Significant progress is being made in reducing surgical site and urinary tract infections, but Clostridium difficile and pneumonia are entrenched in Centers for Disease Control and Prevention (CDC) sentinel hospitals, researchers report.
Working with its clinical partners in the Emerging Infections Program, the CDC recently published a prevalence study of healthcare-associated infections (HAIs).1 Overall, they reported an encouraging 16% percent drop in HAIs in 2015 compared to a 2011 baseline. However, rates of C. diff infections and nonventilator pneumonia showed no improvement over the period.
The hospitals each selected one day to identify and assess a randomized sample of patients. The researchers reviewed medical records using the 2011 definitions of HAIs, comparing the percentages of patients infected and using modeling techniques to determine the risk of HAIs. In 2015, some 13,000 patients in 199 hospitals were surveyed and compared with 11,300 patients in 183 hospitals in 2011.
The study hospital groups bear many similarities to facilities nationwide, but the data cannot be extrapolated to reflect all hospitals, says lead author Shelley Magill, MD, PhD, of the CDC Division of Healthcare Quality Promotion. That said, the hospitals are generally representative and the 2015 follow-up included 74% of the 2011 facilities.
“There are a variety of different types of facilities that participated — some are academic, some are not,” she says.
“A lot of them are urban areas, but we did have some rural hospitals, so there is some variety there.”
Overall, the research showed the HAI prevalence for all patients dropped from 4% in 2011 to 3% in 2015.
“We didn’t go in with any preconceived notions about what we would find,” she says.
“The fact that the prevalence has gone down to 3% — we were definitely pleased to see that. The 16% lower risk had to do with the modeling process, where we did try to account for some of the other factors that would play into patients’ risk of having an HAI. It was a statistically significant reduction and a positive finding.”
The high prevalence of nonventilator-associated pneumonia, which was something of a surprise in 2011, was again the leading infection in 2015.
“We really haven’t made any progress in reducing that,” said co-author Marion Kainer, MD, MPH, director of the Tennessee Department of Healthcare Associated Infections and Antimicrobial Resistance Program.
“We need to better understand what we can do to prevent these pneumonias. There is a very significant opportunity for reducing patient harm.”
While ventilator-associated pneumonia is well characterized, these non-vent infections have less standardized definitions and interventions, she notes.
The findings underscore the need for ensuring good oral care, brushing the patient’s teeth, and encouraging patient elevation and movement, she says.
An unrelated study at 21 hospitals nationally shows that routine oral care of hospitalized patients and other basic measures were strongly associated with decreases in nonventilator hospital-acquired pneumonia.2 Eradicating bacteria in the mouth reduces the likelihood that patients’ aspiration of oral fluids into their lungs will seed a pneumonia infection in the lungs. (See Hospital Infection Control & Prevention, March 2018.)
Kainer also recommends the American Hospital Association’s “Up” program to prevent pneumonia by elevating and ambulating patients.
“The idea is to get people to ambulate as rapidly as possible,” she said. “These are really good principles, and they will help reduce pneumonias.”
Another proven prevention strategy is getting devices out as soon as possible, as catheters serve as a patient restraint.
“You have the ball and chain of a urinary catheter or a central line, and you have to take the IV poll with you,” Kainer says. “Getting devices out will not only help reduce central line- and catheter-associated UTIs, but it also should reduce these non-vent pneumonias because we are encouraging ambulation.”
The other problem pathogen comes as no surprise, as C. diff has become a scourge for patients and long-term care residents nationally.
As C. diff rates remained relatively the same in comparing 2011 and 2015, the investigators wondered whether the increased use of nucleic acid amplification tests, or “overdiagnosis” in general, may have contributed to the result.
Overall antibiotic use did not change between the comparative periods, although there were signs that one of the most often implicated drug classes was reduced to some degree.
“We did see a reduction in fluoroquinolones specifically, so there are some improvements being made, but clearly it is challenging, with more work needed,” McGill said.
More drastic reductions of fluoroquinolones are needed if the U.S. is to see the kind of C. diff reductions achieved in the United Kingdom, says William Schaffner, MD, professor of preventive medicine at Vanderbilt University in Nashville, TN.
“C. diff is a huge continuing problem,” says Schaffner, who was not an author of the study.
“We have issues with early diagnosis, therapy, appropriate intervention. Fortunately, there is work to try to create a C. diff vaccine by several researchers. We need some sort of intervention that we could apply in advance of people getting acute risks of C. diff infection.”
Indeed, there are least three different C. diff vaccines in some stage of clinical trials.
“Many of these vaccines have displayed good efficacy for CDI under laboratory conditions or in clinic trials,” clinicians report.3
The Good News
Citing the reduction in SSIs and UTIs, Schaffner says that overall, the glass is half full. “We continue to move in the appropriate direction. We are doing better and better in preventing healthcare-associated infections.”
Although specific interventions to prevent infections were not included in the study, clearly the ongoing efforts to get devices and catheters out as soon as possible have reduced UTIs and other infections.
“If you exclude the presence of devices, it is not just a 16% reduction but a 24% reduction [of overall HAI risk],” Kainer says. “I think that is because we are reducing the usage of central lines and urinary catheters. That is really important.”
In addition, there has been increasing focus on appropriate diagnostic testing, particularly about collecting urine cultures, which are used typically for diagnosis of UTIs, Magill said.
The reduction in the prevalence of surgical-site infections may reflect the wider implementation of preoperative practices like decolonizing MRSA patients prior to surgery, she theorizes.
“For SSIs, it is a little more complex, just because of the different types of surgeries and infections that occur,” Magill says. “But over this period there have been updates to surgical prophylaxis guidelines and publications looking at interventions perioperatively to prevent SSIs like decolonization.”
One thing that is certain is that infection prevention has come a long way from the days when many HAIs were regarded as an inevitable consequence of caring for high-acuity patients.
“The thinking has changed dramatically over the last couple of decades,” Magill says. “There is broad recognition in public health and the hospital community that these are patient safety issues and many of these infections are preventable.”
The HAI reductions show promise, but the entrenched infections underscore the continuing challenge to protect patients.
“We are not where we need to be,” Kainer says. “We have made significant progress, but there is still a lot of work to be done.”
- Magill SS, O’Leary E, Janele SJ, et al. Changes in Prevalence of Health Care–associated Infections in U.S. Hospitals. N Engl J Med 2018;379:1732-1744.
- Baker D, Quinn B. Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control 2018;45(13):DOI: https://doi.org/10.1016/j.ajic.2017.08.036.
- Peng Z, Ling L, Stratton CW, et al. Advances in the diagnosis and treatment of Clostridium difficile infections. Emerging Microbes & Infections 2018;7: https://go.nature.com/2zxzmWS.