Successful Strategies to Prevent Nosocomial Infections in Health Care
World Small Animal Veterinary Association World Congress Proceedings, 2010
Thomas Haustein, MD, MRCP, FRCPath
Geneva, Switzerland


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.


1.  Pittet D, Donaldson L. Challenging the world: patient safety and health care-associated infection. Int J Qual Health Care 2006; 18: 4-8.

2.  Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121: 182-205.

3.  Astagneau P, L'Heriteau F, Daniel F, Parneix P, Venier AG, Malavaud S, et al. Reducing surgical site infection incidence through a network: results from the French ISO-RAISIN surveillance system. J Hosp Infect 2009; 72: 127-34.

4.  Burton DC, Edwards JR, Horan TC, Jernigan JA, Fridkin SK. Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in US intensive care units, 1997-2007. JAMA 2009; 301: 727-36.

5.  Pearson A, Chronias A, Murray M. Voluntary and mandatory surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) bacteraemia in England. J Antimicrob Chemother 2009; 64 Suppl 1: i11-7.

6.  Gastmeier P, Geffers C, Brandt C, Zuschneid I, Sohr D, Schwab F, et al. Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect 2006; 64: 16-22.

7.  Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000; 355: 1864-8.

8.  Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-32.

9.  Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Crit Care Med 2009; 37: 2167-73; quiz 80.

10. Timsit JF, Schwebel C, Bouadma L, Geffroy A, Garrouste-Orgeas M, Pease S, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009; 301: 1231-41.

11. Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 Suppl 1: S12-21.

12. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, et al. Epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007; 65 Suppl 1: S1-64.

13. Saxer F, Widmer A, Fehr J, Soka I, Kibatala P, Urassa H, et al. Benefit of a single preoperative dose of antibiotics in a sub-Saharan district hospital: minimal input, massive impact. Ann Surg 2009; 249: 322-6.

14. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491-9.

15. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000; 356: 1307-12.

16. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009; 30: 611-22.

17. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002; 51: 1-45, quiz CE1-4.

18. Wertheim HF, Vos MC, Boelens HA, Voss A, Vandenbroucke-Grauls CM, Meester MH, et al. Low prevalence of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission in the Netherlands: the value of search and destroy and restrictive antibiotic use. J Hosp Infect 2004; 56: 321-5.


Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Thomas Haustein, MD, MRCP, FRCPath
Geneva, Switzerland

MAIN : Infectious Diseases : Nosocomial Infections
Powered By VIN