Prevention is better than cure and it is important that all helthcare workers depend on evidence-based infection and control interventions to reduce demand for antibiotic agents by preventing healthcare-associated infections (HAIs) from occurring in the first place, and making every effort to prevent transmission when they occur. The issues surrounding infection prevention and control are intrinsically linked with the issues associated with the use of antibiotic agents and the proliferation and spread of antimicrobial resistance (AMR). The vital work of the infection prevention and control and of the antimicrobial stewardship cannot be performed independently and requires interdependent and coordinated action across multiple and overlapping disciplines and clinical settings.
HAIs are infections that occur while receiving health care. Patients with medical devices (central lines, urinary catheters, ventilators) or who undergo surgical procedures are at risk of acquiring HAIs. HAIs continue to be a tremendous issue today, however most HAIs are preventable.
Every day, HAIs result in prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, massive additional costs for health systems, high costs for patients and their family, and unnecessary deaths. The application of appropriate infection prevention and control strategies by the healthcare workers can reduce the risk of HAIs, as most of them are preventable. The preventable proportion of HAIs may decrease over time as standards of care improve.
A recent systematic review and meta-analysis of studies published between 2005 and 2016 assessing multifaceted interventions to reduce catheter-associated urinary tract infections (CAUTIs), central-line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and hospital-acquired pneumonia not associated with mechanical ventilation (HAP) in acute-care or long-term care settings suggested a sustained potential for the significant reduction of HAI rates in the range of 35%-55% associated with multifaceted interventions irrespective of a country’s income level.
Continued progress in healthcare epidemiology and implementation science research has led to improvements in our understanding of effective strategies for HAIs prevention. Despite these advancements, HAIs continue to affect many hospitalized patients, leading to substantial morbidity, mortality, and excess healthcare expenditures, and there are persistent gaps between what is recommended and what is practiced.
Out of every 100 hospitalized patients, seven patients in high-income countries and ten patients in low-middle income countries acquire an HAI. Other studies conducted in high-income countries found that 5%–15% of the hospitalized patients acquire HAIs which can affect from 9% to 37% of those admitted to intensive care units. Multiple research studies report that in Europe hospital-wide prevalence rates of HAIs range from 4.6% to 9.3%. The WHO reports however that HAIs usually receive public attention only when there are epidemics.
The prevention and management of HAIs has advanced greatly over the last decade. Infection prevention and control (IPC) programs have been repeatedly shown to be effective at decreasing the incidence of HAIs. To prevent HAIs, the World Health Organization (WHO) recommends implementing an IPC program in every acute healthcare facility. However, according a recent survey, only 29% of 133 countries surveyed have IPC programs in all tertiary hospitals and interventions aimed to improve healthcare worker’s compliance with IPC practices such as hand hygiene have achieved varied success around the world.
Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level were published by the WHO in 2016. These guidelines on the core components of IPC programmes form a key part of WHO strategies to prevent current and future threats, strengthen health service resilience and help combat AMR. They are intended also to support countries in the development of their own national protocols for IPC and AMR action plans and to support health care facilities as they develop or strengthen their own approaches to IPC.
The behaviors of the halthcare workers (HCWs) and their interactions with the health care system can influence the rate of HAIs. Because HAIs are a threat to patient safety, many hospitals and healthcare facilities have made the prevention and reduction of these infections a top priority. These resources and interventions have led to an increased focus in prevention efforts, as well as improvements in clinical practice and medical procedures.
Proper hand hygiene is the most important, simplest, and least expensive means of reducing the prevalence of HAIs and the spread of antimicrobial resistance. Cleaning hands healthcare workers can prevent the spread of microorganisms, including those that are resistant to antibiotics and are becoming difficult, if not impossible, to treat. Despite acknowledgement of the critically important role of hand hygiene in reducing the transmission of pathogenic microorganisms, overall compliance with hand hygiene is less than optimal in many healthcare settings worldwide. In most healthcare institutions, adherence to recommended hand-washing practices remains unacceptably low. Hand hygiene reflects awareness, attitudes and behaviors towards infection prevention and control.
