At the beginning of 2007, the Centers for Disease Control and Prevention (CDC) estimated approximately 1.7 million healthcare-associated infections in US hospitals and 99,000 associated deaths each year. Julia Puppe spoke with Dr. Denise Cardo on the major causes of hospital infections and how to prevent them.
Hospital infections are not new, they have been around since the beginning of hospitals. “When we talk about hospital infections today,” says Denise Cardo, Director of the Division of Healthcare Quality Promotion of the National Center for Preparedness, Detection, and Control of Infectious Diseases, “we are talking about the most frequent ones: surgical site infections, bloodstream infections, urinary tract infections and pneumonia. They represent around 80 percent of hospital infections.” It seems contradictory: aren’t hospitals meant to cure diseases? Yet they are the source of some of the worst cases of infection. Cardo explains: “After a surgical procedure, a patient’s body is vulnerable. If the patient is very sick and has immuno-suppression, he or she has a higher risk for infection. The environment often bears microorganisms that are more resistant to antibiotics. All these factors can contribute to the occurrence of an infection.”
With its best practice guidelines and recommendations, the CDC has been at the forefront of promoting patient safety for decades. Despite the alarming figures, Cardo believes that the CDC’s efforts have yielded major improvements in the prevention of hospital infections. However, she admits, there is a lot more that still needs be done: “Hand hygiene is very important to prevent transmission of infections from one patient to another. However, in any survey you see published, adherence is about 50 to 60 percent. That’s not good enough. The same is true for adherence to antibiotic prophylaxis to reduce infections after surgical procedures. Again, in only around 50 percent of cases, the right antibiotic is given at the right time.”
Why aren’t more people following the CDC’s recommendations? Cardo believes that there are several reasons, the most common one being that, “many times, healthcare providers do not know the importance of following our recommendations in order to protect their patients and prevent infections. It takes a whole host of activities at the hospital level and other levels to make enacting our recommendations a priority.” Another problem, says Cardo, is that the prevention of infections is not part of medical school training. It is seen as an additional step. “If preventing infections was incorporated in the training, we would notice an increase in adherence to our recommendations, and a dropping number of infections.” Cardo would like to see a change take place: instead of consciously thinking about it, physicians would perform procedures to prevent infections automatically. The question remains: “How do you translate something from just being a recommendation in a guideline into action and get it into the hands of the ones who are taking care of the patients? That’s the challenge. But it’s also a big opportunity to prevent infections,” says an optimistic Cardo.
What is the solution? More regulations? Or would reaching more hospitals with the CDC’s recommendations suffice? In Cardo’s opinion, it is a comprehensive approach: “We need to be careful. Although we need regulations, too many of them won’t improve adherence. We also need to work with institutions to see how they can implement the recommendations in order to benefit the patient. The focus should really be on the patient.”
The patient undoubtedly agrees. What is more, an increasing public awareness of the problem of healthcare-associated infections has led to a call for public disclosure of healthcare infection rates in the US – a step that could potentially improve patient safety. “We still don’t have data to prove that these approaches are reducing infections. What we do know, though, is that the call for public disclosure had a major role in raising awareness, especially amongst CEOs. We hope that this will make the prevention of infections a priority for healthcare providers.”
An open discussion
When the discussion about public disclosure of healthcare associated infections started, the CDC released a guidance document for states that wanted legislation put in place. Since then, Cardo has been working with those that monitor infections. “I am very happy that the states that are really into this new initiative are not looking at it as just a way to compare rates. They are looking at ways of collecting information so hospitals can use it for local action. This is the really important part, not just to compare what is happening,” Cardo emphasizes.
States can put legislation in place to monitor infections, but they cannot prevent them. Is it all in the hands of the healthcare providers? Cardo says mostly but not all. Patients, too, can do their share. Firstly, by leading a healthy lifestyle: obesity and smoking can increase infections. Secondly, by being proactive and enquiring which procedures clinicians put in place to prevent infections. Thirdly, by making a report if they see a breach of such a procedure. “We know that it should not be the patient’s responsibility to remind people to wash their hands. But at least they could feel empowered to talk about something that doesn’t seem right to them. This is why it is important for institutions to openly discuss with patients the problem of infections and what they are doing to prevent them.”
Unfortunately, even if infection rates decrease, there will still be severe cases such as those caused by bacteria that are resistant to existing antibiotics. This makes prevention even more important, says Cardo. “When you prevent an infection you are also helping to prevent the burden of antimicrobial resistance. If you don’t have an infection, you don’t need to use antibiotics. As a result, you decrease the risk of having more resistance.” The appropriate use of antibiotics is crucial in reducing the number of drug-resistant infections. “There is still a lot of overuse and misuse of antibiotics in the US. The good thing is that clinicians are now starting to see the importance of changing the way they prescribe antibiotics. The industry will not have new antibiotics in the near future so we need to preserve what we have”, says Cardo.
Cardo’s goal for the future is to keep increasing awareness of healthcare-associated infections among the public and healthcare providers not only in the US but also in other countries. “A cultural change is taking place,” Cardo observes and explains: “In the past, people thought that infections were going to happen anyway and there was not a lot that can be done. But now more and more people are seeing that lots can be done and it can really make a big difference in terms of patient safety.”
Denise Cardo: “After finishing her medical training in Brazil, Denise Cardo worked in the prevention of hospital infections for 10 years. In 1993, she joined the CDC in the Division formerly called the Hospital Infections Program. Three and a half years ago, she became the Director of the Division of Healthcare Quality Promotion at the National Center for Preparedness, Detection, and Control of Infectious Diseases.”
Cardo’s four strategies to prevent antimicrobial resistance in healthcare settings: