Background
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received intravenous therapy at home, wound care or specialized nursing care through a healthcare agency, family or friends; or had self-administered intravenous medical therapy in the 30 days before the infection;
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attended a hospital or hemodialysis clinic or received intravenous chemotherapy in the previous 30 days;
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were hospitalized in an acute care hospital for 2 or more days in the previous 90 days,
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resided in a nursing home or long-term care facility.
Methods
Data sources and searches
Study selection
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CAI - infection detected within 48 hours of hospital admission in patients without previous contact with healthcare service.
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HAI - localized or systemic condition: 1) that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and 2) that was present 48 hours or more after hospital admission and not incubating at hospital admission time [15].
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HCAI - infection detected within 48 hours of hospital admission in patients that had previous contact with healthcare service within one year.
Data extraction and quality assessment
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The authors define inclusion criteria,
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The authors define an adequate selection method,
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The selection of participants was consecutive,
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The outcome data (microbiology data by place of acquisition) were complete and reported (no attrition bias) and
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All results were reported (reporting bias).
Data analysis
Author, publication year | Study design | MDR* organisms, n (%) | Risk of bias | ||
---|---|---|---|---|---|
Bacteriemia
|
CAI
|
HCAI
|
HAI
| ||
Friedman et al., 2002 [3] | Prospective, multicenter, 504 patients, USA, 4 to 5 months | Not mentioned | High | ||
Marschall et al., 2009 [16] | Prospective, single center, 250 patients, Gram-negative, USA, 6 months | 0 (0) | 9 (7) | 10 (11) | Low |
Evans et al., 2009 [17] | Retrospective, multicenter, 223 patients, spinal cord injury, USA, 7 years | 6 (17) | 34 (31) | 111 (42) | High |
Son et al., 2010 [18] | Prospective, multicenter, 1,144 patients, Korea, 12 months | 29 (8) | 38 (7) | 162 (79) | Low |
Rodriguez-Bano et al., 2010 [19] | Prospective, multicenter, 821 bacteremia episodes including potential contaminants, Spain, 2 to 5 months | 7 (5) | 29 (15) | 99 (21) | Moderate |
Vallés et al., 2011 [8] | Prospective, multicenter, 726 patients, Spain and Argentina, 12 months | 7 (2) | 11 (8) | 29 (12) | High |
Pneumonia
|
CAI
|
HCAI
| |||
Carratalà et al., 2007 [10] | Prospective, single center, 727 patients, those with neutropenia, AIDS and after transplantation were excluded, Spain, 4 years. | 3 (1) | 2 (2) | Low | |
Shindo et al., 2009 [20] | Retrospective, single center, 371 patients, Japan, 1 year and 3 months | 6 (6) | 17 (22) | Low | |
Park et al., 2010 [9] | Retrospective, single center, 345 patients, CAI and HCAI were considered until 72 h after hospital admission; patients with neutropenia, AIDS and after transplantation were excluded, Korea, 1 year. | 7 (15) | 21 (32) | Moderate | |
Pascual et al., 2010 [21] | Retrospective, single center, 308 patients with bacteriemic pneumonia, Spain, 6 years | CAI (2) | HCAI (12) | HAI (31) | High |
Umeki et al., 2011 [22] | Prospective, single center, 202 patients, Japan, 2 years | 10 (21) | 12 (25) | Moderate | |
Seki et al., 2011 [23] | Retrospective, single center, 34 patients Japan, 4 months | 0 (0) | 6 (43) | Moderate | |
Garcia-Vidal et al., 2011 [24] | Prospective, single center, 2,153 patients, those with more than one condition of HCAI, with neutropenia, AIDS, after transplantation and chronic corticosteroid treatment were excluded, Spain, 8 years and 9 months | 19 (2) | 7 (2) | Low | |
Jung et al., 2011 [25] | Retrospective, single center, 527 patients, Korea, 1 year | 15 (18) | 30 (38) | Low | |
Jeon et al., 2011 [26] | Retrospective, multicenter, 210 patients older than 60 years, Korea, 2 years. | 10 (16) | 20 (67) | Low | |
Depuydt et al. 2011 [27] | Retrospective, single center, 269 patients, those with neutropenia, transplantation or transferred from another hospital were excluded, Belgium, 1 year | 0 (0) | 6 (30) | Low | |
