Nosocomial and health care-acquired infections (HAIs) are the number one cause of death in the United States.1HAIs can cost hospitals billions each year, which decreases their profitability. HAIs were once accepted as a risk for hospitalization, until evidence showed that they could be prevented.2
In the past ten years, governments started holding hospitals responsible for preventable HAIs. While most states have passed laws requiring hospitals infected to report them, many did not.3The Leapfrog Group, an organization that focuses on safety in health care, has released Hospital Safety Grades for 2900 facilities.4This is less than half of all US hospitals. Therefore, we don’t know the extent of HAI’s impact.
HAIs are largely caused by economic and social factors. HAI mitigation programs are difficult to expand for health care organizations due to budget, staff, time and staff constraints. Many hospitals have limited resources and are subject to overcrowding, inadequate supplies, and poor training.5However, the cost of reacting in order to contain HAIs and the resulting loss or life is much higher than the cost for proactive infection prevention strategies.
During this time, hospitals were focusing on COVID-19 for 2 years, while nosocomial diseases thrived.6It is possible to imagine that significant reductions in HAIs could be achieved if health care facilities made the same pandemic-level effort towards HAI mitigation.7
Urgent Threats
Knowing the location of the pathogenic enemies is key to minimizing HAIs. The most common HAIs fall into 6 categories: central lineassociated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, ventilator-associated pneumonia, nonventilator-associated hospital-acquired pneumonia, and gastrointestinal Clostridioides difficile (C difficile) infections.8
While nosocomial infection is a concern in health care, there are other urgent threats. HAIs have been linked to antimicrobial-resistant and multidrug-resistantorganism (MDRO) infections, which are unaffected by 1 or more antibiotic, earning the moniker Superbugs.9 The 5 superbugs that contribute to most HAIs are: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, carbapenem-resistant Enterobacterales, Acinetobacter baumannii, Candida auris (C auris). Long-term care settings, in particular, are vulnerable to MDROs and HAIs. C difficile C auris.10
It is crucial to understand the basic characteristics of pathogens so that they can survive and spread. For example: C difficileThese spores persist on floors and surfaces, and are difficult to eliminate.11While C auris Colonizes skin and can be passed from one person to another or shed onto surfaces. MRSA and C aurisThey can survive in protective biofilms which make them more difficult to eradicate.12
Transmission Ecosystem
Understanding the transmission environment is the next step towards reducing HAIs. It is complex and involves patient susceptibility, infectious agents and infection control practices. The first link in the chain is the source of the infectious agent. The key to breaking the chain is (Figure 1) is to address the source and disrupt its transmission.13
HAI transmission occurs in three main modes: aerosol (airborne), droplets, or contact.14 Some pathogens can be transmitted by more than one route. Despite the pandemic focusing mitigation efforts on aerosol transmission only, it diverted attention away from other modes of transmission, which likely contributed significantly to an increase in HAIs.
According to the Centers for Disease Control and Prevention, environmental contamination is one the most common routes for the transmission of nosocomial diseases.15Reservoirs can be formed from microbiologically contaminated surfaces, also known as fomites.16These conditions allow pathogens to survive for weeks, months, or hours.12 Transmission via fomites starts when inanimate objects are contaminated with an individual, droplets or, in the instance of C aurisYou can shed skin that lands on surfaces.17Indirect transmission occurs mainly through contact with fomites. Infected people can then transmit the microbes to other people.18 This example illustrates a complex chain that links the infection source and the patient.
Studies have shown that cross transmission in hospital environments is primarily due to contamination (Figure 2) and the hands of health care workers.19 Research showed that between 23% – 100% of noncritical medical equipment was contaminated with pathogenic bacteria, up to 80% with pathogenic organisms, and up to 25% with MDROs.20Another study found that gloves didn’t prevent contamination or stop the spread infection.21Yet, around 30% of HAIs can be attributed to the contaminated hands and care of health care workers.1
Hospital floors were not considered high-risk surfaces in the past. However, this has started to shift. Floors are the primary route of transmission for HIV. C diff, 22 C auris You can carry them around in your shoes.17
Disrupting the Chain
It is essential to understand pathogenic transmission mechanisms in order to disrupt the chain of transmission.11
The CDC identified 17 high touch surfaces that were frequently touched by patients and must be addressed during daily and terminal cleanings.23Studies have shown that less then half of all surfaces can be effectively cleaned and disinfected using a sporicidal.24Cleaning and disinfection are the best ways to reduce infection risk in allpatient care areas.Figure 3), as well as floors and all noncritical medical items used across the continuum of care.12
The ideal disinfectant is an important consideration in infection prevention and management (IPC) programs.25Most common hospital disinfection products do not address all the urgent threats and can have dangerous adverse effects. Quaternary ammonium compounds, for example, are not effective against C auris17Although sodium hypochlorite, or bleach (bleach), and peracetic acid(PAA) are available, they do not have the same effect. C auris claims,12Any efficacy is accompanied by health hazards. Hydrogen peroxide might be less toxic, but it can still work. C auris,17But it doesn’t have to be. C diff claim. PAA is the only chemistry that has a biofilm claim, but it is extremely dangerous. A broad-spectrum disinfectant that has claims against all immediate threats and biofilm is the best approach. It also has the ideal safety profile.
