Memorandum by ARHAI (PS 45)
THE EFFECTS OF HEALTHCARE ACQUIRED INFECTIONS
ON PATIENT SAFETY
This response is on behalf of the Advisory Committee
on Antimicrobial Resistance and Healthcare Associated Infections
(ARHAI). The advisory committee is tasked with providing practical
and scientific advice to the Government on strategies to minimise
the incidence of healthcare associated infections and to maintain
the effectiveness of antimicrobial agents in the treatment and
prevention of microbial infections in man and animals. ARHAI considers
that health care acquired infections and antimicrobial resistance
pose a significant threat to patient safety and therefore have
responded to the committee's call for evidence.
This paper concentrates on two different areas
within the committee's remit
the effects of the uncontrolled use
of antibiotics and in particular their role in Clostridium
difficile infection (CDI)
reducing health care acquired infection
(HCAI) by developing an organisational perspective on infection
The use of antibiotics is a key factor for the
development of healthcare associated CDI. CDI is a clear risk
to patient safety and the treatment of CDI consumes significant
healthcare resources primarily due to markedly increased hospital
The paper considers strategies for decreasing
cases of CDI within the healthcare system. Restricting the use
of certain classes of antibiotics has been shown to lower rates
of CDI. Hospitals need to have a clear policy on the prescribing
of antibiotics coupled with mandatory education and audit programmes.
Audit and feedback to staff has been shown to facilitate implementation
of evidence based guidelines on antibiotic prescribing and reduce
incidence of CDI. However these studies are isolated studies and
there are no overall figures for the level of antibiotic prescribing
in the UK. Collecting data on the type and numbers of antibiotics
prescribed would greatly enhance the value of the mandatory surveillance
data already collected on CDI within hospitals. Collecting this
additional data would allow a link to made between cause and effect
and provide a powerful tool for investigating the correlations
between antimicrobial prescribing and CDI. This data could aid
the identification of antibiotics that are less likely to induce
CDI and thus inform future prescribing.
Reducing health care acquired infection (HCAI)
by developing an organisational perspective on infection prevention
Healthcare acquired infection (HCAI) occurs
in 8.19% of all hospital inpatients in England. HCAI is also currently
the most common concern of the population regarding the safety
of an inpatient admission. As such, infection prevention should
be regarded as a core aspect of patient safety. To deliver sustainable
infection prevention within acute Trusts an organisational approach
should be considered, embedding infection prevention in the organisation's
culture, decision making, performance monitoring and all aspects
of management and care.
1. Diarrhoea is one of the most common side
effects of antibiotics, usually because of disturbance of the
normal gut (friendly) bacteria or increased gut motility. However,
some cases of antibiotic associated diarrhoea result from infection
caused by Clostridium difficile (CDI). Antimicrobial agents
that induce CDI are believed to perturb the normal gut bacteria,
which facilitates the germination of C. difficile spores
in patients who acquire, or are colonised by C. difficile.
This leads to proliferation of C. difficile and subsequent
toxin production. It is the toxins that C. difficile produces,
once it has been stimulated by antibiotic exposure, that cause
inflammation of the wall of the large bowel (colitis) with consequent
diarrhoea. Cases that are complicated by severe inflammation of
the gut wall (pseudomembranous colitis) may be more likely to
lead to death. These are associated with recently recognised virulent
C. difficile strains, notably, but not exclusively, in
the frail elderly. Reports of CDI are generally increasing in
many countries; this reflects the emergence of these virulent
strains and greater detection as diagnostic testing increases.
CDI consumes significant healthcare resources primarily due to
markedly increased length of hospital stay. It is increasingly
clear that CDI occurs in people in the community who have not
had recent hospital stays.
