The Risk of Death among Patients with Healthcare-associated Infections and Cardiovascular Diseases Admitted to the Intensive Care Unit in Romania

Cardiovascular disease and healthcare-associated infections (HAIs) are two distinct but significant health concerns that impact individuals and healthcare systems worldwide. In 2016, the European Centre for Disease Prevention and Control (ECDC) estimated that the burden of healthcare-associated pneumonia, surgical site infection, Clostridioides difficile infection, neonatal sepsis, urinary tract infection, and primary bloodstream infection, the six main types of HAI, was higher than the burden of 31 other infectious diseases combined.^1,2 Moreover, the majority of these infections are caused by multidrug-resistant organisms. It is well known that factors such as old water systems, inadequate, irrational, and prolonged usage of antibiotics, poor adherence to regulations regarding hand hygiene, disinfection, and sterilization processes are correlated with a higher incidence of HAIs, therefore surveillance systems were created to reduce mortality and morbidity associated with these type of infections.^3,4,5,6 There is a continuous fight against HAIs, as the burden of these infections is high and they represent a global public health issue.^1,7,8,9

An important problem that needs to be highlighted is that low- and lower-middle-income countries, with limited medical resources, have a higher incidence of HAIs, resulting in a higher percentage of patients with disabilities and consequently increasing costs for their healthcare system. In these countries, information regarding HAIs and the burden of death caused by this type of infection are not as clear and complete as in high-income countries. Aside from the variations caused by objective factors, this issue makes it impossible to apply well-known characteristics regarding HAIs to other countries, regions, and hospitals from data that was already provided.^10,11,12

Patients admitted to the intensive care unit (ICU) often undergo invasive procedures such as the insertion of urinary catheters, intravascular catheters, mechanical ventilation. Together with other risk factors, these procedures increase their susceptibility to developing HAIs,^1,2 which leads to prolonged hospitalization with a negative impact on both the patients and the healthcare system, more frequent readmissions, as well as an increase in morbidity and mortality.^3,4

In order to reduce the incidence of HAIs and prevent the spread of antibiotic-resistant organisms, several organizations have recognized the importance of developing action plans to be implemented in hospitals all around the world.1 As antimicrobial resistance patterns vary greatly between countries and even hospitals, it is mandatory for each hospitals to take into consideration the local antimicrobial resistance patterns while establishing and implementing their action plans.¹

Nowadays, antibiotic resistance is a multilateral problem, therefore it should be addressed from different perspectives. Developing new generations of antibiotics and conducting molecular epidemiological investigations represent necessary parts of a puzzle besides improving hygiene systems, safe disposal of medical waste, and following rigorous procedures for hand hygiene and sterilization processes, in order to reduce the rates of HAIs.^{13,14,15,16,17,18}

Both cardiovascular disease and HAIs are multifaceted issues that require a comprehensive approach involving individuals, healthcare providers, public health organizations, and policymakers. Addressing these challenges can significantly improve patient outcomes and the overall effectiveness of healthcare systems.

The aim of this study is to evaluate the risk of death among patients with HAIs admitted to the ICU, hospitalized for cardiovascular diseases, compared to those with similar pathologies, without infections.

The objective of this study was to highlight the risk of death among patients with cardiovascular emergencies admitted to ICUs in Romania, who acquire a HAI. HAIs are associated with a longer period of hospitalization and higher costs for the already affected Romanian healthcare system. The results of this study can help us see the importance of prevention and careful monitoring with measurable progress regarding the reduction of the rates of HAIs.