Park et al., 2012 [4] | Prospective, single center, 339 patients, Korea, 2 years | 35 (20) | 52 (31) | Low | |
Lee et al., 2012 [28] | Retrospective, multicenter study, 250 patients, Korea, 21 months | 3 (4) | 17 (31) | Low | |
Other foci
|
CAI
|
HCAI
|
HAI
| ||
Benito et al., 2009 [5] | Prospective, single center,1622 patients with endocarditis, comparing CAI with healthcare associated that included non-nosocomial and nosocomial, intra-venous drug users and prosthetic valves were excluded, USA, 6 months. | 25 (3) | 41 (17) | 76 (26) | Low |
Wu et al., 2011 [29] | Retrospective, single center,192 patients with endocarditis, Taiwan, 5 years | 15 (11) | 13 (43) | 17 (81) | Moderate |
Aguilar-Duran et al., 2012 [6] | Prospective, single center, 251 patients with urinary infection, Spain, 7 to 8 months | 2 (2) | 15 (15) | 9 (14) | High |
Study, year of publication | Study design | HCAI criteria | MDR* organisms | Risk of bias | ||
---|---|---|---|---|---|---|
A. Bloodstream infections
| ||||||
Siegman-Igra et al., 2002 [7] | Prospective, single center, 1,028 infections in 912 patients; Israel, 1 year | 1. Discharge from hospital 2 to 30 days previously | CAI | HCAI | HAI | Moderate |
2. Nursing-home acquired | 8 (2) | 24 (10) | 71 (17) | |||
3. Patients with long-term intravenous devices, for hemodialysis, chemotherapy or parenteral nutrition | ||||||
4. Chronic hemodialysis | ||||||
5. Invasive procedure previously or at hospital admission | ||||||
Shorr et al., 2006 [11] | Retrospective, multicenter, 6,697 patients; USA, 2 years | 1. Prior hospitalization within 30 days | CAI | HCAI | HAI | Low |
2. Transfer from another healthcare facility | 152 (2) | 397 (11) | 62 (13) | |||
3. Chronic hemodialysis | ||||||
4. Immunosuppression medication or metastatic cancer | ||||||
Kao et al., 2011 [30] | Prospective, single center, 890 infections in 831 patients older than 14 years; Taiwan, 1 year | 1. Hospitalized for 2 or more days in the previous 90 days | CAI | HCAI | HAI | High |
2. Resided in a nursing home | 11 (2) | 41 (16) | 42 (41) | |||
3. Hemodialysis, intravenous chemotherapy or invasive procedures in the previous 90 days | ||||||
Kollef et al., 2011 [12] | Prospective, multicenter, 1,143 patients; USA, 1 year | 1. Prior hospitalization within 6 months | CAI | HCAI | Low | |
2. Admission from a skilled nursing facility | 79 (19) | 242 (33) | ||||
3. Hemodialysis | ||||||
4. Immunosuppression | ||||||
Al-Hasan et al., 2012 [31] | Retrospective, multicenter, 733 episodes of gram negative bacteremia; excludes polymicrobial, nosocomial and recurrent episodes; USA, 10 years | 1. Hospitalized for 2 or more days in the previous 90 days | CAI | HCAI | Moderate | |
2. Residents in a nursing home or long-term care facility | 12 | 28 (7) | ||||
3. Received intravenous therapy including ATB and chemotherapy | ||||||
4. Hemodialysis in the previous 30 days | ||||||
Lenz et al., 2012 [32] | Retrospective, multicenter, 7,712 patients; only samples obtained in the first 5 days of hospital admission; Canada, 8 years | 1. Hospitalized for 2 or more days in the previous 90 days | CAI | HCAI | HAI | Low |
2. Nursing home or long term-care facility | 59 (2) | 158 (6) | 202 (9) | |||
3. Visit a hospital, clinic or emergency department within the prior 5 to 30 days | ||||||
4. Hemodialysis | ||||||
5. Active cancer | ||||||
B. Pneumonia
| ||||||
Kollef et al., 2006 [13] | Retrospective, multicenter, 4,543 patients with positive cultures within 5 days of hospital admission, USA, 2 years | 1. Prior hospitalization within 30 days | CAI | HCAI | HAI | High |
2. Admission from another care facility | 624 (28) | 537 (54) | 362 (43) | |||
3. Receiving long-term hemodialysis | ||||||
Micek et al., 2007 [33] | Retrospective, single center, 639 patients older than 16 years with positive cultures, Spain, 2 years | 1. Hospitalization in the past 12 months | CAI | HCAI | Low | |
2. Resident in a nursing home or long-term care facility or rehabilitation hospital | 35 (17) | 242 (56) | ||||
3. Outpatient hemodialysis, peritoneal dialysis or infusion therapies requiring regular visits to a clinic | ||||||
4. Immunosuppression | ||||||
Schreiber et al., 2010 [34] | Retrospective, single center study, 190 patients needing mechanical ventilation more than 24 hours after hospital admission, patients without evidence of bacterial infection and patients transferred from other hospitals were excluded, USA, 4 years | 1. Recent hospitalization (90 days) | CAI | HCAI | Low | |
