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infection rates communication plans. Second, it can provide to these same actors a competitive interfacility benchmark for improvement by comparing their hospital’s rates with those of others. The subgroup analysis performed also excludes hospitals that had participated for the entire 10-year period to further isolate surveillance effects and focus on hospitals more likely to be begin- ning their local surveillance of HABSIs. Hence, we believe our results are a valuable evaluation of HABSI behavior after partici- pation in BACTOT surveillance. Among the previously cited HABSI surveillance programs,
some have published reports on longitudinal trends in HABSI. The Belgian program reported a increases between 1992 and 1996 after initiating surveillance; however, a greater increase in blood culturing was concomitant with the surveillance program, along with an absence of prevention efforts.18 The Australian pro- gram in South Australia, which had been running since 1997, reported a reduction between 2010 and 2016.22 There was a decreasing trend in average length of stay during the same period of time, but, to our knowledge, no targeted statewide efforts were made to reduce HABSI.34 Both analyses evaluate changes over cal- endar time, and neither adjust for the changes in hospital partici- pation; therefore, it is challenging to disentangle secular changes from those induced by surveillance. Although it is concerning that HABSI rates have showed no
reduction with continued BACTOT surveillance, they do remain stable and low. For this reason, the usefulness of BACTOT in bur- den suppression cannot be dismissed. Nonetheless, it is unlikely that Quebec hospitals have reached the limit of HABSI prevent- ability, as other SPIN surveillance initiatives, such as SPIN- BACC (CLABSI in the ICUs) and SPIN-HD (BSI associated with venous access for dialysis), have been successful at reducing rates.35,36 Both infection types were subject to bundle interventions and their programs use more specific denominators (catheter- associated days), which allow the detection of smaller changes in incidence than BACTOT. To follow suit, SPIN-BACTOT must consider implementing
active interventions against HABSI, both universal, such as the enforcement of hand hygiene protocols, and targeted to infection types. The latter will benefit from collecting data on more specific denominators for their greater discriminatory power and to adjust for changes in exposure risk. Along with incidence rates, process measures can be calculated to ensure intervention implementation. Burden reduction can also be examined with severity measures, such as case-fatality or specific clinical indicators, which will give a richer understanding ofHABSI epidemiology as well as more dis- criminatory measures for evaluation.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.357
Author ORCIDs. Alexandra M. Schmidt 0000-0002-6448-6367
Acknowledgments. We are grateful to all the infection control practitioners and infectious disease physicians/medical microbiologists who participate in the SPIN program. The SPIN-BACTOT working group members include Élise Fortin, Charles Frenette, Lise-Andrée Galarneau, Sylvie Latreille, Danielle Moisan, Muleka Ngenda-Muadi, Noémie Savard, Marc-André Smith, Claude Tremblay, Mélissa Trudeau, and Jasmin Villeneuve.
Financial support. This work was supported by SPIN, a program from the Quebec Institute of Public Health, funded by the Quebec 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).
Iman Fakih et al
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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