Infected hospitals: Healthcare associated infections on the rise

In 2009, a Hepatitis B epidemic occurred in Modasa, northern Gujarat. The virus outbreak was found to be caused by the reuse of contaminated needles. Over 125 people were infected and up to 49 people died. While the case throws light on extreme impacts of healthcare associated infections (HAI), we often gloss over the ongoing risk of infections occurring in hospitals routinely.

A patient recounted to me that his mother was once admitted for a fracture repair of a bone in her leg. She was successfully operated on and was discharged promptly. Three days later, she developed a fever and burning sensation while urinating. She was diagnosed with a urinary tract infection, which she got during catheterisation during and immediately after the surgery in hospital. While my patient and his mother suffered from increased suffering and additional costs, consequences of hospital acqui-red infections are not limited to these. Results of these infections could be extremely grave and fatal, too.

What are healthcare associated infections (HAI)?
HAI are infections which develop in patients after admission at a healthcare facility or those acquired in hospital but appear after discharge. However, HAI doesn’t include infections that were developing, prior to the time of admission. These infections come at an elevated cost to patients, their families and healthcare institutions. HAIs not only prolong hospital stays, but cause long-term disabilities for patients, create resistant streams of bacteria in hospital environments and lead to preventable deaths in some cases.

They are a massive financial burden to families and healthcare systems. In USA, approximately 99,000 deaths every year can be attributed to such infections. In India, exact figures are unknown due to a scarcity of reliable data, but are more likely to be higher. WHO figures show HAIs in Europe cause increased healthcare costs to the tune of a whopping $8 billion. In the United States, these costs increase dramatically to $ 16.5 billion. In low- and middle-income countries there are no definite estimates, due to more scattered populations and haphazard or low data collection programmes. That said, in Mexican ICUs, a single healthcare infection resulted in loss of $12,555 in revenues, while in Argentina these episodes create an expense of around $5,000 each.

Some common Healthcare Associated Infections
In modern healthcare, many procedures require the use of invasive devices and antibiotics to control infections. Common infections among hospitalised patients, especially in ICUs, include bloodstream infections due to central intravenous lines, urinary infections due to catheters, diarrhoea due to the prolonged use of antibiotics, and pneumonia while on ventilators. ICUs are the most common locations to develop HAIs. If we look at a breakdown of HAIs by countries; developed countries have 7 in 100 patients who suffer from these infections; while developing countries unfortunately boast double that figure.

These HAIs are a result of prolonged and sometimes inappropriate use of invasive devices, people whose self-defence mechanisms are weak (conditions like diabetes, renal failure, HIV and immunosuppressive treatment), high-risk and sophisticated procedures, and inadequate or improper isolation practices. Hospitals further increase the risk of HAIs by overcrowding, poor hygiene practices, improper waste disposal, insufficient equipment, understaffing, and poor understanding of infection control measures.

HAI in developing countries and India
India, along with other developing countries, faces unique problems that are uncommon in the developed world. Poor personal hygiene, both in patients and healthcare workers, poor sanitation facilities, overdependence on antibiotics, limited clinical and laboratory testing facilities and poor infection control have led to the emergence of multidrug resistant infections.

Although high-quality data is scarce, available data shows prevalence of such infections in developing countries, including India, to be around 15 per 100 patients. This is more than double the rate that is found in developed countries. However, things are slowly, but surely changing.

Over the past several years, some large private and government hospitals have participated in understanding and estimating the prevalence and spread of these infections to gain greater insight on this highly problematic issue and eventually help in the preparation of improved healthcare policies. As a country, we recognise the need for policy and guidance documents to prevent such infections and implement control measures. In fact, in 2016, Indian Council for Medical Research issued guidelines for such infection control.

In addition, autonomous bodies like National Accreditation Board of Hospitals include HAI surveillance and prevention as a core part of their certification and review process. We still need to combat problems including poor resources, poor nurse to patient ratios, and inadequate training among doctors and nurses regarding the importance of nosocomial (hospital acqui-red) infection control.

What we can do
Some of the methods that healthcare facilities can incorporate to help prevent HAIs:

• Monitoring patient safety actively and reporting any infections.
• Improved training and independent monitoring of healthcare workers in common standardised procedures like the placement of intravenous or urinary catheters, surgical site wound management and ventilator handling
• Increasing resources like administrative staff and laboratory facilities for monitoring and control of infections.
• Increasing opportunity for training healthcare workers regarding implementation of infection control measures.
• Awareness programmes about problems of infections in hospitals and benefits of following the preventive methods for hospital visitors and general public.

Some of the methods that patients themselves can actively follow, to help prevent HAIs, include:

• Be informed. Whenever you or your loved one is hospitalised there is always a possibility of infections. The best thing you can do as an informed patient is to ask your doctor about the measures the hospital is taking to keep you safe.
• Request all healthcare workers to wash hands before touching you. Ask your doctor about the possible infections and their symptoms that can develop in your case.
• If you notice any symptoms, IMMEDIATELY bring it to the notice of your doctor, so that it can be treated in the early stages.
• Restrict unnecessary visitors — lesser the people, lesser the germs.
• Follow strict hygienic measures.

(The author, a DM from Seth GS Medical College and KEM Hospital, Mumbai in 1995, is currently Chief Gastroen-terologist and Head of Institute of Gastrosciences, Apollo BGS Hospitals, Myso-re. Invited speaker and faculty at major medical conferences and workshops, nationally and internationally)