Cross-contamination is another important consideration, especially when working under time constraints. Touchless electrostatic sprayer technology can make terminal cleans more efficient and effective. When combined with disposable wipes, it is possible to disinfect more thoroughly without recontamination.
Disinfection interventions on environmental surfaces is only one component of a larger IPC strategy. It is critical that health care facilities use a system-level approach for reducing HAIs.25
Holistic Intervention
A holistic approach to infection prevention is essential for reducing HAIs. It must include knowledge of all links in infection’s chain and layered interventions. Multimodal strategies that include monitoring/auditing and prioritizing ongoing education of incoming and current staff are key to sustainability of interventions and program compliance.25
Standardization is essential to reduce HAIs. Standardizing cleaning products and protocols reduces complexity, improves compliance, and creates universally applicable IPC measures.
Everyone has a responsibility to reduce HAIs. All members of the interprofessional health care team have a stake. Anybody can identify gaps in environmental control, from infection prevention to facility management to housekeeping. Integrating multidisciplinary risk assessments and education with compliance monitoring will provide 360 surveillance and allow for greater ability to disrupt transmission.
References:
1 Statistics on HAIs. Healthcare Surfaces Institute. https://www.healthcaresurfacesinstitute.org/statistics-on-hais/
2 McCaughey B. Unnecessary deaths: The human and financial consequences of hospital infections. 3rd Edition. Committee to Reduce Infection Mortality (RID). https://www.hospitalinfection.org/ridbooklet.pdf
3 Hospital Infection Reporting. Committee to Reduce Infection Mortality (RID). https://hospitalinfection.org/resources/state-infection-laws/state-law-summary/
4 Record numbers of hospitals have received an A, B C, D, D, F or F on the Leapfrog Hospital safety Grade. Hospitalsafetygrade.org. November 10, 2021 https://www.hospitalsafetygrade.org/about-our-movement/newsroom/display/1020887
Fact sheet on 5 Health care-associated Infections World Health Organization. https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
6 Weiner-Lastinger L, Pattabiraman V, Konnor R, et al. The impact of coronavirus (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. Cambridge University Press. September 3, 2021 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/impact-of-coronavirus-disease-2019-covid19-on-healthcareassociated-infections-in-2020-a-summary-of-data-reported-to-the-national-healthcare-safety-network/8197F323F4840D233A0C62F4726287E1#
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8 Monegro, Muppidi IV, Regunath A. Hospital acquired infected. StatPearls Publishing. August 30, 2021 https://www.ncbi.nlm.nih.gov/books/NBK441857/
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10 Dyer J. IP strategies that can be used to limit the spread of candida-auris. Infection Control Today. October 27, 2021. https://www.infectioncontroltoday.com/view/strategies-for-mitigating-spread-of-candida-auris
11 Curless M., Forrester L., Trexler PP. Infection prevention and control: A reference manual for health care facilities with limited resource. Module 1. Module 1. Introduction to infection prevention. Johns Hopkins University Affiliate. May 20, 2020. https://www.c19hub.io/module-1-introduction-to-infection-prevention-and-control/
12 Homan L. Environmental hygiene is crucial in the prevention and control candida auris. Healthcare Hygiene Magazine. September 2021. https://viewer.joomag.com/healthcare-hygiene-magazine-september-2021-september-2021/0280572001631046038?page=48
13 Higgins E, Connors B. Understanding infection risk sources and mitigation pathways is essential. Patient Safety & Quality Healthcare (PSQH).. November 12, 2020 https://www.psqh.com/analysis/the-need-to-understand-infection-risk-sources-and-pathways-to-mitigate-hais/
14 clinical educators provide guidance for the prevention and control infection in healthcare. Australian Commission on Safety and Quality in Healthcare. National Health and Medical Research Council. https://www.nhmrc.gov.au/sites/default/files/documents/attachments/publications/icg-clinical-ed-guide.pdf
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17 McCaughey B. RID guidelines to reduce the risk of candida infections. Committee to Reduce Infectious deaths (RID). https://hospitalinfection.org/about/candida-auris/
FAQ on 18 Surfaces and HAIs. Healthcare Surfaces Institute. https://www.healthcaresurfacesinstitute.org/surfaces-and-hais-faq/
19 Doll M. Bearman G. Guide for infection control in healthcare settings-New technologies in prevention. International Society for Infectious Diseases. January 2018. https://isid.org/wp-content/uploads/2019/06/ISID_GUIDE_NEW_TECHNOLOGIES_INFECTION_PREVENTION.pdf
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25 Christenson E, Cronk R, Atkinson H, et al. Evidence map and systematic review on disinfection efficacy of environmental surfaces in healthcare facilities. International Journal of Environmental Research and Public Health. October 22, 2021 https://pubmed.ncbi.nlm.nih.gov/34769620/