The enemy within - healthcare-associated infections

9 December 2016

Healthcare-associated infections are one of the most pressing patient-safety concerns affecting healthcare facilities today. Elly Earls speaks to Dr Najiba M Abdulrazzaq, head of the infection prevention and control central committee at the Ministry of Health in Dubai, as well as the internal medicine department at Al Baraha Hospital, and pharmacy education and training manager at Cleveland Clinic Abu Dhabi Rania el-Lababidi to find out how hospitals in the UAE are working to combat them.

Healthcare-associated infections (HAIs) have become one of the biggest problems facing hospitals around the world, with hundreds of millions of patients affected every year in developed and developing countries. Thanks to a combination of factors, including travel trends, lack of education and overuse of antibiotics, some regions, including the countries of the Gulf Cooperation Council (GCC), are more susceptible than others.

Yet, with a combination approach – including stringent infection-control procedures, antimicrobial-stewardship programmes and comprehensive surveillance – significant ground can be gained in the battle against these often deadly infections.

The statistics around HAIs speak for themselves. Of every 100 hospitalised patients at any given time, seven in developed and ten in developing countries will acquire at least one HAI. In high-income countries, approximately 30% of patients in intensive care units (ICUs) are affected by at least one HAI, while in low and middle-income countries, the frequency of ICU-acquired infections is two to threefold higher. Meanwhile, infection rates among newborns are three to 20 times higher in developing than high-income nations.

There are also trends specific to particular regions, depending on various factors, including popularity as a travel hub, levels of education, and antibiotic prescription practices. The GCC, for example, is facing a rapid growth in antibiotic-resistant bacteria, or superbugs; one particularly deadly strain, carbapenem-resistant bacteria, which kills up to half of infected patients, has increased up to 90% over the past two decades.

Hidden culprits

A wide variety of factors have led HAIs to become such a pressing problem for hospitals – from changing population trends (older people and premature babies have reduced immunity to these bugs) to growing use of medications, like chemotherapy for cancers and immunosuppressants for chronic diseases, as well as the increased ease of travel all over the world.

Overuse or improper use of antimicrobials is a big contributor to the spread of HAIs because it leads to resistance to these drugs, as are the increased use of invasive devices such as catheters, and improperly cleaned and disinfected healthcare settings.

“HAIs can spread from patient to patient, patient to staff or from staff to patient. Reservoirs [for infections] include the patient’s endogenous flora [for example, residual bacteria residing on the patient’s skin, mucous membranes, gastrointestinal tract, or respiratory tract], which may be difficult to suppress, and inanimate environmental surfaces or objects that have become contaminated [such as patient-room touch surfaces, equipment and medications],” says Dr Najiba Abdulrazzaq, head of the internal medicine department at Al Baraha Hospital in Dubai, and the infection prevention and control central committee at the Ministry of Health in Dubai.

“In a study [from 2005, which analysed 1,022 outbreaks], it was shown that the most common sources of infectious agents causing HAIs are [listed in decreasing frequency]: the individual patient, medical equipment or devices, the hospital environment, the healthcare personnel, contaminated drugs, contaminated food and contaminated patient-care equipment.”

Small steps, big difference

The only way to combat HAIs effectively is with a combination approach, encompassing a robust infection-prevention and control programme, a comprehensive antimicrobial-stewardship programme and systematic surveillance. But it’s one of the most seemingly simple steps that can actually make the biggest difference to infection rates.

“Hand hygiene is the single most important process in preventing the spread of infections,” Abdulrazzaq stresses, adding that hospitals and healthcare facilities should be encouraged to adopt international guidelines, such as those provided by WHO, which include the ‘My 5 Moments for Hand Hygiene’ approach. “This would contribute to a greater awareness and understanding of the importance of hand hygiene, leading to improved compliance and sustainability in all countries of the world.”

“It’s crucial to put disinfectant gel dispensing bottles and proper hand-wash technique procedure charts at specified places, and incentivise all relatives of patients and hospital staff to disinfect hands frequently,” adds Dr Mansour al-Zarouni, a consultant medical and molecular microbiologist and executive director of EML Diagnostics in Sharjah, UAE. “These should be in colour and describe the process in large readable fonts.”

Similarly, equipment and medical-device cleaning should follow evidence-based recommendations, according to Abdulrazzaq. “If surgical equipment is not properly sterilised, there are chances that the next patient the equipment is used on can be exposed to a disease or infection that the previous patient had,” he notes. “This can only be prevented if proper disinfection and sterilisation is carried out.”

All of this should be part of a comprehensive infection prevention and control programme, led by a committee that continuously educates, monitors and evaluates the status of HAIs in the facility. “Plus, the staff at a healthcare organisation should be vaccinated, as this prevents them from getting infections from patients and thus spreading the disease to co-workers and patients,” Abdulrazzaq notes.

Drug resistance

Antimicrobial stewardship has also recently emerged as an important part of any strategy to control the spread of HAIs, particularly antibiotic-resistant strains, which are increasingly being allowed to proliferate due to overuse or misuse of these drugs. It’s an area in which Abu Dhabi’s Health Authority (HAAD) has been particularly proactive, mandating antimicrobial-stewardship programmes in every healthcare facility in the emirate, and setting up a national committee to study the situation and formulate legislation to better control the spread of multidrug-resistant organisms.

