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Hospital infection prevention and control: A global perspective
GUEST EDITORIAL Hospital infection prevention and control: A global perspective Denise M. Cardo, MDa Barbara M. Soule, RN, MPAb Atlanta, Georgia, and Olympia, Washington
The 3 principal goals for hospital infection prevention and control programs stated in the Society for Healthcare Epidemiology of America, Inc/Association for Professionals in Infection Control, Inc/Centers for Disease Control and Prevention Consensus Panel Report are to (1) protect the patient, (2) protect the health care worker (HCW), visitors, and other persons in the health environment, and (3) accomplish the previous 2 goals in a cost-effective manner, whenever possible.1 Throughout the past decades, the activities performed by hospital infection control and prevention programs have expanded in the United States. In parallel, the number of hospital infection control programs and activities in many countries also has been increasing.2,3 In this issue of AJIC: American Journal of Infection Control, articles from countries on 4 continents describe a broad variety of individual efforts to prevent infections in hospitals. The hospital infection control and prevention programs reflect the different cultural, social, and economic realities of each country. A synopsis of each article, including its strengths and limitations, follows. To prevent and control hospital infections, it is necessary to have the appropriate infrastructure as well as substantial human and financial resources; however, the allocation of these resources to such programs varies from country to country. For example, several Latin American countries have legislation that mandates an infection control committee in each hospital; nonetheless, in many institutions, the infrastructure to conduct and sustain essential activities to detect and control hospital infections does not exist. In a survey performed in
From the HIV Infections Branch, Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta,a and the Quality Management/Education/Epidemiology Department, Providence St Peter Hospital, Olympia.b Reprint requests: Denise M. Cardo, MD, 1600 Clifton Rd, Mail stop E68, Atlanta, GA 30333. AJIC Am J Infect Control 1999;27:233-5
Denise M. Cardo, MD
Barbara M. Soule, RN, MPA
hospitals in Campinas, Brazil, Oliveira et al4 identified several patterns of infection control program organizations. The authors scored programs on the existence of policies, procedures, and rules for infection control but did not include correlations with accepted measures of efficacy of infection control programs, such as rates of infections. This study showed that despite federal regulations requiring infection control programs in hospitals, administrative support for such programs depended on the type and size of the hospital. Based on their score, public hospitals had a better infection control infrastructure compared with nonpublic hospitals; teaching hospitals, better than nonteaching; and small hospitals, the worst program infrastructure. However, without a correlation between the different patterns of organization and the effectiveness of each program, it is difficult to evaluate the effect of such differences and to identify ways to improve them. In some countries, such as Australia, the accrediting bodies of public and private health care institutions require accredited facilities to have infection control programs. Murphy and McLaws5 surveyed infection control professionals (ICPs) in Australia to assess their role, function, and attributes. A majority of the ICPs in Australia are nurses. Most of the ICPs who responded 233
AJIC
234 Cardo and Soule to the survey worked in public-funded, acute care facilities with fewer than 250 beds and had additional responsibilities, including occupational health, quality assurance, and patient care activities. Full-time ICPs generally were found only in hospitals with more than 250 beds. The Study on the Efficacy of Nosocomial Infection Control (SENIC) suggested that having one ICP per 250 beds was associated with an effective program.6 However, because of the amount and complexity of the ICP’s work in hospital infection programs in the United States, this ratio has been questioned and is not considered adequate.1 Despite these considerations, the SENIC recommendation remains the standard for Brazil and Australia, but the authors of both articles mentioned previously agree that it should be revised. In another survey conducted among ICPs in Australia, Murphy and McLaws7 demonstrated a recent growth of the number of ICP positions in Australia, but no formal career path for ICPs was available. They also discussed