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Hospital-Acquired Infections and Antimicrobial Resistance: Healthcare’s Double Jeopardy


Summary

Hospital-acquired infections (HAIs), also known as healthcare-associated infections, are infections acquired in healthcare settings after admission, typically manifesting 48 hours after admission. They are often caused by mesophilic, facultative pathogenic microorganisms and can be serious, especially when caused by antibiotic-resistant bacteria such as ESKAPE pathogens. These pathogens are classified as urgent and high priority by the World Health Organization due to their global threat. HAIs, including Catheter-Associated Urinary Tract Infection (CAUTI), Central associated stream Infection (CLABSI), Ventilator Associated Pneumonia (VAP), and Surgical Site Infection (SSI), pose a significant challenge to healthcare systems worldwide. Antimicrobial resistance (AMR) compounds the issue, making infections harder and more expensive to treat. Superbugs resistant to multiple antibiotics are emerging rapidly, threatening our ability to combat infections effectively. The indiscriminate use of antibiotics, poor infection prevention and control practices, and lack of access to quality healthcare contribute to this crisis. Without immediate action, we face a future where common infections become untreatable. To address these challenges, hospitals must implement antimicrobial stewardship programs to reduce unnecessary antibiotic use and improve infection prevention and control practices. These measures, along with global efforts to raise awareness and improve access to quality healthcare, are crucial in combating HAIs and AMR.


Keywords: Hospital-acquired infections; Antimicrobial resistance; ESKAPE pathogens; Infection prevention and control; Antimicrobial stewardship


Picture Credit: Osmosis


What are Hospital Acquired Infections (HAI)?Hospital-acquired infections, also known as healthcare-associated infections (HAI), are nosocomially acquired infections that are typically not present or might be incubating at the time of admission. These infections are usually acquired after hospitalization and manifest 48 hours after admission to the hospital. [1] They are often caused endogenously by mesophilic, facultative pathogenic microorganisms. [2] The World Health Organisation stratified the most critical pathogens within HAI into three groups based on their global threat and the urgency of action needed. The first and the second groups (urgent and high-priority pathogens) include so-called ESKAPE pathogens (vancomycin-resistant Enterococcus faecium (VRE), methicillin-resistant, and vancomycin-resistant S. aureus (MRSA/VRSA), carbapenem-resistant and third-generation cephalosporin-resistant Klebsiella pneumoniae, A. baumannii, P. aeruginosa, and Enterobacter spp.) [3]  Agencies such as Center for Disease Control and Prevention (CDC) are actively involved in tracking and putting forth measures to curb these infections. WHO’s first global report on Infection Prevention and Control states that out of every 100 patients in acute-care hospitals, seven patients in high-income countries and 15 patients in low- and middle-income countries will acquire at least one healthcare-associated infection (HAI) during their hospital stay. On average, 1 in every 10 affected patients will die from their HAI.[4]

HAIs are further divided into the following types-

1. Catheter-Associated Urinary Tract Infection (CAUTI)

2. Central Line Associated Blood Stream Infection (CLABSI) 3. Ventilator-Associated Pneumonia (VAP) 4. Surgical Site Infection (SSI)


Picture Credit: GE Healthcare


What is antimicrobial resistance (AMR)?

Antimicrobial resistance is defined as resistance that bacteria, viruses, fungi, and parasites develop over a period of time to antimicrobials. It is a growing menace with which the healthcare industry is grappling, a thorn in the dreams of Universal Health Coverage (UHC). AMR coupled with the fact that it took us 60 long years to discover a new antibiotic threatens our ability to treat common infections, control the adverse effects of medications, and lessen the already burgeoning cost of healthcare. Superbugs known to be resistant to every antibiotic tailored to them are emerging rapidly with the first one being found in India. The future looks bleak as the Golden Age of Antibiotics is ending with a not-so-glittering future of reemerging infections. 


HAIs and AMR: Healthcare’s Double Jeopardy?

