Eurosurveillance

ECDC

Antibiotic use and nosocomial infections among patients at the Arkhangelsk multifield children’s hospital: results of monitoring during 2006-2008

 Rediger
  Published: 19.12.08 Updated: 19.12.2008 14:40:32

O.V Samodova (1), A.Hajdu (2), S.J.Nazarenko (3), E.G.Petrova (3), N.V.Markov (3)

  1. Northern State Medical University
  2. Norwegian Institute of Public Health
  3. Arkhangelsk Vyzhletsov Regional Children’s Clinical Hospital

Citation: Samodova O, Hajdu A, Nazarenko S, Petrova E, Markov N. Antibiotic use and nosocomial infections among the patients at the Arkhangelsk multifield children's hospital: results of monitoring during 2006-2008. - EpiNorth. 2008 Vol. 9 No 3. p. 79-85

Abstract
Hospital-acquired infections continue to be a problem for public health. HAI significantly increase the duration of hospitalization and cost of treatment, reduce the quality of life and are one of the causes of deaths in hospital. Despite the significance and necessity of official registration, HAI surveillance in Russia needs improvement.
A HAI point prevalence study and investigation of antibiotic use was conducted for the first time at the Arkhangelsk Regional Children’s Clinical Hospital within the framework of an international project with the Norwegian Institute of Public Health. Our data indicate that the highest HAI prevalence was 17.7% and the lowest was 6.5% with an average mean HAI prevalence of 13.1% for the entire period. Upper respiratory tract infections represented the most prevalent HAI , the proportion of which varied from 28% to 70.2% with an average mean of 44.8%. The prevalence of the most severe HAI such as urinary tract infections, pneumonia, surgical wound infections was not high and varied from 0.3 to 3.3%. Nosocomial infections were registered more often in patients hospitalized for more than 10 days than among children who were hospitalized for less than 10 days.
The proportion of patients receiving antimicrobial therapy (antibacterial, antiviral and antifungal) on the day of examination varied from 31.5 to 47.6%. Between 82.6-92.3% of the children received antimicrobials for therapeutic purposes. The minority of children received antimicrobials for prophylactic purposes.
Monitoring of antimicrobials is necessary condition for the optimization of antibiotic use in regional children’s hospitals. The HAI point prevalence study evaluated the significance of this pathology, revealed risk factors and determined the structure of nosocomial infections for the development and optimization of prophylactic and antiepidemic measures.

Introduction
Hospital-acquired (HAI) or nosocomial   infections continue to be a problem for public health care service by significantly increasing the length of hospitalization and cost of treatment, decreasing quality of life for patients and being a cause of deaths in hospital (1). From 1990 registration of sporadic cases of nosocomial infections were introduced in all health care facilities in the Russian Federation.  Registered nosologic forms include purulent and septic infections (PSI) of newborns and puerperants, postsurgical PSI, postinfectious purulent and septic diseases, enteric infections, infections of the urinary tract and other infectious diseases, as well as influenza and acute respiratory diseases (2). According to different assessments, HAI in Russia occur in 5-50 % of hospitalized patients and is the 10th leading cause of mortality (3,4). The rate of nosocomial infections in Europe is significantly lower than in Russia and is approximately 6.6 –6.7% according to different reports (5,6). The results of investigations by Russian and foreign authors are difficult to compare and correlate due to differences in diagnostics, case definitions and statistic data assessment. The definition of incidence (morbidity over a period of time) is more often used in Russia while prevalence (morbidity at definite point of time) is frequently evaluated in foreign publications.

Hospital-acquired infections at pediatric departments are one of the factors that result in negative opinions among parents regarding the hospitalization of their children. Parents often refuse to have their children hospitalized. These infections damage the reputation of institutions and the loss in patient care is difficult to assess financially (4).

Despite the significance and necessity of official registration, surveillance of HAI in Russia is still far from perfect. 26,852 cases of HAI were registered in the Russian Federation during 2006 and the incidence rate per 1000 of patients was 0.8. The low level of HAI morbidity was the result of underestimating urinary tract infections, purulent and septic infections among puerperants, newborns and postsurgical patients (7). Respiratory nosocomial infections in pediatric hospitals are infrequently registered despite the wide prevalence (3). The HAI morbidity structure during 2006 amounted to 34.1 % in obstetric institutions, 28.7% in surgical institutions and 10.5% in children’s hospitals (7). The inadequate reporting of HAI underestimated registration is also caused by the absence of uniformed technologies for detecting cases of hospital-acquired infections.