the necessity to define a minimum level of ICP education and to develop a system of credentialing and networking to gain credibility and public confidence. The issues dealt with in the next 4 articles reflect the spectrum of activities of programs to prevent nosocomial transmission of infections: handwashing, antimicrobial use, contamination of intravascular (IV) solutions, and occupational exposures to blood. Handwashing is an important infection control measure; however, improving compliance with handwashing has been a challenge for most hospital infection control programs.8 Zaragoza et al9 conducted a study in a large public university hospital in Barcelona, Spain, to compare the efficacy of an alcohol solution for hand disinfection to that of regular soap and water handwashing in decreasing bacterial counts on HCWs’ hands. They showed that use of the alcohol solution decreased the mean number of colony-forming units in a higher proportion of HCWs than did handwashing and was well tolerated. The authors concluded that the use of an alcohol solution could be an alternative for areas such as intensive care units. One key question was not addressed: will HCWs comply with this recommendation? Alcohol hand disinfection is generally used in Europe. The time required for alcohol hand disinfection has been estimated to be lower than that required for handwashing with soap,10 but the effect of switching from traditional handwashing to hand antisepsis on compliance needs to be tested. In an observational study of HCW compliance with handwashing, Pittet et al11 found an average level of compliance of 48%. Compliance differed significantly among HCWs by profession, location, and type of patient care and was lower for activities that carried higher risk for transmission. Many studies have assessed reasons for lack of compliance with handwashing (eg, being too
June 1999
busy, lack of awareness, and skin irritation). No effective, sustainable approach for increasing compliance has yet been described.8 Antimicrobials represent a substantial portion of the total drug budgets of many countries and often constitute the single largest group of drugs purchased in some countries, such as in Brazil. Contributing to this is the unnecessary cost associated with overuse of prophylactic antibiotics. In this issue, Heineck et al12 describe a study conducted in a teaching hospital in Porto Alegre, Brazil, showing that surgeons did not follow the hospital’s guideline for surgical prophylaxis. The authors observed that in many instances, the use of prophylactic antibiotics for cholecystectomy, hysterectomy, and herniorraphy, including indication, time of first dose, and duration of prophylaxis, was not in accordance with the hospital guideline. In this study, no information was provided regarding how the guideline was implemented and whether practices were modified after such implementation. As stated by the authors, surgeons followed a “nonofficial routine” instead of the hospital’s guideline, reflecting the difficulties in influencing prescribing behaviors. A decrease from 46% to 20% in the inappropriate prophylactic antibiotic use was observed in a surgical unit at a university hospital in Sao Paulo, Brazil, after an intervention consisting of weekly surgical rounds with an infectious diseases physician.13 This decrease may have been a result of both role modeling and additional knowledge acquired during the rounds. Intrinsic and extrinsic contamination of IV solutions are a concern in developing countries.14 Recently, an outbreak of deaths in a newborn unit associated with intrinsic contamination of IV solutions was described in Brazil.15 Concerns that intrinsic and extrinsic contaminations are more frequent than detected in many countries have been raised. Macias et al16 conducted a study to detect extrinsic contamination of IV solutions in 6 hospitals located in 4 cities of Guanajuato State, Mexico. Approximately 2% of the IV solutions tested were contaminated; Klebsiella pneumoniae was the most common isolate. Although no clinical manifestations were observed among the patients who received the contaminated solutions, specific guidelines are necessary for proper handling of IV fluids. The guidelines from the United States are widely accepted in most countries, but many recommendations may not translate well into foreign settings because policies and circumstances may be different. The US guidelines do not address these differences. For example, some of the issues raised in this study (eg, chlorine level of tap water) are not addressed in US guidelines. Hospitals must carefully examine the processes related to producing, handling, and administering IV solutions to prevent contamination.
