Healthcare-associated infections seem to be much higher in Sweden than in most of Europe and the country needs to step up the combat against this problem, according to infectious disease experts.

On average, one in ten hospital patients in Sweden had at least one healthcare-associated infection (HAI) when checked by Swedish teams in a study conducted simultaneously across Europe in 2022 and 2023.

The Swedish results of the point prevalence study led by the European Centre for Disease Prevention and Control, ECDC, involved 54 Swedish acute care hospitals and 13,588 patients.

They were published by the Swedish Public Health Authority (Folkhälsomyndigheten) just before Christmas. The aggregated European results for 2022-2023 are expected to be published by May 2024.

The five-year gap

As Sweden participated in the survey for the first time, its results can only be compared with the European results from the 2016-2017 survey, which included the EU28 plus Serbia.

At that time, the European average of hospitalised patients with at least one HAI was 5.9%, which is just over a half of the level in Sweden (10.3%).

Even though the five-year gap between surveys and some minor differences in protocol may not allow direct comparison, as experts from the ECDC and Sweden told Euractiv, the results are indicative of the issue with HAIs in Sweden.

“In any case, even without comparing the figures, we know that the level of HAIs in Sweden is high according to the survey,” Stephan Stenmark, an investigator at the Swedish Public Health Authority and an infectious diseases doctor, told Euractiv.

“The indications are that the 21 regions really need to step up and intensify the prevention efforts,” he stressed.

The battle with HAIs

The most common HAIs identified were pneumonia or lower respiratory tract infections, post-operative infections, and urinary tract infections. Risk factors included age and the use of, for example, central venous catheters, intubation, or surgery.

Based on the survey, the agency estimates that more than 75,000 patients in acute care hospitals in Sweden suffer an HAI each year and that the yearly cost for the patients’ extra care days in hospital is at least 140 million euros.

The battle to prevent HAIs must now be fought on three fronts, according to the agency.

First, hospital staff need to be more vigilant about healthcare hygiene and medical routines. Second, antibiotic stewardship – the rational use and evaluation of antibiotic treatment – must be improved. And third, organisational conditions also need to be improved to increase the level of patient safety.

According to the new findings, more than a third of the patients had received at least one antibiotic, and more than a third of those were broad-spectrum.

The situation appears to be particularly difficult in intensive care units (ICUs), where the incidence of at least one HAI was almost 20%, and the use of antibiotics was 60%, according to the point prevalence survey.

However, according to Björn Bark, president of the Swedish Society of Intensive Care Medicine and operations manager at the Lund ICU, this usually reflects the fact that patients with HAIs often need to be transferred to an ICU because of severe complications.

“In general, a common reason for patients needing intensive care is precisely serious infections, including healthcare-associated infections.  Therefore, a higher concentration of those in intensive care units is probably to be expected, and it doesn’t mean that patients acquired the infection in the intensive care unit,” he said.

“Tackling HAIs better”, he continued, “would mean reducing patient suffering and relieving pressure on hospitals, including ICUs”.

On the hospital front

Several Swedish hospitals in the survey also failed to meet the recommended minimum number of infection control and prevention staff or antibiotic stewardship staff, Stenmark said, adding that these needs must be fulfilled.

In addition, bed occupancy was high at the time of the survey. A third of hospitals had bed occupancy rates above 100%, excluding ICUs. More than half of these units were struggling with overcrowding.

“High bed occupancy can affect prevention, and if you fail to prevent them, the HAIs will increase,” Stenmark said.

Malin Ackefors, president of the Swedish Society of Infectious Diseases, told Euractiv that “for us, it’s clear that the lack of healthcare staff and a high staff turnover, combined with the shortage of care beds, affect the situation when it comes to healthcare-associated infections in Sweden”.

“When there is a shortage of healthcare staff, or when rooms are overcrowded, it becomes more difficult for staff to adhere to follow the hygiene rules and routines,” she explained.

“The Swedish results signal that we need to work much harder to follow routines and to set up action plans focusing on HAIs at both national and local levels during the coming year”, she says.

Malin Ackefors pointed out it will be very interesting to see how Sweden compares with the rest of Europe in May.

So far, 28 EU/EEA countries have submitted data to ECDC from 1480 hospitals and 337,688 patients, and 3 Western Balkan countries have submitted data for 82 hospitals and 16,109 patients.

The ECDC survey is conducted every five years.  However, this spring, the WHO will launch its new global action plan on infection prevention and control (IPC), under which it will request countries to report the level of HAIs in hospitals and their capacity to cope with them every two years.

[By Monica Kleja, edited by Vasiliki Angouridi/Zoran Radosavljevic]

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