ArticlesBurden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis
Introduction
Health-care-associated infections are deemed the most frequent adverse event threatening patients' safety worldwide.1, 2, 3 However, reliable estimates of the global burden are hampered by a paucity of data adequately describing endemic infections at national and regional levels, particularly in resource-limited settings.4 In countries where less than 5% of the gross national product is spent on health care, and workforce density is less than five per 1000 population,5 other emerging health problems and diseases take priority.6 The epidemiological gap leading to the absence of reliable estimates of the global burden is mainly because surveillance of health-care-associated infection expends time and resources and needs expertise in study design, data collection, analysis, and interpretation. Very few countries of low and middle income have national surveillance systems for health-care-associated infections. Data from the International Nosocomial Infection Control Consortium,7 and findings of two systematic reviews on hospital-acquired neonatal infections8 and ventilator-associated pneumonia,9 suggested not only that risks of health-care-associated infection are significantly higher in developing countries but also that the effect on patients and health-care systems is severe and greatly underestimated.
The aim of this systematic review and meta-analysis is to assess the burden of endemic health-care-associated infection in developing countries by collation of available data from published studies on epidemiology. We also aim to investigate constraints linked to surveillance of health-care-associated infection in resource-limited settings and identify perspectives for improvement.
Section snippets
Search strategy and selection criteria
We undertook a literature search and review process according to a protocol designed before data collection. We aimed to identify studies on the epidemiology of health-care-associated infection in developing countries, with a particular focus on the most frequent bacterial infections—urinary-tract infection, surgical-site infection, bloodstream infection, hospital-acquired pneumonia, and ventilator-associated pneumonia. We searched Medline for reports published between January, 1995, and
Results
Our search yielded 7719 abstracts, of which 271 published articles were eligible for inclusion. For 48 studies (18%), the full paper could not be accessed (n=19) or was not screened owing to language restrictions (n=29); three articles were further excluded at second reading because findings were duplicated in other publications (figure 1). 220 articles in English, French, German, and Spanish were included in the final analysis. Two additional systematic reviews were retrieved on neonatal
Discussion
In this systematic review and meta-analysis, we have shown that endemic health-care-associated infection represents a major burden and safety issue for patients in the developing world, with an even greater epidemiological relevance than in developed countries. Compared with average prevalence of health-care-associated infection in Europe (reported as 7·1 per 100 patients by the European Centre for Disease Prevention and Control)172 and estimated incidence in the USA (4·5 per 100 patients in
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