Health-care-associated bloodstream and urinary tract infections in a network of hospitals in India: a multicentre, hospital-based, prospective surveillance study

Health-care-associated infections (HAIs) cause significant morbidity and mortality globally, including in low-income and middle-income countries (LMICs). Networks of hospitals implementing standardised HAI surveillance can provide valuable data on HAI burden, and identify and monitor HAI prevention gaps. Hospitals in many LMICs use HAI case definitions developed for higher-resourced settings, which require human resources and laboratory and imaging tests that are often not available.

A network of 26 tertiary-level hospitals in India was created to implement HAI surveillance and prevention activities. Existing HAI case definitions were modified to facilitate standardised, resource-appropriate surveillance across hospitals. Hospitals identified health-care-associated bloodstream infections and urinary tract infections (UTIs) and reported clinical and microbiological data to the network for analysis.

26 network hospitals reported 2622 health-care-associated bloodstream infections and 737 health-care-associated UTIs from 89 intensive care units (ICUs) between May 1, 2017, and Oct 31, 2018. Central line-associated bloodstream infection rates were highest in neonatal ICUs (>20 per 1000 central line days). Catheter-associated UTI rates were highest in paediatric medical ICUs (4·5 per 1000 urinary catheter days). Klebsiella spp (24·8%) were the most frequent organism in bloodstream infections and Candida spp (29·4%) in UTIs. Carbapenem resistance was common in Gram-negative infections, occurring in 72% of bloodstream infections and 76% of UTIs caused by Klebsiella spp, 77% of bloodstream infections and 76% of UTIs caused by Acinetobacter spp, and 64% of bloodstream infections and 72% of UTIs caused by Pseudomonas spp.

The first standardised HAI surveillance network in India has succeeded in implementing locally adapted and context-appropriate protocols consistently across hospitals and has been able to identify a large number of HAIs. Network data show high HAI and antimicrobial resistance rates in tertiary hospitals, showing the importance of implementing multimodal HAI prevention and antimicrobial resistance containment strategies.

US Centers for Disease Control and Prevention cooperative agreement with All India Institute of Medical Sciences, New Delhi.

For the Hindi translation of the abstract see Supplementary Materials section.

