Published: 26 February 2014
A Marie Bashir Institute for Emerging Infections and Biosecurity
Centre for Values, Ethics and the Law in Medicine
University of Sydney
and Level 3, Institute of Clinical Pathology & Medical Research, Westmead Hospital
PO Box 533, Wentworthville
NSW 2145, Australia. Tel: +61 2 9845 6252
B Westmead Millennium Institute for Medical Research
C24 – Westmead Hospital
The University of Sydney
NSW 2006, Australia. Tel: +61 2 9845 6255
C Department of Microbiology and Infectious Diseases
and Department of Infectious Diseases and Immunology
Sydney Medical School
University of Sydney
Hospital Road, Concord, NSW 2139
Australia. Tel: +61 2 9767 6658
Healthcare-associated infections (HAIs) are more important than most people realise. They are estimated to affect 7–10% of all patients admitted to hospital and are among the top five causes of death worldwide, including in countries like Australia with sophisticated (and expensive) healthcare systems. In Australia it is estimated that 200,000 HAIs occur each year; they affect 5–10% of hospital patients, contribute to 7,000 deaths and are responsible for A$2–3 billion in excess health costs. In the USA they cause an estimated 99,000 deaths and cost the health system US$10–25 billion. These, and other estimates of the burden of HAIs anywhere in the world, are imprecise and almost certainly lower than the true values, because surveillance and reporting of HAIs is limited and highly variable. What is most shocking about these statistics is that at least 50% of these infections (probably more) are judged to be preventable by measures that are simple, inexpensive and have been shown to be effective.
HAIs have been a problem since hospitals were first established and the principles of prevention have been known since the 19th century, although the major pathogens change from time to time and in different places. In the 21st century most HAIs are due to multiresistant organisms (MROs), mainly bacteria, but also, increasingly, fungi. Antimicrobial resistance is also not a new problem but, until recently, there always seemed to be new drugs available to treat infections that had become resistant to older ones. This is no longer the case and we are hearing more and more about infections for which no available antimicrobials are effective – they are untreatable. This means that infection prevention and control (IPC) in healthcare settings is becoming even more critical, to protect patients from exposure and the risk of infection from resistant pathogens. Reducing the all-too-frequent unnecessary or inappropriate use of antimicrobials is equally urgent, because we know it can slow or even reverse the spread and spectrum of resistance.
It is difficult to explain to anyone, let alone to patients who are the victims of serious HAIs, why healthcare professionals so frequently fail to protect patients by neglecting the simple measures – like hand hygiene – that we know can prevent the spread of microbes. It is not only or necessarily the fault of individual healthcare workers or the healthcare system, but a complex societal problem. Prevention is always more difficult to ‘sell’ than ‘cure’ and our healthcare systems, public expectations and hence healthcare budgets are focused on cures and rescues. However, many of the medical and surgical ‘miracle’ cures and rescues developed over the past 20–50 years – chemotherapy to cure leukaemia and prolong the lives of many cancer patients; life-saving kidney, heart and lung transplantation; prosthetic heart valves and joint replacements – carry associated high risks of infection and so depend on good IPC policies and the availability of antibiotic and antifungal ‘safety nets’. They are now in jeopardy because our IPC and antimicrobial prescribing practices have been often inconsistent with the best policies and are now less reliable.
So what are we to do about this? There have been many innovative approaches to improving this situation, some of which have been very successful. In Australia, the National Hand Hygiene Initiative, sponsored by the Australian Commission on Safety and Quality in Healthcare, has implemented standardised auditing and national reporting, by all public hospitals, of compliance with the ‘5 Moments of Hand Hygiene’, with improvement from an average of 64%, overall, in 2009 to 77% in 2013. All States have implemented mandatory reporting of certain ‘marker’ HAIs, of which healthcare-associated Staphylococcus aureus blood stream infections is now publicly reported, along with hand hygiene compliance data, by hospital, on the MyHospitals website. Public reporting is a controversial and not necessarily very effective strategy for preventing HAIs, but it does have the effect of raising the profile of IPC in the minds of hospital administrators, which is the first step towards improving local IPC practices and, hopefully, providing adequate resources. It also highlights the need for surveillance of selected HAIs and MROs, with microbiological support.
