High- and low-tech solutions to reduce the incidence of hospital-acquired infections and antibiotic resistance

Approximately 1.7 million healthcare-associated infections (HAIs) occur in US hospitals each year. These HAIs, which include pneumonia, bloodstream infections (BSIs), and urinary tract infections (UTIs), account for approximately 99,000 deaths and $5 billion in additional healthcare costs. Central line BSIs account for approximately 250,000 HAIs each year. The estimated mortality rate associated with these infections is 12% to 25%, and the cost per infection is approximately $25,000.

In an effort to reduce the number of central line-associated BSIs in the intensive care units (ICUs) of southwestern Pennsylvania hospitals (N=32), the Pittsburgh Regional Healthcare Initiative, a nonprofit group dedicated to improving healthcare safety and quality in southwestern Pennsylvania, collaborated with the Centers for Disease Control and Prevention (CDC). Over a 4-year period, many targeted interventions were implemented. Targeted, evidence-based catheter insertion practices were promoted (ie, using sterile barrier precautions during insertion, using chlorhexidine to disinfect the skin before insertion, and removing catheters when no longer needed). Educational programs about central lines, including strategies for infection prevention, were provided. Additionally, standardized tools to record adherence to appropriate catheter insertion practices were used. These measures helped reduce the BSI rate per 1,000 central-line days by 68%, from 4.31 to 1.36 (P<.001). The results of this program suggest that coordinated infection-control initiatives among healthcare facilities might be an effective way to reduce infection rates.

The use of “active surveillance” systems can also help to reduce the incidence of HAIs and improve antibiotic susceptibility. These systems use “real time” observation as an antibiotic-resistance prevention technique. One such system is the SafetySurveillor, manufactured by Premier, Inc, Charlotte, North Carolina. SafetySurveillor is a web-based tool that allows hospitals to identify and track HAIs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile. The information can be tracked across all hospital units or surgical procedures, and the program helps distinguish between HAIs and community-acquired infections. It has been suggested by Marianne Billeter, PharmD, BCPS, a member of the Joint Commission’s Infection Control Expert Panel, that any surveillance system should be fully integrated with the hospital’s laboratories, pharmacy, and admissions department and at the bedside (when possible). However, according to Gonzalo Bearman, MD, MPH, associate hospital epidemiologist and assistant professor of internal medicine, Virginia Commonwealth University, Richmond, Virginia, “The use of active surveillance cultures for the control of multidrug-resistant organisms such as MRSA remains controversial.” Dr Bearman stated, “In the nonoutbreak setting, simple infection control interventions, such as hand hygiene and compliance with infection control process of care measures, should be the initial strategy for the control of MRSA and multidrug-resistant organisms.”

Many different tools and guidelines, including a CDC-sponsored campaign to raise awareness, are available to help raise antibiotic resistance awareness and to assist in the reduction of HAI-related mortality and morbidity in healthcare settings (available at: http://www.cdc.gov/drugresistance/healthcare/default.htm). The CDC program focuses on infection prevention, effective diagnosis and infection treatment, wise antimicrobial use, and prevention of infection transmission.

According to studies that have assessed clinicians’ perceptions regarding antibiotic resistance in healthcare facilities, clinicians tend to view antibiotic resistance as a national problem, rather than a local one. Many clinicians do not comply with AR prevention guidelines. In one study, physicians listed the top causes of antibiotic resistance as antibiotics for self-limited nonbacterial infections, broader-than-needed antibiotics, and antibiotic use for shorter-than-standard durations. Other sources of antibiotic resistance include poor hand hygiene and patient expectations, including the expectation of receiving an antibiotic prescription from the doctor to treat a potentially infectious illness and the feeling of undertreatment if an antibiotic is not prescribed following surgery. Although hand hygiene was identified as a source of antibiotic resistance, it ranked low on the list, despite efforts to increase awareness about the importance of hand hygiene among healthcare providers and patients.

National and international guidelines and data such as those included in these studies can assist health-systems in tailoring interventions to help decrease the incidence of HAIs and antibiotic resistance. The Joint Commission is involved in a number of initiatives to reduce these problems, including the patient safety campaign Speak Up, and safety goals to reduce the risk of HAIs through handwashing and the reporting of sentinel events.

Sources
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