By Peter Teska and Jim Gauthier
Outbreaks of infectious diseases, caused by harmful pathogens, can be traced back centuries as the cause of significant morbidity and mortality in humans. The previous century saw two of medicine’s biggest achievements: the introduction of vaccinations to prevent infections and the use of antibiotics to cure infections when they do occur. Preventing and curing infections remain key goals of medicine in providing optimal health for a population. But growing antibiotic resistance and community-acquired infections are on the rise. It’s important to take a closer look at these growing trends.
Prevention vs. Cure
Efforts to prevent infections have shown significant progress in reducing the global burden of infectious diseases over the last century. Both the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) continuously emphasize the importance of the use of vaccinations for the general public and for healthcare providers.
Additionally, hand hygiene, surface cleaning and disinfection and respiratory hygiene are part of an overall bundle of interventions referred to collectively as Standard Precautions. Healthcare workers are expected to practice Standard Precautions with every patient to protect the patient and the employee from the spread of infectious pathogens. Studies have shown the importance of using Standard Precautions in healthcare and the importance of their use grows every year.
Someone who contracts an infectious disease will generally rely on a physician to prescribe a course of action to cure the infection. One of the most common tools is the use of antibiotics. Initially highly effective, within a few years of their introduction, many bacteria started to develop resistance. This resistance trend has grown over time, reducing the overall effectiveness of many antibiotics. New generations and classes of antibiotics were developed to attempt to stay ahead of the rapidly-changing evolution of the bacteria, but each new generation of antibiotics has seen the same issue of resistance. Research into new antibiotics has slowed, and thus antibiotic resistance is today considered one of healthcare’s primary challenges.
Growing Antibiotic Resistance
The National Healthcare Safety Network (NHSN) collects patient data, such as the number of healthcare-associated infections (HAIs), from 17,000 healthcare facilities in the U.S to provide a consistent surveillance and reporting standard (Weiner, 2016). Keeping track of infection data and which antibiotics the bacteria are resistant to is an important part of understanding how infections are changing in healthcare.
Weiner (2016) performed an analysis of NHSN data from 2011 to 2014 and reported that across the U.S., approximately 2 million people get antibiotic-resistant infections each year, resulting in 23,000 deaths. Antibiotic-resistant bacteria can be found in both healthcare and community settings. The NHSN defines a healthcare-associated infection as an infection where signs and symptoms develop more than 48 hours after ad-mission. The numbers from Weiner’s study suggest the bulk of these infections occur in the community.
There are approximately 750,000 HAIs in the U.S. each year. When looking specifically at HAIs reported in this study, the top six antibiotic-resistant bacteria cause 15 percent of HAIs for the facilities in the study. If this is true across the U.S. as a whole, it implies 112,500 antibiotic-resistant HAIs each year in the U.S. and that only 5.6 percent of antibiotic-resistant infections are healthcare-associated.
It is also worth noting that there is a wide variation by pathogen in this data. Weiner (2016) reports in their study that while 52.6 percent of Acinetobacter infections were multidrug-resistant and 47.9 percent of staph infections were methicillin resistant, only 29.5 percent of enterococci infections were vancomycin resistant and 15.9 percent of Pseudomonas infections were multidrug-resistant. This wide range in antibiotic resistance is at least in part a measure of the evolutionary progress of the organisms.
The Truth about Community Acquisition
Community-associated infections include a wide range of bacteria, viruses, and fungi. Erb (2017) published a study that investigated the relationship between when the infection presented and whether it could be linked to other patients in the hospital, and thus be considered healthcare associated epidemiologically. They found that 77 percent of patients with infections had symptoms prior to the 48-hour window and thus would be considered community associated. Of the remaining 23 percent, which were all classified as HAIs, only 51.8 percent of these HAIs could be associated with another patient having the same pathogen. This implies that half of all infections currently classified as HAIs may in fact be community associated, but presenting with symptoms after the 48-hour window. Taken together, this suggests approximately 90 percent of patients treated in hospitals for HAIs have acquired the pathogen in the community.
The standard practices to prevent the transmission of pathogens in a community environment include:
- Vaccination for vaccine preventable diseases
- Hand hygiene, including hand washing and use of alcohol-based hand rubs
- Cleaning and disinfection of environmental surfaces
- Respiratory hygiene
The Role of Hand Hygiene
The importance of hand hygiene in preventing infections is well understood both for healthcare environments and in the general public (WHO, 2009). As the majority of pathogens transferred between people in a community environment are believed to occur through direct or indirect contact with contaminated hands or surfaces, proper hand hygiene is a key practice to prevent the spread of infectious diseases.
Hand hygiene can involve handwashing or the use of alcohol-based hand rubs. In healthcare settings, handrubs are the preferred method of hand hygiene unless hands are visibly soiled because they are milder on the hands than handwashing, can be conveniently placed for employees at the point of care and are highly effective against a wide range of pathogens.
When considering how to reduce the number of antibiotic-resistant infections in the general public, it’s important to consider incorporating parts of the healthcare model of hand hygiene, including:
- Use of alcohol-based hand rubs unless hands are visibly soiled
- Convenient location, which facilitates higher use, including in public/community facilities
- Communication tools such as wallcharts and advertising to raise awareness of the importance of hand hygiene and to advise on proper technique
The increasing risk of antibiotic-resistant infections is a threat in today’s world but can be reduced through key interventions such as hand hygiene. Better hand hygiene cannot eliminate all infections, but because of the central role contaminated hands play in a large number of infections, better hand hygiene practices used broadly in society would help to reduce the risk of infections in general and for those that are antibiotic resistant as well.
Peter Teska is a global infection prevention application expert with Sealed Air’s Diversey Care division and can be reached at [email protected]. Jim Gauthier is a senior clinical advisor with Diversey Care and can be reached at [email protected].