AJIC
Cardo and Soule 235
Volume 27, Number 3
Occupational exposures to blood and bloodborne pathogens are frequent in hospitals. Approximately 40% to 80% of exposures to blood are not reported by hospital-based HCWs in the US.17 In a study conducted in Taiwan, Shiau et al18 observed that whereas occupational exposures to blood were frequent among surveyed workers (at least 1 injury was experienced in 12 months by 87% of surveyed HCWs), only 18% of these HCWs reported the exposure. No differences were found among the occupational groups. The main reasons for underreporting were similar to the reasons in some US reports and included being “too busy,” not knowing the system, and subjective assessment of the severity of the injury. Based on these results, the authors proposed a 24-hour hot line for the reporting and management of occupational exposures to blood as well as educational training of HCWs. Reporting a blood contact is important for proper management of the exposure. Further, information collected about the exposure will help infection control programs to develop strategies for exposure prevention. In summary, this issue includes articles from several countries that represent isolated efforts to identify and address a variety of problems related to the prevention and control of hospital infections in each of the countries. The challenge in all countries is to use the information from studies such as these to design effective interventions for minimizing infection risk. The scope of the international activities of the Hospital Infections Program at the Centers for Disease Control and Prevention reported by Manangan et al19 highlights the importance of collaboration to strengthen programs to control and prevent infections in all countries. References 1. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Infect Control Hosp Epidemiol 1998;19:114-35. 2. Soule BM, Huskins WC. A global perspective on the past, present, and future of nosocomial infection prevention and control. AJIC Am J Infect Control 1997;25:289-93.
3. Widmer AF, Sax H, Pittet D. Infection control and hospital epidemiology outside the United States. Infect Control Hosp Epidemiol 1999;20:17-21. 4. Oliveira TC, Branchini ML. Infection control in a Brazilian regional multihospital system. AJIC Am J Infect Control 1999;27:262-9. 5. Murphy CL, McLaws M-L. Who coordinates infection control programs in Australia? AJIC Am J Infect Control 1999;27:291-5. 6. Haley RW, Culver DH, White J, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205. 7. Murphy CL, McLaws M-L. Credentialing, diversity, and professional recognition—foundations for an Australian infection control career path. AJIC Am J Infect Control 1999;27:240-6. 8. Boyce J. Is it time for action: improving hand washing hygiene in hospitals. Ann Intern Med 1999;130:153-5. 9. Zaragoza M, Sallés M, Gomez J, Bayas JM, Trilla A. Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness. AJIC Am J Infect Control 1999;27:258-61. 10. Voss A, Widmer AF. No time for handwashing? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205-8. 11. Pittet D, Mourouga P, Perneger TV, et al. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126-30. 12. Heineck I, Ferreira MBC, Schenkel EP. Prescribing practice for antibiotic prophylaxis for 3 commonly performed surgeries in a teaching hospital in Brazil. AJIC Am J Infect Control 1999;27:296-300. 13. Freitas MR, Pereira CAP, Correa L, Castelo A, Lopes GJ, Wey SB. Profilaxia antimicrobiana em cirurgia do aparelho digestivo: uma proposta de adequacao. Rev Col Brasil Cirurgioes 1998;25:185-92. 14. Macias-Hernandez AE, Hernandez-Ramos I, Munoz-Barrett JM, et al. Pediatric primary gram-negative nosocomial bacteremia: a possible relationship with infusate contamination. Infect Control Hosp Epidemiol 1996;17:276-80. 15. Centers for Disease Control and Prevention. Clinical sepsis and death in a newborn nursery associated with contaminated parenteral medications, Brazil, 1996. MMWR Morb Mortal Wkly Rep 1998;47:610-2. 16. Macias AE, Muñoz JM, Bruckner DA, Galván A, Rodríguez AB, Guerrero FJ, et al. Parenteral infusions bacterial contamination in a multi-institutional survey in Mexico: considerations for nosocomial mortality. AJIC Am J Infect Control 1999;27:285-90. 17. Cardo DM, Bell DM. Bloodborne pathogen transmission in health care workers—risks and prevention strategies. Infect Dis Clin North Am 1997;11:331-46. 18. Shiao JS-C, McLaws M-L, Huang K-Y, Ko W-C, Guo YL. Prevalence of nonreporting behavior of sharps injuries in Taiwanese health care workers. AJIC Am J Infect Control 1999;27:254-7. 19. Manangan LP, Archibald LK, Pearson ML, Duffy RE, Garrett DO, Alonso-Echanove JA, et al. Selected global health care activities of the Hospital Infections Program, Centers for Disease Control and Prevention. AJIC Am J Infect Control 1999;27:270-4.
