Data extraction

Title, abstract and full text review were performed by two individual researchers (JW, FL). Disagreements were resolved by consensus, and, when necessary, discussed with a third researcher (WZ). Data extraction was stratified by two hospital categories (primary care and secondary/tertiary care hospitals). Articles were further categorised as survey reports, observational studies or interventional studies. The following data were extracted from survey reports: title, authors, publication year, province, total number of hospitals, and the number of hospitals applying specific elements of the three NHCPRC areas. The following data were extracted from observational studies:

title, author, publication year, province, study aim, setting, surveillance protocol, sample size, study duration, methodology, and outcome. The following data were extracted from interventional studies: title, authors, publication year, province, study aim, population, intervention, comparison, study design and outcome. Data extraction for interventional studies followed the “PICO” (population – intervention – comparison – outcome) concept (49). Data were verified by cross-checking (JW, FL and JBXT).

Survey reports and observational studies were quality assessed by using the

“Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) checklist (50). Interventional studies were quality assessed by using the “Integrated quality Criteria for the Review of Multiple Study designs” (ICROMS) checklist (54).

Findings were stratified by the three NHCPRC areas, and compared with the ECDC key components (31), and the WHO core components (32).

2.6.4 Statistical analysis

Frequencies of NHCPRC elements mentioned in the survey reports were calculated on hospital level (with the corresponding 95% confidence interval), and stratified by hospital categories (primary- and secondary/tertiary care hospitals). The difference of each identified element between hospital categories was tested by Pearson’s Chi-Square test. Statistical analysis was performed using STATA version 14.0 (Stata Corporation, College Station, Texas, USA). Results of the observational and interventional studies were summarized descriptively.

2.6.5 Roles and contributions of the candidate

JW and WZ established the study protocol. JW and FL preformed literature search and data extraction independently. JW, FL and JBXT did data verification and cross-checking. Data analysis was done by JW and WZ. JW, JBXT and WZ wrote the first draft of the manuscript. All authors reviewed and contributed to subsequent drafts. All authors had full access to the study data.

RESULTS

3.1 Article 1 – Dongguan city HAI PPS study

In the 2015 Dongguan PPS, 37 secondary-care and 14 tertiary-care hospitals assessed a total of 9679 and 11,641 patients, respectively. A large proportion of patients were hospitalised in surgery (8105, 38.0%), followed by internal medicine (5924, 27.8%) and gynaecology and obstetrics (2714, 12.7%).

A total of 616 patients had 681 HAIs. The pooled HAI prevalence in secondary care, tertiary care, and all hospitals together was 2.3% (95%CI: 2.0-2.6%), 3.4%

(95%CI: 3.0-3.7%), and 2.9% (95%CI: 2.6-3.1%), respectively. There was significant variation among the hospitals (Figure 1). Together, LRTI, UTI, SSI, and BSI

accounted for 73.1% of all HAIs. LRTI (35.5%) was the most frequently diagnosed HAI, followed by UTI (17.0%) and SSI (15.1%).

Figure 1 Prevalence of healthcare-associated infections – Dongguan city point prevalence survey 2015

Note: •: Pooled HAI prevalence; −: 95% confidence interval

The pooled HAI point prevalence was highest in adult intensive care (29.4%, 95%CI: 23.4-35.5), followed by surgery (3.5%, 95%CI: 3.1-3.9), internal medicine (3.5%, 95%CI: 3.0-4.0), and neonatology (3.3%, 95%CI: 1.7-4.9).

A total of 533 microorganisms were identified. Gram-negative bacteria were most frequently isolated (363/533, 68.1%), followed by Gram-positive bacteria (103/533, 19.3%). E. coli was the most frequent single pathogen (79/533, 14.8%), followed by P. aeruginosa (74/533, 13.9%), K. pneumonia (59/533, 11.1%), and A. baumannii (58/533, 10.9%). In LRTI patients, P. aeruginosa was the most frequent pathogen (42/210, 20%), followed by A. baumannii (38/210, 18.1%). A total of 175 isolates (32.8%) were multidrug-resistant organisms.

Thirty-five secondary and 12 tertiary hospitals provided information about

antimicrobial use in 19,445 patients. A total of 6759 patients (34.8%) received one or more antimicrobials, 4581 (23.6%) for treatment and 2178 (11.2%) for prophylaxis. A total of 5350 (79.2%) patients received a single antimicrobial, 1327 (19.6%) received

a combination of two antimicrobials, and 82 (1.2%) received a combination of three or more antimicrobials.

