Defend against infection

13 April 2020

Healthcare-associated infections (HAIs) cost the US healthcare system around $8.9 billion per year, but this immense figure can be reduced by more than half by simply upping the game on infection control practices. Incredible advances in developing strategies to prevent and control such infections have already been made, but healthcare workers need to remain alert to spotting bugs and continuing key infection control procedures to guarantee they can prevent infections.

“HAIs are infections that are acquired in the healthcare setting – including hospitals and long-term care facilities,” explains Keith Kaye, professor of medicine in the Division of Infectious Diseases at the University of Michigan Medical School. “Many of these types of infections are preventable and some are associated with poor outcomes such as prolonged hospital stays and missed work.

“The most common ones right now include urinary tract infection, surgical site infection and Clostridioides difficile infection (C. diff infection or CDI),” continues Kaye, who is also president of SHEA’s board of trustees.

All under review

Few studies have estimated the amount of infections prevented or the number of lives saved when hospitals applied best practices in infection prevention and control. Recent research from University Hospital Zurich and the Swiss National Centre for Infection Control (Swissnoso) reviewed 144 studies conducted between 2005 and 2016 to determine the proportion of HAIs prevented through infection control interventions in different economic settings.

All the included papers focused on efforts to prevent at least one of the five most common HAIs – central line-associated bloodstream infections, catheterassociated urinary tract infection, surgical site infection, and ventilator-associated and healthcareassociated pneumonia – using a combination of two or more interventions, education and surveillance, or pre-operative skin decolourisation and pre-operative changes in skin disinfection protocol, for example.

The researchers concluded that up to 55% of HAIs could be eliminated by systematically implementing evidence-based infection prevention and control practices. The review indicated that interventions consistently reduced new infections by 35–55%, with the largest effect seen in central line-associated bloodstream infections. Primary bloodstream infections are among the most common HAIs that can lead to substantial patient morbidity and significantly increase healthcare costs, in addition to lengthening treatments and hospital stays.

There is no miracle cure for HAIs, and the proportion of preventable HAIs is still under debate, but the results observed are in line with previous estimates. The increased implementation of evidencebased best practices has been met with a global trend of ageing and multimorbidity. Studies later in the timeline are likely to have included a larger proportion of older and/or sicker patients prone to HAIs.

 As the population ages there is a higher rate of hospitalisation and predisposition to developing chronic diseases, which in turn increases the likelihood of multimorbidity and the presence of two or more chronic illnesses, and therefore necessitates additional efforts to further decrease HAIs. It’s likely that the preventable proportion of HAIs may decrease over time as the standards of care improve.

Methods of prevention

“Healthcare workers can help prevent these types of infections by practicing hand hygiene before and after every patient contact, and hygienically caring for medical devices in patients (such as vascular catheters and urinary catheters),” notes Kaye. “Also, by keeping a clean hospital environment through appropriate routine cleaning by environmental services, these types of infections can be prevented.”

Patient rooms should receive regular and thorough cleaning; this is the most effective way of controlling the spread of superbugs in hospitals. An important aspect to consider is how germs are being transported; they are being carried from place to place on shoes, carts, handbags and cases placed on floors, and even wheelchairs.

A simple splash from a sink can contribute to the spread of E. Coli, according to a study from the University of Virginia, and if left it can form an infectious biofilm that works its way across surfaces. In both isolation and non-isolation rooms, C. Diff was found on high-touch surfaces such as clothing and linen, call buttons, and medical devices and supplies. Floors were also often contaminated with MRSA, VRE (vancomycin-resistant Enterococcus) and C. Diff.

Cleaning protocols are fairly standard across all hospitals, but if not conducted properly, it’s likely that bacteria are lurking in most common areas of a facility. Comprehensive standard protocols should always be followed but there are additional procedures that could be implemented to reduce the risk of infections.

Educating staff, visitors and healthcare workers about the importance of not placing high-touch objects and equipment on the floor can have a huge impact, and better floor cleaning is key. Sporicidal disinfectants used to clean rooms and kill germs are not often used on floors, but maybe they should be. However, short of telling people they can’t put things on the floor, these facilities will never be completely sterile.            

High-tech solutions and economic considerations

Additional cleaning methods might include employing a UV robot that can disinfect hospital rooms. It uses high-energy xenon or mercury bulbs arranged in a circle, allowing the rays to reach all parts of surfaces quickly and better sanitise them. But this would be used in addition to current practices and not to replace them. The Orlando Health System reported a 46% reduction in HAIs when employing such technology over a three-year period.