We identified a high rate of HAIs among patients admitted to ICUs caused by multiresistant germs (60.3%) compared to bacteria sensitive to antibiotic treatment (39.7%). The average age of patients in the case group was 62.61 years, similar to data reported in the study conducted by Voidazan et al.,²⁰ and 67.1% of these patients were men. Among the respective pathogens, Gram-negative bacteria had the highest frequency: Klebsiella pneumoniae (33.6%) and Acinetobacter baumnannii (20.6%). Similar results were obtained in a study conducted at a tertiary hospital in Jining, China, regarding the analysis of multiresistant bacteria.²¹ In other studies, multidrug-resistant Acinetobacter baumannii was present in a significantly higher percentage of cases (43.48%) compared to our percentage of 20.6%, but Klebsiella pneumoniae was present in a lower percentage of cases (7.27%).²² The number of deaths that occurred in patients with multiresistant infections was considerably higher compared to patients with infections sensitive to antibiotic therapy (75.9% vs. 22.4%). A higher probability of death was also observed in association with certain Gram-negative pathogens, such as Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa, an outcome also observed in studies on mortality associated with infections with multi-resistant Gram-negative germs and MRSA.^23,24 The probability of death was significantly higher in the case group, showing that infections are a major factor in patient prognosis. The alarming situation observed not only in this study but also in numerous other studies should put us in a heightened state of awareness, as we are at a critical moment in healthcare.^25,26,27,28

The risk of death among patients admitted to the ICU is increased for patients presenting severe acute cardiovascular complications such as acute myocardial infarction, or severe chronic cardiovascular diseases like valvular disease. For patients acquiring a HAI during their stay in the ICU, the risk of death is significantly higher than for those with similar cardiovascular pathologies, with a longer hospitalization and a consequent rise in costs for the healthcare system.

Intensive care units are the main frontline in the fight against infections because the vulnerability of patients is at its highest. Invasive monitoring devices, ventilators, and immunosuppression are some of the causes favoring the emergence of infections. In many cases, the biggest problem is represented by the limited treatment options. This is due to the ineffectiveness of antibiotic therapy caused by errors in prescribing the right antibiotic, dosage errors, low compliance in terms of doctor–patient collaboration, failure to observe the necessary time interval for treatment, and many others.

Regarding the length of hospitalization in the ICU, a longer hospitalization was associated with a significantly higher probability of death, illustrating the unfavorable prognosis related to the time required for treatment, similar to findings in other studies.²² The longer the patient remains in the ICU, the higher the risk of acquiring an infection that can often become fatal. Acquiring a nosocomial infection also increases the length of hospitalization, which will lead to increased expenditure. Cost-effectiveness also benefits when the infection is treated correctly, and even more so when the infection is prevented. The occurrence of organ failure was also a decisive factor for the occurrence of death in the exploratory analysis performed on the 29 patients, the strongest statistical association being observed in the case of cardiovascular failure and respiratory failure. Similar results were observed in a study in which more days spent in the ICU were associated with higher long-term mortality in both ventilated and non-ventilated patients,²⁹ but another study resulted in a lack of association with risk of death in terms of ICU days.³⁰

Studies have shown that inadequate antimicrobial treatment is an important risk factor for death in critical patients, suggesting that the aim should be to reduce the occurrence of this important problem by using efficient prophylactic methods.³¹ Important studies have revealed the association of dysbiosis with the development of various pathologies including cardiovascular diseases, as the microbiota affects the host’s immunity.³²

Because of the steadily increasing incidence of nosocomial infections related to cardiac surgery in the last decades, prophylaxis should mainly target the prevention and appropriate treatment of bacteremia associated with invasive hospital-based procedures performed in high-risk patients. Further studies are needed in this area.

The limitations of our study include incomplete data from medical charts, a disadvantage created by retrospective collection of data, as well as the lack of information listed in our informatics system. The prospective extension of the study would enable us to collect all data needed, and information storage in our electronic system would facilitate data collection. Another limitation of our study is that we did not follow if the antibiotic treatment was changed after receiving the results of the culture and antibiogram, in order to establish the adequate use of antibiotics.

In conclusion, patients with cardiovascular diseases admitted to the ICU who acquired HAIs were more likely to die, in the majority of cases HAIs being caused by multi-resistant germs. Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa were the organisms more likely to be involved in infections among patients who have died. It was shown that a higher probability of death is associated with a longer hospitalization, and one of the main causes for prolonged stay in the ICU was a nosocomial infection. Balancing the urgency of addressing cardiovascular emergencies with the need to prevent HAIs is a complex challenge. Healthcare providers must follow established protocols, maintain high standards of infection control, and collaborate across specialties to optimize patient outcomes in these critical situations.