While infections that develop during hospitalization may appear to be an uncommon but recognized risk of hospital care today, the incidence of these infections has been increasing dramatically during the last 2 to 3 decades, and the risk of acquiring an organism that is resistant to 1 or more antibiotics is becoming increasingly common. Recent studies estimate that approximately 2 million patients contract healthcare-associated infections each year (1). These infections are the most common type of serious adverse event in health care, affecting up to 5–10% of hospitalized patients, leading to approximately 90,000 deaths annually, and adding approximately $5 billion to annual healthcare costs (1-3). Increasingly, healthcare-associated infection risk is viewed as a patient safety issue, as many of these infections may be avoidable or preventable by following evidence-based best practices in infection control and patient care while patients are hospitalized. This article will summarize some of the overlap between patient safety and infection control, explain some of the pressures that have led to development and cultivation of antimicrobial resistance, and describe the Centers for Disease Control and Prevention (CDC) campaign for prevention of healthcare-associated infections and antimicrobial resistance, as well as the role of hospitalists in such prevention.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifically identifies in its 2005 National Patient Safety Goals that hospitals and clinicians reduce the risk of healthcare-associated infections. The goals encourage clinicians to comply with current CDC hand hygiene guidelines and that hospitals and clinicians manage as sentinel events all identified cases of unanticipated death or permanent loss of function associated with a heathcare-associated infection. A sentinel event is defined by JCAHO as an unexpected occurrence involving death or serious physical or psychological injury. Such an event signals the need for immediate investigation and response by the institution. By including healthcare-associated infections in this category of high-risk event, with potential morbidity and mortality, JCAHO highlights the frequency and importance of infections acquired in our healthcare system today.
Further, the Agency for Healthcare Research and Quality (AHRQ) recently published an evidence-based report, developed and written primarily by hospitalists, delineating 79 patient safety practices, of which 22 (28%) involved infection control (4). At least 5 of these 22 infection control practices were considered valuable enough, and with sufficiently strong supporting evidence, to mandate widespread implementation. Additionally, the Institute for Healthcare Improvement (IHI; www.ihi.org) recently launched its 100,000 Lives Campaign, enlisting hundreds of hospitals around the United States in a commitment to implement changes that have been proven to prevent avoidable deaths. Three of their first 6 interventions involve the reduction of healthcare-associated infections, including central-line infections, surgical-site infections, and hospital-acquired pneumonia.
Increasingly, hospital-onset infections have become a patient safety issue, and they will remain under public and institutional scrutiny while hospitals take efforts to reduce their incidence and improve care quality. Hospitalists have evolved to serve a unique role as advocate of both patients and hospitals. They should therefore foster quality improvement in the hospital, as well as lead and support initiatives that reduce hospital-acquired infections and resistance.
Healthcare-Associated Infections and Development of Resistance
Bacteria have developed multiple microbiologic and genetic mechanisms to elude antimicrobial agents. Certain practices in medical care, whether intentional or not, can promote persistence or spread of resistant microbes that can cause infections. Such practices may include:
- Inattention to basic infection control measures (e.g., hand washing)
- Unrecognized colonization (e.g., treating colonized urinary or vascular catheters, without evidence of infection)
- Unrecognized reservoirs (e.g., environmental)
- Selective pressure from overuse or inappropriate use of antibiotics
- Movement of patients and staff within a single institution and between institutions