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UDC 616.94:616-006-08-06(571.15)
RISK STRATIFICATION OF INFECTIONS CONNECTED WITH HEALTHCARE DELIVERY IN PATIENTS WITH MALIGNANT NEOPLASMS ON THE BACKGROUND OF CHEMOTHERAPEUTIC AND RADIOTHERAPEUTIC TREATMENT IN ALTAI KRAI
1 Altai State Medical University, Barnaul 2Altai Regional Oncology Center, Barnaul
A.N. Neshatayev 12, N.V. Lukyanenko 1, A.F. Lazarev2, N.Ya. Lukyanenko1
The current article presents the results of retrospective analysis of incidence and principles of risk stratification of infections connected with healthcare delivery in patients with malignant neoplasms exposed to chemotherapeutic treatment outpatiently and inpatiently. Key words: risk groups, ICHD, chemotherapeutic treatment.
Infections connected with healthcare delivery (ICHD) are registered in 5-10% of patients of in-patient hospitals and hold the 10th position among causes of mortality. In Russia, according to the official statistics, there areannually registered about 30 thous. cases of ICHD (0,8 per 1000 patients). According to international and Russian specialists in the sphere of ICHD, there truth number constitutes not less than 2-2,5 million people. Some groups of patients are especially vulnerable: newborns, elderly people, patients with severe course of the basic pathology and numerous concomitant diseases, patients exposed to aggressive and invasive medical manipulations, organ transplantations, etc. In these groups, the indexes of ICHD morbidity are much higher.
Patients with malignant neoplasms are one of the ICHD risk groups, taking into account that chemotherapeutic and radiotherapeutic treatment leads to the decrease of immune response to the influence of various bacterial and viral etiological factors. According to V.M. Gelford (2012), basic clinical forms of ICHD in oncological departments are pseudomonas sepsis, acute respiratory distress, ventilation-associated pneumonia. This group of patients (N.I. Petrova, 2009) is also characterized by long-term complications after release from hospital determined by ICHD of viral, parasitic and fungal etiology. According to her data, mycoses generally caused by Candida fungi damage from 10 to 15% patients exposed to chemother-apeutic and radiotherapeutic treatment.
Intensive development of high-tech invasive methods of diagnosis and treatment in combination with wide spread of microorganisms with multiple drug resistance determines the necessity of continuous improvement of systems of surveillance and control.
Patients with ICHD stay in hospital 2-3 times longer than similar patients without infection symptoms. There stay is averagely 10 days lon-
ger, the treatment cost is 3-4 times higher, the risk of lethal outcome is 5-7 times higher. The economic damage cause by ICHD is considerable: in the Russian Federation it can lead 10-15 milliard rubles per year (for comparison - annual economic damage from ICHD in Europe constitutes about 7 milliard euro, in the USA - 6,5 milliard dollars).
Epidemiological and economic aspects determine more through study of epidemiologi-cal aspects of the course of epidemic processes of infections connected with healthcare delivery in patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment aimed at improvement of systems of surveillance and control.
Research objective
Optimization of the information subsystem of epidemiological surveillance of ICHD in patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment.
Tasks:
1) To perform retrospective analysis of incidence and reveal ICHD risk groups in patients with malignant neoplasms exposed to chemother-apeutic treatment outpatiently and inpatiently.
2) To perform retrospective analysis of incidence and reveal ICHD risk groups in patients with malignant neoplasms exposed to radiothera-peutic treatment outpatiently and inpatiently.
3) To elaborate criteria of assessment and algorithms of determination of ICHD risk groups patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment.
4) Optimization of the information subsystem and managing subsystem in the system of epide-miological ICHD process management in the oncological center.
Materials and methods
Research materials were the data of the official statistical reporting, informational, analytical materials, records and reports andalso results of laboratory microbiology tests selected in 2011-2016 in the Regional State Budgetary Healthcare Institution Altai Regional Oncological Center.
The study included the data of official state statistical reporting and report forms of epy Russian Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing (Rospo-trebnadzor) (№2 "Records on infections and infestations", №5 "Records on preventive vaccinations".
The research is based on the retrospective ep-idemiological analysis of dynamics and structure of morbidity of patients with malignant neoplasms on the background of chemotherapeutic and ra-diotherapeutic treatment and ICHD in the period from 2011 to 2016.
