The Fifth Decennial International Conference on Healthcare-Associated Infections 2010, held in March in Atlanta, featured experts from several different fields discussing the significant prevalence of healthcare-associated infections (HAIs) and strategies that may be implemented to reduce their occurrence.
HAIs precipitated by the use of such devices as central venous catheters (CVCs), mechanical ventilators, and indwelling urinary catheters received special emphasis as important sources of patient morbidity and mortality.
Naomi O’Grady of the National Institutes of Health (NIH) summarized the current available knowledge regarding the prevention of central-line-associated bloodstream infections (CLABSIs). Strategies targeting appropriate line maintenance include:
- Chlorhexidine sponge dressings at the CVC insertion site in patients with short-term catheters;
- Cleanse catheter hubs and connectors with alcoholic-chlorhexidine (rather than alcohol alone) after each use; and
- Consider daily bathing of patients with chlorhexidine soap.
Speakers stressed that novel technologies, such as antimicrobial lock solutions and antiseptic- or antibiotic-impregnated catheters, should be considered when CLABSI rates remain high. Mark Shelly, MD, of Rochester, N.Y., emphasized awareness that CLABSIs occur frequently outside the ICU. “If you are only looking for CLABSI in the ICU, then you are missing more than half of the story,” Dr. Shelly said. Researchers from the National Health Safety Network (NHSN) provided more information about the substantial numbers of CLABSIs that occur on general medical wards.
Carolyn Gould, MD, MS, of the Centers for Disease Control and Prevention (CDC) confirmed that catheter-associated urinary tract infections (CAUTIs) are the most common type of HAI. CAUTIs occur at a frequency of >560,000 infections per year and cost as much as $500 million per year, she explained. Strategies to prevent CAUTIs include inserting urinary catheters only for appropriate indications and leaving them in place for the shortest possible duration.
In recent years, concern has grown about the prevalence of healthcare-associated Clostridium difficile infection (HA-CDI), which can lead to uncomplicated diarrhea, sepsis, or even death. Several speakers described strategies that reduce HA-CDI development, including the identification and removal of environmental sources of C. diff, accommodating CDI patients in a private room with contact precautions, and minimizing both the frequency and duration of antimicrobial therapy.
Uncertainty about the most reliable tests to confirm CDI was a topic of focus. Enzyme immunoassay (EIA) testing, cell cytotoxin assays, and polymerase chain reaction (PCR) testing are readily available in most U.S. hospitals; however, PCR testing might prove to be the most advantageous since it is rapid, sensitive, and specific.
Neil Fishman, MD, of the University of Pennsylvania School of Medicine in Philadelphia was one of several speakers to address the important role of antimicrobial stewardship program (ASP) development. According to Dr. Fishman, ASP goals should be to “ensure the proper use of antimicrobials” and to “promote cost-effectiveness.” By taking actions that promote the appropriate use of antimicrobials, the following positive consequences can be anticipated:
- Improved clinical outcomes;
- Reduced risk of adverse drug effects; and
- A reduction in, or stabilization of, the rate of antimicrobial resistance.
Multidrug-resistant (MDR) gram-negative Bacillus is a major challenge for hospitals worldwide. The CDC offers two guidelines for the optimal management and isolation of MDR organisms (MDRO): HICPAC 2006 (a management guideline) and HICPAC 2007 (MDRO isolation precaution guidelines). Consistent utilization of these guidelines is crucial to control the spread of MDRO.
The CDC’s Alexander Killen, MD, discussed the increasing proportion of MDR Acinetobacter and Enterobacteriaceae. Emerging issues among these organisms include the development of highly resistant strains, the incidence of which is increasing in nonacute-care settings.
The CDC’s Karen Anderson reported laboratory data on carbapenem-resistant Enterobacteriaceae (CRE) in a long-term-care facility. Her team demonstrated that CRE colonization can persist for up to six months. She speculated that the transfer of resistance between different species occurs, as does patient-to-patient transmission.
The CDC recommends the use of surveillance cultures as part of enhanced precautions. Surveillance is to continue until no new cases are detected.
Karen Clarke, MD, MS, MPH
Ketino Kobaidze, MD, PhD
Mohamad Moussa, MD
Sheri Tejedor, MD
School of Medicine, Atlanta