The study was performed in May 2003. Seven hospitals from different regions of Latvia were included. Hospitals were selected based on the presence of an infection control specialist in the hospital and support from the hospitals administration.
In each hospital, one trained investigator collected the data. A modified point prevalence study protocol was used. All patients treated in each ward were surveyed during one day. Only patients who received antimicrobial therapy were included in the study sample. All antimicrobials administered were recorded according to the purpose of the administration: treatment of community and hospital acquired infection, prophylaxis, or the purpose was unclear to investigator. Antibiotics, antivirals and antifungals were defined as antimicrobials. The type of infection and major risk factors for nosocomial infections were registered for each patient who received antimicrobials.
Data were entered in duplicate and analyzed by EpiData 3.02 and Epi Info 2000 software packages.
Seven hospitals were included in the study. Eight hundred forty six patients received antibiotics, 23 patients received antifungals and five patients received antivirals on the day of the survey. Antimicrobials were administered to 855 (27%) of 3,150 hospitalized patients. Four hundred and two (47%) were males and 453 (53%) were females. Six hundred and sixteen patients received one antibiotic each, 210 patients received two and 220 patients received three.
Table 1. Indications for antimicrobial administration to patients in seven Latvian hospitals, 2003
Most patients received antimicrobials because they had an infection, usually a community acquired infection (Table 1). However, more than a fifth of the treated patients received antimicrobials for no obvious reason. The 855 patients received 907 antibiotic prescriptions, meaning that some patients received antimicrobials for more than one indication.
The five most commonly used antibiotics were cefazolin, gentamicin, ampicillin/amoxicillin, metronidazole, and ciprofloxacin (Table 2). Ten different antibiotics were used for surgical prophylaxis. Cefazolin was used for surgical prophylaxis in 58% of all cases.
Table 2. Antimicrobials used in seven Latvian hospitals, 2003
Among the 516 patients who received antimicrobials because of an infection, there was a total of 545 infections because some patients had more than one infection. Therefore, the total prevalence of infection was 17.3%. There were 422 community acquired infections (13.4%) and 123 hospital acquired infections (3.9%) (Table 3).
The most common nosocomial infections recorded were surgical site infections (28%) and infection of the lower respiratory tract (pneumonia, 20%) (Table 3). The main recorded risk factors for hospital acquired infections were surgical intervention (31%), mechanical ventilation (11%) and urinary catheter (8%).
Table 3. Number and prevalence of different types of infections in seven Latvian hospitals, 2003
There was a large difference in the prevalence of hospital acquired infections between different wards (variation from 0.5% to 20.2%). The highest prevalence was recorded in intensive care units and surgical departments (Table 4).
Table 4. Prevalence (%) of hospital acquired infections in different departments of seven Latvian hospitals, 2003
The concept of nosocomial infections is still unclear to the Latvian medical community. Most professionals believe that nosocomial infections are equivalent to community acquired infectious diseases treated in specialized hospitals or departments. Nosocomial infections are not included in the official diagnosis list and treatment is not covered by medical funds.
In our study 57% of the antimicrobials were prescribed for treatment of infections. The burden of the infection is thus high in multidisciplinary Latvian hospitals.
Overuse of antibiotics can lead to increased antimicrobial resistance and facilitate the spread of multiresistant microorganisms. In our study, antibiotics were prescribed without clear clinical reason, primarily due to unnecessary extension of surgical prophylaxis, in 20% of all cases.
The prevalence of nosocomial infection was found to be similar or slightly lower than previously reported prevalences in other countries (2-5). We assume that some infections were not registered in our study because only patients who received antimicrobials were included. Nevertheless, the number of infections not registered would account for a very small number of cases because doctors in Latvian hospitals tend to prescribe antimicrobials even when the lowest suspicion arises. The most likely explanation for this rather small prevalence is that patients often stay in hospital until the treatment is completed. Therefore, the proportion of hospitalized patients who are very ill is smaller than in other countries with more extensive hospital health care and shorter hospitals stays.
The highest burden of nosocomial infection was found in intensive care units and surgical departments. This is similar to other studies. Comprehensive preventive and surveillance measures should be employed within these clinical units.
The methodology we used was applicable in all seven hospitals and none of the investigators reported serious problems with the implementation. Similar methodology has been used in other countries (6,7) and was considered successful. We plan to repeat the investigations annually with improved protocols to monitor changes in the prevalence of nosocomial infections and pattern of antimicrobial use over time.
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