One of the most effective ways to decrease infection is proper handwashing, as Kaye said, but it’s still not always being executed properly, so it’s now gone high tech. Wearable badges connected to Wi-Fi can remind staff to wash their hands; it works through a sensor that detects when someone enters or leaves a patient’s room and flashes to remind the wearer to wash their hands. The badges boast a 95% compliance rate.

“Compliance with best practices by healthcare workers can be improved by having institutional leaders value infection prevention, champion it, and practice good infection prevention behaviours themselves,” says Kaye, whose career has been devoted to prevention and management of healthcare-associated infections.

“Also, frequent and eye-catching reminders to providers to wash their hands and follow infection prevention guidelines and practices are very helpful. Finally, having patients and their families remind providers to wash their hands helps.”

Wealthy, more developed countries with widespread access to technology and greater advances in infection control don’t necessarily do a better job of combatting illness – improvement can still be possible. The review from University Hospital Zurich and Swissnoso found a relative reduction in infection rates independent of country and its economic income status. This suggests that quality improvement projects with multifaceted interventions may substantially reduce infection rates, regardless of the economic setting.

The quality of infection control measures can’t be inferred by a country’s economic classification alone; even in high-income countries where a high adherence to current recommendations might be expected, there is still room for progression. Healthcare institutions have an obligation to improve the quality of patient care and reduce infection rates by employing customised, multidimensional strategies and improve patient outcomes.

Although many hospitals, particularly those in high-income areas, may claim to obey current evidence-based standards, implementation science suggests a large discrepancy between their intention to effect change by employing standard operating procedures and actually implementing them into their daily practices.

Kaye believes the economic status of a country has a significant effect on the quality of infection control measures. “Some countries with lower economic status don’t have the resources to practice routine infection control,” he states.

“For example, some hospitals don’t even have running water, and some lack adequate gloves, gowns and mask supplies,” says Kaye. “We, in the US and other higher economic status countries, are very lucky to have basic materials needed to practice infection prevention – many other countries are not so fortunate.”

The HAIs considered in the University Hospital Zurich and Swissnoso review focussed on five deviceassociated infections – these represent only a fraction of all HAIs and data on the preventable proportion of non-device-associated infections is scare. However, the review is promising, and illustrates that it is possible to reduce the number of HAIs regardless of the economic setting.


HAIs could be eliminated by systematically implementing evidence-based infection prevention and control practices. 


The amount at which interventions were found to consistently reduce new infections, with the largest effect seen in central line-associated bloodstream infections. 

Infection Control &  Hospital Epidemiology


Hand hygiene guidance to prevent infection

Public Health England monitors the epidemiology of certain HAIs through routine surveillance programmes, and also advises on how to prevent and control infection in establishments, such as hospitals.

All UK National Health Service (NHS) hospitals must have an infection prevention service in place. Evidence-based guidelines for preventing HAIs in NHS hospitals in England state that healthcare professionals (HCPs) need to apply standard infection control precautions to the care of all patients.

The guidelines also affirm that one aspect of infection control is the consistent adherence to a hygiene protocol comprising hospital environmental hygiene; hand hygiene; use of personal protective equipment; safe use and disposal of sharps; and principles of asepsis.

These guidelines specify that a hand hygiene protocol requires HCPs to decontaminate their hands immediately:

  • Before each episode of direct patient contact or care, including clean/aseptic procedures
  • After each episode of direct patient contact or care
  • After contact with body fluids, mucous membranes and non-intact skin
  • After other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated
  • After the removal of gloves.

This hand hygiene protocol is consistent with the World Health Organization (WHO)’s ‘My Five Moments of Hand Hygiene’.

Auditing with performance feedback is an important component of WHO’s hand hygiene guidelines, and is undertaken routinely in many high and low income countries. This can improve the uptake of healthcare interventions generally and is an important component of many hand hygiene interventions.

High levels of hand hygiene adherence are frequently overestimated as a result of the Hawthorne effect and other sources of bias. Awareness of being watched encourages HCPs to cleanse their hands more often while audit periods are typically brief (15–20 minutes) giving an incomplete picture of usual practice, especially if intricate procedures with high risk of hand contamination are postponed until the audit is over.

Source: BMJ Open


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