By Bruce Flickinger
The concept of disease prevention is simple–but not easy
Hospital-acquired infections (HAIs; also called nosocomial infections) are a distressing issue on two levels: one, it is a sad fact that many people leave the hospital with infections and associated problems that they were not admitted with; and two, these infections are, for the most part, largely preventable.
Common wisdom says the concept of disease prevention is simple but not easy. The complicating factor in the European Union (EU) is tremendous variability on several levels: patient populations; hygiene awareness; standards and practices; and most critically perhaps, the microorganisms themselves–those invisible, elusive culprits that have developed a singular proficiency for surviving and proliferating in even the most hostile environments.
These variable conditions conspire to hamper preventative efforts and provide a fertile foothold for infectious organisms, and if an experience reported this past summer in U.K. newspaper The Guardian is any indication, the battle to eradicate disease-causing organisms from our hospitals and health care facilities is far from won. In their first enforcement of the new U.K. Hygiene Code, National Health Service (NHS) officials noted that the violative hospital employed only one microbiologist working four hours a week on infection control. Even someone at the periphery of the problem knows that this is an entirely insufficient response to the problem of bacterial infection and resistance as it exists today.
Anecdotal evidence about infection control successes and failures abounds. Some European countries, such as the Netherlands, have some of the lowest rates of HAIs, while awareness and vigilance of the problem tend to lessen in Southern Europe and in the emerging infrastructures in Eastern Europe, where multi-drug-resistant tuberculosis is a problem. Fortunately, the overall trend is toward heightened government oversight and regulatory accountability–the U.K. Hygiene Code, which went into effect October 2006, is but one example. Larger pieces of hospital budgets are also going to hygiene infection control.
Figure 1. STERIS’s VaproSure™ sterilizer is effective for sterilizing targeted hospital room surfaces. Photo courtesy of STERIS.
The bottom line, says Gerald McDonnell, PhD, vice president of Research and European Affairs with STERIS Ltd. (Basingstoke, UK), is that “life is a constant battle between humans and certain types of disease-causing microorganisms, which we attempt to control through vaccinations, our own immune systems, and good hygiene practices. When we are healthy we generally tend to win these battles, but the sad part is that oftentimes we lose.”
Standard practice, new perspectives
The tenets of winning the war against HAIs are well established. They include good personal hygiene practices; patient involvement and empowerment; instrument and equipment sterilization; isolation and infrastructure controls; and proper surgical and catheterization procedures. How effectively each and all of these are implemented in a facility and ingrained in the staff through education and training will impact infection rates.
“Infection control, or more correctly infection prevention, is always a combination of a number of interventions to reduce risk,” McDonnell says. “It starts in the ambulance or emergency ward and goes all the way through to discharge. The sicker the patients, the more at risk they are, but vigilance by patients and staff mitigates this risk, along with good practice and products.”
In addition to hygiene practices, the misuse and overuse of antibiotics has become an acute concern. A 2005 report from the European Antimicrobial Resistance Surveillance System (EARSS), a database of test results reported from 30 European countries, notes that resistance is “most convincing” where orally administered antimicrobial compounds, which are preferred in ambulatory care, are used. That is, they are convenient and often overused. EARSS says, “The growing availability of third-line antimicrobial drugs as oral formulations is a matter of concern and underscores the need of locally or nationally advised prescribing practices for both ambulatory and hospital-based care.” A number of companies serving the health care market offer antibiotic management services, in which mismatched antibiotics can be identified and formularies adjusted accordingly.
Another topic gaining more attention of late is environmental surveillance, particularly of patient-contact surfaces. This is particularly salient in light of the emphasis that is usually placed on handwashing and personal hygiene. “A number of recently published studies have shown that contact surfaces can be contaminated with important pathogens such as MRSA (methicillin-resistant Staphylococcus aureus, VRE (vancomycin-resistant Enterococcus), and Clostridium spores,” McDonnell says. “In some cases, these organisms have been shown to survive for weeks on surfaces. With patient or staff contact, this becomes a significant source of infection.”
So while infection control professionals spend a lot of time teaching hospital staff and patients about the importance of handwashing in reducing hand contamination, “we should remember what happens to those hands after they have been washed, or even gloved,” McDonnell says. “Contact with contaminated surfaces such as bedrails or bedside tables can quickly recontaminate the hands/gloves and be a further source of infection.”
McDonnell says the merits of surveillance are “often a debated point,” but that it does “make sense for hospital administrators to at least understand the levels and types of contaminants or microorganisms that can be present in high-risk areas, wards, or patients, and in particular during outbreak situations.”
Quantifying the problem
Broadly speaking, the importance of epidemiological surveillance both for better understanding HAIs and for crafting appropriate responses to them cannot be overstated. Numerous local, national, and pan-European efforts, such as EARSS, are in place to carry out this work. Another is Improving Patient Safety in Europe (IPSE), funded by the EU Directorate General for Health and Consumer Protection, which oversees HELICS (Hospitals In Europe Link for Infection Control through Surveillance). HELICS, in turn, is an international network that collects, analyzes, and disseminates data about the risks of nosocomial infections in European hospitals.
