Journal of Hospital Infection xxx (2016) 1e9

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

Point-prevalence survey of healthcare-associated

infections in Beijing, China: a survey and analysis in
2014
J.Y. Liu a, Y.H. Wu b, *, M. Cai a, C.L. Zhou c
a
Division of Hospital Infection Control and Prevention, Beijing Hospital, Beijing, China
b
Division of Hospital Infection Control and Prevention, Peking University People’s Hospital, Beijing, China
c
Division of Hospital Infection Control and Prevention, Beijing Friendship Hospital, Capital Medical University, Beijing, China

A R T I C L E I N F O S U M M A R Y

Article history: Background: Point-prevalence studies can identify priorities for infection control.
Received 1 October 2015 Aim: In May 2014, the Beijing Nosocomial Infection Control and Quality Improvement
Accepted 16 March 2016 Centre organized a point-prevalence survey in 124 acute care hospitals in Beijing province.
Available online xxx By analysing the survey results and factors affecting the point prevalence of healthcare-
associated infections (HCAIs) in secondary and tertiary acute care hospitals in a certain
Keywords: area of China, this study provides evidence and reference to monitor HCAIs in a wide
Healthcare-associated variety of hospitals.
infections Methods: An epidemiological cross-sectional survey conducted by infection control
Monitoring practitioners was used to assess the point-prevalence rate of HCAIs by reviewing cases and
Point-prevalence survey performing bedside surveys.
Findings: In total, 124 hospitals and 61,990 patients were surveyed, and 1389 (2.2%) HCAIs
were diagnosed in 1294 (2.1%) patients. Respiratory tract infections were the most com-
mon HCAIs (54.4%, 51.7e56.9%), followed by urinary tract infections (15.0%, 13.2e16.9%),
gastrointestinal tract infections (7.7%, 6.3e9.1%), surgical site infections (6.3%, 5.1e7.6%)
and bloodstream infections (5.5%, 4.3e6.8%). In this survey, the top three pathogens were
Pseudomonas aeruginosa, Acinetobacter baumannii and Escherichia coli. Rates of central
vein catheter insertion, urethral catheterization and mechanical ventilation were 9.9%,
12.4% and 3.8%, respectively. Overall, 23.7% of the patients underwent surgery on or
before the date of the survey. HCAIs were present in 14.5% of intensive care unit patients,
2.3% of medical patients and 2% of surgical patients. Diarrhoea was found in 0.8% of the
assessed cases; however, tests for Clostridium difficile are not routinely available in
China.
Conclusion: In areas with limited personnel and resources, regular investigation of the
point prevalence of HCAIs can be performed in lieu of comprehensive monitoring to
elucidate risk factors and disease burdens of HCAIs.
ª 2016 Published by Elsevier Ltd on behalf of The Healthcare Infection Society.

* Corresponding author. Address: No. 11 Xizhimen South Street,

Xicheng District, Beijing 100044, China. Tel.: þ86 10 88325504.
E-mail address: 593857975@qq.com (Y.H. Wu).

http://dx.doi.org/10.1016/j.jhin.2016.03.019
0195-6701/ª 2016 Published by Elsevier Ltd on behalf of The Healthcare Infection Society.

Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
2 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9
Introduction
Healthcare-associated infections (HCAIs) are a major public
health issue due to their association with significant morbidity
and mortality, prolongation of hospital stays and increased
costs of care. For example, in the USA, there are 2e3 million
HCAIs each year, resulting in approximately 88,000 deaths and
an economic loss of approximately $4.5 billion.1 The preva-
lence of HCAIs is closely associated with the regional economic
level, the level of medical services, race, diet, lifestyle and
behaviours.2e9 In addition, HCAI surveillance standards and
control measures affect their prevalence. Surveys conducted
worldwide2e9 have demonstrated an inverse relationship be-
tween HCAIs and national prosperity, although the diagnostic
criteria vary between countries. The surveillance standards in
most countries incorporate the definitions and diagnostic
criteria for healthcare-associated surveillance established by
the US Centers for Disease Control and Prevention (CDC).10
The gold standard for HCAI surveillance is a large, pro-
spective, continuous, hospital-wide, incidence survey. How-
ever, few hospitals opt for this approach because incidence
surveys require a significant amount of manpower, material
resources and a greater number of trained personnel.11,12
Point-prevalence surveys are simple, fast and relatively inex-
pensive compared with incidence surveys. Performing targeted
and sustained active surveillance helps explore the root causes
of HCAIs in order to improve management and prevention.12e16
In addition, point-prevalence surveys of HCAIs are an important
method for inter-regional and international monitoring and
comparison. In China, the Healthcare-associated Infections
Surveillance Network of the Ministry of Health has conducted
six nationwide point-prevalence surveys.17e19 The point prev-
alence of HCAIs was 5.22% in 2001 (107,466 inpatients were
surveyed, 5614 HCAIs were found), 4.81% in 2003 (89,539 in-
patients were surveyed, 4309 HCAIs were found), 4.77% in 2005
(115,143 inpatients were surveyed, 5492 HCAIs were found),
3.60% in 2010 (407,208 inpatients were surveyed, 14,674 HCAIs
were found), and 3.22% in 2012 (786,028 inpatients were sur-
veyed, 25,273 HCAIs were found); the prevalence in 2014 has
not yet been published. This indicates a downward trend,
which may indirectly reflect the effect of surveillance and
national infection control efforts that have been in place for
more than 10 years. Point-prevalence studies of HCAIs can also
provide a basis for health administrators to understand na-
tional HCAI trends and design appropriate policies and regu-
lations. To enhance current understanding of these trends and
evaluate infection control efforts in Beijing, the Beijing Noso-
comial Infection Control and Quality Improvement Centre
(BNICC) initiated a point-prevalence survey of HCAIs in 2014.
Methods
Study design and hospital selection
Hospitals in China are classified into the following four
categories: hospitals within the public health system; hospitals
affiliated with medical education and research institutes;
military hospitals; and ‘other’, which includes private hospi-
tals. The first two types are the most common in China as well
as in Beijing province. In 1993, the Chinese Ministry of Health
subdivided hospitals according to size into primary hospitals
Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
(1e100 beds), secondary or second class hospitals (101e500
beds), and tertiary or third class hospitals (>500 beds). Primary
and secondary hospitals mainly provide basic services, whereas
tertiary hospitals are referral centres for specialist care with
medical teaching and research. On 21st May 2014, the BNICC
conducted point-prevalence surveys in tertiary and secondary
hospitals (rehabilitation hospitals, gerontological centres,
community and township hospitals were not included) that
applied for the Management System for Healthcare-Associated
Infections Monitoring programme.
The survey included all patients at the hospital at 0:00 h on
21st May 2014 and patients who were discharged on the same
day. Patients who were admitted to the hospital after 0:00 h on
21st May 2014 were not included.
Data collection and definitions
The definition of HCAIs used in this study is widely used in
China, and was established by the Ministry of Health in 2001
[issued by the Hospital Infection Diagnostic Criteria (Trial)].20
Medical records were reviewed for HCAIs according to the
abovementioned definition, modified from the case definitions
of the US CDC (1988). The main differences involve the cate-
gorization of respiratory tract infection (RTI) and the definition
of infection in patients aged 12 months. In China, the case
definition of RTI includes the CDC categories of ‘pneumonia’,
‘lower respiratory tract infection other than pneumonia’ and
‘upper respiratory tract infection’. In addition, patients aged
12 months are listed independently in the CDC definitions
from 1988, whereas in China, they are included in the overall
population numbers, except for cardiovascular and central
nervous system infections.
Survey
An epidemiological, cross-sectional design was used. The
medical institutions participating in the point-prevalence sur-
vey on the survey date (21st May 2014) used the Point-
prevalence Survey Form of Healthcare-associated Infections
issued by the BNICC to survey the hospitalized patients. Ac-
cording to Staff Responsibilities of Data Collection in the Survey
Program of Prevalence of Healthcare-Associated Infections,
2014 by the BNICC, staff in all positions were responsible for
the organization, implementation and quality control of the
entire survey process.
There were three trained physicians in the team of vali-
dators. All team members had been trained for over 8 h at the
BNICC. All face-to-face and case surveys were combined, and
the use of antibiotics and test results were verified. The case
survey focused on temperature records, diagnosis at admis-
sion, imaging and laboratory test results. In compliance with
the Hospital Management Assessment Guide, 2008 by the Min-
istry of Health and the Point-prevalence Survey Questionnaire
of Healthcare-Associated Infections issued by the BNICC,
infection control practitioners (ICPs) completed a supple-
mental questionnaire using medical notes for patients under-
going surgery at the time of the survey or patients who had
been discharged. In each ward, completed survey question-
naires were checked individually to ensure completion of
missing items and to avoid errors. The collected data were
reported to the HCAI control department, where the staff
checked, completed and corrected the data.
 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9
The survey content included HCAI status, use of invasive
devices and surgical procedure details (venous catheter, uri-
nary catheter, ventilator, surgical and peri-operative
medication).
Quality control
To improve the authenticity of information, the results
needed to reflect the prevalence of HCAIs in Beijing objec-
tively. Therefore, the measures described below were taken to
control possible biases and to ensure effective quality control
for the survey.
Selection bias control
A census survey of all patients hospitalized on the survey
date was obtained to avoid sampling errors and to control for
selection bias.
Information bias control
Staff from medical institutions taking part in the survey
underwent training to understand the purpose and procedures
correctly, including diagnostic criteria and survey methods.
This resulted in greater awareness and better standardization
during questionnaire completion. The questionnaires collected
from each ward were checked for missed entries, errors and
incorrect information. To ensure that every diagnosed case was
recorded accurately, proofreading was undertaken and HCAI
cases detected in this survey were rechecked to avoid errors.
3
ICPs collected survey questionnaires on each ward and
checked if questionnaires were fully completed. Data were
entered on to the HCAI control management system, and ICPs
verified the information once again to avoid bias from typo-
graphical errors.
Data analysis
After data collection, the data analysis staff of the BNICC
exported the data to a spreadsheet and established a data-
base. Statistical analyses were performed using Statistical
Package for the Social Sciences Version 21.0 (IBM Corp.,
Armonk, NY, USA). The prevalence of HCAIs and the prevalence
of HCAI patients were calculated, together with 95% confi-
dence intervals (CIs). Categorical differences were calculated
using Chi-squared test. When P<0.1 was observed under uni-
variate analysis of risk factors, logistic regression was entered
to check for possible interaction or confounding variable ef-
fects. Correlation among variables was examined using Pear-
son’s correlation model. All P-values calculated were two-
tailed, and P<0.05 was considered to indicate statistical
significance.
Results
Actual survey rate
All secondary and tertiary hospitals that met the inclusion
criteria participated in this survey (N¼124 medical in-
stitutions). The participation rate was 100%. Of the 124

