Scientific Communication
adrid · Spain
Submitted to the EWMA
Journal based on a presentation given at a key session
(A broad perspective in
infection: The magnitude
of today’s problem) at the
infections (HCAIs):
The magnitude of the problem
Healthcare-associated infections (HCAIs) are
an important and costly complication of healthcare throughout both primary and secondary
sectors. In the European Union alone, the
financial burden associated with HCAIs is up
to €10b annually. HCAIs add unacceptable
costs to healthcare economies – a 2- to 3-fold
overall increase in the cost of the affected
patient’s care in terms of extended hospital stay
and associated costs. Increasing resistance
following the use, mis-use, and over-use of
antibiotics poses a world-wide problem that is
compounded by the fact that no new antibiotics are in the pipeline. The recent and expanding appearance of carbapenemase resistance
is of particular concern, as some strains of
Klebsiella pneumoniae that produce carbapenemase are almost pan-resistant, meaning
that antimicrobial therapy is virtually impossible. There is, however, good evidence that
control measures can be effective. In the UK,
the overall numbers of methicillin-resistant
Staphylococcus aureus (MRSA) and Clostridium
difficile infections have fallen due to increased
compliance with infection prevention/control
procedures. In particular, the delivery of care
bundles containing evidence-based interventions has proved highly effective in preventing
MRSA bacteraemias along with the “cleanyour-hands” campaign and other measures
such as universal admission screening. Surgical
site infection (SSI) is probably the most preventable HCAI, yet due to the inconsistent implementation of level 1A evidence-based interventions, the UK and US have shown disappointing failures to reduce SSI. The reason for this
lack of progress in SSI likely reflects poor compliance with guidelines and checklists.
After noting in 1928 that Penicillium notatum
inhibited Staphylococcus aureus in a Petri dish,
Alexander Fleming and his colleagues went on to
successfully treat Police Constable Alexander for
staphylococcal bacteraemia, although the patient
relapsed and died when the antibiotic ran out.
Nevertheless, a new class of antimicrobial drugs
had been born, and although we have ever since
relied on antibiotics to prevent and control infection, we did not heed Fleming’s prophetic warning
that inappropriate use might lead to resistance.
We now know that resistance inevitably follows
the introduction of new antibiotics within 15-20
years or even as little as 2-3 years1. Until recently,
however, there has always been an alternative antibiotic when resistance was encountered. Now,
times have changed; no new class of antibiotic
has been introduced for well over a decade, and
there are no new antibiotic classes in the pipeline, rather just combinations of existing agents.
Although there are many reasons for this lack of
progress, it is mostly related to economic factors
bound to research and development, regulatory
procedures, and financial returns on investment
for pharmaceutical companies.
Martin Kiernan
Nurse Consultant
Prevention and Control
of Infection
Southport and Ormskirk
Hospitals NHS Trust
David Leaper
Professor of Clinical
University of
Huddersfield, UK
Conflicts of interest: None
With increasing antibiotic resistance, healthcareassociated infections (HCAIs) have become a
more challenging problem. These iatrogenic complications, which are acquired through contact
with healthcare services and institutions and are
associated with considerable morbidity and mortality, are to a significant extent avoidable. Their
costs to healthcare are enormous - up to €10b annually in Europe due to added costs of treatment
and extended hospital stays. Additionally, some
individuals become reservoirs of resistant organ䊳
2014 VOL 14 NO 2
isms (i.e., carriers) for whom suppression is expensive and
complex, resulting in national screening programmes or
“search and destroy” strategies. Today, the leading HCAIs
are hospital-acquired pneumonia (not ventilator-associated); urinary tract infection (UTI), including those associated with catheters2; ventilator-associated pneumonia3;
prosthetic and surgical site infection (SSI)4 caused by Staphylococci, including methicillin-resistant and -sensitive
Staphylococcus aureus (MRSA and MSSA, respectively) and
multiply resistant coagulase negative staphylococci, which
are often associated with joint replacement or intravascular
catheters; secondary bacteraemias; and complicated skin
and soft tissue infections. Clostridium difficile infection
(CDI)5, occurs as a secondary infection due to gut flora
disturbances resulting from treatment with other HCAIs.
