Hospital-acquired Infection Rates—USA
Nosocomial or hospital-acquired infections (HAI) are a leading cause of morbidity
and mortality in the USA.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,
18, 19, 20, 21, 22, 23, 24, 25, 26 Several studies have been conducted over the years
to characterize and quantify this ever-growing public health problem. In a 2002 study
published in 2007, the estimated number of HAI in US hospitals, adjusted to include
federal facilities, was 1.7 million, with almost 99,000 deaths directly resulting
from the infection.
1
The highest infection rates per 1000 patient-days occurred in intensive care units
(ICU), followed by high-risk nurseries.1, 2, 4, 18, 27 Surgical site infections accounted
for a significant number of infections.1, 2, 4, 28, 29, 30 The most common sites of
infection in this study included urinary tract infections, which accounted for 36%
of HAI, surgical site infections (20%), pneumonia (11%), and bloodstream infection
(11%).1, 2, 4 In 1995, the Centers for Disease Control and Prevention estimated 1.9
million HAI.1, 2, 3, 4, 6 Among the deaths associated were the following 35,967 pneumonia,
30,665 bloodstream infections, 13,088 urinary tract infections, 8205 surgical site
infections, and 11,062 other infections.
1
Other national estimates are closely aligned with these data.
Within the context of HAI are selected pathogens that are or have emerged as significant
public health threats—methicillin-resistant staphylococcus aureus (MRSA),31, 32
Enterococcus-resistant vancomycin, and Clostridium difficile (C diff).30, 33, 34,
35, 36, 37, 38, 39, 40, 41, 42, 43 The latter is especially problematic as it is highly
difficult to eradicate from the health care environment and is increasing in incidence
and certain strains are emerging with increased virulence.32, 33, 34, 35, 38, 42,
43, 44 C diff will be discussed in the next article. Moreover, antibiotic use is a
preceding catalyst as are other commonly employed medical interventions, especially
among the very young and old.15, 20, 35, 37, 45 Given the well-recognized reality
that hand hygiene rates are abysmal among health care workers, another risk factor
for C diff, it is likely continued unnecessary deaths from C diff specifically and
HAI in general are likely to continue until fundamental changes occur in health care
practice.5, 6, 7, 8, 9, 10, 11, 40
HAI and the distribution of pathogens vary according to the clinical setting, patient
characteristics (primary diagnosis, multiple morbidities, procedures done) and the
health care setting (intensive care, burn unit, surgical care) and also by cohort
(neonate, adult, region, or nation).
The most recent large-scale data and estimates available to evaluate the scope and
threat of HAI resulted in the report from the 2002 National Nosocomial Infections
Surveillance System (NNIS) of the Centers for Disease Control and Prevention, including
the American Hospital Association Survey, and the National Hospital Discharge Survey.2,
3, 13 While NNIS uses standardized data collection protocols, each organization represents
different health care facility members and/or uses a variety of data sources—including
hospitals over 100 beds with at least 1 infection-control officer, admission/discharge
data, the use of risk component areas (ICUs and neonatal intensive care unit (NICU))
instead of hospital-wide surveillance, voluntary participation of the health care
facility (HCF) in sharing data, and other variables. Nevertheless, nosocomial infections
represent the eighth leading cause of death in the USA.
Regardless how HAI are estimated, the fact remains they are a persistent and in some
regions growing problem causing significant suffering, extra days of hospitalization,
even death. At a time when our health care system is overburdened, HAI are a preventable
strain on limited resources and a burden patients as well as their families do not
need. What is so disturbing is that some of the most effective preventive measures
are the most basic and easily performed.
In addition to being a leading cause of morbidity and mortality, as well as increased
hospital stays, HAI cause $17 to $20 billion in associated additional health care
costs each year.1, 2, 3, 4, 7, 10, 11 While exact data are lacking, it is estimated
that approximately 2 million HAI occur in children and adults in the USA annually.1,
2, 3, 4, 7, 11, 14, 43, 45 It is one of the most common adverse events associated
with hospitalization and health care. The main challenge to deriving estimates is
that no single source of representative data is available to estimate the burden of
health care-associated infections in the USA.
