Healthcare-Associated Infections

Infectious diseases pose special challenges in healthcare settings, where people are more at risk due to underlying illness and vulnerability. Healthcare-associated infections (HAI) are common causes of morbidity and mortality and lead to high financial burden on healthcare systems.

WHO estimates indicate:

  • Europe: 37,000 deaths directly attributed to HAI annually; plays a role in 110,000 more
  • USA: 99,000 attributable deaths annually
  • Low-resource countries: preventable HAI-related deaths in ICUs may be 1/4 or more
  • Annual economic burden: €7 billion in Europe; $6.5 billion in USA

Source: World Health Organization 2011: Report on the Burden of Endemic Health Care-Associated Infection Worldwide

Definition

Healthcare-associated infections (HAI) are caused bacteria, viruses and fungi. Most of these diseases can be contracted anywhere, but they present greater challenges in the healthcare setting. The majority of HAI are caused by bacteria already present in the patient’s body prior to the infection, and may lead to cross-transmission between patients or between patients and healthcare professionals. The environment in a healthcare facility can also be a source of infection, with microorganism spread through air, water or surfaces. Patients in health facilities are more vulnerable than the general population due to underlying illness, greater fragility (such as for premature babies, the elderly, and immunocompromised patients), and exposure to invasive medical procedures.
 

HAI is a global challenge

In many high-income countries, national and regional health authorities, along with individual healthcare institutions, are putting into place prevention, control, surveillance and reporting measures. Even if significantly reduced in the recent years, incidence of HAI remains high, particularly among at-risk populations. For example, approximately 25-30% of ICU patients in high-income countries experience at least one HAI episode1,2. In low- and middle- income countries, the challenges are further complicated by underdeveloped infrastructures and issues related to hygiene and sanitation. The WHO estimates that ICU-acquired infection is at least 2-3-fold higher than in high-income countries and that device-associated infection may be up to 13 times higher than in the US1.

HAIs include all types of infections including urinary-tract infections (most common in higher-income countries1,2), surgical site infections (most common in lower-income countries1), respiratory infections, gastro-intestinal infections and bloodstream infections.  The emergence of antimicrobial resistant organisms is contributing to an increase in the spread and severity of HAI. A healthcare institution experiencing an outbreak of HAI faces serious patient-care challenges, cost burden, and potential for negative effect on image and reputation.
 

When is an infection considered to be HAI?

An infection is called a healthcare-associated infection (HAI) when a patient does not present an infection when admitted, but contracts one 48 hours or more after admission to a healthcare facility. For surgical patients, an infection is considered HAI up to three months after surgery, or up to one year in the case of bone or joint surgery3.

 

Diagnosis

It is critical to regularly carefully monitor all patients in a healthcare facility for infectious diseases, especially those in the ICU or at particular risk for other reasons. In vitro diagnostics are used to accurately determine the infectious agent responsible, and to test for antimicrobial susceptibility, to select appropriate antimicrobial therapy to fight the disease. It is also important to identify and limit potential epidemics by surveying at-risk patient populations and rapidly determining the origin of infections.
 

Microorganisms commonly involved in HAI1,2,4

  • Staphylococcus aureus
  • Methicillin resistant Staphylococcus aureus (MRSA)
  • Enterococci
  • Escherichia coli
  • Klebsiella pneumoniae
  • Carbapenem-resistant Enterobacteriaceae (CRE)
  • Clostridium difficile
  • Extended spectrum β-lactamase-producing Enterobacteriaceae (ESBLs)
  • Pseudomonas aeruginosa
  • Acinetobacter baumannii
  • Vancomycin-resistant Enterococcus
  • Streptococci
  • Candida albicans

 

Prevention and management / Treatment

Prevention and management

Prevention measures to fight HAI must be implemented at both the patient level and institution-wide.
 

  • Environmental control

    • Regular air, water and surface monitoring
    • Stringent cleaning and disinfection of equipment and environments
    • Patient isolation (or cohorting) when appropriate
  • Infection control
    • Close monitoring of at-risk patients and populations
    • Hand hygiene and good general hygiene practices
    • Hygienic conditions for medical procedures
    • Appropriate use antimicrobial drugs
    • Use of catheters only as indicated
  • Surveillance
    • Outbreak management
    • Automated alerts for antimicrobial-resistant infections
    • Information transfer and management
    • High-level, coordinated reporting
    • Epidemiological surveillance and tracking
  • Treatment
    • Treatment with appropriate antimicrobials
    • Removal of temporary medical devices (such as catheters) if possible
    • Therapeutic monitoring to stop antimicrobials as early as possible

 

Guidelines

 

 

​References

1. World Health Organization 2011: Report on the Burden of Endemic Health Care-Associated Infection Worldwide

2. CDC, Public Health Reports 2007: Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002

3. CDC/NHSN 2014: Surveillance Definitions for Specific Types of Infections 

4. CDC: Antibiotic Resistance in the United States 2013

 

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