Health-care-associated infection surveillance in India

Health-care-associated infections (HAIs) are the infections acquired while patients receive treatment for medical or surgical conditions. HAIs are among the most common complications occurring during the health service delivery, often caused by endemic multidrug-resistant organisms on account of indiscriminate use of antibiotics.1 HAIs are associated with increased morbidity and mortality, prolonged hospital stays, and health-care costs. Surveillance for endemic HAIs is important to measure their burden, identify high-risk populations and procedures, and guide efforts to reduce HAI incidence. HAI surveillance is a core component of infection prevention and control programmes worldwide. The reliability of HAI surveillance depends on the use of standardised definitions. The case definitions used in National Healthcare Safety Network (NHSN) or European Centre for Disease Prevention and Control (ECDC) HAI surveillance are complex, requiring dedicated human resources and funds and expertise in diagnostics, epidemiology, and infection control. Probably on account of this, only 16% of low-income and middle-income countries (LMICs) in 2010 had HAI surveillance at the national and sub-national level.2
The frequency of different HAIs varies between countries and according to economic conditions. The risk of acquiring HAI is up to 20 times higher in LMICs.1 Surveillance from an International Nosocomial Infection Control Consortium comprising 45 LMICs, reported three to six times high pooled rates of catheter-associated urinary tract infection (CAUTI) and central line-associated bloodstream infections (CLABSI) compared with intensive care units (ICUs) in the USA.3 Surveillance data from 2004 to 2013 from 40 hospitals in India reported a pooled prevalence of CLABSI to be 5·1 per 1000 central line days and of CAUTI to be 2·1 per 1000 catheter days.4 A 2019, single-centre study in India reported a pooled CLABSI rate of 4·3 per 1000 central line days.5 In a global survey, the prevalence of resistance to antibiotics including third-generation cephalosporins and carbapenems among Enterobacteriaceae, was significantly higher in LMICs.6 High levels of resistance, including against carbapenems among Acinetobacter spp, Pseudomonas spp, and Klebsiella spp have been reported from India.7
In The Lancet Global Health, Purva Mathur and colleagues8 report results of health-care-associated bloodstream and urinary tract infections in 89 intensive care units of 26 tertiary care hospitals in India.8 The authors modified the NHSN and ECDC case definitions to facilitate standardised HAI surveillance, adjusting for the available resources in Indian hospitals. In adult and paediatric ICU types, the pooled rates of BSI ranged between 5·3–7·3 per 1000 patient days and CLABSI rates ranged between 8·3–12·1 per 1000 central line days. The pooled UTI and CAUTI rates in these ICUs ranged between 1·7–2·8 per 1000 patient days and 8·3–12·1 per 1000 catheter days, respectively. Neonatal ICUs had higher pooled BSI and CLABSI rates in all birthweight categories. The authors also report high levels of resistance to at least one carbapenem in HAIs caused by Klebsiella spp, Escherichia coli, Acinetobacter spp, and Pseudomonas spp. The rates of HAI and associated antibiotic resistance reported in this study are either similar to or higher than those from previous studies in India.
The HAI surveillance established by Mathur and colleagues8 represents a well laid foundation that needs to be continued and expanded further as a national-level surveillance system for major HAI, including ventilator-associated pneumonia and surgical site infection. However, the modified case definitions used in the study need to be validated before its large-scale implementation. This platform will also enable early detection and containment of outbreaks caused by novel or emerging infectious diseases and multidrug resistant organisms. The antimicrobial resistance data will inform local, regional, and national antimicrobial resistance stewardship strategies and initiatives. Linkage to other global HAI or antimicrobial resistance surveillance platforms, such as the Global Antimicrobial Resistance and Use Surveillance System, will enable learning and sharing of the best practices of infection prevention and control.
In India, a large segment of the population seeks in-patient health-care at secondary or district-level health facilities in public and private sectors, many of which have inadequate infection prevention and control measures. The major barriers to infection prevention and control implementation are scarcity of dedicated and trained staff, availability and inappropriate use of PPE, and sanitary and hygiene measures, compounded with patient overcrowding. The widespread transmission of infection in health facilities during the ongoing COVID-19 pandemic underscores the need for strengthening infection prevention and control practices.
In the past decade, there have been governmental initiatives, such as Kayakalp, aimed at improving and promoting the cleanliness, hygiene, waste management, and infection control practices in public health-care facilities in India.9 Although it is desirable that the national HAI surveillance system is eventually extended to district-level hospitals, the immediate priority should be to ensure that the minimum requirements of infection prevention and control are in place in these hospitals.10 The eventual outcomes of implementing evidence-based, best infection prevention and control practices will be a substantial reduction in HAIs and an improvement in the overall health-care quality.
We declare no competing interests.

