Root Cause Analysis

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http://dx.doi.org/10.2147/IDR.S177247

Health care-associated infections – an overview

Mainul Haque1

Massimo Sartelli2 Judy McKimm3 Muhamad Abu Bakar1

1Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia; 2Department of Surgery, Macerata Hospital, via Santa Lucia 2, 62100 Macerata, Italy; 3Swansea University School of Medicine, Swansea University, Singleton Park, Swansea, wales SA2 8PP, UK

Abstract: Health care-associated infections (HCAIs) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more

after hospital admission, or within 30 days after having received health care. Multiple studies

indicate that the common types of adverse events affecting hospitalized patients are adverse

drug events, HCAIs, and surgical complications. The US Center for Disease Control and Pre-

vention identifies that nearly 1.7 million hospitalized patients annually acquire HCAIs while

being treated for other health issues and that more than 98,000 patients (one in 17) die due to

these. Several studies suggest that simple infection-control procedures such as cleaning hands

with an alcohol-based hand rub can help prevent HCAIs and save lives, reduce morbidity, and

minimize health care costs. Routine educational interventions for health care professionals can

help change their hand-washing practices to prevent the spread of infection. In support of this,

the WHO has produced guidelines to promote hand-washing practices among member countries.

Keywords: health care-associated infections, central line-associated bloodstream infections, sur- gical site infections, catheter-associated urinary tract infections, ventilator-associated pneumonia

Background Health care-associated infections (HCAIs) are those infections that patients acquire

while receiving health care.1 The term HCAIs initially referred to those infections linked

with admission to an acute-care hospital (earlier called nosocomial infections), but

the term now includes infections developed in various settings where patients obtain

health care (eg, long-term care, family medicine clinics, home care, and ambulatory

care). HCAIs are infections that first appear 48 hours or more after hospitalization or

within 30 days after having received health care.2 Multiple studies indicate that the

most common types of adverse events affecting hospitalized patients are adverse drug

events, HCAIs, and surgical complications.3–7 The US Center for Disease Control and

Prevention identifies that nearly 1.7 million hospitalized patients annually acquire

HCAIs while being treated for other health issues and that more than 98,000 of these

patients (one in 17) die due to HCAIs.8 The Agency for Health care Research and

Quality reported that HCAIs are the most common complications of hospital care and

one of the top 10 leading causes of death in the USA.9 Out of every 100 hospitalized

patients, seven patients in advanced countries and ten patients in emerging countries

acquire an HCAI.10 Other studies conducted in high-income countries found that

5%–15% of the hospitalized patients acquire HCAIs which can affect from 9% to

37% of those admitted to intensive care units (ICUs).11,12 Multiple research studies

Correspondence: Mainul Haque Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia Mobile +60 10 926 5543 email [email protected]

Journal name: Infection and Drug Resistance Article Designation: Review Year: 2018 Volume: 11 Running head verso: Haque et al Running head recto: Health care-associated infections and prevention strategy DOI: http://dx.doi.org/10.2147/IDR.S177247

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report that in Europe hospital-wide prevalence rates of HCAIs

range from 4.6% to 9.3%.13–21 The WHO reports however that

HCAIs usually receive public attention only when there are

epidemics.22 HCAIs also have impact on critically ill patients

with around 0.5 million episodes of HCAIs being diagnosed

every year in ICUs alone.7,14,23 ICU patients are often in a very

critically ill, immuno-compromised status which increases

their susceptibility to HCAIs.24,25

Brief history There has been long-standing awareness that the practice of

medicine can do harm as well as good. For example, Hip-

pocrates, the father of modern medicine, stated more than

2,500 years ago that “I will use treatments for the benefit of

the ill in accordance with my ability and my judgment, but

from what is to their harm and injustice I will keep them.”26

It was also recognized (eg, by Semmelweis discussing puer-

peral fever) many years ago that coming into hospitals (in

particular) can be dangerous.27 In this century, the idea that

medicine could cause harm, including death is described as

“unintended physical injury resulting from or contributed to

by medical care, including … [its] absence … that requires

additional monitoring, treatment or hospitalization, or …

results in death.”28,29 Offering another perspective, an Ameri-

can natural sciences writer noted that HCAIs are now killing

around 100,000 people, many more than HIV/AIDS, cancer,

or road traffic accidents.30

The Hungarian obstetrician Professor (Dr) Ignaz Phillip

Semmelweis is largely considered as the medical doctor

who realized that health care providers could communicate

disease. His work identified the mode of communication

and spread of puerperal sepsis while working at the Mater-

nity Hospital in Vienna. In 1847, he observed higher rates

of maternal mortality among patients treated by obstetri-

cians and medical students than among those cared for by

midwives. At that time, he also found that a pathologist had

died of sepsis after wounding himself with a scalpel while

carrying out an autopsy on a patient with puerperal sepsis.