3.2 Article 2 – HAI prevalence in China: a systematic review

In total, 115 studies were eligible for quality assessment and data extraction: 42 reports from general hospitals, 19 from children’s hospitals, 27 from maternal and child health hospitals, and 27 from oncology hospitals (Figure 2). Seventeen (14.78%), 84 (73.04%) and 14 (12.17%) reports were of high, moderate and low quality, respectively.

Figure 2 Systematic review profile – HAI prevalence in China: a systematic review

Healthcare-associated infections in different healthcare settings

In total, 53,642 patients had 57,479 HAIs. Pooled and weighted prevalence were 2.98% (95% CI: 2.96-3.01) and 3.12% (95% CI: 2.94-3.29), respectively (Table 1).

Children hospitals had the highest prevalence (4.43%, 95%CI: 3.39-5.47), followed by oncology hospitals (3.96%, 95%CI: 3.12-4.79), general hospitals (3.02%, 95%CI:

2.79-3.26), and maternal and child health hospitals (1.88%, 95%CI: 1.47-2.29).

In general hospitals, the highest weighted prevalence was reported in intensive care (26.07%, 95%CI: 23.03-29.12), followed by surgery (3.26%, 95%CI: 2.96-3.57), and internal medicine (3.06%, 95%CI: 2.67-3.46).

Table 1 Pooled and weighted prevalence of healthcare-associated infections in general hospitals, children hospitals, maternal and child health hospitals, and oncology hospitals

Types of healthcare-associated infections

LRTI was the most frequent type of HAI (24,185 infections, 47.28%), followed by UTI (5773 infections, 11.29%), upper URTI (5194 infections, 10.15%), and SSI (5044 infections, 9.86%). Together, LRTI, UTI, SSI, and BSI accounted for 71.33% of all HAIs. The three most frequent HAIs in general hospitals were LRTI, UTI, and SSI.

The three most frequent HAIs in children’s hospitals were LRTI, URTI, and gastrointestinal infection (GI) (Table 2).

Table 2 Types of healthcare associated infections in Mainland China, 2006 - 2016

Healthcare-associated infections in different provinces of China We observed marked variation in HAI prevalence among the provinces and municipalities of China (Figure 3). The range of weighted prevalence in different provinces and municipalities in China was 1.73% to 5.45%.

The distribution of HAI prevalence and the number of reports varied across

provinces and municipalities in Mainland China for 2006-2016 (Figure 4). No eligible survey had been performed in more than one province. The GDP of the different provinces and municipalities was significantly associated with the weighted HAI prevalence (coefficient=-0.022, p<0.001, 95%CI, -.035 to -.008); this difference represents an HAI reduction of 2.2% per 1000 CNY increase of GDP (Figure 5).

Figure 3 Weighted prevalence of healthcare-associated infections in the different provinces and municipalities of China

Note: Boxes show prevalence of HAIs and their 95% confidence intervals. The reference lines show the 95% CI of the prevalence of healthcare associated infections for the entire population.

Figure 4 Prevalence of healthcare associated infections and number of reports in the different provinces of Mainland China in Mainland China, 2006-2016

Note: GH: General hospitals; CH: Children hospitals; MCH; Maternal and child health hospitals; OH:

Oncology hospitals; HAI: healthcare-associated infection

Note: The size of circles represents the number of publications; the shade of colour represents the prevalence of healthcare-associated infection. Provinces without colour did not contribute to this systematic review either because there were no reports or because publications did not fulfil the inclusion criteria.

Figure 5 Association of healthcare-associated infection prevalence and gross domestic product per capita in Mainland China, 2006-2016

Note: The HAI prevalence decreases by 2.2% with an increase of 1,000 Chinese Yuan (CNY) in GDP per capita.

Distribution of pathogens

The two most common microorganisms isolated in general hospitals were P.

aeruginosa (15%) and E. coli (13%), respectively. K. pneumoniae (19%) and E. coli (10%) were the two most common microorganisms in children’s hospitals,

respectively. K. pneumoniae (24%) and E. coli (18%) were the two most common microorganisms in maternal and child health hospitals, respectively. In oncology hospitals, E. coli (19%) and K. pneumonia (15%) were the two most common microorganisms.