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Background: Hospital-acquired infections (HAIs) are a global problem in hospitals and significant causes of mortality and morbidity regardless of advances in supportive care, antimicrobial therapy and prevention. The study aimed to determine a comprehensive estimate of the HAIs prevalence, influential factors, and types of these infections in Iran.
Methods: A systematic literature review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the online databases; Medline, EMBASE, Scopus, Cochrane, SID, Magiran, and Medlib from January 1995 to September 2020 using a combination of medical subject heading terms (‘Nosocomial infection [Mesh] OR ‘’ Hospital infection [Mesh] OR Hospital Acquired Infection[Mesh] OR Healthcare-associated infection ‘’AND (‘Iran’ [Mesh]) among observational and interventional studies. SPSS version 25 and STATA version 11 were used for data analysis.
Results: A total of 66 (cross-sectional, cohort, and case-control) observational studies were identified. More of the studies had been done before 2014(43 papers or 65%). Based on the random-effects model, the overall prevalence of HAIs in Iran was 0.111 [95% CI: 0.105 - 0.116] with a high, statistically significant heterogeneity (I2= 99.9%). The infection rate was 0.157 and 0.089 before and after the Iranian Health Transformation Plan (HTP), respectively. HAIs rates reported more in the South and West of Iran rather than other regions (0.231 and 0.164) (p= 0.001). Escherichia coli and klebsiella infections were reported in 53 and 52 papers (0.239 and 0.180, respectively). In addition, respiratory and urinary infections were reported 0.296 and 0.286 in 51 and 38 papers, respectively.
Conclusion: The prevalence of HAIs in Iran is relatively high. Preventing and decreasing hospital nosocomial infections can considerably affect reducing mortality and health-related costs. This should be taken into consideration by health policymakers for pathology and revision of some previous programs and standards as well as the development of appropriate and evidence-based control and education programs to reduce this health problem.
Keywords: Hospital infection, Nosocomial infection, Meta-analysis, Hospital, IranHospital-acquired infections (HAIs) represent a serious public health concern worldwide. Increased prevalence of HAIs in some cases leads to patient’s arbitrary use of drugs, causing severe health hazards as well as significant problems such as drug resistance and death in patients.
This study aimed to update and measure the prevalence of HAIs in Iran using a meta-analytic approach. The overall prevalence of HAIs in Iran was 11.1%. The prevalence of HAIs in the South and West of Iran is high. HAIs decreased after Health Transformation Plan in Iran.
Hospitals are the most important and costly components of health care systems. They account for more than two-thirds of health care spending. Therefore, they significantly affect the overall health care quality. Prevention of infections is part of efforts to improv e the quality of health care services that are vital to patient safety. Hospital-acquired infections (HAIs), also known as nosocomial infections (NI), remain significant causes of mortality and morbidity regardless of advances in supportive care, antimicrobial therapy and prevention.
HAIs are a global problem in hospitals. The popular definition of hospital infection is an infection that happens within 48 hours after hospitalization, or three days after discharge, or 30 days after surgery. Therefore, symptoms of HAIs may occur at the time of patient's hospitalization or after discharge. According to the World Health Organization (WHO) report, hundreds of millions of people are affected by HAIs every year throughout the world. Studies showed that the HAIs rates vary worldwide. In high-income countries, HAIs prevalence in hospitalized patients was 7.6%. This figure was 10.1% (varied from 5.7% to 19.1%) in low-and middle-income countries. Annually, roughly 2 and 4.5 million HAIs are reported in the United States (US) and the European Union, respectively. The infections result in 100,000 deaths and impose additional medical care costs of about $ 6.5 billion annually in the US. According to the WHO's report on 2001, hospital infection has the highest percentage in South-East Asia and the Eastern Mediterranean. Based on this report, one of the main reasons for HAIs is inadvertent misuse of antibiotics leading to widespread resistance. Unfortunately, hospitals in developing countries are hotbeds of infection transmission. These infections lead to increased mortality, longer periods of hospitalization cause emotional and mental stress, failure of surgeries, rejection of organ transplantation and a significant financial burden for healthcare systems and patients. Moreover, they are linked to the spread of multi-drug resistance (MDR) in pathogenic bacteria.