Cleveland Clinic Abu Dhabi’s antimicrobial-stewardship programme, led by a multidisciplinary team comprised of stakeholders from various sectors, including infectious diseases, infection prevention, microbiology, respiratory and critical care, nursing and pharmacy, is an example others should follow.

“Our programme charter is focused on key metrics that are measured around antimicrobial consumption and antimicrobial resistance on a routine basis, and we have implemented several interventions to optimise antimicrobial use, including prior authorisation of broad-spectrum antimicrobials, prospective audit with intervention, and feedback, among others,” explains Rania el-Lababidi, manager of pharmacy education and training, where she is also co-chair of the antimicrobial-stewardship programme in the department of pharmacy services.

“In addition to antimicrobial stewardship rounds and routine education to our clinical caregivers, we have also leveraged our electronic medical-record (EMR) system to optimise our antimicrobial-stewardship programme strategies. For example, an indication is required for prescribing antimicrobials, which has been embedded in the EMR and allows quick audit of use prospectively as well as retrospectively.

“We have also invested in a real time alert surveillance software that can identify bug-drug mismatches, as well as other opportunities for intercepting antimicrobial usage in an efficient and timely fashion. Additionally, we have created several guidelines and order sets to encourage wise antimicrobial prescribing.”

For el-Lababidi, the only way to build a successful antimicrobial-stewardship programme is as a team. “It requires executive leadership support to ensure its continued success in the organisation – which, I’m happy to say, we have been able to achieve for our programme,” she notes, adding that the team at Cleveland Clinic Abu Dhabi is also committed to sharing and bringing their best practices to healthcare providers across the UAE and region via speaking at and hosting various conferences.

Healthcare surveillance

The final part of the equation is surveillance, which is defined by CDC as ‘the ongoing systematic collection, analysis and interpretation of health data, closely integrated with the timely dissemination of these data to those who need to know,’ and which WHO proclaims as ‘fundamental for disease prevention and control’.

For Abdulrazzaq, this statement also stands correct for antibiotic-resistance surveillance. “Surveillance is vital to the fight against resistance. Antibiotic-resistance surveillance systems are an accurate and appropriate source of information to drive interventions and measure the effects of such interventions,” he says, adding that a well-planned surveillance study should provide data that will monitor changes in susceptibility and the progress of resistance, and thus help in the control of resistance and in the use of the most appropriate antibacterial agents.

HAAD, again, is ahead of the game in this regard, having established the Abu Dhabi Antibiotic Resistance Surveillance (AD ARS) system in 2010. “The AD ARS system is very important because it collects data specific to our region. It finds out what the important infections are caused by and finds the resistance pattern in our part of the world,” Abdulrazzaq explains. “By doing this, the local ‘antibiogram’ can be plotted, and antibiotic recommendations can be tailored to the common pathogens in our region, [so we can] better treat our patients and limit the spread of multidrug-resistant organisms.”

In 2014 alone, the database reported 33,415 different isolates, which is as much data – in just one emirate – than had been published in the scientific literature for all GCC countries combined in the past 21 years. The system was established at no cost and uses WHO’s free-of-charge WHONET platform for data analysis.

While stringent infection-control procedures, antimicrobial stewardship and surveillance programmes are all of paramount importance in the ongoing battle against HAIs, no one of these alone will ever have a significant impact. The only way to effectively tackle what the Patient Safety Movement Foundation has described as one of the most pressing patient safety concerns we face today is a joined-up approach, encompassing everything from hand hygiene to systematic surveillance.

Focus on ICU

A recent study carried out in the adult non-cardiac ICU at Sheikh Khalifa Medical City (SKMC) in Abu Dhabi has found that having dedicated infectious-disease (ID) clinicians conducting rounds in the unit on every weekday can have a beneficial impact on patient outcomes.

The authors compared the cost of antimicrobial agents, total hospital and ICU length of stay, and inpatient mortality over the six-month period, before and after institution of these rounds, between those seen versus those not seen by the ID team, and the results were impressive.

Among those seen by the ID team, there was an 18% decrease in total antimicrobial cost, a 40% decrease in ICU length of stay, a 33% decrease in overall hospital length of stay and a 34% decrease in mortality from pre-intervention to post-intervention period.

With infection rates in ICUs known to be significantly higher than elsewhere in hospitals (according to a recent European multicentre study, the proportion of infected patients in ICUs can be as high as 51%, with most of these healthcare-associated), it’s a crucial area for hospitals to address.

High frequency of infection is particularly associated with the use of invasive devices, in particular central lines, urinary catheters and ventilators, with the frequency of infections associated with these devices up to 19 times higher in some developing countries than those reported in Germany and the US.

Meanwhile, the longer a patient stays in an ICU, the more at risk they become of acquiring an infection. On average, the cumulative incidence of infection in adult high-risk patients in high-income countries is 17 episodes every 1,000 patient days.

Dr Najiba M Abdulrazzaq is head of the infection prevention and control central committee at the Ministry of Health in Dubai, UAE, and head of the internal medicine department at Al Baraha Hospital in Dubai. She is a member of the Royal College of Physicians.
Rania el-Lababidi is the pharmacy education and training manager at Cleveland Clinic Abu Dhabi, where she co-chairs the hospital’s antimicrobial-stewardship programme. She is a board-certified pharmacotherapy specialist with added qualifications in infectious disease.

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