1
Hospital-acquired Infection Rates—Worldwide
While HAI are an important health care concern worldwide, they are especially troublesome
in developing nations. Nosocomial infection rates range from 1% in Northern Europe,
especially The Netherlands, which introduced extremely aggressive infection control
measures, to > 40% in some parts of Asia, South America, and sub-Saharan Africa.1,
2, 3, 4, 5, 6, 7, 46, 47, 48 Sanitation is clearly a major factor for such high rates
of HAI in developing nations. Lack of resources is another. Studies suggest more than
50% of injections administered at HCF in developing countries are unsafe. Often the
needles and/or syringes are reused, including between patients. Some of those injections
are also unnecessary such as routine injections of vitamin B-12 or antibiotics. However,
when a hammer is all you have, everything looks like a nail; HCF use what they have,
albeit sometimes in a well-meaning but ill-conceived attempt to heal. A major consequence
of this is that an estimated 80,000-160,000 new human immunodeficiency virus (HIV)
infections occur annually in sub-Saharan Africa, and even more cases of hepatitis
B virus and hepatitis C virus occur worldwide each year because of unsafe injections.
Among the more industrialized and developed nations, the World Health Organization
found 8.7% of all hospital patients had nosocomial infections. Annual HAI prevalence
studies revealed that among 100 admissions, Greece had 9.1%, Spain had 7%, while Norway
had 5.1% and Slovenia had 4.6%.1, 47, 49 Not unsurprisingly, the highest prevalence
of HAI occurred in ICUs and acute care surgical and orthopedic settings. Old age,
multiple morbidities or disease severity, and decreased immunity increase patient
susceptibility. Poor infection control measures are an overall risk factor as are
certain invasive procedures including central venous or urinary catheter placements.1,
18 Antimicrobial misuse is associated with drug-resistant HAI. Other risk factors
for HAI will be discussed in the following section on specific pathogens.
Leading Causes of Death
While it is true that chronic diseases such as coronary disease and diabetes have
replaced acute infections as the leading cause of mortality in persons older than
65 in the USA with outbreaks of contagious infectious diseases remaining uncommon,22,
24, 25, 50, 51 such chronic illnesses often result in hospitalizations; therein lies
a risk for acquiring an infection or other adverse outcome.
This dramatic change in the top leading causes of death from infection related to
chronic disease over the last century can give the false sense of “victory” that we
have conquered pathogens in the USA (Table 1). We should consider this a cautionary
time. “Victory” is better exchanged for the term “stalemate” with infections—possible
only as long as we practice the sound infection control practices that lead to the
changes in mortality from 1900 to 2000.
51
The increased inattention to these infection control practices being reported may
account for the death rate from infectious diseases rising 58% between 1980 and 1992
(making them in the aggregate the third leading cause of death in the USA). Influenza
and pneumonia remain responsible for 5.5% of the deaths of people 65 and older (95,640)
in 1997, with an increase in infection-related deaths among older persons from 1980
to 1992.
51
Also, the combined death rate from influenza and pneumonia for all age-race-sex groups
has increased.
