Device and surgical procedure-related infections in Canadian acute care hospitals

Table 1: Characteristics of acute care hospitals participating in device and surgical procedure-related healthcare-associated infection surveillance, 2024

Characteristic of hospitals	CLABSI-adult mixed ICU	CLABSI-adult CVICU	CLABSI-PICU	CLABSI-NICU	CSF shunt SSI	Paediatric cardiac SSI	Hip and knee SSI	Total unique hospitals
Total number of participating hospitals	40	9	12	20	11	6	30	67
RegionFootnote a
Western	17	4	5	8	4	1	16	29
Central	19	4	6	9	5	4	7	28
Eastern	4	1	1	3	2	1	7	10
Northern	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Hospital type
AdultFootnote b	22	4	N/A	N/A	2	N/A	12	26
Adult-NICU	6	2	N/A	3	N/A	N/A	2	6
MixedFootnote c	12	3	1	5	2	N/A	16	22
PaediatricFootnote d	N/A	N/A	8	8	7	4	N/A	99
Paediatric-OB	N/A	N/A	3	4	N/A	2	N/A	4
Hospital size
Small (1–200 beds)	4	1	7	9	5	4	6	19
Medium (201–499 beds)	20	3	4	7	3	2	14	29
Large (500 or more beds)	16	5	1	4	3	N/A	10	19

Table 2: Number of device and surgical procedure-related healthcare-associated infection, by type and year, 2020–2024

Infection type	2020	2021	2022	2023	2024	Total 2020–2024
ICU-CLABSI	273	416	356	435	366	1,846
CSF shunt SSI	22	20	28	14	19	103
Paediatric cardiac SSI	37	35	25	52	50	199
Hip and knee SSI	85	126	166	165	170	712
Total infections	417	597	575	666	605	2,860

Table 3: Distribution and rank of the most frequently reported gram-negative, gram-positive and fungal pathogens, 2020–2024^{footnote a}

Pathogen category	Rank	Pathogen	ICU-CLABSI N=3,111		Hip and knee N=805		CSF shunt N=111		Paediatric cardiac N=156
			n	%	n	%	n	%	n	%
Gram-positive	1	Coagulase-negative staphylococcifootnote b	678	21.8	139	17.3	33	29.7	22	14.1
	2	Enterococcus spp.	666	21.4	50	6.2	2	1.8	1	0.6
	3	Staphylococcus aureusfootnote c	305	9.8	315	39.1	32	28.8	92	59.0
	4	Streptococcus spp.	65	2.1	70	8.7	4	3.6	11	7.1
	Other gram-positivefootnote d		139	4.5	59	7.3	15	13.5	8	5.1
	Total gram-positive		1,853	59.6	633	78.6	86	77.5	134	85.9
Gram-negative	1	Klebsiella spp.	173	5.6	14	1.7	8	7.2	4	2.6
	2	Escherichia coli	132	4.2	25	3.1	3	2.7	0	0.0
	3	Enterobacter spp.	129	4.1	34	4.2	4	3.6	6	3.9
	4	Pseudomonas spp.	95	3.1	28	3.5	3	2.7	0	0.0
	5	Serratia spp.	58	1.9	14	1.7	2	1.8	2	1.3
	Other gram-negativefootnote e		182	5.9	52	6.5	3	2.7	3	1.9
	Total gram-negative		769	24.7	167	20.7	23	20.7	15	9.6
Fungi	1	Candida albicans	259	8.3	4	0.5	0	0.0	0	0.0
	2	Other Candida spp.footnote f	215	6.9	1	0.1	2	0.9	7	4.5
	Other fungifootnote g		15	0.5	0	0.0	0	0.0	0	0.0
	Total fungal		489	15.7	5	0.6	2	1.8	7	0.0
Total			3,111	100	805	100	111	100	156	100

Table 4: Patient characteristics and outcomes of intensive care unit central line-associated bloodstream infections, 2020–2024

Characteristic	Adult mixed ICU (N=1,846)	Adult CVICU (N=182)	PICU (N=289)	NICU (N=484)
Age, median (IQR)	59 years (46 years–68 years)	65 years (52 years–72 years)	6 months (3 months–24 months)	21 days (9 days–52 days)
Sex, female/total (%)	582 (31.5%)	55 (30.2%)	123 (42.6%)	184 (38.0%)
Birthweight (g), median (IQR)	N/A	N/A	N/A	947 (IQR: 669–2,130)
Gestational age (weeks), median (IQR)	N/A	N/A	N/A	27.0 (IQR: 24.1–34.0)
Days from ICU admission to infection, median (IQR)	11 (IQR: 6–21)	10 (IQR: 6–18)	28 (IQR: 12–66)	15 (IQR: 8–38)
Deaths, thirty-day all cause (%)	606 (32.9%)	58 (31.9%)	28 (9.7%)	51 (10.6%)

Trends over time: From 2020 to 2024, adult mixed ICUs had the highest overall CLABSI rates (1.89 infections per 1,000 line days), followed by PICUs (1.88 infections per 1,000 line days), NICUs (1.66 infections per 1,000 line days) and adult CVICUs (0.97 infections per 1,000 line days) (Appendix, Table A1). From 2020 to 2024 in adult ICU settings, CLABSIs rates fluctuated for adult mixed ICUs (1.74–1.82 infections per 1,000 line days, p=0.45) and adult CVICUs (0.80–1.19 infections per 1,000 line days, p=0.57) (Figure 1). Both adult mixed ICU CLABSI and adult CVICU rates peaked in 2021 with a rate of 2.14 and 1.27 infections per 1,000 line days, respectively. Catheter utilization from 2020 to 2024 ranged from 70.1%–74.2% in adult mixed ICUs and 66.4%–87.0% in adult CVICUs (data available on request).

Figure 1 - Text description

Figure 1

Year	Adult mixed ICU	Adult CVICU	PICU	NICU
2020	1.74	0.92	1.95	1.5
2021	2.14	1.19	1.45	1.79
2022	1.86	0.80	1.81	1.46
2023	1.95	0.92	2.00	1.84
2024	1.76	1.04	2.15	1.69

In paediatric ICUs, NICU and PICU CLABSIs fluctuated from 2020 to 2024, with NICU CLABSI rates ranging between 1.46 to 1.84 infections per 1,000 line days (Figure 1). In addition, PICU CLABSIs were lowest in 2021 (1.45 infections per 1,000 lines days), followed by increases in each year from 2022 to 2024 (Figure 1). Of the 65.7% (n=318/484) of NICU CLABSI cases from participating sites with birthweight-specific data, rates of CLABSIs in the NICU per 1,000 line days were highest among the infants with lower birthweight (1,000 g or less) from 2020 to 2024, peaking in 2022 for 750 g or less (4.75 infections per 1,000 lines days), with rates generally decreasing as birthweight increased (Figure 2). Catheter utilization in PICUs ranged from 58.9%–66.6% from 2020 to 2024 while NICU had the lowest catheter utilization overall during the same time period, ranging from 28.1%–29.5% (data available on request).

Figure 2 - Text description

Figure 2

Year	750g or less	751g–1,000g	1,001g–1,500g	1,501g–2,500g	Greater than 2,500g
2020	2.19	3.16	3.32	2.08	1.07
2021	3.48	4.61	1.89	1.33	1.93
2022	4.75	2.91	2.13	1.52	1.17
2023	3.46	2.35	1.98	1.62	1.60
2024	3.81	2.70	2.87	1.79	1.63

All-cause mortality at thirty days was highest in the adult mixed ICU and adult CVICU at 32.8% and 31.9%, respectively, while thirty-day all-cause mortality ranged from 9.7%–10.6% in paediatric and neonatal ICU settings. The most commonly identified pathogens among ICU-CLABSIs overall were CoNS (21.8%) and Enterococcus spp. (21.4%), which aligned with the most commonly identified pathogens among adult mixed ICUs and adult CVICUs. Among PICU and NICU CLABSIs, the most commonly identified pathogens were CoNS and S. aureus (data available on request).

Hip and knee surgical site infections

Infection characteristics: Between 2020 and 2024, a total of 712 complex hip and knee SSIs were reported, with hip arthroplasties accounting for most of the cases (n=440, 61.8%). Among these SSIs, 51.8% (n=369) were organ/space infections, while 48.2% (n=343) were deep incisional infections (Table 5). The median patient age was 69 years (IQR: 60–77 years) for hip SSIs and 67 years (IQR: 61–75 years) for knee SSIs. The median time from procedure to infection onset was 23 days (IQR: 16–36 days) for hip SSIs and 24 days (IQR: 18–37 days) for knee SSIs. The median length of stay was two days for hip (IQR: 1–7.5 days) and one day for knee (IQR: 1–3 days) SSIs.

Trends over time: Between 2020 and 2023, knee SSI rates increased non-significantly by 32.4% (0.34–0.45 infections per 100 surgeries, p=0.31), before decreasing to a rate of 0.35 infections per 100 surgeries in 2024. Hip SSI rates fluctuated between 0.47 and 0.74 infections per 100 surgeries (p=0.31) (Figure 3; Appendix, Table A2). Most patients (74.0%, n=527/712) with a hip or knee SSI were readmitted and 65.3% (n=465/712) required revision surgery. Within 30 days after the first positive culture, 15 all-cause deaths (3.5%, n=15/440) were reported among patients with a complex SSI following a hip arthroplasty, while no deaths were reported among knee arthroplasty SSI patients. The most common pathogens identified among hip and knee SSIs were S. aureus (39.1%) and CoNS (17.3%) (Table 3), with no significant differences by infection type.

Figure 3 - Text description

Figure 3

Year	Hip	Knee
2020	0.47	0.34
2021	0.63	0.26
2022	0.74	0.42
2023	0.62	0.45
2024	0.74	0.35

Cerebrospinal fluid shunt surgical site infections

Infection characteristics: Between 2020 and 2024, a total of 103 CSF shunt SSIs were reported. The median patient age was 49 years (IQR: 34–66 years) for adult patients and two years (IQR: 0.3–11 years) for paediatric patients. The median time from procedure to infection onset was 19 days (IQR: 8–40 days). More than half of CSF shunt SSIs (54.4%, n=56/103) were identified from new surgeries, while 45.6% (n=47/103) were from revision surgeries. Women represented 46.6% (n=48/103) of cases.

Trends over time: The overall rate of CSF shunt SSIs was 2.64 infections per 100 surgeries (range: 1.99–3.19 infections per 100 surgeries; Appendix, Table A3). Paediatric and adult/mixed hospitals infection rates were not significantly different at 3.07 and 2.18 infections per 100 surgeries, respectively (p=0.15). From 2020 to 2024, no significant trend was observed in CSF shunt SSI rates for adult and mixed hospitals (range: 1.76–2.53 infections per 100 surgeries, p=0.88), paediatric hospitals (range: 1.47–4.18 infections per 100 surgeries, p=0.11) and all hospital types combined (p=0.50) (Figure 4). The most common pathogens identified from CSF shunt SSIs were CoNS (29.7%) and S. aureus (28.8%) (Table 3). Outcome data were not collected for CSF shunt SSI surveillance.

Figure 4 - Text description

Figure 4

Year	Adult and mixed hospitals	Paediatric hospitals	All hospitals
2020	2.17	3.20	2.73
2021	1.76	2.80	2.32
2022	2.14	4.18	3.19
2023	2.48	1.47	1.99
2024	2.53	3.44	3.07

Paediatric cardiac surgical site infections

Infection characteristics: Between 2020 and 2024, a total of 199 paediatric cardiac SSIs were reported (Table 6). Most infections were superficial incisional SSIs (68.8%), followed by organ/space infections (21.1%) and deep incisional infections (10.1%). The median patient age was 69 days (IQR: 8–365 days) and the median time from surgery to infection onset was 14 days (IQR: 8–22 days) (data available on request). The proportion of deep incisional infections increased from 5.4% in 2020 to 15.4% in 2023, followed by a decrease to 8.0% in 2024; however, the increase observed between 2020 and 2023 was not significant (p=0.09, Table 6).

Trends over time: The overall paediatric cardiac SSI rate was 3.61 infections per 100 surgeries, with annual rates fluctuating between 2.59 and 4.43 infections per 100 surgeries (Figure 5; Appendix, Table A4). No significant trend was observed during this five-year period. From 2020 to 2024, at 30 days post-infection, 70.0% of patients had been discharged. Five deaths (2.5% of cases) were reported within 30 days of infection onset, including one death indirectly attributable to the paediatric cardiac SSI (data available on request). The most common pathogens identified among paediatric cardiac SSIs were S. aureus (59.0%) and CoNS (14.1%).

Figure 5 - Text description

Figure 5

Year	Rate
2020	3.62
2021	3.31
2022	2.59
2023	4.43
2024	4.11

Antibiogram

Results of antimicrobial susceptibility testing for the most frequently identified gram-positive, gram-negative and fungal pathogens from device and surgical procedure-related HAIs are listed in Figure 6 and Figure 7. The S. aureus isolates were resistant to cloxacillin/oxacillin (MRSA) in 15.1% (n=32/212) of ICU-CLABSIs and 11.1% (n=41/370) of SSIs. Meropenem resistance ranged from 0% to 23% in gram-negative pathogens identified from ICU-CLABSIs. No meropenem resistance was observed among pathogens isolated from SSIs. Ninety-seven vancomycin-resistant Enterococci were identified among ICU-CLABSIs (24.8%, n=97/391).