Antibiotic prescribing and CDI risk
2. Use of antibiotics is the key risk factor
for the development of healthcare associated CDI, especially third-generation
cephalosporins given to the elderly, as well as clindamycin and
prolonged use of aminopenicillins. In fact all antibiotics may
predispose to CDI and this should influence prescribing practice
ie all antibiotic prescriptions should be justifiable because
there is a real risk of harm, especially if high risk agents are
used in patients at high risk of CDI. The same is true concerning
the number of antibiotic prescriptions and their duration. Thus,
if a patient receives more antibiotic courses and or longer prescriptions
(including administration of prophylactic peri-operative antibiotics
for longer than the recommended 24 hours) then the risk of CDI
Strength of evidence
3. The quality of the evidence concerning
the level of CDI risk associated with specific antibiotics is
modest. Crucially, studies have frequently failed to account for
the risk of C. difficile acquisition, remembering that
CDI cases are often caused by bacteria that have recently been
acquired by the patient. Also, hospital patients often receive
more than one antibiotic, and they may have had prior antibiotic
exposure. Despite these issues, some antibiotics are less likely
to induce CDI, including penicillin and vancomycin, and some broad
spectrum agents such as gentamicin, and anti-pseudomonal penicillins,
with or without a beta-lactamase inhibitor.
Effectiveness of altered antibiotic prescribing
4. If all the available evidence is examined
to determine the effectiveness of changing antibiotic prescribing
in order to reduce the risk of infection, the most robust finding
is that restricting use of broad spectrum antibiotics, specifically
cephalosporins or clindamycin, can reduce the incidence of CDI.
Two crossover studies and a follow-on surveillance study on acute
elderly wards, all performed in NHS hospitals, showed that effective
restriction of third-generation cephalosporins was associated
with a reduction in C. difficile. Such findings do not
lessen the importance of good infection prevention and control
practice that reduces to a minimum the chance that pathogens such
as C. difficile can spread in healthcare settings. Clearly,
even low risk antibiotic use could lead to CDI if it is undermined
by patient acquisition of C. difficile.
Education and audit
5. No one sets out to induce CDI when they
prescribe an antibiotic. Education of young and old doctors is
important to reduce the risk of CDI occurring. Every prescriber
should consider, "Is this patient at particular risk of CDI?"
and should modify prescribing behaviour accordingly. Choosing
the correct antibiotic(s) initially affects the success of treatment,
including the chance of survival. Repeated changes to antibiotic
therapy not only risk poor treatment response, but also increase
the selection pressure for resistance bacteria and the risk of
CDI. Hospitals should have policies to control antibiotic prescribing
and mandatory education and audit programmes in place. Hospital
pharmacy initiatives to improve antibiotic management, notably
via the appointment of antimicrobial pharmacists, appear to facilitate
greater local multidisciplinary working between pharmacy and microbiology/infectious
diseases departments. Systematic reviews suggest that audit and
feedback may improve the implementation of evidence-based guidelines
by healthcare workers. This approach has been shown to reduce
CDI rates following decreased cephalosporin prescribing.
Identifying high risk antibiotics
6. Identification of antibiotics that are
less likely to induce CDI is important, particularly so that policies
can be designed to promote their use, especially in at risk patients.
Given the difficulties in the clinical setting of identifying
which antibiotics are truly high risk agents for inducing CDI,
greater attention should be paid to pre-clinical and pre-licensing
assessment of this risk. It is commonplace not to recruit elderly
and particularly frail patients to clinical trails of new antibiotics.
Thus, at the time that licensing decisions and cautions for antibiotic
use are agreed only very limited data on antibiotic risk of CDI
are available. Post market surveillance to obtain real life data
on CDI risk is important for new antibiotics and should be formally
required, unless risk data are already available. Also, a model
system has been described that can identify which antibiotics
induce C. difficile to start producing toxins. This approach
can provide data on CDI risk that appears to correlate well with
Monitoring antibiotic prescribing
7. An important gap currently exists in
our ability to compare antibiotic prescribing practice between
NHS hospitals. Systems are in place, and indeed targets have been
set, to monitor rates of CDI (and MRSA). It is illogical, however,
that a national systematic surveillance system to measure antibiotic
prescribing is not available, as antimicrobial use is a key driver
of healthcare associated pathogens. Information technology issues
represent a significant barrier to achieving such a surveillance
system, but a simplified mandatory scheme could be established
for NHS hospitals. This could at least identify major outliers
in terms of overall antibiotic use and/or prescribing of specific
types of antimicrobials; this in turn could prompt further data
collection and audit. Information technology can also be used
to control real time antibiotic prescribing; for example, each
prescription can automatically be compared against a standard,
preventing deviations from agreed policies, minimising polypharmacy
and/or broad spectrum therapy, and requiring the use of automatic
stop or review dates.
