Nosocomial infections in an intensive care unit (ICU) are common and associated with a high mortality but there are no published data from the Oceania region. A retrospective study in Fiji’s largest ICU (2011-12) reported that 114 of a total 663 adult ICU admissions had bacteriological culture-confirmed nosocomial infection. The commonest sites of infection were respiratory and bloodstream. Gram negative bacteria were the commonest pathogens isolated, especially
Health-care-associated (or nosocomial) infection is a major problem in hospitals worldwide and the prevalence is two- to threefold higher in developing countries compared to Europe or USA [
There are no published data reporting the prevalence of nosocomial infections in Fiji. Such information is required to describe the current epidemiology and to improve infection control practices in the adult ICU. This retrospective study aimed to describe bacteriological culture-confirmed nosocomial infections in Fiji’s largest adult ICU.
This was a retrospective, descriptive study of bacteriological culture-confirmed nosocomial infections in an adult ICU in 2011 and 2012. The study was conducted at the Colonial War Memorial Hospital (CWMH) in Suva, Fiji. The adult ICU ward at the CWMH has 6 beds and is the largest ICU ward in Fiji. There is a separate ICU ward for children and neonates (0–14 years). The adult ICU provides care for both ventilated and nonventilated patients and a mix of medical and general surgical patients. Patients may be admitted directly from the community or from other hospital wards.
The study only included patients with clinical features of invasive sepsis who had a bacterial pathogen isolated on culture from at least one specimen taken from the patient more than 48 hours after admission to the ICU, that is, those with clinically suspected nosocomial sepsis that was microbiologically confirmed. When the onset of invasive sepsis is clinically suspected on the basis of the patient developing evidence of a systemic inflammatory response syndrome (SIRS, see Box
Temperature (onset of fever) >38°C Increased white cell count >12,0003 Increased heart rate >90 beats per minute Tachypnoea >20 New chest infiltrates Purulent endotracheal/tracheal discharges
Blood cultures were processed using the BACT/ALERT 3D system (BioMerieux, Marcy L’Etoile, France) and incubated at 36°C for 7 days. If a blood culture bottle was flagged positive, a Gram stain was performed on one drop of the culture fluid. Subculture was performed using selective and nonselective agar depending on the Gram stain result. Gram negative organisms were identified using the Microbact Identification Kit (Oxoid, Basingstoke, UK).
Data were sourced from the infection control surveillance records and the ICU patient records with cross-checking between these records and the microbiology laboratory records. Data collected for all ICU admissions for 2011-2012 included numbers of admissions, devices used, and number of days the devices were used. The patient name was used for cross-checking between registers but not included in data entry or data storage.
Data were collected in a structured proforma using a unique identification number and the following variables were entered: age, date of admission, date of specimen collection, length of stay in ICU, and bacterial pathogens isolated and from which specimen the pathogen was isolated. Respiratory specimens include those that were taken from the respiratory tract—usually aspiration of endotracheal or tracheostomy tubes from ventilated patients—or pleural aspirates while blood stream infections include those taken from peripheral blood cultures, those samples taken through a venous cannula device such as a central venous line and catheter tips.
Data were double entered into EpiData version 3.1 (EpiData Association, Odense, Denmark). The rate of nosocomial infections was calculated by dividing the number of patients with nosocomial infections by the total number of patients in the ICU during the same study period. Numbers of isolates per site of specimen are presented.
There were 663 patients admitted to the ICU during the two-year study period. This represented 2891 total patient days of admission during which patients were ventilated for 2175 days. Of the 663 admissions, 114 (17%) developed culture-confirmed nosocomial sepsis. Table
Characteristics of bacteriologically-confirmed nosocomial infections from an adult intensive care unit 2011-2012.
