Reducing HCAIs - Reality or Fantasy?

1
Reducing HCAIs - Reality or Fantasy?

• HCAIs community is the new hospital

2
Outline

1. Introduction joined-up approach to hospital and
   community HCAIs reasons benefits
   community, colonisation vs. infection
2. Why (a joined-up approach)? - disease control
   model, (epidemiologic triad) characteristics of
   hospital and community HCAIs, and incidence rates
3. Benefits complete disease burden picture for
   descriptive research, critical mass for
   funding, better efficiency of interventional
   models
4. Specific ( local) steps surveillance
   reporting, risk factors research, control
   interventions

3
Community LTCFs

•  "Community" - non-hospital setting where
  health-related care is provided i.e. household
  and long-term care facility (LTCF)
• LTCFs - nursing, care or residential and
  retirement homes
• Continuing strategic shift towards provision of
  healthcare in the community (Primary Care)

4
Infection vs. colonisation

• Colonisation - presence of a known (local) normal
  flora no expression of inflammation

• Infection - presence of a known normal flora
  unusual tissue/body cavity expression of signs
  and symptoms of inflammation

5
Disease control burden of disease model
6
Iceberg IC fallacy

• Hospital HCAIs same phenomenon of all
  disease-burden iceberg phenomenon
• Current approaches address minority of cases of
  same (community and hospitals) disease
  infection control fallacy
• More translocation of normal flora occurring in
  community because

7
Epidemiologic Triad

• Virulent pathogen normal flora retain ability
  to harm, especially 2.0 versions of these same
  bugs!
• Susceptible host immuno compromised age,
  surgery/medication, underlying medical condition,
  etc
• Favorable environment non-usual tissue/cavity,
  catalyst to multiply repeated inoculation,
  removal of growth inhibitor(s), etc

8
Incidence trends
Hospital HCAIs Community HCAIs
Prevalence from 5.1 5.4 Prevalence from 6.6 7.3
RTIs/LRTIs 1.57 UTIs 1.84 SSIs 1.51 BSIs 0.43 RTIs/LRTIs 1.4 UTIs 3.65 SSIs 0.37 SSTs 1.83

• Eriksen, H.M, Iversen ,B.G, Aavitsland ,P.,
  (2004). Prevalence of nosocomial infections and
  use of antibiotics in long-term care facilities
  in Norway, 2002 and 2003. J Hosp Infect. 4,
  316-20
• Eriksen, H.M, Iversen, B.G, Aavitsland, P.,
  (2005). Prevalence of nosocomial infections in
  hospitals in Norway, 2002 and 2003. J Hosp
  Infect. 1, 40-5.

9
Epidemiologic Triad susceptible host
Hospital HCAIs Community HCAIs
Older age Underlying condition - (multiple organ failure) Compromised immunity - (cancer therapy, steroids, infection, etc) Obesity or malnutrition Loss of skin integrity Primarily elderly Immunosuppression Underlying long-term conditions (with alteration in organ systems) Functional impairment (resulting in personal care) Malnutrition

• Emori, T.G., Gaynes, R.P., (1993). An overview
  of nosocomial infections, including the role of
  the microbiology laboratory. Clin Micro Rev. 6,
  428-442
• Nicolle, L.E., Strausbaugh, L.J., Garibaldi,
  R.A., (1996). Infections and antibiotic
  resistance in nursing homes. Clin Microbiol Rev.
  9, 1-17.

10
Epidemiologic Triad virulent pathogen
Hospital HCAIs Community HCAIs
E. coli S. aureus P. aeruginosa Enterococcus spp Coag-neg staph Candida spp Klebsiella spp Proteus spp S. pneumoniae E. coli Proteus spp Klebsiella spp P. aeruginosa S. aureus Enterococcus spp Providencia spp
11
Epidemiologic Triad favorable environment
Hospital HCAIs Community HCAIs
Immunosuppressive therapy Presence of invasive devices Surgical/post-op Use of antimicrobial agent (0, gt10 days, lt10 days) Recent hospitalisation Invasive devices Personal care Polypharmacy

• Emori, T.G., Gaynes, R.P., (1993). An overview
  of nosocomial infections, including the role of
  the microbiology laboratory. Clin Micro Rev. 6,
  428-442
• Nicolle, L.E., Strausbaugh, L.J., Garibaldi,
  R.A., (1996). Infections and antibiotic
  resistance in nursing homes. Clin Microbiol Rev.
  9, 1-17.

12
Single Over-Arching Approach- Policies and
interventions

• National surveillance (pathogen-specific), RD
  - less invasive diagnostic (MRI, CT) and surgical
  (laser, USS, fibre-optic)
• Local health community communications (IC cmtes
  and protocols, patient procedure and guidelines)
• Pathogen-specific IC protocols guidelines

13
Single Over-Arching Approach- national

• Surveillance
• Pathogen-specific
• Proxy pathogens
• RD
• Epidemiological (RFs) studies
• Less invasive diagnostic (MRI, CT) and surgical
  (laser, USS, fibre-optic) tools

14
Single Over-Arching Approach - local

• Single HCAIs (co-ordination) Lead for local
  health community
• More joined-up working within Infection Control
  Committees (ICCs)
• Greater IC role for link nurses
• Institution-specific IC protocols and guidelines
  to be based on common local approaches)

15
Single Over-Arching Approach- pathogen-specific
protocols

• Pathogen-specific IC protocols guidelines
• S. pyogenes maintain skin integrity
• C. difficile avoid growth catalysts maintain
  mechanical homeostasis of natural barriers
• E. coli achieving anti-adhesive states(?)
• S. aureus pre-operative patient-specific flora
  antibiotic prophylaxis(?)

16
Conclusion

• surveillance (needs) to encompass the broad
  range and complex nature of HCAIs and the modern
  healthcare economy. By focusing single pathogens
  at a hospital level there is significant danger
  that important trends in other pathogens or types
  of infection will be overlooked or neglected and
  that infection prevention activity may be
  misdirected.
• - Trends in rates of HCAI in England 2004 to
  2008, Jennie Wilson, Nurse Consultant/Programme
  Lead SSI surveillance, HPA