The media has a huge impact on the HCAI political agenda6 by driving public awareness and fostering the need for
politicians to “do something” about “superbugs”, “killer
microbes”, and outbreaks of “flesh-eating viruses”7. For
instance, the media portrayed England as one of the “dirtiest” countries because of the rise of MRSA bacteraemia between 1991 and 2003. While the actions of politicians may
have been driven by media influence, infection prevention
and control teams have turned the tide through hand hygiene campaigns, improved clinical practice with respect
to invasive devices, undertaking root cause analysis when
infections occur, and implementing search and destroy
campaigns (historically effective in the Low Countries and
Scandinavia). The contribution of individual interventions
is difficult to assess, but together with care bundles for
central venous and peripheral intravenous catheter use and
improvements in antibiotic stewardship, rates of MRSA
bacteraemia continue to decline in the UK with impressive zero tolerance in NHS Trusts. It has been claimed by
one UK “red top” daily newspaper, however, that MRSA
has been minimised through a “plea to medics” to wash
their hands.
Unfortunately, infection prevention and control issues are
not at the top of busy clinicians’ agendas. Despite that
mandatory infection control lectures are considered therapeutic for sleep-deprived staff members, infection/prevention team-led training, surveillance, and feedback on local
infection data have significantly reduced rates of MRSA
and CDI. Interestingly, this does not seem to have been
the case with Escherichia coli bacteraemia, the majority of
which occur in community settings. Root cause analysis
of increasing rates of infection in community settings suggests a relationship among use of urinary catheters, UTI,
and the lack of effective antibiotics available to general
practitioners. The evidence base for long-term urinary
catheter use and related complications is poor, but we
know that catheterisation is not an intervention without
complication. Urinary catheters are foreign bodies, and
colonisation with Proteus mirabilis and Providentia rettgeri
can cause biofilm formation, encrustation, and blockage8.
␤-lactamases are enzymes that destroy the ␤-lactam ring
of penicillins and cephalosporins. Common coliforms
producing these enzymes are becoming resistant to most
␤-lactam antibiotics, and simple E. coli UTIs may be impossible to treat in primary care due to a lack of effective
oral therapies. Controlling the spread of resistance in community settings is a huge challenge9, as plasmid-mediated
resistance facilitates spread and makes resistance difficult
for microbiology laboratories to detect10. This in turn leads
to challenges in antibiotic formulary construction and a
lack of information for clinical decision-making. Again,
the media has drawn attention to extended spectrum
␤-lactamase-related deaths and has demanded tougher
action, despite these deaths not being related to spread
in hospitals. Carbapenem antibiotics are the current last
resort in this battlefield, but already there are increasing
numbers of carbapenemase-producing Enterobacteriaceae,
such as New Delhi metallo-␤-lactamase producers and
carbapenemase-resistant Klebsiella pneumonia, which have
implications for global travel, health-care tourism, overseas
military action, and inter-hospital transfers.
Resistance to antibiotics is an issue for all, not just clinicians and specialists but also health-care and procurement
managers, politicians, and, of course, patients and carers.
It is time to move on from MRSA and CDI, which are
coming closer to being under control. Multi-drug resistant
Gram negatives, such as carbapenemase-resistant Klebsiella, should in principle present no differences in terms
of control. Reduction of HCAIs can be achieved through
the use of care bundles (provided that compliance is measured and reported) together with strict hand hygiene and
environmental cleaning. Care bundles addressing intravascular care have proved effective in preventing MRSA
bacteraemia, but similar success has not been found in
reducing SSIs on either side of the Atlantic, despite that
such bundles may contain several elements with a level
I evidence base. The problem is related to poor compliance. We all need to understand that the real problem
posed by antibiotic resistance is not just the over-use or
2014 VOL 14 NO 2
Scientific Communication
mis-use of antibiotics; it is any antibiotic use that risks
the development of resistance. We need to preserve the
gift of antibiotics.
