Evaluation of the implementation of WHO infection prevention and control core components in Turkish health care facilities: results from a WHO infection prevention and control assessment framework (IPCAF)-based survey.

BACKGROUND: The core components (CCs) of infection prevention and control (IPC) from World Health Organization (WHO) are crucial for the safety and quality of health care. Our objective was to examine the level of implementation of WHO infection prevention and control core components (IPC CC) in a developing country. We also aimed to evaluate health care-associated infections (HAIs) and antimicrobial resistance (AMR) in intensive care units (ICUs) in association with implemented IPC CCs. METHODS: Members of the Turkish Infectious Diseases and Clinical Microbiology Specialization Association (EKMUD) were invited to the study via e-mail. Volunteer members of any healt care facilities (HCFs) participated in the study. The investigating doctor of each HCF filled out a questionnaire to collect data on IPC implementations, including the Infection Prevention and Control Assessment Framework (IPCAF) and HAIs/AMR in ICUs in 2021. RESULTS: A total of 68 HCFs from seven regions in Türkiye and the Turkish Republic of Northern Cyprus participated while 85% of these were tertiary care hospitals. Fifty (73.5%) HCFs had advanced IPC level, whereas 16 (23.5%) of the 68 hospitals had intermediate IPC levels. The hospitals' median (IQR) IPCAF score was 668.8 (125.0) points. Workload, staffing and occupancy (CC7; median 70 points) and multimodal strategies (CC5; median 75 points) had the lowest scores. The limited number of nurses were the most important problems. Hospitals with a bed capacity of > 1000 beds had higher rates of HAIs. Certified IPC specialists, frequent feedback, and enough nurses reduced HAIs. The most common HAIs were central line-associated blood stream infections. Most HAIs were caused by gram negative bacteria, which have a high AMR. CONCLUSIONS: Most HCFs had an advanced level of IPC implementation, for which staffing was an important driver. To further improve care quality and ensure everyone has access to safe care, it is a key element to have enough staff, the availability of certified IPC specialists, and frequent feedback. Although there is a significant decrease in HAI rates compared to previous years, HAI rates are still high and AMR is an important problem. Increasing nurses and reducing workload can prevent HAIs and AMR. Nationwide "Antibiotic Stewardship Programme" should be initiated.

A global priority list of the TOp TEn resistant Microorganisms (TOTEM) study at intensive care: a prioritization exercise based on multi-criteria decision analysis.

The World Health Organization (WHO) proposed a global priority pathogen list (PPL) of multidrug-resistant (MDR) bacteria. Our current objective was to provide global expert ranking of the most serious MDR bacteria present at intensive care units (ICU) that have become a threat in clinical practice. A proposal addressing a PPL for ICU, arising from the WHO Global PPL, was developed. Based on the supporting data, the pathogens were grouped in three priority tiers: critical, high, and medium. A multi-criteria decision analysis (MCDA) was used to identify the priority tiers. After MCDA, mortality, treatability, and cost of therapy were of highest concern (scores of 19/20, 19/20, and 15/20, respectively) while dealing with PPL, followed by healthcare burden and resistance prevalence. Carbapenem-resistant (CR) Acinetobacter baumannii, carbapenemase-expressing Klebsiella pneumoniae (KPC), and MDR Pseudomonas aeruginosa were identified as critical organisms. High-risk organisms were represented by CR Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and extended-spectrum beta-lactamase (ESBL) Enterobacteriaceae. Finally, ESBL Serratia marcescens, vancomycin-resistant Enterococci, and TMP-SMX-resistant Stenotrophomonas maltophilia were identified as medium priority. We conclude that education, investigation, funding, and development of new antimicrobials for ICU organisms should focus on carbapenem-resistant Gram-negative organisms.

Epidemiology and cost implications of candidemia, a 6-year analysis from a developing country.

Surveillance of candidemia is essential to monitor trends in species distribution and change in the incidence and antifungal resistance. In this study, we aimed to investigate prevalence, resistance rates, antifungal utilization and costs. A 6-year retrospective analysis of the data belonging to patients with candidemia hospitalized between 2010 and 2016 was performed. The annual usage of fluconazole and caspofungin and the usage of these antifungals in different units were described in defined daily doses (DDD) per 1000 patient days. In total, 351 patients of candidemia were included. Median age of the patients was 45 (0-88) and 55.1% of them were male. Overall, 48.1% of the candidemia episodes (169/351) were due to C. albicans, followed by C. parapsilosis (25.1%), C. glabrata (11.7%). Length of hospital stay was longer with a median of 20 days among patients with non-albicans candidemia. Presence of a central venous catheter was found to be an associated risk for candidemia caused by non-albicans strains. Annual incidence of candidemia increased from 0.10 to 0.30 cases/1000 patient days. Antifungal use was increased over years correlated with the cost paid for it. The policy against candidemia should be specified by each institution with respect to candidemia prevalence, resistance rates, antifungal use and costs.

