Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

Background Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries. Methods We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence including overall health-care-associated infection and major infection sites, and their microbiological cause were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis. Findings Of 271 selected articles, 220 were induded in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15.5 per 100 patients [95% CI 12.6-18.9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47.9 per 1000 patient-days (95% CI 36.7-59.1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5.6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance. Interpretation The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices.