Infection Control & Hospital Epidemiology
Table 3. The Effect of Hospital Type on Overall Healthcare-Associated Bloodstream Infections (HABSI) and Source-Specific Incidence Rates Incidence Rate Ratio in Comparison to Nonteaching Hospitals Without ICUs (95% CI)a
Hospital Type
Nonteaching with ICUs
Teaching
HABSI 1.47
(1.08–2.02) 3.10
(2.06–4.64)
CA-BSI 1.75
(0.85–3.64) 5.27
(2.25–12.36)
NCA-BSI 1.41
(0.83–2.39) 3.27
(2.07–5.16)
BSI-UTI BSI-PULM BSI-SSI BSI-ABDO BSI-SST BSI-BONE BSI-Other 2.25
1.19
(1.62–3.14) 2.39
(1.58–3.60)
(0.78–1.80) 2.22
(1.34–3.65) 2.30
(1.38–3.84) 5.85
(3.54–9.69) 0.98
(0.48–2.01) 2.37
(1.06–5.29) 1.29
(0.59–2.80) 2.69
(1.11–6.49) 4.05
(0.57–28.73) 4.09
(0.55–30.24) 1.76
(0.75–4.14) 2.39
(1.14–5.01)
Note. ICU, intensive care unit; HABSI, healthcare-associated bloodstream infection; CA-BSI, catheter-associated primary bloodstream infection (BSI); NCA-BSI, non–catheter-associated primary BSI; BSI-UTI, BSI secondary to urinary tract infections; BSI-PULM, BSI secondary to pulmonary infections; BSI-SSI, BSI secondary to surgical site infections; BSI-ABDO, BSI secondary to intra-abdominal infections; BSI-SST, BSI secondary to skin-and-soft-tissue infections; BSI-BONE, BSI secondary to bone-and-joint infections; BSI-other, BSI secondary to any other primary
focus; CI, confidence interval. aEstimated using generalized estimating equations.
1207
Fig. 1. Annual incidence rates of all healthcare-associated bloodstream infections (HABSIs) in hospitals that have participated in the Québec HABSI surveillance program (BACTOT) from 2007–2008 (study year 1, Y1) to 2016–2017 (Y10), stratified by hospital type. NT with ICU, nonteaching hospitals with an intensive care unit; NT no ICU, nonteaching hospital without an intensive care unit; Teaching: teaching hospitals. Note. Between Y4 and Y6, BSIs following invasive procedures were considered primary NCA- BSIs if they occurred 2 days after the procedure. Outside this period, the window of causality was 7 days.
The CA-BSI rates began as the highest subtype in Y1 and
showed a statistically significant drop in rates in Y8 (2014–2015) that was not sustained. A 2014 decrease was also seen in a recent study by Li et al25 on another SPIN surveillance program (SPIN- BACC) that targets CLABSI in ICUs; it may be explained by bundled practices introduced in the beginning of Y3. While this drop may have contributed to the results seen here, our study includes an overall insubstantial number (6.4%) of patient days spent in ICUs compared to the Li et al study, which was limited to CLABSI in the ICU. The NCA-BSI rates exhibited a sustained statistically sig-
nificant increase in Y7 (2013–2014) and overtook other subtypes to become the most frequent in Y8–Y10. This rise coincides with returning the window of causality for BSIs following invasive procedures from 2 to 7 days. However, if the rise was a result of the definition change, an equal reduction should have been seen in Y5 when the window was reduced to 2 days, which was not the case. Y7 was also the year the new data entry platform for BACTOT data collection was implemented in participating hos- pitals. Because this was suspected to cause artificial changes in rates, SPIN validated the platform and concluded that new data entry rules contributed to some cases being miscategorized or erroneously rejected, and corrections were subsequently made.
Because our analyses utilize the corrected data, it is plausible that the persistent increase in NCA-BSI reported here is a true one. A possible explanation could be an increase in the number of procedures performed. Among secondary HABSIs, BSI-UTIs were consistently the
most frequent, which is often the case in hospitals due to extensive use of urinary catheters, the main contributing cause of urinary tract infections and consequent BSI-UTIs.11,24 A con- siderable number of HABSIs were BSI-PULMs, BSI-ABDOs, and BSI-SSIs, but their rates did not exhibit any lasting changes in the 10-year study period. BSI-SST, BSI-BONE, and BSI-other occurred at relatively negligible rates. The absence of a sustained change in HABSI rates is con-
cerning but not necessarily an indication of ineffective surveil- lance. The observed trend may be a function of demographic changes and hospital performance developments masking the true effect of BACTOT participation on HABSI rates. For instance, the aging Canadian population results in more elderly patients in hospitals. The 13.5% increase in patient days con- tributed by patients aged ≥65 years from 2007–2008 to 2016–2017 indicates that more patients have become vulnerable to poten- tially nonpreventable HABSI.26 Additionally, lengths of stay are reportedly decreasing following efforts to reduce unnecessary
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