Prevalence, incidence burden and clinical impact of healthcare-associated infections and antimicrobial resistance: a national prevalent cohort study in acute care hospitals in Greece

Purpose: Assessing the overall burden of healthcare-associated infections (HAIs) is challenging, but imperative in evaluating the cost-effectiveness of infection control programs. This study aimed to estimate the point prevalence and annual incidence of HAIs in Greece and assess the excess length of stay (LOS) and mortality attributable to HAIs, overall and for main infection sites and tracer antimicrobial resistance (AMR) phenotypes and pathogens. Patients and methods: This prevalent cohort study used a nationally representative cross-section of 8,247 inpatients in 37 acute-care hospitals to record active HAIs of all types at baseline and overall LOS and in-hospital mortality up to 90 days following hospital admission. HAI incidence was estimated using prevalence-to-incidence conversion methods. Excess mortality and LOS were assessed by Cox regression and multistate models correcting for confounding and time-dependent biases. Results: HAIs were encountered with daily prevalence of 9.1% (95% confidence interval [CI] 7.8% – 10.6%). The estimated annual HAI incidence was 5.2% (95%CI 4.4% – 5.3%), corresponding to approximately 121,000 (95%CI 103,500 – 123,700) affected patients each year in the country. 90-day mortality risk was increased by 80% in patients with HAI compared to those without HAI (adjusted hazard ratio 1.8; 95%CI 1.3 – 2.6). Lower respiratory tract infections, bloodstream infections and multiple concurrent HAIs doubled the risk of death, whereas surgical site and urinary-tract infections were are not associated with increased mortality. AMR had significant impact on the daily risk of 90-day mortality, which was increased by 90%-110% in patients infected by carbapenem-resistant gram-negative pathogens (CR-GNBs). HAIs increased LOS for an average of 4.3 (95% CI 2.4– 6.2) additional days. Mean excess LOS exceeded 20 days in infections caused by major CR-GNBs. Conclusion: HAIs, alongside with increasing AMR, pose significant burden to the hospital system. Burden estimates obtained in this study will be valuable in future evaluations of infection prevention programs

Implementation of multimodal infection control and hand hygiene strategies in acute-care hospitals in Greece: a cross-sectional benchmarking survey

Background: In this first attempt to suggest achievable standards for improvement in hospital infection prevention and control (IPC) in Greece, we assessed main IPC structure and process indicators emphasizing on hand hygiene. Methods: Acute-care hospitals across the country participated in a cross-sectional survey by completing the World Health Organization Hand Hygiene Self-Assessment Framework (HHSAF) and by providing hospital-level IPC indicators. Results: Seventeen hospitals completed the survey, comprising 14% of the country’s public hospitals. Median IPC staffing levels were 0.8 nurses and 0.5 doctors per 250 beds, respectively. Few hospitals implemented full multimodal IPC programs. HHSAF indicated that appropriate hand hygiene practices and promotion strategies were in place in most hospitals, but mean HHSAF score (289) was lower compared to studies in Italy (332, p=0.040) and the USA (373, p<0.001). Presence of one additional IPC nurse was independently associated with increases by 53% in the HHSAF median score for training-education (p=0.035) and by 38% in the lower 30th percentile score for safety climate (p=0.049). Conclusions: Surveyed hospitals are, on average, at an intermediate level in hand hygiene practice but require improvements on training-education, evaluation-feedback and safety climate. Ensuring adequate IPC nurse staffing levels and systematically implementing multimodal IPC programs may lead to substantial improvements

Impact of SARS-CoV-2 preventive measures against healthcare-associated infections from antibiotic-resistant ESKAPEE pathogens: a two-center, natural quasi-experimental study in Greece

The COVID-19 pandemic led to unprecedented stress on healthcare systems worldwide, forming settings of concern for increasing antimicrobial resistance. We investigated the impact of SARS-CoV-2 preventive measures against healthcare-associated infections (HAIs) from antibiotic-resistant bacteria in two tertiary-care hospitals. We compared infection rates between March 2019 and February 2020 (pre-intervention period) and March 2020 and February 2021 (COVID-19 intervention period) from drug-resistant ESKAPEE bacteria (methicillin-resistant Staphylococcus aureus; vancomycin-resistant Enterococci; carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species and Escherichia coli). Over 24 months, 586 drug-resistant ESKAPEE HAIs occurred in 439 patients (0.3% of 179,629 inpatients) with a mean age of 63 years, with 43% being treated in intensive care units (ICUs), and having a 45% inpatient mortality rate. Interrupted time series analysis revealed increasing infection rates before the intervention that were sharply interrupted by abrupt drops for most pathogens and henceforth remained stable in the ICUs but progressively increased in ordinary wards. In the ICUs, the pooled infection rate was 44% lower over the intervention period compared to the pre-intervention period (incidence rate ratio (IRR) 0.56, 95%CI 0.41–0.75, p < 0.001). Pooled infection rates in the wards were slightly higher over the COVID-19 period (IRR 1.12, 95%CI 0.87–1.45, p = 0.368). The findings confirmed the ancillary beneficial impact of the enhanced bundle of transmission-based precautions adopted against SARS-CoV-2 in rapidly constraining antimicrobial-resistant HAIs in two Greek hospitals

Excess mortality due to pandrug-resistant Acinetobacter baumannii infections in hospitalized patients

Background Pandrug-resistant Acinetobacter baumannii (PDRAB) is increasingly being reported as a nosocomial pathogen worldwide, but determining its clinical impact is challenging. Aim To assess the spectrum of excess mortality attributable to PDRAB infection in acute care settings. Methods This four-year cohort study was conducted in a tertiary-care referral hospital in Greece to estimate excess in-hospital mortality due to PDRAB infection by comparing patients infected to those colonized with PDRAB by means of competing risks survival analysis. Findings The study cohort comprised 91 patients (median age: 67 years; 77% men). For most patients, PDRAB was first isolated in the intensive care unit (ICU) (N = 51; 57%) or following ICU discharge (N = 26; 29%). Overall in-hospital mortality was 68% (95% confidence interval (CI): 57.5–77.5%). PDRAB-infected patients (N = 62; 68%) and PDRAB-colonized patients (N = 29; 32%) had similar baseline characteristics, but the absolute excess risk of 30-day mortality in infected patients compared to colonized patients was 34% (95% CI: 14–54%). Multivariable competing risks regression showed that PDRAB infection significantly increased the daily hazard of 30-day in-hospital death (cause-specific hazard ratio (csHR): 3.10; 95% CI: 1.33–7.21) while simultaneously decreasing the daily rate of discharge (csHR: 0.24; 95% CI: 0.08–0.74), thereby leading to longer hospitalization. Stronger effects were observed for bloodstream infections. Conclusion New effective antimicrobials would be expected to prevent mortality in one of every three patients treated for PDRAB infection and reduce their length of hospitalization. However, available therapeutic options remain extremely limited and emphasis on preventing healthcare-associated transmission of PDRAB is ever more important

Beyond spontaneity: crisis, violence and collective action in Athens

This article argues for the analytical potentials of the concept of spontaneity in our effort to understand critically the socio-spatial dynamics of Athens, but especially the contemporary collective protest actions in the city. Such critical understanding emerges as a significant task given the current urgency to grasp the capitalist crisis and the collective reactions to it. However, taking into account the re-configuration of extreme-Right violence in the streets of Athens, the article attempts to revisit the Marxist dichotomy between spontaneity and non-spontaneity. Via an anthropological critique of this distinction, the paper suggests an additional point of focus beyond spontaneity