By Thomas Rosenthal

Minneapolis—Health care–associated infections, which the CDC states take tens of thousands of lives and cost the U.S. health care system billions of dollars each year, decreased from one in every 20 to one in every 25 hospitalized patients from 2013 to 2018, according to the federal agency.

“The tremendous reductions in central line–associated bloodstream infections (CLABSIs) are the greatest success story in modern HAI prevention,” Arjun Srinivasan, MD (CAPT USPHS), from the CDC’s Division of Healthcare Quality Promotion, said in a presentation at the Association for Professionals in Infection Control and Epidemiology (APIC) 2018 annual conference. “These reductions totally shifted the discussion about HAI prevention from some HAIs might be preventable to most HAIs are preventable.”

CLABSIs decreased 50% nationally between 2006 and 2014; after a slight uptick in 2014, they dropped another 11% between 2015 and 2016, Dr. Srinivasan said. With 2015 as the new baseline, the CDC set a 50% reduction target by 2020 for CLABSIs, he said (Table).

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Table. CDC Goals for HAIs
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The CDC is optimistic the country is on track to reach its 2020 goals of continued reductions in several of the leading HAIs, but called for increased efforts to cut those infections whose decreases have slowed.

The national health care goals for 2020 are all reasonably ambitious targets, Dr. Srinivasan said. “We think they are attainable, stretch goals. These are where we want to be as a nation in 2020.”

Nearly 20 years ago, the health care community “thought HAIs were the price we pay for delivering modern health care, and they were largely unavoidable side effects of the care we provide,” Dr. Srinivasan said. However, in 2003 to 2004, two studies showed that CLABSIs could be reduced dramatically. The studies transformed the health care community’s perception of HAIs: Such infections were preventable.

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“The tremendous success in CLABSI prevention helped lead to a fundamental attitude shift in many hospitals from infection prevention is the job of the infection preventionist-health care epidemiologist to infection prevention is the job of front-line providers with support from the infection preventionist-health care epidemiologist,” Dr. Srinivasan said. He added that the success ushered in the current HAI reporting practices and pay-for-performance models.

In the 2015-2016 reporting period, 55.3% of CLABSIs were in hospital wards, 7.4% in other non-ICU hospital areas and 37.3% in ICUs. Because CLABSI reductions in hospital wards had lagged behind, Dr. Srinivasan said it was encouraging to see more aggressive prevention efforts now occurring in wards.

“We’ve had the most success on central line infections,” Janet Haas, PhD, RN, FSHEA, FAPIC, the president of APIC, said during the same presentation, but acknowledged that “we certainly have more to do” regarding the other major HAIs targeted by the CDC.

Originally, reduction in CLABSIs required what Dr. Haas said was straightforward prevention, while the remaining CLABSIs present a greater challenge. “With some, we know what to do. With more complicated patients, we’re not always sure what to do” to meet the target reduction goals, she said.

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Dr. Srinivasan noted that catheter-associated urinary tract infections (CAUTIs) were relatively stable from 2009 to 2015, and dropped 7% between 2015 and 2016, according to the CDC. The CDC revised its definition of CAUTIs to remove yeast as an infection, he said. The focus is on preventing “true infections,” with the 2020 goal of a 25% reduction.

There has been a significant reduction of CAUTIs outside hospital ICUs but a lot less reduction in the ICU, Dr. Srinivasan said. “We need to figure out ways to enhance prevention in the ICU,” he said. Striking an optimistic note, Dr. Srinivasan said with the definitional change, “we can focus our efforts on prevention.”

Reducing CAUTIs, as well as surgical site infections and Clostridioides difficile (formerly Clostridium difficile) infections (CDIs), involve “really complex patient care issues” and present a challenge to current practices, Dr. Haas said.

Increased antibiotic stewardship program efforts and enhanced environmental cleaning are needed, particularly for ssIs and C. difficile infections, she said.

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Although there have been declines in ssIs after abdominal hysterectomies, overall progress in ssI prevention has stalled, and they remain a concern, Dr. Srinivasan said. ssIs after abdominal hysterectomies declined 13% from 2015 to 2016 and ssIs after colorectal surgery fell 7%, according to CDC data. The 2020 target calls for a 30% decline. Because ssIs are multiple infections, prevention efforts need to engage different practices and specialties in the effort, he said.

The focus is now: “How can we do more to engage the surgical specialties in ssI prevention?” Dr. Srinivasan said. “These are ‘one’ infection to us but involve many distinct entities, each with its own interest group. We need to explore common approaches while recognizing the need for tailored approaches.”

To truly reduce ssIs, according to Dr. Haas, surgeons have to develop new workplace “habits.” “The role of the surgeon has been fairly autonomous. They have to give up a little control and change habits to adopt some newer practices in terms of ssIs,” she said.

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As for the CDC target of a 50% reduction for both invasive methicillin-resistant Staphylococcus aureus (MRSA) and facility-onset MRSA, U.S. hospitals reported a 6% decrease in MRSA bacteremia between 2015 and 2016, the CDC reported.

“We’re not on track to where we need to be by 2020 to meet the reduction goals,” Dr. Srinivasan said. “We have to find ways to accelerate our MRSA infection prevention” in both HAIs and outside the health care environment in the community, he said. “We are really trying to consider what things we can do to make a bigger impact.”

The 8% decrease in CDIs among hospitalized patients that occurred from 2015 to 2016 is encouraging, Dr. Srinivasan said. Calling the decrease good progress, he said, “We’re seeing decreases in health care–associated C. diff infections.”

The increases in community-onset CDIs mean health care providers must continue to work toward decreasing HAIs while also focusing on community infections. The biggest yield will come in improving antibiotic stewardship efforts, Dr. Srinivasan said.

“Because health care is an exceedingly complex service delivery operation, HAI prevention requires a bundle of strategies that need to be applied every day throughout the hospital stay,” said Hilary Babcock, MD, MPH, an associate professor of infectious diseases at Washington University School of Medicine in St. Louis.

The challenge of reducing HAIs is that a single OR procedure can put a patient at risk for an array of infections. “In addition to HAIs, providers are asked to prevent a wide array of other events from occurring,” said Dr. Babcock, who in January 2019 will become the president of the Society for Healthcare Epidemiology of America, which works with infectious disease clinicians to develop best practices in all health care settings.

Reducing HAIs requires clinicians and hospital leadership to coordinate efforts. For example, Dr. Babcock said, the emphasis is on clinicians’ individual practices, such as proper hand sanitation or full-barrier drapes. But, she noted, the responsibility is on the administration to support that by ensuring the proper materials are all in one place to facilitate the effort. “Both sides of the equation need to be focused on,” she said.

Dr. Haas also said the ongoing effort to reduce HAIs to zero requires a change in culture. One area that will be important to include in the discussion is end-of-life care. She questioned why antibiotics are administered to patients who are dying from a noninfectious cause. These antibiotics have the potential to create antibiotic-resistant organisms that can be spread to others, and there is very limited evidence that they decrease the patient’s suffering, she said.

“Are we serving the patients’ best interests by poking them and sticking them when death is imminent?” Dr. Haas asked.