The pathologist’s illness mirrored that of women with puer-

peral sepsis, and Semmelweis wrote that both a scalpel and

a physicians’ contaminated hands could transmit organisms

to mothers during labor. He introduced chlorinated lime

hand washing to the obstetric hospital staff, resulting in

large improvements in maternal mortality rates.31 However,

Semmelweis’ theories were dismissed by most of the medi-

cal establishment because of a lack of appropriate statistical

analysis of the data. Nevertheless, after Koch’s postulates

were published in 1890, the germ theory of disease and

Semmelweis’ theory of transmission of disease from doctor

to patient were found to be valid. Semmelweis was therefore

the first to describe an HCAI and provide an intervention to

avert its spread through hand hygiene.32

Prevalence and brief outline of HCAIs A survey conducted in 183 US hospitals with 11,282 patients

reported that 4% of patients had at least one HCAI with the

most common microorganism being Clostridium difficile.

Most infections were surgical site infections (SSIs), pneumo-

nia, and gastrointestinal infections.33 A study 2 years earlier

by the same group found that 6% (51) of patients had suffered

from HCAIs with the top 75.8% acquiring SSIs, urinary tract

infections (UTIs), pneumonia, and bloodstream infections.

Staphylococcus aureus was the most frequently detected

microorganism.34 The group conducted a comparative study

between 2011 and 2015 and found a statistically significant

(P<0.05) reduction of HCAIs in SSIs, UTIs, and central line infections, probably due to a national initiative.35

HCAIs are also problematic elsewhere in the world. For

example, a study in Singapore reported 11.9% (646) patients

with HCAIs, primarily undetermined clinical sepsis, and

pneumonia caused mainly by S. aureus and Pseudomonas

aeruginosa.36 This study also reported that the Acinetobacter

species and P. aeruginosa were extremely resistant to car-

bapenem.36 A recent European study found that 2,609,911

new patients were identified as having HCAIs annually in

the European Union and European Economic Area.37 This

study revealed that for every 20 patients hospitalized, at least

one acquired an HCAI which was preventable.37 Klebsiella

pneumoniae and the Acinetobacter species were exceedingly

resistant to multiple antimicrobials, and the lack of new anti-

microbials increases the huge burden in Europe.37 In Greece,

the HCAI prevalence rate was 9.1%. The frequent types

of HCAIs were lower respiratory tract infections (LRTIs),

bloodstream infections, UTIs, SSIs, and systemic infections.38

One systematic review and meta-analysis regarding HCAIs in

Southeast Asian countries (Brunei, Myanmar, Cambodia, East

Timor, Indonesia, Laos, Malaysia, the Philippines, Singapore,

Thailand, and Vietnam) found an overall prevalence rate of

9.1% with the most common microorganisms being P. aerugi-

nosa, the Klebsiella species, and Acinetobacter baumannii.39

A study conducted in eight university hospitals of Iran

(ranging from 60 to 700 beds) reported an overall HCAI

frequency of 9.4%, the most common HCAIs were blood-

stream infections, SSIs, UTIs, and pneumonia.40 A logistic

regression analysis showed that the odds ratio (OR) for males

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as opposed to females acquiring infections was 1.56 (95%

confidence interval [CI] 1.21–2.02). Additional risk factors

for HCAIs include a central intravascular catheter, adjusted

OR of 3.86 (95% CI 2.38–6.26), and with a urinary catheter,

adjusted OR of 3.06 (95% CI 2.19–4.28). Being admitted to

an ICU is not in itself a self-determining HCAI risk factor.

The OR for all HCAIs of acquiring an infection was 3.24

(95% CI 2.34–4.47) in patients with hospital stays longer

than 8 days.33 Seventy-one percentage (71%) of the studied

patients received antimicrobials, but 9.4% had at least one

evidence of infection.33 Another study revealed that the

average number of microbes ranged from on (9.67×1011), working surfaces (1.64×1012), door handles (1.71×1012), and highest in taps (2.08×1012).41 The highest number (23) of pathogens were isolated from door handles, and the peak