Figure 6 - Text description

Figure 6

Category	Pathogen	Antimicrobial	Percent resistant (%)
Fungi	Candida albicans	Amphotericin B	0footnote e
Fungi	Candida albicans	Caspofungin	2footnote e
Fungi	Candida albicans	Fluconazole	2
Fungi	Candida albicans	Micafungin	0footnote e
Fungi	Candida albicans	Voriconazole	3footnote e
Fungi	Candida parapsilosis	Fluconazole	6
Fungi	Candida parapsilosis	Voriconazole	0footnote e
Fungi	Candida glabrata	Caspofungin	7footnote e
Fungi	Candida glabrata	Fluconazole	0footnote e
Gram-negative	Acinetobacter spp.	Ciprofloxacin	0
Gram-negative	Acinetobacter spp.	Gentamicinfootnote d	3
Gram-negative	Acinetobacter spp.	Meropenem	0footnote e
Gram-negative	Acinetobacter spp.	Piperacillin/tazobactam	9
Gram-negative	Acinetobacter spp.	Trimethoprim/sulfamethoxazole	3footnote e
Gram-negative	Enterobacter spp.	Ampicillin	96footnote e
Gram-negative	Enterobacter spp.	Cefazolin	48footnote e
Gram-negative	Enterobacter spp.	Ceftriaxone	73footnote e
Gram-negative	Enterobacter spp.	Ciprofloxacin	8footnote e
Gram-negative	Enterobacter spp.	Ertapenem	13footnote e
Gram-negative	Enterobacter spp.	Gentamicinfootnote d	4footnote e
Gram-negative	Enterobacter spp.	Meropenem	5footnote e
Gram-negative	Enterobacter spp.	Piperacillin/tazobactam	42footnote e
Gram-negative	Enterobacter spp.	Tobramycin	4footnote e
Gram-negative	Enterobacter spp.	Trimethoprim/sulfamethoxazole	19footnote e
Gram-negative	Escherichia coli	Ampicillin	75
Gram-negative	Escherichia coli	Cefazolin	48footnote e
Gram-negative	Escherichia coli	Ceftriaxone	36footnote e
Gram-negative	Escherichia coli	Ciprofloxacin	50footnote e
Gram-negative	Escherichia coli	Ertapenem	0footnote e
Gram-negative	Escherichia coli	Gentamicinfootnote d	22
Gram-negative	Escherichia coli	Meropenem	2footnote e
Gram-negative	Escherichia coli	Piperacillin/tazobactam	20footnote e
Gram-negative	Escherichia coli	Tobramycin	17footnote e
Gram-negative	Escherichia coli	Trimethoprim/sulfamethoxazole	42footnote e
Gram-negative	Klebsiella spp.	Amoxicillin/clavulanic acid	16footnote e
Gram-negative	Klebsiella spp.	Ampicillin	100footnote e
Gram-negative	Klebsiella spp.	Cefazolin	40footnote e
Gram-negative	Klebsiella spp.	Ceftriaxone	27footnote e
Gram-negative	Klebsiella spp.	Ciprofloxacin	19footnote e
Gram-negative	Klebsiella spp.	Ertapenem	10footnote e
Gram-negative	Klebsiella spp.	Gentamicinfootnote d	10
Gram-negative	Klebsiella spp.	Meropenem	9footnote e
Gram-negative	Klebsiella spp.	Piperacillin/tazobactam	18footnote e
Gram-negative	Klebsiella spp.	Tobramycin	6footnote e
Gram-negative	Klebsiella spp.	Trimethoprim/sulfamethoxazole	18footnote e
Gram-negative	Pseudomonas spp.	Ciprofloxacin	11footnote e
Gram-negative	Pseudomonas spp.	Gentamicinfootnote d	4footnote e
Gram-negative	Pseudomonas spp.	Meropenem	23footnote e
Gram-negative	Pseudomonas spp.	Piperacillin/tazobactam	17footnote e
Gram-negative	Pseudomonas spp.	Tobramycin	2footnote e
Gram-negative	Serratia spp.	Ampicillin	100footnote e
Gram-negative	Serratia spp.	Ceftriaxone	32footnote e
Gram-negative	Serratia spp.	Ciprofloxacin	6footnote e
Gram-negative	Serratia spp.	Gentamicinfootnote d	0footnote e
Gram-negative	Serratia spp.	Meropenem	0footnote e
Gram-negative	Serratia spp.	Piperacillin/tazobactam	10footnote e
Gram-negative	Serratia spp.	Trimethoprim/sulfamethoxazole	0footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Benzylpenicillin	90footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Cefazolin	83footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Clindamycin	71footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Cloxacillin/oxacillin	87footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Erythromycin	86footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Gentamicinfootnote d	36footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Linezolid	0footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Rifampicin	3footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Tetracycline	20footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Trimethoprim/sulfamethoxazole	56footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Vancomycin	0footnote e
Gram-positive	Enterococcus spp.	Ampicillin	43footnote e
Gram-positive	Enterococcus spp.	Benzylpenicillin	54footnote e
Gram-positive	Enterococcus spp.	Daptomycin	0footnote e
Gram-positive	Enterococcus spp.	Erythromycin	76footnote e
Gram-positive	Enterococcus spp.	Gentamicinfootnote d	13footnote e
Gram-positive	Enterococcus spp.	Linezolid	5footnote e
Gram-positive	Enterococcus spp.	Tetracycline	69footnote e
Gram-positive	Enterococcus spp.	Vancomycin	25footnote e
Gram-positive	Staphylococcus aureusfootnote c	Benzylpenicillin	75footnote e
Gram-positive	Staphylococcus aureusfootnote c	Cefazolin	15footnote e
Gram-positive	Staphylococcus aureusfootnote c	Clindamycin	34footnote e
Gram-positive	Staphylococcus aureusfootnote c	Cloxacillin/oxacillin	15footnote e
Gram-positive	Staphylococcus aureusfootnote c	Erythromycin	34footnote e
Gram-positive	Staphylococcus aureusfootnote c	Gentamicinfootnote d	0footnote e
Gram-positive	Staphylococcus aureusfootnote c	Linezolid	0footnote e
Gram-positive	Staphylococcus aureusfootnote c	Rifampicin	0footnote e
Gram-positive	Staphylococcus aureusfootnote c	Tetracycline	4footnote e
Gram-positive	Staphylococcus aureusfootnote c	Trimethoprim/sulfamethoxazole	2footnote e
Gram-positive	Staphylococcus aureusfootnote c	Vancomycin	1footnote e
Gram-positive	Streptococcus spp.	Benzylpenicillin	3

Figure 7 - Text description

Figure 7

Category	Pathogen	Antimicrobial	Percent resistant (%)
Gram-positive	Coagulase-negative staphylococcifootnote b	Cefazolin	75footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Clindamycin	32footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Cloxacillin	69footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Erythromycin	48footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Rifampicin	4footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Trimethoprim/sulfamethoxazole	29footnote e
Gram-positive	Coagulase-negative staphylococcifootnote b	Vancomycin	0footnote e
Gram-positive	Enterococcus  spp.	Ampicillin	3
Gram-positive	Staphylococcus aureusfootnote c	Cefazolin	13footnote e
Gram-positive	Staphylococcus aureusfootnote c	Clindamycin	22footnote e
Gram-positive	Staphylococcus aureusfootnote c	Cloxacillin/oxacillin	11
Gram-positive	Staphylococcus aureusfootnote c	Erythromycin	32footnote e
Gram-positive	Staphylococcus aureusfootnote c	Gentamicinfootnote d	0footnote e
Gram-positive	Staphylococcus aureusfootnote c	Rifampicin	1footnote e
Gram-positive	Staphylococcus aureusfootnote c	Trimethoprim/sulfamethoxazole	2footnote e
Gram-positive	Staphylococcus aureusfootnote c	Vancomycin	0footnote e
Gram-positive	Streptococcus spp.	Benzylpenicillin	0footnote e
Gram-positive	Streptococcus spp.	Clindamycin	21footnote e

Discussion

Between 2020 and 2024, there were up to 67 unique hospitals submitted device (ICU-CLABSI) and surgical procedure-related infection data, including 1,846 ICU-CLABSIs and 1,014 surgical procedure-related infections. A total of 3,111 pathogens were identified from ICU-CLABSIs and 1,072 pathogens from surgical procedure-related cases between 2020 and 2024. Similar to what has been reported in past CNISP surveillance, reports ^{Footnote 10Footnote 11Footnote 12}, the majority of these pathogens were gram-positive and the most commonly reported pathogens were coagulase-negative staphylococci and S. aureus.

