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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 14-17

A cross-sectional surveillance on healthcare-associated infections in a trauma centre in Eastern Uttar Pradesh: Experience of a student researcher


1 Faculty of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Trauma Centre, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission14-Sep-2021
Date of Acceptance03-Jul-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Dr. Tuhina Banerjee
Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_22_21

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  Abstract 


Objectives: Surveillance of healthcare-associated infection (HAI) is extremely important for the implementation and monitoring of infection prevention and control (IPC) policies and practices in health-care organisations. This study led by a Phase 2 medical student researcher was performed to assess the burden of different HAIs in a type 1 trauma centre.
Materials and Methods: A cross-sectional study was conducted on patients with a provisional diagnosis of HAI. Pretested and predesigned pro forma fulfilling the criteria for surveillance of HAIs from the Centers for Disease Control and Prevention-National Healthcare Safety Network was used to collect data. The microbiological culture reports were reviewed. The rates of different HAIs were calculated in Microsoft Excel 2010 based on standard definitions.
Results: The rates of catheter-associated urinary tract infection and ventilator-associated event (VAE) were 1.19/1000 catheter days and 36.99/1000 ventilator days, respectively. The surgical site infection rate was 4.97/100 surgeries with the majority of infections noted after orthopaedic interventions.
Conclusions: Among all HAIs, VAE rate, mostly due to Acinetobacter baumannii, was higher than the existing Indian estimate, requiring immediate attention on prevailing IPC practices. The involvement of medical student researchers could help in the generation of baseline data in resource-limited settings.

Keywords: Device-associated infection rates, India, student researcher, surveillance, ventilator-associated event


How to cite this article:
Seth A, Das A, Singh R, Banerjee T. A cross-sectional surveillance on healthcare-associated infections in a trauma centre in Eastern Uttar Pradesh: Experience of a student researcher. J Patient Saf Infect Control 2022;10:14-7

How to cite this URL:
Seth A, Das A, Singh R, Banerjee T. A cross-sectional surveillance on healthcare-associated infections in a trauma centre in Eastern Uttar Pradesh: Experience of a student researcher. J Patient Saf Infect Control [serial online] 2022 [cited 2022 Dec 6];10:14-7. Available from: https://www.jpsiconline.com/text.asp?2022/10/1/14/361004




  Introduction Top


According to the World Health Organization (WHO) patient safety fact sheet, out of every 100 hospitalised patients, seven acquires at least one healthcare-associated infection (HAI) in developed countries and 10 in developing countries.[1] The increasing emergence of HAIs in low-middle-income countries is of recent concern. The problem of antimicrobial resistance (AMR) is an added burden.[2] Lack of awareness and compliance with infection prevention and control (IPC) guidelines has posed life-threatening challenges of infections to patients in hospital settings in developing countries including India.[3] The magnitude of the problem becomes severe owing to the paucity of established data on HAI in India, with the lack of proper documentation and maintenance of records being one of the biggest shortcomings. In this context, the WHO strongly recommends the inclusion of the concepts of infection control in the training of medical students for early awareness and effective practice.[4] In line with this, the recent introduction of similar concepts in the training of the 'Indian Medical Graduate' by the National Medical Commission (NMC) of India is a remarkable step towards the implementation of effective IPC practices in hospitals.[5]

Majority of the HAIs are exogenous in origin and endemic in nature. There exists a wide range of diversity between the institutions, hospitals and trauma centres regarding the prevalence of predominant pathogens and their antimicrobial susceptibility patterns.[6],[7] Realising the importance of this preliminary data for any intervention, this study was conducted to assess the burden of different HAIs in a type 1 trauma centre of a tertiary care hospital in Varanasi based on the standard guidelines and to identify the common pathogens of HAI with their susceptibility profile. The importance of the study lies in the fact that it was led by a student researcher during his medical training.


  Materials and Methods Top


A cross-sectional study was conducted in the 340-bedded Trauma Centre of the Institute of Medical Sciences, Banaras Hindu University, Varanasi from June 25, 2019 to August 31, 2019. The study was approved by the institute ethical committee (Letter no. 2019/EC/1024). Informed consent was taken from every patient or their guardian before their recruitment in the study. During the conduct of this study, regular meetings or activities of the hospital infection control committee were not in place in the study centre. However, the existing infection control team consisting of the infection control officer, infection control nurse and clinical microbiologist continued their efforts for initiating effective IPC practices.

In-patients of trauma centre admitted during the above period were included following the inclusion criteria of a provisional diagnosis of HAI made by the visiting clinician and being admitted in various wards and intensive care units (ICU) for more than 48 h. Patients who succumbed before the collection of specimens for microbiological investigation and those with signs and symptoms of suspected HAI before 48 h of admission were excluded. Those who did not provide consent for the study were also excluded.

A pretested and predesigned pro forma for surveillance was used for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs) and ventilator-associated events (VAEs) in accordance with the standard surveillance protocols.[6],[7],[8],[9] Data collection was done by the team comprising of the Phase 2 student researcher (Indian council of Medical Research [ICMR]-Short-term Studentship) and trained infection control nurse and microbiologists. The student researcher was trained in the basics of IPC and surveillance by the team before data collection. Records of microbiological culture from appropriate specimens and antimicrobial susceptibility testing were also noted. The culture reports were reviewed and documented along with the specific HAI.