variance of pathogens were on hospital floors (7). Among

those microbes, those that were disease-producing were

46.14%, 53.86% were nonpathogenic, the most common was

S. aureus at 14.42% and 45.2% of the total bacterial isolates

comprised Bacillus subtilis. A study conducted in Ghana

reported that gentamicin was the most effective antibiotic

(100%) on both Gram-positive and Gram-negative organisms,

but of the 12 antibiotics tested (ampicillin, cefuroxime, cotri-

moxazole, cefotaxime, tetracycline, amikacin, gentamicin,

chloramphenicol, cefixime, cloxacillin, and erythromycin),

six were resistant to either Gram-positive or Gram-negative

organisms.41 Most of the HCAIs in the US are triggered by

the ESKAPE group, comprising the antimicrobial-resistant

Gram-negative microorganisms (K. pneumoniae, A. bauman-

nii, P. aeruginosa, and Enterobacter spp.) and the Gram-

positive species, Enterococcus faecium and S. aureus.42–44

Multiple studies report that Gram-negative organisms are

responsible for 10%,45 20%–40%,46 of HCAIs and that anti-

microbial resistance places a significant burden on the global

health care system, particularly in low resource countries.47,48

This problem is exacerbated as research and development

into new antimicrobials targeting Gram-negative organisms

has rapidly decreased in recent years.48

Among the newer aminoglycosides, plazomicin has

been found to be active against the extended-spectrum beta-

lactamase (ESBL) generating strains of Enterobacter spp.,

Escherichia coli, and K. pneumoniae49 and more effective

in laboratory experiments against A. baumannii than genta-

micin, tobramycin, and amikacin.50 Plazomicin has a better

safety profile than other drugs, with no report of damage

to the cochlea, auditory nerve, vestibular, and renal system

in healthy volunteers, even with high and multiple doses.51

Another study found that, in a comparison between HCAIs

due to methicillin-sensitive S. aureus and methicillin-resistant

S. aureus (MRSA), isolates were statistically significantly

(P<0.005) more resistant to ciprofloxacin, clindamycin, trimethoprim/sulfamethoxazole, erythromycin, gentamicin,

and tetracycline.52 Hospital waste, especially contaminated

surgical waste, often acts as a reservoir for pathogenic viru-

lent microorganisms, and it suggested that 20%–25% of the

waste produced by health care outlets is considered to have

high potential to cause HCAIs, it therefore needs appropriate

handling and disposal.53,54

Causative organisms Around 12–17 microorganisms cause 80%–87% of HCAIs:

S. aureus, Enterococcus species (eg, faecalis, faecium), E.

coli, coagulase-negative Staphylococci, Candida species

(eg, albicans, glabrata), K. pneumoniae and Klebsiella

oxytoca, P. aeruginosa, A. baumannii, Enterobacter spe-

cies, Proteus species, Yeast NOS, Bacteroides species, and

other pathogens.45,55,56 Among these pathogens, 16%–20%

include multidrug-resistant (MDR) phenotypes: MRSA,

vancomycin-resistant E. faecium, carbapenem-resistant

P. aeruginosa, extended-spectrum cephalosporin-resistant

K. pneumoniae, K. oxytoca, E. coli, and Enterobacter spe-

cies, and carbapenem-resistant P. aeruginosa, K. pneumoniae/

K. oxytoca, E. coli, Enterobacter species, and A. bauman-

nii.45,55 Some of these Gram-negative microorganisms have

a much higher rate (20%–40%) of resistance than others45

with the organisms isolated from device-associated HCAIs

having the highest antimicrobial resistance phenotypes.56 In

the latter study, although similar to the percentage resistance

for most phenotypes was that in an earlier research study,45 an

upsurge in the scale of the resistance fractions against E. coli

pathogens was observed, especially with fluoroquinolones.56

Acinetobacter, Burkholderia spp. and Pseudomonas spp.

isolates were 100% were 92% resistant to cephalosporins

respectively. Burkholderia spp. was again totally resistant to

fluoroquinolones and Acinetobacter spp. and Pseudomonas

spp. were 94.2% and 95.8% resistant, respectively. The same

study reported that 86.4% Acinetobacter spp. and 62.5%

Pseudomonas spp. showed a high resistance to carbapenems,

the preferred drug regime in ICUs. Carbapenems were found

more effective against Burkholderia spp. with 20% resistance.57

In another study, Enterobacteriaceae community were found

to be completely resistant to third-generation cephalosporins.58

Over 80% of the Klebsiella spp. community were resistant

to ciprofloxacin, gentamicin, piperacillin, tazobactam, and

imipenem showing 48.6% resistance. E. coli was equally

resistant although carbapenems were effective in almost

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80% cases. Although Citrobacter spp.-related HCAIs are a

relatively minor proportion, they also show resistance toward

cephalosporins, fluoroquinolones, and aminoglycosides.58

Another study reported that although the Acinetobacter spp.

were 76.99%–92.01%, resistant to most antimicrobials, only

30% of Acinetobacter spp. isolated were susceptible.59 It can

be seen therefore that the causative pathogenic microorganisms

differ from country to country as does patterns of resistance.