2. Admission from a long-term facility | 17 (18) | 48 (48) | ||||
3. Recent treatment with broad spectrum antibiotics (30 days) | ||||||
4. Chronic hemodialysis | ||||||
5. Wound care | ||||||
6. Immunosuppression | ||||||
Grenier et al., 2011 [14] | Retrospective, single center study, 3,295 patients, those transferred from other hospitals or discharged from an acute care facility within 14 days were excluded, Canada, 12 years | 1. Hospitalization in the past 90 days, but not in the last 14 days | CAI | HCAI | Low | |
2. Resident of a nursing home or long-term care facility | 42 (4) | 21 (10) | ||||
3. Outpatient intravenous therapy or cancer therapy within the previous month | ||||||
4. Long term hemodialysis | ||||||
Guimarães et al., 2011 [35] | Retrospective, single center study, 197 patients, Portugal, 1 year | 1. Hospitalization for 2 days or more in the preceding 90 days | CAI | HCAI | High | |
2. Resident of a nursing home or extended-care facility | 2 (18) | 9 (82) | ||||
3. Intravenous antibiotic therapy or chemotherapy within 30 days | ||||||
4. Chronic dialysis within 30 days | ||||||
5. Home wound care | ||||||
6. Family member with multi-drug resistant pathogen | ||||||
Chalmers et al., 2011 [36] | Prospective, single center, 1,348 patients; Scotland, 4 years and 5 months | 1. Hospitalization for 2 days or more in the preceding 90 days | CAI | HCAI | High | |
2. Resident of a nursing home or extended-care facility | 3 (1) | 5 (6) | ||||
3. Home infusion therapy (including antibiotics and long-indwelling devices as catheters) | ||||||
4. Chronic dialysis within 30 days | ||||||
5. Home wound care | ||||||
6. Family member with multi-drug resistant pathogen | ||||||
Tasbakan et al., 2011 [37] | Retrospective, single center study, 187 patients, Turkey, 1 year | 1. Hospitalization for 2 days or more in the preceding 90 days | CAI | HCAI | Low | |
2. Resident of a nursing home or extended-care facility | 1 (13) | 17 (44) | ||||
3. Home infusion therapy (including antibiotics) | ||||||
4. Chronic dialysis within 30 days | ||||||
5. Home wound care | ||||||
6. Family member with multi-drug resistant pathogen | ||||||
Ishida et al., 2012 [38] | Retrospective, single center, 893 patients; Japan, 3 years | 1. Discharged from a hospital in the preceding 90 days | CAI | HCAI | Low | |
2. Resident in a nursing home or extended-care ward | 6 (3) | 37 (21) | ||||
3. A patient who regularly requires vascular access for dialysis, antimicrobial treatment, chemotherapy or immunosuppressive therapy in an outpatient setting | ||||||
4. Elderly or handicap who needs long-term care with an ECOG of 3 or 4 | ||||||
Miyashita et al., 2012 [39] | Prospective, multicenter, 1,385 patients; CAI and HCAI were considered until 72 h after hospital admission, Japan, 6 years | 1. Discharged from a hospital in the preceding 90 days | CAI | HCAI | High | |
2. Resident in a long-term nursing home setting or healthcare home | 21 (4) | 78 (20) | ||||
3. Continuous receiving endovascular therapy in an ambulatory setting (including dialysis, antibiotics, anticancer drugs and immunosuppression) | ||||||
4. Elderly persons or physical disable persons who need healthcare | ||||||
Wu et al., 2012 [40] | Retrospective, multicenter study, 1,646 patients, those with pneumonia developing 2 days after admission or less than 14 days after the last hospitalization, with lung cancer obstructive pneumonia or HIV positive status with CD4+ t <200 were excluded, Taiwan,1 year | 1. Undergoing repeated hospitalization within 90 days before | CAI | HCAI | Low | |
2. Residing in a nursing home | 122 (15) | 169 (28) | ||||
3. Receiving radiation therapy or chemotherapy at an outpatient clinic | ||||||
4. Received regular dialysis at an out patients clinic | ||||||
Sugisaki et al., 2012 [41] | Retrospective, single center study, 526 patients, Japan, 4 years | 1. Hospitalization for 2 days or more in the preceding 90 days | CAI | HCAI | Low | |
2. Resident of a nursing home or extended-care facility | 50 (15) | 72 (40) | ||||
3. Home infusion therapy (including antibiotics and long indwelling devices as catheters) | ||||||
4. Chronic dialysis within 30 days | ||||||
5. Home wound care | ||||||
6. Family member with multi-drug resistant pathogen | ||||||
Giannella et al., 2012 [42] | Prospective, multicenter, 1,002 patients older than 16 years admitted into internal medicine departments, Spain, 2 weeks | 1. Hospitalization in the past 180 days | CAI | HCAI | HAI | Low |
2. Resident in a nursing home or extended-care facility | 6 (4) | 19 (29) | 11 (52) | |||
