Division of Infectious Diseases

By: Kelly Cawcutt, MD, MS, FACP, FIDSA; Sponsored by Clorox Healthcare

Hospital-acquired infections (HAIs) are infections acquired during medical care and are often directly related to the use of medical devices or procedures, along with lapses in critical infection control practices such hand hygiene, and appropriate cleaning and disinfection. Every day in the US, approximately 1 in 31 patients will suffer from a HAI. These infections can include central line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSIs), ventilator-associated pneumonia (VAP) and development of Clostridiodes difficile infection (CDI). The Centers for Disease Control (CDC), along with State and county health departments, along with individual hospitals, monitor these closely via reports to the National Healthcare Safety Network, which assess outbreaks and monitors progress towards future prevention efforts – with a goal of elimination of HAIs in the future of medicine.

The impact of COVID-19 on HAIs may ultimately be profound due to the use of antibiotics for possible bacterial co-infection and prolonged ICU stays, including the use of multiple invasive devices placing these vulnerable patients at risk for CLABSI, CAUTI, VAP, CDI. Additional factors clearly impacting HAIs in during this pandemic include lack of appropriate resources and supply chain issues (such as personal protective equipment and testing supplies), combined with varying rates of infected healthcare workers and risk of burnout impacting the available workforce. Finally, there is ongoing concern that fear amidst this pandemic may negatively impact adherence to infection control practices.  Never has prevention of HAIs been more critical given the burden of COVID-19 on healthcare around the world. 

Prevention of HAIs

Prevention of HAIs is comprised of several key concepts: avoid both device placement and antibiotic use unless clearly indicated, remove devices and stop antibiotics as soon as possible, and follow infection control measures for the healthcare workers and environment (such as standard and transmission-based precautions, hand hygiene and environmental and equipment cleaning).

With the clear impact of HAIs, there are several different guidelines focusing on how to prevent HAIs. A few critical recommendations and guidelines are:

• The Society for Healthcare Epidemiology of America’s compendium of strategies to prevent HAIs
• CDC guidelines for preventing HAIs
• WHO guidelines for infection prevention

Anyone within the healthcare field, including the patient, is accountable to help prevent HAIs. This is truly a multidisciplinary effort!

Patient’s role

In the end, we are all patients and, as mentioned above, can play a role in prevention of HAIs. There are several key actions anyone can take to keep ourselves, and our loved ones, safe from these infections. Practicing excellent hand hygiene, watching closely for signs of developing infection, remembering to only take antibiotics when your healthcare team feels it is necessary and remaining an advocate for safety throughout your hospital stay (such as reminding healthcare workers to perform hand hygiene). (Here is a quick video on five tips to prevent HAIs as a patient.)

Device-Related Risks

There are many invasive devices that are frequently used for patient care, and once they are in place for at least 48 hours, those devices carry the risk for a possible reportable HAI to develop. Some patients require infusions of medications or frequent access to blood draws and monitoring, therefore may have a central venous catheter placed, thereby creating a simultaneous risk for developing CLABSI. Certain patients will have trouble urinating, or need very close monitoring of urine output due to impaired kidney, so an indwelling urinary catheter is inserted and, with that, the risk for CAUTI arises. Patients with severe lung disease, such as those with respiratory failure from COVID-19, may require invasive mechanical ventilation, as provided via an endotracheal tube. Much like the two catheters listed above, with insertion and use of the endotracheal tube, the risk for development of VAP evolves.

In essence, all of these devices are inserted through a potential non-sterile source and therefore carry a risk for bacteria to create a biofilm on the external surface of the catheter, or have bacterial inoculated on the internal surface during cares, increasing the risk of a possible life-threatening HAI. Understanding appropriate indications, insertion techniques, maintenance and prompt removal, once no longer indicated,  is of paramount importance.

Environmental Cleaning

All of these simple components around us can serve as conduits for infection. Although this may be top of mind for many during this pandemic and tempt us to focus only on COVID-19, the more ‘mundane’ aspects of environment infection control are just as important in 2020 as they were each year prior. It’s critical that healthcare team members, including nurses, doctors, technicians and  EVS staff  responsible for cleaning equipment, or the environment, use products that are EPA-registered to be effective against these HAIs.

Seeing C. diff Differently – What Has Changed in Prevention?