18

16 ICU

14
Patients with HCAIs (%)

12

10
Medicine Surgery
8

6 Other
Paediatrics
Gynaecology Ophthalmology &
4 & obstetrics otorhinolaryngology

Figure 1. Prevalence of healthcare-associated infections (HCAIs) in different departments. Note: (1) Within Medicine, the groups are
listed, in the order of lowest to highest percentage of HCAIs, as follows: Internal secretion group, Angiocarpy group, Respiratory group,
Digestion group, Traditional Chinese medicine group, Neurology group, Infectious disease group, Other (medicine), Oncology group,
Nephropathy group and Haemopathy group. (2) Within Surgery, the groups are listed as follows: Plastic surgery, Orthopaedics depart-
ment, Other (surgery department), General surgery department, Urinary surgery, Burns department, Cardiac surgery, Chest surgery and
Neurosurgery. (3) Within Gynaecology and Obstetrics, the groups are listed as follows: Obstetrics-neonatal group, Gynaecology and
Obstetrics-adult group. Within Paediatrics, the groups are listed as follows: Paediatrics-non-infant group, Paediatrics department
intensive care unit (ICU) and Paediatrics department-infant group. (4) Within Ophthalmology and Otorhinolaryngology, the groups are
listed as follows: Other (ENT), ENT department, Ophthalmology and Stomatology department. (5) Within ICU, the groups are listed as
follows: Medicine ICU, Surgery ICU and Comprehensive ICU. Within Other, the groups are listed as follows: Psychiatry and Other. Grey bars
indicate the percentage of departments (e.g. Medicine, Surgery, etc.); black bars indicate the percentage of groups.

Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
4 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9
surveyed medical institutions, 25 were excluded because of a
very low questionnaire completion rate (<5%), a higher number
of completed questionnaires compared with the number of
patients in hospital, and failure to reveal the total number of
patients present in the hospital. Of the remaining 99 medical
institutions, 95 had a questionnaire completion rate of >95%
which is in line with the requirements for prevalence surveys in
China and Beijing. The total survey completion rate was 97.8%
(50,554/51,674), which meets the compliance requirement
(95%) of the Beijing Municipal Health Bureau.
Prevalence and infection sites
61,908), and the ICU rate was 49.6% (479/965). The overall
urinary tract catheterization rate was 12.4% (7684/61,908),
and the ICU rate was 67.3% (649/965). In total, 23.7% of the
patients underwent surgery prior to the survey date, and 0.8%
of patients had experienced more than three episodes of
diarrhoea in the 24 h preceding the survey date.
Table III shows several risk factors for HCAIs by univariate
and multi-variate analyses. In the overall logistic regression
model, the following risk factors were independently associ-
ated with HCAI: male sex, 65 years of age, 28 days of age,
ICU admission, tertiary hospital admission, non-traditional
Chinese medicine hospital admission, invasive device use

In total, 61,990 patients and 62,087 cases were surveyed,

and 61,908 and 62,003 met the inclusion criteria, respectively. Table I
Patients were considered to be ineligible if data were missing Infection site distribution in the Beijing 2014 point-prevalence
from the survey questionnaire. In the 61,908 cases, 1389 (2.2%, study of healthcare-associated infections
2.1e2.4%) HCAIs were reported from 1294 (2.1%, 2.0e2.2%)
Type of infection No. of Proportion of all healthcare-
patients. There was a significant difference in the prevalence
infections associated infections (N¼1389)
of HCAIs between secondary and tertiary hospitals (P<0.05).
(%) (95% CI)
Across the range of hospital departments, the prevalence of
HCAIs in intensive care units (ICUs) was 14.5%, which was Respiratory system 755 54.4 (51.7e56.9)
greater than the prevalence of HCAIs in internal medicine Lower respiratory 649 46.7 (44.1e49.4)
(2.3%) and surgical (2.0%) departments. The prevalence of tract
HCAIs was lowest in the ophthalmology and otorhinolaryn- Upper respiratory 95 6.8 (5.5e8.2)
gology departments (0.3%) (Figure 1). tract
RTI was the most prevalent HCAI (54.4%, 51.7e56.9%), fol- Pleural cavity 11 0.8 (0.3e1.3)
lowed by urinary tract infection (15.0%, 13.2e16.9%), gastro- Urinary tract 209 15.0 (13.2e16.9)
intestinal infection (7.7%, 6.3e9.1%), surgical site infection Gastrointestinal 107 7.7 (6.3e9.1)
(6.3%, 5.1e7.6%) and bloodstream infection (5.5%, 4.3e6.8%) system
(Table I). In patients with lower respiratory infection, chest Gastrointestinal 55 4.0 (2.9e5.0)
radiography indicated that only 47.9% (311 patients) had tract
radiological evidence of pneumonia. Intra-abdominal 52 3.7 (2.8e4.7)
Surgical site 88 6.3 (5.1e7.6)
Micro-organisms Superficial 56 4.0 (3.0e5.1)
incisional
Most HCAIs were diagnosed by physical symptoms and radi- Deep incisional 20 1.4 (0.8e2.1)
ography, and 85% (1187/1389) of infections were confirmed Organ/space 12 0.9 (0.4e1.4)
microbiologically; from these, 745 taxa of pathogenic bacteria Bloodstream 77 5.5 (4.3e6.8)
were isolated. The top five pathogens isolated were Pseudo- Primary 63 4.5 (3.4e5.6)
monas aeruginosa, Acinetobacter baumannii, Escherichia coli, bloodstream
Klebsiella pneumoniae and Staphylococcus aureus (Table II). infection
P. aeruginosa was most frequently detected from infections Catheter-related 14 1.0 (0.5e1.5)
involving the lower respiratory tract (73.1%, 68/93), urinary bloodstream
tract (8.6%, 8/93) and abdomen (3.2%, 3/93). A. baumannii was infection
most frequently detected from infections involving the lower Central nervous 52 3.7 (2.8e4.7)
respiratory tract (86.2%, 75/87), abdomen (3.4%, 3/87) and system
urinary tract (3.4%, 3/87). E. coli was most frequently detected Skin and soft tissue 39 2.8 (1.9e3.7)
from infections involving the urinary tract (47.2%, 42/89), Skin or soft tissue 38 2.7 (1.9e3.6)
surgical wounds (11.2%, 10/89) and lower respiratory tract infection
(11.2%, 10/89). Burn infection 1 0.1 (0.0e0.2)
System infection 30 2.2 (1.4e2.9)
Baseline and factor distribution Eye, ear, nose, 12 0.9 (0.4e1.4)
throat and mouth
Among the 61,908 patients surveyed, there were more men Reproductive tract 8 0.6 (0.2e1.0)
than women, and the mean age was 53.90 (standard deviation Cardiovascular 7 0.5 (0.1e0.6)
22.12) years. Individuals aged 45e64 years represented the system
largest set of patients. Of the surveyed hospitals, 13.1% were Endocarditis 4 0.3 (0.0e0.6)
traditional Chinese medicine hospitals. In this survey, the Myocarditis or 3 0.2 (0.0e0.5)
overall invasive ventilation rate was 3.8% (2374/61,908), and pericarditis
the ICU invasive ventilation rate was 44.2% (427/965). The Bone and joint 5 0.4 (0.1e0.7)
overall central venous catheter insertion rate was 9.9% (6149/ CI, confidence interval.

Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9 5

Table II
Healthcare-associated infection (HCAI) pathogen composition in the Beijing 2014 point-prevalence study of HCAIs
Pathogen All HCAI patients Lower Urinary Upper Primary bloodstream Surgical site (superficial
(N¼1389) respiratory tract respiratory infection (N¼63) incisional) (N¼56)
N (%) tract (N¼209) tract N (%) N (%)
(N¼649) N (%) (N¼95)
N (%) N (%)
Pathogen Rank 745 (53.6) 380 (67.5) 121 (57.9) 18 (27.7) 56 (88.9) 32 (0.6)
detected
Pseudomonas 1 103 (13.8) 76 (20.0) 8 (6.6) 1 (5.6) 2 (3.6) 3 (9.4)
aeruginosa
Acinetobacter 2 96 (12.9) 81 (21.3) 3 (2.5) 2 (11.1) 2 (3.6) 1 (3.1)
baumannii
Escherichia coli 3 94 (12.6) 13 (3.4) 39 (32.2) 1 (5.6) 11 (19.6) 10 (31.3)
Klebsiella 4 71 (9.5) 47 (12.4) 5 (4.1) 2 (11.1) 3 (5.4) 1 (3.1)
pneumoniae
Staphylococcus 5 66 (8.9) 30 (7.9) 1 (0.8) 2 (11.1) 9 (16.1) 7 (21.9)
aureus
Candida albicans 6 39 (5.2) 13 (3.4) 14 (11.6) 0 (0.0) 2 (3.6) 0 (0.0)
Enterococcus 7 38 (5.1) 2 (0.5) 18 (14.9) 0 (0.0) 4 (7.1) 0 (0.0)
Enterobacter 8 26 (3.5) 11 (2.9) 4 (3.3) 0 (0.0) 3 (5.4) 3 (9.4)
cloacae
Other fungi 9 22 (3.0) 9 (2.4) 4 (3.3) 0 (0.0) 1 (1.8) 0 (0.0)
Staphycoccus 10 14 (1.9) 2 (0.5) 1 (0.8) 0 (0.0) 4 (7.1) 2 (6.3)
epidermidis
Others 11 176 (23.6) 96 (25.3) 24 (19.8) 10 (55.6) 15 (26.8) 5 (15.6)
No pathogenic 440 (31.7) 183 (32.5) 55 (26.3) 49 (75.4) 6 (9.5) 12 (0.2)
bacteria
detected
No samples 204 (14.7) 86 (15.3) 33 (15.8) 28 (43.1) 1 (1.6) 12 (0.2)
submitted