51
TABLE 1
Leading causes of death 1900 and 1997 USA, 1992 Peru17, 22
Major Causes of Death (Attributable)
1900 USA
1992 Peru
1997 USA
1
Respiratory disease
Respiratory infections
Heart disease
2
Tuberculosis
Cancer
Cancer
3
Gastrointestinal disease
Gastrointestinal disease
Cerebrovascular disease
4
Heart disease
Heart disease
Pulmonary disease
5
Infectious/parasitic diseases
Tuberculosis
accidents
6
Kidney disease
Cerebrovascular disease
Pneumonia/influenza
7
Early infancy diseases
Urinary system disease
Diabetes
8
Cerebrovascular disease
Nutritional deficiencies
Suicide
9
Cancer
Early infancy
Homicide
10
Liver disease
HIV AIDS
With almost 2 million patients acquiring nosocomial infections each year in United
States hospitals, the war against infectious diseases is clearly not over.1, 2, 3,
4, 5, 6, 7, 24, 51
HAI Causes: An Overview
Key factors associated with HAI that are unlikely to change without a concerted and
sustained effort1, 8, 13, 15, 20, 23, 31, 32, 35, 37, 52 include the following:
•
Increasingly sicker patients being admitted to HCF
•
Lack of surge capacity resulting in overcrowding of patients
•
Increasing number of immune impaired patients
○
HIV
○
Age
○
Immunosuppressive agents
▪
Autoimmune diseases
▪
Cancer
▪
Transplants
•
New and/or emerging pathogens
○
Acinetobacter
▪
C difficile
•
Increasing antimicrobial resistance
○
MRSA
○
Vancomycin-resistant S aureus
○
Vancomycin-resistant C difficile
Failure to perform appropriate hand hygiene is a leading cause of health care associated
infections and the spread of multidrug-resistant organisms and contributes to outbreaks.
Overcrowded waiting rooms and health care facilities lacking surge capacity and filled
to overflowing give less time for proper sanitation.52, 53 Health care workers not
adhering to good hygiene practices contributes to the rising infection problem. Overcrowding
in the absence of an epidemic only portends a system-wide failure in the presence
of a highly transmissible virus.52, 54, 55, 56, 57 Recent Emergency Department closures
in the face of increased patient volume and lack of affordable resources for uninsured
persons contribute to diversions and overcrowding. Lack of hospital beds exacerbates
the problem.
Hospital-acquired Infections: Pathogens to Watch—Overview
Health care associated infection has emerged as one of the most critical and worrisome
clinical issues in contemporary society and a significant public health concern. HAI
results in unnecessary human suffering and death as well as health care expenditures.
Few have not read cautionary articles from the Institute of Medicine, Institute for
Healthcare Improvement, and other well-respected organizations in addressing the almost
runaway rates of HAI and the unacceptable risk health care facilities and professionals
place on their patients in the absence of or inconsistent use of good infection control
practices.
Virtually any pathogen from a long list of organisms found in hospitals is causing
a nosocomial infection. However most HAI are caused by a relatively short list of
pathogens, some of which target patients in selected cohorts such as those who are
immune-compromised, or with specific risk factors such as antibiotic exposure, burns,
surgery, or trauma.28, 29, 30, 58, 59
No discussion of HAI could begin without at least mentioning S aureus, especially
MRSA.31, 32 Of concern, the proportion of S aureus isolates among ICU patients that
are resistant to methicillin (MRSA) as well as oxacillin or nafcillin is on the rise
at approximately 60%. Of such concern is MRSA that the Joint Commission on the Accreditation
of Healthcare Organizations (JCAHO) has recently empanelled a scientific team and
issued newer guidelines.
60
Klebsiella pneumoniae have demonstrated a 50% increase in resistance to third-generation
cephalosporins. Other HAI including Pseudomonas aeruginosa and C diff are demonstrating
increased antimicrobial resistance.
While some pathogens are the result of extraordinary circumstances—for example, Acinetobacter
baumanii infections associated with battle field injuries as is being experienced
by wounded Gulf War troops,58, 59 others should have been readily predictable—MRSA,
vancomycin-resistant Enterococcus, and C diff, which will be discussed in greater
detail in the next article.
The C diff pathogen is especially worrisome for several reasons. First, many of us
were trained at a time when this bacterium was considered an unusual event associated
with only a few antimicrobial medications. Second, the perception is that it can be
readily treated. Third, the true epidemiology (growing) is underappreciated among
health care professionals and patients.
