Healthcare-associated Infections—Can We Do Better?

Abstract

HEALTHCARE-ASSOCIATED INFECTIONS: DEADLY, COSTLY, AND WIDESPREAD Healthcare-associated infections (HAIs), which occur when a patient is receiving care in a hospital or other healthcare facility, are the most frequent adverse event in healthcare worldwide. HAIs cause significant increases in morbidity, mortality, length of hospital stays, and healthcare costs and have a particularly severe impact in low- and middle-income countries (LMIC).1 In Europe, approximately 1 in 20 patients will contract an HAI leading to an annual loss of 2.5 million disability-adjusted life years (DALYs), mostly in neonates and children, and direct costs of up to €7 billion per year.1,2 Yet research also shows that most HAIs are preventable through simple, low-cost infection prevention and control (IPC) practices. The importance of preventing HAIs is especially clear in light of the current COVID-19 pandemic, which has put healthcare systems around the globe under enormous stress, and has highlighted the role of IPC practices in protecting both the public and healthcare workers.3 THE BASIC PRINCIPLES OF INFECTION PREVENTION AND CONTROL Surveillance—Knowing Your Enemy Robust surveillance mechanisms are a critical tool in the fight against HAIs. Data that shows who is getting infected, where infections are happening, and how many infections are occurring are essential to the design and implementation of effective interventions. In addition, an established surveillance system provides the means to assess the effectiveness of IPC programs and to invoke changes when needed. In the United States, the Centers for Disease Control and Prevention tracks HAIs through the National Healthcare Safety Network, and in Europe HAIs are tracked through the Healthcare-Associated Infections Surveillance Network. While National Healthcare Safety Network is an active surveillance network that uses mostly epidemiologic definitions, and the Healthcare-Associated Infections Surveillance Network is a point prevalence survey-based system with more clinically and laboratory-focused definitions, both aim to create metrics that allow for benchmarking and target identification. Globally, despite some differences in terms and definitions, HAI surveillance tends to focus on the following: central line-associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated events (VAEs)—the evolution of ventilator-associated pneumonia; surgical site infections; hospital-onset infections involving specific pathogens such as Clostridium difficile and multidrug-resistant organisms; and hand hygiene, the simplest and most effective way to prevent HAIs. Evidence-based Practices—Fighting Your Enemy There is a robust and expansive body of literature on the prevention of the most common HAIs,4–6 which are focused around compliance with IPC best practices and the resultant prevention of transmission. As established and described by the World Health Organization, the core components of an effective IPC program include: establishing guidelines; supporting education and training; establishing HAI surveillance; using multimodal strategies; monitoring and evaluation of IPC practices; adequate staffing according to workload; adequate availability of materials and equipment for IPC.6 Table 1 shows some indicative strategies for each type of infection. As evidence is still lacking for the prevention of VAEs we have to resort to the guidelines developed for the prevention of ventilator-associated pneumonia. It is necessary to always assess the latest literature as for example previously recommended oral care with chlorhexidine was shown to increase negative outcomes for mechanically ventilated patients. Prevention in the form of care bundles, which comprise a small set of coordinated, evidence-based practices, have been successful in improving compliance with best practices and patient outcomes in a variety of countries and settings. In addition, checklists have b