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Ontarians trust that health care facilities are clean and safe places that will help them get better when they are sick. Yet some people acquire health care-associated infections (HAIs) that can cause illness, complications or even death. The prevention and control of these infections in hospitals, long-term care facilities and clinics is key to keeping patients safe.

Highlights

In 2014, 2,811 cases of Clostridium difficile infection (CDI), 227 cases of bloodstream infection caused by methicillin-resistant Staphylococcus aureus (MRSA) and 64 cases of bloodstream infection caused by vancomycin-resistant enterococcus (VRE) were reported by hospitals in the province.

Throughout the 1990s and 2000s, cases of MRSA in hospitals increased sharply, CDI became a greater concern and VRE emerged as a new threat to patient safety. Since 2009, rates of infection for these three HAIs reported by hospitals have been relatively stable.

In the past five years, CDI outbreak control in Ontario hospitals has improved patient safety leading to better patient outcomes. There has been a decrease in the total number of outbreaks each year (19 in 2014 compared to 26 in 2010), the average number of patients involved in each outbreak (7 in 2014 compared to 22 in 2010) and the mortality during outbreaks (17% in 2014 compared to 26% in 2010).

Cases of CDI reported during outbreaks in hospitals disproportionately affect older adults. Rates do not differ for males and females.

Monitoring and reporting of existing and emerging HAIs help to manage and reduce risks to ensure that patient care is as safe as possible.

Size of the problem

Health care-associated infections (HAIs) happen when a patient acquires an infection in a setting where care is delivered, such as a hospital or long-term care facility. This infection was not present or developing at the time of admission. HAIs have a direct impact on patient safety and health care quality. It is estimated that there are over 70,000 HAIs and 2,600 resulting deaths a year in Ontario, assuming a proportionate burden based on the number of patient bed days in the province (1) and Canadian estimates of the number of infections and deaths (2).

Ontario hospitals report cases of CDI and bloodstream infections caused by MRSA and VRE (3). These rates provide a strong indicator of overall trends, even if they are a small per cent of the total number of health care-associated infections. Public reporting is required for hospitals, but not for other health care settings such as long-term care facilities or clinics. In 2014, 2,811 cases of CDI, 227 cases of MRSA and 64 cases of VRE were reported by Ontario hospitals. Reported rates of HAIs are higher in acute teaching hospitals and hospitals with more beds, reflecting the greater complexity of cases at those facilities. Hospitals that treat a higher proportion of seniors report lower rates, likely because seniors often stay in hospital while awaiting transfer to long-term care, rather than being actively treated (Figure 1).

In the past five years, CDI outbreak control in Ontario hospitals has improved patient safety leading to better patient outcomes. There has been a decrease in the total number of outbreaks each year (19 in 2014 compared to 26 in 2010), the average number of patients involved in each outbreak (7 in 2014 compared to 22 in 2010) and the mortality during outbreaks (17% in 2014 compared to 26% in 2010) (4).

Figure 1: {{orgRadio}} rates by {{typeRadioName}}, Ontario, 2009–14

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Data source: Hospital self-reported data (Self Reporting Initiative), Ministry of Health and Long-Term Care, extracted 2015 Jun 29.

Trends

Throughout the 1990s and 2000s, cases of MRSA in hospitals increased sharply, CDI became a greater concern and VRE emerged as a new threat to patient safety (5). Thanks in part to infection prevention and control efforts, reported rates of these infections have been relatively stable over the last five years (Figure 2). This is notable as rates of MRSA outside of health care facilities have gone up in the same time period (6). Rates of HAIs also show variation across public health units and Local Health Integration Networks. This variation may reflect differences in the types of hospitals located in those geographic areas, the proportion of at-risk patients and the complexity of care provided.

Figure 2: {{orgCheckboxSelected}} rates, {{geoSelect}}, 2009–2014

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Data source: Hospital self-reported data (Self Reporting Initiative), Ministry of Health and Long-Term Care, extracted 2015 Jun 29.

 

Populations at risk

Some individuals are more likely to acquire HAIs, notably seniors, people who are immunocompromised and people who have an underlying chronic condition or experience a prolonged hospital stay (8). Ontario hospitals report demographic factors only for CDI outbreaks involving multiple patients. Cases of CDI reported during outbreaks in hospitals disproportionately affect older adults. Rates do not differ for males and females (Figure 3).

Figure 3: CDI outbreak cases in hospitals by {{categoryRadioName}}, {{yearSelectName}}

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Data source: Integrated Public Health Information System (iPHIS), 2010-14, Ontario Ministry of Health and Long-Term Care, extracted 2015 7 Jul.

 

Health impacts

While bacteria are present in healthy people who do not have any symptoms of infection, some people do become infected and start to show symptoms (6). C. difficile bacteria are found in feces and cause mild to severe diarrhea as well as more serious, life-threatening conditions such as inflammation of the lining of the colon, bowel perforation or a systemic blood infection (9). MRSA infections may start as a minor skin sore, pimple or boil before becoming more serious, causing potentially fatal bloodstream infections, pneumonia and surgical site infections (10). VRE can cause infections anywhere in the body, including the intestines, urinary tract and wounds (11).

The elderly, the very young and people with weakened immune systems (e.g., patients being treated for cancer or with a long-term illness) are more likely to have more severe complications from health care-associated infections, including death (8).

Preventing the spread of HAIs

HAIs can be spread from person-to-person either through direct contact with the person who is infected or through contact with contaminated surfaces. Many HAIs are increasingly resistant to antibiotics and difficult to treat, making prevention ever more important.

