Sheikh Abdul Alam, 96, was admitted to a private hospital on December 20, 2021, with a broken hip from a fall.

Apart from the injury, he had no medical issues – no chronic issues like diabetes or hypertension – and was in perfect health.

Doctors at the hospital were able to conduct a successful hip-ball replacement surgery as well.

However, when he was kept in a high dependency unit for surveillance, Alam developed a nagging cough two days in.

On the third day, doctors had to begin manually vacuuming his upper respiratory system. And on the sixth day, he was dead from pneumonia.

The man, who had survived the surgery, did not have the immunity to survive the pneumonia picked up at he hospital.

A study done across 11 tertiary level hospitals in the country by icddr,b and the Directorate General of Health Services found that none of the hospitals conduct surveillance for hospital-acquired infections.

Tertiary, the highest level, hospitals or institutes have medical colleges and universities, specialised departments, and are usually referral hospitals, where patients from all over the country seek medical help.

These 11, comprised of nine public and two private hospitals, represent a quarter of all the country's tertiary level hospitals, and a third of the public facilities of this scale.

The study was published last month in a journal titled "Antimicrobial Resistance & Infection Control".

Md Golam Dostogir Harun, lead author of the study and project research manager at icddr,b's infectious diseases division, said, "Hospital-acquired infections show up in a patient after being admitted to a facility. It is a result of poor infection control."

According to the DGHS, such infections include urinary tract infections, pneumonia, diarrhoea, infections following surgery or invasive medical procedures, and infections in new mothers and newborns.

Doctors often find hospital-acquired infections turning fatal, as some patients survive the initial illnesses they were admitted with but die later due to an infectious disease.

Dr Ahmed Abu Saleh, professor and former head of the microbiology and immunology department at Bangabandhu Sheikh Mujib Medical University, said hospital-acquired infections are a major cause of death among patients in ICUs.

"These infections are usually resistant to multiple antibiotics. The antibiotics they are resistant to will depend on what the hospital usually prescribes."

These infections lengthen a patient's hospital stay and increase mortality rate.

According to the study, "None of the hospitals had a surveillance system ... All hospitals cited a lack of necessary IT support and specialised professionals skilled in epidemiology to carry out surveillance."

Nine of the hospitals did not conduct any surveillance to see if surgical site infections crop up following an operation, or infections are transmitted through medical equipment.

In addition, six of them did not conduct any surveillance in their ICUs, or among infants, while the surveillance for tuberculosis and flu was also ignored.

It found that all 11 hospitals, except one, could only be ranked as "basic" or lower, on the World Health Organization's infection prevention and control assessment scale.

This means infection prevention and control is not sufficiently implemented in those hospitals and further improvement is required.

One 450-bed public hospital, which routinely houses up to 2,600 patients and has an annual turnover of 85,000 patients, was ranked as "inadequate" in terms of infection prevention and control, where "implementation is deficient and significant improvement is required".

The second lowest score was obtained by a private 580-bed tertiary hospital, which treats over 15,000 patients every year.

The study did not name the hospitals, but said they are all teaching hospitals with huge patient loads, where patients from district-level hospitals also get referred to.

Overcrowding, a lack of beds, inadequate manpower, insufficient toilets, and non-existent wastewater treatment systems -- all contribute to the crisis, found the study. Wastewater has been proven time and again to be a carrier of pathogens.

Only about a quarter of the hospitals assess the number of staffers needed to manage patient loads, while 45 percent of them did not maintain the government proposed healthcare worker-patient ratio.

"It was found that cleaners were left out of training for infection prevention and control," said lead author Harun.

The study also found that two-thirds of the hospitals did not maintain adequate spacing between patient beds.

Only six of the hospitals could maintain one patient per bed, found the study. It is observed that large hospitals cram multiple patients to a single bed or make bedding on the floor.

Four hospitals had no way to assess or respond when the bed capacity was exceeded. About half of the hospitals had no patients placed outside in the corridors, the study further read.

It also found that seven hospitals did not have sufficient working toilets.

Four of the hospitals did not have functional waste collection containers, and five did not have medical waste pick-up or disposal facilities.

Only one had an incinerator.

Former BSMMU professor Ahmed Abu Saleh recommended a concerted initiative to conduct surveillance for hospital-based infections.

"There needs to be a collective effort because BSMMU is a referral hospital and ICU patients, for example, are admitted in private hospitals before being transferred here. I don't know what infections they are bringing from there."

Meanwhile, other healthcare workers were not receiving sufficient training in infection control, while the cleaners received almost none.

"The resilience of healthcare facilities in containing and treating diseases without propagating infectious threats will depend on enhancing infection prevention and control practices," concluded the study titled "Infection prevention and control in tertiary care hospitals of Bangladesh: results from WHO infection prevention and control assessment framework".