Intensive care unit central line-associated bloodstream infections

Overall rates of CLABSIs in adult ICUs from 2020 to 2024 (1.89 and 0.97 infections per 1,000 line days in adult mixed ICUs and CVICUs, respectively) were lower than the ICU-CLABSI rates reported from adult ICUs in England during the same period (ranging from 1.8 to 3.6 infections per 1,000 line days) ^{Footnote 13}. Conversely, CNISP adult ICU CLABSI rates and were higher than quarterly rates reported from 12 adult ICUs in Western Australia (range: 0–0.63 infections per 1,000 line days) ^{Footnote 14}. Comparisons made between CNISP data and those from other jurisdictions should be interpreted with caution, as data collection is not standardized; therefore, there may be differences in the two populations being compared.

The incidence of CLABSIs in paediatric and neonatal ICUs reported via CNISP was higher compared to England, where rates decreased from fiscal years 2020 to 2024 (1.0 and 0.8 infections per 1,000 line days, respectively) ^{Footnote 10}. Neonatal ICU-CLABSI rates reported in South Korea from 2020–2022 were 12% lower compared to rates reported by CNISP during the same time period (1.39 vs. 1.58 infections per 1,000 line days) ^{Footnote 15}.

Differences in catheter utilization ratios likely contributed to the observed variation in CLABSI burden across ICU settings, with higher catheter utilization ratios in adult ICUs (66%–87%) compared to the lowest in the NICU (28%–30%). Thirty-day all-cause mortality was highest in adult ICUs (32%–33%), consistent with greater baseline severity, while paediatric and neonatal mortality remained substantially lower (9.7%–11%), representing different population risk profiles across ICU settings. Thirty-day all-cause mortality was highest in adult ICUs (32%–33%), consistent with greater baseline severity, while paediatric and neonatal mortality remained substantially lower (9.7%–11%). Day-all-cause mortality was highest in adult ICUs (32%–33%), consistent with greater baseline severity, while paediatric and neonatal mortality remained substantially lower (9.7%–11%).

Surgical site infections

Hip and knee surgical site infections: Hip SSI rates fluctuated across reporting years, while knee SSI rates increased non-significantly from 2020 and 2023, before decreasing again in 2024. Hip and knee SSI rates demonstrate ongoing variation across jurisdictions. Long term trends from England’s National Health Service hospitals show a continued steady decline in inpatient hip and knee SSI incidence over the past decade from 2015 to 2025 ^{Footnote 16}. From 2020 to 2024, hip SSI rates in Western Australia were higher than those reported by CNISP (0.75 vs. 0.64 infections per 100 surgeries), while knee SSI rates were lower (0.29 vs. 0.36 per 100 surgeries) ^{Footnote 14}.

Cerebrospinal fluid shunt surgical site infections: The overall rate of SSIs from CSF shunts was 2.65 per 100 surgeries from 2020 to 2024. The rate is similar to what was previously reported by CNISP from 2019 to 2023 (2.89 per 100 surgeries); however, differences may reflect changes in hospital participation (two fewer hospitals participated in reporting CSF shunt SSIs in 2024 at the time of this study) ^{Footnote 10}. A national survey conducted in England in 2017 reported a mean brain shunt infection rate of 1.9% (range: 0%–4.4%), which is lower than the overall rate reported by CNISP ^{Footnote 17}. In contrast, a retrospective single-center study in Sweden reported a higher shunt infection rate of 4.8% in adult hydrocephalus patients who underwent surgery between 2013 and 2019 ^{Footnote 18}.

Cerebrospinal fluid shunt infection rates vary widely by population (paediatric vs adult), centre and country ^{Footnote 18}. Combined with a lack of recent literature, comparisons of the data in this report with other regions is limited; therefore, CSF shunt SSIs reported during this time period were compared with previously published CNISP surveillance data ^{Footnote 10Footnote 11Footnote 19}. Consistent with earlier findings, CSF shunt SSI rates fluctuated from 2020 to 2024 ^{Footnote 10Footnote 11Footnote 19}. The rates observed from 2020 to 2024 were lower than those reported in earlier periods (2000–2002) for both paediatric (3.1% vs 4.9%) and adult patients (2.2% vs 3.2%), similar to the most recent published report ^{Footnote 10Footnote 19}.

