Not much known about infections originating in hospitals

Healthcare-associated infections (HAIs) are acquired by patients during their stay in a hospital or other healthcare facilities such as nursing homes, outpatient clinics or health centres. Such infections are an important cause of morbidity, mortality, prolongation of hospital stay and increased healthcare expenditure. These also result in increased rate of intensive-care unit (ICU) admissions, increased re-hospitalisation rates, and sometimes catastrophic healthcare expenditure. HAIs can affect any age group, including new born babies.

HAIs are not a single-disease entity and include a wide variety of infections. Some of the common ones include catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI). These three infection types are also classified within device-associated infections.

However, there are many other types of HAIs such as surgical site infection, hospital-acquired pneumonia and transfusion-transmitted infection. Many infections which are generally acquired in the community or outside healthcare facilities may also be acquired by patients within hospitals because of transmission of infectious agents from other patients, staff or visitors. Such infections can include tuberculosis, chickenpox, influenza, food borne and waterborne infections such as typhoid.

Unclean hospitals

The problem of HAIs is not unique to India or other low or middle income countries and affects all countries globally including the developed, the powerful and industrialised economies. It is now a global menace, especially in an era when there is overcrowding in hospitals, extensive use of medical devices, widespread use of broad spectrum antibiotics, and inadequate sanitation or hygiene in healthcare facilities. Many HAIs are caused by superbugs or multi drug resistant organisms. This makes the treatment more difficult and more expensive.

We have heard about superbugs with New Delhi metallo-beta-lactamase 1 (NDM-1) gene. But NDM-1 is not the only antibiotic resistance gene and there are many others. There are Gram positive bacteria such as Methicillin-resistant Staphylococcus aureus and Gram negative group of bacteria such as E coli, Klebsiella, Pseudomonas and Acinetobacter with resistance genes such as OXA48, IMP, VIM, KPC and OXA23. Bacteria are classified as Gram positive or negative on the basis of staining. Many of these superbugs may coexist in the same patient, thus making treatment and infection prevention very difficult.

But not much is known about the prevalence of hospital infection in India. The most significant surveillance project of such infections is currently being undertaken by the All-India Institute of Medical Sciences (AIIMS), New Delhi, United States-based Centers for Disease Control and Prevention (CDC) and the Indian Council of Medical Research (ICMR).

The multicentric study is coordinated by AIIMS, New Delhi. The importance of this study is its large and varied reach in terms of inclusion of public and private sector hospitals, stringent attention to data quality and quality assurance of processes which lead to data generation and many others. However, the final results of this study would be available only after a few years.

Then there is the international Nosocomial Infection Control Consortium, which is collecting HAI data globally as well as in India. Their latest report was published in February 2016 in the journal Infection Control and Hospital Epidemiology. This study included data from 0.23 million ICU patients and analysed information for 0.97 million bed-days.

It is important to understand the concept of bed days in this context. If there are 10 intensive care unit beds in a hospital, the total number of available bed days is 300 (30 days in a month multiplied by 10 beds per day) in a month and 3,650 in a year. This study estimated that the device-associated infection rates for adult and pediatric ICUs to be 5.1 central line-associated bloodstream infections/1,000 central line-days, 9.4 cases of ventilator-associated pneumonia / 1,000 mechanical ventilator-days, and 2.1 catheter-associated urinary tract infections / 1,000 urinary catheter-days.

This same study reported the following HAI rates from the multicentric pooled data of several neonatal ICUs: 36.2 central line-associated bloodstream infections / 1,000 central line-days and 1.9 ventilator-associated pneumonia / 1,000 mechanical ventilator-days.

The study reported that the extra length of stay in adult and pediatric ICUs was 9.5 days for central line-associated bloodstream infections, 9.1 days for ventilator-associated pneumonia and 10 days for catheter-associated urinary tract infections. The extra length of stay in Neonatal Intensive Care unit was about 15 days for central line-associated bloodstream infections and 39 days for ventilator-associated pneumonia.

This study also reported that HAIs may lead to deaths. The extra mortality (from all causes and not just due to HAIs) was about 16 per cent for central line-associated bloodstream infections, 23 per cent for ventilator-associated pneumonia, and seven per cent for catheter-associated urinary tract infections in adult and pediatric ICUs. The figures were about one per cent for central line-associated bloodstream infections and eight per cent for ventilator-associated pneumonia in neonatal ICUs.