SSIs are the most common HAIs among surgical patients. It is obviously important to improve patient safety by reducing the occurrence of surgical site infections. Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have published guidelines for the prevention of surgical site infections.
The 2016 WHO Global guidelines for the prevention of surgical site infection are evidence-based including systematic reviews presenting additional information in support of actions to improve practice. The guidelines include 13 recommendations for the pre-operative period, and 16 for preventing infections during and after surgery. They range from simple precautions such as ensuring that patients bathe or shower before surgery, appropriate way for surgical teams to clean their hands, guidance on when to use prophylactic antibiotics, which disinfectants to use before incision, and which sutures to use.
Despite clear evidence and guidelines to direct SSIs prevention strategies, compliance is uniformly poor and major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. High rates of inappropriate IPC practices in surgery continue to be reported in the literature.
In hospitals, cultural, contextual, and behavioral determinants influence clinical practice. Improving behavior in IPC practices remains a challenge.
There are generally three primary levels of influence related to behavior modification and infection control in healthcare facilities:
1) Intrapersonal factors
2) Interpersonal factors
3) Institutional or organizational factors
Including these three levels of influence in IPC interventions may be a key in preventing HAIs.
On an individual level, healthcare workers should have the necessary knowledge, skills, and abilities to implement effective infection control practices. Increasing the knowledge may influence their perceptions and motivate them to change behavior. Education and training represent an important component for accurate implementation of recommendations. Education of all health professionals in preventing HAIs should begin at undergraduate level and be consolidated with further training throughout the postgraduate years. Hospitals are responsible for educating clinical staff about infection prevention and control programs. Active education initiatives, such as educational workshops, should be implemented in each hospital worldwide according to its own resources. However, increasing knowledge alone may not be sufficient for effective infection control and may be insufficient to effect sustained change especially considering the multi-factorial nature of the problem of HAIs.
Peer-to-peer role modeling on an interpersonal level have been shown to positively influence implementation of infection control practices. Many practitioners use educational materials or didactic continuing medical education sessions to keep up-to-date. However, these strategies might not be very effective in changing practice, unless education is interactive and continuous, and includes discussion of evidence, local consensus, feedback on performance (by peers), making personal and group learning plans, etc.
Identifying a local opinion leader to serve as a champion may be important because the “champion” may integrate best clinical practices and drive the colleagues in changing behaviors, working on a day to day basis, and promoting a culture in which infection prevention and control is of high importance. Clinicians with satisfactory knowledge in surgical infections may provide feedback to the colleagues, integrate the best practices among surgeons and implement change within their own sphere of influence interacting directly with IPC team.
Organizational obstacles may influence infection prevention and control implementation. Many different hospital disciplines are typically involved in IPC, making collaboration, coordination, communication, teamwork and efficient care logistics essential. IPC teams have been shown to be both clinically effective improving patients outcome, and cost-effective providing important cost savings in terms of fewer HAIs, reduced length of hospital stay, less antimicrobial resistance and decreased costs of treatment for infections. Raising awareness of IPC to stakeholders is a crucial factor in changing behaviors. Probably clinicians are more likely to comply with guidelines when they have been involved in developing the recommendations. One way to engage health professionals in guideline development and implementation is to translate practice recommendations into a protocol or pathway that specifies and coordinates responsibilities and timing for particular actions among a multidisciplinary team. There is now a substantial body of evidence that effective team-work in health care contributes to improved quality of care. Leading international organizations, such as the WHO, acknowledge that collaborative practice is essential for achieving a concerted approach to providing care that is appropriate to meet the needs of patients, thus optimizing individual health outcomes and overall service delivery of health care. The use of such approaches reinforces the concept that each one brings with them their particular expertise and is responsible for their respective contributions to patient care.