Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?
Purpose of Review
To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes.
HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes.
Perhaps up to 55–70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.
KeywordsInfection prevention Patient safety Implementation science Hospital epidemiology Public health Healthcare quality
Authors would like to recognize Ms. Tina Olkonen for her assistance with preparing the final manuscript.
Compliance with Ethical Standards
Conflict of Interest
Gonzalo Bearman, Michelle Doll, Kaila Cooper, and Michael Stevens declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.•• Leapfrog Group. Healthcare associated infections. In: reports on hospital performance: 2018 report series. Available at: http://www.leapfroggroup.org/sites/default/files/Files/Leapfrog-Castlight%202018%20HAI%20Report.pdf. Accessed November 1st 2018. Up to date assessment of HAI prevention performance.
- 15.•• Edmond MB, Bearman G, Masroor N, Steven M, Ober J. The impact of discontinuing contact precautions for VRE and MRSA on device-associated infections. Infect Control Hosp Epidemiol. 2015;36:978–80 Important publication on the controversy of discontinuing contact precautions for endemic pathogens: MRSA and VRE.CrossRefGoogle Scholar
- 16.•• Martin EM, Russell D, Rubin Z, Humphries R, Grogan TR, Elashoff D, et al. Elimination of routine contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: a retrospective quasi-experimental study. Infect Control Hosp Epidemiol. 2016;37:1323–30 Important publication on the controversy of discontinuing contact precautions for endemic pathogens: MRSA and VRE.CrossRefGoogle Scholar
- 17.•• Bearman G, Abbas S, Masroor N, et al. Impact of discontinuing contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: an interrupted time series analysis. Infect Control Hosp Epidemiol. 2018;39:676–82 First interrupted time series analysis published on discontinuing contact precautions for endemic pathogens: MRSA and VRE.CrossRefGoogle Scholar
- 18.• Morgan DJ, Bearman G, Murthy R, et al. Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol. 2015;36:1163–72 Important summary of contact precautions controversy and evidence.CrossRefGoogle Scholar
- 20.•• Madden GR, Weinstein RA, Sifri CD. Diagnostic stewardship for healthcare-associated infections: opportunities and challenges to safely reduce test use. Infect Control Hosp Epidemiol. 2018;39:214–8 Important paper that highlights the evolving role of diagnostic stewardship in infection prevention.CrossRefGoogle Scholar
- 23.•• Leekha S, Preas MA, Hebden J. Association of national healthcare safety network--defined catheter-associated urinary tract infections with alternate sources of fever. Infect Control Hosp Epidemiol. 2015;36:1236–8 Paper highlights the potential inaccuracies of national surveillance definitions.CrossRefGoogle Scholar
- 27.• Mullin KM, Kovacs KS, Fatica C, et al. A multifaceted approach to reduction of catheter-associated urinary tract infections in the intensive care unit with an emphasis on “stewardship of culturing”. Infect Control Hosp Epidemiol. 2017;38:186–8 Paper highlights diagnostic stewardship to reduce catheter associated urinary tract infections.CrossRefGoogle Scholar
- 28.Ives, Crystal, Human beings as chaotic systems. http://www.fractal.org/Life-Science-Technology/Publications/Human-beings-as-fractal-systems.pdf . Accessed 10.23.18.
- 34.•• Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP, Swissnoso. The preventable proportion of healthcare-associated infections 2005–2016: systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2018;39:1277–95 Most up-to-date assessment of proportion of preventable healthcare-associated infections.CrossRefGoogle Scholar
- 35.The Sveriges Riksbank prize in economic sciences in memory of Alfred Nobel 1978. NobelPrize.org. https://www.nobelprize.org/prizes/economics/1978/press-release/. Accessed October 27, 2018.
- 37.• Dellinger EP. Prevention of hospital-acquired infections. Surg Infect. 2016:17422–6 Publication defines and distinguishes potentially preventable vs apparently unpreventable HAIs.Google Scholar
- 38.McChesney C, Covey S, Huling J. The 4 disciplines of execution: achieving your wildly important goals. New York: Free Press; 2012.Google Scholar