ECDC point prevalence surveys and the number of cases contributed by each country, not accounting for the type of HAI) (25). The higher AMR rate in this population of deceased patients with HAI seems to be associated with death as AMR was perceived as definitely or possibly contributing to death in 70‐72% of these patients. In a German mortality review of 215 patients deceased with a multidrug‐resistant hospital‐acquired infection the infection was considered the cause of death in 36% (26), which is slightly higher than the 28‐30% of our cases where contribution of (not necessarily multidrug) resistance was considered definite. Overall, antimicrobial treatment was considered inadequate in 15% of the cases, in the lower ranges of what has been reported elsewhere (27). Inadequate antimicrobial treatment was associated with a higher contribution of AMR to death. Inadequate treatment is a known and confirmed risk factor for mortality of patients with infections in observational studies (28). Our study showed that healthcare‐associated BSI, pneumonia and CDI were perceived to have definitely or possibly contributed to the death of a patient in the majority of cases. The presence of a pathophysiological mechanism that explained the contribution of the HAI to the death of the patient, and the severity of the HAI, were items that were most strongly associated with the perceived contribution (Supplementary Table S5). For CDI, ‘complicated course’ fitted the results better than severity. In some cases, a clear pathophysiological mechanism can relate the HAI to the cause of death. However, in other cases, the perceived presence of a pathophysiological mechanism can be considered as a proxy of the assessment of the contribution and may therefore not be useful to guide a reviewer’s assessment. Some but not all reviewers described the ‘checklist’ as helpful in gathering the relevant information. Altogether, the variables shown to be significantly associated with death may be used as tools for facilitating and standardising the assessment. When evaluating only pneumonia, BSI and related infections in the study by Kaoutar et al. (10), the proportions of cases with definite and possible contribution of pneumonia were 29 and 40%, respectively, which is comparable to our study. For BSI, the contributions were 36 and 38% respectively, lower than in our study (51 and 43%). Differences in the patient population (more ICU patients in our study) and improvement in the prognosis of BSI since Kaoutar’s study in 2000 and 2001 may account for this difference. Decoster et al. found that death was attributable to an HAI in 33% of patients with McCabe score 1 or 2 and a bacteraemia, systemic, respiratory or catheter infection (29). In the same patient category, the contribution was classified as definite in 47% (TP) and 42% (OSI). Branger et al. found that the death was ‘most likely’ associated with the 120 Chapter 6
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