Supporting midwifery is the answer to the wicked problems in maternity care

The film Don’t Look Up, examines what it will take to get world leaders and the public to be proactive about a comet that is on a collision course with earth. We argue that the same attitude of self-interested denialism is stopping crucial action being taken when it comes to supporting midwifery models of care to address the current problems in maternity care.
Although life-saving when indicated, medical interventions in childbirth can be harmful when overused.1 A challenge in striking the right balance is that the bar for benefit when it comes to birth outcomes has been set at immediate survival. This approach overlooks clinical complications, such as placenta praevia or accreta associated with caesarean, and fails to value the personal autonomy of women and communities. In global settings, caesarean section rates, which are often used as a proxy to understand the safety of a maternity system, have recently come under scrutiny. Inquiries into adverse outcomes in the Shrewsbury and Telford Hospital National Health Service Trust in the UK has led to sensational media reporting and concerns about the dangers of setting caesarean section targets. This reporting has led to a focus on individual decision makers rather than faulty systems. We know a bad system will beat the best health-care provider every time
The centrality of midwives in supporting the physiological process of giving birth is at the core of this debate. Midwives have been singled out for blame when it comes to poor outcomes, with little consideration given to the fragmented models of care they work in, where they do not always have professional autonomy and respectful collaboration. This attitude creates an environment of professional and philosophical conflict that does not put women’s optimal care and needs at the centre. Relational models of care such as continuity of midwifery care, which are supported by high-level evidence as being cost effective and leading to optimal outcomes,3 are ignored. Such models have the potential to save 4·3 million lives per year, but realising this opportunity requires a deeper understanding of why they are not reaching scale.
The way we treat women during pregnancy, childbirth, and postpartum, and the institutional options of care we provide them within health systems, directly reflect the way we value women in our societies. In too many settings we are ignoring the benefits of midwifery models of care, degrading the status of midwives, and removing financing from midwifery services and education, under the guise of safety that ignores physiology and women’s chances for optimal mental and physical health.
There is a shortage of approximately a third of the midwives we need globally, which is crucial considering that midwives who are educated and regulated to international standards of care can provide 87% of essential maternity care needs and would prevent 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths.4 Midwifery provides a 16 times return on investment.3, 5 Evidence is mounting on how midwives improve maternity care globally; yet, midwives are leaving the profession—burned out, disillusioned, and under valued.6 The latest sensationalised media reporting in the UK has demoralised midwives even more, with global impacts. As a predominantly female profession, midwives continue to be marginalised, overworked, poorly paid, and do not have decision making authority in many countries.
The aim of intervening in the physiological processes of pregnancy and birth is to improve outcomes and safety for women and babies. Commonly used birth interventions such as caesarean sections and induction, which were previously used to treat obvious complications, are used more commonly for women that are unlikely to benefit from them, and can even cause harm to healthy women. These harms contribute to gender, racial, and geographical inequities, and there is growing concern regarding generational inequities. Less concern is afforded to women suffering from birth trauma, which is higher following intervention in birth, especially when women feel poorly informed and coerced into this.10
Although high-income countries (HICs) often drive the dominant discourse when it comes to maternity care, in some low-income and middle-income countries (LMICs) women cannot access a safe caesarean section even when it is needed, demonstrating significant inequalities in maternal care. Caesarean section rates have escalated in LMICs without adequate training or access to additional skills such as anaesthetics, leading to deadly outcomes; and maternal mortality rates are up to 100 times higher in LMICs than HICs. There is increased economic hardship for communities and stretched health systems, and distrust of hospital care and health-care providers.8 Women who become pregnant after caesarean section are at a higher risk of subsequent surgery, with inadequate attention given to additive morbidity over their reproductive life course.
The use of technology and interventions in childbirth scale up quickly and are difficult to de-implement, even when there is evidence of harm. Fiscal accountability and resource-intense care that contributes to the health-care carbon footprint (10% of the US total) should be key considerations.
To meet the 2030 Sustainable Development Goals and prevent an unfolding disaster, we call for urgent action and a united voice on the four main groups of action in the Midwifery 2030 Pathway (panel).

Real-world visual outcomes of cataract surgery based on population-based studies: a systematic review

Background/aims Quantity of cataract surgery has long been an important public health indicator to assess health accessibility, however the quality of care has been less investigated. We aimed to summarise the up-to-date evidences to assess the real-world visual outcomes after cataract surgery in different settings.

Methods A systematic review was undertaken in October 2021. Population-based cross-sectional and longitudinal studies reporting vision-related outcomes after cataract surgery published from 2006 onward were included. A meta-analysis was not planned.

Results Twenty-six cross-sectional studies from low-income and middle-income countries (LMICs) and five cross-sectional studies from high-income countries (HICs) were included. The proportions of participants with postoperative presenting visual acuity (VA) ≥0.32 (20/60) were all over 70% in all HICS studies, but mostly below 70% in LMICS studies, ranging from 29.9% to 80.5%. Significant difference in postoperative VA was also observed within countries. The leading causes for postoperative visual impairment (defined mostly as presenting VA <20/60) mainly included refractive error, ocular comorbidities and surgical complications including posterior capsule opacification, except for one study in Nigeria wherein the leading cause was aphakia. Only four population-based cohort studies were included with 5–20 years of follow-up time, generally demonstrating no significant changes in postoperative visual outcomes during the follow-up.

Conclusions We observed large inequality in the visual outcomes and principal causes of visual impairment after cataract surgery among different countries and regions. Structured quality control and enhancement programmes are needed to improve the outcomes of cataract surgery and reduce inequality.