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Fig. 2. Annual incidence rates of 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 infection source. BSI-ABDO, bloodstream infection (BSI) secondary to intra-abdominal infections; BSI-BONE, BSI secondary to bone-and-joint infections; BSI-PULM, BSI secondary to pulmonary infections; BSI-SSI, BSI secondary to surgical site infections; BSI-SST, BSI secondary to skin- and-soft-tissue infections; BSI-UTI, BSI secondary to urinary tract infections; BSI-other, BSI secondary to any other primary focus; CA-BSI, catheter-associated primary BSI; NCA- BSI, non–catheter-associated primary BSI. 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.
healthcare utilization. In Québec, the average length of stay decreased from 8.4 days in 2007–2008 to 7.8 in 2016–2017.26 While this is a welcome improvement in hospital performance, it can result in inflated HABSI rates. Nevertheless, it is not our objective to infer a causal mechanism
of the observed trend. Our study’s goal istoreportthe cohort-level trend as it occurred, which it does with several strengths. This study covers 44% of all acute-care hospitals in Québec, capturing 47% of all patient days in 2016–2017.13 Hospitals included in the study did not exhibit statistically significant differences in reported characteristics from excluded ones, suggesting that the cohort is representative of all eligible hospitals. The substantial overlap between our Y10 (2016–2017) HABSI rate (5.30; 95% CI, 5.22– 5.64) and that published by SPIN-BACTOT (5.61; 95% CI, 5.31– 5.77) further supports the validity of our results.13 In addition, the study produces precise estimates of endemic rates not skewed to a particular type of hospital because of the diversity of included hospitals; therefore, these rates can be used for benchmarking, informing future prevention measures, and as a baseline for further evaluations. Rates were calculated using patient days, avoiding time-dependent bias common in point-prevalence studies and reducing confounding due to exposure duration when comparing rates across time or populations, which is a limitation of population-based denominators. The 10-year period covered by our study allowed the exploration of time trends in HABSI rates, which is a rarity in recently published literature. Finally, it was possible to stratify incidence based on the primary source of infection because HABSI clinical diagnoses were systematically reported. To our knowledge, this stratification has only been done once before and not to the granularity reported here.24 While our study estimates HABSI rates and subtype char- acterizations comparable to those reported by other recent HABSI studies, the lack of an overall reduction in HABSI rates over the prolonged period is concerning, especially given the amount of resources employed by SPIN and the participating hospitals. For this reason, we recommend a more detailed exploration of the effect of BACTOT surveillance on HABSI to evaluate whether current surveillance measures are worthwhile. Aside from
surveillance, interventions targeting potentially preventable BSI types are needed to see substantial reductions in rates. Alternative surveillance modalities should be considered, including less fre- quent HABSI reporting and prioritization of high-burden BSI types.
Acknowledgements. We are grateful to all the infection control practi- tioners and infectious disease physicians/medical microbiologists who parti- cipate in the SPIN program. SPIN-BACTOT working group members: Élise Fortin, Charles Frenette, Lise-Andrée Galarneau, Sylvie Latreille, Danielle Moisan, Muleka Ngenda-Muadi, Noémie Savard, Marc-André Smith, Claude Tremblay, Mélissa Trudeau, Jasmin Villeneuve.
Financial support. This work was supported by SPIN, a program from the Québec Institute of Public Health, funded by the Québec Ministère de la Santé et des services sociaux (Ministry of Health). Dr Quach is supported through an external salary award (FRQ-S merit, grant no. 252775). Dr Alex Carignan is supported through an external salary award (FRQ-S junior 1).
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Si D, Runnegar N, Marquess J, Rajmokan M, Playford EG. Characterising healthcare-associated bloodstream infections in public hospitals in Queensland, 2008–2012. Med J Austral 2016;204:1.
2. Redder JD, Leth RA, Moller JK. Incidence rates of hospital-acquired urinary tract and bloodstream infections generated by automated compilation of electronically available healthcare data. J Hosp Infect 2015;91:231–236.
3. Kanamori H, Weber DJ, DiBiase LM, et al. Longitudinal trends in all healthcare-associated infections through comprehensive hospital-wide surveillance and infection control measures over the past 12 years: substantial burden of healthcare-associated infections outside of intensive care units and “other” types of infection. Infect Control Hosp Epidemiol 2015;36:1139–1147.
4. Brady M, Oza A, Cunney R, Burns K. Attributable mortality of hospital- acquired bloodstream infections in Ireland. J Hosp Infect 2017;96:35–41.
5. Goto M, Al-Hasan MN. Overall burden of bloodstream infection and nosocomial bloodstream infection in North America and Europe. Clin Microbiol Infect 2013;19:501–509.
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