Target Goals for the Reduction of Healthcare-Associated Infections: Ambitious But Achievable
In October 2016, the U.S. Department of Health and Human Services (HHS) announced new targets using data from calendar year 2015 as a new reference point for the national acute care hospital metrics for the National Action Plan to Prevent Healthcare-Associated Infections (HAIs).
These metrics address the following goals:
- Reduce central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) in intensive care and ward-located patients
- Reduce the incidence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections
- Reduce facility-onset MRSA and Clostridium difficile infections (CDI)
- Reduce CDI and surgical site infection (SSI) hospitalizations
- Improve adherence to process measures to prevent SSI
[The data source for the infection metrics is the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC) and for hospitalizations, the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP).]
Progress toward the original targets, which were established in 2013, revealed that the CLABSI target was met (50% reduction), no change in CAUTIs with a 25% reduction target, suboptimal reductions of the MRSA, CDI and SSI metrics and an 18% increase in CDI hospitalizations. The 2016 targets were more aggressive for facility-onset MRSA (25% to 50% reduction) and SSI (25% to 30% reduction).1
In order to bridge understanding of the transition to a new baseline, CDC recently published a high-level assessment of 2006-2016 data to detail the progress made toward these HAI reduction targets and next steps toward further prevention of HAIs.2
Highlights from the CDC Progress Report
- Despite a 51% reduction in the CLABSI standardized infection ratio (SIR) from the 2006-2008 baseline, a leveling off in the magnitude of decline from 2012-14 was observed. This was more pronounced on the wards, to which the majority of CLABSI reported to NHSN were attributed in 2015.
- “There is a needto expand prevention through improved maintenance of central lines.” Resources provided emphasize the need for improved blood culture collection and disinfection of catheter hubs before each access into a central line – scrubbing the hub.3
- Applying the more clinically-relevant CAUTI definition that no longer includes yeast (as of 2015) retrospectively, there have been consistent year-to-year declines in CAUTIs in both ICUs and wards from 2012 through 2016.
- In addition to reducing unnecessary urinary catheter usage in ICUs and on the wards, prevention efforts need to include an emphasis on meticulous catheter care and accurate CAUTI diagnosis.
- The Surgical Care Improvement Project (SCIP) SIR, which includes cardiac, vascular, hysterectomy, colon and knee and hip arthoplasty procedures, revealed an initial decline from 2008 and 2011, but was level through 2014.
- A 2015 HAI prevalence survey comparing data to a similar survey conducted by CDC and the Emerging Infections Programin 2011 found a lower proportion of patients had surgical site (SSI) and/or urinary tract infections (UTI) in 2015 (77/8833, 0.9%) vs. 2011 (136/8954, 1.5%) P<0.001 suggesting that national efforts are succeeding.4
- “Further SSI declines will require collaborative efforts with the surgical community to develop innovative prevention strategies aimed at specific procedures.”5
- A slow continuous decline in the unadjusted NHSN crude rate of hospital-onset MRSA bacteremia (the outcome represented by the SIR) was observed from 2012 through 2016, ranging from 0.61 cases per 10,000 patient days to 0.55 cases per 10,000 patient days, with no increase in 2015.
- Much of the progress in preventing MRSA bacteremia reflects progress in preventing insertion-related CLABSIs.
- Little to no decline in community-associated MRSA bacteremia has been observed. A comprehensive, multidisciplinary community-based public health approach to prevention is needed.
- Due to the transmissible nature of MRSA, new strategies are needed to prevent non-CLABSI related MRSA bacteremia.6
- The NHSN CDI SIR, which takes into account the sensitivity of different diagnostic test types, suggests slow progress in preventing hospital-onset CDI.The 8% decline observed from 2015 to 2016 needs to remain steady or increase in order to meet the HHS 2020 target goal.
- Community-associated CDI is not decreasing at the same rate as inpatient healthcare-associated CDI.
- The transmissible nature of CD underscores the need for a multi-faceted approach to prevention through accurate and prompt diagnosis, prompt initiation of patient isolation with meticulous attention to hand hygiene and environmental hygiene practices and antimicrobial stewardship.7
Despite the progress that this report illustrates, the 2020 HAI reduction targets for CAUTI, SSI and CDI may fall short.
This report is a call to action for prevention strategies that address the barriers to implementation of best practices and the use/development of products and technologies that facilitate those best practices.
These best practices include:
- To meet the need to expand CLABSI prevention with improved central line maintenance, investigators have found that a 5-second scrub for disinfection of needleless connectors with chlorhexidine gluconate/alcohol (CHG/ALC) was superior to 70% alcohol alone and alcohol-impregnated caps8.
- Further, the use of CHG/ALC for skin antisepsis prior to blood culture collection has been shown to reduce blood culture contamination rates9 and in a recent survey of blood culture practices, 74% of respondents are using CHG/ALC for blood culture collection skin preparation.10
- The immediate and sustained bactericidal activity of CHG/ALC makes it an attractive option for disinfection of the urinary catheter sampling port to reduce culture contamination and improve the accuracy of CAUTI diagnosis.
- With respect to SSI and MRSA bacteremia reduction, decolonization protocols are gaining popularity. The goal of decolonization is to lower the microbial bio-burden on patient body sites to reduce 1) the risk that endogenous colonization will lead to infection when host defenses are altered e.g. surgery, insertion of invasive devices and 2) the risk of exogenous colonization from other patients and/or the environment e.g. poor hand hygiene practices by healthcare workers, contaminated equipment.
- Historically, Mupirocin® has been the gold standard for nasal decolonization; however, concern about antibiotic resistance from selective ‘pressure’ and reports of treatment failures with increasing widespread use of Mupirocin® has led to the use of antiseptics as alternative decolonization agents. One such alternative, povidone-iodine, is gaining popularity due to its efficacy in eradicating S. aureus (a leading pathogen of SSIs), safety, patient satisfaction and cost.
- This contribution to antimicrobial stewardship efforts may aid in the prevention of CDI, along with hand hygiene, isolation, and meticulous environmental cleaning practices.
4 Magill S et al. Reduction in the Prevalence of Healthcare-Associated Infections in US Acute Care Hospitals: 2015 vs. 2011. Abstract 1768. ID Week 2017 San Diego, CA.
8 Flynn JM, Rickard CM, Keogh S, Zhang L. Alcohol Caps or Alcohol Swabs With and Without Chlorhexidine: An In Vitro Study of 648 Episodes of Intravenous Device Needleless Connector Decontamination. Infect Control Hosp Epidemiol 2017; 38(5):617-18.
9 Marlowe L, Mistry R, Coffin S, et al. Blood Culture Contamination Rates After Skin Antisepsis with Chlorhexidine Gluconate versus Povidone-Iodine in a Pediatric Emergency Department. Infect Control Hosp Epidemiol 2010; 31:171-176.
10 Garcia RA, Spitzer ED, Kranz B, Barnes S. A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. Am J Infect Control 2017. https://doi.org/10.1016/j.ajic2017.11.009