33
Times have changed. C diff, antibiotic-associated diarrhea, or medication-host--dependent
infections such as C diff infection are a growing and significant health hazard for
patients. Although it will be discussed in more depth later in this monograph, C diff
is increasingly the result of common medical practices that include routine alteration
of patient pH (widespread use among the elderly of proton pump inhibitors and gastric
acid suppressant therapy,61, 62, 63 inattention to the benefit of probiotic adjunct
therapy when prescribing antibiotics; albeit that remains somewhat controversial,
it is a low-risk possible benefit, judicious use of antimicrobial medications, and
attention to infection control—especially hand washing,64, 65 cohorting infectious
patients, and other methods. Putting it into perspective, although estimates of HAI
are approximately 2 million annually, C diff associated diarrhea [C diff associated
disease (CDAD)] is estimated to affect over 3 million inpatients a year in the USA23,
66).
Control of emerging and existing infectious diseases can be a daunting task given
the large number of disease-causing organisms, the evolution of antimicrobial resistant
or increasingly virulent pathogens, the discovery of new microbes, and overpopulation—within
communities and HCFs.1, 18, 22, 24 Changing patterns in host factors and prescribing
practices, as briefly discussed earlier, also contribute.
Global travel can lead to the importation of novel pathogens uncommon in the new environment,
which thus may go unsuspected or initially unidentified.24, 56
Examples include avian flu (avian influenza, H5N1) and severe acute respiratory syndrome.
HAI of avian flu were demonstrated in a retrospective study. Health care workers exposed
to patients with H5N1 infection were more likely to be seropositive and this was not
attributable to animal exposure.54, 55, 67, 68, 69, 70 It is reasonable to assume
that the route of infection for avian influenza patients, like most influenza patients,
can be from inhalation of infective respiratory secretions and/or contact with virus-laden
secretions and subsequent transference contact with mucous membranes. Studies suggest
that the airborne transmission of influenza explains the sometimes numerically explosive
nature of flu epidemics.54, 55, 67, 68, 69, 70 It is important to recognize that seasonal
influenza can be transmitted within health care and long-term facilities. The basic
reproductive number for influenza (the number of secondary cases produced by 1 primary
case) varies from 1.68 to 20.
As discussed earlier, given health care in the 21st century is provided in acute care
hospitals, long-term care facilities, and home health settings, emphasis on strict
infection control measures cannot be directed solely toward hospital personnel; all
caregivers must be taught and subsequently held accountable for adhering to infection-prevention
strategies. These cannot be overemphasized or repeated too frequently: hand washing,
barrier protections, vaccination (patients, caregivers, and health care workers),
and other strategies to be discussed.
Most HAI are associated with urinary tract infections, surgical site infection pneumonia,
bloodstream infection, and others, including gastrointestinal tract infection such
as CDAD.
1
Urethral catheters are a well-known risk. Surgical site infections accounted for over
240,000 HAI in the NNIS report.1, 2, 3 There are also seasonal variations associated
with certain pathogens. The return of severely wounded troops from the Persian Gulf
is becoming a risk factor for HAI—especially related to the bacteria Acinetobacter,
most notably Acinetobacter baumannii at health care facilities.58, 59, 71, 72 Multidrug-resistant
A baumannii is considered near epidemic among the wounded in Iraq compared to Afghanistan.
A recent outbreak of A baumannii at Walter Reed Army Medical Center resulted in 53
HAI and 4 deaths.58, 59 Because of this, returning wounded troops are often isolated
until they are cleared of this pathogen. Although typically occurring in ICU settings
in US hospitals, the risk of A baumannii as an HAI is increasing.
72
Although organisms causing many nosocomial infections often come from the patient's
own body flora, contact in a hospital environment where pathogens often can survive
on surfaces or instruments remains a significant risk. Patients also interact with
staff and contaminated instruments. Because patients are highly mobile and hospital
stays are becoming shorter, patients often are discharged while asymptomatic, before
the infection becomes apparent. An infection control challenge resides in the fact
that many nosocomial infections in hospitalized patients especially originating from
ambulatory care facilities become apparent only after the patients are discharged.