Incidence and economic burden of prosthetic joint infections in a university hospital: A report from a middle-income country.

In this study, we aimed to evaluate the incidence and economic burden of prosthetic joint infections (PJIs) in a university hospital in a middle-income country. Surveillance data between April 2011 and April 2013 in the Orthopedic Surgery Department was evaluated. Patients (>16 years old) who had primary arthroplasty in Erciyes University were included in the study, and patients with preoperative infection were excluded. Patients were followed up during their stay in the hospital and during readmission to the hospital for PJI by a trained Infection Control Nurse. During the study period, 670 patients were followed up. There were 420 patients (62.7%) with total hip arthroplasty (THA), 241 (36.0%) with total knee arthroplasty (TKA) and 9 (1.3%) with shoulder arthroplasty (SA). The median age was 64, and 70.6% were female. The incidence of PJI was 1.2% (5/420) in THA, 4.6% (11/241) in TKA and 0% (0/9) in SA. PJI was significantly more prevalent in TKA (p=0.029). All of the PJIs showed early infection, and the median time for the development of PJI was 23.5 days (range 7-120 days). The median total length of the hospital stay was seven times higher in PJI patients than patients without PJI (49 vs. 7 days, p=0.001, retrospectively). All hospital costs were 2- to 24-fold higher in patients with PJI than in those without PJI (p=0.001). In conclusion, the incidence and economic burden of PJI was high. Implementing a national surveillance system and infection control protocols in hospitals is essential for the prevention of PJI and a cost-effective solution for the healthcare system in low-middle-income countries.

Is it worth screening for vancomycin-resistant Enterococcus faecium colonization?: Financial burden of screening in a developing country.

BACKGROUND: The screening of critically ill patients at high risk of vancomycin resistant enterococci (VRE) colonization, to detect and isolate colonized patients, is recommended to prevent and control the transmission of VRE. Screening asymptomatic carriers brings financial burden for institutions. In this study, we performed risk analysis for VRE colonization and determined the financial burden of screening in a middle-income country, Turkey. METHODS: We retrospectively analyzed the VRE surveillance data from a pediatric hospital between 2010 and 2014. A case-control study was conducted to identify the risk factors of colonization. Total cost of VRE screening and additional costs for a VRE colonized patient (including active surveillance cultures and contact isolation) were calculated. RESULTS: During the 4-year period, 6,372 patients were screened for perirectal VRE colonization. The rate of culture-positive specimens among all patients screened was 239 (3.75%). The rate of VRE infection was 0.04% (n = 3) among all patients screened. Length of hospital stay, malignancy, and being transferred from another institution were independently associated risk factors for colonization. Annual estimated costs for the laboratory were projected as $19,074 (76,295/4) for all patients screened. Cost of contact isolation for each patient colonized in a ward and an intensive care unit was $270 and $718, respectively. CONCLUSIONS: In developing countries, institutions should identify their own high-risk patients; screening priorities should be based on prevalence of infection and hospital financial resources.

Economic evaluation of appropriate duration of antibiotic prophylaxis for prevention of neurosurgical infections in a middle-income country.

BACKGROUND: Preoperative antibiotic prophylaxis is one of the preventive measures for surgical site infections (SSIs). Very little data about the cost effectiveness of the appropriate duration of antibiotic prophylaxis in low- and middle-income countries are available. We aim to assess the cost effectiveness of the use of antibiotic prophylaxis for <24 hours to prevent neurosurgical infections in a middle-income country, Turkey. METHODS: A 1-year prospective study was performed between June 2012 and June 2013. During this study period patients were followed-up on for the development of SSI by means of hospital and postdischarge surveillance. Patients included in the study group received appropriate duration of antibiotic prophylaxis (<24 hours), and the duration of prophylaxis was longer in the control group. The antibiotic costs per patient, including prophylaxis and treatment, were calculated. RESULTS: A total of 822 operations consisting of craniotomy (n = 558), spinal fusion (n = 220), and ventricular shunt (n = 44) were included in the study. The study group included 488 (59.4%) patients who underwent operations with appropriate duration (<24 hours) of antibiotic prophylaxis. Prophylactic antibiotic cost per patient was significantly lower in the study group ($3.35 and $20.41, respectively). The SSI rates did not differ between the 2 groups: 3.5% (17/488) in the study group and 3.6 (12/822) in the control group (P > .05). CONCLUSION: This cost-analysis study demonstrates that prolonged antibiotic prophylaxis correlates with increased burden of cost, but it is not preventive for SSI.

Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study.

OBJECTIVE: We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia. METHODS: A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists. RESULTS: Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%). CONCLUSION: ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.

Prevaccination screening of health-care workers for immunity to measles, rubella, mumps, and varicella in a developing country: What do we save?

A structured questionnaire was administered to health-care workers (HCWs). The HCWs were also screened for measles, rubella, mumps, and varicella (MMRV) using serological methods. One thousand two hundred and fifty-five HCWs were tested. Of the HCWs examined, 94% were immune to measles, 97% to rubella, 90% to mumps and 98% to varicella. The positive predictive values of histories of measles, mumps, rubella and varicella were 96%, 93%, 100% and 98%, respectively. The negative predictive values of histories of measles, mumps, rubella and varicella were 13%, 17%, 5% and 2%, respectively. The cost of vaccination without screening was significantly more expensive (cost difference: €24,385) for varicella, although vaccination without screening was cheap (cost difference: €5693) for MMR. Although the use of cheaper vaccines supports the implementation of vaccination programs without screening, the cost of vaccination should not be calculated based only on the direct costs. The indirect costs associated with lost work time due to vaccination and its side effects and the direct costs of potential side effects should be considered. However, if prescreening is not conducted, some HCWs (2-7%) would be unprotected against these contagious illnesses because of the unreliability of their MMRV history. In conclusion, the screening of HCWs before vaccination continues to be advisable.

Doxycycline plus streptomycin versus ciprofloxacin plus rifampicin in spinal brucellosis [ISRCTN31053647].

BACKGROUND: The optimal treatment regimen and duration of the therapy is still controversial in spinal brucellosis. The aim of this study is to compare the efficacy, adverse drug reactions, complications and cost of ciprofloxacin plus rifampicin versus doxycycline plus streptomycin in the treatment of spinal brucellosis. METHODS: The patients diagnosed as spinal brucellosis between January 2002 to December 2004 were enrolled into the study. Patients were enrolled into the two antimicrobial therapy groups (doxycycline plus streptomycin vs. ciprofloxacin plus rifampicin) consecutively. For the cost analysis of the two regimens, only the cost of antibiotic therapy was analysed for each patient. RESULTS: During the study period, 31 patients with spinal brucellosis were enrolled into the two antimicrobial therapy groups. Fifteen patients were included in doxycycline plus streptomycin group and 16 patients were included in ciprofloxacin plus rifampicin group. Forty-two levels of spinal column were involved in 31 patients. The most common affected site was lumbar spine (n = 32, 76%) and involvement level was not different in two groups. Despite the disadvantages (older age, more prevalent operation and abscess formation before the therapy) of the patients in the ciprofloxacin plus rifampicin group, the duration of the therapy (median 12 weeks in both groups) and clinical response were not different from the doxycycline plus streptomycin. The cost of ciprofloxacin plus rifampicin therapy was 1.2 fold higher than the cost of doxycycline plus streptomycin therapy. CONCLUSION: Classical regimen (doxycycline plus streptomycin), with the appropriate duration (at least 12 weeks), is still the first line antibiotics and alternative therapies should be considered when adverse drug reactions were observed.

Ventilator associated pneumonia and infection control.

Ventilator associated pneumonia (VAP) is the leading cause of morbidity and mortality in intensive care units. The incidence of VAP varies from 7% to 70% in different studies and the mortality rates are 20-75% according to the study population. Aspiration of colonized pathogenic microorganisms on the oropharynx and gastrointestinal tract is the main route for the development of VAP. On the other hand, the major risk factor for VAP is intubation and the duration of mechanical ventilation. Diagnosis remains difficult, and studies showed the importance of early initiation of appropriate antibiotic for prognosis. VAP causes extra length of stay in hospital and intensive care units and increases hospital cost. Consequently, infection control policies are more rational and will save money.