Infection Control - A Problem For Patient Safety PDF

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Infection Control A Problem for Patient Safety

John P. Burke, M.D.
Nosocomial, or hospital-acquired, infections (more
appropriately called health careassociated infections) are today by far the most common complications affecting hospitalized patients. Indeed, the
Harvard Medical Practice Study II found that a single type of nosocomial infection surgical-wound
infection constituted the second-largest category of adverse events.1 Long considered the greatest
risk that the hospital environment poses to patients,2 nosocomial infections abruptly became the
province of public health officers at the time of a
nationwide epidemic of hospital-based staphylococcal infections, in 1957 and 1958.3 Since then, the
study and control of nosocomial infections have
been profoundly shaped by the discipline of public health, with its emphasis on surveillance and
epidemiologic methods. These infections are not
only the most common types of adverse events in
health care; they may also be the most studied.
Currently, between 5 and 10 percent of patients
admitted to acute care hospitals acquire one or more
infections, and the risks have steadily increased during recent decades (Table 1).4,5 These adverse events
affect approximately 2 million patients each year in
the United States, result in some 90,000 deaths, and
Table 1. Nosocomial Infections in the United States.*

Variable
Year
1975
1995
No. of admissions (106)
37.7
35.9
No. of patient-days (106)
299.0
190.0
7.9
5.3
18.3
13.3
No. of nosocomial infections

(106)
2.1
1.9
Incidence of nosocomial infections

(no. per 1000 patient-days)
7.2
9.8
Average length of stay (days)

No. of inpatient surgical procedures (106)
*Data are from Weinstein4 and Jarvis.5
n engl j med 348;7
add an estimated $4.5 to $5.7 billion per year to the

costs of patient care.6,7 Infection control is therefore
a critical component of patient safety. In this article
I describe the common ground shared by these two
disciplines. I also discuss the major problems in infection control, approaches to their solutions, the
role of the National Nosocomial Infections Surveillance (NNIS) System of the Centers for Disease Control and Prevention (CDC) as a model, and the need
for renewed commitment to and innovations in infection control to help ensure patient safety.
the nature of nosocomial

infections
Four types of infection account for more than 80
percent of all nosocomial infections: urinary tract
infection (usually catheter-associated), surgical-site
infection, bloodstream infection (usually associated with the use of an intravascular device), and pneumonia (usually ventilator-associated) (Fig. 1).8,9
One fourth of nosocomial infections involve patients in intensive care units, and nearly 70 percent
are due to microorganisms that are resistant to one
or more antibiotics an emerging public health
crisis that is due in large part to indiscriminate use
of antibiotics.10
Nosocomial infections can also be ranked according to their frequencies, associated mortality rates,
costs, and relative changes in frequency in recent
years.4,7 Catheter-associated urinary tract infections
are the most frequent (accounting for about 35 percent of nosocomial infections) but carry the lowest
mortality and lowest cost. Surgical-site infections
are second in frequency (about 20 percent) and third
in cost. Bloodstream infections and pneumonia are
less common (about 15 percent each) but are associated with much higher mortality and costs. Bloodstream infections and methicillin-resistant Staphylococcus aureus infections share notoriety for being
both the highest-cost infections and the most rapidly increasing in frequency; the current incidence
of bloodstream infections is nearly three times the
incidence in 1975.4,11 The rates of both urinary tract
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Nosocomial Pathogens (no. of isolates)
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
Urinary
Tract
Infection
SurgicalSite
Infection
Bloodstream Pneumonia
Infection
Other
Sites
Figure 1. Number of Nosocomial Pathogens, According to Infection Site,

Identified in the Hospital-Wide Component of the National Nosocomial Infections Surveillance System from January 1990 to March 1996.
The hospital-wide component of the National Nosocomial Infections Surveillance System consists of a subgroup of hospitals reporting data on nosocomial infections from all patients. In January 1999, this component was
eliminated from the system.
and surgical-site infections have declined slightly,