Based on the 2006 HELICS survey, which encompasses results of hospital-wide surveillance programs throughout the EU, IPSE estimates that roughly 3 million patients acquire a nosocomial infection in the EU each year, and that 50,000 of these infections result in death. The most frequent infections are urinary and respiratory tract infections (28 and 25 percent prevalence, respectively), and surgical site infections (17 percent).
Significantly, 20 to 30 percent of nosocomial infections are considered to be preventable by intensive infection prevention and control programs, according to ISPE.
The most prevalent offender continues to be MRSA, which is isolated in approximately 5 percent of all nosocomial infections in the HELICS database. EARSS confirms this. In 2005, the database included results from more than 27,000 isolates of invasive S. aureus. Prevalence of MRSA among these isolates was under 3 percent in only seven countries, around 20 to 25 percent for most of the “EU25,” and above 40 percent for eight, primarily southern European, countries.
While not as prevalent, E. coli resistance is “a disturbing development with seemingly inexorable vigor,” EARSS says. The pathogen’s resistance to both aminopenicillins and fluoroquinolones is increasing, and combined resistance is a frequent occurrence.
It is generally thought that MRSA strains are more frequently isolated from ICU patients than non-ICU patients. This again is supported by EARSS, which says that in some countries, such as Poland, Bulgaria, Croatia, Greece, the U.K., Cyprus, and Romania, the proportion of MRSA found among ICU patients reaches over 60 percent. These figures remain troubling, and ICU infection control procedures are often a main component of a hospital’s overall program.
McDonnell and others caution against making broad generalizations about the ICU being a key problem in the spread of HAIs. “Although HAIs are often identified within ICUs and some have been acquired in ICUs, in many cases patients are already carrying various pathogenic microorganisms when they come into these departments,” McDonnell says. “An example is the recent understanding that many strains of MRSA are actually community acquired. A patient may not know they are carrying these strains, but when they become sick, are put on antibiotics, or are immunocompromised they are more at risk from these organisms causing an infection that normally they could fight off. Patients in ICUs are very vulnerable to infection. They are very sick and predisposed to illness.”
National surveillance figures provide important information, but hospital administrators also need a better understanding of how infectious organisms and antibacterial resistance pervade their own facilities. One new tool is MedMined™, a service offered through Cardinal Health (Birmingham, AL) that enables the automated collection and standardization of infection data throughout a facility. Management can use the information to track its own infection rates and preventive efforts and, because the data is fed anonymously into a national database encompassing all MedMined sites, an individual facility’s performance can be compared to others.
A surveillance component continuously scans the hospital for problems using data uploaded from a laboratory information management system. It then uses pattern mapping and a kind of artificial intelligence to track microbial populations, potential hot spots, and the effects of any interventions. Says Patrick Hymel, MD, vice president with Cardinal Health, “You don’t have to direct the system or ask specific questions like you do with manual epidemiology. It provides regular, standardized feedback about the effectiveness of infection control procedures, so people can see change almost immediately. They’re often surprised at the opportunities they have for improvement.”
MedMined is currently in use in 250 hospitals across the U.S., and users have been able to document an average 13.5 percent reduction in infection rates in the first year of using the service, the company says.
“There are major changes coming in how payers will reimburse for complications from HAIs,” says Hymel. ‘It’s important for hospitals to know their true exposure, and it is hard to know this if they are using a strictly manual approach to case finding and tracking.”
Hymel adds, “Infection control departments have traditionally been viewed as a cost center at hospitals, but with improving practice over time, you can really transform the department into a significant source of cost savings that can be directly applied to the bottom line and improve the overall financial performance of the hospital.”
Good practice pays off
While HAI control and prevention is a complex, multi-factorial public health issue, with proper infection control implementation, such as hand hygiene, proper vaccination of staff, and sterile techniques, hospitals can save lives and minimize economic losses. This realization is turning health care into a strong market for contamination/infection control technologies and services, much like microelectronics was several years ago, observers say. Awareness and education are increasing concurrently.
“In the post-antibiotic era many countries employed medicine to treat disease, but not necessarily to prevent it. Now the focus is on prevention or controlling early, and the same should be held for infection prevention,” McDonnell says. “Medical staff should be spending significant time during training on infection prevention earlier in their careers. Some countries are doing this effectively today while others have a long way to go.”
- Surveillance reports and other information are available from the Improving Patient Care in Europe web site at http://helics.univ-lyon1.fr/
- The European Antimicrobial Resistance Surveillance System (EARSS) web site is http://www.rivm.nl/earss/
- Information about the VaproSure system and other STERIS technologies is available at http://www.steris.com/aic/aic.cfm
- Information about MedMined is available at http://www.cardinal.com/medmined/