Infection Control & Hospital Epidemiology HABSI types
Of all reported cases, 41% were primary BSIs (23% CA-BSI and 18.2% NCA-BSI). The most common secondary HABSI was BSI- UTI (21.5%), followed by BSI-SSI (12.7%), BSI-PULM (11.2%), and BSI-ABDO (7.2%). BSI-SST represented 3.2% of all cases, BSI-other represented 2.6%, and BSI-BONE represented 0.5%.
Ten-year rates
The 10-year HABSI incidence rate for the cohort was 5.59 per 10,000 patient days (95% CI, 5.54–5.63) (Table 1). On average, nonteaching hospitals with ICUs had annual rates that were 1.47 (95% CI, 1.08–2.02) times higher than nonteaching hospitals without ICUs, while teaching hospitals had rates 3.10 (95% CI, 2.06–4.65) times higher than nonteaching hospitals without ICUs (Table 3).
Primary BSI The 10-year incidence rate for CA-BSI’s was 1.29 per 10,000 patient days (95% CI: 1.24-1.34). It was the most frequent HABSI in teaching hospitals. The 10-year incidence rate for NCA-BSI was 1.01 per 10,000 patient days (95% CI, 0.97–1.05). Both types were significantly higher in teaching hospitals compared to nonteaching hospitals without ICUs (Table 3).
Secondary BSI The 10-year incidence rate for BSI-UTI was 1.2 per 10,000 patient days (95% CI, 1.16–1.25) and was the most frequent HABSI in nonteaching hospitals. BSI-SSI had a relatively lower 10-year incidence rate of 0.71 per 10,000 patient days (95% CI, 0.68–0.75). The 10-year incidence rate for BSI-PULM was 0.62 per 10,000 patient days (95% CI, 0.59–0.65), and for BSI-ABDO, the 10-year incidence rate was 0.4 per 10,000 patient days (95% CI, 0.38– 0.43). BSI-SST, BSI-other, and BSI-BONE were relatively infre- quent (Table 2). For all secondary HABSIs except BSI-BONE, teaching hospitals had significantly higher rates than nonteaching hospitals without ICUs, while only BSI-UTI and BSI-SSI rates were significantly higher in nonteaching hospitals with ICUs (Table 3).
Time trends
The HABSI rate in study year 1 (Y1) was 5.63 per 10,000 patient days (95% CI, 5.34–5.79) and showed minimal fluctuation until Y10, in which the rate was 5.61 per 10,000 patient days (95% CI, 5.31–5.77) (Fig. 1). Furthermore, GEE analyses showed no sta- tistically significant effect of year on the incidence rates for the cohort.
Primary BSI In Y1, annual CA-BSI rate was 1.47 per 10,000 patient days (95% CI, 1.32–1.63) and appeared to decrease consistently until Y8 (Fig. 2). However, only Y8 showed a statistically significant drop of 42% (95% CI, 26%–55%) relative to Y1, but the rate rebounded in the last 2 years of the study (Table 2). The NCA-BSI rate started at 0.69 per 10,000 patient days (95% CI, 0.59–0.8), almost half the rate of CA-BSI in Y1. These rates showed a steep increase in Y7, when the rate was 1.13 per 10,000 patient days (95% CI, 1.01– 1.28), a 67% (95% CI, 20%–133%) increase from Y1. In Y8, the NCA-BSI rate of 1.32 per 10,000 patient days (95% CI, 1.18–1.48) surpassed the CA-BSI rate. This rise was sustained until Y10,
1205
when it ended with a rate that was 110% (95% CI, 60%–176%) higher than Y1.
Secondary BSI Annual BSI-UTI rates showed little year-to-year change (Table 2). Only in Y10 did the rates drop to 0.98 per 10,000 patient days (95% CI, 0.86–1.12), a 25% (95% CI, 2%–43%) reduction from the Y1 rate. The BSI-SSI rate was 0.81 per 10,000 patient days (95% CI, 0.70–0.93) in Y1 and dropped by 26% (95% CI, 9%–39%) in Y3, but this decrease was not sustained in the following years. The BSI-SST annual rates showed a statistically significant bump in Y4, with a 52% (95% CI, 4%–123%) increase compared to Y1. Similarly, BSI-other showed increases in Y5 and Y6 of 60% (95% CI, 19%–116%) and 108% (95% CI, 25%–244%), respectively, but these were not sustained. Annual BSI-PULM, BSI-ABDO, and BSI-BONE rates showed no statistically significant changes.
Discussion
Our study is one of the largest published reports on HABSI epidemiology describing a large population surveyed over a full decade with a high number of cases. It adds substantial knowledge to the scarce literature, especially from North America. We reported an overall HABSI rate of 5.59 HABSI cases per 10,000 patient days, similar to 6.0 per 10,000 patient days reported by the only recent high-coverage (24 hospitals), multicenter study in Queensland, Australia during a period overlapping ours.1 A smaller study in Denmark reported a rate of 6.4 per 10,000 patient days and another in the United States reported a range between 11.2 and 6.7 per 10,000 patient days.2,3 The HABSI rates were consistently higher in teaching hospitals
and often higher in nonteaching hospitals with ICUs compared to nonteaching hospitals without ICUs. It is common for HAI rates to be higher in teaching hospitals because they often receive sicker patients given their mission to provide specialized care for severely ill patients who are more vulnerable to HABSI.14–17 Higher HABSI rates in hospitals with ICUs can be explained by the usually higher rates in ICUs compared to wards outside the ICU.18 The longitudinal nature of surveillance data collection allowed
us to analyze temporal trends in rates. We found no significant changes in annual HABSI rates at the cohort level. While no province-wide interventions targeted HABSI as a whole, a cam- paign targeting multidrug-resistant HABSI, CLABSI, SSI, and ventilator-associated pneumonia was implemented in 2014 (Y7– Y8).19 The degree to which hospitals complied with the campaign guidelines and its subsequent effects on our results are unknown. Other multicenter studies have reported variable temporal trends in HABSI rates. Some exhibited decreases,3,20 others increases,21 and some no consistent trend.2,22,23 It is difficult to compare our reported temporal trends because (1) time periods did not over- lap,20,22,23 (2) studied hospitals had characteristics different to ours,2,3 or (3) denominators used were population based, not hospital based.21,22 The BACTOT data collection procedure facilitated our ana-
lysis of HABSI cases and rates by infection source. The leading sources of cases were CA-BSIs, which include central-line–asso- ciated BSI (CLABSIs, the most targeted subset of HABSIs in infection prevention and control), BSI-UTIs, and NCA-BSI. Valles et al24 reported relatively similar proportions.
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