Prevention of Health Care-Associated Infections in an Era of Public Reporting Texas Medicine February 2017

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Symposium on Infectious Diseases — February 2017

Tex Med. 2017;113(2):42-47.

By Chetan Jinadatha, MD, and Edward J. Septimus, MD

Health care-associated infections (HAIs) are a leading cause of wasted health care dollars, and prevention of HAIs is a quintessential pillar of patient safety and satisfaction. Catheter-associated urinary tract infections, central line-associated blood stream infections, ventilator-associated pneumonias, surgical site infections, and Clostridium difficile infections are the important HAIs seen in U.S. hospitals. C. difficile infections are an emerging threat to modern health care systems, attributed to antibiotic overuse and resistance. Combined payment bundle increases the pressure on hospitals to take ownership of hip and knee replacement surgery patients. Health care facilities are heavily penalized for HAIs by the Centers for Medicare & Medicaid Services, not to mention the potential for negative publicity with public reporting. The role of initiatives such as prevention bundles, decolonization, antibiotic stewardship, and no-touch disinfection are emerging, but proper hand hygiene still remains the most important step in preventing HAIs.

Background

Health care-associated infections (HAIs) are a significant burden on modern health care systems. HAIs represent a large consumption of scarce resources.1 In the United States, about 1.7 million HAIs occur each year, accounting for up to $9.7 billion annually in additional health care costs and approximately 99,000 deaths.2,3

HAIs are of clinical relevance in patients who have in one way or another been entangled in any of the numerous pathways of HAIs. The most commonly reported HAIs are pneumonia (22 percent), surgical-site infections (22 percent), and gastrointestinal infections (17 percent). Clostridium difficile was the most commonly reported organism, causing 12 percent of HAIs. Device-associated infections account for 25 percent of HAIs.4 Methicillin-resistant Staphylococcus aureus (MRSA), in particular, is known as one of the most common causes of ventilator-associated pneumonia, bloodstream infection associated with central venous catheters, and surgical-site infections.1,4

Other HAIs have also been known to arise as a result of exposure to surgical procedures, ongoing hemodialysis, and residence in long-term care facilities, in addition to shared risk factors with MRSA.5 HAIs result in longer length of stay (LOS; 21.9 vs. 5.0 days), higher 30-day readmission rates (31.3 percent vs. 6.3 percent), and greater mortality (9.1 percent vs 1.7 percent) compared with patients without an HAI.6 The various pathways to infection for HAIs are numerous but frequently include contamination of the hands of health care workers due to inadequate hand hygiene practices or inadequate cleaning of environmental surfaces. This makes potential risk factors limitless in a hospital environment and makes it consequently difficult to establish effective interventions.7-9

The Affordable Care Act authorizes payers such as the Centers for Medicare & Medicaid Services (CMS) to reduce payment to hospitals for HAIs. As a part of their value-based purchasing measures and health care-associated conditions reduction measures, CMS can penalize hospitals for excessive rates of HAI; the bottom 25th percentile of hospitals can lose 1 percent to 2 percent of their total payment from CMS. Nonpayment for HAIs and resultant penalties could lead to closure of low-performing hospitals. There is a renewed interest even among civilian hospitals in adapting and implementing novel ways to decrease HAIs.10-12

HAIs can be broadly classified into device-related and non-device-related infections. The common device-related infections are catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). The common non-device-related infections are surgical site infections (SSIs) and Clostridium difficile infections (CDIs). A significant number of these HAIs are preventable using evidence-based strategies such as prevention bundles.13 The other HAIs that are not classified in any of the aforementioned conditions are health care-associated Legionnaires' disease, norovirus, and respiratory viruses, which are not discussed in this article.

Catheter-Associated Urinary Tract Infections 

CAUTIs are one of the most common hospital-associated infections, accounting for approximately 15 percent to 20 percent of all HAIs.4 The catheter most commonly associated with HAIs is the indwelling urinary catheter. Approximately one in five patients is subjected to an indwelling urinary catheter at some point during a hospital stay.4 Major differences exist between what the Infectious Diseases Society of America (IDSA) defines as CAUTI and the definition used by the U.S. Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN) surveillance. Infection preventionists use the latter to report to NHSN as a part of their CMS reporting requirement.14,15 The costs associated with taking care of CAUTIs range from $896 to $1,500, as some CAUTIs may be associated with bacteremia.16 Organisms that most commonly cause CAUTI include Escherichia coli, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella pneumoniae, and rarely Candida or other staphylococcal species.14

Many noninfectious complications associated with urinary catheters further escalate the costs associated with patient care. They include reduced mobility (and this has been referred by some as a form of restraint) and risk of falls, deep vein thrombosis, and increased incidence of pressure ulcers.17 In addition, urethral strictures, risk of hematuria, and urethral tears from demented patients trying to remove the catheter in a confused state can result in acute trauma to the bladder and urethra.18  

The primary risk factor for a CAUTI is the presence of an indwelling urinary catheter. Duration of the catheter, age of the patient, underlying immunosuppression, position of the drainage bag, insertion errors, and gaps in care are other risk factors noted in the literature.14 Proper education of staff on best practices for insertion, maintenance, and removal can result in prevention of CAUTI.19

Hospitals can implement evidence-based, detailed strategies to prevent CAUTI. (See Table 1.)14 These guidelines include information on strategies that do not prevent infections such as antimicrobial impregnated catheter usage, instillation of antibiotics in the drainage bag, or changing catheters at regular intervals.14

Central Line-Associated Bloodstream Infections

Great emphasis has been placed on the prevention of CLABSIs. There are 75,000 to 80,000 CLABSIs per year in United States.20 The majority of CLABSIs happen outside the intensive care unit.21 On a per-case basis, CLABSIs are the most expensive HAI at $45,000 to $65,000.16

A central venous line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels and is used for infusion of large volumes of fluid and also serves the purpose of blood draw as well as hemodynamic monitoring in an intensive care unit setting. The most common organisms associated with catheter-associated bloodstream infection include Staphylococcus aureus, coagulase negative Staphylococci, Enterococcus, and enteric gram-negative bacilli such as Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Candida species.21 There are two major mechanisms for the occurrence of a CLABSI: colonization at the insertion site with migration of organism(s) along the external surface of the catheter within the first few weeks of catheterization and direct contamination of connectors or hubs resulting in internal colonization and subsequent CLABSI. Rarely can a catheter be seeded hematogenously from another site of infection or rarely from a contaminated infusion fluid.22 Further, similar to CAUTI, the clinical definition of CLABSI may vary from an NHSN-based surveillance definition to identify a bloodstream infection that occurred in patients with a central venous line.23,24

Many prevention strategies that involve insertion, maintenance, and other special approaches have been proposed to be extremely beneficial. (See Table 2.) Appropriate implementation of these strategies may reduce the overall incidence of CLABSIs.24

Ventilator-Associated Pneumonia

In 2013, VAP surveillance transitioned to ventilator-associated events (VAEs) monitoring as an alternative approach for surveillance of events related to the patient being on a ventilator. VAE is associated with increased mortality and increased length of stay.25 The purpose of the transition was to more accurately define what can be reliably determined using surveillance definitions and to reduce ambiguity, improve reproducibility, and enable electronic collection of all variables.26

The transition to VAE emphasizes the importance of preventing all mechanical ventilator-associated complications, not just pneumonia. These include fluid overload, acute respiratory distress syndrome, and atelectasis.27 A VAP may cost a health institution approximately $36,286 to $44,220.16 Many tools are available on the CDC's NHSN website (www.cdc.gov/nhsn), including calculators to help assess whether the patient has VAE.28

About 37 percent of VAEs are preventable with proper implementation of prevention strategies called VAP/VAE bundle. It has been suggested that a typical VAP bundle should be implemented in its entirety for maximal benefits.29 The components of a typical VAP bundle are daily sedation vacations, daily spontaneous breathing trials (SBTs), daily assessment of readiness to wean, peptic ulcer disease prophylaxis, daily oral care with chlorhexidine, venous thromboembolism prophylaxis (VTE), and elevation of the head of the bed (HOB).30

Studies have shown bundle components vary in their associations with patient-centered outcomes. HOB elevation, sedative infusion interruptions, SBT, and VTE appear beneficial, whereas daily oral care with chlorhexidine and stress ulcer prophylaxis appeared to be harmful in some patients.31 Further, CDC's Wake Up and Breathe Collaborative demonstrated that minimizing sedation, paired with daily spontaneous breathing trials and spontaneous awakening trials, early exercise and mobility, low tidal volume ventilation, and conservative fluid management along with minimization of blood transfusions can decrease VAE rates. Further decrease in duration of mechanical ventilation and targeting the primary conditions associated with VAEs can reduce them, as well.32

Surgical Site Infections 

SSIs can be superficial, deep, or organ space-related to the implantation of a prosthesis.33 A typical SSI may cost a health organization anywhere from $18,902 to $22,667.16 If the infection is related to an implanted hip or knee prosthesis, the costs could be substantially more expensive. 

The new Comprehensive Care for Joint Replacement model aims to support better and more efficient care for Medicare beneficiaries undergoing the most common inpatient surgeries: hip and knee replacements (also called lower extremity joint replacements). The bundled payment and quality measurement associated with this model for hip and knee replacements encourages hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from initial hospitalization through recovery. The penalties associated with this model are severe and potentially crippling to a health care system that may not be practicing good prevention strategies when it comes to SSIs associated with hips and knees.34

Initiatives such as preoperative showering of patients with an antiseptic soap the day before or day of surgery, keeping staff movements in and out of the operating area to a minimum, selecting appropriate antibiotic prophylaxis with appropriate timing of administration before surgery, appropriate hand decontamination for the first operation of the day using an aqueous antiseptic surgical solution (with a pick for the nails) and for subsequent surgeries (using either an alcoholic hand rub or an antiseptic surgical solution), use of sterile gowns and gloves during surgery, antiseptic skin prep with an alcohol containing  povidone-iodine or chlorhexidine, and maintaining patient homeostasis along with appropriate wound care have all been shown to prevent surgical site infections. Maintenance of normothermia, supplemental oxygenation, and control of blood glucose levels during the immediate postoperative period are additional measures that prevent SSIs.35,36    

Clostridium difficile Infections 

In 2013, CDC classified the antibiotic resistance threat as urgent (the highest level) for C. difficile.37 These threats, although currently not widespread, have the potential to become so and require urgent public health attention to limit transmission. It is estimated that the number of CDIs in the United States is about 500,000 infections per year, with 29,000 deaths and $4.5 billion in excess health care costs.37,38 Each infection costs about $13,500 and potentially more if the infections are serious.16 During 2000-07, deaths related to C. difficile increased 400 percent because of a more virulent bacteria strain that emerged. A majority of the deaths occur in people who are aged 65 and older. 