Challenges related to HAI are closely connected with issues of antibiotic treatment under hospital conditions. Irrational antibiotic use contributes to an increase in hospital microorganisms that are resistant to antimicrobials and the selection of highly virulent strains. These factors lead to ineffective patient therapy, the development of complications and fatal cases.
The present point prevalence study of nosocomial infections and antibiotic use was conducted for the first time at the Arkhangelsk Regional Children’s Clinic Hospital (RCCH). The project was performed within the framework of the established collaboration with the Norwegian Institute of Public Health taking into consideration the above mentioned facts.

The purpose of the study was to investigate the prevalence of HAI according to the type of infection, departments, sex and age among the patients at the multifield children’s hospital. In addition, risk factors and antibiotic use were assessed in order to optimize prophylactic measures.

Materials and method
The study was conducted at the Arkhangelsk Vyzhletsov Regional Children’s Clinical Hospital. The hospital is a multifield health care institution that provides specialized medical assistance in 26 disciplines for children in the Arkhangelsk region. The hospital has 435 stationary beds and a polyclinic that can provide 300 consultations during each shift. Hospital capacity is organized into 15 clinical and 8 paraclinical departments. The hospital includes departments for premature babies, newborns and infants, infectious diseases, surgery, traumatology,  otolaryngological, psychoneurological, oncological, resuscitation and intensive  care units as well as a department for older children. 10,500 children are treated in the hospital annually and more than 80,000 receive consultative help at the out-patient department.

HAI prevalence and antibiotic use were registered within one day in all patients at the Children’s Clinical Hospital. HAI prevalence was defined as the number of HAI cases divided by the number of admitted patients and multiplied by 100. Patients who were hospitalized for less that 48 hours were excluded from the study. We have in a previous report (8) presented the modified HELICS definitions for HAI. Date of admission, sex, age, HAI type, surgical procedures, antimicrobial therapy, indications for prescription (therapy, prophylaxis, unknown reasons), risk factors for HAI (immunodeficiency, hypogranylocytosis, immunosuppressive therapy, ureteral stent, intravenous cannulas) were registered. HAI character was defined on the basis of clinical-laboratory data according to an examination protocol (8) that included standard case definitions for all HAI nosological forms. All HAI detected including urinary tract infections, low respiratory tract, postsurgical wound infection, sepsis, as well as upper respiratory tract infections, gastro-intestinal tract infection, central nervous system infection, skin and soft tissues infections were registered. All patients registered in the hospital were included in the sampling for the analysis of antibiotic use. Registration forms at every department were completed 9.00 until 14.00 on the day of examination. A HAI prevalence investigation was conducted for the first time on February 1, 2006 in collaboration with the Department of Infectious Disease Epidemiology at the Norwegian Institute of Public Health (Oslo). Additional  investigations and the analysis of results were performed by hospital physicians two times each year.

A database was produced using the information provided on the registration forms. The data were analyzed using Microsoft Excel, EpiInfo 2000, SPSS 11.5, Epitable programs. The level of significance of compared average parameters was defined using two-sided t-test for groups with different dispersions. Chi square test was used for comparison of categorical variables. Risk factors for HAI were evaluated using logistic regression model.

Results and discussion
The investigation of HAI prevalence at the Arkhangelsk Children’s Clinical Hospital was conducted 6 times: 01.02.2006, 17.05.2006, 26.12.2006, 29.05.2007, 24.12.2007, 21.04.2008. The number of patients varied from 308 to 400. HAI prevalence is presented in Table 1.

Table 1. Prevalence of hospital-acquired infection at the Arkhangelsk Regional Children’s Clinical Hospital in 2006-2008

Type of infection / Типинфекции

Dateofsurvey / Дата исследования

01.02.2006

17.05.2006

26.12.2006

29.05.2007

24.12.2007

21.04.2008

Infections of veins and arteries / Инфекция вен и артерий

0

0

0

0

0

0.28

Necrotizing enterocolitis / Некротический энтероколит

0

0

0

0

0.61

0.28

Asymptomatic bacteriuria / Бессимптомная бактериурия

0

0

0.75

0

0

0.28

Decubitus / Пролежни

0.25

0

0

0

0

0

Omphalitis / Омфалит

0.25

0

0

0

0

0

Vulvovaginitis / Вульвовагинит

0.25

0

0.50

0.32

0.61

1.14

Skin infection / Инфекция кожи

0.25

0

0.25

0.97

0.30

0

Infectionoforalcavity / Инфекция ротовой полости (молочница)

