Hospital infections, those that patients contract while they are admitted to a health center, cause an average of 18 deaths per day in Spain. This is the conclusion of a large study presented last week at the congress of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID Global) held in Barcelona. The work estimates that a total of 6,393 deaths from this cause occur annually in the country in public and private hospitals, which allocate almost 2,000 million additional euros to the care of patients who require admission nine days longer on average.
“There are four times more deaths than those registered from traffic accidents. If we take into account that more than half of infections are considered preventable, these figures show the enormous challenge we face as a health system,” describes Mireia Cantero, one of the authors of the study, a doctor at the Puerta de Hierro Majadahonda Hospital (Madrid). ) and member of the Spanish Society of Preventive Medicine, Public Health and Health Management (SEMPSPGS).
This specialist highlights that the resistance that bacteria have developed to many antibiotics—and some fungi to antifungals—explain only part of the problem: “The majority of so-called superbacteria, understood as multi-resistant microorganisms, are in hospitals. But most healthcare-associated infections are not caused by superbacteria”, but by pathogens still sensitive to available treatments.
The data on which the research is based, in which doctors Ángel Asensio and Lina Parra have also participated, come from EPINE, an epidemiological surveillance system promoted by the SEMSPGS since the 90s of the last century. “EPINE collects data from more than 300 hospitals, so it offers a very complete image of the entire health system,” adds Cantero.
At each hospital, a coordinator reviews how many patients admitted on a given day have contracted an infection at the facility and rechecks their status—whether they have been discharged, whether they are still admitted, or whether they have died—30 days later. Subsequently, she compares these data with those patients free of infections to make the estimates included in the conclusions of the work. The research includes a total of nearly 100,000 patients.
The first relevant data is that 7.8% of patients contract an infection in hospital, a percentage somewhat higher than the European average (7.1%) and which has grown slightly since the pandemic. The crude mortality in this group amounts to 10.9%, while in those who do not do so it is 5.9%. Once the data from both groups have been adjusted in relation to sex, age, disease and severity, the authors observe that “suffering from a healthcare-related infection increases the risk of dying by 60%.”
Infections also cause patients’ hospital stays to be 9.2 days longer on average. Taking into account that each day of admission represents an average expense of 901 euros, the total cost amounts to 1,925 million euros. According to data from the Ministry of Health corresponding to 2021, this figure represents just over 5% of the total expenditure of Spanish hospitals (33,802 million).
Microorganisms live in hospitals as they do virtually anywhere else on the planet. “Many arrive at the centers with the patients themselves or healthcare workers, because they are part of our microbiota and live in the bodies of many people without harming them,” explains Astrid Pérez, Miguel Servet researcher in the group of infections related to care. health of the National Center of Microbiology (CNM).
A hospital, however, is a different place and bacteria that hardly cause any problems outside of them (or none at all) can be lethal here. The first, obvious reason is that the people admitted have health problems and, often, have a weakened immune system. “We must also take into account that in spaces such as ICUs or operating rooms, invasive procedures are very common. Having a catheter can cause harmless bacteria on the skin such as Staphylococcus aureus enters the bloodstream and causes sepsis, which can be fatal. Or that bacteria like Klebsiella pneumoniae, Acinetobacter baumannii either Pseudomonas aeruginosawhich may be harmlessly colonizing the upper airways, reach the lungs through assisted breathing systems…,” adds Pérez.
The protocols that hospitals apply to minimize the damage caused by microorganisms do not apparently include very complex measures – disinfection of surfaces, sterilization of materials, cleaning of hands, isolation of the infected… – but in practice they end up being very complex to always apply them well. “It has to be done every time, every day, in every shift and by all professionals. An unforeseen event or urgency that leads to skipping a step, or the slightest failure at a single point in the process, is enough for microorganisms to proliferate,” the experts agree. The adequate training of health workers, the stability of the workforce, suitable staff ratios and adequate spaces are, according to all of them, key factors to face the threat of hospital infections with greater chances of success.
Albert Garcia
The resistance that many microorganisms end up developing to available treatments is another crucial variable. “In hospitals, pathogens are under enormous evolutionary pressure. Routine disinfections, high consumption of antibiotics… many procedures in a hospital push them to become resistant,” says Pérez.
Faced with this, active surveillance is another weapon for hospitals. It basically consists of routinely monitoring the bacteria that live in your spaces and analyzing the resistance they present. The results of these analyzes sometimes bring surprises, as occurred in an outbreak recorded at the Bellvitge Hospital (Barcelona) and whose response has been presented in the ESCMID Global.
“In total we detected 56 infected by Enterococcus faecium resistant to vancomycin,” explains Jordi Càmara, specialist physician in the center’s Microbiology service. This bacteria, part of the intestinal flora of some people in contact with the healthcare environment and almost always harmless, can be lethal if it infects weakened people. “This strain is frequently detected in the United States and northern Europe, but not in Spain. Although fortunately the cases were not serious, resistance to vancomycin is worrying because it leaves you with practically no therapeutic options. Then we learned that other Catalan hospitals have also discovered resistant strains, although somewhat different from ours. This shows a global change in which there have been several introductions of these microorganisms into our environment,” says Càmara.
What happened in Bellvitge illustrates well the relentless fight that hospitals must wage against bacteria. The center first detected the pathogen on April 23, 2023 in the urine of a patient. During the following months, despite routine infection control efforts, the bacteria was identified in unrelated patients. Finally, in early August, there were several cases related to the surgical units. The center’s reaction was to establish a multidisciplinary team, with meetings every 48 hours and a package of measures, which soon gave good results, according to the work presented at the congress. Despite this, recent research shows that sporadic cases continue to be detected, which shows the need to “insist on staff training and comply with recommended infection control measures.”
Much larger, with 319 cases, was the outbreak recorded at the Donostia Hospital due to another resistant bacteria and which has also been presented in the ESCMID Global. The infections had “little clinical impact on patients,” according to those responsible for the center, but the outbreak caused great concern for three reasons. “First, because we encountered a very unusual and worrying type of resistance. It was a staphylococcus resistant to linezolid, a so-called rescue or last resort antibiotic. Second, due to the ease with which the pathogen spread throughout our ICU, 45 individual boxes. And the third thing, because all this happened during the first wave of the pandemic, when working conditions were very difficult,” recalls Diego Vicente, head of the Microbiology service at the center.
At the congress held in Barcelona, success stories were also presented, such as the plan developed by eight Catalan hospitals to address a recurring problem: bacteremia – the entry of bacteria into the bloodstream – related to the use of catheters, small tubes that enter the circulatory system. “This was traditionally one of the biggest problems in ICUs, but its incidence has been reduced in recent years. On the other hand, the trend in conventional hospitalization wards is the opposite,” says Oriol Gasch, researcher at the Parc Taulí Research and Innovation Institute (I3PT), in Sabadell.
This expert’s opinion is that the fact that ICUs are a more controlled space, with fewer personnel and better trained in the management of vascular catheters, explains these differences even though these spaces host more seriously ill patients. The study presented shows how incidents such as bacteremia were reduced by more than a quarter thanks to a package of measures consisting of greater training for professionals and attention to the maintenance of these devices.
“Most nosocomial infections are preventable. But to do this, as this work shows, it is necessary to implement adequate work systems, with good training for the professionals and necessary materials. Reducing the incidence is and will be something very complicated, but the data show that it is something that is within our reach,” Gasch concludes.
