T

he nosocomial infection rate in patients in a

facility is an indicator of quality and safety of

care. The development of a surveillance process to
monitor this rate is an essential first step to identify
local problems and priorities, and evaluate the effectiveness
of infection control activity. Surveillance,
by itself, is an effective process to decrease the frequency
of hospital-acquired infections (1,2,3).
_ improvements in health care with increased
quality and safety
but
_ changes in care with new techniques, new
pathogens or changes in resistance, increased
patient acuity, ageing population, etc.

=
need for active surveillance to monitor changing
infectious risks
and
_ identify needs for changes in control measures.
_

3.1 Objectives

The ultimate aim is the reduction of nosocomial

infections, and their costs.
The specific objectives of a surveillance programme
include:
_ to improve awareness of clinical staff and other
hospital workers (including administrators) about
nosocomial infections and antimicrobial resistance,
so they appreciate the need for preventive
action
_ to monitor trends: incidence and distribution of
nosocomial infections, prevalence and, where
possible, risk-adjusted incidence for intra- and
inter-hospital comparisons
o identify the need for new or intensified prevention
programmes, and evaluate the impact of
prevention measures
_ to identify possible areas for improvement in
patient care, and for further epidemiological studies
(i.e. risk factor analysis).

3.2 Strategy

A surveillance system must meet the following

criteria (Table 1):
_ simplicity, to minimize costs and workload, and
promote unit participation by timely feedback
_ flexibility, to allow changes when appropriate
_ acceptability (e.g. evaluated by the level of participation,
data quality)
_ consistency (use standardized definitions, methodology)
_ sensitivity, although a case-finding method with
low sensitivity can be valid in following trends,
as long as sensitivity remains consistent over time
and cases identified are representative
_ specificity, requiring precise definitions and
trained investigators.
The extent to which these characteristics are met will
vary among different institutions.

3.2.1 Implementation at the hospital level

Ensuring a valid surveillance system is an important
hospital function. There must be specific objectives
(for units, services, patients, specific care areas)

and defined time periods of surveillance for all

partners: e.g. clinical units and laboratory staff,
infection control practitioner (ICP)/nurse, and director,
administration.
Initially, discussion should identify the information
needs, and the potential for the chosen indicators to
support implementation of corrective measures (what
or who is going to be influenced by the data). This
discussion will include:
_ the patients and units to be monitored (defined
population)
_ the type of infections and relevant information
to be collected for each case (with precise definitions)
_ the frequency and duration of monitoring
_ methods for data collection
_ methods for data analysis, feedback, and dissemination
_ confidentiality and anonymity.
The surveillance programme must report to hospital
administration, usually through the Infection
Control Committee (ICC), and must have a dedicated
budget to support its operation.

3.3 Methods

Simply counting infected patients (numerator) provides

only limited information which may be difficult
to interpret. Further data are necessary to fully
describe the problem on a population basis, to quantify
its importance, to interpret variations, and to
permit comparisons. Risk factor analysis requires
information for both infected and non-infected
patients. Infection rates, as well as risk-adjusted rates,
can then be calculated.
Passive surveillance with reporting by individuals
outside the infection control team (laboratory-based
surveillance, extraction from medical records postdischarge,
infection notification by physicians or
nurses) is of low sensitivity. Therefore some form of
active surveillance for infections (prevalence or
incidence studies) is recommended (Table 2).
FIGURE 1. Surveillance is a circular process
3.
Prevention: decisions and
corrective actions
2.
Feedback and
dissemination: data
analysis,
interpretation,
comparisons,
discussion
4.
Evaluation of the
impact on
nosocomial
infections by
surveillance (trends)
or other studies
1.
Implementation of surveillance:
goals definition, surveillance
protocol data collection

The optimal method (Figure 1) is dependent on hospital

characteristics, the desired objectives, resources
available (computers, investigators) and the level of
support of the hospital staff (both administrative and
clinical).

3.3.1 Prevalence study (cross-sectional/

transverse)

Infections in all patients hospitalized at a given point

in time are identified (point prevalence) in the entire

hospital, or on selected units. Typically, a team
of trained investigators visits every patient of the
hospital on a single day, reviewing medical and nursing
charts, interviewing the clinical staff to identify
infected patients, and collecting risk factor data. The
outcome measure is a prevalence rate.
Prevalence rates are influenced by duration of the
patients stay (infected patients stay longer, leading
to an overestimation of patients risk of acquiring
an infection) and duration of infections.
Another problem is determining whether an infection
is still active on the day of the study.
In small hospitals, or small units, the number of
patients may be too few to develop reliable rates, or
to allow comparisons with statistical significance.
A prevalence study is simple, fast, and relatively inexpensive.
The hospital-wide activity increases
awareness of nosocomial infection problems among
clinical staff, and increases the visibility of the infection
control team. It is useful when initiating a
surveillance programme to assess current issues for
all units, for all kinds of infections, and in all patients,
before proceeding to a more focused continuing
active surveillance programme. Repeated
prevalence surveys can be useful to monitor trends
by comparing rates in a unit, or in a hospital, over
time.

3.3.2 Incidence study (continuous/longitudinal)

Prospective identification of new infections (incidence

surveillance) requires monitoring of all patients
within a defined population for a specified time period.
Patients are followed throughout their stay, and
sometimes after discharge (e.g. post-discharge surveillance
for surgical site infections). This type of
surveillance provides attack rates, infection ratio and
incidence rates (Table 3). It is more effective in
detecting differences in infection rates, to follow
trends, to link infections to risk factors, and for
inter-hospital and inter-unit comparisons (6).
This surveillance is more labour-intensive than a
prevalence survey, more time-consuming, and costly.
Therefore, it is usually undertaken only for selected
high-risk units on an ongoing basis (i.e. in intensive
care units), or for a limited period, focusing on
selected infections and specialties (i.e. 3 months in
surgery) (7,8,9,10).
Recent trends in targeted surveillance include:
_ Site-oriented surveillance: priorities will be to
monitor frequent infections with significant impact
in mortality, morbidity, costs (e.g. extrahospital
days, treatment costs), and which may
be avoidable.
Common priority areas are:
ventilator-associated pneumonia (a high mortality
rate)
surgical site infections (first for extra-hospital
days and cost)
primary (intravascular line) bloodstream infections
(high mortality)
multiple-drug resistant bacteria (e.g. methicillinresistant Staphylococcus aureus, Klebsiella spp.
with extended-spectrum beta-lactamase).
This surveillance is primarily laboratory-based.
The laboratory also provides units with regular
reports on distribution of microorganisms isolated,

and antibiotic susceptibility profiles for the most

frequent pathogens.
_ Unit-oriented surveillance: efforts can focus on
high-risk units such as intensive care units, surgical
units, oncology/haematology, burn units,
neonatalogy, etc.
_ Priority-oriented surveillance: surveillance undertaken
for a specific issue of concern to the
facility (i.e. urinary tract infections in patients with
urinary catheters in long-term care facilities).
While surveillance is focused in high-risk sectors,
some surveillance activity should occur for the
rest of the hospital. This may be most efficiently
performed on a rotating basis (laboratory-based
or repeated prevalence studies).
TABLE 2. Key points in the process of surveillance
for nosocomial infection rates
Active surveillance (prevalence and incidence studies)
Targeted surveillance (site-, unit-, priority-oriented)
Appropriately trained investigators
Standardized methodology