(central venous catheter insertion, urinary tract catheteriza-
tion and invasive ventilation), surgery and presence of diar-
rhoea (Figure 2).
Discussion
Analysis of HCAIs
The prevalence survey results from 2014 were similar to
those from 2012. The prevalence of HCAIs in Beijing from 2006
to 2014 shows a downward trend, and the overall prevalence in
2014 was lower than the national prevalence rate in 2012
(3.2%).19 Compared with the prevalences of HCAIs in other
Chinese provinces and cities, the prevalence in Beijing was
close to the lower end of the range. Over the past 10 years, the
prevalence of HCAIs in China and Beijing has been declining, for
which there are several possible reasons. Although infection
prevention and control in Chinese hospitals began only
recently, rapid development has been witnessed over the past
10 years. This has been driven by national legislation; hygiene
standards and technical specifications issued by the Health
Administrative Department of State Council. Laws and regula-
tions, as well as industry standards, have defined higher re-
quirements in order to prevent nosocomial infections.
Standards and legislation include: Technical Standard for
Disinfection (Health Administrative Department of People’s
Republic of China No.27), issued in 2002; Law of the People’s
Republic of China on the Prevention and Treatment of
Infectious Disease (People’s Republic of China, Presidential
Decree No.48), issued in 2004; Nosocomial Infection Manage-
ment Method (Ministry of Health of People’s Republic of China,
Decree No.48), issued in 2006; Technique Standard for Isolation
in Hospital (WS/T 311-2009), issued in 2009; and Management
Standard for Hospital Sterilization and Supply Center (WS310-
2009) and Technical Standard for Disinfection of Medical
Institution (WS 36-2012), issued in 2012. In addition, the Beijing
Health Administration Department has also issued many doc-
uments to regulate the management of nosocomial infections
and environmental health sanitation in Beijing City. These
include Rules for the Implementation of Nosocomial Infection
Prevention and Control Plan (2013e2015), and Environmental
Health Technology and Management Standard of Beijing Medi-
cal Institution. These laws and regulations, as well as technical
specifications, form the legal basis for infection control in
Chinese hospitals.
The highest prevalence of HCAIs was in ICUs, which is
consistent with other research performed in China and other
countries.2,3,19 This is likely to be related to factors that pre-
dispose to HCAIs, including the critical condition of patients,
immune dysfunction, and invasive procedures such as ventila-
tion and catheterization.
The lower respiratory tract was one of the main HCAI sites in
this survey; these infections were substantially more common
than surgical site infections. This is similar to the results of the
prevalence study of HCAIs throughout China (2012).19 However,
USA and European studies have generally reported that

Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
6 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9