0.50

0.31

0.50

0.97

0.91

0

Sinusitis / Синусит

0

0.51

0.25

0

0

0

Gastroenteritis / Гастроэнтерит

1.0

0.51

0.75

0

3.1

0.85

Conjunctivitis / Конъюнктивит

1.0

0.93

0.75

0.32

1.2

0

Surgicalsiteinfection / Инфекция операционной раны

0.50

0.31

0

0

0.30

0

Urinarytractinfection / Инфекция мочевыводящих путей

2.0

0.93

2.5

1.3

2.1

0.28

Pneumonia / Пневмония

3.3

1.6

1.5

0.32

1.8

0.85

Upper respiratory tract infection / Инфекция верхних дыхательных путей

7.6

12.4

4.3

2.3

4.3

6.3

Total prevalence / Общая превалентность

17.0

17.7

12.0

6.5

15.2

10.3

Attempts to compare the data collected with data from other Russian children’s hospitals were unsuccessful. We did not find any published reports of prevalence surveys. Most of the studies were devoted to HAI morbidity over periods of  time within a year. According to reports from foreign authors, HAI prevalence in children’s hospitals was lower than in Russia (5,6).
According to our observations the highest HAI prevalence was approximately 17. 7% and the lowest was 6.5%. The average mean HAI prevalence for the entire monitoring period was 13.1%. Upper respiratory tract infections (ARI) were most frequent among all registered HAI, from 28 % to 70.2 % with an average mean of 44.8%.

The prevalence of the most severe HAI such as urinary tract infections, pneumonia, surgical wound infection was not high and varied from 0.3 to 3.3. These data are comparable with other reports (6,7).
The relative contribution of separate factors in the development of nosocomial infections was determined by binomial logistic regression. The following factors were evaluated: presence of intravenous cannulas and ureteral stent, hypogranylocytosis,   immunodeficiency, duration of hospitalization, sex, age and department. The results of regression analysis showed that duration of hospitalization was a significant characteristic-predictor factor. The following regression equation was used:

 


where Х = duration of hospitalization. The odds ratio was 2.8, 95% confidence interval – 1.6-4.7.

Nosocomial infections were registered statistically more often in patients that stayed at the hospital for more than 10 days than in children hospitalized for less than 10 days (Table 2). Children hospitalized for more than 10 days were at greater risk of contracting HAI (Table 2).

Table 2. Number and risk of HAI in relation to duration of hospitalization at the Arkhangelsk Regional Children’s Clinical Hospital 2006-2008

Date of the survey / Датаисследования

Days of hospitalization before the survey / Днигоспитализациидодняисследования

Relativerisk / Относительный риск (RR)

95% Confidence interval  RR / ДИ RR

P-value / Значения вероятности

Less than 10 days / До 10 дней

More than 10 days / Более 10 дней

01.02.2006

14/210

53/185

4.7

2.7-8.1

0.001

17.05.2006

12/158

45/165

3.6

2.0-6.5

0.001

26.12.2006

1/56

47/344

7.9

1.1-56.3

0.004

29.05.2007

5/143

15/165

2.6

1.0-7.0

0.03

24.12.2007

11/173

39/155

4.0

2.1-7.5

0.001

21.04.2008

9/163

27/188

2.6

1.3-5.4

0.005

The age of hospitalized patients was a significant factor. Children during the first year of life are at greatest risk of HAI (Table 3).

Table 3. Number and risk of HAI among children of different ages at the Arkhangelsk Regional Children’s Clinical Hospital 2006-2008

Dateofsurvey / Дата исследования

Age / Возраст

Relativerisk / Относительный риск (RR)

95%  Confidence interval RR/ДИ RR

P-value / Значения вероятности

Younger than 12 month / До 12 мес

Older than 12 month / Старше 12 мес

01.02.2006

31/131

36/264

1.7

1.1-2.6

0.01

17.05.2006

25/102

32/221

1.7

1.1-2.7

0.02

26.12.2006

28/158

20/242

2.1

1.3-3.7

0.004

29.05.2007

11/89

9/219

3.0

1.3-7.0

0.01

24.12.2007

29/134

21/194

2.0

1.2-3.4

0.006

21.04.2008

18/108

18/243

2.3

1.2-4.2

0.009

We did not find a relation between HAI and risk factors such as immunodeficiency, hypogranylocytosis, presence of intravenous cannulas and ureteral stent. This may be explained by the fact that most infections were upper respiratory tract infections where these factors were not expected to play an important role. Viral nosocomial infections in contrast to bacterial infections affect all the children and not only those who are considered to be at high risk. These infections are characterized by lack of severe clinical symptoms, but they increase the duration of hospitalization and cost of treatment. Infection etiology verification was not addressed in this project. A significant part of these infections may have been caused by common respiratory viruses. An increase in the number of nosocomial respiratory infections corresponded to the common seasonal increase of this pathology. The prevalence of HAI was equal among boys and girls.

For the evaluation of antimicrobial use the entire population of children at the hospital was included. Monitoring results showed that on the day of examination the proportion of patients receiving antimicrobial therapy (antibacterial, antiviral and antifungal) varied from 31.5% to 47.6% (Table 4).

