By Kelly M. Pyrek
More than 3,200 professionals in the fields of infection prevention and control, public health, occupational health, quality improvement and others convened in mid-March to set the agenda for the next 10 years of research and discourse pertaining to healthcare-acquired infections (HAIs). The Fifth Decennial International Conference on HAIs, co-organized by the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiologists of America (SHEA), the Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC), represents the first time that four leading scientific organizations committed to infection prevention are working together to further a scientific and educational agenda toward elimination of HAIs.
“Healthcare-associated infections can have tragic outcomes,” says Thomas Frieden, MD, MPH, director of the Centers for Disease Control and Prevention (CDC). “This meeting brings together experts from around the world to share the latest strategies in infection prevention, bringing us closer to our goal of eliminating healthcare-associated infections.”
In the opening plenary session, Frieden delivered an inspired presentation on "The U.S. Approach to Maximize Infection Prevention in the Next Decade" with an emphasis on "defining the unacceptable." What this entails, according to Frieden, is the number of people who are sickened or die from hospital-acquired infections, how little we know about the burden of infections, how rare the implementation of prevention measures is, and the fact that we don't know how many infections are preventable. “Defining unacceptable is ending the old ways of doing things,” Frieden said.
The toll of HAIs is staggering – as many as 1 in 20 patients is affected by an HAI, triggering up to $33 billion in excess medical costs annually. Frieden said the challenge for this new decade is to better understand transmission factors, but the effort is confounded by the lack of compliance with evidence-based practices; he reports that just 30 percent to 38 percent of hospitals are in full compliance with key infection prevention and control guidelines, and just 40 percent of hospitals adhere to hand hygiene practices. Frieden said that the norm in U.S. hospitals must be changed, so that HAIs are seen as being preventable and that improved guideline adherence is critical for curbing infections. He added that this would require additional funding and resources, as well as improved surveillance, better research, additional prevention tools and the engagement of stakeholders and the media – all of which are components of the Department of Health and Human Services’ Action Plan to Prevent Healthcare-Associated Infections.
Frieden says the action plan boils down to taking three concrete steps to reducing HAIs: improving surveillance, taking practical action (including creating an organizational culture of safety and following evidence-based guidelines) and addressing knowledge gaps, which also includes an implementation gap. Frieden encouraged the continued development of partnerships between state and local health departments, healthcare institutions, healthcare consumers, members of industry, global and national health partners and professional organizations.
These efforts are nothing, however, without a focused research agenda, says the CDC’s John Jernigan, MD, who moderated a plenary session on “Setting the Research Agenda for the Next Decade.” As Jernigan observed, “Great strides have been made due to better use and implementation of what we already know, but we need to aggressively pursue what we don’t know.”
Panelist David Henderson, MD of the National Institutes of Health, noted that there is a problem with the science base that supports infection prevention and control. He explained that it is inadequate to provide definitive support for the HAI-reduction recommendations that are made. “Implementation science has reduced risk but it is not the complete answer,” Henderson said. “The existing guidelines have a one-size-fits-all approach that won’t work in diverse healthcare settings.” For example, Henderson pointed to the concept of bundles; while they appear to be effective, Henderson said some aspects of the interventions are better known than others and this knowledge gap is of concern. At the heart of translational research is translating an idea from research into practice, going from the concept to the proof of the principle and then moving principle into practice in the real-world setting of healthcare. Henderson pointed to the current knowledge gaps, which included pathogenesis and the mechanisms of acquisition; epidemiology (including the role of the environment, optimal sites for culturing, settings in which screening is beneficial); the efficacy of prevention interventions such as hand hygiene, isolation, bundles, decolonization); study design; and technology (such as rapid diagnostics).
Henderson reported that these knowledge gaps and concern about their impact on HAI reduction, were reflected in the results of a 2009 survey of SHEA members; 92.4 percent of respondents cited “setting the scientific agenda” as a top priority, as well as 91.8 percent citing establishing a collaborative infrastructure and 89.9 percent citing the development of funding for more and better research. The SHEA survey also pointed to key clinical issues relating to research of drug-resistant Gram-negative rods, antimicrobial stewardship, MRSA, C. difficile and hand hygiene. The SHEA members recommended the creation of a consortium to further support research efforts, and Henderson announced the formation of the SHEA Research Collaborative, whose first research project is a survey of the institutional response to the H1N1 influenza pandemic.
Panelist Louis Rice, MD, of the Louis Stokes Cleveland VA Medical Center, spoke on “Progress and Challenges in Implementing Research to Combat ESKAPE Pathogens,” explaining that the ESKAPE acronym stood for the pathogens that continue to pose enormous challenges: Enterococcus faecium, Staphylococcus aureus, Klebsiella species, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species. Rice noted that there is still little knowledge about how increasing levels of resistance are created and little progress made in identifying novel compounds with potent in vivo activity against these dangerous pathogens. “What we know tells us how much we don’t,” Rice said, adding that the role of patient-to-patient transmission must be studied carefully. The challenges, Rice said, remain attitudinal, scientific, economic and political, and that the conundrum persists – new drugs are needed but antimicrobial discovery is a slow, unprofitable business.