The most important bacteria causing HAIs are Escherichia coli (E. coli), Klebsiella, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Enterococci. The most common nosocomial infections are urinary tract infections, surgical wound infections, pneumonia, and septicemia. Risk factors of the infections for hospitalized patients are divided into two categories: unavoidable risk factors (including old age and serious underlying causes of one's hospitalization) and risk factors that can be mitigated by appropriate treatment (including a longer period of hospitalization, use of inappropriate catheters, excessive use of broad-spectrum, prolonged use of fixed catheters, and improper hand hygiene by healthcare workers).
Prevention of hospital infections is a key way to improve the quality of healthcare. Detailed information on the extent of these infections is essential for evaluating current infection prevention activities and planning for further intervention in the hospitals nationally. An overall review of the documents shows that the reported incidence of all types of HAIs in Iran is very different; so a systematic review of all the documents and their combinations can provide a complete picture of the dimensions of this problem in Iranian society, as well as increase the use of the best and the highest quality documents available. In fact, the purpose of this study was to determine a comprehensive estimate of the prevalence of HAIs, affective factors, and types of these infections in Iran. Our study updates a systematic review that was published in 2018.
A systematic and meta-analysis study was done in 2020. Relevant studies were found in PUBMED, EMBASE, SCOPUS and WEB OF SCIENCES as international databases and Magiran, SID and Medlib as Persian databases from 1995 to September 2020. The following search terms were used: (‘Nosocomial infection [Mesh] OR ‘’ hospital infection [Mesh] OR Hospital acquired infection [Mesh] OR health care associated infection ‘’AND (‘Iran’ [Mesh]). Also, the reference of identifies papers were studied and if their title were in line with the topic, they were investigated by the authors.
The searches were done from July to September 2020. The observational studies (cohorts, case-control, and cross-sectional) both in English and Persian Language were investigated.
Inclusion criteria were: 1) population-based observational studies reporting the prevalence of HAIs, 2) cross-sectional, retrospective and case-control studies, and 3) relevant studies with clear and detailed data. Also, case reports, case series, editorials, letters to the editor, commentaries, reviews and clinical trials as well as studies that were not calculating the prevalence of HAIs, were excluded.
Abstract of all papers were imported into Endnote software version 16 then the duplicates were removed. After that, the authors read the full text, and if they had the inclusion criteria, they were kept for more investigation.
Also, the review and editorial articles were excluded. The checklist was prepared by examining the content of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The PRISMA Statement comprises a 27-item checklist and a four-phase flow diagram. The checklist includes items considered essential for the transparent reporting of a systematic review. In this Explanation and Elaboration document, the meaning and rationale for each checklist item were explained. For each item, an example of good reporting was included and, anywhere possible, reference to pertinent empirical studies and methodological literature.
In the next stage, we checked the results of the papers. If they had reported the rate of nosocomial infection, they were kept as the final suitable papers for analysis.
A data sheet was created in the Excel software and imported the data of suitable variables. The extracted data were as follows: title, year of the study, HAIs rate, gender of patients, type of infection and bacteria, setting, type of hospital, and sample size.
The search generated a total of 1320 records, of which 602 papers were duplicated, and 718 titles and abstracts were reviewed. The most fundamental reasons for omission were: studies conducted outside Iran, publication type, and studies not reporting HAIs’ rate. A total of 66 articles were included in the meta-analysis and data were extracted. Supplementary information can be accessed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 flow diagram ( Fig. 1 ). Also, for assessing the risk of bias, we used ROBVIS as a web app designed for visualizing risk-of-bias.