Even the Best Facilities Need to do More to Prevent Hospital Acquired Infections

Healthcare-associated infections (HAI) can be reduced by up to 55% by systematically implementing evidence-based infection prevention and control strategies. HAI come at a considerable expense to patient and families but also cost the US healthcare system an estimated $9.8 billion each year. This study found healthcare institutions have a responsibility to improve the quality of patient care and reduced infection rates by effectively implementing customized multifaceted strategies and improved patient outcomes (Schreiber et al, 2018).

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Candida auris is emerging multidrug-resistant yeast that can cause invasive infections and has been associated with outbreaks in the healthcare setting. First identified in 2009, it is now reported in over a dozen countries. Although the attributable mortality is unknown, 30% to 60% of patients with C. auris have died. In 2015 a specialty hospital in the United Kingdom (UK) identified a C. auris outbreak among patients in the cardiac intensive care unit. When testing revealed additional patients with C. auris as well as on surfaces of the hospital and equipment, an aggressive infection control practices including thrice-daily room cleaning with bleach, and contact precautions were instituted.

The UK outbreak clearly showed C. auris can be transmitted in the healthcare setting. In response, the CDC issued a clinical alert (to US healthcare facilities) in June 2016. As of July 2017, 209 patients (99 from clinical cultures, 110 screened contacts) were reported to either have C. auris or were colonized with it. Experience with multidrug-resistant organisms (MDRDs) has shown it is recommended an early aggressive approach to control organisms when newly emerging is more effective.

Many of the principles for containment of C. auris are similar to those of other MDRDs. Antifungal susceptibility testing (AFST) for all clinically relevant Candida isolates is recommended by the 2016 Infectious Diseases Society of America for Candidiasis. In addition, consultation with an infectious disease specialist is highly recommended. Most C. auris isolates to date have been susceptible to echinocandins (Eraxis, Mycamine).

Switching to or adding liposomal amphotericin B (5m/kg daily; example-212 pound person need to receive 480mg/day) to aid in controlling transmission of C. auris in hospital contact precautions, thorough environmental cleaning and hand hygiene are paramount. In addition to testing patients, testing of healthcare workers should be considered (Tsay et al, 2018).

Healthcare-associated infection (HAI) rates are subject to public reporting and are linked to hospital reimbursement from the Centers for Medicare and Medicaid Services (CMC). The increasing pressure to lower HAI rates comes at a time when advances in the clinical microbiology laboratory (CML). Provide more precise and sensitive tests, altering HAI detection in ways that may increase reported HAI rates. I can review how changing CML practices can impact HAI rates and how the financial implications of HAI metrics may produce pressure to change diagnostic testing practices.

Example of this-Lab changes to a nucleic acid amplification test (NAAT) for C. diff detection, your positivity rate has increased by over 100%. And the hospital-onset C. diff infection (HO-CDI) has increased as well. During an investigation of the increase in CDI, you find that many samples positive by NAAT are toxin negative by enzyme immunoassay (EIA) and that many patients with decrease pretest probability of disease are being tested. Concerned about how the rate will impact value-based purchasing (VBP) and healthcare-associated condition (HAC) scores, the hospital leadership asks you to change back to EIA for CDI diagnosis.

This is an actual situation experienced by clinical microbiologists in practice. And in each case, the Lab was asked to change its testing approach in order to reduce the number of cases meeting a current National Healthcare Safety Network (NHSN) HAI definition. This is no doubt fueled by the fact CMS reimbursements rely on the reduction of HAC programs in an effort to link hospital payments to improvements in quality of care. Unfortunately, financial penalties based upon inter-facility comparisons place a great deal of pressure on HAI surveillance metrics, which changes the metrics by distorting the incentives associated with them. Whenever extreme pressure in the form of financial rewards or penalties are placed on a metric, human nature guarantees that complications will follow (Diekema, 2017).

Surgical site infections (SSI) are infections of the incision or organ or space that occurs after surgery. Emerging antimicrobial-resistant pathogens increase the cost and challenge of treating SSIs. Administering preoperative antimicrobial agents should only be given when published clinical practice guidelines and timed such that a bactericidal concentration of agents is established in serum and tissues when the incision is made.

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Advise patient to shower or bathe (full body) with antimicrobial soap or an antiseptic agent on at least the night before the operative day. In addition, use of intra-operative skin preparation with an alcohol-based antiseptic agent unless contraindicated. SSIs are persistent and preventable HCI. There is an increasing demand for evidence-based interventions; however, there are also substantial gaps found that warrant future research. A select list of these unresolved issues may be prioritized to formulate a research agenda to advance the field. Adequately powered, well-designed studies that assess the effect of specific interventions on the incidence of SSIs are needed to address these evidence gaps. Subsequent revisions to these guidelines need to be guided by new research and technological advancements for preventing SSIs (Berrios-Torres et al, 2017).

There have been more than 2,322 infectious diseases nosocomial (infection acquired while a patient in hospital) outbreaks filed in the World Outbreak Data based on articles since 1966, indicating frequent and continuous occurrence across the globe. Outbreaks occur frequently in hospitals and healthcare centers and pose a serious risk of colonization or illness to susceptible patients and healthcare staff. Hospitals providing acute care published reports on how the closing of wards helped to control infections and communicable disease some four decades ago.

Currently, some infection control strategies include enhanced hand hygiene, additional housekeeping, and environmental services, isolation, and personal protection equipment (PPE). This topic was found to be a novel one in using ward (floors/units in the US) closure in Canada to manage HAI outbreaks. The reported frequency or continuous use of overcapacity/full capacity protocol (OCP/FCP) by respondents to the studies survey reflects a broader issue of insufficient acute care capacity, inappropriate use of acute care beds, or gaps throughout the continuum of care within Canadian healthcare system.
These survey findings suggested that OCP/FCP has become the new normal for dealing with regular daily pressures at many Canadian hospitals. Some respondents said ward closure was not an option because of patient volumes suggesting administrative and patient care demands take precedence over the use of ward closure. The data accumulated by this study has identified gaps in knowledge and practice. More studies are also needed to understand the actual influence of ward closures in containing outbreaks and whether ward closure is actually effective for certain outbreaks such as antimicrobial resistant organisms versus respiratory or norovirus (the most common cause of foodborne diarrhea and vomiting), and endemic versus epidemic settings (Ocampo et al, 2017).

Work Cited
Berrios-Torres, S.I. et al. (2017). Centers for Disease Control and Prevention (CDC) guideline for prevention of surgical site infection. Journal of American Medical Association-Surgery(JAMA-Surgery),152(8). American Medical Association. Doi:10.1001/jamasurg.2017.0904

Diekema, D. (2017). Rising stakes for healthcare-associated infection prevention: Implications for the clinical microbiology laboratory. Journal of Clinical Microbiology. American Society for Microbiology. Doi:10.1128/JCM.02544-6

Ocampo, W. et al. (2017). Environmental scan of infection prevention and control practices for containment of hospital-acquired infectious disease outbreaks in acute care hospital setting across Canada. American Journal of Infection Control,45(10). http://dx.doi.org/10.1016/j.ajic.2017.05.014

Schreiber, P.W. et al. (2018). Even the best healthcare facilities can do more to prevent infections. Society for Healthcare Epidemiology of America. http://www.shea-online.org

Tsay, S. et al. (2018). Approach to the investigation and management of patients with Candida auris, an emerging multidrug-resistant yeast. Clinical Infectious Disease,66(2). Doi:10.1093/cid/cix744

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now the hyperlinks have been fixed. Sorry for any inconvenience.