Infection control compendium updated
New section on hand hygiene added
The leading infection control and infectious disease organizations are issuing updated recommendations in new compendium guidelines that will be published in sections over the next few months.
The first published update focuses on preventing catheter-associated urinary tract infections [CAUTIs] (See related story, p. 54.) Revised guidance on several other health care associated infections (HAIs) are slated to follow in the coming months.
First published in 2008, the compendium guidelines are designed to provide the best practical guidance on infection prevention in the absence of randomized clinical trials, which have not been conducted on many infection prevention practices.
"The compendium was always meant to be a practical guide to preventing HAIs in acute care hospitals," says Edward Septimus, MD, a lead author in the project and Medical Director of the Infection Prevention and Epidemiology Clinical Services Group for the HCA Healthcare System.1 "You have to weigh the evidence, but I don’t think you can say there’s not a randomized controlled trail for that so you don’t have to implement it. [There may be] strong observational studies that suggest what in fact may be a practical, reasonable things to do. It’s the old Voltaire comment, you don’t want perfect to be the enemy of the good."
In contrast, the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee (HICPAC) faces such a high bar for proof of practices it is often forced to issue "no recommendations" on "unresolved issues." For example, recently updated HICPAC guidelines for preventing surgical site infections focused on some difficult issues in an exhaustive and largely futile attempt to find conclusive data.
In comments submitted to the CDC, the Association for Professionals in Infection Control and Epidemiology (APIC) expressed "concern that the application of these guidelines by healthcare professionals has the potential to lead to great confusion on topics for which there are limited or absent recommendations. We fear that many professionals will misunderstand the statement No recommendations’ and revert back to traditional or unstudied practices."
Another concern is the body of evidence that was excluded from the document due to an exclusive reliance on systematic reviews and randomized controlled trials, APIC noted.
Grading the evidence
"A lot depends upon how you grade evidence and HICPAC uses a very high bar," Septimus says. "We all want to look at evidence for interventions, but everything can’t be based on a randomized control trial. Some of us look at this in a more practical way. If you have a number of observational trials that show significant reduction of infections, we sort of [push] that up a bit in terms of whether it should be a strong recommendation."
In addition to APIC, other groups collaborating on the compendium update include the Society for Healthcare Epidemiology of America, the Infectious Disease Society of America, The Joint Commission, and the American Hospital Association. CDC input also informed the process as the compendium was updated. The CAUTI update was recently published in the SHEA journal — Infection Control and Hospital Epidemiology — where the remaining recommendations will also be published over the next few months.2
"We felt that there is a lot of interest and usefulness in providing these documents as soon as possible," says Deborah Yokoe, MD, MPH, one of the project leaders and a hospital epidemiologist at Brigham and Women’s Hospital in Boston.3 "We didn’t want to hold up publication of any of the specific documents while awaiting completion of the other documents. In particular, we have one new compendium section on hand hygiene and we knew that would take more work to complete than the other sections, which are basically updates."
In addition the compendium synthesizes best evidence for the prevention of surgical site infections, central line-associated bloodstream infections, ventilator-associated pneumonia, Clostridium difficile, and MRSA. As for hand hygiene, it remains both the cardinal principle and enduring compliance problem for many infection control programs.
"It really is such an important, fundamental practice for infection prevention," Yokoe says. "There continues to be a lot of interest in improving hand hygiene in health care facilities so the decision was made to add that as a new section."
The 2014 updated compendium guidelines include basic HAI prevention strategies augmented by advanced approaches for outbreak management and other special circumstances. The new guidelines include performance and accountability measures to apply to individuals and groups implementing infection prevention practices.
"A lot of the updates and recommendations are very similar to the 2008 versions, but some of the special approaches — which hospitals can consider if they had the basic practices in place but they still think there is room for improvement — have been updated based on more recent studies," she says.
In this latest iteration of the compendium, a new segment has been added to each article that briefly describes examples of published implementation strategies and provides references that hospitals can access for more detailed information. Each section contains a "statement of concern," a brief summary of previously described detection and prevention approaches, recommended infection prevention strategies, proposed performance measures, and examples of implementation strategies for consideration. Each hospital must apply the recommendations to their setting and distinct safety culture, Septimus emphasizes.
"The bottom line is you want to have this adaptive culture of safety occur within frontline health care workers," he says. "We may understand the science, but on a local basis, what adaptive, behavioral changes need to take place? In my facility — not some generic facility — based on our culture and my leadership? It has to be owned at the local level. Safety ought to be part of the basic DNA of all organizations and health care workers."
- Septimus E, Yokoe DS, Weinstein RA, et al. Maintaining the Momentum of Change: The Role of the 2014 Updates to the Compendium in Preventing Healthcare-Associated Infections. Infect Control Hosp Epi 2014;35:455-459
- Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Cont Hosp Epi 2014;35(5):464-479.
- Yokoe DS, Anderson DJ, Berenholtz SM, et al. Introduction to "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates" Infect Control Hosp Epi 2014;35:455-459