8. Antibiotic prescribing data should of
course be analysed alongside the considerable surveillance information
that is available from the mandatory C. difficile scheme,
which is managed by the Health Protection Agency. This approach
would provide a powerful tool to investigate correlations between
antimicrobial prescribing (overall and for specific antibiotics)
and rates of CDI. Furthermore, detailed C. difficile fingerprinting
data are also available from the Health Protection Agency's C.
difficile Ribotyping Network for England. Thus, we would be
able to identify which antibiotics were most responsible for CDI,
including for established and emergent epidemic strains. Measuring
both cause and effect would greatly increase the value of surveillance
INFECTION (HCAI) BY
9. The extreme public concern, media interest
and political target setting around HCAIs as well as the incidence
of occurrence, particularly in vulnerable patient groups makes
infection prevention a patient safety priority for the NHS. Trusts
need to recognise infection prevention as a key area of their
patient safety and quality improvement agenda and should consider
an organisational approach to address it.
10. External reinforcement provides a driving
force for change and improvement and the targeting of some resources,
but for effective and sustainable improvement, particularly in
large complex organisations a comprehensive organisational perspective
should be considered with strong internal reinforcement, systems
based approaches and shared aspirations and values.
11. It is now increasingly recognised that
an organisational development approach to embed infection prevention
within the running of Trusts and the delivery of clinical care
is the way forward rather than a historical model with reliance
on a small separate expert team. Infection prevention relies on
a complex interconnection of risk reduction, prioritisation, leadership,
behaviours and practices across multiple management systems and
clinical care as well as the intrinsic risk factors of the individual
patient. A piecemeal approach will be limited in effectiveness.
The Organisational Development Approach
12. The organisational development approach
can be understood at a trust (corporate) level, as well as at
a unit (team/department) level, with a particular emphasis on
high risk units such as intensive care units (ICUs) and high dependency
units (HDUs). Organisational development approaches can be used
to address the challenge of competing NHS priorities, developing
a shared culture of safety and infection prevention and provide
opportunities to also use infection prevention related measures
(both processes and outcomes) as proxy quality indicators of systems
management, governance and clinical service.
At Trust level
13. The emphasis is that achieving safety
requires more than individual carefulness. It is a corporate responsibility
that should have equal or higher status for hospital boards than
finance. However, it is recognised that the corporate responsibility
and action may require external pressure to achieve. From an organisational
perspective, HCAIs can be considered a marker of organisational
governance, management competence, reliability of systems, levels
of training and levels of staffing. This is demonstrated in the
Healthcare Commission's reports in which organisational issues
are recurring themes; recent mergers, pre-occupation with the
financial situation, service reconfigurations, conflicting priorities
between finances and patient safety and poor antibiotic stewardship.
These themes are reflective of systemic problems that are embedded
in the culture of the organisation and can only be addressed through
organisational-level interventions. The evidence-base for this
perspective is weak in healthcare, but well-evidenced in high
risk industries, such as the aviation, oil, gas and nuclear industries
which have developed a high reliability approach to managing risk
over the last two decades. Their risk strategies are informed
by a human factors approach to error prevention that recognises
the effect of behavioural issues on accidents.
