patients with any CLABSI-related sequela, and the result was statistically significant (p<0.033). It was also significantly higher in patients with delayed central line removal (p<0.001). A patient’s setting (i.e., in the intensive care unit prior to or following infection) was not a factor associated with prolonged LOS. Nevertheless, the requirement for inotropes after the infection was linked to prolonged LOS in a statistically significant way (p<0.048).

Conclusions

For ill patients who need hemodynamic support following infection, CLABSI can significantly increase hospital LOS. Delayed decisions or slow central line removal are associated with significant increases in LOS.

Healthcare workers' perspectives on healthcare-associated infections and infection control practices: a video-reflexive ethnography study in the Asir region of Saudi Arabia

Background

Healthcare-associated infections (HAIs) are a global public health problem. For the fulfillment of Saudi Arabia’s Vision 2030, the promotion of preventive care medicine through HAI management is a crucial issue. This study explores the perspectives of Saudi tertiary healthcare workers (HCWs) on HAIs and infection control measures.

Methods

Quantitative data were assessed to determine HCWs’ knowledge of HAI and their attitudes towards and practice of infection control measures. Semi-structured interviews were used to collect qualitative data from 40 doctors and nurses. The interviews were audio-recorded and transcribed verbatim. Further, routine sterile procedures in the wards and intensive care units were video recorded, and the footage was discussed by the infection control team and the personnel involved in the videos. This discussion was videographed and transcribed. Both interview data and reflective discussion of the video were analysed using thematic analysis. The quantitative data were analysed using the Kruskal–Wallis test and logistic regression analysis.

Results

Kruskal–Wallis test revealed no difference in mean knowledge, attitude, or practice scores between nurses/ doctors or the genders. There was a significant difference in knowledge score and practice scores between the Intensive care unit & the Paediatric ward /infection control department with the maximum scores in knowledge and practice among participants from the intensive care unit. Logistic regression analysis for dependent variables (knowledge and attitude) and independent variables like age, gender, designation, and departments was not significant. The qualitative data yielded four themes: knowledge of HAI and infection control, infection control measures in practice, a shortfall in infection control measures and HAI, and required implementation. Video-reflexive ethnography (VRE) revealed lapses in handwashing practice and proper usage of personal protective equipment (PPE), especially surgical masks.

Conclusion

Early introduction of training programmes in medical and nursing schools and video demonstrations of appropriate infection control practices during sterile procedures would be highly beneficial to HCWs. A possible reason for the outbreak of Middle East Respiratory Syndrome coronavirus in this part of Saudi Arabia could be a lapse in PPE usage. Intensive training programs for all the HCWs, strict vigilant protocols, and a willingness to change behaviour and practice, will significantly benefit the spread of outbreaks.