2011 |
2012 |
Total |
|
---|---|---|---|
Age | |||
15–30 yrs | 15 (26) | 14 (25) | 29 |
31–60 yrs | 30 (52) | 29 (52) | 59 |
61–100 yrs | 12 (21) | 12 (21) | 24 |
Unknown | — | 2 (4) | 2 |
Sex | |||
Male | 38 (66) | 34 (60) | 72 |
Female | 19 (33) | 21 (38) | 40 |
Unknown | 2 (4) | 2 | |
Admission status | |||
Direct admission | 15 (26) | 19 (34) | 34 |
Transferred | 43 (74) | 36 (64) | 79 |
Unknown | 1 (2) | 1 | |
Length of stay | |||
1–7 days | 18 (31) | 8 (14) | 26 |
8–14 days | 20 (34) | 22 (39) | 42 |
15–21 days | 10 (17) | 7 (13) | 17 |
22–31 days | 7 (12) | 11 (20) | 18 |
31 days and more | 2 (3) | 7 (13) | 9 |
Unknown | 1 (2) | 1 (2) | 2 |
Mechanical Ventilation | |||
Ventilated | 57 (98) | 54 (96) | 111 |
Not ventilated | 0 | 1 (2) | 1 |
Unknown | 1 (2) | 1 (2) | 2 |
Patient outcomes | |||
Transferred from ICU | 35 (60) | 23 (41) | 58 |
Deceased | 16 (28) | 22 (39) | 38 |
Unknown | 7 (12) | 11 (20) | 18 |
Table
Distribution of bacterial pathogens associated with nosocomial infection in relation to site of specimen.
Pathogen | Site of pathogen |
Total |
|||
---|---|---|---|---|---|
Respiratory tract |
Blood |
Surgical site |
Urinary tract |
||
|
34 (27%) | 21 (17%) | 18 (18%) | 21 (24%) | 94 (22%) |
|
33 (26%) | 21 (17%) | 18 (18%) | 20 (23%) | 92 (21%) |
|
24 (19%) | 11 (9%) | 25 (25%) | 13 (15%) | 73 (17%) |
|
8 (6.4%) | 9 (7%) | 11 (11%) | 5 (6%) | 33 (8%) |
Coagulase-negative |
1 (0.8%) | 20 (16%) | 1 (0.9%) | 8 (9%) | 30 (7%) |
|
2 (1.6%) | 13 (11%) | 2 (2%) | 5 (6%) | 22 (5%) |
Other |
6 (4.8%) | 2 (1.6%) | 6 (6%) | 5 (6%) | 19 (4%) |
Other Gram negative species | 5 (4%) | 6 (5%) | 6 (6%) | 0 | 17 (4%) |
|
2 (1.6%) | 2 (1.6%) | 2 (2%) | 3 (3%) | 9 (2%) |
MRSA# | 1 (0.8%) | 1 (0.8%) | 1 (0.9%) | — | 3 (0.2%) |
Others | 9 (7.2%) | 16 (13%) | 12 (12%) | 8 (9%) | 45 (1.1%) |
Outcome was known in 84% (96/114) patients and 40% (38/96) with known outcome died in ICU (Table
This study provides original descriptive data from Fiji of common nosocomial bacterial infections in ICU. A recent global systematic review of the published literature on the burden of nosocomial infections in developing countries did not identify previously published data from the Pacific Island region [
Mortality was very high among these ICU patients with nosocomial infections. High mortality has been previously reported from developing countries ICUs [
In this study, Gram negative bacteria were the predominant pathogens isolated with
This study has a number of important limitations. It is a retrospective study that relies on previous data records for which accuracy and completeness cannot be validated. However, protocols and recording are structured and have been used for infection control purposes in the CWMH for many years. Data on the use of all devices over the study period were not available and so rates of nosocomial infection associated with specific device utilization over time could not be calculated. The data on outcome were also incomplete.
Despite these limitations, this study provides important baseline data that strongly suggest that infection control practices could be improved. There are known interventions that can reduce the burden of nosocomial infections in ICUs even in the resource-limited setting [
Ethical approval was obtained from the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease (The Union), the National Health Research Ethics Committee, and the Fiji National Ethics Review Committee.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This research was conducted through the Structured Operational Research and Training Initiative (SORT IT). The training was run in Fiji by the College of Medicine, Nursing and Health Sciences, Fiji National University, Fiji and The Union. Additional support for running the course was provided by the Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia; Regional Public Health, Hutt Valley District Health Board, New Zealand; the National TB Programme, Fiji Ministry of Health, Fiji. Funding for the course was provided by the Global Fund to fight AIDS, TB, and malaria, with cofunding by The Union; the Special Programme for Research and Training in Tropical Diseases (TDR); Public Health Division of the Secretariat of the Pacific Community, New Caledonia; Centre for International Child Health, the University of Melbourne, Australia; School of Population Health, University of Queensland, Australia.