Lack of antibiotic stewardship and environmental transmission of spores have been attributed as main causes for occurrence of C. difficile.37 Other risk factors include immunosuppression, proton pump inhibitor usage, age over 65, hospitalization, severe illness, enteral feeding, and gastrointestinal surgery.39 It is recommended that patients with active C. difficile diarrhea be placed in contact isolation rooms and proper hand hygiene be performed with soap and running water instead of alcohol-based hand gel, which has been found to be ineffective. Similarly, CDC also recommends hospital cleaning be performed thoroughly and augmented using an Environmental Protection Agency-approved spore-killing disinfectant in rooms where C. difficile patients are treated.37

Hospital Environment and Its Relation to HAI

Patients admitted to rooms where previous patients were infected with MRSA, vancomycin-resistant Enterococcus (VRE), or C. difficile are at increased risk (two to three times higher) for acquiring these organisms during their stay due to the persistence of these organisms in the patient's environment.39-41 The full extent to which hospital surfaces influence the transmission of HAIs is unknown, but it is widely accepted that surface contamination plays a major role in the spread of disease.6,7,42

Contaminated hands of health care workers, which can come from contact with infected surfaces or persons, have been outlined as a potential factor in the acquisition of HAIs, which, in turn, results in direct and indirect exposure of other patients to the infectious agent.  

Scientific evidence has clearly supported the need to enforce handwashing in order to minimize the risk of surface and hand contamination.6 The pervasiveness of these pathogens coupled with their survivability on health care surfaces presents a difficult obstacle in the fight against HAIs and implies a high degree of responsibility for surface-mediated transmission in the natural ecology of HAIs.43 The longevity and prevalence of some of the most common nosocomial pathogens emphasize the important need to incorporate preventive surface disinfection into health care settings.42,43 This implication is supported by sanitation of "high-touch" surfaces as a commonly accepted critical step in preventing HAIs.44  Manual disinfection can significantly reduce environmental spore counts of pathogenic microbes. Studies have been able to show how improved surface disinfection can decrease environmental contamination of health care-associated pathogens and decrease the likelihood of patients acquiring a HAI.8,45-47    

Favorable results have been shown by adopting diluted bleach to clean and disinfect contaminated rooms housing significant colony counts of health care-associated pathogens.47 But manual disinfection alone generally has been shown to be inadequate, sometimes leaving residual contamination.6-8 There are several possible reasons for residual contamination in spite of manual disinfection. They include lack of proper staff training, using the wrong disinfectants for the microorganisms present, inadequate contact time, cross-contamination, and human error.41 As a result, novel no-touch disinfection (NTD) technologies have recently been incorporated into cleaning protocols in hospital settings. NTD that utilizes ultraviolet light (mercury or pulsed xenon based) has been shown to be effective at reducing microbial burden, possibly with greater consistency than is achieved with manual methods.8,42,45-47 On the other hand, UV lacks the ability to reach around corners and beneath beds and tables where light does not fall. In addition, it cannot be used when the patient is present and is not useful for treating linens.48

Hydrogen peroxide vapor (HPV) deployed as NTD has yielded favorable results in its ability to disinfect medical equipment that is difficult to clean with bleach; HPV can also reach surfaces that UV light cannot.48 However, although various NTD technologies have shown promise, they still have disadvantages.48 Usually, implementation is difficult. Convincing housekeeping staff to use novel units regularly is a challenge because of quick room turnaround pressure or lack of an adequate number of devices.  

Overall, NTD technologies used in terminal cleaning are not well suited to daily disinfection or keeping the bioburden low continuously. Copper-embedded surfaces have been efficacious with regards to some of the most important antibiotic-resistant organisms, including VRE, carbapenem-resistant Klebsiella pneumoniae, and multidrug-resistant Acinetobacter; copper-clad or brass surfaces have shown efficacy against these, as well as the specifically mentioned C. difficile.49-53  

In summary, HAI prevention is important because it is a patient safety issue and has potentially severe financial implications to a hospital. HAI prevention is everyone's responsibility.

Chetan Jinadatha, MD, is chief of infectious diseases at the Central Texas Veterans Health Care System in Temple and is an associate professor of medicine at Texas A&M Health Science Center. 

Edward J. Septimus, MD, is medical director of infection prevention and epidemiology at the Hospital Corporation of America and clinical professor of internal medicine Texas A&M Health Science Center College of Medicine.

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