What is the single most important strategy to prevent the spread of infection?

Healthcare-associated infections are the most common complication affecting patients in hospital. They cause unnecessary pain and suffering for patients and their families, and usually result in longer hospital stays.  The cost to the health system is also significant. 

Infection prevention and control practices play a key role in reducing antibiotic resistance in hospitals. Standard precautions for infection prevention and control should be included in every hospital program and should include:

• hand hygiene 
• the use of personal protective equipment 
• the safe use and disposal of sharps
• reprocessing of reusable medical equipment and instruments 
• routine environmental cleaning 
• respiratory hygiene and cough etiquette 
• aseptic non-touch technique
• effective waste management
• appropriate handling of linen
• vaccination. 

Infection prevention and control guidelines

The Australian Guidelines for the Prevention and Control of Infection in Healthcare (the guidelines) describe the best way to prevent and reduce infections occurring in healthcare settings including resistant infections. The guidelines include how to manage common infectious agents, for example, gastrointestinal viruses and evolving infectious agents, for example influenza or multi-drug resistant organisms.

The guidelines contain recommendations for:

• the key design features for isolation units to minimise infection transmission
• effective work practices to assist healthcare workers, including:
  • standard and transmission-based precautions
  • basic management of multi-drug resistant organisms
  • organisational support
  • workplace health and safety.

The guidelines are an important resource to support the National Quality and Health Service Standard: Preventing and Controlling Infections.

National Safety and Quality Health Service (NSQHS) Standard 3

The NSQHS Standard 3: Preventing and Controlling Healthcare-Associated Infections aims to minimise the risk of patients acquiring a healthcare-associated infection. 

Standard 3 describes the systems and strategies to prevent infection and to manage infections effectively when they occur. They also explain how to prevent and contain antimicrobial resistance through the development and implementation of effective antimicrobial stewardship programs.

Guidelines for multi-drug resistant organisms

Several governments and organisations have developed specific infection prevention and control guidelines for multi-drug resistant organisms. 

The Australian Commission on Safety and Quality in Health Care has updated the national guidelines Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE): A guide for acute care health facilities in May 2017. The Commission also developed information sheets on CPE for clinicians and patients.

The Victorian Department of Health and Human Services has developed CPE management guidelines and a suite of information sheets to assist clinicians, patients and visitors in health services. These aim to prevent infections and control the spread of CPE. 

The National Health and Medical Research Council, in collaboration with the Australian Commission on Safety and Quality in Health Care has developed fact sheets on healthcare-associated infections from:

• Methicillin-resistant Staphylococcus aureus (MRSA)
• Vancomycin resistant Enterococcus (VRE)
• Clostridium difficile.

Hand hygiene

Healthcare workers' effective hand hygiene is the single most important strategy to prevent healthcare-associated infections. 

The National Hand Hygiene Initiative (NHHI) was established in 2008 by the Australian Commission on Safety and Quality in Health Care as part of a suite of initiatives to prevent and reduce healthcare-associated infections in Australian healthcare settings.

The NHHI provides education, audit and feedback to clinicians and hospital executives. Its aim is to protect patients, the health workforce and the community from the spread of infection. Further information and resources about hand hygiene are available from the Australian Commission on Safety and Quality in Health Care. 

Horizontal and vertical infection control strategies have their pros and cons. While horizontal strategies are generally favored, vertical interventions are useful in certain situations. The choice of infection control strategies should be informed by local epidemiology.

Active surveillance and testing (AST)

• In most non-outbreak settings, the costs associated with AST outweigh their benefits. This includes direct costs as well as opportunity costs (in terms of personnel and financial resources).
• In outbreak settings AST can be useful in controlling the spread of organisms such as MRSA and CRE9,10.

Hand Hygiene

• Hand hygiene is the most important of infection prevention strategies. This involves minimizing the spread of microorganisms between patients via the contaminated hands of healthcare workers. Hand hygiene may be implemented in conjunction with other strategies as part of a bundle11.
• The World Health Organization recommends five moments of hand hygiene: before contact with patients, before performing aseptic procedures, after exposure to body fluids, following contact with patients and contact with patient surroundings (Figure 14.1)12.

Universal Decolonization

• CHG is the most commonly used agent for decolonization. CHG bathing may be limited to high acuity areas such as ICUs or implemented hospital-wide.
• Hospitals should formulate guidelines and bathing protocols and these should be made available to hospital staff. Compliance with CHG bathing should be monitored periodically. CHG resistance should be considered but testing is not routinely recommended7.

Antibiotic Stewardship

• According to a CDC estimate, 30-50% of antibiotics prescribed in the United States are unnecessary. Antibiotic stewardship programs (ASPs) can help reduce antibiotic exposure, lower rates of Clostridium difficile infections and minimize healthcare costs13. Most antimicrobial stewardship activities effect multiple organisms simultaneously and have as a primary goal the prevention of the emergence of antibiotic resistance. Thus, ASPs can largely be viewed in the context of horizontal infection prevention. Additionally, ASPs can contribute to the prevention of surgical site infections via the optimized use of surgical antibiotic prophylaxis.

Environmental Cleaning

• Surfaces of bedrails, nurse call buttons, television remote controls, and medical equipment may harbor organisms such as MRSA, VRE, difficile, Acinetobacter species, Pseudomonas aeruginosa, and norovirus, amongst others10.
• Staff who perform environmental cleaning should be dedicated to specific units to reduce the risk for cross-contamination. Thorough cleaning of commonly contaminated surfaces such as bedrails, bedside charts, medical equipment, and door knobs is recommended10.
• Units should be frequently monitored to ensure compliance with environmental cleaning practices.

SUGGESTED PRACTICE IN UNDER-RESOURCED SETTINGS

Infection control strategies in under-resourced areas are often limited by access to human, technologic, and financial resources. Many under-resourced areas lack infection prevention infrastructure and guidelines on optimized infection prevention practices are often not available to hospital staff members. As a result, infection surveillance is often not performed consistently, perioperative prophylactic antibiotics are often not optimally administered, and hand hygiene is suboptimal, as well14.

• Infection control programs should be created and guidelines formulated. Guidelines should be made available to hospital staff members to help ensure consistency in practices.
• Educational programs should be designed to familiarize hospital staff with infection prevention guidelines.
• Infection prevention programs should collaborate with microbiology labs to find economical means for performing surveillance and other related tests.
• ASPs should be established to promote the judicious use of antibiotics.
• Adherence to measures such as hand hygiene, perioperative antibiotic administration, and the disinfection of equipment and patient care areas should be promoted. Local epidemiology and antibiograms should inform practices at individual centers.
• Periodic assessments should be informed to ensure compliance with guidelines.

SUMMARY

Infection control strategies designed to prevent the spread of healthcare-associated infections can be grouped into two categories: vertical and horizontal. Vertical strategies focus on a single organism while horizontal strategies aim to control the spread of multiple organisms simultaneously. Horizontal strategies include hand hygiene, universal decolonization, selective digestive tract decolonization, antimicrobial stewardship, and environmental cleaning. Horizontal and vertical infection prevention strategies have their pros and cons. While horizontal strategies are generally favored, vertical interventions are useful in certain situations. The choice of infection control strategies should be informed by local epidemiology.

What is the single most important way to prevent the spread of infection?

What is the most effective strategy for controlling the spread of infection?