Research paperHospital acquired viral respiratory tract infections: An underrecognized nosocomial infection
Introduction
Hospital acquired infections are a major cause of morbidity, mortality and increased hospital expenditure [1]. A systematic review by Mitchell et al. [2] noted the paucity of data on these infections in Australia. This inadequacy is felt even more with respect to nosocomial viral respiratory infections. Our study assumes significance in this context, as it is one of few that attempts to understand the epidemiology of these infections in both adults and children in a major tertiary hospital in North Queensland, Australia.
Respiratory viral infections have been studied in specific groups of patients. These include those who have undergone hematopoietic stem cell or solid organ transplants [3]. Little is known about the impact of these infections in the non-transplant population and our study targeted this group of patients. Influenza and respiratory syncytial viruses (RSV) are the most commonly encountered viruses in nosocomial pneumonia, the latter being particularly common in the pediatric population [4]. Patients with cardiac and chronic pulmonary or kidney disease are at risk of acquiring influenza and suffer the complications such as secondary bacterial infection.
Outbreaks in hospitals can occur via transmission from infected patients, health care workers and visitors who introduce the virus into the hospital environment. Early detection of the virus, prophylactic oseltamivir, isolation and strict personal protective measures have contained outbreaks of influenza in children on chemotherapy [5]. However, all these measures may not be practical for large outbreaks involving different virus species as they can overwhelm hospital resources. Studies have shown that isolation precautions are associated with higher costs and increased length of stay in hospitals [6,7]. Increased incidence of depression and delirium have also been noted in these patients [8]. This necessitates reevaluation of infection control measures in outbreaks of HAVRI.
Approximately 20% of patients with health care-associated pneumonia have viral respiratory infections, with an incidence that typically reflects the level of virus activity within the community [9,10]. Our study aimed to collect demographic and clinical data for patients with positive viral respiratory swabs over 7 years (between 2012 and 2019). Children were studied separately from adults. As mortality data alone cannot reflect the burden of HAVRI, we chose the need for intensive care, mechanical ventilation and length of stay as morbidity indicators, and this was analysed for different age groups. We also analysed the occurrence of outbreaks of these infections.
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Study design and location
We chose a retrospective observational design as the aim was to observe the changing trends in the incidence of these infections over the study period. The study was approved by the Human Research Ethics Committee of the Hospital (LNR/2019/QTHS/53733). The hospital is a public tertiary level hospital in Northern Australia with 700 beds with a variety of medical and surgical specialties that include cardiothoracic and neurosurgical units. All the clinical areas that were included in the study
Results
292 patients with positive respiratory swabs for hospitalised patients over the study period were identified. Of these, 283 patients met the definition of HAVRI based on our inclusion criteria. There was an increase in the incidence of the infections over the years with the rate of infection increasing from 0.63 to 3.38 per 10,000 bed days (Fig. 1.)
The incidence of different virus types is described in Fig. 2. Influenza A was the commonest at 35% (n = 101). A significant association (p < 0.01)
Discussion
The study provides much needed insight on the impact of HA-VRI on morbidity and mortality in hospitalized patients of different age groups. HA-VRI has been shown to be associated with negative outcomes in neonates including prolonged hospitalization, a need for respiratory support, and an increased risk of developing bronchopulmonary dysplasia (BPD) [10,11]. We found similar results in our study with the younger age group more likely to need intensive care and mechanical ventilation. However,
Ethics
The study was approved by the Human Research Ethics Committee of the Hospital (LNR/2019/QTHS/53733). This study had low risk to participants and we requested a waiver of consent with the HREC due to the following reasons.
- 1.
Involvement in the study will not affect patient's wellbeing as this is entirely a retrospective study. There will be review of patients' management but no direct contact of patients involved. There will be no identifiable data presented in the final report.
- 2.
The potential
Authorship statement
N. Manchal: Project design, Data collection, Supervision, Writing, Editing; R. Norton: Project design, Supervision, Editing; R. Mohammad: Project design, Data collection, Editing; M. Ting: Project design, Data collection, Editing; F. Francis: Project design, Supervision, Editing; H. Luetchford: Project design, Data collection, Writing, Editing; J. Carrucan: Project design, Data collection, Writing, Editing.
Conflict of interest
All authors report no conflicts of interest relevant to this article.
Funding
None reported.
Provenance and peer review
Not commissioned; externally peer reviewed.
Acknowledgements
Dr. Daniel Lindsay for statistical analysis.
References (22)
- et al.
The burden of healthcare-associated infection in Australian hospitals: a systematic review of the literature
Infect Dis Health
(2017) - et al.
Respiratory viruses in transplant recipients: more than just a cold. Clinical syndromes and infection prevention principles
Int J Infect Dis
(2017) Nosocomial viral infections revisited
Clin Microbiol Newsl
(2001)- et al.
Pandemic A/H1N1/2009 influenza in a paediatric haematology and oncology unit: successful management of a sudden outbreak
J Hosp Infect
(2011) Nosocomial viral respiratory infections: perennial weeds on pediatric wards
Am J Med
(1981)- et al.
Economic burden of nosocomial pneumonia in non-intensive care clinics
Tuberk Toraks
(2015) - et al.
The effect of hospital isolation precautions on patient outcomes and cost of care: a multi-site, retrospective, propensity score-matched cohort study
J Gen Intern Med
(2017) - et al.
Direct costs of a contact isolation day: a prospective cost analysis at a Swiss University Hospital
Infect Control Hosp Epidemiol
(2018) - et al.
Patient isolation precautions: are they worth it?
Can Respir J Can Thorac Soc
(2016) - et al.
Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisory committee
Morb Mortal Wkly Rep
(2004)
Hospital-acquired respiratory viral infections: incidence, morbidity, and mortality in pediatric and adult patients
Open Forum Infect Dis
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