Paediatric cardiac surgical site infections: From 2020 to 2024, CNISP hospitals reported an overall paediatric cardiac SSI rate of 3.7 infections per 100 surgeries, with no significant trend observed over the five-year period. Due to a lack of published national reports from other jurisdictions, these data could not be compared directly with other countries. Single-center studies from several jurisdictions have observed varied rates of paediatric cardiac SSIs: from 0.9 infections per 100 surgeries in a California, United States centre ^{Footnote 20} to 1.97 in a single centre in Ontario, Canada from 2022 to 2023 ^{Footnote 21}, to 4.34 in a centre in Chile from 2015 to 2020 ^{Footnote 22}. However, these studies may not be representative of the entire nation. When compared to previously published CNISP surveillance data, rates of paediatric cardiac SSIs have remained relatively unchanged since data collection began in 2010. From 2011 to 2020, the rate of infection was 3.5 per 100 surgeries ^{Footnote 11}.

Antibiogram

Meaningful comparisons with other regions are limited by gaps in recent literature and variation in how antibiogram data are reported for device-related and surgical procedure-related infections. To address this, we compared 2020–2024 data with CNISP surveillance data from 2011 to 2020; however, since the time periods overlap, observed changes may not reflect true trends and should be interpreted with caution ^{Footnote 11}. The percentage of S. aureus isolates that were MRSA among ICU-CLABSIs (15%) and SSIs (11%) in the CNISP network remained relatively stable over the 2020–2024 period compared to previous surveillance data from 2011 to 2020, where MRSA accounted for 15% of ICU-CLABSIs and 14% of SSIs. Among Enterococcus spp. identified in ICU-CLABSIs, 25% were vancomycin-resistant Enterococci, compared to 16% in 2011–2020 ^{Footnote 11}. During the 2011–2020 time period, results for meropenem resistance in Pseudomonas spp. identified in ICU-CLABSIs were not available; however, in later CNISP surveillance reports, a decrease in resistance was observed; from 38% in 2018–2022 to 30% in 2019–2023 to 23% in 2020–2024 ^{Footnote 10Footnote 12}. Meropenem resistance among other gram-negative pathogens identified in ICU-CLABSIs ranged from 0% to 9% in 2020–2024 and from 2% to 7% in 2011–2020 ^{Footnote 11}.

Strengths and limitations

The main strength of CNISP surveillance is the standardized collection of detailed epidemiological and molecular-linked data from a large representative network of sentinel hospitals from across Canada. From 2020 to 2024, CNISP coverage of Canadian acute care beds has increased from 35% to 49%, including increased representativeness in northern, community, rural and Indigenous populations. To further improve representativeness, CNISP has launched a simplified dataset accessible to all acute care hospitals across Canada to collect and visualize annual HAI rate data. Despite the increased representativeness of CNISP surveillance data, the number of hospitals participating in each HAI surveillance project differed and epidemiologic data collected were limited to the information available in the patient charts. For CLABSI surveillance, data were limited to infections occurring in the ICU settings and, as such, may represent only a subset of CLABSIs occurring in the hospital. Furthermore, when comparing our infection rates with data from other countries, several limitations must be considered, including differences in surveillance methodologies, patient populations and number and types of hospitals under surveillance.

Conclusion

This report summarizes 1,846 device-related infections and 1,014 surgical procedure-related infections as well as antibiogram data identified over five years of surveillance, 2020–2024, from up to 67 hospitals across Canada. During this time, rates of device- and surgical procedure-related HAIs have fluctuated from year to year with no significant trend throughout the study period. The collection and analysis of national surveillance data are important to understanding and reducing the burden of device and surgical procedure-related HAIs. These data provide benchmark rates for national and international comparison and inform antimicrobial stewardship and infection prevention and control programs and policies.

Authors' statement

Canadian Nosocomial Infection Surveillance Program hospitals provided expertise in the development of protocols in addition to the collection and submission of epidemiological and microbiological data. Epidemiologists from Public Health Agency of Canada were responsible for the conception, analysis, interpretation, drafting and revision of the article.

Competing interests

None.

