Prescribing Prevention: Why Infection Control is the Best Medicine

By Emilie Croft, BHS

Imagine walking into your doctors office, after being evaluated, you wait anxiously for the physician to return with their magic prescription pad that will no doubt conjure up some new super antibiotic to cure all that ails you. After all, youre not so concerned with the how or why you got sick, as you are with receiving the instant gratification from whatever drug is going to make you feel better. However, when he/she returns with the treatment plan they have prescribed for you it is not the standard take two of these and call me in the morning solution you were expecting; instead you are given an educational brochure and a prescription that reads: PRACTICE BETTER HAND HYGIENE.

Although this scenario may seem far-fetched to many, the concept of promoting hand hygiene and infection control practices is not a new idea. Scientists have been researching infections and the microorganisms that cause them since the invention of the microscope in the late 1600s. The microscope marked a beginning of a new era in science. For the first time in history we were able to visualize bacteria and other organisms, document some of their characteristics and gain a deeper understanding through study. Once it was known that these cells existed, more research was done to define the role they played in contributing to disease and prevention practices were developed to reduce the risk of transmission. The smallpox vaccination in 1776 marked the first scientific attempt to control an infectious disease. Studies were conducted to support that vaccination was an effective method of protection against disease, and evidence grew to validate theories that bacteria and microorganisms could be transmitted from person to person to cause infection.

Prevention practices were brought to the medical forefront in the 1840s after an independent study established a link between the hands of healthcare workers and the spread of hospital acquired infections. Dr. Ignaz Semmelweis analyzed an outbreak of puerperal fever seen in mothers in the delivery room. He reveled that medical students who were responsible for the deliveries often performed autopsies directly before assisting in the delivery room without washing their hands. He speculated the increase in infection was due to unseen contaminants on the hands, and required all medical students to wash their hands with chlorinated lime before assisting in any procedures. The effects were dramatic and deaths on the maternity ward fell fivefold. From this study it was concluded that disinfection of the hands could help prevent the transmission of infections.

Handwashing was one of the first infection control measures to be performed by healthcare workers. As a result of these early studies, additional research was completed, providing data and guidelines to support the efficacy of good hand hygiene to reduce the incidence of hospital-acquired infections (HAIs).

These infections related to medical care can be devastating. They are known to cause severe pneumonia, urinary tract infections (UTIs), wound and blood stream infections, and in some cases even death. Based on data from the American Journal of Infection Control, in 2002 the number of HAIs reported exceeded the number of cases of any currently notifiable disease, and deaths associated with these infections exceeded the number attributed to several of the top ten leading causes of death reported in the U.S. The rates continue to grow, according to the Centers for Disease Control and Prevention (CDC) currently each year an alarming 2.4 million-plus HAIs occur in the U.S. alone. They are estimated to cause directly 30,000 deaths and contribute to another 70,000 deaths each year, not to mention the financial burden exceeds $4.5 billion annually in extended care and treatment.

Science has gained the knowledge to define and even classify levels of infection, but our limitations currently lie in our understating of how these infections spread, and of what measures we need to take to prevent them. Hands, especially those of healthcare workers have already been established as a source of contamination however, they are not the only source to consider. Microorganisms can also be transmitted and infect susceptible hosts via environmental contamination as well. In the mid-1800s Florence Nightingale, a military nurse providing care to soldiers in deplorable conditions, made note of the overwhelmingly high death toll in her hospital and strived to make improvements in the cleanliness of their care environment. She provided increased ventilation and light, cleaned infested hospital blankets and discarded soiled supplies. The mortality rate dropped from 42.7 percent to 2.2 percent in just a short amount of time. Through her research she showed that most deaths were due to infectious diseases that thrived in the environment, and by improving sanitary conditions for the patients the mortality rates could be reduced.