perhaps because of surveillance artifacts caused by
decreases in the length of hospital stays and increasing numbers of infections that develop after discharge from the hospital.
Each of the main types of infection comprises
more than one syndrome and has multiple pathogenetic pathways. For example, ventilator-associated pneumonia, a cause of one fourth of the deaths
attributed to nosocomial infections, commonly occurs as a result of infection with one or more bacterial species, but it may also occur with less common
pathogens, such as legionella, respiratory viruses,
or Aspergillus fumigatus.12 For each of the device-associated infections, multiple risk factors are related to
the patient, the personnel caring for the patient, the
procedures they use, and the device itself.
prevention of
nosocomial infections
Identification of risk factors permits elucidation
of those that are alterable from those that are not
and facilitates the development of targeted inter-
652
n engl j med 348;7
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ventions to reduce the risk of infection. For example, avoiding the use of invasive devices altogether
by means of alternative strategies (for example, performing urinary drainage by condom catheter) and
shortening the duration of use of the device (for example, reducing the number of days of mechanical
ventilation) have been proposed in many guidelines.
Strategies to prevent infections have been subdivided into several groups (education-based, process-based, and systems-based),13 but many of the
suggested interventions such as use antibiotics
wisely or educate and train staff12 have been
vague and difficult to implement.
Behavioral change remains a formidable obstacle. For example, cross-infection of patients by
health care workers with contaminated hands is a
major source of infections. Despite educational efforts, health care workers, including physicians,
continue to fail to adhere to standards for hand hygiene, which is universally considered the single
most important method for infection control. The
average level of compliance has varied among hospitals from 16 percent to 81 percent.14 Barriers to
compliance include understaffing and poor design
of facilities, confusing and impractical guidelines
and policies, failure to apply behavioral-change theory fully, and insufficient commitment and enforcement by infection-control personnel.14,15 Remarkably, the use of waterless antiseptic hand rubs, when
part of a multifaceted campaign that encourages
appropriate hand washing, has been shown to be
more practical than standard hand washing alone
and has been shown to improve the adherence of
health care workers to hand-hygiene guidelines and
to prevent the transmission of methicillin-resistant
S. aureus to patients.16
The new Guideline for Hand Hygiene in HealthCare Settings, developed by a multidisciplinary
task force,17 may facilitate system improvements
by resolving many inconsistencies among previous
guidelines from the CDC and other groups. It also
includes a requirement for monitoring adherence
to the guideline, along with suggested methods for
doing so. The guideline bans the use of artificial
nails when providing patient care, defines the different indications for hand washing as opposed to
decontamination, and calls for the use of alcoholbased, waterless antiseptics for decontaminating
the hands before and after any direct contact with a
patients intact skin.
The history of infection control is littered with
commercial products and devices to prevent infec-
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february 13, 2003

tion that were widely promoted after limited testing and have since been discredited.18 The development of safer devices (for example, needles with
safety features and antimicrobial-coated catheters)
has produced incremental gains in infection control, but devices constructed of biomaterials that
fully prevent infections remain a tantalizing prospect. Conversely, the actual infection-control benefits of many technological improvements that were
not designed primarily to prevent infections, such
as improvements in anesthesia equipment and practice,19 are inestimable but probably great.
Because of the limitations of infection-control
methods, the fundamentals of prevention have necessarily been grounded in epidemiology through the
development of standard definitions and classifications; surveillance and early reporting of infections, with feedback to those who need to know
(i.e., responsible authorities); evaluation of riskbased interventions; and production of evidencebased guidelines.20 This process has been guided by
the CDC, with the help of the American Hospital
Association and the regulatory efforts of the Joint
Commission on Accreditation of Healthcare Organizations.
Epidemiologic analysis, often by means of case
control studies, is a powerful tool for identifying
the cause or source of nosocomial infections. One
example among hundreds is the recognition of a
hospital outbreak in which 11 cases of neonatal
sepsis over a period of four years were traced to a
single human carrier.21 Root-cause analysis of individual cases would have been incapable of identifying the source of these or most other hospital infections. Another example is the recognition of
erroneous handling of closed urinary-drainage systems as a cause of catheter-associated urinary tract
infections.22 In this analysis, too, there was epidemiologic evidence of the importance of errors, even
though most of the errors were not followed by infection. Moreover, voluntary reporting of frequently
occurring infections has been found to underestimate greatly the true rate of avoidable infections, because most infections are considered unfortunate,
inevitable consequences of medical procedures.
Active surveillance is necessary to identify alterable risk factors (sometimes called process indicators). Various indicators for infection control have
been extensively evaluated, for example, in the development of a collaborative project to monitor health
care processes and outcomes.23 The growing importance of monitoring process indicators is a be-
n engl j med 348;7
lated but major trend in infection control, but one