Acknowledgements

We gratefully acknowledge the contribution of the physicians, epidemiologists, infection control practitioners and laboratory staff at each participating hospital: Vancouver General Hospital (VGH), Vancouver, British Columbia (BC); Richmond General Hospital, Richmond, BC; UBC Hospital, Vancouver, BC; Lion’s Gate, North Vancouver, BC; Victoria General Hospital, Victoria, BC; Royal Jubilee Hospital, Victoria, BC; Nanaimo Regional General Hospital, Nanaimo, BC; BC Women’s Hospital, Vancouver, BC; BC Children’s Hospital, Vancouver, BC; Kelowna General Hospital, Kelowna, BC; Penticton Regional Hospital, Penticton, BC; University Hospital of Northern BC, Prince George, BC; Abbotsford Regional Hospital, Abbotsford, BC; Chilliwack General Hospital, Chilliwack, BC; Royal Columbian Hospital, New Westminster, BC; Surrey Memorial Hospital, Surrey, BC; Peter Lougheed Centre, Calgary, Alberta (AB); Rockyview General Hospital, Calgary, AB; South Health Campus, Calgary, AB; Foothills Medical Centre, Calgary, AB; Alberta Children’s Hospital, Calgary, AB; University of Alberta Hospital, Edmonton, AB; Stollery Children’s Hospital, Edmonton, AB; Royal University Hospital, Saskatoon, Saskatchewan (SK); Regina General Hospital, Regina, SK; Pasqua Hospital, Regina, SK; St. Paul’s Hospital, Saskatoon, SK; Health Sciences Centre-Winnipeg, Winnipeg, Manitoba (MB); University of Manitoba Children’s Hospital, Winnipeg, MB; Children’s Hospital of Western Ontario, London, Ontario (ON); Victoria Hospital, London, ON; University Hospital, London, ON; Toronto General Hospital, Toronto, ON; Toronto Western Hospital, Toronto, ON; Mount Sinai Hospital, Toronto, ON; Sunnybrook Hospital, Toronto, ON; Kingston General Hospital, Kingston, ON; The Hospital for Sick Children, Toronto, ON; McMaster Children’s Hospital, Hamilton, ON; St. Joseph’s Healthcare, Hamilton, ON; Juravinski Hospital and Cancer Center, Hamilton, ON; Hamilton Health Sciences General Site, Hamilton, ON; The Ottawa Hospital Civic Campus, Ottawa, ON; The Ottawa Hospital General Campus, Ottawa, ON; University of Ottawa Heart Institute, Ottawa, ON; Children’s Hospital of Eastern Ontario (CHEO), Ottawa, ON; North York General Hospital, Toronto, ON; Sudbury Regional Hospital, Sudbury, ON; SMBD-Jewish General Hospital, Montréal, Québec (QC); Montreal Children’s Hospital, Montréal, QC; Hôpital Maisonneuve-Rosemont, Montréal, QC; Hôtel-Dieu de Québec, QC; Centre hospitalier de l’Université de Montréal, Montréal, QC; Montreal General Hospital, Montréal, QC; Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC; Royal Victoria Hospital, Montréal, QC; Montreal Neurological Institute, Montréal, QC; The Moncton Hospital, Moncton, New Brunswick (NB); Halifax Infirmary, Halifax, Nova Scotia (NS); Victoria General, Halifax, NS; Dartmouth General Hospital, Halifax, NS; IWK Health Centre, Halifax, NS; General Hospital & Miller Centre, St. John’s, Newfoundland and Labrador (NL); Janeway Children’s Hospital and Rehabilitation Centre, St. John’s, NL; St. Clare’s Mercy Hospital, St. John’s, NL; Western Memorial Regional Hospital, Corner Brook, NL; James Paton Memorial Hospital, Gander, NL.

Thank you to the staff at Public Health Agency of Canada in the Centre for Communicable Diseases and Infection Control, Ottawa, ON (J Bartoszko, J Cayen, K Choi, N Jeyakumar, D Lee, M LaFreniere, C Lybeck, C McClellan, E McGill, A Neitzel, N Papayiannakis, S Rudat, A Silva, Z Suleman, O Varsaneux) and the National Microbiology Laboratory, Winnipeg, MB (S Ahmed, A Bangit, A Bharat, T Du, R Edirmanasinghe, K Fakharuddin, G Golding, G Grewal, R Hizon, X Li, L Mataseje, M McCracken, M Reimer, N Lerminiaux, J Tinsley).

Funding

This work was supported by Public Health Agency of Canada.

Appendix

Supplemental material is available upon request to the author: cnisp-pcsin@phac-aspc.gc.ca

Case definitions

Table A1: Rate of central line-associated bloodstream infection per 1,000 line days by intensive care unit type, 2020–2024

Table A2: Rate of hip and knee surgical site infections per 100 surgeries, 2020–2024

Table A3: Cerebrospinal fluid shunt surgical site infection rates per 100 surgeries by hospital type, 2020–2024

Table A4: Paediatric cardiac surgical site infection rates per 100 surgeries, 2020–2024