First rate hygiene is vital to prevent infections in hospital

Although such fears may be exaggerated, the risk of infection is considerable and its consequences can be serious. Research has demonstrated that approximately one patient in nine admitted to hospital in the UK will develop an infection, and those who become infected cost three times more to treat then those who do not. They also stay in hospital, three times longer [1].

Resistance to antibiotics is a global problem created through their indiscriminate use in both the community and in hospital. The use of antibiotics to increase yields in farming and in veterinary practice has exacerbated the problem. The exposure of bacteria to antibiotics has promoted the survival of antibioticresistant strains to the extent that outside hospitals more than 95% of Staphylococcus aureus is no longer susceptible to the effects of penicillin.

In hospital, infection with MRSA can develop when the patient is in theatre and tissues are exposed, or it can be transferred by cross-infection on the wards. Non-antibiotic venues to prevent and control HAI are therefore assuming increasing importance, particularly as research to develop new antibiotics to replace those which are performing poorly is proceeding slowly.

Hand hygiene using skin disinfectants such as Chlorhexidine gluconate, is a valuable way of reducing the risk of cross-infection because it has substantivity, which means that its effects persist for some time between applications. Alcohol is a useful adjunct to traditional washing with skin disinfectants because it can be applied at times when staff are very busy and do not have time to use a sink when moving between patients. However, alcohol hand rubs do not replace traditional approaches, as alcohol is effective only when applied to physically clean skin and surfaces.

Environmental cleanliness is also of key importance in hospital: if equipment and surfaces are not clean, hands will rapidly become re-contaminated when they are touched. In recent years it has become clear that patients have a role to play in reducing the risks of HAI. Whole body antisepsis has the potential to contribute to infection prevention and control by reducing the number of bacteria on the patients’ skin which maycontribute to infection. The procedure involves applying a disinfectant such as Chlorhexidine gluconate to the skin in the bath or showerfor five days before admission. A similar procedure is used to de-colonise patients who are known carriers of MRSA, especially before surgery.

There have been some concerns that bacteria will develop resistance against commonly used antiseptics, and indeed genes enabling bacteria to withstand the effects of Chlorhexidine have been isolated (qac genes). However, the importance of these genes in conferring resistance in the clinical situation remains to be established. In general, antibiotics have a highly specific effect on the cellular functioning of bacteria. Antibiotic resistance requires relatively small changes in the genetic make-up of the bacterial cell. In contrast, antiseptics are much more general in their effects, and resistance would require the simultaneous modification of a much larger number of genes, which is unlikely. At present, there is no reason to fear the imminent emergence of bacterial resistance to skin disinfectants in common use.

However, successful infection control requires strict adherence to hand hygiene protocols. Unfortunately audits reveal that hospital staff wash or disinfect their hands approximately half as often as they should. A second problem is that too little attention is paid to the technique of hand hygiene: hands will not be mechanically cleansed or disinfected unless all surfaces receive contact with the product.

The prevention and control of HAI is likely to remain an enduring challenge in health care. As the population ages, with increasing numbers of elderly and very sick people undergoing surgery and other invasive procedures, the potential of weakly pathogenic organisms to cause infection will increase, while continuing exposure to antibiotics will promote the emergence of new antibiotic- resistant strains. Even if a way of preventing or treating MRSA was found tomorrow, something else would soon take its place. The problem is that bacteria are able to adapt well to the changing hospital environment.

References:

1 Plowman, R et al 2001. The rate and cost of hospital-acquired infections
occurring in patients admitted to selected specialities of a district general
hospital in England and the national burden imposed. Journal of Hospital Infection 47 198-209.