Causes and conditions of ICHD cases in the Altai Regional Oncological Center in the period from 2011 to 2016 were evaluated by the analysis of records of epidemiological examination of focuses (f.
№ 391 u) including the data on 5365 patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment and 45 ICHD patients in the period from 2011 to 2016.
In 2011-2016, in terms of study, there were selected and examined 120 specimens of clinical material and 360 specimens of external environment of the Altai Regional Oncological Center for microbiological and immunological examinations.
The work implied descriptive evaluative epi-demiological, laboratory, statistical methods of research, quantitative method of complex evaluation of ICHD risks and also elements of mathematical modelling.
Results and discussion
The performed retrospective epidemiologi-cal analysis of dynamics of morbidity of patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment in 2011-2013 compared to 2004 revealed the growth of the overall index of malignant neoplasm incidence by 17,2% (Table 1).
Table 1 Dynamics of morbidity of patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment in 2011-2013 compared to 2004
Malignant neoplasms 2004 2011 2012 2013 Index growth (by 2004), %
1 esophagus 5,5 7,6 6,9 7,9 +43,6
2 gaster 39,6 32,3 37,0 34,9 -11,9
3 middle intestine 17,6 25,6 24,7 24,5 +39,2
4 straight intestine 18,4 19,4 23,6 22,4 +21,7
5 liver 8,3 5,6 5,5 5,9 -28,9
6 pancreatic gland 12,3 14,1 13,8 12,7 +3,3
7 larynx 11,7 13,9 11,6 13,8 +17,9
8 trachea, bronchi, lungs 115,0 107,7 102,9 109,1 -5,1
9 bones, articular cartilages 1,7 0,9 1,8 1,5 -11,5
10 connective and soft tissues 2,1 2,7 2,7 2,9 +38,1
11 skin melanoma 4,1 5,0 5,7 4,4 +7,3
12 other skin neoplasms 43,7 55,6 50,3 56,1 +28,4
13 prostatic gland 26,5 47,9 53,8 62,6 +136,2
14 urinary bladder 17,5 19,7 19,2 20,7 +18,3
15 kidneys 14,9 17,7 20,6 20,4 +36,9
16 thyroid gland 2,9 6,4 7,5 7,0 +141,4
17 lymphoid tumors 11,6 10,5 11,5 9,4 -18,9
18 leukemia 11,2 5,6 10,6 7,5 -33,9
19 Total 413,2 456,8 465,0 484,2 +17,2
The overall index of morbidity constituted 484,2 cancer - by 43,6%, kidney cancer - by 36,9%. This
per 100,0 thous. people in Altai Krai. The maxi- period was characterized by the reduction of leu-
mum increase was registered among the follow- kemia incidence by 33,9%, lymphoma - by 18,9%,
ing pathologies: thyroid gland cancer - by 141,4%, bronchopulmonary system - 5,7%. prostatic gland cancer - by 136,2%, esophageal
The age and sex composition of patients with malignant neoplasms on the background
The structure of age and sex composition of patients with malignant neoplasms on the background of chemotherapeutic and radiotherapeutic treatment in 2011-2013 was not exposed to changes.
The specific gravity of male patients constituted from 46,9% to 49,2%, female patients - from 50,0% to 53,8%.
The overall structure of patients was prevailed by elder age groups over 70 - 36,7%, 60-69 - 25,3%, children under 14 - 0,4%.
The most spread oncological pathologies among men were prostatic gland cancer - 12,9%, urinary bladder cancer - 4,3%, kidney cancer - 4,3%, lung cancer - 22,5%, skin neoplasms - 11,6%. Among women there prevailed mammary gland cancer -17,0%, uterine body and uterine cervix cancer -13,2%, thyroid gland cancer - 8,0%.
Prevailing methods of treatment of patients with malignant neoplasms were the methods of combined complex treatment using surgical method - 76,9% (Table 3).
The treatment did not require surgical intervention in 23,1% of patients including only radial method - 18,1%, chemotherapeutic and radial methods - 20,3%.
According to the obtained data and in order to perform retrospective study of hospital-acquired infection incidence and routes and factors of infection, our objective was to determine ICHD risk groups.
