Report slams poor infection control

Patient advocate Betsy McCaughey gives hospitals and government a failing grade on infection control. As founder and chairman of the Committee to Reduce Infection Deaths, or RID, she calls infection control in most American hospitals "shoddy."

"We have the knowledge to prevent these infections," McCaughey said. "What's lacking is the will. Hospital administrators have not made infection prevention a top priority, and the public has not demanded it." The RID report is available at http://www.hospitalinfection.org/ridbooklet.pdf.

CDC warns that more than 70% of organisms involved in nosocomial infections are resistant to at least one commonly used antibiotic. By some estimates, nosocomial infections cost hospitals $30 billion annually in longer stays, more expensive drug regimens, and readmissions.

The two biggest problem areas are methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE), Muto said.

"CDC has endorsed precautions that focus on hand hygiene," McCaughey said. "You can do better by testing patients for resistant bacteria before they are admitted. That is routine in Denmark, Finland, Holland, and other countries that have virtually eliminated drug-resistant infections in their hospitals."

Kevin Garey, Pharm.D., infectious disease pharmacist and assistant professor at the University of Houston College of Pharmacy, agreed. The return on investment in active surveillance, isolation, and contamination barrier controls is about 10 to 1, he said. But few American institutions are willing to invest the money, personnel, and leadership needed to slash MRSA rates.

Active surveillance cultures are a key recommendation in infection control guidelines published in 2003 by the Society for Healthcare Epidemiology of America (SHEA). Other measures include isolation of patients with resistant strains, strict barrier precautions similar to those used for SARS and avian influenza, hand hygiene, and proper antimicrobial use. Following the SHEA recommendations has nearly eliminated VRE in-house, Muto said. The incidence of MRSA in the intensive care unit is down by 90%.

Muto, lead author of SHEA's infection control guidelines, said, "SHEA took an aggressive position on active surveillance cultures and barrier protection. I'm willing to believe other methods can work, but I have seen that anything less is less effective."

Most hospitals try to follow CDC's hand hygiene recommendations. The Joint Commission on Accreditation of Healthcare Organizations also advocates hand hygiene to slow the spread of infection in hospitals. Hand cleaning before and after each patient contact is vital, Muto said, but it is not enough. The same goes for appropriate antimicrobial use: It is a necessary step, but not enough. "The goal must be to identify the reservoirs for infection and isolate them," she said. And the main reservoir is that cohort of colonized patients who would go unrecognized without active surveillance."

SHEA advocates performing surveillance cultures for antimicrobial susceptibility on admission for all patients at risk for carrying MRSA or VRE. That could mean culturing every patient admitted.

Barry Farr, M.D., professor of internal medicine at the University of Virginia, saw MRSA rates skyrocket in 1990. Active surveillance had controlled an outbreak a decade earlier, but the hospital let down its guard.