Abstract
Background:
Healthcare-associated infections (HAIs) are increasing in health facilities in Mali, due to health disparities and growing costs. Twenty to fifty percent of HAIs in the surgery department can be prevented with appropriate measures.
Objectives:
This study aimed to determine the burden of HAI and its risk factors.
Materials and Methods:
This was a prospective cohort study from January to June 2021 at the CHU Gabriel TOURE, Bamako, Mali. The sample size was determined based on the CDC Atlanta criteria, used to confirm HAI in surgical settings. Demographic, clinical, and biological parameters were determined. For the confirmed case of infection, the incriminated bacteria were isolated and tests were performed for the choice of drugs.
Results:
Of the total 1001 patients included in this study, 195 patients (19.48%) have HAIs. The types of infections were as follows: 70 cases of surgical site infections, 54 infections on burns victims, 40 urinary tract infections, and 31 cases of bacteraemia. Germs such as Escherichia Coli, Klebsiella pneumoniae, and Acinetobacter were often isolated. We found increasing hospital stays as well as some postoperative mortality related to infections. At the end of this study, corrective efforts were implemented to prevent HAI. Among them are improvements in sterilisation techniques as far as surgical materials were concerned. In addition to a surgical checklist, locally used drapes were replaced with single-use surgical supplies. Advanced training of the surgical team on things such as bladder catheterisation was also conducted in the department. It is important to put in place a committee, to prevent nosocomial infection in our hospital. The selected committee will be responsible for planning and implementing diverse strategies to prevent infections.
Conclusions:
The prevention of HAIs will reduce health costs and improve the quality of surgical care.
Keywords: Antibiotics, healthcare-associated infection, resistance
Introduction
An infection is associated with care if it occurs during or as a result of a patient’s management (diagnostic, therapeutic, palliative, preventive or educational) and if it was not present or incubating at the beginning of management.[1] HAIs need to take in charged in an emergency manner.
The World Health Organization (WHO) estimates between 5% and 12% of hospitalised patients worldwide develop HAI, of which more than 60% is associated with the implantation of a medical or surgical device.[2] However, with appropriate measures, 20%–50% of the cases can be prevented. In Mali, at the Department of Surgery, Konaté et al.[3] reported in 2020 an incidence of 10.5% of postoperative infection, and Escherichia coli was the most frequent germ (31.2%). A study carried out by Bocoum et al.[4] in the obstetrics–gynaecology department found an incidence of 15% of HAI. The consequences on the quality of care and the additional cost of this complication are rarely assessed in previous studies. The objectives of this study are to determine the frequency of HAI, describe the different types of HAI, identify germs and their sensitivity to antibiotics, and assess the consequences of these HAI.
Materials and Methods
We performed a prospective cohort study from January 1 to June 30, 2020, in the Departments of Surgery at the Teaching Hospital Gabriel T (Paediatrics Surgery, General Surgery, Obstetrics–Gynaecology, Urology, and Neurosurgery).
Patients
The study covers all patients admitted to the department of surgery. All cases of HAIs occurring 48 h after admission, confirm by bacteriological examinations in the laboratory. We did not include patients who presented with a postoperative infection at admission. Each patient after inclusion in the study was followed up for 1 month. This follow-up made it possible to assess the evolution of the disease, collect data on postoperative complications, and data on antiprograms. The follow-up was done by setting visits day based on the diagnosis and the clinical condition of the patient, if necessary follow-up data were collected by telephone call also. To evaluate the consequences, we compared arm 1 (patients with infections) and arm 2 (patients without infections).
Bacteriological diagnosis
Samples collected undergo bacteriological investigation in the laboratory. Surgical site infections and burns infections were swabbed, and 24-h urine was collected for this bacteriological examination. A blood culture was performed to look for bacteria responsible for this HAI.
Data processing
Data capture and analysis were performed in Epi Info, Version 7.2.5 (CDC d’Atlanta, Atlanta, Georgia, USA). The statistical comparison test used was Chi-square with a significance threshold of P < 0.05.
The odds ratio (OR) was used to assess the relationship between risk factors and the occurrence of infections associated with care. When the OR is less than 1, the factor studied is a protective factor; when the OR is equal to 1, there is no link between the factor and the occurrence of infection; and when the OR is greater than 1, the factor considered is a risk factor for HAI.