3. Attending a hospital regularly because of chronic underlying disease | ||||||
4. Undergoing hemodialysis | ||||||
5. Wound care or specialized nursing care in the past 30 days | ||||||
6. Chemotherapy in the past 30 days | ||||||
7. Surgery in the past 180 days | ||||||
C. Other foci
| ||||||
Swenson et al., 2009 [43] | Retrospective, single center study, 2,049 intra-abdominal infections; Canada, 10 year | 1. Patients with a story of any hospitalization in the previous 30 days | CAI | HCAI | High | |
2. Resident of a nursing home or rehabilitation facility in the previous 30 days | 27 (7) | 221 (28) | ||||
Merli et al., 2010 [44] | Prospective, single center study, in 54 patients with cirrhosis, patients with HIV infection, under high dose of corticosteroid treatment or immunosuppressive therapy were excluded, Italy, 9 months | 1. Hospitalization for 2 or more days or had undergone surgery during the preceding 180 days | CAI | HCAI | HAI | Low |
2. Resident of a nursing home or long-term care facility | 2 (50) | 9 (82) | 5 (45) | |||
3. Attended a hospital or hemodialysis clinic or received intravenous chemotherapy in the 30 days before | ||||||
Ha et al., 2011 [45] | Retrospective, single center study, in 319 patients with urinary infection; Korea, 1 year | 1. Hospitalization for 2 or more days in an acute care hospital in the preceding 90 days | CAI | HCAI | Low | |
2. Resident of a nursing home or long-term care facility | 1 (1) | 28 (14) | ||||
3. Received intravenous therapy, wound care or specialized nursing care at home in the previous 30 days | ||||||
4. Attended a hospital or hemodialysis clinic or received intravenous chemotherapy in the 30 days before | ||||||
5. Received an invasive procedure, urological surgery or urethral catheterization in the previous 7 days | ||||||
Sy et al., 2012 [46] | Retrospective, multicenter study, in 1,536 patients with endocarditis; patients transferred from another hospital, recurrent admissions or day-stay admissions were excluded, Australia, 6 years | 1. Hospitalization for 2 days or more in the preceding 90 days | HCAI | Non-HCAI | High | |
2. Resident of a nursing home or in a long-term facility | 40 (26) | 61 (18) | ||||
3. Attended a hemodialysis clinic or received intravenous therapy in the 30 days before |
Results
Infections by source
Criteria for HCAI | Low risk of bias | Moderate risk of bias | High risk of bias | All studies |
---|---|---|---|---|
Number of studies (number of patients)
| ||||
Received intravenous therapy | 16 (13,082) | 7 (3,239) | 8 (6,284) | 31 (22,605) |
Received wound care or specialized nursing care | 16 (10,086) | 5 (1,594) | 7 (3,560) | 28 (15,240) |
Attended a hospital or a clinic in the last 30 days | 16 (17,588) | 5 (1,594) | 5 (2,015) | 26 (21,197) |
Received chemotherapy in the last 30 days | 15 (10,883) | 6 (2,506) | 7 (3,043) | 28 (16,432) |
Receiving hemodialysis | 23 (31,272) | 7 (2,639) | 10 (10,470) | 40 (44,381) |
Prior hospitalization (in the last year) | 24 (32,165) | 7 (3,239) | 12 (13,904) | 43 (49,308) |
Resident in a nursing home or long term-care facility | 23 (25,468) | 7 (3,239) | 11 (9,361) | 41 (38,068) |
Criteria NOT included in the initial definition[3] | ||||
Transfer from another care facility | 1 (6,697) | 1 (4,543) | 2 (11,240) | |
Immunosuppression | 4 (8,669) | 4 (8,669) | ||
Active or metastatic cancer | 1 (7,712) | 1 (7,712) | ||
Submitted to invasive procedures previously | 1 (319) | 1 (912) | 1 (831) | 3 (2,062) |
Family member with a multi-drug resistant microorganism | 2 (713) | 2 (1,545) | 4 (2,258) | |
Elderly person or physical disable persons who need healthcare | 1 (893) | 1 (1,385) | 2 (2,278) | |
Surgery in the last 180 days | 2 (1,056) | 2 (1,056) | ||
Received radiation therapy | 1 (1,646) | 1 (1,646) | ||
Recent (30 days) treatment with antibiotics | 1 (190) | 1 (733) | 1 (197) | 3 (1,120) |
Discussion
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received invasive procedures in the 30 days before the infection, including specialized nursing care;
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attended a hospital or hemodialysis clinic in the previous 30 days;
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were hospitalized in an acute care hospital for 2 or more days in the previous year;
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resided in a nursing home or long-term care facility;
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treatment with broad spectrum antibiotics in the last 30 days.