UWL: Association With Outcomes (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The purpose of this study was to determine the incidence of nosocomial infections and its association with malnutrition.

Inclusion Criteria:
  • Patients who were aged 70 years or older consecutively admitted to the Albert Cheneveir Hospital (Certiel) between January 2002 and July 2004 were enrolled
  • Patients were medically stable at admission and required long-term care and rehabilitation.
Exclusion Criteria:
  • Near-terminal medical disorders (e.g., advanced malignancy, decreased consciousness, advanced dementia) precluded participation in the study
  • Patients were also excluded from the study if their stay in the rehabilitation unit was shorter than 72 hours.
Description of Study Protocol:


Patients admitted to the Albert Chenevier Hospital between January 2002 and July 2004. Patients were informed of the purpose of the study and gave their oral consent.


Prospective cohort study.

Subjects were given a standardized questionnaire on admission to the hospital and a nutritional assessment was done at that time. They were monitored during the hospitalization for nosocomial infections until discharge or death.

Statistical Analysis

  • The results were expressed as means with their standard errors
  • Three groups were compared by one-way ANOVA, with the Bonferroni all-pair-wise multiple comparison
  • Differences in means between two groups were analyzed by the unpaired student's T-test
  • Differences between non-continuous variables and percentages were tested by chi-square analysis
  • Correlations between two variables were calculated with least squares regression analysis
  • Logistic regression was used to identify the significant independent factors associated with diagnosis of nosocomial infection.
Data Collection Summary:

Timing of Measurements

The questionnaire, measurement of anthropometric values and evaluation of dietary intakes were conducted upon admission (Day zero). Serum was obtained after an overnight fast for biochemical analysis.

Dependent Variables

Presence of a nosocomial infection determined through review of medical records. 

Independent Variables

Undernutrition, assessed through anthropometric measures [weight, height, body mass index (BMI), mid-arm circumference and triceps and biceps skinfold thickness], serum measurements of nutritional status (C-reactive protein, orosomucoid and transthyretin concentrations, albumin) and dietary intake.


Description of Actual Data Sample:
  • Initial N: 185 hospitalized older adults (45 males, 140 females)
  • Attrition (final N): Same as above
  • Age: Mean 81.6±0.6 years
  • Location: France.
Summary of Results:



Anthropometric and Biological Variables in the Three Groups of Patients


No Infection

One Infection

More than One Infection


Weight (kg)

61.2 ±1.5




BMI (kg/m2)





MAC (cm)





Energy intake (kcal per day)





Energy intake (kcal per kg per day)


27.2± 2.1



Albumin (g per L)





Transthyretin (g per L)






Patient Characteristics


No Infection


One Infection


More than One Infection


Age (years) 80.0±7 84.4±1.2 85.2±1.3 0.0002
Gender (M/F) 37/79 3/35 5/26 0.006
Mini-Mental State score 23.7±0.7 20.1±1.4 18.1±1.5 0.0005
Length of stay (days) 60.1±4.9 78.9±10.7 122.2±19.5 <0.0001

Other Findings

  • The incidence rate of nosocomial infections was 59% and the global infection rate was 7.6 out of 1,000 bed days
  • The most common infection site was the urinary tract (N=63)
  • The nutritional status was compared among those with an absence of nosocomial infection (N=116), presence of one infection (N=38) or presence of more than one infection (N=31)
  • All but one anthropometric parameter and total energy intake varied among the three groups
  • Those who did not have a nosocomial infection had higher daily nutrient intake than the other two groups (P=0.004 and P<0.0001), respectively
  • Albumin, transthyretin and C-reactive protein levels differed significantly among the three groups (P<0.0001, P<0.0001 and P=0.0003, respectively)
  • Age, energy intake, length of hospital stay and the presence of a urinary catheter were independent risk factors of nosocomial infection.
Author Conclusion:

Our findings show that patients with multiple nosocomial infections were older, showed an altered nutritional status and a prolonged recovery, more frequently had urinary catheters and more discharge placement.

Funding Source:
University/Hospital: Departement de Medecine Interne et Geriatrie, Hopital Albert Chenevier, Cedex, France
Reviewer Comments:

Overall, this was a well-done study. However, nutritional assessment was only done upon admission to the hospital. Might have been helpful to assess nutritional status again after 30 days to see if there were changes in nutritional status relating to nosocomial infections.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? ???
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes