What are healthcare-associated infections?
Healthcare-associated infections (HAI) are infections that patients get as a result of their stay in a healthcare facility. The infection can be contracted via contact with contaminated surfaces, healthcare workers, or other patients, or via surgical wounds or medical equipment such as catheters. The Centers for Disease Control and Prevention (CDC) report that at any given time, 1 in 31 patients has at least one HAI. These infections increase the economic burden of healthcare by costing $45 USD billion each year. In addition, more than 10% of people with an HAI will die during their hospitalization.
Why can’t we just use antibiotics to treat HAIs?
While antibiotics are administered to counteract these infections, antimicrobial-resistant pathogens are on the rise. Indeed, methicillin-resistant Staphylococcus aureus (MRSA) doesn’t respond to most antibiotics and is one of the most common and insidious bacteria found in hospitals. Alarmingly, 15 to 50% of people infected with MRSA who are treated with antibiotics die from infection-associated complications.
With MRSA effectively evading treatment and antibiotic development underway to combat resistant bacteria, prevention has become key. And yet, universal and outlined prevention measures were severely lacking in US hospitals up until the 21st century. To begin to address this shortcoming, the CDC launched in 2005 the National Healthcare Safety Network. Over 17,000 healthcare facilities representing all 50 states made up this surveillance network that reports the incidence of HAI to identify common modes of transmission and resistance prevalence. For example, MRSA colonization occurs primarily in the nose, and infection is most commonly spread via catheters and surgical wounds.
But what about prevention?
By 2007, the Department of Veterans Affairs (VA) enacted one of the first MRSA prevention programs across all of its acute care medical centers. Called an “MRSA bundle,” this program gave birth to an “institutional culture change” that focused on hand hygiene, universal nasal MRSA testing for incoming patients, and extra precautions for handling patients infected with MRSA, such as wearing disposable gloves and gowns at all times when interacting with a patient and his or her environment. Hospitals were held accountable for participation in the program by surveyors who reported adherence to the program, the prevalence of MRSA colonization, and MRSA transmission and/or infection each month via a central database.
Over the course of 10-plus years (2005-2017), the VA acute care medical centers’ system-wide dedication to MRSA prevention reduced MRSA infections by 55%. Which prevention measure is responsible for the significant decrease of MRSA infection? Hand washing? Screening for nasal MRSA colonization? Just being more conscientious of proper hygiene conduct when interacting with patients? That’s difficult to determine, given that multiple measures were implemented simultaneously.
Since the advent of the VA’s MRSA prevention program, the World Health Organization (WHO) published guidelines on the best practices to use for infection prevention and control (IPC) in acute care facilities. The core of the IPC program is having a staff of healthcare workers who are trained to detect, prevent, and report infection outbreaks in order to reduce the burden of healthcare-associated infections. Here are some of the practices:
Hand hygiene
No surprise that this tops the WHO’s list of the most effective ways to control the spread of HAI. The WHO has issued instructions to healthcare workers regarding proper hand hygiene practices, and “clean hands” programs are promoted both nationally and internationally, with some promising results. A 4-year Cleanyourhands campaign in England and Wales reported a 50% reduction in S. aureus and Clostridium difficile incidence per 10,000 patients with an overnight stay in a healthcare facility. Since bacteria spreads from hand-to-hand contact, frequently washing hands with soap and water or an alcohol-based sanitizer greatly reduces the spread of infection.
Contact precaution
In the same vein as hand hygiene, healthcare workers who wear the appropriate attire and dispose of all gloves, masks, and gowns after coming into contact with infected patients and/or contaminated equipment also reduced the spread of infection. Additionally, cleaning patient rooms daily with a sporicidal disinfectant decreased C. difficile infection by almost 70%.
Chlorhexidine bathing
Bacteria such as MRSA tend to migrate across body parts very easily and quickly. Rather than focusing exclusively on killing bacteria commonly found in the nasal passages by using topical treatments such as mupirocin, daily full-body bathing of patients with chlorhexidine—a strong antiseptic that is also used to clean surgical instruments—has proven to be more effective at reducing infections.
Active screening
Though expensive, some hospitals screen all incoming patients for MRSA and other types of bacteria colonization. The turnaround time for these screening results can exceed 5 days, which is enough time for the colonization and infection to spread if proper hygiene methods are not used by healthcare workers and patients alike.
How effective and sustainable are these HAI prevention strategies?
The CDC reported that in 2015, healthcare-associated infections affected 687,000 patients in acute care facilities and accounted for 77,000 deaths in the United States. Given the gaps in HAI surveillance, monitoring, and reporting, this number may be underrepresented. The IPC guidelines published by the WHO outline reasonable and effective ways to prevent HAIs. Things are moving in the right direction, with the CDC reporting an 8% and a 13% decrease in MRSA and C. difficile infections, respectively, in acute care hospitals between 2016 and 2017. Reduced infection rates are more often reported when combinatorial prevention strategies such as improved hand hygiene coupled with daily chlorhexidine bathing are used rather than a single strategy prevention.
Despite improvement in HAI prevention, these policies and surveillance regimens are not universally practiced in healthcare facilities. Policymakers at the local and national levels are ultimately responsible for monitoring and enforcing practices aimed at reducing HAI. Unfortunately, inconsistent monitoring of the cleanliness of healthcare facilities sustains the high rate of HAIs. In a study by Infection Control and Epidemiology, staff received feedback after cleaning high-touch surfaces of ICU rooms with an ultraviolet-tagged bleach solution to visualize the completeness of sanitation. Monthly monitoring revealed that the staff improved their cleaning performance from 52% to 85% within the first 6 months of the study. However, without constant monthly monitoring and feedback over the subsequent 9 months, performance regressed to 57%.
Eliminating healthcare-associated infections is the goal, and the prevention measures sound simple enough. But prevention is not so straightforward if there are not systemic institutional changes. According to the WHO’s guidelines, “access to health care services designed and managed to minimize the risks of avoidable HAI for patients and health care workers is a basic human right,” and we should expect nothing less from our healthcare facilities.