Statistical analysis

All data were fed in Microsoft Excel 2010 and standard formulae based on international guidelines were used for the calculation of CAUTI, SSI, VAE, CLABSI and device-associated infection (DAI) rates.[6],[7],[8],[9]


  Results Top


A total of 58 provisionally diagnosed HAI cases were studied. The age of the patients ranged from 8 years to 80 years (mean age 36.65 ± 18.2 years) with a male-to-female ratio of 53: 5. The prevalence of CAUTI, SSI and VAE was 5.17% (3), 46.55% (27) and 46.55% (27), respectively. While no case of CLABSI was detected, only one case (1.72%) of both CAUTI and SSI was found. The mean period for the development of a HAI was 10.14 days from the day of intervention (10.4 days from the day of endotracheal intubation and 10.3 days from the day of surgery). The rate of CAUTI and VAE was 1.19/1000 catheter days and 36.99/1000 ventilator days, respectively. The DAI rate was 5.9/1000 device days. The rate of SSI was 4.97/100 surgeries performed, whereas the rate was 17.65/100 surgeries among patients admitted to ICU.

Of the 58 cases, specimens from 50 patients yielded growth on culture. [Table 1] shows the frequency distribution of the organisms isolated from the HAI cases. The most common organism from SSI was Escherichia coli (E. coli) and VAE was Acinetobacter baumannii (A. baumannii), followed by Pseudomonas aeruginosa (P. aeruginosa). Majority of SSI cases occurred after orthopaedic surgeries (10, 43.47%), followed by abdominal (8, 34.78%) and neurosurgical (5, 21.73%) interventions. The susceptibility profile showed that E. coli, Klebsiella pneumoniae and Citrobacter spp were mostly sensitive to imipenem (66.7%–75%), whereas P. aeruginosa and A. baumannii were resistant to most of the drugs including cefepime (66.7%), piperacillin-tazobactam (66.7%–93.34%), carbapenems (77.8%–93.34%) except polymyxin B (22.2%). Both Staphylococcus aureus and Enterococcus spp. showed 100% sensitivity to vancomycin and linezolid. The isolated Candida species showed sensitivity to fluconazole, voriconazole and amphotericin B. Based on the results, antibiogram was derived as shown in [Figure 1].
Table 1: Distribution of the organisms isolated from the various hospital-acquired infection cases

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Figure 1: Antibiogram of Gram-negative organisms from different HAI based on surveillance, HAI: Healthcare-associated infection

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  Discussion Top


This prevalence-based study is important for three different reasons. First, besides providing the estimates of HAI prevalence for the first time from this part of the country, this study was conducted primarily by a trained undergraduate medical trainee as a part of his medical training. For the past few years, several initiatives in the form of programmes launched by the National Health Mission, extensive networking on AMR surveillance and IPC training by the ICMR, All India Institute of Medical Sciences, New Delhi, with international collaborations have already laid the cornerstones to address the existing gaps related to HAI surveillance and prevention in India.[10] In addition, the radical change in the course curriculum of medical undergraduates laid down by NMC has also emphasised 'early exposure' of students to the concepts of HAI and IPC.[5] To meet this end, this study was planned and thus conducted. Third, microbiological confirmation of the infections was emphasised in this study for further standardisation of the surveillance data.

In the present study, the CAUTI rate was slightly lower (1.19/1000 catheter days) than the existing International Nosocomial Infection Control Consortium (INICC) CAUTI rate (2.13/1000 catheter days) and pooled mean CAUTI rate according to the Centers for Disease Prevention and Control (CDC, 2.1/1000 catheter days).[11] This could be attributed to the strict maintenance of bundle care and the absence of risk factors (viz. diabetes and obstructive uropathy) in the studied cases. Although there was no case of CLABSI which provided an assurance to the prevailing nursing care directed to such devices, the short time span of the study might have underestimated the actual rate. In a similar study, however, the rate of CLABSI from trauma care was zero even after 21 months of surveillance.[3]

The global estimate of SSI ranged from (0.5 to 15/100 surgeries). The rate in India was significantly higher (ranging from 23 to 38/100 surgeries).[12] This study revealed a lower rate of SSI. According to the INICC, the SSI rates amongst hospitals in India were significantly higher after abdominal, cardiothoracic surgeries and breast surgeries when compared with the US data.[13] In this case, majority of the SSI cases occurred after orthopaedic interventions which might be due to failure in adhering to strict practices and nursing care. Based on this, continuous education and strict monitoring of the health-care staff were advised. The VAE rate (36.99/1000 ventilator days) in this study was quite higher than the Indian estimate (9.4/1000 ventilator days) and these events occurred solely in ICU where highly resistant strains of A. baumannii were prevalent.[9] This could be predicted from the previous studies in these ICU settings which revealed an endemicity of these organisms in the ICU environment.[14] Thorough surface disinfection to eliminate environmental reservoirs and the role of antimicrobial stewardship in controlling these cases was emphasised. Following this, regular sensitisation of the health-care workers in the form of continuous medical education was initiated.