Ethics approval
The study has been approved by the ethics committee.
Results
Frequency
Of the total of 1001 patients included, we found 195 in arm 1 patients (19.48%) who presented 201 HAIs and 806 in arm 2 patients without infections. Some patients presented two or more HAIs. Patients with infections were mainly men: 58.54% (114/195) versus 41.46% (81/195) women, with a sex ratio of 1:41 in favour of men. The rates of HAI are summarised in Figure 1.
Figure 1.
Rates of healthcare-associated infection by specialty
Types of healthcare-associated infection
The types of infections were surgical site infections in 72 patients (35.82%), followed by infected burns in 53 patients (26.37%), urinary tract infection in 40 cases (19 90%), and bacteremia in 30 patients (14.93%).
Germs
The following germs were found: Escherichia Coli, Klebsiella pneumoniae, and Acinetobacter. Enterobacteriaceae are present in 61.19% of cases and extended-spectrum β-lactamase-producing Enterobacteriaceae for 55 patients (45%). The germs and their sensibility are summarised in Tables 1,2–3.
Table 1.
Type germs found in the samples
| Germs | Number (%) |
|---|---|
| Acinetobacter baumanii | 29 (14.43) |
| Enterobacter Cloacae | 4 (1.99) |
| Enterococcus faecalis | 15 (7.46) |
| Enterococcus faecium | 1 (0.50) |
| Escherichia coli | 69 (34.33) |
| Klebsiella oxytoca | 1 (0.50) |
| Klebsiella pneumoniae | 40 (19.90) |
| Proteus mirabilis | 5 (2.48) |
| Providencia stuartii | 2 (1.00) |
| Pseudomonas aeruginosa | 15 (7.46) |
| Staphylococcus aureus | 20 (9.95) |
| Total | 201 (100.00) |
Table 2.
Sensibility/résistance of germs to amoxicillin and amoxicillin + acid clavulanic
| Germs | Amoxicillin | Amoxicillin + acid clavulanic | ||
|---|---|---|---|---|
| Resistant | Sensible | Resistant | Sensible | |
| Acinetobacter baumanii | 29 | 0 | 4 | 25 |
| Escherichia coli | 55 | 14 | 32 | 37 |
| Enterococcus faecalis | 4 | 11 | 0 | 15 |
| Klebsiella Pneumonia | 25 | 15 | 24 | 16 |
| Pseudomonas aeruginosa | 14 | 1 | 1 | 14 |
| Staphylococcus aureus | 17 | 3 | 5 | 15 |
Table 3.
Sensibility/resistance of germs to imipenem and ertapenem
| Germs | Imipenem | Ertapenem | ||
|---|---|---|---|---|
| Resistant | Sensible | Resistant | Sensible | |
| Acinetobacter baumanii | 4 | 25 | 0 | 29 |
| Escherichia coli | 1 | 68 | 1 | 68 |
| Enterococcus faecalis | 0 | 15 | 1 | 14 |
| Klebsiella Pneumonia | 1 | 39 | 1 | 39 |
| Pseudomonas aeruginosa | 1 | 14 | 0 | 15 |
| Staphylococcus aureus | 0 | 20 | 0 | 20 |
Risk factors
Diabetes and emergency surgery were found to be risk factors associated with HAI in this study (P < 0.0001). The risk factors are summarised in Table 4.
Table 4.
Risk factor of HAI
| Risk factors | Effective | Rate of HAI % | P value |
|---|---|---|---|
| Diabetic | |||
| Diabetes present | 22 | 59.09 | OR = 6.6 (2572–17,042) |
| Diabetes absent | 979 | 18.59 | |
| Type of admission | |||
| Emergency | 584 | 25 | OR = 2196 (1468–3286) |
| Nonemergency | 417 | 11.75 | |
| Haemoglobin | |||
| ≤10 g/dL | 241 | 23.24 | OR = 1327 (0.913–1927) |
| >10 g/dL | 759 | 18.31 | |
| WHO Index of performance | |||
| 3 and 4 | 182 | 39.23 | OR = 2695 (1855–3914) |
| 0, 1, and 2 | 819 | 15.14 | |
HAI: healthcare-associated infection, OR: odds ratio, WHO: World Health Organization
Assessments
The consequences were serious. The hospital stay was 8.6 ± 5 days for arm 2 (patients without infections) versus 17.6 ± 8 days for arm 1 (patients with infections). The mortality was 3.35% in patients without infections versus 15% in cases of infections. The mean cost was 310 USD for patients without infections versus 1050 USD for those who had infections.