WHAT’S NEXT FOR AJIC? Issue August
Topic Sterilization, Disinfection, and Antisepsis
October
Occupational Health and Safety
The 3 principal goals for hospital infection prevention and control programs stated in the Society for Healthcare Epidemiology of America, Inc/Association for Professionals in Infection Control, Inc/Centers for Disease Control and Prevention Consensus Panel Report are to (1) protect the patient, (2) protect the health care worker (HCW), visitors, and other persons in the health environment, and (3) accomplish the previous 2 goals in a cost-effective manner, whenever possible.1 Throughout the past decades, the activities performed by hospital infection control and prevention programs have expanded in the United States. In parallel, the number of hospital infection control programs and activities in many countries also has been increasing.2,3 In this issue of AJIC: American Journal of Infection Control, articles from countries on 4 continents describe a broad variety of individual efforts to prevent infections in hospitals. The hospital infection control and prevention programs reflect the different cultural, social, and economic realities of each country. A synopsis of each article, including its strengths and limitations, follows. To prevent and control hospital infections, it is necessary to have the appropriate infrastructure as well as substantial human and financial resources; however, the allocation of these resources to such programs varies from country to country. For example, several Latin American countries have legislation that mandates an infection control committee in each hospital; nonetheless, in many institutions, the infrastructure to conduct and sustain essential activities to detect and control hospital infections does not exist. In a survey performed in
From the HIV Infections Branch, Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta,a and the Quality Management/Education/Epidemiology Department, Providence St Peter Hospital, Olympia.b Reprint requests: Denise M. Cardo, MD, 1600 Clifton Rd, Mail stop E68, Atlanta, GA 30333. AJIC Am J Infect Control 1999;27:233-5
Denise M. Cardo, MD
Barbara M. Soule, RN, MPA
hospitals in Campinas, Brazil, Oliveira et al4 identified several patterns of infection control program organizations. The authors scored programs on the existence of policies, procedures, and rules for infection control but did not include correlations with accepted measures of efficacy of infection control programs, such as rates of infections. This study showed that despite federal regulations requiring infection control programs in hospitals, administrative support for such programs depended on the type and size of the hospital. Based on their score, public hospitals had a better infection control infrastructure compared with nonpublic hospitals; teaching hospitals, better than nonteaching; and small hospitals, the worst program infrastructure. However, without a correlation between the different patterns of organization and the effectiveness of each program, it is difficult to evaluate the effect of such differences and to identify ways to improve them. In some countries, such as Australia, the accrediting bodies of public and private health care institutions require accredited facilities to have infection control programs. Murphy and McLaws5 surveyed infection control professionals (ICPs) in Australia to assess their role, function, and attributes. A majority of the ICPs in Australia are nurses. Most of the ICPs who responded 233
AJIC
234 Cardo and Soule to the survey worked in public-funded, acute care facilities with fewer than 250 beds and had additional responsibilities, including occupational health, quality assurance, and patient care activities. Full-time ICPs generally were found only in hospitals with more than 250 beds. The Study on the Efficacy of Nosocomial Infection Control (SENIC) suggested that having one ICP per 250 beds was associated with an effective program.6 However, because of the amount and complexity of the ICP’s work in hospital infection programs in the United States, this ratio has been questioned and is not considered adequate.1 Despite these considerations, the SENIC recommendation remains the standard for Brazil and Australia, but the authors of both articles mentioned previously agree that it should be revised. In another survey conducted among ICPs in Australia, Murphy and McLaws7 demonstrated a recent growth of the number of ICP positions in Australia, but no formal career path for ICPs was available. They also discussed the necessity to define a minimum level of ICP education and to develop a system