Types of HCAIs Alongside infections due to cross-contamination between

patients and health workers, patients being susceptible to

common infections due to diminished immune responses,

and infections at surgery sites (SSIs), many HCAIs are due

to implants and prostheses. These include central line-associ-

ated bloodstream infections (CLABSIs), catheter-associated

UTIs, and ventilator-associated pneumonia (VAP).57,60,61

CLABSIs CLABSIs substantially increase morbidity, mortality, and

health care costs, and great attention has been paid to

addressing these.62,63 As a consequence, in 2009, 25,000

fewer CLABSIs occurred in the ICUs of US hospitals than

in 2001, a 58% reduction, with about 6,000 lives saved and

estimated financial savings of US$414 million in potential

excess health care costs, although the costs of reducing such

infections is very high.64 It is estimated that it costs ~$1.8 billion between 2001 and 2009 to save an additional 27,000

lives.64 Despite this investment, a considerable number of

CLABSIs still occur, especially in outpatient hemodialysis

centers and inpatient wards.64 Another study also reported

the link between CLABSIs and considerable morbidity and

mortality, although there is a wide variation in reported infec-

tion rates (from 20% to 62.5%) in emerging economies.65

A study conducted in Taiwan reported the occurrence of

CLABSIs as 3.93 per 1,000 central-catheter days.66 The most

common causative pathogens were Gram-negative (39.2%),

Gram-positive (33.2%), and Candida spp. microorganisms

(27.6%).66 In this study, patients developed CLABSIs 8 days

from the time of insertion of the central line catheter.66 Mul-

tivariate analysis showed that a higher Pitt bacteremia score

(OR 1.41; 95% Cl=1.18–1.68) and the prolonged interval between the onset of CLABSIs and catheter removal (OR

1.10; 95% CI=1.02–1.20) were associated with higher death rates.66 Another similar study identified prolonged catheter

in situ, pediatric ICU stay, and intravenous nutrition were

significant prognosticators of peripherally inserted central

catheter-related CLABSIs among hospitalized children.67

SSIs SSIs (formerly termed “wound infections”) are still one of

the most common adverse events that occur in hospitalized

patients undergoing surgery or in outpatient surgical mea-

sures, regardless of the advances in preventive procedures.68

SSI is the most common complication in postoperative surgi-

cal patients, associated with significant morbidity, high death

rates, and financial stress on national budgets and individual

patients.69–71 SSIs are defined as infections arising up to 30–90

days after surgery in patients receiving an organ, group of

cells, or device and affecting both the incisional site and

deeper tissues around the surgery location.72,73

The type of surgery determines the proportion of SSIs.

Between 2% and 36% of patients may develop SSIs, with

the highest risk for orthopedic followed by cardiac and intra-

abdominal surgery.14,72,74,75 The length of hospital stay for

patients with SSIs increases from 4 to 32 days as compared

with patients with no post-surgical infections.76–78 Approxi-

mately 25% of patients with SSIs develop severe sepsis and

shock and are moved to an ICU.65 SSIs cause statistically

significant morbidity, mortality, and financial burdens for

individuals and for communities.69–71,78

HCAIs are common following cardiac surgery, with a

reported incidence rate of between 5.0% and 21.7%,79,80

often accompanied with multiple organ failure and prolonged

hospital stays, leading to increased mortality rates.79,80 The

three most common locations for HCAIs after cardiac surgery

are lungs, central venous catheters, and surgical sites.69 SSIs

followed by cardiac surgery classically present with local-

ized cellulitis (erythema, warmth, and tenderness), purulent

discharge, sternal instability, chest pain, and systemic upset

with deep infections.81–83 SSIs are devastating for orthopedic

patients as it is very difficult to rid the bones and joints of the

infection.83 One Saudi Arabian study reported an incidence of

SSIs in orthopedic patients of 2.55% (79 of 3,096 patients)

with the most common pathogens being Staphylococcus

species including MRSA (29.11%); Acinetobacter species

(21.5%); Pseudomonas species (18.9%), and Enterococcus

species (17.7%).84 Surgical wound contamination potentials,

patients’ clinical conditions, type of surgery, and length of

surgery were variables statistically significantly associated

with SSIs and should be viewed as risk factors.85 The move-

ment and number of staff and the structural features of the

operating theater also affect the incidence of SSIs.85,86 One

study found that 73.33% cases of SSIs following orthopedic

surgery were culture positive, and a total of 35 bacterial

strains were isolated, among which 65.72% were Gram-

positive isolates and 34.28% were Gram-negative bacteria.87

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About 68.6% of all bacterial isolates were resistant to cefu-