Key Cohorts
While all hospitalized patients are at risk for HAI, certain subpopulations are at
increased risk. These include the elderly, the immune-compromised, the very young
or premature, and burn and surgical patients.
Neonates are susceptible to infection because of immature immune systems and exposure
to extrinsic risk factors associated with HCF such as central venous catheters and
surgical procedures, resulting in nosocomial infection rates between 15% and 20% in
the NICU.1, 2, 3, 12 These rates are significantly greater than those found in the
pediatric ICU population. According to the NNIS there were 33,269 HAI among newborns
in high-risk nurseries, of which gram-positive organisms including MRSA, Escherichia
coli, a gram-negative organism, and Candida albicans fungal infections were the most
common.1, 2, 3, 4, 12 Neonatal meningitis, a difficult diagnosis in this population,
appears to be more common than previously thought. Staph, Group B Streptococcus, E
coli, Klebsiella, Serratia, and Candida have been implicated as significant causes.
MRSA, recognized in the 1970s, continues to be a major pathogen in adult, pediatric,
and neonatal HAI, and Candida is a significant cause of mortality among neonates in
the ICU. Although beyond the scope of this article, some studies support the newer
strategy of using prophylactic fluconazole in high-risk neonates in the ICU such as
those < 750 g to reduce the risk of fungal infections.12, 73, 74, 75
Not unlike other patients, newborns, even those not requiring NICU care, are susceptible
to HAI. According to the NNIS, there were 19,059 HAI among newborns in well-baby nurseries.
1
Among adults and children outside ICU settings, there were 1,266,851 HAI and of adults
and children treated in intensive care units; 417,946 annual HAI were acquired.
Hospital-acquired Infections—Prevention: An Overview
So how can HAI happen amid the world's leading health care facilities? Why is an admission
to a HCF now a risk factor for contracting a potentially deadly infection, often unrelated
to the admission diagnosis? What can be done to reduce HAI?
Sometimes the best interventions are also the lowest technologically (Table 2). In
the 1800s a young obstetrician, Philipp Semmelweis, recommended disinfecting the hands
of health care professionals before examining pregnant women or assisting in their
childbirth as a way of preventing puerperal or “childbed fever,” which Dr Louis Pasteur
in 1879 subsequently identified as hemolytic streptococcal infection.12, 49 Dr Semmelweis
noted that women giving birth on the street had less likelihood of becoming infected
with “childbed fever” or dying, compared to those who were attended by health care
professionals!
49
What would seem so basic now, especially knowing germ theory, in the 21st century,
in a nation blessed with and abundance of clean water coast to coast, is the need
for hand washing. It would seem almost embarrassingly obvious to any health care professional
the need for cleanliness before touching a patient, let alone after using the bathroom,
yet such is not so apparent nor practiced.5, 6, 7, 8, 11, 40, 60, 64, 65
TABLE 2
Readily applied strategies to reduce HAI12, 35, 40
•
Hand hygiene
○
Use soap and water after patient contact, especially if hands become contaminated
•
Skin cleaning
○
Avoid scrubbing skin with brushes or harsh soaps
•
Gowns/gloves
○
Use best barrier practices when doing procedures, especially inserting catheters,
central lines, or changing dressings
•
Antimicrobial stewardship protocols
○
Promote the use of the simplest and most targeted antimicrobials. Whenever possible
avoid broad-spectrum antibiotics
•
Avoid drugs associated with increased HAI risk
○
H2 blocking agents can alter the pH of the GI tract and affect the balance between
normal/beneficial flora and pathogenic flora
○
Systemic steroids can alter immune status and increase the risk of HAI
•
Minimize practices that disrupt skin barrier
○
Venipunctures or heel sticks
○
Catheters. NB attempt to minimize the duration of central catheter and other invasive
instruments
•
Patient spacing
○
Isolate or cohort infectious patients
○
Attempt to maximize space between patients
○
Attempt to avoid overcrowding
○
Use alcohol bases antiseptic before patient contact
While we increasingly rely on high-technology measures to improve health outcomes,
such low-technology preventive measures cannot and should not be abandoned. In an
era of advanced medications, evidence-based medicine protocols, mass media coverage
of adverse health outcomes, and computer technology, it is both amazing and appalling
that patients still are harmed through acquiring HAI during the course of their care.