This CDC-National Healthcare Safety Network criteria-based surveillance study was not without limitations. While a short study period was involved, lack of follow-up and outcome data limited the findings from the determination of the major risk factors associated with the studied HAI. Besides, this was a single-centre study, the findings of which might be of limited relevance to the nation at large. Nonetheless, the data generated provided first-hand information on the actual burden of HAI in this setting that would help in the delineation of the actual strength and weaknesses of the ongoing health-care practices. As it is not limited to a laboratory-based audit, future policies could be designed for betterment based on this study. Further, this protocol could be used in the generation of larger data on HAI in the study setup involving medical students for early exposure to similar concepts.


  Conclusions Top


Among all HAIs, VAE rate was found to be higher than the existing Indian estimate. These events occurred solely in the ICU where highly resistant strains of A. baumannii were most prevalent. Majority of the SSI cases occurred after orthopaedic interventions in our set up which require attention. The involvement of medical student researcher in such surveillance studies could assist in the generation of baseline data for future interventions in resource-limited settings.

Ethical approval

The study was approved by the institute ethical committee (Letter no. 2019/EC/1024).

Acknowledgements

The authors would like to thank ICMR for the approval of the short-term studentship (STS 2019-01069) to the first author (AS) for this study. We also thank the Professor-In-charge at trauma centre for facilitating this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Health Care-Associated Infections FACT SHEET. World Health Organization (WHO). Available from: https://www.who.int'gpsc_ccisc_fact_sheet_enWHO. [Last accessed on 2021 Jan 10].  Back to cited text no. 1
    
2.
Indian Council of Medical Research. Antimicrobial Stewardship Program Guideline. Available from: https://icmr.nic.in/sites/default/files/guidelines/AMSP_0.pdf. [Last accessed on 2019 Dec 12].  Back to cited text no. 2
    
3.
Deepashree R, Raghavan R, Sastry AS. Implementation of active surveillance system to track hospital-acquired infections in a tertiary care hospital in India. J Curr Res Sci Med 2017;3:21-8.  Back to cited text no. 3
  [Full text]  
4.
The Burden of Health Care-Associated Infection Worldwide – WHO. Infection Prevention and Control. World Health Organization (WHO); 2021. Available from: https://www.who.int'publications'burden_hcai. [Last accessed on 2021 Jan 10].  Back to cited text no. 4
    
5.
Medical Council of India. Module on Pandemic Management; 2020. Available from: https://www.nmc.org.in/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/Pandemic-MGT-Module-UG.pdf. [Last accessed on 2021 Jan 10].  Back to cited text no. 5
    
6.
Centers for Disease Control and Prevention. “Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) Events.” Device-associated Module (UTI). Atlanta, GA: Centers for Disease Control and Prevention (CDC). Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 6
    
7.
Centers for Disease Control and Prevention. “Surgical Site Infection (SSI) Event.” Procedure-Associated Module (SSI). Atlanta, GA: Centers for Disease Control and Prevention (CDC). Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 7
    
8.
Centers for Disease Control and Prevention. Atlanta. “Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection).” Device-associated Module. Atlanta, GA: Centers for Disease Control and Prevention (CDC). Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf. [Last accessed on 2019 Dec 09].  Back to cited text no. 8
    
9.
Centers for Disease Control and Prevention. “Ventilator-Associated Event (VAE).” Device-Associated Module (VAE). Atlanta, GA: Centers for Disease Control and Prevention (CDC). Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf. [Last accessed on 2019 Dec 9].  Back to cited text no. 9
    
10.
Swaminathan S, Prasad J, Dhariwal AC, Guleria R, Misra MC, Malhotra R, et al. Strengthening infection prevention and control and systematic surveillance of healthcare associated infections in India. BMJ 2017;358:j3768.  Back to cited text no. 10
    
11.
Mehta Y, Jaggi N, Rosenthal VD, Kavathekar M, Sakle A, Munshi N, et al. Device-associated infection rates in 20 Cities of India, data summary for 2004-2013: Findings of the international nosocomial infection control consortium. Infect Control Hosp Epidemiol 2016;37:172-81.  Back to cited text no. 11
    
12.
Kamat US, Fereirra AM, Kulkarni MS, Motghare DD. A prospective study of surgical site infections in a teaching hospital in Goa. Indian J Surg 2008;70:120-4.  Back to cited text no. 12
    
13.
Singh S, Chakravarthy M, Rosenthal VD, Myatra SN, Dwivedy A, Bagasrawala I, et al. Surgical site infection rates in six cities of India: Findings of the international nosocomial infection control consortium (INICC). Int Health 2015;7:354-9.  Back to cited text no. 13
    
14.
Banerjee T, Mishra A, Das A, Sharma S, Barman H, Yadav G. High prevalence and endemicity of multidrug resistant Acinetobacter spp. in intensive care unit of a tertiary care hospital, Varanasi, India. J Pathog 2018;2018:9129083.  Back to cited text no. 14
    


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