It is a truism that we can’t improve what we can’t (or don’t) measure. We need to identify key indicators of the burden of HAIs and the prevalence of MROs before we can hope to reduce them, monitor the effectiveness of preventive programs and motivate front-line clinicians to take responsibility for the safety of their patients. Many clinicians believe that HAIs are rare; annual or quarterly statistics fail to resonate; when a HAI occurs in their own patient many see them as unavoidable collateral damage due to the patient’s underlying condition, a failure of the ‘system’, and that there was nothing they could have done to prevent it. Some regard colonisation with MROs as unavoidable. Doctors have, legitimately, complained that microbiological results are generally too slow to guide logical choice of antibiotic therapy in critically ill patients – and so they have developed bad prescribing habits to cover all bases.
Rapid diagnostics and susceptibility testing; carefully targeted, relevant and rapidly reported microbial surveillance data (including strain typing for common hospital pathogens); automated electronic data management, reporting and decision support and monitoring systems; and a better understanding of the epidemiology and evolution of ‘hospital’ pathogens and antibiotic resistance – among other things – can help to dispel these myths, motivate efforts to reduce individual risks, limit outbreaks and improve management of hospital infections. But we also need a better understanding of the complex and varied healthcare ‘cultures’, personal and professional relationships and environmental factors that determine how well patients – and healthcare professionals – are protected, from the very real risk of infection associated with healthcare. Any of us – or our parents, children or friends – is a potential vector or victim of infection and so it is in our interests to make it our business. In this issue of Microbiology Australia we highlight current trends and new developments in infection control and antimicrobial resistance and hope you will find it stimulating and instructive.
Lyn Gilbert (MD, FRACP, FRCPA, MBioethics, FASM) is a clinical microbiologist and infectious diseases physician who, until recently, was Director of Centre for Infectious Diseases (CIDM) Laboratory Services and CIDM-Public Health, Westmead Hospital. She is currently Clinical Lead in Infection Prevention and Control for Western Sydney Local Health District. Her research interests include clinical and molecular epidemiology, prevention and control and ethics of communicable diseases of public health importance, including healthcare-associated infections.
Jon Iredell is an Infectious Disease Physician and Microbiologist who divides his time between Westmead Hospital in a combined Infectious Diseases and Microbiology Department and his research, which is supported by the NHMRC at the University of Sydney. His major interests are in critical infection, including the study of bacterial septic shock, and in bacterial genetics and ecology. He is Director, NHMRC Centre of Research Excellence in Critical Infection and conjoint Professor of Medicine and Microbiology at Sydney Medical School/Westmead Millennium Institute and the Marie Bashir Institute and Director of Infectious Diseases, Western Sydney and Westmead Hospital.
John Merlino is a senior scientist in the Department of Microbiology and Infectious Diseases at Concord Hospital, NSW Pathology and lectures at the University of Sydney, Faculty of Medicine, Department of Infectious Diseases and Immunology. He completed a Master of Science with honours in Microbiology and Biotechnology focusing on detection, identification and antimicrobial resistance in Enterococcus spp. at Macquarie University in the School of Biological Sciences. He later completed a PhD in Medicine in Bacteriology and Infectious Diseases focusing on the detection and expression of methicillin and oxacillin resistance in S. aureus in the Department of Infectious Diseases and Immunology, Faculty of Medicine at the University of Sydney. He is a Fellow of the Australian Society for Microbiology and a Founding Fellow of the Faculty of Science, RCPA. He is the current Convenor and Chairperson of the Antimicrobial Special Interest Group of the Australian Society for Microbiology.
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