What is Infection Control?
Infection control is focussed on preventing and reducing the impact of nosocomial or Healthcare-Associated Infection (HAIs). It addresses factors related to the spread of infections within the health-care setting (whether patient-to-patient, from patients to staff and from staff to patients, or among-staff).
Definitions HAI's or superbugs are a concern because they are difficult to treat - they do not respond to antibiotic treatment. The main bacteria that are of concern are:
| Staphylococcus aureus: |
1 in 3 people carry the Staphylococcus aureus bacterium in their nose or on their skin. In most cases the bacteria does not cause problems. Occasionally it can cause serious health problems such as skin or wound infections, pneumonia or infections in the blood or bone. The concern is for the hard to treat variants that are resistant to antibiotics such as - Methicillin Resistant Staphylococcus Aureus (MRSA) (commonly known as "Golden Staph") and Methicillin Sensitive Staphylococcus Aureus (MSSA). Staphylococcus aureus is responsible for the largest proportion of healthcare-associated bacterial infections (Cruikshank and Ferguson 2008) and is usually spread by direct skin contact (typically via hands) with a person who is infected or colonised, or through contact with shared items, such as towels and shared surfaces like door handles, taps and benches. There are various strains of MRSA.
| ||Clostridium difficile: |
Is an anaerobic toxin-producing bacterium that usually causes diarrhoea, and is the most common cause of healthcare-associated gastrointestinal infection. Transmission usually occurs through shared equipment, a contaminated environment or the hands of healthcare workers. The organism can be readily cultured from inanimate environmental sources such as beds, cupboards, floors and walls, as well as from the hands of healthcare workers. The impact of Clostridium Difficile on the health-care system is considerable, with patients requiring additional infection-control precautions and specific treatment, and can spend an extra 1 to 3 weeks in hospital (McGregor, Riley and Van Gessel 2008).
Is an antibiotic used to treat infections caused by enterococci, bacteria which are normally residing in the bowel without causing any illness. VRE infections are dangerous for people with a weakened immune system, but most recover with appropriate antibiotic treatment. VRE infections are typically spread by physical contact with faeces, skin or objects that have been contaminated with VRE. This includes contact with contaminated hands, hospital equipment, bathroom taps and door handles.
The benchmark incident rate for infection of MRSA is 2 cases for every 10,000 occupied bed days. The incident rate in Australia varies by State with those with mandatory incident reporting (WA) having the lower incident rate (1.1 per 100,000 population). Ferguson (2007)(1) indicated in his research that the average for Australia was 4.5-5.7 per 100,000 population. Prof. Collignon estimated that these figures are under reported as it is voluntary reporting in most states except WA. His figure from his study is 35/100,000 population or today 7,700 episodes a year in Australia(2).
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Consequence of S.aureus bacteremia (SAB) includes serious infection of endocarditis (heart infection), osteomyelitis (chronic bone infection) and septic arthritis (joint infection) leading to prolonged hospital stays and costs. Average stay in hospital for a patient with S.aureus is 26.5 days.
As reported by the Australian Productivity Commission (2009), a study estimated that Australian hospitals have a minimum of 180,000 Hospital Acquired Infections annually!
According to the Australian Council for Safety and Quality in Health Care, approximately 1 in 5 suffer serious harm and approximately 1 in 30 die. Prof. Peter Collignon, an infectious disease expert from Canberra Clinical School of the Australian National University, has estimated in his research that 1700 deaths a year could be attributable to Staphylococcus aureus2.
180,000 HAI per year in Australia
1700 deaths per year in Australia for SAB
UK studies(3) show the death rate from MRSA infection at 34% and MSSA at 25%. In NSW recently where over 500 cases of MRSA were identified across 46 hospitals the death rate was estimated at 20% by Prof. Collignon.
Each case of MRSA translates to a cost of $22,000 per case. NSW this equates to a cost of $11 Million(2).
