Healthcare-associated Infections. Policy Analysis

Healthcare-associated Infections: Policy Analysis

Nosocomial infections, having arisen at the dawn of the first medical institutions, became an increasingly complex and urgent problem of medicine. In modern conditions, the incidence of nosocomial infections, to a certain extent, reflects the quality of medical care provided to the population and is one of the important components of economic damage in practical health care.

According to research conducted by a single methodology under the auspices of WHO in fourteen countries, an average 8% of hospitalized patients infections are infected with with nosocomial infections. In the European region, the incidence of nosocomial infections is more than 7%, in the United States - about 5%; mortality is 2.7% (El-Saed, Balkhy, & Weber, 2013). The most common variants of nosocomial infections include nosocomial pneumonia, urinary tract infections, catheter-associated infections, and pseudomembranous colitis, or antibiotic-associated diarrhea. It should be understood that the localization of nosocomial infection depends on both the etiology of the pathogen and the source of nosocomial infections. Approximately 1 in 10 cases ends in death (Boev & Kiss, 2016). However, at least half of the infections are preventable. Policies and programs to combat nosocomial infections are aimed at this prevention.

In the structure of hospital mortality, nosocomial infections occupy the fourth place after diseases of the cardiovascular system, malignant tumors, acute disorders of cerebral circulation. The mortality of patients with nosocomial infection is almost two to three times higher in comparison with similar groups without this complication (Tawfiq & Tambyah, 2014). However, nowadays, few medical workers will dare to talk about the problem of nosocomial infection out loud and name the actual number of healthcare-associated infections in their medical institution, for fear of sanctions from regulatory bodies (Stone et al., 2015). The lack of a unified approach to the identification of patients with nosomial infections in medical institutions, poor-quality organization of micro-biological monitoring, concealment of cases of healthcare-associated infections led to the fact that the registered incidence rate does not correspond to the actual one, which does not allow the hospital epidemiologist to carry out high-quality epidemiological diagnostics and targeted prevention. Meanwhile, nosocomial infections, in modern conditions, should be considered as a problem of the quality of treatment, the safety of medical care in a medical institution, and an important socio-economic problem.

Despite the fairly extensive information on nosocomial infections, it is difficult to get a true idea of the level, structure, and dynamics of the development of nosocomial infections and their epidemiological features. However, available information suggests that there is no tendency to reduce infections associated with the provision of medical care (Gomes et al., 2016). The need to improve the quality of medical care requires the development of a scientifically based set of preventive and anti-epidemic measures.

At the present stage, there are certain difficulties in combating nosocomial infections due to the presence of a large number of sources of infectious agents, their ways of transmission, high pathogen resistance to the effects of adverse environmental factors, variability of clinical manifestations, difficulty diagnosing individual nosological forms of nosocomial infection, and as a result - the lack of effective methods of specific prevention. All this does not allow effective impact on any link in the epidemic process.

The epidemiological surveillance program in each specific health facility must be adapted to the specific features of the institution. According to American researchers, an effective epidemiological surveillance program, given the current level of knowledge and technology, can prevent about one-third of all cases of nosocomial infection. However, if it is possible to achieve at least a 6% reduction in the level of nosocomial infections, the costs of this program pay off. The high incidence of nosocomial infections should not be considered as an excuse to punish the medical staff of a medical institution. In this case, it is necessary to look for the cause in the system of organization of epidemiological surveillance and make the necessary adjustments to it (El-Saed, Balkhy & Weber, 2013).

A new study has demonstrated how the risk of catching a nosocomial infection is changing with each day spent in an inpatient hospital at an American hospital. Researchers at South Carolina Medical University (MUSC) analyzed historical data from their academic medical center. The analysis included 949 cases of infection of patients with Gram-negative bacterial flora in the hospital, registered for the entire time of work. Scientists have discovered that the patient's chances of becoming infected with a multi-resistant gram-negative bacterial infection during treatment increase by an average of 1% for each day in the hospital. In their study, MUSC staff estimated that, in the first few days of hospitalization, about 20% of infections are associated with multi-resistant gram-negative bacteria. This percentage grows steadily in the first 4-5 days, and by the 10th day, it reaches 35%. After conducting a statistical analysis, the team concluded that the risk of multi-resistant gram-negative infections increases by 1% for each day of hospital stay. Professor John Bosso, from MUSC, says the data indicate the danger of nosocomial persistent infections. Statistics show that, at a minimum, unnecessary hospitalizations and unreasonably long hospitalizations should be avoided (Amin & Deruelle, 2015).