roxime used in the management of orthopedic SSIs. This

study also found that diabetes mellitus, smoking, operations

lasting more than 3 hours, the absence of antibiotic prophy-

laxis, and a history of previous surgery were positive risk

factors associated with a significant upsurge in SSIs.87

SSIs comprise at least 14%–22.2% of all HCAIs for

abdominal surgery88–90 and often lead to extended hospital-

ization and higher antimicrobial costs.71 The microorganisms

generally involved in such SSIs include S. aureus, coagulase-

negative Staphylococci and Enterococcus spp., and E. coli.71

S. aureus has been known to be a major cause of HCAIs for

over 100 years.91 When first introduced, nearly all strains were

susceptible to penicillin, but since its wide and often irratio-

nal use, S. aureus started to become resistant by producing

β-lactamase enzyme.91 By 1960, 95% hospital variants of S. aureus were resistant.91,92 To help combat resistance, several

new penicillins were developed to resist Staphylococcal

β-lactamase, such as methicillin, oxacillin, cloxacillin, and flucloxacillin.91 However, within 1 year of methicillin being

marketed in 1960, the first MRSA strain of S. aureus was

reported in England.93 The MRSA strain represents 50% of

HCAIs in the US and Europe and causes infections that are

very difficult to manage because of their potential resistance

to multiple antimicrobials.94–96 In one study, the incidence

of SSIs was after gastrectomy in 11.3%, after colorectal

surgery in 15.5%, after hepatectomy in 11.3%, and after

pancreaticoduodenectomy in 36.9%.97 While the incidence

of SSIs was higher in the absorbable stitching material than

the silk group for all surgical procedures, the difference was

not statistically significant. 97A Japanese study on abdominal

surgery reported an overall SSI rate of 14.4%. The SSI rates

in the suture-less, Vicryl, and silk groups were 4.8%, 14.8%,

and 16.4%,88 respectively, again with no statistically signifi-

cant differences between the groups. In colorectal surgery,

the SSI rate in the polyglactin 910 (absorbable, synthetic,

usually braided suture; VicrylTM) group was 13.9%, which

was statistically significantly lower than that of the silk

group (22.4%; P=0.034). The incidence of deeper SSIs in the Vicryl group, including deep incisional SSIs (ISSIs) and

organ/space SSIs (OSIs), was statistically significantly lower

than that in the silk group (P=0.04).88 The SSI rates did not differ among the suture types overall in gastric surgery or in

appendectomy.98 A US study of pediatric patients found that

while this was only 2.5% of the caseload, colorectal surgery

contributed to 7.1% of the SSIs.98 The SSI rates of all types

of colorectal surgery were 5.9% (ISSIs: 3.2%; OSIs: 2.7%)

with the uppermost being total abdominal colectomy (11.4%)

trailed by partial colectomy (8.3%) and colostomy closure

(5.0%).98 Inflammatory bowel diseases caused the topmost

health problems in a comparison of all colorectal diagnosed

diseases (24.9%; ISSIs: 22%; OSIs: 28.6%). Hirschsprung’s

disease (14.2%; ISSIs: 15.4%; OSIs: 12.8%) and anorectal

malformations (12.4%; ISSIs: 17.6%; OSIs: 6.4%) were the

next major group in colorectal diseases.98 Finally, a study uti-

lizing univariate analysis defined 13 statistically significantly

variables related to SSIs. Those were patients aged over 60

years, lower functional status, diabetes mellitus, congestive

heart failure, immunocompromising disease, anticancer

medications, immunosuppressive agents, impaired immune

system, open cholecystectomy, laparotomy, an American

Society of Anesthesiologists score above 2, drain insertion,

and dirty wound.99 Using multivariate regression analysis,

this study also found that immunosuppressive agents (OR

=2.5, 95%, CI =1.099–143.443), open cholecystectomy (OR =2.25, 95% CI =2.242–40.109), and contaminated wound (OR =2.179, 95% CI =3.80–20.551) were statistically sig- nificantly linked with SSIs.99

Catheter-associated urinary tract infections (CAUTIs) Internationally, UTIs are the most common HCAIs and one

of the top ranking microbial infections, representing around

40% of HCAIs, with significant consequences for morbidity

and mortality and substantial financial implications.14,99,100

Although CAUTIs are typically benign, some patients have

potentially pathogenic virulent bacteria but are asymptom-

atic, and these patients were associated with a three-times

higher mortality than in non-bacteriuric patients.101,102 Multi-

variate analysis indicates the risk factors for CAUTIs includ-

ing prolonging the duration of the catheter, female sex, older

age, diabetes mellitus, the absence of systemic antibiotics,

catheter insertion outside the operating room, and a breach in

the closed system of catheter drainage.101,103 The rate of CAU-

TIs has been estimated to be about 5% per day, regardless of

the duration of the indwelling catheter, with E. coli being the

main infecting pathogenic microorganism, although a wide

spectrum of other microorganisms were identified, including

eukaryotic fungus.104,105 The repetitive inappropriate admin-

istration of antimicrobials often leads to greater bacterial

resistance. CAUTIs habitually lead to biofilm formation on

both the extraluminal and intraluminal portal catheter surface,

largely from extraluminal microorganisms.106–108 The biofilm

defends microbes from both antimicrobials and host defense

mechanisms.109 Although morbidity from CAUTIs with short-

term catheter use is limited if catheters are appropriately

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inserted and cleaned, in patients with long-term indwelling

catheters, fever from CAUTIs is common with a frequency

fluctuating from one per 100 to one per 1,000 catheter days.105

Patients in institutional care with long-term indwelling

catheters have a greater risk for the presence of pathogenic

microorganisms and other urinary tract diseases than those

without catheters.105 One meta-analysis found that CAUTIs

were linked with statistically significantly higher death rates

(OR =1.99; 95% CI =1.72–2.31; P<0.00001; I2=54%; eight studies; 62,063 patients) and days in the ICU (weighted mean

difference of +12 days; 95% CI =9–15; P<0.00001; I2=96%; seven studies; 13,011 patients) and hospital (mean difference

+21 days; 95% CI =11–32; P<0.0001; I2=98%; five studies; 10,183 patients).110 An Australian health care-associated

urinary tract infection (HCAUTI) non-concurrent cohort

study carried out for 4 consecutive years found that patients

had an extra 4 days (95% CI =3.1–5.0 days) of hospitaliza- tion.111 This study further reported that the infection rate was

statistically significantly minimized utilizing a Cox regres-

sion model (HR =0.78; 95% CI =0.73–0.83) when patients were released from the hospital.111 HCAUTIs very rarely

cause death (HR =0.71; 95%CI =0.66–0.75), especially in large hospitals when compared to other health care institutes,

even when compared with age and sex (HR =0.74; 95% CI =0.69–0.78), although elderly patients more often died (HR =1.40; 95% CI =1.38–1.43).111

vAP The death risk for patients in the ICU is not only because

of their original illness but often because of HCAIs.2,54,112

Pneumonia is the second commonest HCAI in ICUs,

affecting more than one-quarter of patients.113,114 Around

86% of HCAIs are associated with motorized automatic

ventilation and VAP.113 Between 9% and 27% of patients

with assisted ventilation develop this kind of pneumonia,

and VAP has been identified internationally as a potential

major cause of death.114 The average critical time to develop

VAP following endotracheal intubation and mechanical

ventilation was 2–3 days.115 Patients usually develop a

fever, altered bronchial sounds, white blood cell counts

reduced, changes in sputum, and causative organisms are

often identified.116–121 A US study found a range of VAP of

between 1.2 and 8.5 per 1,000 ventilator days122 although an

international group reported a much higher occurrence of

VAP of 13.6/1,000 ventilator days.123 In Asian countries, a

different picture of 3.5–46 infections/1,000 ventilator days

emerges,124 with a very high incidence rate in India of 40.1

per 1,000 ventilator days.125 The initial 5 days of mechanical

ventilation is the most critical time for the development of

VAP, with a mean duration of 3.3 days between intubation

and the development of VAP.119–126 Another recent Indian

study reported that non-fermentative Gram-negative

bacilli127 were the predominant organisms, followed by

Pseudomonas and Klebsiella genus. In this study, S. aureus

reduced in prevalence from 50% to 34.9% between 2011

and 2013, but between 2012 and 2013 vancomycin-resistant

Enterococci increased from 4.3% to 8.3%, while methicil-

lin resistance among S. aureus exceeded 50% in 2013. In

addition, an upwavard trend in resistance by Pseudomonas

genus was observed for piperacillin-tazobactam, amikacin,

and imipenem. The incidence of non-fermenters’ resis-

tance continued to be very high except for amikacin and

imipenem (33.1%) and polymyxin-B (2.4%).127 A study at

Chonnam National University Hospital in South Korea of

the transtracheal aspirates or bronchoalveolar lavage of

patients suffering from VAP found that S. aureus (44%)

was the most frequently detected causative microorganism

followed by A. baumannii (30%), P. aeruginosa (12%),

Stenotrophomonas maltophilia (7%), K. pneumoniae (6%),

and Serratia marcescens (2%).128 In addition, S. aureus was

found as MRSA and 69% of Acinetobacter baumannii were

imipenem-resistant.128 No statistically significant variance

was observed in the imipenem-resistant A. baumannii128

between the earlier and late VAP-related study groups (73%

[8/11] vs 67% [14/21], P=1.000).128 In this study, 67% of K. pneumoniae was ESBL-positive.128 VAP was frequently

linked with substantially increased morbidity, including

prolonged ICU and hospitalization, and higher ventilator

days and health care costs.129

In the UK and the Republic of Ireland, a European

study of HCAIs connected with respiratory infection found

a prevalence rate of 7.59%. Among these HCAIs, 15.7%

were pneumonia, and 7% were lower respiratory tract infec-

tions other than pneumonia (LRTIOP).130 Around 21% of

patients in both the groups were having artificial ventila-

tion, which was much higher when compared to the rest of

the patients with HCAIs. MRSA was the principal invading

microorganism for both pneumonia and LRTIOP. Although

the patients with LRTIOP suffered more from C. difficile-

induced diarrhea than pneumonia, this was not statistically

significant.130 A recent Chinese study reported that 14.94%

(895) of inpatients acquired a LRTI which prolonged their

hospital stay and increased the costs per individual case by

US$2,853.93.131 Another study revealed that 9.6% of patients

developed HCAIs, of which respiratory tract infections

were the highest at 65.8%.132 The most frequently identified

respiratory pathogen was Gram-negative Acinetobacter spe-

cies (40.4%), and among these 21% were MDR.132

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Health care-associated infections and prevention strategy

A significant number of patients develop pneumonia after

surgery which includes both hospital-acquired pneumonia

(pneumonia developing 48–72 hours after admission) and (as

discussed above) VAP (pneumonia developing 48–72 hours

after endotracheal intubation).133 Postoperative pneumonia

has been described as one of the leading consequences of

all types of surgery with a high incidence of morbidity and

mortality.134 It increases hospital stays on an average of 7–9

days and increases health care costs from US$12,000 to

US$40,000.114,135,136

HCAIs HCAIs are a major safety concern for both health care pro-

viders and patients. They continue to escalate at an alarm-

ing rate, especially in emerging economies, with infection

rates 3–20 times higher than in high-income countries.1,2,137

HCAIs increase morbidity, mortality, length of hospital

stays, and costs;138–140 therefore, more research and changes

in practice are needed to ensure hospital safety and prevent

HCAIs.32,141–143 The annual costs for HCAIs alone in the

USA are between US$28 and US$45 billion, but with even

this amount of spending, 90,000 lives are still lost per year:

HCAIs are among the top five killers in the USA.14,144–147 The

WHO advocates that effective hand hygiene is the single

most important practice to prevent and control HCAIs, which

form colonies with MDR microbes.1,2,148,149 Several studies

report that a simple and straightforward process, taking only

a few seconds to clean hands with an alcohol-based hand rub

helps prevent HCAIs and save lives, reduce morbidity, and

minimize health care costs.150,151 However, factors such as

the availability of alcohol-based hand rubs and up-to-date

knowledge of the importance of hand washing hinder good

practice in hand hygiene. For example, an Australian observa-

tional study of community nurses highlighted poor practices

of hand hygiene in comparison with a standard protocol.152

The WHO promotes and advocates that all health care

workers (HCWs) must wash their hands before touching a

patient, before clean/aseptic procedures, after body fluid

exposure/risk, after touching a patient, and after touching

patient surroundings.153 The Center for Disease Control

and Prevention has developed a comprehensive plan and

guidelines for the prevention of HCAIs which covers basic

infection prevention and control (IPC); antibiotic resistance;

device- and procedure-associated infections; disease/

organism-specific infections; and guidance for health work-

ers working in specific settings.154 This guidance, like that

of the WHO and the UK Royal College of Nursing (RCN)

also emphasizes the importance of hand washing.153–155 The

RCN also promotes and advocates that all health care profes-

sionals must receive compulsory “infection control training

as part of their induction and on an ongoing annual basis.

