Keeping Expectations for Infection Control in Perspective

The seismic fall-out from the recent global credit crunch has shown that change, and even crisis, is a constant theme in the modern world. That is certainly true in the field of hospital-acquired infections, where there is no panacea to eradicate risk or any simple, “quick fixes” that we can turn to. As Professor Dinah Gould wrote in the previous issue of Exsero, “the prevention and control of HAI is likely to remain an enduring challenge in health care.”
  History shows that infectious diseases have always been present and will continue to be with us, as witnessed by the recent swine flu outbreak. New viruses and new strains are also to be expected, In Europe, socio-economic trends are not working in our favour: increased foreign travel and trade, an ageing population, impaired immune systems, microbial adaption, higher rates of surgical intervention and more invasive surgical techniques, are all factors that militate against improvements in infection control. In many ways it would be fair to say the risk of a pandemic is greater than it has ever been.

At the same time, our knowledge base is increasing all the time. The number of scientific papers published each year about nosocomial infection has doubled since 2000, to about 2,800 in 2007(1). We are almost in danger of information overload and one of the challenges that lies ahead is how we can best share and make effective use of so much data.

A subject we all read about is hand hygiene and this will always be a crucial component in the fight against cross-infection;but we need to be careful that we
do not become obsessed about it to the detriment of other areas. I hesitate to use that word ‘panacea’ again, but we know that even the achievement of 100% hand hygiene – an impossible dream – will not solve all our problems.

In 1999, a review of 34 published studies on hand washing adherence among health care workers(2) found that compliance rates varied between 5% and 81%, with an average of only 40%. Although it is reasonable to expect compliance rates to be increasing in view of WHO campaigns and a constant focus on the subject, we should not forget that we are human beings, not robots, and there will always be room for improvement. We must also ask ourselves the question: “Is hand hygiene really the most important preventive measure against nosocomial infections?” There are other very important risk areas in the operating room, such as surgical site infections and the prevention of pneumonia and septicaemia, where cross infection via the hands of health care workers only contributes to a minor proportion of the infections.
  A controversial issue is the use of probiotics. As new knowledge emerges about them, and new approaches to infection control based on the management of “good” and “bad” bacteria are evaluated, the potential risks and benefits will hopefully be clarified. With the ever present threat of new, resistant micro-organisms, this work will develop in parallel with the need to reduce our consumption of and dependency on antibiotics.

The business case for infection control, with a full-time infection control professional in place for every 250 beds, was established in the 1980’s following publication of the seminal SENIC study in the United States(3). An effective infection control program was shown to reduce infection rates by 30 – 50% and its costs were recovered with an improvement of just 6%. Today, however, due to changes in hospital practices, the resources needed for effective infection prevention are significantly greater.
  Another challenge is the need to bridge the gap between attitudes and behaviour, between knowing what to do and applying that knowledge consistently in our everyday work. Infection prevention professionals must learn and apply the knowledge generated through behavioural research.

There is every reason, then, to expect future challenges in infection control to be even greater and more complex than those we currently confront. As professionals, we must do the best job we can. That includes accurately communicating risk stratification through international cooperation. With increasing demands for the public reporting of infection rates in hospitals, the infection control community must ensure that spending decisions, made by nonprofessionals, are based on the application of sound, statistical research and the correct stratification by risk.
  In minimizing nosocomial infection, we must constantly adapt to new threats and make the most of new opportunities. The job is on-going and it will always be necessary. We must ensure that the challenges we face are properly understood by those outside our profession whose expectations of progress may be considerably higher than our own.

References

1. Medline survey of published
   papers, 1990 – 2007, with multiple key words: MRSA, pneumonia, surgical site infection, blood stream infection, hand hygiene, nosocomial infection
2. Hospital Epidemiol Infection Control, 2nd Edition, 1999 (CDC)
3. Study on the Efficacy of Nosocomial Infection Control (SENIC), American Journal of Epidemiology, Vol.III, No.5, May 1980