For Australia with an estimated 7,700 episodes a year - the estimated cost is $169 million annually 7,700 MRSA cases per year in Australia $169 Million per year cost of MRSA
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How is this caught?
Hospital Acquired Infection (HAI) is nothing new. To become infected is a simple process; firstly there must be a place for the bacteria to reproduce, then a method of transmission, and lastly a vulnerable host. Breaking the chain of infection at any point will stop it.
Ulrich and Wilson state from their research(6), under favourable conditions microorganisms will proliferate and remain in an infectious form (as shown in the example pictured).
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Who is at risk? Those at risk are people with compromised immune systems
People with weak immune systems(people living with HIV/AIDS, cancer patients, transplant recipients, severe asthmatics, etc.)
DiabeticsIntravenous drug users
Use of quinolone antibiotics
Solutions for impacting HAI's
The following are the recognised means for reducing the risk of S.aureus and seen as part of any infection control program:
1. Hand hygiene - the five critical moments 2. Decontamination of the environment and shared
3. Contact precautions for infected and colonised
4. Active surveillance and screening; 5. Effective programs that prevent common infections
(eg, intravascular catheter sepsis, surgical site 6. Good antibiotic stewardship; and
7. Better hospital design to include more single rooms for
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Design of our healthcare and correctional facilities; this is seen as critical; for the best way to stop HAI is to eliminate the infectious agent or deny it a reservoir in which to grow.
Single room design - In the UK, the NHS Confederation has gone even further; it suggests single rooms with en-suite facilities as a way of optimising infection control. Studies including Mulin's(8) suggest single room with convenient sink access improves hand hygiene compliance. The cost of such a design should be viewed in the long term. The financial savings from efficient control are, according to a Philadelphia study, three times the cost of control measures.
Studies have shown for the Prevention and Control of HAI's hydraulic and architectural design must ensure adequate access of suitable hand wash facilities. Basins should be sited, in addition to washroom applications, in all patient areas, treatment rooms, sluices and kitchens. In clinical areas they should be fitted with wrist or elbow operated mixer taps or ideally a mixer with automatic 'no touch' operation. Beyond building design and hand washing facilities, specifying products designed to break the infection chain, will produce a safer environment.
The Five Critical Moments
Hand Hygiene Compliance
Compliance within the healthcare environment to hand hygiene is the focus of the Five Most Moments of Hand Hygiene program. With WHO setting a minimum benchmark of 55% compliance and with other local bodies setting higher goals to reduce the risk (Department of Human Services Victoria has a 65% target) our healthcare professionals are falling well short:
(1) Ferguson JK. Healthcare-associated methicillin-resistant Staph. aureus (MRSA) control in Australia and New Zealand. Aust Infect Control 2007; 2: 60-66.
(2) Collignon P., Nimmo G., Gottlieb T., Gosbells I., ?Staphylococcus aureus Bacteremua, Australia?, CDC 1010-6059, Vol11, No. 4 April 2005.
(3) Second Year of the Department of Health?s mandatory MRSA bacteraemia surveillance scheme in acute trusts in England: April 2002-March 2003
(4) Collignon PJ, Grayson ML, Johnson PDR. Methicillin-resistant Staphylococcus aureus in hospitals: time for a culture change [editorial]. Med J Aust 2007; 187: 4-5.
(5) Hand Hygiene project (Http://wiki.qut.edu.au/display/hhe/hand+hygiene+evaluation+project
(6) Ulrich R.S. & Wilson P., Evidience based design for reducing infections, Public Review. Health. 8, 24-25 (2006)
(7) Westmead project on watersaving (2004/05) accessible at http://www.sydneywater.com.au/Publications/CaseStudies/HospitalsSavesLivesandWaterConserver6.pdf
(8) Mulin, B., Rouget, C., Clement, C., Bailly, P., Julliot, M. C., Viel, J. F. et al. (1997). Association of private isolation rooms with ventilator-associated Acinetobacter baumanii pneumonia in a surgical intensive-care unit. Infection Control and Hospital Epidemiology,18(7), 499?503.