Feasibility of National Surveillance of Health-Care-Associated Infections in Home-Care Settings

Lilia P. Manangan, Michele L. Pearson, Jerome I. Tokars, Elaine Miller, William R. Jarvis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA


Emerging Infectious Diseases. 2002;8(3) 

In This Article

Rationale for a National Surveillance System in Home-Care Settings

The epidemiology of health-care-associated infections in home-care settings has not been defined, but infections certainly occur. Outbreaks have been documented in association with use of central venous catheters, parenteral nutrition, bathing practices, educational level of caregivers, and the introduction of new products, such as needleless devices for intravenous infusion[6,7,8].

Needleless devices are used for connecting and accessing intravenous infusion tubing, replacing traditional needles. These devices are used in both home and hospital settings and are perceived to be safe for patients and effective in reducing needlestick injuries.

From 1993 through 1995, the Hospital Infections Program, Centers for Disease Control and Prevention (CDC), now Division of Healthcare Quality Promotion investigated three outbreaks of bloodstream infections (BSI) in patients receiving infusion therapy in their homes. In all three outbreaks, needleless devices were associated with BSIs. The first outbreak occurred in Rhode Island in 1993-1994. The endcaps on these devices were changed every 7 days. BSIs were frequent when needleless devices were used to administer total parenteral nutrition[6]. The second outbreak, in Oakland, California, during 1992-1994, occurred among pediatric hematology-oncology patients. The BSI rate was higher when needleless devices were used by Asian or Hispanic children but not by white or black children. The racial/ethnic differences were thought to stem from socioeconomic factors or possibly from language barriers that prevented full understanding of instructions on infection control[7]. The third outbreak occurred in Houston, Texas, in 1994-1995. The BSI rate was higher when the needleless device endcaps were changed every 7 days and lower when they were changed every 2-3 days. Patients who showered may have had a higher BSI rate than those who took tub baths[8].

These outbreak investigations were, by necessity, retrospective, and some data were difficult to obtain. To better define the epidemiology of BSIs in the home-care setting, in 1995 the Hospital Infections Program conducted a prospective multicenter study of home infusion therapy patients. The objectives were to determine rates of BSI and to identify risk factors, especially the use of needleless devices. The study, which was conducted in Cleveland, Ohio, and Toronto, Canada, involved 827 patients (69,532 catheter-days)[9]. The most common underlying diagnoses among this cohort were infections caused by organisms other than HIV (67%), malignancy (24%), nutritional and digestive disease (17%), heart disease (14%), organ transplantation (11%), and HIV infection (7%).

Overall, 7% of these patients had one or more BSIs during a median of 44 days of catheter use (range 1 to 395 catheter days). A multivariate analysis showed that independent risk factors included recent bone marrow transplant, receipt of total parenteral nutrition, receipt of infusion therapy outside the home (e.g., in a clinic or physician's office), use of a multilumen catheter, and having had a previous BSI[9]. Needleless devices were not associated with BSI.

Two prevalence surveys of infections among patients of Missouri home health agencies were conducted by CDC in collaboration with the Missouri Alliance for Home Care (MAHC) and the Missouri Department of Health, the first during summer (June 1-30, 1999) and the second during winter (February 15-March 15, 2000). Of 5,100 home-care patients enrolled in the summer survey, 16% (793) were reported to have infections; 8% (63) of these infections were reported as being acquired at home, 16% (127) as hospital acquired, 35% (278) as unknown source, and 41% (325) as community acquired. The infection sites reported were urinary tract (214 [27%]), respiratory tract (190 [24%]), skin or soft tissue (190 [24%]), surgical site (95 [12%]), or bloodstream (17 [2%]); 18% (143/793) of infections occurred at other body sites (e.g., gastrointestinal, bone)[10]. Of 2,890 patients enrolled in the winter survey, 16% (466) had infections. The prevalence of respiratory tract infections was higher during the winter survey than during the summer survey. These results suggest that an estimated 1.2 million patients receiving home care in the United States have infections annually, supporting a need for surveillance of infections among home-care patients[11].

A nationwide hospital-acquired infection surveillance system and standardized infection definitions have been in existence since the 1970s[12,13,14]. However, no national surveillance or standardized definitions exist for monitoring infections in the home-care setting. The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) published draft definitions for surveillance of infections in home-care patients[15]. However, these definitions have not yet been validated.

National surveillance of health-care-associated infections in home care may potentially decrease infection rates, as has been documented in hospitals by the National Nosocomial Infections Surveillance system (NNIS). This voluntary, hospital-based reporting system was established to monitor hospital-acquired infections and to guide the prevention efforts of infection control practitioners. During 1990-1999, risk-adjusted infection rates in intensive-care units decreased by approximately 40% among hospitals participating in NNIS[16].

A national system for surveillance of health-care-associated infections in home care would not only provide useful data on incidence and types of infections but also simplify identification of risk factors for infection and development of national benchmarks for comparing infection rates. Risk-adjusted rates may assist individual home-care agencies to identify areas for performance and quality improvement and to evaluate the impact of prevention interventions on infection rates.


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