Table III
Intrinsic and extrinsic risk factors for healthcare-associated infections (HCAIs): univariate and multi-variate analysis (logistic regression)
Risk factors Patients with HCAIs, N (%) Univariate OR (95% CI) Multi-variate ORa (95% CI)
Sex
Male (N¼32,386) 791 (2.4) 1 1
Female (N¼29,522) 503 (1.7) 0.7 (0.6e0.8) 0.8 (0.7e0.9)
P¼0.00 P¼0.00
Age, N (%)
18 years (N¼4009) 66 (1.6) 1 1
19e24 years (N¼1775) 22 (1.2) 0.8 (0.5e1.2) 1.1 (0.7e1.9)
P¼0.25 P¼0.61
25e44 years (N¼2082) 136 (1.1) 0.7 (0.5e0.9) 1.0 (0.7e1.4)
P¼0.11 P¼0.87
45e64 years (N¼21,734) 370 (1.7) 1.0 (0.8e1.4) 1.2 (0.9e1.6)
P¼0.79 P¼0.20
65e84 years (N¼18,905) 553 (2.9) 1.8 (1.4e2.3) 1.9 (1.4e2.6)
P¼0.00 P¼0.00
85 years (N¼2826) 132 (4.7) 2.9 (2.2e3.9) 2.2 (1.6e3.2)
P¼0.00 P¼0.00
28 days (N¼577) 15 (2.6) 1.6 (0.9e2.8) 3.3 (1.7e6.3)
P¼0.11 P¼0.01
Department classification, N (%)
Medicine (N¼28,312) 641 (2.3) 1 1
Surgery (N¼18,459) 375 (2.0) 0.9 (0.8e1.0) 0.5 (0.5e0.6)
P¼0.09 P¼0.00
Gynaecology and obstetrics (N¼5220) 18 (0.3) 0.1 (0.1e0.2) 0.2 (0.1e0.3)
P¼0.00 P¼0.00
Paediatrics (N¼1302) 31 (2.4) 1.1 (0.7e1.5) 0.8 (0.5e1.4)
P¼0.78 P¼0.46
Ophthalmology and otorhinolaryngology (N¼2300) 6 (0.3) 0.1 (0.1e0.3) 0.1 (0.1e0.3)
P¼0.00 P¼0.00
ICUs (N¼965) 140 (14.5) 7.3 (6.0e8.9) 1.5 (1.2e1.9)
P¼0.00 P¼0.00
Otherb (N¼5350) 83 (1.6) 0.7 (0.5e0.9) 0.7 (0.6e0.9)
P¼0.00 P¼0.02
Hospital classification, N (%)
Second level (N¼21,069) 319 (1.5) 1 1
Tertiary (N¼40,839) 975 (2.4) 1.6 (1.4e1.8) 1.4 (1.2e1.6)
P¼0.00 P¼0.00
Traditional Chinese medicine hospital, N (%)
Yes (N¼8127) 95 (1.1) 1 1
No (N¼53,781) 1199 (2.2) 2.0 (1.6e2.5) 1.7 (1.4e2.1)
P¼0.00 P¼0.00
Central venous catheter in place on survey date, N (%)
No (N¼55,759) 819 (1.5) 1 1
Yes (N¼6149) 475 (7.7) 5.6 (5.0e6.3) 2.2 (1.9e2.5)
P¼0.00 P¼0.00
Urinary tract catheterization on survey date, N (%)
No (N¼54,224) 714 (1.3) 1 1
Yes (N¼7684) 580 (7.5) 6.1 (5.4e6.8) 3.6 (3.1e4.2)
P¼0.00 P¼0.00
Patient receiving invasive ventilation on survey date, N (%)
No (N¼59,534) 1035 (1.7) 1 1
Yes (N¼2374) 259 (10.9) 6.9 (6.0e8.0) 1.3 (1.1e1.6)
P¼0.00 P¼0.00
Surgery prior to survey date, N (%)
No (N¼47,253) 885 (1.9) 1
Yes (N¼14,655) 409 (2.8) 1.5 (1.3e1.7) 1.2 (1.1e1.5)
P¼0.00 P¼0.01

Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9
Table III (continued )
Risk factors
Diarrhoeac, N (%)
No (N¼61,417)
Yes (N¼491)
OR, odds ratio; CI, confidence interval; ICUs, intensive care units.
a
Adjusted for all variables in the model.
b
Refers to all departments not included in the listed categories.
c
The definition of diarrhoea in the study was three or more loose stools in one day.
pneumonia and surgical site infections account for similar
proportions of all HCAIs.2,3 One reason for the difference in the
present study may be that postdischarge surveillance for sur-
gical site infections was not undertaken. The 2013 Europe
Nosocomial Infection and Infectious Disease and Epidemic
Disease Report found that 50% of surgical site infections
occurred after discharge.21 Secondly, differences in diagnostic
criteria for respiratory tract infections in this study may also
account for lower respiratory infection being more common in
this study. In China, a wider range of symptoms are categorized
as ‘lower respiratory infection’,20 including pneumonia, tra-
chitis and bronchitis, while lower respiratory infection in the
USA is categorized separately from pneumonia.10 Thirdly, in
China, microbiological diagnosis is often based on sputum
culture, with little attempt to distinguish between colonization
and infection.
The most common pathogens in this survey were
P. aeruginosa and A. baumanii, as in a previous Chinese HCAI
prevalence survey19; this differs from the pathogen distribution
of HCAIs in American and European countries.2,3 One possible
explanation is that there is lower awareness among Chinese
clinicians of the need to submit microbial samples for exami-
nation, especially before antimicrobials are administered.
Guoli et al. conducted a study on specimen culture in 841 cases
of ICU patients in 2014, and showed that only 33.5% of 269
patients on broad-spectrum antibiotics had samples collected
for microbiological examination.22 There are few specific data
on HCAIs, but reports on community-acquired pneumonia show
12
10
Central venous catheter
Patients with HCAIs (%)
8 7.7%
2 1.5%
0
No Yes
Figure 2. Prevalence of healthcare-associated infections (HCAIs) in relation to invasive devices on survey date.
Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019
7
Patients with HCAIs, N (%) Univariate OR (95% CI) Multi-variate ORa (95% CI)
1231 (2.0) 1 1
63 (12.8) 7.2 (5.5e9.4) 4.5 (3.4e6.1)
P¼0.00 P¼0.00
that detection rates in sputum cultures in community-acquired
pneumonia are very low.23e25 The detection rate of antibiotic-
resistant Gram-negative bacteria such as P. aeruginosa and
A. baumanii in respiratory samples is increased following
antibiotic exposure.26 In addition, sputum is the most
commonly submitted sample in Chinese hospitals, whereas
samples from the lower airway (e.g. bronchoalveolar lavage)
are more commonly collected in other countries.27
P. aeruginosa and A. baumannii are common pathogens in the
hospital environment.28,29 Indeed, A. baumannii isolated from
patients and the ICU environment have been shown to be
indistinguishable.30
Patients with diarrhoea accounted for 0.8% of all re-
spondents in this survey. Clostridium difficile is rarely detec-
ted in China, which is inconsistent with research worldwide.
The latest US prevalence of HCAI survey reveals that gastro-
intestinal tract infections are important nosocomial infections,
and C. difficile is the most common cause, accounting for 12.1%
of all diarrhoeal pathogens.2,3 In Beijing, only a few microbi-
ology laboratories can perform C. difficile testing, and it is not
included in routine testing. Moreover, many clinicians are not
aware of C. difficile. As such, the true picture of C. difficile
infection in China is not known.
Risk factors for healthcare-associated infections
Advanced age (>65 years), ICU stay, invasive procedures
(central venous catheter insertion, urethral catheterization
Invasive ventilation
10.9%
Urinary tract catheter
7.5%
1.7%
1.3%
No Yes No Yes
8 J.Y. Liu et al. / Journal of Hospital Infection xxx (2016) 1e9
and mechanical ventilation) and use of antibiotics were among
other main risk factors, which is consistent with a US point-
prevalence survey conducted in 2011.2 However, while the US
study showed that infections associated with invasive devices
(central-venous-catheter-related bloodstream infections,
catheter-associated urinary tract infections and ventilator-
associated pneumonia) accounted for 25% of all HCAIs, these
infections were not diagnosed accurately (and their occurrence
was probably underestimated) in this study. Based on the ex-
periences of this study, systems for the prevention and control
of device-associated infections have been strengthened.
Strengths and limitations
This survey was a census which significantly minimized
sampling error, meaning that the results are representative. In
addition, this is the first report of the prevalence of HCAIs in
China that includes the incidence of diarrhoea caused by
C. difficile, although the reported prevalence may not be
accurate.
The survey focused on a relatively small number of risk
factors for HCAIs. In addition, few data on antibiotic usage
were available. It is suggested that future Chinese surveys
should collect more data on antibiotic usage.
Conclusion
In countries like China with limited personnel and resources,
regular investigation of the point prevalence of HCAIs can be
performed in lieu of comprehensive monitoring to elucidate
risk factors and disease burdens of HCAIs. However, limited use
of microbiology laboratories in the diagnosis of HCAIs is an
important constraint to obtaining data that can be compared
with other countries.
Acknowledgements
The authors wish to thank all of the tertiary and secondary
hospitals that participated in this survey.
Conflict of interest statement
None declared.
Funding sources
None.
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Please cite this article in press as: Liu JY, et al., Point-prevalence survey of healthcare-associated infections in Beijing, China: a survey and
analysis in 2014, Journal of Hospital Infection (2016), http://dx.doi.org/10.1016/j.jhin.2016.03.019