Infection Prevention Post-Pandemic: What To Keep? What To Stop?

When it comes to infection prevention, some things just make sense—like having all patients and family members entering an emergency department wear masks. We should have been doing that a long time ago. Infection prevention, as a field, has made amazing gains in approaches to prevent COVID-19 transmission that could also be used to make hospitals and health care facilities safer every day, COVID-19 or not. This opportunity won’t last long, however, if people naturally revert to old behaviors and practices. The time is ripe to be thoughtful about what the

Mark Stibich, PhD

future of infection prevention should look like and how infection preventionists (IPs) can take COVID-19 prevention practices and use them to fight antimicrobial resistant organisms and health care-acquired infections (HAIs)—which have increased during the pandemic and are projected to be major sources of suffering and cost in the near future. Here are a few infection control strategies to examine in light of the developments due to COVID-19:

Masks: Simple, cheap surgical masks have been shown to be effective for source control and N95 masks have been shown to offer excellent protection for the wearer. Where should we continue to wear masks? Places where either vulnerable persons or potentially infectious persons gather such at emergency rooms, cancer treatment centers, infusion centers, dialysis centers and many others. Before the COVID-19 pandemic, some facilities were asking people to mask during flu season if they had any symptoms. What about health care workers? Under what circumstances should N95 masks be required? Be available? Masking policies should be expanded well beyond the pre-COVID-19 level, but where and for whom is not 100% clear.

Air: Infection control has focused on air for certain pathogens. The COVID-19 pandemic brought out the importance of maintaining the filtration systems that are already in place and upgrading systems when necessary. Areas with low air turnover pose a greater risk for COVID-19 transmission. Luckily, most existing air filtration systems in facilities are adequate for providing enough fresh air to prevent viral build-up. Air system maintenance and upgrades, when needed, should certainly be part of every infection control program.

Surfaces: Surface disinfection is absolutely essential. At the beginning of the COVID-19 pandemic, some people took disinfection to the extreme and disinfected their mail and food delivery bags. That wasn’t necessary, but IPs and other health care professionals know that surface disinfection always was and always will be essential. Pathogens such as C. diff and MRSA can readily spread in the environment. The biggest problem here is that environmental services (EVS) workers are given an impossible task—in a limited amount of time, to make a room clean and beautiful for the next occupant, while at the same time, making the same room pathogen-free using wipes, rags and liquid chemicals that require multi-minute dwell times.

Prior to 2020, automated disinfection technologies that used ultraviolet (UV) light were gaining acceptance for disinfecting surfaces, and that use expanded during the pandemic. It is well known that manual cleaning alone does not make a room or area free of pathogens and that some UV room disinfection technologies have demonstrated in peer-reviewed studies to remove substantially all of the pathogens remaining after manual cleaning. EVS workers should have the right tools for the essential job they are doing, but it is important for health care facilities to carefully evaluate the various disinfection options before making a choice. Hospital administrators and IPs should ask the manufacturer to provide you with peer-reviewed and published studies validating the efficacy of that specific device or system. If the technology hasn't been proven effective in multiple peer-reviewed studies, then it hasn’t met the bar of an evidence-based solution.

Hand Hygiene: Hand hygiene was a major focus for infection prevention prior to 2020 and continues to be a focus throughout the pandemic. Hand hygiene should continue to be practiced and compliance rates improved upon. The pandemic educated the public about the importance of washing hands and we should encourage all visitors and patients to perform frequent hand hygiene.

Testing: COVID-19 created the need for tens of millions of tests for a whole range of purposes: tests before health care procedures, tests to return to work, tests before and after travel, tests to go to school, tests for close contacts and more. The testing information informed our behaviors and allowed a real-time understanding of the state of the pandemic. Testing drives our infection prevention restrictions. Should we be doing more routine testing? What about the flu? What about C. diff on high-risk units? COVID-19 may have enlightened us about the usefulness of testing as information for the control of outbreaks.

Surveillance:Whole genome sequencing (WGS) was a new tool in the infection prevention toolbox in 2020. In 2021, WGS is commonly used for tracking variants as well as examining microbial samples to determine if they are linked. Our WGS capacity has increased and can be applied to understanding patterns of infection in facilities, counties, states and countries to inform infection prevention decisions and allocate resources. Additionally, COVID-19 forced communication about infections across county and state lines and across industries from schools to nursing homes to hospitals. This sharing of accurate information has been amazing. Additional networks for antimicrobial resistant organisms can easily be established based on the COVID model.

Isolation/quarantine: We need some new ideas around isolation and quarantine. Our current practices have had mixed effect on COVID-19 transmission while increasing depression and loneliness. Additionally, many people do not live in homes where there are extra rooms in which to isolate or quarantine. Sending people home and telling them to isolate or quarantine often spreads infection within the household. Schools and businesses are struggling with determining who needs to quarantine after a close contact, leading to chaos and frustration in communities. New ways exist: South Korea, for example, early in the pandemic used supported isolation and quarantine. They realized many people live in crowded apartments while the hotels were empty. The government supported quarantine by having individuals check into hotels where they could be monitored, provided with care as needed and even given food (and presumable lots of free streaming media). In the end, this saved money as they were able to rapidly bring case counts down and avoided a major peak.

These are just a few examples of infection prevention strategies that were tweaked or put in place in response to COVID-19 that we should consider maintaining in order to fight health care associated infections and the rising antimicrobial resistance problem. Preventing infections not only prevents the suffering of the patient, it frees up resources (including antibiotics) for other patients. We have made great gains in infection prevention because of the COVID-19 response and should be thoughtful about how we modify those gains moving forward.

Mark Stibich, PhD, is chief scientific officer and co-founder of Xenex Disinfection Services. He can be reached at mark.stibich@xenex.com.