that does not diminish the need for surveillance of
outcomes. Without surveillance, we will not know
the effect of our efforts to prevent infection. Two
examples illustrate the value and limitations of process indicators and the need for continued surveillance: surgical-site infections and outbreaks in
hospitals.
surgical-site infections
Many quality-improvement projects have identified errors in the administration of antibiotic prophylaxis before surgery as an independent risk factor for some postoperative infections. Incorrect
timing of surgical prophylaxis is associated with
increases by a factor of two to six in the rates of
surgical-site infection for operative procedures in
which prophylaxis is generally recommended.24
Failure to administer the first dose of antibiotic
within the two-hour window before incision (to
achieve adequate blood levels of the antibiotic during surgery) remains a common error, occurring,
for example, in 27 to 54 percent of all selected operations in a 1996 New York State study.25 Effective programs have recognized and addressed the
root causes of errors that result from faulty systems
of care.26 In most patients who receive inappropriate prophylaxis, however, infections do not develop, and therefore relatively stable (and seemingly
low) rates of surgical-site infections in an individual
hospital can mask the problem and create complacency. Therefore, some limited monitoring of process indicators, such as timely prophylaxis, is necessary to detect system problems.
Improving the timing of antibiotic prophylaxis
does not supersede other elements of infection control. In several early studies, surveillance of surgical-site infections with confidential feedback of the
relevant data to surgeons was found to reduce the
risk of infection.27 Regardless of the reasons for
these results, the reasons for surveillance are no less
pressing today and have additional justifications,
with the use of ever more complex surgical procedures and with the development of most postoperative infections after discharge from the hospital. Voluntary reporting of wound infections by
surgeons has not worked, and effective surveillance
requires active identification of cases by trained personnel and consideration of the use of automated
detection systems.28 The downsizing of many infection-control programs due to hospitals financial
constraints29 has further increased the need for
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february 13, 2003

653
The
new england journal
of
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new types of surveillance and process indicators to of infections and to improve the use of isolation and
barrier precautions for infection control.35 Also
identify surgical-site infections.
called signals or alerts, clinical triggers are eleoutbreaks in hospitals
ments drawn from patients electronic medical recAt least 5 to 10 percent of infections occur in clus- ords by means of programmed logic or algorithms
ters, or outbreaks, that can be detected from care- that suggest ongoing or potential adverse events,
ful review of surveillance information.30 Many out- including infections. Continuous, real-time scanbreaks are recognized only by astute clinicians or ning of laboratory and pharmacy records, for exlaboratory workers. Most, if not all, infections in ample, facilitates cost-effective surveillance and acoutbreaks can be construed as accidental injuries. tive interventions to prevent or ameliorate adverse
Therefore, the detection, investigation, and control events. The LDS Hospital team monitored drug
of outbreaks are a critical issue in patient safety and doses, renal function, the prescription of common
require vigilance.
antidotes, and other triggers to track and prevent
Though occasionally dramatic, outbreaks may adverse drug events.36 Interventions by a clinical
be insidious and may be protracted causes of sub- pharmacist reduced the use and misuse of antibiotstantial morbidity and mortality.21,31 They occur in ics and showed that the potential to stabilize antiall health care settings and with all classes of infec- biotic resistance existed.37 Voluntary reporting of
tious agents, especially antibiotic-resistant bacteria, medication errors had little overlap with adverse
and because of their sometimes widespread nature, drug events detected by this method. These concepts
often have a considerable effect on the public. Of are now being widely adopted by hospitals across
114 health careassociated outbreaks investigated the country through collaborative efforts coordiby CDC personnel over a 10-year period, 6 were na- nated by the Institute for Healthcare Improvement.
tional in scope and were traced to contaminated
Recently, the Agency for Healthcare Research
products or devices.32 Contamination of commer- and Quality released a controversial report that recially distributed products may be detected only by viewed the evidence in favor of 79 patient-safety
spontaneous reporting from infection-control units practices, of which 22 (28 percent) involved infecin hospitals.
tion control.38 Further illustrating the common
Recently, data-mining tools have been applied ground shared by these two disciplines, 5 of the 11
to detect previously unrecognized outbreaks.33 practices that were judged worthy of widespread
Molecular techniques have been used to show that implementation involved infection control. Two of
seemingly unrelated infections have been caused these five practices the appropriate use of antibiby interspecies transfer of genes encoding antibiot- otic prophylaxis in surgical patients and the use of
ic resistance, suggesting that the true rate of cross- maximal sterile barriers during the placement of
infection in hospital settings remains greatly un- central venous catheters were readily accepted.
derestimated.34 These data indicate that the role of Curiously, the Agency for Healthcare Research and
laboratory-based surveillance in public health is Quality reported that there was weaker evidence
likely to increase.
supporting methods to improve adherence to hand
hygiene and limitations in antibiotic use practices that some infection-control experts believe offer
the patient-safety movement
the greatest potential benefit. These and other inThe importance of the patient-safety movement in fection-control practices were listed as priorities
energizing infection control is already manifest. for further research.
Many infection-control units have broadened their
activities in monitoring the use of antibiotics and
is the nnis system a model
in preventing adverse drug events due to antibiot- for infection-control programs?
ics. (Antibiotic resistance may even be considered
a special type of adverse drug event, one with sociThe NNIS System of the CDC is a voluntary,
etal consequences.)
confidential, hospital-based reporting system that
More than 25 years ago, the Department of Clin- has been influential in guiding infection-control
ical Epidemiology and Infectious Diseases of the efforts in hospitals across the United States and
LDS Hospital, in Salt Lake City, devised clinical around the world; it is the only national source of
triggers to facilitate the detection and surveillance systematically gathered data on hospital infections.
654
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february 13, 2003

Monthly reports of nosocomial infections from

more than 300 hospitals (a nonrandom sample of
U.S. hospitals, all with at least 100 beds and nearly
60 percent academic medical centers) have allowed
benchmarks for infection rates to be established
through the use of standardized case definitions
and data-collection methods and computerized
data entry and analysis.30 Analysis of NNIS System
data helps reveal changes in patterns of incidence,
distribution, antibiotic resistance, sites of infection,
outcomes, and risk factors for infection. In March
2000, the NNIS System reported that during the
1990s, the rates of infection for respiratory tract,
urinary tract, and bloodstream sites, after adjustment for the duration of the use of invasive devices,
had decreased in intensive care units in selected hospitals.39 The multiple reasons for these reductions,
however, cannot be attributed to any specific interventions, nor does the report mean that all hospitals providing data to the NNIS System obtained
these salutary results, since only a subgroup of hospitals participated.
The NNIS System is viewed as a benchmark on
the basis of the reasonable expectation that the participating infection-control programs possess the
components for effectiveness identified by the CDC
in previous studies: intense surveillance, intense
control measures, and an adequate number of infection-control professionals. Though not fully adjusted for patient risk factors, the rates of endemic
infections in participating hospitals have been used
to help drive improvement efforts. A few success
stories have been reported from selected hospitals
in which problems (such as excessive use of certain
invasive devices and deviations from national guidelines) were identified and addressed, but evaluation
is still incomplete.
Each hospital participating in the NNIS System provides data on only one or two high-risk components of surveillance, such as intensive care or
selected surgical procedures. In addition, case ascertainment is time-consuming and costly for hospitals, and the definitions for infections are complex
and difficult to apply. Therefore, the NNIS System is
a model for focused surveillance but not for overall
infection control. This system has not yet addressed
many important safety issues, such as clinical errors
of omission leading to failures to diagnose infection or delays in the diagnosis of infection. Furthermore, the definitions used during surveillance (for
example, the definitions for ventilator-associated
n engl j med 348;7
pneumonia and for infections developing after hospital discharge) are a work in progress.
Perhaps the most important outcome of the
NNIS System is the infrastructure of trained infection-control professionals that it has nurtured and
the cadre of CDC-trained infectious-disease physicians who have migrated to university and community hospitals during the past 30 years. These human resources are now endangered because of the
economic forces shaping health care and the downsizing of many, if not most, infection-control units
in hospitals. The voluntary nature of NNIS may be
an important factor in its success, but participation
also helps hospitals meet regulatory requirements.
In addition, the support of CDC epidemiologists is
a vital asset. More than a decade ago, the Institute
of Medicine called for further development of the
NNIS System and its expansion to include more U.S.
hospitals40; indeed, the system has grown rapidly,
from 120 hospitals in 1991 to more than 300 in
2001. The call for broader participation among all
U.S. hospitals is even more urgent today.
From the Department of Clinical Epidemiology and Infectious
Diseases, LDS Hospital; and the Department of Internal Medicine,
University of Utah School of Medicine both in Salt Lake City.
1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse
events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
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3. Langmuir AD. The Epidemic Intelligence Service of the Center
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4. Weinstein RA. Nosocomial infection update. Emerg Infect Dis
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5. Jarvis WR. Infection control and changing health-care delivery
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6. Public health focus: surveillance, prevention, and control of
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7. Stone PW, Larson E, Kawar LN. A systematic audit of economic
evidence linking nosocomial infections and infection control interventions: 1990-2000. Am J Infect Control 2002;30:145-52.
8. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The
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14. Pittet D. Improving adherence to hand hygiene practice: a mul-
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15. Farr BM. Reasons for noncompliance with infection control
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20. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for
infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Infect Control Hosp
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21. Burke JP, Ingall D, Klein JO, Gezon HM, Finland M. Proteus mirabilis infections in a hospital nursery traced to a human carrier.
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22. Garibaldi RA, Burke JP, Dickman ML, Smith CB. Factors predisposing to bacteriuria during indwelling urethral catheterization.
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Indicators: a collaborative effort between the Joint Commission on
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26. Burke JP. Maximizing appropriate antibiotic prophylaxis for
surgical patients: an update from LDS Hospital, Salt Lake City. Clin
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Infect Control 2002;2:81-5.
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of managed care. Infect Control Hosp Epidemiol 2002;23:407-10.
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HELP system and its application to infection control. J Hosp Infect
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39. Monitoring hospital-acquired infections to promote patient
safety United States, 19901999. MMWR Morb Mortal Wkly Rep
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National Academy Press, 1992:121-2.
Copyright 2003 Massachusetts Medical Society.
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