It should therefore be no surprise that evidence supports hand hygiene to reduce health
care associated infection rates—whether using soap and water or other waterless interventions
including alcohol-based hand rubs, although CDAD is more amenable to prevention using
soap and water. In a nation blessed with clean water and an abundance of soap and
disinfectants, it is incredible that health care professionals need to be reminded
to wash their hands—accepted as one of the most effective infection-control procedures.
With estimates suggesting 1 patient in 20 will fall victim to a HAI, the Joint Commission
on the Accreditation of Healthcare Organizations has issued new guidelines to address
MRSA and is becoming more aggressive in penalties for nonadherence to good infection-control
practices among its member organizations.32, 60 In addition to hand washing, other
key recommendations from JCAHO and the Ministry of Health and Long Term Care–Canada
guidelines emphasize a broad as well as focused view on C diff/infection control covering
the facility/environment, the patient, health care workers, and medication selection
(Table 3).
40
TABLE 3
Overview of infection control measures12, 35, 40
I
Patient
a
Antibiotic selection
b
Risk factors for infection
c
Multidisciplinary team involved in infection control
d
Patient care guidelines
i
Catheters
ii
Antimicrobial use
iii
Surgical wound care
iv
Postoperative care
v
GI care
II
Accommodation
a
General consideration to limit the spread throughout the facilities
i
Cohorting
ii
Isolation precautions
iii
Patients suspected of having C diff should be placed in rooms with the following
1
Signage as to risk, required personal protective equipment (PPE)
2
Available barrier PPE with laundry hamper or dedicated waste disposal for PPE
3
Placement in a single room with dedicated toileting facilities
4
If the number of cases exceeds single room capacity then
a
Prioritize cohorting
b
Dedicated commode wherever possible
III
Contact precautions
a
Signage with precautions on doors of cohort and isolation patients
b
PPE readily available with instruction placards
c
Procedures on specific handling with regard to infected patients should be provided
to all employees coming in contact—housekeeping to senior attending
d
Dedicated equipment and/or barrier covers
i
Wheelchairs
ii
Commodes
1
SPECIAL handling precautions to prevent spore spread
iii
BP cuffs
iv
Lifts
v
Thermometers (avoid rectal temperatures)
vi
Other
IV
Hand hygiene
a
Soap and water as well as other hand rubs—time and attention to complete washing
i
Remove gloves
ii
Alcohol based if dedicated hand washing sink not available (avoid patient sink)
iii
Wash hands with soap and water at nonpatient sink
V
Environmental cleaning
a
All surfaces in the room and items within reach of patients with suspected C diff
or other aggressive HAI should be cleaned twice daily with hospital-grade disinfectant
b
Special attention to patient-specific items and “high touch” surfaces (phone, bedside
rails, call and light activators, door handles, faucets, commodes, etc)
c
Work from clean to dirty
d
Change cloths and mop heads frequently
e
Disposable toilet brushes should be used in ALL patients with C diff/HAI
f
Discharge/transfer level cleaning must occur when patient is cleared
g
Educational and auditing materials should be developed for environmental/housekeeping
and communicated throughout the chain of care
VI
Visitors
a
Should receive instruction especially concerning
i
Hand hygiene
ii
PPE
iii
Safe visitation procedures
VII
Patient transfer
a
Transportation services and all downstream services/departments should be alerted
to and trained in the care of C diff and HAI patients
b
Educational and audit materials should be made available
c
Availability of PPE with instruction on proper usage
d
Coordination with environmental/housekeeping on proper cleaning of transport equipment
VIII
Patient discharge
a
Precautions and educational material should be provided for patients and their family
members/caregivers.