Having reliable, accurate, complete, continuous and relevant data about HAIs is extremely important for effective planning which translates into better diagnostic, treatment, prevention and control strategies. Without data, it is not possible to effectively plan for the need of laboratory or radiology-based diagnosis; it is not possible to plan for appropriate treatment protocols or keep adequate stock of necessary medicines or develop focused infection prevention and control interventions.

Since in a given hospital there may be many types of HAIs occurring simultaneously or during the same time period affecting various patient categories, it is extremely important that we understand the epidemiology of HAIs in a specific healthcare facility.

Epidemiological studies would tell us which type of infections are common, what are the specific agent-host- environmental factors that lead to HAIs, and what the outcome of existing management strategies are. Since resources are always limited even in the best of centres, knowledge of epidemiology help to prioritise so that we can focus our time, money and energy on certain HAI problems which are most damaging to the patient's well-being.

Data quest

In the case of antibiotic resistance, availability of data is important. Without reliable and accurate data, it is not possible to have short-term or long-term planning with regard to human resource requirement and use medical technologies required to effectively diagnose, treat or prevent HAIs. Data also helps us know incidence and prevalence of HAIs.

Incidence implies the number of new cases over a period of time (day, week or month), whereas prevalence denotes total number of new and old cases over similar time periods. If we have access to such data, we can also calculate the risks to patients for a given procedure such as chemotherapy, surgery and endoscopy. This enables doctors and specialists to counsel patients so that more informed decisions can be taken.

In India, reporting of HAIs is still voluntary and not mandatory for hospitals and other healthcare facilities in public or private sectors. Moreover, these infections are still not under the category of notifiable diseases. As a result, there are very few mechanisms in place to track and monitor HAIs in India.

In the last one or two decades, some steps have been taken to increase awareness and get some data from the tertiary care hospitals. However, there are currently very few systems in place to monitor HAIs at the primary or secondary care levels.

There has been some major development with regard to HAI data collection within India in the last five years. These efforts have been led by ICMR and the National Centre for Disease Control (NCDC), New Delhi. Some of these efforts are supported by CDC. Besides going for accreditation to the National Accreditation Board for Hospitals and Healthcare Providers (NABH), hospitals are also required to submit HAI data to the monitors on a regular basis.

However, these efforts have mostly covered tertiary care hospitals in major cities. There is also a greater participation of private sector corporate hospitals within these monitoring systems.

In the future, we would have to include all public and private sector hospitals, district general hospitals and nursing homes within these HAI surveillance systems. There should also be adequate legislative support and regulatory supervision to ensure that HAIs reporting becomes mandatory for all hospitals and HAIs are included within the list of notifiable diseases.

At present, HAI data is reported voluntarily mostly as an academic exercise on an ad hoc basis in scientific journals within India. These ad hoc reports may lack scientific rigour, quality control scrutiny and may not report inconvenient truths for political, financial or social reasons.

It is very important that we get over this situation and put in place effective systems which collects data according to the best practice recommendations and takes appropriate actions at various levels as and when necessary for better patient safety. We can hope that within the next five years, structured, quality-assured and relevant HAI data would come into the public domain within India and be an important subject of our national agenda for better healthcare for all.

The concepts of Infection Prevention and Control (IPC) have been well known in developed countries for decades. In the case of India, though the theory behind IPC was known and understood decades ago, we lacked in practice and implementing IPC as a routine part of medical education, nursing education and healthcare culture. This has been a major problem and currently efforts are on to overcome this.

Unlike an individual medical or surgical procedure, IPC is something which cannot be done in isolation or as a solo effort. It is always a teamwork and support from the top level healthcare administrators is essential for resource provision or to ensure compliance.

The basic technology of IPC such as the Standard Precautions are neither difficult nor expensive. The real hurdle is in their implementation which requires long-term planning and vision with regard to education, sustained and regular training and administrative measures to ensure compliance. In a way IPC is another type of Swachh Bharat Abhiyan.

(Courtesy: Down to Earth)