According to the data of world and Russian statistics, the most significant ICHD risk groups were patients undergoing combined complex treatment implying surgical method - 76,9% (first group -4289 patients). The given group of patients was exposed to lung ventilation with risk of ventilation associated pneumonia. Due to numerous intravenous injections, these patients had the risk of catheter-associated purulent-septic pathologies. Accord-
of chemotherapeutic and radiotherapeutic treatment in 2011-2013 is presented in Table 2.
ing to literature, ventilation associated pneumonia in this group is registered in 20-50% of patients.
The second risk group was the group of patients with prostatic gland and urinary bladder cancer - 145 patients exposed to the urinary bladder catheterization. According to the data of world and Russian statistics, the risk of purulent-septic complications in this group by the urinary bladder catheterization and suprapubic urinary catheter constitutes from 1,5% to 38,3%.
The third risk group were patients with straight intestine, rectosigmoid junction and anus cancer -185 patients. 25,0% of patients in the given group had statistically significant risk of purulent-septic infections including endogenous genesis.
The fourth risk group consisted of patients with lymphatic and blood-forming tissues cancer - 176 patients, which has the risk of purulent-septic infections - 70,6%. 81,8% exposed to chemotherapeu-tic treatment only.
Conclusion
Thus, there has been determined four ICHD risk groups:
1. Patients exposed to combined complex treatment implying surgical method - 4289 patients.
2. Patients with prostatic gland and urinary bladder cancer exposed to the urinary bladder catheterization - 145 patients.
3. Patients with straight intestine, rectosigmoid junction and anus cancer - 185 patients.
4. Patients with lymphatic and blood-forming tissues cancer - 176 people.
References
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Table 2
Dynamics of age and sex composition of patients with malignant neoplasms on the background of chemotherapeutic and
radiotherapeutic treatment in 2011-2013
Age 2011 2012 2013
male female male female male female
0- 14 years 0,6 0,5 0,5 0,6 0,5 0,4
15-29 years 1,1 1,6 1,1 2,0 0,9 1,7
30-39 years 2,3 4,8 2,0 4,4 2,1 4,7
40-49 years 5,8 9,3 5,7 9,1 4,9 7,9
50-59 years 24,7 23,5 24,3 23,2 23,8 23,4
60-69 years 28,4 21,8 27,8 22,2 34,6 25,3
70 years and older 37,1 38,5 38,6 38,4 33,1 36,7
Total 49,2% 50,8% 46,9% 53,1% 48,8% 51,2%
Methods of treatment of patients with malignant neoplasm in 2013 lauie o
Implying surgical method, % Without surgical treatment %
Localization, nosological form abs. number only surgical treatment combined/ complex treatment total with surgical treatment only radial method chemo-radial method total with radial method only drug method
All malignant tumors 5578 44,9 32,0 76,9 18,1 2,2 20,3 2,8
including children (under 14) 21 19,0 23,8 42,9 0,0 9,5 9,5 47,6
Oral and pharyngeal cavity 57 10,5 29,8 40,4 29,8 29,8 59,6 0,0
Esophagus 18 55,6 22,2 77,8 0,0 22,2 22,2 0,0
Gaster 208 38,9 61,1 100,0 0,0 0,0 0,0 0,0
Straight intestine, rectosigmoid junction, anus 185 53,0 38,4 91,4 3,2 5,4 8,6 0,0
Larynx 72 13,9 45,8 59,7 34,7 5,6 40,3 0,0
Trachea, bronchi, lungs 355 46,5 47,3 93,8 1,7 4,5 6,2 0,0
Skin melanoma 118 69,5 30,5 100,0 0,0 0,0 0,0 0,0
mammary gland 673 21,4 78,6 100,0 0,0 0,0 0,0 0,0
Uterine cervix 239 22,2 13,8 36,0 54,0 10,0 64,0 0,0
Uterine body 309 36,9 56,6 93,5 5,8 0,6 6,5 0,0
Ovaries 80 13,8 86,3 100,0 0,0 0,0 0,0 0,0
Urinary bladder 145 32,4 67,6 100,0 0,0 0,0 0,0 0,0
Lymphatic and blood-forming tissues 176 0,0 4,0 4,0 0,0 14,2 14,2 81,8
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Contacts:
Corresponding author: Lukyanenko Natalya Val-entinovna, Doctor of Medical Sciences, Professor of the Department of epidemiology, microbiology and virology of ASMU, Barnaul. 656056, Barnaul, ul. Papanintsev, 126. Tel.: (385) 256-69-24. E-mail: natvalluk@mail.ru