For more complete information, refer to Best Practices Document for the Management
of Clostridium difficile in all health care settings. PIDAC. Ministry of Health and
Long Term Care. Published December 2004, Revised November 2007.
Of interest, in 2006, 7 states in the USA have implemented mandatory reporting of
HAI by hospitals.1, 8 Such legislative mandates are an important step in what must
be a comprehensive approach to a strategy of reducing nosocomial infections. Consistent
training, greater emphasis on sanitation, investment in single-use equipment when
necessary, greater communication, and coordination of care across disciplines, including
directed guidance by infection control professionals, are needed. Amazingly, blood
pressure cuffs and other equipment continue to be shared between patients with C diff
or other HAI and those uninfected! Solutions include single-use sphygmomanometers
that can then be billed to the patient (they are low cost as anyone who has purchased
one at a chain pharmacy can attest, especially in the grand scheme of hospital expenses),
cuff barriers, which are increasingly available and low cost, or disposable cuffs—all
significantly less expensive than a hospital-wide outbreak.
Outcome measures need to be “owned” by every member of the facility team. Updating
the staff where positive- and negative-infection control outcomes are occurring in
a “no blame” environment can promote greater awareness, problem-solving, and effort.
A recent unpublished survey of health care professionals revealed most were not aware
C diff was a leading HAI or was readily transmitted by shared stethoscopes or blood
pressure cuffs. Some thought it was an ICU problem. In 2008, C diff and HAI should
be top concerns at HCF. Too many patients and no support staff are not viable excuses
in the short term to not wash hands or attend to infection-control measures. However,
they are viable problems that must be addressed for the long term. Local HCF trends
in infection-control successes and failures need to be shared across departments and
not just the purview of the medicine or infection-control departments. Departmental
compartmentalization or annual in-service updates are inadequate to address the daily
threat of HAI.
Educational programs, with posted outcomes measures and communications about progress
or areas needing improvement, not in a blameful manner but with the goal of continuous
quality improvement, should be implemented. Everyone who works at or is a patient/visitor
in a health care facility is a stakeholder, and a potential problem or solution. Everyone
needs to be engaged from the top to the most entry level worker. Infection Control
is a team sport.
Cost remains a driver in HCF policies and infection control measures. However, balanced
against human suffering, preventable death, and the billions of dollars in added health
care costs associated with HAI, clearly greater investment in infection control must
be expended. Given the number of deaths associated with HAI exceeds that associated
with many of the top 10 causes of death in the USA, reinforcement is needed to address
this problem. In the coming years increasingly sicker and older patients will be admitted
to HCF, and their likelihood of acquiring an HAI will increase as will their untimely
death unless dramatic change occurs.
Conclusions
The purpose of this monograph is to increase awareness about HAI, especially C diff,
as largely preventable causes of death and suffering, to share best practices in infection
control, to introduce emerging pathogens yet to be fully appreciated, and to discuss
one of the most dangerous HAI, which is at epidemic proportions, C diff.
Without question, C diff has become an infection-control challenge of enormous proportions
affecting hospital patients, as well as long-term care residents, even outpatients.
Of additional concern is its increase in virulence as well as antimicrobial resistance.
Moreover, antibiotics heretofore considered low risk as contributory to clostridial
overgrowth or development of symptomatic illness are now becoming associated with
CDAD. Unless infection control measures improve facility-wide and until health care
professionals, especially physicians and nurses, adhere to basic tenets of hygiene,
not the least of which should be hand washing before and after every patient encounter,
HAI will continue to harm our patients.
As a profession we have contributed to the increase in HAI, including C diff; with
little additional effort, together we can significantly reduce this major public health
problem and with it increase the likelihood of protecting our patients.
76