It is particularly important that knowledge and skills are

continually updated.”155 Multiple research studies indicate

that policy changes and the adoption of novel multifactorial,

multimodal, multidisciplinary strategies offer the greatest

possibility of success in terms of hand hygiene improvement

and the reduction of HCAIs.156–167

Instigating best practice in health care stems “from

a response to factors that are outside a purely scientific

understanding of infection and not simply understood as a

deficit in knowledge.”168,169 Good practice for infection pre-

vention among HCWs can be ensured through compliance

to IPC guidelines.168 Specific individuals acting as “change

champions” can act as arbitrators or negotiators, contribut-

ing to changing behaviors and implementing best practice

to ensure patient safety.168–171 This calls for educational

interventions that reflect the philosophies, principles, and

community understanding of dirt and infection.169 An edu-

cational intervention involving 4,345 health professionals

in three public hospitals in the USA successfully improved

hand hygiene immensely with the use of alcohol hand rub.

Nurses, physicians, and allied HCWs improved from 14% to

34%, 4.3% to 51%, and 12% to 44%, respectively.172 Other

studies also highlight how behavior change around hand

washing can result from educational interventions.149,151,172

Health professionals must protect themselves with barriers

for example, gloves, gowns, face masks, protective eyewear,

and face shields,173 to decrease the work-related transmis-

sion of microorganisms. Regular use of personal protective

equipment (PPE)173 devices protects both the professional

and the patient from potentially infectious body fluids.173

Nevertheless, the use of PPE does not confirm 100% pro-

tection,174 for example, needlestick injury can breach PPE,

and, in many occasions, issues might go unrecognized

which might cause a dangerous health hazard including

hepatitis B or HIV.175

Respiratory microorganisms, for example, influenza

virus, Bordetella pertussis, Haemophilus influenzae, Neis-

seria meningitidis, and Mycoplasma pneumoniae, severe

acute respiratory syndrome-associated coronavirus, Group

A Streptococcus, adenovirus and rhinovirus, and tubercular

bacilli176 are easily dispersed through droplets (particles ≤5 µm in size) in closed health care settings and often cause

endemics and epidemics.176 PPE, vaccines, and drugs are

the main measures to prevent and control such infections.177

This includes national annual campaigns such as requiring all

health professionals to have a flu vaccine. Multiple research

studies have found that poor cleaning of hospital surfaces is a

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major source of HCAIs because of the transmission of many

dangerous microorganisms such as MRSA, vancomycin-

resistant Enterococcus spp. (VRE), C. difficile, Acinetobacter

spp., and norovirus.178–182 Meticulous cleaning of hospital

surfaces is therefore vital to maintain standards and reduce

the risk of HCAIs.183 Several studies conclude that ultraviolet

devices and hydrogen peroxide vapor technologies success-

fully eradicate potentially dangerous hospital microorgan-

isms adhering to the surfaces in ward or patient rooms.183–186

Furthermore, hydrogen peroxide vapor efficiently sterilizes

and sanitizes all clinical areas where potentially dangerous

microbial MDR microorganisms and spores were suspected

to be present.187

Conclusion In the early to mid-19th centuries in both Europe and USA,

thousands of young women died from puerperal sepsis and

fever, the diseases rampant in the charity maternity clinics

of the time188 and, due to the efforts of (among others) Dr

Ignaz Phillip Semmelweis and Dr Oliver Wendell Holmes, the

fight against puerperal fever was won and it was confirmed

that HCAIs were transmitted via the hands of HCWs.188–192

Despite the development of many hi-tech methods, hand

washing with soap and water or alcohol rub is still the

most important means of maintaining personal hygiene and

preventing HCAIs.192 However, due to the rise of antibiotic-

resistant bacteria and a reluctance of some HCWs to imple-

ment best practice infection control, HCAIs remain one of

the biggest causes of death in most countries. Therefore, it

is essential that strategic, policy, and education initiatives

continue to focus on managing and controlling such (pre-

dominantly needless) infections.

Limitations of the study The topic of HCAIs is a very broad issue, and it has therefore

not been possible to cover all aspects of HCAIs in one paper;

hence, we have been selective in selecting key aspects of the

current debate.

Acknowledgments The authors are grateful to Dr Zakirul Islam, Associate

Professor and Head of The Department, Pharmacology and

Therapeutics, Eastern Medical College, Comilla, Bangladesh

for his cooperation in converting the video abstract from a

PowerPoint file to video format.

Disclosure The authors report no conflicts of interest in this work.

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1. Publication Info 4:

RCA Article 2.pdf

• Barriers and facilitators on hand hygiene and hydro-alcoholic solutions' use: representations of health professionals and p ...
• Background
• Method
• Participants
• Measures
• Procedure
• Ethical considerations
• Data analysis
• Results
• Barriers of the use of ABHR
• Facilitators of the use of ABHR
• Discussion
• Summary of results
• Comparison to literature
• Limitations
• Implication for practice
• Conclusion
• Authors' contributions
• Funding
• Conflict of interest statement
• References