of credentialing and networking to gain credibility and public confidence. The issues dealt with in the next 4 articles reflect the spectrum of activities of programs to prevent nosocomial transmission of infections: handwashing, antimicrobial use, contamination of intravascular (IV) solutions, and occupational exposures to blood. Handwashing is an important infection control measure; however, improving compliance with handwashing has been a challenge for most hospital infection control programs.8 Zaragoza et al9 conducted a study in a large public university hospital in Barcelona, Spain, to compare the efficacy of an alcohol solution for hand disinfection to that of regular soap and water handwashing in decreasing bacterial counts on HCWs’ hands. They showed that use of the alcohol solution decreased the mean number of colony-forming units in a higher proportion of HCWs than did handwashing and was well tolerated. The authors concluded that the use of an alcohol solution could be an alternative for areas such as intensive care units. One key question was not addressed: will HCWs comply with this recommendation? Alcohol hand disinfection is generally used in Europe. The time required for alcohol hand disinfection has been estimated to be lower than that required for handwashing with soap,10 but the effect of switching from traditional handwashing to hand antisepsis on compliance needs to be tested. In an observational study of HCW compliance with handwashing, Pittet et al11 found an average level of compliance of 48%. Compliance differed significantly among HCWs by profession, location, and type of patient care and was lower for activities that carried higher risk for transmission. Many studies have assessed reasons for lack of compliance with handwashing (eg, being too
June 1999
busy, lack of awareness, and skin irritation). No effective, sustainable approach for increasing compliance has yet been described.8 Antimicrobials represent a substantial portion of the total drug budgets of many countries and often constitute the single largest group of drugs purchased in some countries, such as in Brazil. Contributing to this is the unnecessary cost associated with overuse of prophylactic antibiotics. In this issue, Heineck et al12 describe a study conducted in a teaching hospital in Porto Alegre, Brazil, showing that surgeons did not follow the hospital’s guideline for surgical prophylaxis. The authors observed that in many instances, the use of prophylactic antibiotics for cholecystectomy, hysterectomy, and herniorraphy, including indication, time of first dose, and duration of prophylaxis, was not in accordance with the hospital guideline. In this study, no information was provided regarding how the guideline was implemented and whether practices were modified after such implementation. As stated by the authors, surgeons followed a “nonofficial routine” instead of the hospital’s guideline, reflecting the difficulties in influencing prescribing behaviors. A decrease from 46% to 20% in the inappropriate prophylactic antibiotic use was observed in a surgical unit at a university hospital in Sao Paulo, Brazil, after an intervention consisting of weekly surgical rounds with an infectious diseases physician.13 This decrease may have been a result of both role modeling and additional knowledge acquired during the rounds. Intrinsic and extrinsic contamination of IV solutions are a concern in developing countries.14 Recently, an outbreak of deaths in a newborn unit associated with intrinsic contamination of IV solutions was described in Brazil.15 Concerns that intrinsic and extrinsic contaminations are more frequent than detected in many countries have been raised. Macias et al16 conducted a study to detect extrinsic contamination of IV solutions in 6 hospitals located in 4 cities of Guanajuato State, Mexico. Approximately 2% of the IV solutions tested were contaminated; Klebsiella pneumoniae was the most common isolate. Although no clinical manifestations were observed among the patients who received the contaminated solutions, specific guidelines are necessary for proper handling of IV fluids. The guidelines from the United States are widely accepted in most countries, but many recommendations may not translate well into foreign settings because policies and circumstances may be different. The US guidelines do not address these differences. For example, some of the issues raised in this study (eg, chlorine level of tap water) are not addressed in US guidelines. Hospitals must carefully examine the processes related to producing, handling, and administering IV solutions to prevent contamination.
