HAI in only 20% of the cases but this study did not exclude infections with little impact on mortality, such as UTI (30). Two earlier studies included autopsy reports in the evaluation. Hospital‐acquired bacteraemia/sepsis and pneumonia were perceived as the ‘immediate cause of death’ in 33% of BSI and 59% of pneumonia cases in the first study (22), and in 49% pneumonia cases in the second study (21), i.e. more or equally frequent as in our results for pneumonia, but less frequent for BSI. Although the attributable mortality of CDI has been frequently documented (31‐33), mortality review data are scarce for CDI. Mlangeni et al. found that CDI contributed to death in 24% of 85 cases (34), which is less than the 82% (TP) and 85% (OSI) in our study. It is difficult to conclude what reasons might explain the differences in the perceived contribution of BSI and CDI to death. The specific hospital mix of the studies might contribute to this. Although in our study, the perceived contribution of HAI to death was higher in tertiary care centres than in secondary care centres, this does not need to necessarily be the case (22). The cited studies were all performed in a single country, but countries differ with regards to the availability of ICU beds (35) and consequently the average disease severity, infection prevention and control practices (36), prevalence of AMR (25) and other, including cultural, factors that may affect the contribution of HAI to death and the assessment of this contribution. A strength of our study was the multicentre design, including hospitals from 11 countries, which increased the generalisability of its results and insight into possible differences among countries and hospitals, but also introduced new sources of variance that cannot always be controlled for. The results for CDI are less robust as 45% of all cases originated from one centre and the majority from three. A local team performed the reviews as in routine HAI surveillance. As a consequence, there were known and unknown differences among the review practices despite initial training at the kick‐off meeting and use of a standardised protocol. Strongly opinionated reviewers and other subjective factors may be sources of bias in individual centres, but are expected to average out when a large number of hospitals contribute to regular HAI surveillance. The contribution of specific types of HAI might have been overestimated as the most severe HAI, in cases with more than one HAI present, was selected for the mortality review. Our results may not be representative of all types of hospitals. The majority of the participating hospitals were tertiary care centres, and the inter‐rater reliability appeared to be higher than in secondary care centres. This could be due to the smaller number of reviewed cases in secondary hospitals. Autopsies were not performed in the framework of our study. 6 121 Mortality review reproducibility study
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