Discussion

This survey represents the first implementation of the GAIHN HAI point prevalence survey protocol. Conducted at the KHCC, a tertiary oncology hospital, the survey generated baseline estimates of HAIs and antimicrobial use while providing practical insight into the feasibility of conducting structured HAI surveillance in a high-complexity facility in a middle-income country.

As a specialized oncology facility caring for immunocompromised patients, KHCC represents a distinct clinical environment in which infection risk and antimicrobial exposure patterns may differ from those of general acute care hospitals. At the same time, KHCC maintains an exceptional IPC infrastructure that is uncommon in the regional context with a dedicated full-time IPC team, an active antimicrobial stewardship program, a multidisciplinary IPC committee, and sustained engagement with international surveillance networks. This combination of elevated baseline infection risk and robust preventive capacity makes KHCC a particularly informative setting for piloting the GAIHN HAI PPS methodology, as findings reflect both the clinical complexity of oncology care and the operational feasibility of implementing standardized surveillance within a well-resourced regional institution.

The overall HAI point prevalence in the wards surveyed of 4.8% (95% CI: 2.2%–10.1%) falls within the lower range of estimates reported in regional and international PPS studies. A multi-country point-prevalence survey conducted in seven Middle Eastern countries reported a prevalence of 11.2% in acute care settings. ^{Reference Alothman, Al Thaqafi and Al Ansary20} Pooled HAI prevalence in mixed patient populations has been reported at 7.6% in high-income countries, while hospitalwide prevalence in low- and middle-income countries ranged from 5.7% to 19.1%, with a pooled prevalence of 10.1%, and was notably higher in high- than in low-quality studies (15.5% vs 8.5%). ⁸ Differences across studies likely reflect variation in patient populations, case mix, surveillance methodology, diagnostic capacity, and healthcare infrastructure.

Antimicrobial use was common, with 63.7% receiving at least one systemic agent and more than half of treated patients receiving combination therapy. WHO recommends that at least 60% of a country’s or facility’s total antimicrobial consumption come from the Access category, corresponding to a target Access-to-Watch ratio of at least 1.5; higher ratios indicate prescribing patterns weighted toward narrower-spectrum, lower-resistance-risk agents. ²¹ The predominance of Watch-category antibiotics and the low Access-to-Watch ratio in our study was 0.23—which is below the WHO-recommended benchmark ratio of 1.5—indicate that prescribing at KHCC was heavily weighted toward broader-spectrum, higher-resistance-risk agents rather than first-line Access agents, and that’s highlight opportunities for antimicrobial stewardship review. These findings demonstrate the value of PPS methodology in generating standardized prescribing metrics aligned with WHO AWaRe benchmarks, providing actional data to inform local stewardship discussions.

From an implementation perspective, this pilot demonstrated that a structured PPS could be conducted within an established IPC framework using electronic medical records and trained IPC/nursing staff. The GAIHN HAI PPS data collection system was well-received and easy to use. The algorithmic guide to data entry led to parsimonious data collection, reducing staff burden. The system was able to identify HAIs in a standardized objective fashion. Staff participation in the survey improved IPC capacity and use of standardized case definitions and structured data abstraction, contributing to internal capacity building. At the same time, the activity required dedicated staff time and coordination across wards, underscoring the importance of aligning surveillance activities with available human resources. Sequential ward-level data collection extended the survey period and required careful tracking to avoid duplication. As in many PPS implementations, the completeness and accuracy of findings were dependent on the quality of clinical documentation. The insights gained from this pilot directly informed refinements to the global HAI PPS protocol and demonstrate its potential utility in diverse healthcare settings. As such, this experience represents an important step toward establishing sustainable, scalable HAI surveillance systems that support infection prevention and control across the full spectrum of resource availability.

In total, the survey was conducted by five members of the KHCC IPC team over approximately one month, with data extraction independently validated by a second reviewer for each patient chart, involving both KHCC-based and CDC/CRDF Global-based team members. This dual-review process supported data quality and consistency in the application of standardized case definitions. Findings from this pilot were used to directly inform infection prevention and control efforts at KHCC.

Several limitations merit consideration. The survey was conducted in a single tertiary oncology facility limiting generalizability. The sample size was modest, reducing precision for less common infection types. Data collection occurred during a defined period and may not reflect seasonal variation. In addition, detailed HAI assessment was limited to patients receiving systemic antimicrobial therapy or with recent surgery, consistent with the operational screening approach used to reduce staff burden. While pragmatic, this strategy may have resulted in under-ascertainment of untreated infections. Additionally, this pilot did not incorporate postdischarge case finding for SSI, as recommended by the GAIHN HAI PPS protocol. Because a substantial proportion of SSIs, particularly superficial incisional infections, are diagnosed after hospital discharge, their absence from this survey’s ascertainment method likely resulted in underestimation of true SSI prevalence and may partly explain the relatively low burden of this infection type observed here. Finally, reliance on electronic medical record documentation may have influenced case classification where clinical details were incomplete.