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On any given day in the U.S. one of every 25 hospitalized patients is infected by a pathogen acquired during hospital care. Every year 722,000 of these health care associated infections (HAIs) strike patients, with roughly 200 of them dying daily, according to the Centers for Disease Control and Prevention.1
As bad as that sounds, these recently released numbers are actually an improvement over the 1.7 million infections and 99,000 deaths annually that the CDC has estimated since 2007. Likewise, it was then estimated that 1 of every 20 hospitalized patients had an HAI. The figures are not directly comparable however, as they are drawn from different surveillance data and other measures over different time spans. With that considerable caveat included, it is fair to say progress is being made and real HAI reductions are occurring. (See summary data, p. 55)
"First and foremost, this is probably the best quality of data we’ve had in a very long time to look at the burden and type of infections we’re seeing in health care," says Michael Bell, MD, deputy director of the CDC’s Division of Healthcare Quality Promotion. "The previous estimates, I think were useful in a very big picture, non-granular kind of way to say that it used to be bigger, now it seems to be smaller, but they definitely are not the same methodology. I wouldn’t compare them directly. But I think there seems to be a trend [of HAI reductions]."
However, the mood at a recent CDC press conference announcing the numbers was more sober than celebratory after publication of the landmark HAI point prevalence study.1
"Despite the progress we’ve seen, three quarters of a million patients every year end up with HAIs," Bell adds. "Of those people, as many as 1 out of 9 go on to die. This is not a minor issue."
That said, a separate CDC HAI Progress Report shows that significant reductions are being seen for many infections. (See story, p. 56.)
"It’s not all bad news," Bell said. "Some of the successes we’re seeing are in protecting the most fragile patients, the patients in intensive care units. We’ve seen good progress preventing blood stream infections related to central lines. We have seen that the number of these infections have gone down by almost half since 2008."
The prevalence study included surveys of 183 hospitals. Of 11,282 patients, 452 had 1 or more health careassociated infections (4%). Of 504 such infections, the most common types were pneumonia (21.8%), surgical-site infections (21.8%), and gastrointestinal infections (17.1%). Clostridium difficile was the most commonly reported pathogen, causing 12.1% of HAIs.
The continuing ascension of C. diff is being driven by the highly virulent NAP1 strain.
"In the past, going back 20 years or so ago, [C. diff] was more of a nuisance than anything else," Bell says. "But today the type of this bacteria spreading in this country has such a strong toxin that it’s a very severe infection — requiring colon removal in some cases. This deadly diarrhea is contributing to an unacceptable number of infections."
One of the key ways to reduce C. diff is through antibiotic stewardship, which reigns in use and overuse of antibiotics that wipe out commensal bacteria in the gut.
"I think we have a lot of opportunities to improve that," says Marion Kainer, MD, co-author of the point prevalence study." I also believe that with C. diff what is happening in the community and in transitions of care are really important. So that as you get a patient — for example if they came from a nursing home — they may come in with C. diff because they were treated with antibiotics for asymptomatic bacteriuria. They may actually be classified as having community-onset C. diff, so they don’t appear in these figures. But they are a reservoir and they cause transmission to other patients by the hands of health care workers and through imperfect cleaning of the environment. I think we have opportunities to improve communication between facilities and during transitions of care."
The increasing calls for hospital antibiotic stewardship programs — possibly mandated and enforced by the CMS — are due in large part to the emergence of carbapenem-resistant Enterobacteriaceae (CRE), which can cause infections that are virtually untreatable.
"This is a family of bacteria that includes E. coli and many common organisms that live in the gut and need to be there for us to be healthy," Bell says. "The challenge that we see is that some of those bacteria, the nightmare bacteria’ are now completely untreatable. That means that as a doctor, I have nothing left I can offer a patient who has an infection like this in the hospital. The challenge of antibiotic resistance really can’t be overstated. We’ve found that over half of hospitalized patients end up getting an antibiotic at some point. This is a huge amount of antibiotic pressure. We’re focusing on improving the prescribing of antibiotics specifically because these nightmare bacteria and deadly diarrhea are such a threat to patient health."
While some great strides have been made in some areas, newly identified challenges and old infections that still resist reduction underscore how much more needs to be done, says Linda Greene, RN, MPS, CIC, director of infection prevention and control at Rochester (NY) General Health System.
"There is no doubt that progress has been made, but I think [IPs] would all say that there has not been enough progress yet," she says. "We have focused on ICUs where critically ill patients are and I think that was the right thing to do. But now those same patients are in med-surg wards and they are also in nursing homes and extended care facilities. The population wher-e care is delivered has moved, and we have to improve and move our efforts."
Key findings in a Centers for Disease Control and Prevention point prevalence study1 on health care-associated infections (HAIs) include the following:
On any given day, about 1 in 25 hospital patients has at least one HAI.
There were an estimated 722,000 HAIs in U.S. acute care hospitals in 2011.
About 75,000 hospital patients with HAIs died during their hospitalizations.
These new numbers update and replace the old estimates of 1.7 million HAIs in U.S. hospitals and 99,000 deaths associated with HAIs.
The most common infection types were:
• pneumonia (22%)
• surgical site infections (22%)
• gastrointestinal infections (17%)
• urinary tract infections (13%),
• bloodstream infections unrelated to an infection at another site (10%)
The most common pathogens causing healthcare-associated infections were:
• C. difficile (12%)
• Staphylococcus aureus (11% including MRSA)
• Klebsiella (10%)
• E. coli (9%)
• Enterococcus (9%)
• Pseudomonas (7%)
[CDC note: Klebsiella and E. coli are members of the Enterobacteriaceae family. Several of the pathogens in this group are showing strong antibiotic resistance and are known as carbapenem-resistant Enterobacteriaceae (CRE), or "nightmare bacteria."]