Practices to prevent the spread of HAIs include:

  • cleaning your hands
  • disinfection and sterilization of equipment
  • the use of personal protective equipment such as gloves and gowns
  • careful and thorough cleaning of the environment
  • isolating patients to minimize contact
  • careful use of antibiotics

Of all of these practices, cleaning your hands is the single most important measure to prevent HAIs (12).

Importance

HAIs are a significant and continuing challenge in hospitals and long-term care facilities. Patients with one or more HAIs during their in-patient stay remain in hospital longer and incur costs three times greater on average than uninfected patients (13). After a sharp increase in the incidence of HAIs over the past decades, effective infection prevention and control measures are working to reduce their spread. Public health plays a role in helping to control the spread of HAIs by developing and disseminating best practices for infection prevention and control, supporting outbreak management, monitoring to detect current and emerging issues, and informing the public and public health professionals about the consequences of the overuse of antibiotics.

While some HAIs are currently reported by hospitals, a more comprehensive and robust surveillance system that collects data across all health care settings is needed to improve patient safety in Ontario. The Public Health Agency of Canada recommended national and targeted surveillance beyond what is currently collected to inform and develop guidelines and responses to emerging HAI issues and trends (6).

Routine surveillance continues to be important, however, surveillance for emerging pathogens is also necessary. For example, Public Health Ontario works with public health units and hospitals to monitor emerging pathogens such as Carbapenemase producing Enterobacteriaceae, which are bacteria that have become resistant to one of the most powerful antibiotics used for treatment (14). This enhanced reporting informs analysis and identifies changing trends in the province.

HAIs affect patients at a vulnerable time. Clean and safe health care environments are a shared responsibility of health care institutions, health care providers and the public. Continued infection prevention and control efforts along with more comprehensive and robust surveillance are required to continue to reduce the incidence and impact of HAIs.

References

  1. Canadian Institute for Health Information. Quick Stats: DAD/HMDB Inpatient Hospitalizations: Volumes, Length of Stay, and Standardized Rates [Internet]. Ottawa, ON: Canadian Institute for Health Information; 2015 [cited 2015 July 7]. Available from: https://www.cihi.ca/en/quick-stats
  2. Zoutman, D. E., Ford, B. D., Bryce, E., Gourdeau, M. et al. The state of infection surveillance and control in Canadian acute care hospitals. American Journal of Infection Control 2003, 31(5), 266-273.
  3. Ontario Hospital Association. Public Reporting of Patient Safety Indicators [Internet]. Toronto, ON: Ontario Hospital Association; 2013. Available from: http://www.oha.com/CurrentIssues/keyinitiatives/PatientSafety/Pages/PatientSafetyIndicatorsandPublicReporting.aspx
  4. Integrated Public Health Information System (iPHIS), 2010-14, Ontario Ministry of Health and Long-Term Care, extracted 2015 Jul 7.
  5. Public Health Agency of Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2013: Infectious Disease-The Never-ending Threat. Ottawa, ON: Her Majesty the Queen in Right of Canada; November 2013. Available from: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/index-eng.php
  6. Public Health Agency of Canada. Canadian Antimicrobial Resistance Surveillance System Report 2015. Ottawa, ON: Her Majesty the Queen in Right of Canada; March 2015. Available from: http://healthycanadians.gc.ca/alt/pdf/publications/drugs-products-medicaments-produits/antibiotic-resistance-antibiotique/antimicrobial-surveillance-antimicrobioresistance-eng.pdf
  7. Health Quality Ontario. Patient Safety Public Reporting [Internet]. Toronto, ON: Queen's Printer for Ontario; 2015 [cited 2015 Jun 25]. Available from: http://www.hqontario.ca/public-reporting/patient-safety
  8. Canadian Institute for Health Information. Patient Safety in Ontario Acute Care Hospitals: A Snapshot of Hospital-Acquired Infection Control Practices. Ottawa, ON: Canadian Institute for Health Information; 2008
  9. Public Health Agency of Canada. Fact sheet: Clostridium difficile [Internet]. Ottawa, ON: Her Majesty the Queen in Right of Canada; May 2014. Available from: http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php
  10. Public Health Agency of Canada. Fact sheet: Methicillin-Resistant Staphylococcus aureus [Internet]. Ottawa, ON: Her Majesty the Queen in Right of Canada; June 2008. Available from: http://www.phac-aspc.gc.ca/id-mi/mrsa-eng.php
  11. Public Health Agency of Canada. Fact sheet: Vancomycin-resistant enterococci [Internet]. Ottawa, ON: Her Majesty the Queen in Right of Canada; November 2010. Available from: http://www.phac-aspc.gc.ca/nois-sinp/vre-erv-eng.php
  12. Public Health Ontario. IPAC Core Competencies Course [Internet]. Toronto, ON: Queen's Printer for Ontario. Available from: http://www.publichealthontario.ca/en/LearningAndDevelopment/OnlineLearning/InfectiousDiseases/IPACCore/Pages/Course.aspx
  13. Plowman R, Graves N, Griffin MA, Roberts JA, Swan AV, Cookson B, et al. The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. J Hosp Infect 2001;47(3):198-209.
  14. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Carbapenemase-producing Enterobacteriaceae (CPE) Surveillance Report April 2015 [Internet]. Toronto, ON: Queen's Printer for Ontario; 2015 [cited 2015 Jun 25]. Available from: http://www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServices/Pages/Management-of-Carbapenem-Producing-Enterobacteriaceae-(CPE).aspx

Report last updated: December 1, 2015

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