Table 4. The proportion of children receiving antimicrobial therapy at the Arkhangelsk Regional Children’s Clinical Hospital 2006-2008

Dateofsurvey / Дата исследования

Number of patients / Количествопациентов

Proportion of patients received antimicrobial therapy / Удельныйвеспациентов, получавшиха/б (%)

95% Confidenceinterval / ДИ

Hospitalized / Госпитализированные

Received antimicrobial therapy / Получавшиха/б

01.02.2006

472

183

38.8

34.3-43.1

17.05.2006

404

133

32.9

28.4-37.8

26.12.2006

400

141

35.3

30.6-40.1

29.05.2007

381

120

31.5

26.8-36.4

24.12.2007

359

171

47.6

42.4-52.9

21.04.2008

376

149

39.6

34.7-44.8

Total / Всего:

2392

897

37.5

35.5-39.5

The proportion of patients receiving antimicrobial therapy did not differ significantly in relation to seasons.

Between 82.6% and 92.3% of the children received antimicrobial treatment. A minority of the children received antimicrobials for prophylaxis (perioperative antibiotic prophylaxis of surgical infections, syphilis prophylactic treatment, severe hypogranulocytosis) while the majority of the children who received antibiotics were treated at department of infectious diseases, resuscitation and premature children units.
Cephalosporins (I-III generations) were the most commonly used antibiotics.(29.6 to 42.6%). The use of penicillins and macrolides was also registered. The last study reported a decrease in the use of aminoglycosides and an increase in nitofurans (Table 5).

Table 5. Most widely used antibiotics (by classes) at the Arkhangelsk Regional Children’s Clinical Hospital 2006-2008

Date / Дата

Classes of antibiotics / Классыантибиотиков

Cephalosporin / Цефалоспорин

Penicillin / Пенициллин

Macrolide / Макролид

Aminoglycoside / Аминогликозид

Nitrofuran / Нитрофуран

Proportion / Удельный вес (%)

Confidenceinterval / Доверительный интервал

01.02.2006

38.9

32.3-45.8

21.8

16.4-28.0

10.4

6.7-15.4

6.6

3.7-10.9

8.1

4.8-12.6

17.05.2006

32.7

25.5-40.6

26.4

19.8-34.0

10.1

5.9-15.8

8.2

4.4-13.6

7.5

4.0-12.8

26.12.2006

42.6

35.0-50.4

13.0

8.3-19.0

8.3

4.6-13.5

7.7

4.2-12.8

6.5

3.3-11.4

29.05.2007

35.0

27.2-43.4

11.2

6.5-17.5

7.7

3.9-13.4

12.6

7.6-19.2

9.8

5.5-15.9

24.12.2007

29.6

23.4-36.5

26.1

20.2-32.8

8.0

4.7-12.7

7.5

4.3-12.1

5.5

2.8-9.7

21.04.2008

40.4

32.3-48.6

22.2

15.8-29.7

12.1

7.3-18.4

2.0

0.42-5.8

12.1

7.3-18.4

Bacterial monitoring and “resistance certificates” for microorganisms have been written at hospital departments since 2004 with the intent to optimize antibacterial therapy and control HAI. From 2007 microbiological examination data have been processed by the «Whonet 5,4» computer  program. Bacterial monitoring results are presented at each department 1-2 times every 6 months. On the basis of these examinations guidelines for starting antibacterial therapy in children have been developed. These guidelines include recommendations for initiating antibacterial therapy for the treatment of different diseases. The guidelines were developed with support from the Norwegian Institute of Public Health (9).

Conclusion
Antimicrobial monitoring is essential for the optimization of policy regarding the use of antibiotics at regional children’s hospitals. The aim is to decrease the development of antimicrobial resistance and increase the efficiency of treatment. Data analysis showed that most of the patients received antimicrobials for treatment. Nevertheless, rational restriction of the use of some types of antibiotics is necessary.
Successful prophylaxis and prevention of HAI requires dynamic control of the prevalence of these infections. The HAI point prevalence study elucidated the significance of this pathology, revealed risk factors and established nosocomial infection structure for the development and optimization of prophylactic and antiepidemic measures. Prevalence monitoring enables the evaluation of the efficiency of prophylactic measures. This is essential for appropriate management decisions regarding the specialties in different departments. However, to date some  of the challenges associated with HAI remain unsolved. Treatment of HAI is not covered by medical insurance funds and HAI registration in the patient’s medical history may lead to punitive measures from insurance companies.

Acknowledgements
The authors thank the Norwegian Institute of Public Health for assistance in conducting the initial investigations included in this study.

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