Healthcare-Associated Infections _ ______________________________________________________________
Among the national initiatives to reduce the number of HAIs was a move by the Centers for Medicare and Medicaid Services (CMS) to suspend reimbursement of hospital costs related to HAIs it considers “reasonably preventable:” catheter-related urinary tract infection, central line-associated bloodstream infection, and some surgical site infections [11; 12]. However, studies have shown that this policy has not been a contributor to any decrease in the rate of HAIs, and a survey indicated that adherence to only some prevention strategies has increased as a result of the policy [63; 64]. The policy also has the potential to lead to increased unnecessary use of antimicrobials in an effort to prevent infections [65]. In contrast, educating healthcare personnel helps to reduce HAIs, with a systematic review showing a statistically significant decrease in infection rates after an educational intervention in 21 of 26 studies [66]. Education is one of the key elements found to be necessary for a successful HAI prevention program. When such programs at 33 diverse hospitals were evaluated, the following were found to be essential for success [67]: • Educate and re-educate providers, patients, and families • Foster change by first understanding resistance • Engage frontline staff by involving them in the program and enlisting champions • Commit to regular strategic communication and join a collaborative • Start small and tailor implementation to local needs and cultures • Convince administration to provide leadership, funds, and dedicated staff and assign accountability • Provide timely, relevant feedback and celebrate successes Accurate data collection is crucial for understanding trends and the burden of HAIs and for identifying emerging infectious threats. The Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the Society for Healthcare Epidemiol- ogy of America (SHEA) have led efforts to establish uniform standards for surveillance of HAIs and standardized systems for collecting and reporting. The CDC’s National Healthcare Safety Network (NHSN), the nation’s most widely used HAI surveillance system, is a shared resource for HAI prevention. More than 25,000 hospitals and other healthcare facilities provide data to NHSN, which in turn is used for national- and state-level analyses, including for periodic HAI reports and for targeted prevention initiatives by healthcare facilities, states, regions, quality groups, and national public health agencies, including the CDC [17; 68].
In response to a call for mandatory reporting of HAIs, several states passed legislation requiring the mandatory reporting of specific HAIs, and reporting requirements vary by state. As of August 2024, the CDC provides technical expertise and funding to HAI/AR programs in 64 state, local, and territorial health departments [3; 69].
MICROBIAL PATHOGENESIS AND DEVELOPMENT OF DRUG RESISTANCE
A comprehensive description of the pathogenesis of infection is beyond the scope of this course. However, a broad overview of pathogen-host interaction will aid in the understanding of how infection develops in the healthcare setting. In addition, a discussion of the development of antibiotic resistance is war- ranted because of the substantial impact of resistant pathogens on the management of HAIs. A healthy human body has several defenses against infection: the skin and mucous membranes form natural barriers to infection, and immune responses (nonspecific and specific) are activated to resist micro-organisms that are able to invade. The skin can effectively protect the body from most micro-organisms unless there is physical disruption. For example, the human papillomavirus can invade the skin, and some parasites can penetrate intact skin, but bacteria and fungi cannot [70]. Other disruptors of the natural barrier are lesions, injury, or, in the healthcare setting, invasive procedures or devices. In addition to breaks in the skin, other primary entry points for micro-organisms are mucosal surfaces, such as the respira- tory, gastrointestinal, and genitourinary tracts. The membranes lining these tracts comprise a major internal barrier to micro- organisms due to the antimicrobial properties of their secre- tions. The respiratory tract filters inhaled micro-organisms, and mucociliary epithelium in the tracheobronchial tree moves them out of the lung. In the gastrointestinal tract, gastric acid, pancreatic enzymes, bile, and intestinal secretions destroy harmful micro-organisms. Nonpathogenic bacteria (commensal bacteria) make up the normal flora in the gastrointestinal tract and act as protectants against invading pathogenic bacteria. Commensal bacteria are a source of infection only if they are transmitted to another part of the body or if they are altered by the use of antibiotics [18]. The transmission of infection follows the cycle that has been described for all diseases, and humans are at the center of this cycle [18]. In brief, a micro-organism requires a reservoir (a human, soil, air, or water), or a host, in which to live. The micro-organism also needs an environment that supports its survival once it exits the host and a method of transmission. Inherent properties allow micro-organisms to remain viable during transmission from a reservoir to a susceptible host, another essential factor for transmission of infection. The
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