Keeping Nosocomial Infections at Bay
Handwashing, switch to closed infusion cited as effective ways
Nosocomial infections are a serious public-health problem in many developing countries. According to Dr. Victor Rosenthal, an expert on hospital-infection control in Latin America, high rates of nosocomial infections in intensive-care units (ICUs) are associated with longer hospitalization, higher health-care costs, and increased mortality.
Speaking at a recent conference organized by Baxter Philippines, Rosenthal detailed the most important issues surrounding hospital-acquired infections and their control. Rosenthal chairs the infectious disease and infection control department at Vernal Medical Center in Buenos Aires, Argentina.
According to Rosenthal, urinary-tract infections (UTI), pneumonia, phlebitis, bloodstream infections (BSI) and surgical-site infections (SSI) are the most frequent nosocomial infections. The most important risk factors are the urinary catheter for UTI, mechanical ventilator for pneumonia, peripheral intravenous catheter for phlebitis, central venous catheter for BSI and the surgery itself for SSI.
Determining nosocomial-infection rates is not simple. "We know that the most important risk factor for nosocomial infection is the [use] of invasive devices in patients," stressed Rosenthal. "Reasonably, we expect to have higher nosocomial rates among the medical/surgical ICUs, which use more mechanical ventilators and central catheters. [But comparing them by [means of] percentages alone [is not sufficient]."
A better measure is the Nosocomial Infections Incidence Density used by Emori et al. in 1991 for the US-CDC's National Nosocomial Infections Surveillance system report, in which the number of each infection is expressed per 1,000 days use of the invasive device.
HIGH COSTS, LONGER HOSPITAL STAY
Rosenthal and his colleagues performed prospective surveillance of nosocomial-infection-related mortality and length of stay for ICU patients in Argentina. The study found high rates of nosocomial infections in ICUs (27 percent; 90/1,000 patient days), associated with considerable attributable mortality (five to 35 percent), and excess length of stay (five to 12 days).
Among the other countries surveyed, the pooled mean for nosocomial infections would cost US$11,000 and 10 days of additional hospital stay in Mexico, US$1,500 and 20 days in Turkey. Mortality rates are also unacceptably high. Brazil registers a 48.7-percent crude death rate from nosocomial infections; Mexico, 21.7 to 25.5 percent; and Spain, 42 percent.
Rosenthal said that nosocomial infection rates can be significantly reduced by implementing a strict hand-washing compliance program. In two years, nosocomial-infection rates in Argentine hospitals decreased by more than 20 percent after such a program was initiated.
CLOSED V. OPEN
The impact of the switch to closed infusion, nonvented, collapsible systems from the previous externally vented, semirigid, noncollapsible single-port fluid containers has also been the subject of investigation.
Said Rosenthal: "The open system allows the entrance of fresh air particles, which enters the infusion. If these particles have bacteria, you will have blood infection." In a prospective controlled cohort trial, Rosenthal and Maki (Am J Infect Control, 2003) found major reductions in the incidence of catheter-associated bacteremia (2.36 vs. 6.52 per 1,000 catheter-days) in closed systems. There was a 64-percent reduction in gram-negative bacilli infection. The mortality rate was also significantly lower at 0.2 percent with closed systems vis-a-vis 2.8 percent for open systems.
The adoption of a closed intavenous infusion system is also known to reduce bacteremia, mortality, hospital stays, and resistance to bacterial contamination as shown in a prospective study by Rangel-Fausto et al. in Mexico. It showed that within 1,000 central-vein-catheter days, adopting a closed infusion system could lower bacteremia by as much as 82 percent.
"With basic interventions like handwashing we could reduce the most common nosocomial infections," said Rosenthal. "Education is very important in changing the behavior of people. But education may not be enough. [Appropriate] devices and materials are important defenses. Even a simple shift from the open infusion systems to the closed will reduce you 30 percent of the blood infection rates. The use of more effective infection control strategies, in fact, reduces the cost of health care. In this regard, a cost-effective product like Viaflex, which prevents entry of air, plays a major preventative role."
Roger Badillo II, MD
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