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Infection control and quality health care in the new millenium

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Health care-associated infection remains a major issue of patient safety. It complicates a significant proportion of patient care deliveries, adds to the burden of resource use, and contributes to unexpected deaths. Early infection control pioneers showed that surveillance and prevention programs can be successful and have set the scene for today's infection control activities. Parameters for success include those to recognize and explain health care-associated infections and implement interventions to decrease infection rates and limit antimicrobial resistance spread. Current major challenges facing infection control programs are reviewed with an emphasis on recent trends in health care delivery systems, together with some vision on future activities and interactions toward such changes. Benchmarking of infection rates is considered inevitable, and, thus, surveillance strategies, adapted to changing health care systems, should improve and emphasize intervention and standardization. Major challenges for the future include antimicrobial use and control of resistances, new materials, emerging pathogens, infection control issues related to transgenic therapy, massive and complete immunosuppression and xenotransplantation, prion diseases, use of fully computerized patient record and data-mining-derived epidemiology, development of evidence-based recommendations for infection control and prevention, addressing cost constraints and newly apparent health care system trends, and health care worker behavior modification.

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Strong historical background

Models for infection prevention are many, but Ignaz F. Semmelweis and Florence Nightingale are to be considered the pioneers of infection control and hospital epidemiology (Fig 1A). Most of us are familiar with Semmelweis' intervention in 1847 at the Maternity Clinic of the Allgemeine Krankenhaus (General Hospital) in Vienna where he observed that women whose babies were delivered by students and physicians consistently had a higher mortality than those delivered by midwives. Postulating that

Surveillance

Surveillance of nosocomial infections has been the foundation of infection control in the United States since the 1960s. It is defined as “the ongoing, systematic collection, analysis, and interpretation of data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know.”

Its major components are the detection and understanding of infections (risk factors), summarizing and

Intervention

Recognize and explain is not sufficient in infection control. We need to act. Interventions to reduce the incidence of patient care-associated infections should become daily practice for infection control professionals. Examples of successful interventions are many.

A large proportion of sepsis episodes and a majority of those associated with multiple organ failure are related to acute bacteremia and fungemia. This infection is responsible for significant excesses in mortality, morbidity, length

Current challenges

Challenges for today's infection control professionals are many and varied. Table 1 summarizes some of the most current ones. Antimicrobial resistance and spread of multiresistant pathogens, whether gram positive, gram negative, or fungi, constitute one of the major tasks of most infection control programs in health care institutions. Both antibiotic control and improved infection prevention practices are cardinal measures in such a long-standing fight.

Infection prevention and surveillance

Cost-effectiveness of infection control

The impact of infection is determined by the attributable part of the parameters that are considered. Accordingly, the attributable mortality of nosocomial infections is defined as the difference in the death rate of infected and noninfected patients in a series adjusted for the presence of other confounding factors. Several epidemiological methods may be used to determine the attributable mortality or any other parameter associated with the acquisition of nosocomial infection. Nosocomial

Trends in health care

Infection characteristics and risks are strongly related to changes in health care (Table 2). Health care-associated infections are becoming increasingly important as a result of different converging evolutions. Technical and scientific progress introduce more risk for acquiring infection such as by increase in device use, care complexity, immunosuppressive therapy, and organ transplantation. Shortening of hospital stay is an issue of survival for hospitals, especially under capitation, leading

Patient safety

Patient safety is becoming increasingly important as a result of different converging evolutions. Infection control and prevention is a model for quality management and patient safety. It relies on measuring parameters integrated in the health care structure, process, or outcome as categorized by Donabedian. Once defaults are unmasked, action may be directed at improving structure- or process-related issues. For the latter, infection prevention should include influence on health care partners'

New mandate for infection control

Some infection control programs have broadened their activities in monitoring the use of antibiotics and in preventing antimicrobial-related adverse events. Some also monitor noninfectious adverse events such as medication errors and patient falls. The Centers for Disease Control and Prevention (CDC) is planning a new health care worker safety network ultimately to include noninfectious adverse events such as medication errors and patient falls. After almost a decade of discussion, this

Future of infection control programs

The understanding of infection as an indicator of flaws in patient safety and as being an often preventable event concerning all components of the health care system raises the issue of new organizational structures. It is not yet clear how this challenge will be met. Two conceptually different solutions are possible: expanding current duties and activities of hospital-based infection control teams regarded as centers of excellence to the remainder components of the health care system and to

Education and behavioral change

Microbiology and epidemiology have made significant contributions to the field of infection control. However, most health care-associated infections are endemic and result from cross transmission related to inappropriate patient care practices. To improve health care workers compliance with practices, infection control professionals should learn from the behavioral sciences. Infection control professionals play key roles in the identification and prevention of nosocomial infections. They act as

Conclusion

Infection control professionals should never forget the lessons from the past. Surveillance remains the primary tool of prevention; its impact needs to be more explicitly assessed. The primary objective of surveillance is to drive the conduct of interventions that reduce infection rates and control resistance spread and outbreaks. The active implementation of prevention strategies by infection control programs is essential.

Antibiotic control is mandatory in the hospital as well as in the

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Keynote opening lecture: 2nd International Congress of the Asia Pacific Society of Infection Control, Singapore, March 2004.

Invited paper for publication in the American Journal of Infection Control.

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