Discussions
Frequency
Up to 7% of hospitalised patients will develop an HAI during their treatment. However, it is possible to prevent 20%–50% of cases by targeted measures.[5] We found an incidence of 19.48% (195/1001). In studies carried out in the intensive care unit, Merzougui et al.,[6] in Tunisia, identified 125 episodes of nosocomial infections in 81 patients, with a rate of 30.6%, Andrianarivelo et al.[7] in Madagascar found an incidence of 52.4%. These HAI rates are higher than ours (19.95%). The difference can be explained by the fact that this study was conducted in intensive care units. Chemsi et al.[8] in Morocco found 7.5% HAI, and this result is lower and acceptable.
Bacteria
In our study, bacteria Gram-negative represented 84.58% (170/201). Gram-negative bacilli accounted for 84.08% (169), and Enterobacteriaceae represent 61.19% (123). In Cameroon, Njall[9] reported that of the 11 infected patients in her study, 13 biological samples were taken isolating 11 Gram-negative bacteria (84.62%), and 2 Gram-positive Cocci (15.38%). These results were similar to ours.
Types of infections
The most of time, in developed countries, urinary infections are more frequent with 37.68%.[10] In our study, we found more surgical site infections at 35.28%. Some African authors similar to our study reported 40% surgical site infection.[11] In a study at Benin, Afle et al.[11] reported that 20 of 139 patients had HAI; of which site and respiratory infections were the most common, 5% and 5% respectively. Urinary tract infections accounted for 20% and surgical site infections for 40%.[11]
In the African surgical area, it appears that the prevention of surgical site infection is the first way in fighting against HAI.
Risk factors
The Tunisian national survey finds an association between the occurrence of nosocomial infection and a number of intrinsic factors such as diabetes (OR = 1.3; P = 0.01).[12]
In the second French national survey of the prevalence of nosocomial infection conducted in 2001, the presence of immunosuppression (prevalence ratio of 3.8) was also significantly associated with an increased frequency of infection.
The factors favouring infections associated with care are multiple, diabetes is one of the factors that weaken the body, thus promoting the occurrence of HAI. We found the same result as Hamza[12]; however, we did not assess immunosuppression in our study, the French national survey reported immunosuppression as a factor favouring the occurrence of HAI.[13]
Consequences of healthcare-associated infection
HAIs impact morbidity, mortality, and healthcare cost. According to the WHO (Geneva, Switzerland), HAIs caused 37,000 deaths per year in Europe and 99,000 deaths per year in the USA.
HAIs increase healthcare costs in Europe by €7 billion per year and in the USA by $6.5 billion per year. Surgical site infections, particularly deep surgical site infections, are associated with up to a $20,000 increase in cost per patient admission.[14] Increased healthcare costs from HAIs are borne by the government, insurance companies, patients, and hospitals.[14]
In France, it is estimated that of the 600,000–1100,000 patients who contract an infection associated with care each year, about 10,000–20,000 will die from an infection associated with care that will be directly or indirectly the cause of death.[15] In the literature, we reported the same increase in cost.
Impact of the study
At the end of this study, we shared the results with all hospital staff to prepare the team for HAI prevention. These results were used when drafting protocols by the national antimicrobial resistance program in Mali.
We implement the below actions:
Improvement of surgical materials sterilisation
Implementation of surgical checklist
Replacement of the local drapes with single-use equipment for surgery.
A course on bladder catheterisation in the department.
A course of cutaneous preparation before surgery
The creation of the fighting nosocomial infection committee in our hospital.
This committee has responsibility for planning and monitoring the implementation of various actions to prevent infections.
Limitations of the study
In this study, we did not assess the average time it took for people to resume work between those who had HAI and those who did not, and also the shortfall in money associated with care-related infections. These variables will be addressed in future studies to better understand the impact of this problem and to improve control strategies.
Conclusion
HAIs are becoming more and more frequent in our health establishments, a better organisation of the system by creating an infection prevention and control program is necessary in Mali to effectively fight against HAIs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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