A world without antibiotics is almost unimaginable in the
modern era. Formerly fatal infections such as meningitis,
bacteraemia, and pneumonia would become killers again;
postoperative SSIs would increase to 30% or more after
“at risk” contaminated/dirty surgery due to the lack of
effective agents for prophylaxis; transplantation of tissue
and organs might need to cease; cancer chemotherapy
with the attendant risk of infection would be too risky;
joint replacement and implants, such as vascular grafts,
would become very high risk procedures; and post-partum
and neonatal infections would return. Although there are
options for action that involve the development of new
antibiotics and vaccines, the motivation for such actions
remains poor. Certainly we can sustain the effectiveness of
existing antibiotics with close antibiotic stewardship. Perhaps better communication and precision concerning the
choice and duration of antibiotic use could occur between
microbiological laboratories and clinicians at the front line.
The burden of infection can be reduced by monitoring
and enforcing hygiene and other public health measures,
the adoption of novel immunisation strategies (which have
been so effective for polio and smallpox), and continuous
improvement in the design of healthcare environments.
Antibiotics will always have a role in treating cellulitis and
lymphangitis before they progress to systemic inflammatory response syndrome, sepsis, or multiple organ dysfunction syndrome. In situations in which host defences
are poor, such as immunosuppression or diabetes, and in
which the bioburden in chronic wounds is out of control and leads to critical colonisation and local spreading
infection, there will always be a need to consider antibiotic therapy, although early intervention with topical
antiseptics should also be considered. HCAIs are not an
inevitable part of the provision of healthcare. Effective
infection control measures help us protect patients from
themselves and each other when in their most vulnerable
states. Staff delivering healthcare should continually reflect
on their practice. We owe this level of care to the memory
of Alexander Fleming and his legacy.
1.Krummenauer EC, Carneiro M, Alves Machado JA, de Mello Rauber J, Adam MS,
Muller LB, et al. The impact of antimicrobial resistance and the challenge for
professionals. Am J Infect Control. 2013;41(4):386-7.
2. Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, et al. Strategies to
prevent catheter-associated urinary tract infections in acute care hospitals: 2014
update. Infect Control Hosp Epidemiol. 2014;35(5):464-79.
3. Tedja R, Nowacki A, Fraser T, Fatica C, Griffiths L, Gordon S, et al. The impact of
multidrug resistance on outcomes in ventilator-associated pneumonia. Am J Infect
Control. 2014;42(5):542-5.
4. Anderson DJ, Podgorny K, Berrios-Torres SI, Bratzler DW, Dellinger EP, Greene L, et
al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update.
Infect Control Hosp Epidemiol. 2014;35(6):605-27.
5. Dubberke ER, Carling P, Carrico R, Donskey CJ, Loo VG, McDonald LC, et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update.
Infect Control Hosp Epidemiol. 2014;35(6):628-45.
6. Kiernan MA. Public reporting of healthcare-associated infection: professional
reticence versus public interest. J Hosp Infect. 2013;83(2):92-3.
7. Chan P, Dipper A, Kelsey P, Harrison J. Newspaper reporting of meticillin-resistant
Staphylococcus aureus and ‘the dirty hospital’. J Hosp Infect. 2010;75(4):318-22.
8. Wyndaele JJ. The encrustation and blockage of longterm indwelling catheters. Spinal
Cord. 2010;48(11):783.
9. Cochard H, Aubier B, Quentin R, van der Mee-Marquet N, Reseau des Hygienistes
du C. Extended-spectrum beta-lactamase-producing Enterobacteriaceae in French
nursing homes: an association between high carriage rate among residents,
environmental contamination, poor conformity with good hygiene practice, and
putative resident-to-resident transmission. Infect Control Hosp Epidemiol.
10. Munoz-Price LS, Quinn JP. The spread of Klebsiella pneumoniae carbapenemases:
a tale of strains, plasmids, and transposons. Clin Infect Dis. 2009;1;49(11):1739-41.
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