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The Prevalence and Risk Factors of Nosocomial Infections in the Intensive Care Unit of a Hospital in Iran

Background: Nosocomial infections account for about one third of deaths in hospitals.  Objective: In this study, we aim to determine the factors affecting the incidence of nosocomial infections in the Intensive Care Units (ICUs) to provide more information for helping improve the prevention and treatment of these infections in the hospitals located in Iran. Methods: This is a comparative cross-sectional study conducted in 2017 on 86 patients admitted to the general ICU of  Boo Ali Sina Hospital in Qazvin, Iran. We extracted the patients’ demographic and clinical information (e.g. blood and urine culture results) from their medical records. Findings: The prevalence of nosocomial infections were reported 24.3; 38.4% of infections was related to Acinetobacter and 18.6% to Pseudomonas aeruginosa and other microorganisms. The highest antibiotic resistance in patients was to Cefepime (64%) and Ciprofloxacin (60%). Conclusion: The prevalence of nosocomial infections in the general ICU of the study hospital is relatively high with different strains and varied patterns of antibiotic resistance indicating the need for more comprehensive studies and preventive measures in the country.


Introduction
osocomial infection refers to an infection that acquired in a hospital, and manifest during hospitalization or after discharge. Infections that appear 48-72 hours after hospitalization can usually be considered as nosocomial infections, and if an infection occurs shorter than 48 hours after hospitalization, it is likely that the person was at the incubation period at the time of admission to the hospital [1]. Today, investigation and control of nosocomial infections is a global priority which aims to minimize infection rate and reduce mortality, hospitalization period, and health care costs [2,3]. Currently, these infections account for about 5%-15% of admissions in developed countries and about 25% in developing countries. Although only 5% of hospital beds are belonged to the Intensive Care Unit (ICU) and less than 10% of patients are treated in this ward, more than 25-33% of nosocomial infections occur in ICUs [4]. Careful study of the risk factors of nosocomial infections and their common pathogens and antibiotic resistance patterns can provide more comprehensive information and can

Materials and Methods
By referring to the infection control system and, if necessary, the ICU of Boo Ali Sina Hospital in Qazvin, Iran, the medical files of 86 patients admitted to the General ICU in 2017 were checked. Demographic (age and gender) and clinical information including underlying diseases such as diabetes, cirrhosis, kidney failure, length of hospital stay, recent use of antibiotics, having an intravenous or arterial catheter, having a urinary catheter, having a endotracheal tube, ventilation and intubation period, culture and antibiogram response, Erythrocyte Sedimentation Rate (ESR), and C-reactive Protein (CRP) were extracted from these medical files. If necessary, interviews with physicians and nurses were conducted and the results were recorded in a separate checklist. Collected data were analyzed in SPSS V. 22 software.

Results
The prevalence of nosocomial infections was slightly higher in males than females, and most of patients were in the age group of 65-95 years which is consistent with the findings reported the increasing age as one of the important causes of nosocomial infection [18,19]. The average length of hospital stay was 31.5 days. The mean ESR and CRP was 45.09 and 9.57, respectively; however, due to the older age of the subjects, the ESR and CRP values were not strong predictors of nosocomial infection. The prevalence of nosocomial infections was higher in patients with a recent history of antibiotic use (67.4%). The most common nosocomial infection in these patients was respiratory tract infection followed by urinary tract infection and bloodstream infection ( Figure 1). The highest reported positive cultures obtained from the samples were related to Acinetobacter and Pseudomonas aeruginosa, while the lowest reported one was related to Staphylococcus. In the antibiogram test, the highest antibiotic resistance in Acinetobacter, Pseudomonas aeruginosa and Klebsiella was to imipenem and cefepime, while the lowest reported resistance in Acinetobacter was to vancomycin and amikacin; in Pseudomonas to vancomycin; and in Klebsiella to amikacin.

Discussion
The prevalence of nosocomial infections in the general ICU of Boo Ali Sina Hospital in the present study was 24.3% of hospitalized patients. Compared to the rates reported in the studies conducted in recent years in Iran, including Bijari (17.3%), Akbari (54.45%) and Isfahani et al. (25.4%), it was at moderate level [13][14][15]. In the study by Datta et al. [16], the prevalence of nosocomial infections in the ICU was 11.98%, and in another study it was 17.7% [17]. However, in Ozer et al.'s study, it was reported 2.16%, which was much lower than the global average rate [5]. The prevalence rate of nosocomial infections in the present study and other studies in Iran was much higher than in the similar studies conducted in other countries. This discrepancy can be due to higher effectiveness of control systems used for controlling nosocomial infections in other countries, and less self-administered antibiotics and unnecessary prescriptions of antibiotics in their health system. Most of the subjects in our study had high blood pressure, diabetes and chronic obstructive pulmonary disease or a recent history of antibiotic use, which, like other studies, showed the importance of the underlying disease and the arbitrary use of antibiotics and their role in the incidence of nosocomial infection [21]. The mean intubation duration in the patients was 25.2 days, which, as reported by other studies, is one of the most important risk factors for nosocomial respiratory infection [22]. After this infection, urinary tract and bloodstream infections have been reported as the most common nosocomial infections in general ICUs [23,24], which is consistent with the results of our study. The results obtained in this study can be useful for the prevention and optimal treatment of nosocomial infections.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Conflicts of interest
The authors declare no conflict of interest.