Panelist Stephan Harbarth, MD, of Geneva University Hospital, addressed “Infection Prevention Research in Europe: Recent Advances and Future Priorities” and noted that progress in HAI reduction has been made in Europe due to benchmarking, quality improvement initiatives and implementing infection prevention and control guidelines in hospitals. He said that directions for the future encompassed improved screening for MDROs, further study of the behavioral science approach to hand hygiene, studying the impact of the environment in transmission of pathogens, improved surveillance, and an improved evidence base for infection prevention practices.
Panelist Sanjay Saint, MD, of the University of Michigan, addressed “Implementation Science: How to Jump Start Infection Prevention,” citing Machiavelli who once observed that there was nothing more perilous to conduct than the introduction of change. Meaningful change is never easy, Saint acknowledged, pointing to Semmelweis as an example of why non-adoption of his hand cleansing theory was rampant – not only did Semmelweis not publish his findings in a timely fashion, but his approach was considered to be offensive and he did not have a conceptual model with which to explain his findings (the germ theory had not been invented yet). This holds a valuable lesson for today’s infection preventionists, Saint said, in that there is a significant gap between knowing what should be done and what is actually done to prevent infections. The focus, Saint said, should be placed on implementation science, which is the concept that knowledge leads to persuasion, which leads to decision, which leads to implementation and then confirmation. It’s a road map that can affect adoption decisions in the healthcare environment; these decisions can be affected by the characteristics of the infection prevention practice, organizational characteristics, and environmental context. Saint pointed to Peter Pronovost’s work with the Keystone Project in Michigan, where the “4E” model was used in terms of a needs assessment: engage stakeholders, educate clinicians, execute intervention and evaluate the impact of the interventions. But because healthcare settings are unpredictable and non-linear, Saint said that implementation is a clinical and a social discipline, and tools from the social sciences can be borrowed to better understand issues such as non-compliance with infection prevention practices.
The Decennial's closing plenary featured the panel session, "The Decade: Influential Events That Shape Our Future." Panelist Arjun Srinivasan, MD, of the CDC, addressed "Influential HAI Outbreaks of the Past Decade" and noted that while MRSA has become a household word now, the NAP-1 strain of Clostridium difficile is rapidly becoming known among policy-makers and that the medical community should expect to see similar discussion about surveillance and prevention efforts. Another significant emerging issue of concern, Srinivasan said, is carbapenemem-resistant Klebsiella and KPC-producing organisms. He added that the identification of clonal epidemic strains is shifting infection preventionists' focus now and that focus must be on a level bigger than local or national. Srinivasan alluded to an increase in device-related outbreaks in the last decade -- approximately 46 such incidences and more than 150,000 patients notified about potential infectious exposure in the last 10 years.
Panelist Neil Fishman, MD, president of SHEA, outlined for attendees the most influential infectious disease-related issues of the past decade, including MDROs, public reporting and informatics. He emphasized the increasing impact that external entities were having on infection prevention, citing the 2008 Edmond and Eickhoff paper, "Who is Steering the Ship?" Fishman noted that these entities included government agencies, legislative bodies, payors, consumer watchdog groups, the mainstream media, accreditation bodies, non-profit organizations such as the NQF and the IHI, industry and professional societies. Fishman also pointed to ABC News' list of the top healthcare scares of the last decade, which included H1N1 influenza, avian influenza, SARS, MRSA and anthrax. Coming in as honorable mentions in his mind, Fishman said, was advances in study design (including the acceptance of quasi-experimental studies), SARs (because the long-lasting impact is questionable), and the 2009 novel H1N1 flu (because the jury is still out), and that for the latter issue, the big question that remains is the role of respiratory protection as we face another potential pandemic in the future.
Panelist Julie Gerberding, MD, MPH, former CDC director and currently working for Merck Vaccines, delivered a talk on "Healthcare Epidemiology: Looking Back, Moving Forward." She reviewed the themes of the previous Decennial conferences, noting the emerging issues covered in each, and made some predictions about the future. From 2000 to 2010, the focus has been on the rapid increase of healthcare complexity and its impact on delivery and infection prevention, and Gerberding predicted that in the coming decade, HAI reduction strategies would be ubiquitous, with a theme of "everywhere, everyone, everyday."
In addition to hundreds of other sessions, more than 900 studies were presented during the five-day program. The Decennial provided a dynamic vehicle through which scientific evidence was reviewed and updated, including emerging evidence-based practices for handling and preventing the spread of infectious diseases, including organisms such as MRSA, C. difficile and Gram-negative bacteria, plus the standardization of reporting so that adequate comparisons may be made across healthcare settings, as well as the development and implementation of best practices in all types of healthcare facilities across the country.
“As healthcare professionals, our relentless goal is safety, for our patients, ourselves and our colleagues,” said Fishman. “The research presented at the Fifth Decennial represents the work of the best minds in the field that will ultimately provide meaningful data that can be used at the bedside to improve patient care and patient outcomes, while moving the bar forward in protecting both patients and healthcare workers.”
Edmond M, Eickhoff TC. Who is steering the ship? External influences on infection control programs. Clin Infect Dis 2008; 46:1746-50.