AJIC
Cardo and Soule 235
Volume 27, Number 3
Occupational exposures to blood and bloodborne pathogens are frequent in hospitals. Approximately 40% to 80% of exposures to blood are not reported by hospital-based HCWs in the US.17 In a study conducted in Taiwan, Shiau et al18 observed that whereas occupational exposures to blood were frequent among surveyed workers (at least 1 injury was experienced in 12 months by 87% of surveyed HCWs), only 18% of these HCWs reported the exposure. No differences were found among the occupational groups. The main reasons for underreporting were similar to the reasons in some US reports and included being “too busy,” not knowing the system, and subjective assessment of the severity of the injury. Based on these results, the authors proposed a 24-hour hot line for the reporting and management of occupational exposures to blood as well as educational training of HCWs. Reporting a blood contact is important for proper management of the exposure. Further, information collected about the exposure will help infection control programs to develop strategies for exposure prevention. In summary, this issue includes articles from several countries that represent isolated efforts to identify and address a variety of problems related to the prevention and control of hospital infections in each of the countries. The challenge in all countries is to use the information from studies such as these to design effective interventions for minimizing infection risk. The scope of the international activities of the Hospital Infections Program at the Centers for Disease Control and Prevention reported by Manangan et al19 highlights the importance of collaboration to strengthen programs to control and prevent infections in all countries. References 1. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Infect Control Hosp Epidemiol 1998;19:114-35. 2. Soule BM, Huskins WC. A global perspective on the past, present, and future of nosocomial infection prevention and control. AJIC Am J Infect Control 1997;25:289-93.
3. Widmer AF, Sax H, Pittet D. Infection control and hospital epidemiology outside the United States. Infect Control Hosp Epidemiol 1999;20:17-21. 4. Oliveira TC, Branchini ML. Infection control in a Brazilian regional multihospital system. AJIC Am J Infect Control 1999;27:262-9. 5. Murphy CL, McLaws M-L. Who coordinates infection control programs in Australia? AJIC Am J Infect Control 1999;27:291-5. 6. Haley RW, Culver DH, White J, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205. 7. Murphy CL, McLaws M-L. Credentialing, diversity, and professional recognition—foundations for an Australian infection control career path. AJIC Am J Infect Control 1999;27:240-6. 8. Boyce J. Is it time for action: improving hand washing hygiene in hospitals. Ann Intern Med 1999;130:153-5. 9. Zaragoza M, Sallés M, Gomez J, Bayas JM, Trilla A. Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness. AJIC Am J Infect Control 1999;27:258-61. 10. Voss A, Widmer AF. No time for handwashing? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205-8. 11. Pittet D, Mourouga P, Perneger TV, et al. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126-30. 12. Heineck I, Ferreira MBC, Schenkel EP. Prescribing practice for antibiotic prophylaxis for 3 commonly performed surgeries in a teaching hospital in Brazil. AJIC Am J Infect Control 1999;27:296-300. 13. Freitas MR, Pereira CAP, Correa L, Castelo A, Lopes GJ, Wey SB. Profilaxia antimicrobiana em cirurgia do aparelho digestivo: uma proposta de adequacao. Rev Col Brasil Cirurgioes 1998;25:185-92. 14. Macias-Hernandez AE, Hernandez-Ramos I, Munoz-Barrett JM, et al. Pediatric primary gram-negative nosocomial bacteremia: a possible relationship with infusate contamination. Infect Control Hosp Epidemiol 1996;17:276-80. 15. Centers for Disease Control and Prevention. Clinical sepsis and death in a newborn nursery associated with contaminated parenteral medications, Brazil, 1996. MMWR Morb Mortal Wkly Rep 1998;47:610-2. 16. Macias AE, Muñoz JM, Bruckner DA, Galván A, Rodríguez AB, Guerrero FJ, et al. Parenteral infusions bacterial contamination in a multi-institutional survey in Mexico: considerations for nosocomial mortality. AJIC Am J Infect Control 1999;27:285-90. 17. Cardo DM, Bell DM. Bloodborne pathogen transmission in health care workers—risks and prevention strategies. Infect Dis Clin North Am 1997;11:331-46. 18. Shiao JS-C, McLaws M-L, Huang K-Y, Ko W-C, Guo YL. Prevalence of nonreporting behavior of sharps injuries in Taiwanese health care workers. AJIC Am J Infect Control 1999;27:254-7. 19. Manangan LP, Archibald LK, Pearson ML, Duffy RE, Garrett DO, Alonso-Echanove JA, et al. Selected global health care activities of the Hospital Infections Program, Centers for Disease Control and Prevention. AJIC Am J Infect Control 1999;27:270-4.
WHAT’S NEXT FOR AJIC? Issue August
Topic Sterilization, Disinfection, and Antisepsis
October
Occupational Health and Safety