There are many other factors that can contribute to and increase the risk of infection. It seems we are constantly at war against bacteria, viruses and other superbugs known to cause some of the most tenacious infections in healthcare.  With antimicrobial resistance on the rise we find ourselves asking, how do we combat these bugs, and what is the best practice for preventing their transmission? The answer is knowledge. To prevent infections it is essential to understand how they are spread. Microorganisms need a susceptible host. In health care environments there is a higher population of those who are immunocompromised and increasingly vulnerable to infections.

or disease to travel to and infect these susceptible hosts it must first have a route of transmission. Infectious particles are capable of traveling certain distances and can become suspended in the air for inhalation by hosts. However, the most frequent mode of transmission is by direct contact with the pathogenic material, involving physical body surface- to-surface exchange, usually via the hands, between the infected person and the host. Bacteria from infected patients can survive for a long time on surfaces, up to two years for some, and continue to infect their hosts via indirect contact with contaminated surfaces, surgical instruments, gloves or medical devices such as urinary catheters. Urinary tract infections are now the most common type of HAI, and approximately 75 percent of these infections are associated with the insertion of a urinary catheter. Several investigations have been conducted involving contamination by direct/indirect contact. In one study, nurses were asked to touch patients heavily colonized with gram negative bacilli for 15 secondsas though they were taking a femoral pulse. They were then asked to clean their hands as they normally should and touch a piece of urinary catheter with their fingers. The catheter was cultured, and the study reveled that if the catheter had been inserted, despite their hand washing, the nurses would have transferred infectious organisms back to the catheter potentially causing infection.

We have learned through our research of the versatility of these infectious microorganisms. It is now estimated that 1 out of every 20 hospitalized patients will contract an HAI. These estimates reinforce the need for improved infection control and prevention programs and surveillance efforts not only in our hospitals and healthcare settings but in the community as well. In order to reduce the number of infections we need to shift our focus from treatment to prevention. We can accomplish this by combating infection transmission through infection control measures such as the use of standard and transmission based precautions and personal protective equipment (PPE) such as gowns, masks and gloves. The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood, body fluids, or other potentially infectious materials. The effectiveness of gloves in preventing the contamination of healthcare workers (HCWs) has been confirmed in several clinical studies. One study found that when interaction was complete, HCWs who wore gloves during patient contact had only an average of three colony forming units (CFUs) of bacteria per minute of care on their hands, compared to the 16 CFUs per minute for those who did not wear gloves. Environmental disinfection and good hand hygiene practices have also been studied and clinically proven to be effective measures of infection control and prevention.

Hospital-acquired infections have been documented since shortly before the 19th century and as our scientific knowledge base surrounding microorganisms grew so did our awareness and understanding of how infection spreads. Though despite our advances, infection rates continue to rise. Since the middle of the 20th century following the development of vaccines and antimicrobial therapy it seems we have lost our focus. We have become complacent in a world where superbugs dominate, and advances in medicine and public health seem to make us believe that those infectious diseases might soon be a thing of the past. However it should be clear that this is not the case as HAIs are among the leading causes of death in the U.S. today.

The answer to those alarming rates is increased attention to multidisciplinary infection control surveillance programs. Combating the spread of infection requires evaluating, analyzing, and working to remove risk factors that exist as potential modes of transmission for disease. Prevention really is the best medicine, when it comes to breaking the chain of infectious pathogens and sometimes it can be as simple as washing your hands!

References
Aiello AE, Bloomfield SF, Cookson B, Boyle CO and Larson EL. The Effectiveness of Hand Hygiene Procedures in Reducing the Risks of Infections in Home and Community Settings Including Hand washing and Alcohol-based Hand Sanitizers. American journal of infection control. Vol. 35, No. 10. Pages S27-S64. December 2007.

Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51(No. RR-16): [1-5, 26, 29].

Centers for Disease Control and Prevention (December 2012). HAIs- The Burden. Retrieved November 09, 2012, http://www.cdc.gov/HAI/burden.html

Centre for Healthcare Related Infection Surveillance and Prevention [CHRISP]. Infection Prevention and Control History 1674-2011 http://www.health.qld.gov.au/chrisp/ip_week/ip_wk_history.asp, State of Queensland (Queensland Health) 2011

Mirza A and Steele R. Hospital Acquired Infections. Medscape. June 2012. Retrieved Nov. 30,2012 from http://emedicine.medscape.com/article/967022-overview