Healthcare-associated infections (HCAI) affect hundreds of millions of patients each year and are a global issue for patient safety. In developed countries, the overall prevalence of HCAI is 5 to 15 per 100 hospitalized patients, and around 30% amongst those admitted to intensive care units.1 The commonest types of HCAI, accounting for 80% of all infections, are catheter-associated urinary tract infections, surgical site infections, pneumonia and blood stream infections (BSI).1
Nosocomial infections result in significantly increased costs for healthcare. Affected patients often need to stay in hospital longer and require additional investigations and treatments. Most importantly, many of these infections are disasters for affected patients and can cause serious harm or death.
A significant proportion of HCAIs are preventable by simple measures. Successful strategies to prevent nosocomial infection have to combine these measures and ensure the participation of all health care workers.
Recognize and Quantify the Extent of the Problem
Recognizing and understanding a problem may be the first step to solve it. In the 1970s, the Study on the Efficacy of Nosocomial Infection Control (SENIC) first provided formal evidence that HCAI surveillance in combination with active control efforts by qualified professionals and feedback of some infection rates to hospital staff was associated with a considerable reduction of HCAI.2 National HCAI surveillance networks have since been established in many countries and have been operating with significant success.3-6
Minimize the Risk Associated with Invasive Devices
Invasive devices, e.g., urinary catheters, intravascular catheters or endotracheal tubes bypass fundamental physiological defense mechanisms against infection. They are widely used and, as a consequence, are associated with many HCAIs. Successful strategies to prevent HCAIs have to aim at optimizing the use of these devices. The basic principles are similar for most devices: First, avoid unnecessary use. Second, maintain asepsis during insertion. Third, choose an appropriate insertion site, e.g., subclavian access for central venous lines. Fourth, avoid contamination of the device while it is in place. Fifth, limit the time that a device is in place to the necessary minimum. Strategies based on these principles have been highly successful,7-10 and are reflected in current guidelines.11-12
Minimize the Risk of Surgical Site Infections
Surgery causes major disruptions to the skin and mucosal barriers against infection. Appropriate surgical site preparation and perioperative antimicrobial prophylaxis13 are primarily aimed at reducing the risk of inoculation of bacteria that belong to the patient's own flora. Surgical hand antisepsis, sterile equipment and well-engineered operating theatre facilities limit the risk of transmission of new pathogens to the patient. Excellent surgical technique helps to reduce the infection risk by minimizing tissue damage. Surveillance of surgical site infections and feedback of results to the surgical teams are key for maintaining awareness and improving practice.2-3,6 Perioperative safety checklists further reduce morbidity and mortality.14
Minimize the Risk of Nosocomial Transmission
In view of the importance of the hands of health care workers for nosocomial transmission of pathogens, hand hygiene is a fundamental component of any infection control strategy.15-16 Hand washing with soap and water removes dirt and reduces the loosely adherent transient microbial flora, including bacterial spores (e.g., Clostridium difficile). However, frequent hand washing is tedious and time consuming, damaging to the skin if done on a regular basis, and therefore unpopular.17 Major progress has been achieved through the introduction of alcohol-based hand rubs. Their application is less time consuming and faster acting, and skin irritation is rare. Limitations of alcohol-based hand rubs are their low activity on bacterial spores and non-enveloped viruses.17
The promotion of hand hygiene is the cornerstone of the World Health Organization's First Global Patient Safety Challenge "Clean Care is Safer Care".16
When standard precautions (hand hygiene, use of protective clothing, and prevention of sharps injuries) alone may not be sufficient to stop transmission of infectious agents, isolation of patients becomes necessary. Stringent prevention of nosocomial transmission is cited as one of the reasons for the low prevalence of meticillin-resistant Staphylococcus aureus in certain countries.18
Minimize the Risk of Antimicrobial Resistance
For many years, increasing bacterial resistance was matched by the introduction of new antibiotics to the market, fostering a carefree approach to the use of these drugs. In stark contrast, recent years have seen a shortage of novel antibacterial agents. As resistant bacterial strains continue emerging, this opens up the very real prospect of untreatable infections, particularly those caused by gram-negative pathogens. The strategy to better contain anti-infective drug resistance necessitates more prudent use of antibiotics in human medicine, in animal medicine, and in animal husbandry/agriculture; and measures to prevent the spread of drug-resistant organisms, including stronger surveillance. The ultimate goal to combat anti-infective drug resistance must be: conservation of existing anti-infective drugs through prudent use, and investment in research and development both for new anti-infective drugs and for vaccines.
A Joint Effort
No single intervention will "solve" the problem of avoidable HCAIs, and no intervention can be implemented without collaboration between multiple partners. Only multimodal strategies involving system change, education of health care workers, monitoring and feedback of performance, and the support of the highest levels of leadership within organizations are likely to succeed.
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