The global number of HARIs (Hospital Associated Drug Resistant Infections) per year is estimated to be 136 million per year, with the highest burden in China, Pakistan, and India respectively. Among income groups, middle-income countries bear the highest burden of HARIs per year. [5] Many HAIs are now not controlled by first-line antibiotics like penicillin and cephalosporin which is a cause of concern as stands upon the threshold of a global crisis.[2] Indiscriminate prescribing of antimicrobials, lack of access to sanitation; poor infection and disease prevention and control practices, poor access to quality and affordable vaccines, diagnostics, and medicines; lack of awareness and knowledge; and lack of enforcement of relevant legislation are some of the major contributing factors that are leading to the rise of this emerging pandemic of resistance. Unless concrete measures are undertaken, we might find ourselves submerged deep in a pool of infections - both old and new- without any cure. The most pressing concern is that some bacteria have become resistant to almost all of the readily available antibiotics. This can make infections and diseases more challenging and costly to treat. These bacteria can also spread from person-to-person, increasing the burden on the healthcare system.


What solutions can we employ?

• Antimicrobial stewardship: Hospitals need to have policies that are conveyed to all staff about when, where, and how to use a specific antibiotic. It is important to reduce unnecessary and over-prescribing of antibiotics. For example, when antibiotics are prescribed for conditions such as viral illness (antibiotics do not work against viruses).


Infection Prevention and Control

Standard precautions in hospitals provide a base level of infection prevention and control for the care of all people. These precautions should be followed in all hospitals and healthcare facilities and include:

• performing hand hygiene before and after all patient contact, after touching a patient’s surroundings, and before.

• the use of personal protective equipment such as gloves, gowns, masks, or eye protection when contact with blood or body fluids is expected.

• appropriate handling and disposal of sharps.

• aseptic techniques - when changing wound dressings or performing invasive procedures.

• routine cleaning of the environment.

• appropriate reprocessing of reusable medical equipment and instruments.

• respiratory hygiene and cough etiquette. [6] Many countries are demonstrating a rapid progress in scaling-up actions to put in place minimum requirements and core components of IPC programmes. Progress is being strongly supported by key players like WHO. Sustaining this progress in the long-term is a critical need that requires urgent attention and investments.


Picture Credit: World Health Organization


Author: Sejal Gupta, MBBS, Rajiv Gandhi Medical College, Thane, Maharashtra, India.

Editor: Dr. Sidhant Ochani, MBBS, Khairpur Medical College, Khairpur, Pakistan.


References


1. Monegro AF, Muppidi V, Regunath H. Hospital Acquired Infections. Nih.gov. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK441857/

2. Friedrich AW. Control of hospital acquired infections and antimicrobial resistance in Europe: the way to go. Wiener Medizinische Wochenschrift. 2019;169(S1):25-30. doi:https://doi.org/10.1007/s10354-018-0676-5

3. Avershina E, Shapovalova V, Shipulin G. Fighting Antibiotic Resistance in Hospital-Acquired Infections: Current State and Emerging Technologies in Disease Prevention, Diagnostics and Therapy. Frontiers in Microbiology. 2021;12. doi:https://doi.org/10.3389/fmicb.2021.707330

4. WHO. WHO launches first ever global report on infection prevention and control. www.who.int. Published May 6, 2022. https://www.who.int/news/item/06-05-2022-who-launches-first-ever-global-report-on-infection-prevention-and-control

5. Balasubramanian R, Van Boeckel TP, Carmeli Y, Cosgrove S, Laxminarayan R. Global incidence in hospital-associated infections resistant to antibiotics: An analysis of point prevalence surveys from 99 countries. PLoS medicine. 2023;20(6):e1004178. doi:https://doi.org/10.1371/journal.pmed.1004178

6. Better Health Channel. Antibiotic resistant bacteria. Vic.gov.au. Published 2015. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/antibiotic-resistant-bacteria


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