CDI is the most common cause of HAIs in the US, with specific guidelines for infection prevention given its prevalence from national societies (Infectious Diseases Society of America and the Society of Healthcare Epidemiology of America) and from the CDC. There are several key steps to preventing CDI as a HAI:

• Antibiotic use is the primary driver for development of CDI, therefore it is imperative to follow antibiotic stewardship principles to minimize risk of development of CDI.
• Implement contact precautions for those with confirmed or suspected infections, to avoid unintended spread to others.
• Consider use of innovative engineering for improving adherence to isolation precautions with solutions such as the ‘Red Box.’
• Maintain appropriate personal protective equipment with gowns, gloves and hand washing (especially in outbreak settings) to prevent spread of spores.
• Confirm with appropriate testing strategies. This is key as colonization exists with this organism, so non-infectious etiologies should be considered, do not test if laxatives have been used in the last 48 hours, do not send solid stool for testing and remember that repeat testing for cure is not necessary.
• If non-disposable equipment is used, dedicating equipment to the patient room should be done if possible. If there is an inadequate equipment supply, cleaning before and after each patient use should be done.  For CDI, even if using a 2-in-1 product, cleaning should occur prior to disinfecting and should be completed with a  compatible sporicidal disinfectant (EPA List K agents; such as Bleach Germicidal Wipes) should be utilized.
• Terminal room cleaning for patient rooms in which C. diff was present is also critical to prevent ongoing spread of infection as the spores can survive for months within the hospital room and many standard disinfectants are ineffective, therefore effective disinfection is critically important, especially during outbreak situations. Methods may include cleaners, such as Bleach Germicidal Disinfectants.

Despite all the efforts on COVID-19, as frontline healthcare teams, we must all pitch in to continue the fight against HAIs. Our patients are depending on us.

Full original post can be found here: https://www.cloroxpro.com/blog/infection-inside-out-focus-on-hospital-acquired-infections/

By: Kelly Cawcutt, MD, MS, FACP, FIDSA; Sponsored by Clorox Healthcare

Infectious diseases remain a critical cause of morbidity, mortality and cost in all healthcare facilities including outpatient clinics, long-term care facilities and acute care facilities, such as hospitals. Infections can come from two main places – inside the hospital walls and from outside within a community. A patient can develop a community-acquired infection prior to arrival in any healthcare setting, which often is what prompted the patient to seek care. The most recent example of this is COVID-19 (SARS-CoV-2). This virus is impacting healthcare facilities around the world with increased patient burdens and human-to-human spread in which infected patients are transmitting the infection to other patients, visitors and healthcare workers.

There are also many healthcare-associated infections (HAIs) that patients in both acute and long-term care settings are at specific risk for based on multiple factors such as: having chronic medical problems that increase possible risks (such as requiring dialysis or conditions causing weakened immune systems), prior admission to healthcare facilities or receipt of antibiotics (placing patients at increased risk of acquisition of antibiotic-resistant (AR) infections or Clostridiodes difficle (C.diff) infection), the use of invasive devices (such as a ventilator in the setting of respiratory failure), and any procedures (such as surgery) needed for medical care. Lapses in infection control practices such as hand hygiene and cleaning and disinfection are another HAI risk factor. Going forward, we will specifically focus on HAIs in acute healthcare settings. This is the first post in a blog series originally published for Clorox Healthcare, in which we’ll be diving further into HAIs.

The primary reported infections under the umbrella of HAIs include central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI), and surgical site infections (SSIs) and ventilator associated pneumonia (VAP), and C. diff gastroenteritis (actually the leading cause of HAI). These HAIs are reported and tracked nationally by the National Healthcare Safety Network (NHSN). However, it is important to note that these infections can be caused by both antibiotic-susceptible and AR pathogens. According to the CDC, each year in the U.S., there are over 2.8 million infectious causes by AR pathogens. This results in over 35,000 deaths. Microorganisms that are frequently also discussed in this category include C. diff infections and detection of AR bacteria, such as Carbapenem-resistant Enterobacteriaceae (CRE) or Methicillin-resistant Staphylococcus aureus (MRSA). Prevention of these infections is clearly of paramount importance and infection control practices such as adherence to guidance for hand hygiene, isolation practices, when to wear gloves and gowns and environmental cleaning, to prevent spread throughout the hospital. Additional infection control expert guidance is available through many organizations including the CDC, Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC).

The toll that infections can have on patients, and healthcare facilities as a whole, can be daunting when you consider the needs for ongoing surveillance, diagnosis, management and complex infection prevention strategies. Strategies for the prevention of HAIs nearly all start with maintaining excellent hand hygiene, minimizing unnecessary invasive devices, prudent and correct use of antibiotics, employing appropriate precautions to prevent spread of infection within a facility and correct and thorough environmental and equipment cleaning and disinfecting to help eliminate pathogens. In many ways, the strategies are easier said than done; however, they are important to helping prevent the spread of the pathogens that cause infection, especially when you consider the substantial cost, they have on patient health and hospital cost.

Over the next posts, we will break down some of the key aspects of infectious diseases and prevention in the acute healthcare setting, including AR, HAIs, biofilms, multi-drug resistant organisms and challenges of infection prevention. Together, we can all strive to better understand and improve infection prevention thereby improving patient safety and care.

Full post originally at https://www.cloroxpro.com/blog/infections-know-no-bounds-the-reality-of-infections-in-healthcare-facilities/