According to the US Centers for Disease Control and Prevention, gram-negative bacteria represent a very serious problem for American health care. They often cause severe postoperative infections, pneumonia, sepsis, meningitis. It is becoming increasingly obvious and frightening their growing resistance to widely used and most affordable antibiotics. Gram-negative bacteria acquire resistance to antibiotics through several mechanisms. They can transmit mutations to new generations, so resistance is quickly fixed and a new strain of bacteria appears that cannot be treated. The authors of the study say that nosocomial infections are responsible for a significant percentage of hospitalized patient deaths, and this percentage is increasing year by year (instead of decreasing due to the introduction of new antibiotics and antiseptic methods) (Shang et al., 2015).

Every day in the United States, 1 in 25 inpatients in US hospitals becomes infected a nosocomial infection, more than 30% of which are caused by Gram-negative bacteria. However, today, there is not enough information about how many infections and deaths are caused by this flora. The CDC estimates that in 2016, out of 722,000 ill patients, 75,000 people died from nosocomial infections. Over 50% of these deaths are recorded outside the intensive care unit (Zimlichman et al., 2013).

In the United States, the Active Bacterial Core Surveillance / Emerging Infections Program Network was developed in collaboration between the CDC, several state health departments, and universities. This program examines incidence trends in several states using molecular and microbiological antibiotic resistance testing methods for Streptococcus pneumoniae, Streptococcus pyogenes, Streptococcus agalactiae, Neisseria meningitidis, and Haemophilus influenzae (Boev & Kiss, 2016). Pharmaceutical companies, such as Alexander Project, MYSTIC, SENTRY, and TRUST are also often sponsors of antibiotic resistance research. The programs funded by the US government include the National Nosocomial infection surveillance system (NNIS), which conducts a study on antibiotic resistance in intensive care units in part of the hospitals participating in this system. However, up to 2 million cases of nosocomial infection are registered annually in US hospitals, in the structure of which 35% are accounted for purulent-septic infections (Amin & Deruelle, 2015).

To date, there are no standardized forms of accounting and a developed nomenclature of nosocomial infections that meets the requirements of WHO, which causes regular difficulties in registering and accounting for this group of diseases. The United States Centers for Disease Control and Prevention (CDC) distinguishes several major modes of transmission, depending on the isolation and restrictive measures that are required to protect patients and health care workers in particular transmission routes. Thus, the CDC classification is based on purely practical considerations and ignores some biologically significant transmission mechanisms that are rarely faced in the hospital and do not require special isolation-restrictive measures (Ellingson et al., 2014). For a long time, the concept of "nosocomial infections" was attributed only to infections and diseases in hospitals. Namely, this part of the nosocomial infection, the most significant in scale, attracted the attention of the health services in the first place. Of fundamental importance was the inclusion in the number of nosocomial infections in the 70s of all diseases associated with infection in hospitals, regardless of where the signs of the disease appeared and where nosocomial infection was diagnosed - in the hospital or after discharge. Currently, diseases of patients associated with the provision of medical care not only in hospitals, but also in any medical and preventive treatment institutions (polyclinic, medical unit, health center, ambulance) are classified as nosocomial infections. The breadth of distribution of these nosocomial infections is not well understood. The number of nosocomial infections, in addition to the diseases of patients, also includes diseases of medical workers. This aspect of the problem is the least studied (El-Saed, Balkhy, & Weber, 2013).

The lack of a full account and registration of nosocomial infection does not allow revealing the main causes of infection foci in a timely manner, makes it difficult to carry out in-depth analysis of the incidence, necessary to ascertain the conditions and nature of the epidemic process. Unfortunately, today, there is no single unified document containing important information for epidemiological analysis.

There are infection control departments in US hospitals. The staff is made of epidemiologists and nurses who have been trained in infection control at special courses. The nurses are taken to the department if they have at least ten years of experience; then they are assigned to the most experienced nurse of the infection control department, and only after completing the internship, the employee of the department has the right to work independently. The work is based on the principle of supervision of the departments (1 employee for 250 beds), collecting information, and analyzing cases of nosocomial infections. The data obtained as a result of this analysis is communicated to the department staff and discussed with it. However, there have been no significant improvements in the prevention of nosocomial infections (Stone et al., 2015).

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