Infection Control Measures are Reducing Serious Infection

In recent years, there has been a concerted effort in Australia and internationally to decrease the incidence of healthcare associated infections (HAIs). One specific HAI, Staphylococcus aureus bacteraemia (SAB) has been a particular focus to governments in Australia and overseas. In part, this may be due to this infection being considered largely preventable in the context of healthcare provision, writes Dr Brett Mitchell.
Staphylococcus aureus, the pathogen responsible for SAB is a pathogen of significance, due to its ability to adhere, invade and develop antimicrobial resistance. Worldwide, SAB is a serious cause of morbidity and mortality, with associated mortality rates of 20% to 50% [1, 2]. This infection also has significant associated economic burden [3].
Measures to reduce SAB and HAIs more generally, have been established in numerous countries. In Australia, the Australian Commission on Safety and Quality in Health Care (ACSQHC) has a national program specific to HAI prevention. These measures include the development of national infection control guidelines, a national hand hygiene initiative, surveillance of specific organisms – including SAB and education. Surveillance of SAB in a nationally consistent manner was possible, following work from the ACSQHC and agreement by state and territory health ministers in 2008.  The SAB surveillance program has continued to evolve and today, individual hospital rates of healthcare associated SAB can be found on the MyHospitals website. However, caution regarding the reliability and usefulness of such public reporting has been called for. In a recent study published in JAMA Internal Medicine, hospital leaders in the United States were asked about hospital quality measures found on a public website. These leaders indicate the measure reported (such as SAB) exert strong influence over local planning and improvement efforts. They did however, express concerns about the clinical meaningfulness, unintended consequences, and methods of public reporting [4].
Nonetheless, the approach to reduce healthcare associated SAB in Australia appears to be working. A Victorian study examined the burden of SAB and trend over a three year period [5].  The authors found that continuous surveillance for SAB infection showed a significant reduction in rates across Victoria during the first three years of a coordinated program. The authors also suggest that early onset, device-related SAB infections are an important target for prevention strategies. This call to focus on the insertion and management intravascular devices is a key element of SAB prevention.
Other measures undertaken in Australia to reduce the burden of SAB have included hand hygiene initiatives [6-8]. An evaluation of the national hand hygiene initiative is drawing to a close, with several publications looking at different aspects of the initiative [9, 10]. Further, an article in Healthcare Infection, the official peer review journal of the Australasian College of Infection Prevention and Control will soon be published. This article explores the changes in healthcare associated infections after the introduction of a national hand hygiene initiative.
To understand where Australia has come from, progress to date and comparisons internationally, a study recently published in Clinical Infectious Disease explored the incidence of hospital onset SAB over an 11 year period [11].  During this period, the authors report a 63% decrease in hospital-onset SAB, with significant reduction in sensitive and resistant strains. The authors suggest that this major and significant reduction in incidence of hospital onset coincided with a range of infection prevention and control activities implemented during this time.  Further they suggest that national and local efforts to reduce the burden of healthcare associated infections have been very successful. The study suggests Australia compares well internationally and is unique in that reduction in both sensitive and resistance strains of SAB have been reduced – arguably a world first.
Despite conjecture and debate regarding individual approaches to healthcare associated infection prevention in Australia, what is clear is that current approach is working in the context of reducing a notable healthcare associated infection – SAB.

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About The Author

Dr Brett Mitchell is an honorary fellow at Australian Catholic University (School of Nursing and Midwifery) and is a senior lecturer at Avondale College (Faculty of Nursing and Health). He is the Editor-in-Chief of Healthcare Infection and is actively engaged with national strategies to reduce healthcare associated infections and antimicrobial resistance through work with the Australian Commission on Safety and Quality in Health Care. Dr Mitchell is an active researcher in infection control and undertakes consultancy work. He has worked in Australia and internationally in nursing, infection control positions and consultancy work.

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About ACIPC

The College is the peak body for Infection Prevention and Control professionals in the Australasian region. The College commenced in January 2012 and brings together the various State and Territory infection control associations formerly in AICA (The Australian Infection Control Association) to support and encourage collaboration across Australasia, using a corporate model.

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References

1. Wyllie DH, Crook DW, Peto TEA: Mortality after Staphylococcus aureus bacteraemia in two hospitals in Oxfordshire, 1997-2003: cohort study [corrected] [published erratum appears in BMJ 2006 Sep 2;333(7566):468]. Br Med J 2006, 333(7562):281-284.
2. Turnidge J, Kotsanas, D., Munckhof, W., Roberts, S., Bennett, C., Nimmo, G., Coombs, G., Murray, R., Howden, B., Johnson, P., Dowling, K., Australia New Zealand Cooperative on Outcomes in Staphylococcal Sepsis.: Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand. Med J Aust 2009, 191(7):368-373.
3. de Kraker ME, Davey PG, Grundmann H: Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: estimating the burden of antibiotic resistance in Europe. PLoS Med 2011, 8(10):e1001104.
4. Lindenauer PK, Lagu T, Ross JS, et al.: Attitudes of hospital leaders toward publicly reported measures of health care quality. JAMA Internal Medicine 2014.
5. Worth LJ, Spelman, T., Bull, A., Richards, M.: Staphylococcus aureus bloodstream infection in Australian hospitals: findings from a Victorian surveillance system. Med J Aust 2014, 200:282–284.
6. Grayson L, Russo, R., Cruickshank, M., Bear, J., Gee, C., Hughes, C., Johnson, P., McCann, R.,
McMillan, A., Mitchell, B., Selvey, C., Smith, R., Wilkinson, I.: Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative. Med J Aust 2011, 195(10).
7. Grayson ML, Jarvie LJ, Martin R, Johnson PDR, Jodoin ME, McMullan C, Gregory RHC, Bellis K, Cunnington K, Wilson FL et al: Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust 2008, 188(11):633-640.
8. Russo P, Pittet D, Grayson L: Australia: a leader in hand hygiene. Healthc Infect 2012, 17(1):1-2.
9. Page K, Barnett AG, Campbell M, Brain D, Martin E, Fulop N, Graves N: Costing the Australian National Hand Hygiene Initiative. J Hosp Infect (0).
10. Barnett AG, Page K, Campbell M, Brain D, Martin E, Rashleigh-Rolls R, Halton K, Hall L, Jimmieson N, White K et al: Changes in healthcare-associated Staphylococcus aureus bloodstream infections after the introduction of a national hand hygiene initiative. Infect Control Hosp Epidemiol 2014, 35(8):1029-1036.
11. Mitchell BG, Collignon PJ, McCann R, Wilkinson IJ, Wells A: A Major Reduction in Hospital-Onset Staphylococcus aureus Bacteremia in Australia-12 Years of Progress: An Observational Study. Clin Infect Dis 2014, 59(7):969-975.