Further research is undertaken on
the organisational development approach to patient safety and
infection prevention in health
The full integration of infection
prevention into the patient safety agenda
The development of toolkits to assist
Trusts in the development of a sustainable strategy for infection
Infection prevention-focused impact
assessments with senior sign-off for any changes to health infrastructure
eg estates, policies, clinical systems, eg patient flows or service
Table top exercises/decision making
workshops with multidisciplinary teams of managers and senior
clinicians to simulate the management of conflicting priorities
and maintaining infection prevention goal.
At Unit Level with a focus on High Risk Areas
14. Recently, a growing recognition by clinicians
of the nature and impact of organisational pressures on areas,
such as ICUs has led to preliminary studies centred on high risk
units within healthcare. Studies from the US have highlighted
the patient safety and cost issues associated with infections.
For example, infections in patients in intensive care are associated
with an estimated attributable mortality of 35%, an additional
cost of $40,000 per survivor and an additional 8 days length of
stay in a surgical intensive care unit (SICU) admission. Further
research has examined factors such as workload, staffing ratios,
protocol adherence, hand hygiene promotion and training as having
an impact on the effective management of infections. The economic,
clinical and emotional impact of these results merits a re-examination
of the use of conventional, organism-specific or device-related
approaches to address infection occurrences in high risk units.
The evidence-base for infection in UK healthcare high risk units
is developing, as the contained nature of these units lend themselves
to small, tightly focused research studies.
Systems management indicators in
ICUs particularly regarding staffing (ratios and levels of training)
should be considered safety and infection prevention performance
Provision of feedback data on compliance
with best practice (eg care bundles and antibiotic prescribing)
and detailed infection surveillance with unit ownership to be
considered a quality indicator of unit management and clinical
Delivery and management of a regular
planned programme of closure to allow maintenance and deep clean
Learning from, and sharing experience
of high risk units for vulnerable patient groups
Infection Outcomes as Indicators of Complex System
15. Infection related outcomes, such as
rising infection rates and particular outbreaks may also be considered
indicators of failures in organisational sustainability. To achieve
the development of a safety culture in regards to infection prevention,
attention has to be paid to managing staffing ratios, service
configuration, bed management etc. Furthermore, infection prevention
related outcomes can be considered markers of the extent to which
organisations can work within competing priorities within the
NHS without compromising patient safety and patient experience,
an approach that more recently has been widely discussed in the
light of the Darzi Report.
16. Infection related indicators in balanced
scorecards are one mechanism to monitor outcomes in relation to
other organisational indicators. Scorecards were originally developed
as a framework to measure performance beyond finances in private
industry. The drawback to scorecards is that they can skew activity
as the organisation focuses only on the indicators measured and
therefore needs regular refreshing and updating. To address this,
checks and balances are needed within performance metrics to provide
a level of sensitivity to patient safety factors. For example,
to address high level of patient flow with high bed occupancy
and admission targets, may lead to moving patients around the
hospital from ward to ward several times. However, minimising
bed moves for patients is a critical component of infection prevention,
patient safety and the patient experience, therefore a bed move
monitoring programme has been introduced locally as a quality
indicator, and serves as a "check".
17. Whilst the evidence-base for the use
of scorecards exists, less research has been undertaken on the
use and effectiveness of infection-related indicators, or the
extent to which they can be considered markers of effective organisational
Research into the use of infection
indicators as a barometer of patient safety
Research into the use of checks and
balances in Trust performance score cards to minimise the infection
risk in the face of competing priorities and challenges.
HCAIs present a risk to patient safety and are
a considerable financial burden on NHS Trusts. Further research
is needed to identify the best mechanisms to lower levels of HCAIs.
However it is clear that an integrated approach to infection control
within organisations, with support from staff at all levels, is
essential to ensure good infection control. Robust hospital polices
on antibiotic prescribing along with audits of compliance and
feedback are important in reducing levels of antibiotics used
and in reducing in CDI, an important HCAI. Surveillance of HCAIs
and antibiotic prescribing is essential to identify areas where
improvements can be made and also to provide new information about
the most effective ways to control HCAIs.
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