Infection Prevention and Control

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Table of Contents

Introduction
Pathogenesis
Infection Control Practice in Work Area
Existing practices with their strengths and weaknesses
Audits in Infection Prevention and Control
Effectiveness and respect for cultural values
Recommendations to improve practice
Conclusion
References

Introduction

The subject of infection prevention and control has received unprecedented attention over the last decades with the media and scientific literature equally contributing to this attention. Boyce et al. (2009, p. 12) report that media has reported on several occasions about the absence of hand hygiene and insufficient cleaning practices among health workers. The malpractice has amounted to carelessness. One of the infections that commonly pose a challenge to health workers is the Methicillin Resistant Staphylococcus Aureus (MRSA), which is one of those infections caused by multiple resistant bacteria. Research has shown that, with the application of intensive infection prevention programs in health institutions, a third to a quarter of all hospital-acquired infections could be prevented (Fraise & Bradley, 2009, p. 23). Adherence to these measures is a problem with research showing that health workers are unaware of the measures. They exhibit ignorance on the rationale behind the measures by projecting the problem to hygiene experts (Verhoeven et al. 2009). Several infection control practices are in place in all health institutions with specific measures being aimed at preventing MRSA infections. The role played by health workers especially the nursing staff cannot be overemphasised. However, much work is yet to be implemented. A multifaceted approach is therefore necessary to cut the spread of the infection. This essay is a critical review of the infection control practices in place for the microorganism. It analyses literature on the same in addition to making recommendations to the practice.

Pathogenesis

According to Gould and Brooker, “Staphylococcus aureus bacteria are Gram-positive cocci that are both coagulase and catalase positive, and have long been recognised as important pathogens in human disease” (2008, p. 81). The argument is true because bacteria can cause infection by both noninvasive and invasive methods thus affecting virtually all tissues of the body in human beings. Since bacteria are commonly found on the skin of healthy individuals, they may be inoculated through injury. However, with the introduction of penicillin in the 1940s, some strains of the bacteria were isolated after being found to be resistant to the antibiotic (Fraise, & Bradley, 2009, p. 27). With the introduction of methicillin, a group of the bacteria was also found to be resistant to the drug a year later in the hospital set up (Gould, & Brooker, 2008, p. 11). The bacteria were then referred to as MRSA based on the resistance. It has a rate of transmission that is greater than that of its Methicillin sensitive strain especially between health workers and patients (Gould, & Brooker, 2008, p. 11).

Verhoeven et al. claim that the infections by MRSA are mainly seen in patients who are frequently exposed to the hospital environment. The argument mainly points at patients with open wounds such as those who recently had surgery, dialysis, hospitalisation, or those who reside in a care facility such as nursing homes (2009, p. 16). Aside from this study, it is worth noting that the isolation of MRSA is not only on patients with exposure to a health facility, but can also occur in those without healthcare risk factors (Verhoeven et al. 2009). The isolated community-acquired MRSA and those that are hospital-acquired are different in the toxin profiles and in the number of beta lactam antibiotics to which the strains are resistant. However, infection with any strain of MRSA causes infections in individuals that are both expensive and difficult to treat. Hospitalisation is necessary in most cases.

Infection Control Practice in Work Area

In most of the health institutions all over the world, a standard procedure is used for infection prevention against MRSA. The main guidelines used are those that are laid down by the Centres for Disease Control and prevention (CDC). The personal work place is no different. However, there exist differences and alterations in the measures put in place especially in the workplace. The measures at the personal workplace can be grouped into those preventing transmission of bacteria and those that are standard precautions for the institution.

In the preventive standard precautions at the institution, an assumption is made that the body fluids and secretions contain microorganisms. The precautions are aimed at preventing inoculation. These precautions are therefore standard to all patients at the institution irrespective of the infective organism. They comprise “gowning, the use of gloves when handling patients, mask protection, hand hygiene, safe injections, and shielding of the face and eyes from exposure” (Gould, & Brooker, 2008, p. 12). Use of gloves is applied where the healthcare giver is at risk of coming into contact with bodily fluids such as blood and mucous from the patients when they need to practice safe injections.

In the same institution, gowning is used to prevent contamination of clothing by material that may be infectious more so in the operating theatres and in the general wards where a caregiver is always in contact with infectious materials. A combination of masks, goggles, and face shields is frequently used in the institution especially where a procedure being performed is likely to produce a splash. The same procedure is also used in the management of patients who may have one or more sites where there is a high likelihood of large bacterial colonisation and overgrowths in patients with tracheostomies.

Standard precautions are applied to almost all patients in the institutions. However, other patients require transmission-based precautions, which are additional measures that the hospital applies to prevent infections that are not necessarily prevented by the standard precautions. The precautions are more focused on the transmission routes for the infection. Gould and Brooker state that the interventional strategies that employ transmission-based precautions can either be airborne precautions, droplet precautions, or contract precautions (2008, p. 11). The strategies are utilised in the health institution of practice. However, as Fraise and Bradley state, contact precautions are necessary for patients with an established MRSA infection or colonisation (2009, p. 12). This suggestion should however be regarded as inaccurate, as the transmission of the bacteria is shown to be via many routes. Therefore, contact prevention is not enough for prevention. The findings by Baldwin et al are more accurate since they suggest the use of multiple transmission-based interventions for the prevention of MRSA infection (2010, p. 24). In the institution of contact precautions, the hospital is required to place the patient in a single room with the caregivers being required to gown and glove before any interaction with the patient or contaminated materials from the patient and his or her vicinity (Gould, & Brooker, 2008, p. 17). However, the institution has few of these rooms. At times, the best that can be done is to keep the patient in a room of two contrary to the rules.

Existing practices with their strengths and weaknesses

Many practices and measures have been put in place to counter the spread of infection caused by MRSA. These measures have stemmed from the extensive research that has been conducted on the topic with the various researchers having their own suggestions and findings. The practices are unique to the institutions in different parts of the world with some having universal application. Some of these have been documented to be effective in the prevention of infection with others showing no benefit to the same. It is therefore important to consider some of these practices with a critical evaluation of the effects that each has had on the spread of the MRSA infection.

Baldwin et al. (2010, p. 24) performed a study on the spread of MRSA in clinical settings with recommendations on measures to be implemented to curtail the same. Among the infection control measures that they researched was the use of hand and environmental hygiene (Baldwin et al. 2010, p. 24). Another method of prevention was the use of personal protective equipment. The group performed a randomised control trial on the efficacy of these measures in the prevention of the infection (Baldwin et al. 2010, p. 24). The prevalence of the MRSA associated infections and the bacteria were found to be reduced in the population where the measures were applied within a period of one year (Baldwin et al. 2010, p. 24). The study demonstrated that the use of hand washing is effective. However, the technique used for the same was not effectively demonstrated. The sample size used for the study was also not sufficient to generalise the results. Moreover, the sensitivity of the tests used to evaluate the microorganisms was not given. Therefore, the validity of the conclusions made is wanting.

Bassetti et al. (2009, p. 234) also conducted a study in Italy on the prevalence of MRSA in one of the health institutions. Their study focused on the use of medication to reduce the prevalence of MRSA. With the reduction in the use of cephalosporins and increase in the use of ciprofloxacin, the researchers observed a reduction in the MRSA (Bassetti et al. 2009, p. 234). They proved that one can use medication to eliminate MRSA in health institutions. However, one of the weaknesses in this interventional measure is the cost of the medication. The cost was not factored in during the research, and that health institutions may find it hard to treat the infection. Burkitt et al. (2010, p. 230) also conducted a similar study in the United States where patient screening and isolation were investigated as prevention methods in addition to the use of hand and personal hygiene. A limitation to hand hygiene is the use of alcohol-based hand sanitizers in the place of soap and water. Another limitation is that most of the people using the hand hygiene method of preventing the spread of infection were not consistent as reported by Burkitt et al. (2010, p. 332). They only washed at certain times. Some of the respondents also complained that the use of hand hygiene was associated with the bruising of the hands and damage to the skin by the soap they were using, which in turn deterred them from using the hand hygiene method.

Carboneau et al. performed a similar study on the prevention of MRSA infection with the inclusion of the utilisation of changes in physical structure, facilities, and equipment in addition to hand hygiene (2010, p. 234). The research reported a decrease in the cases of MRSA that were reported months after the interventions thus supporting both the use of hand hygiene and general hygiene measures (Carboneau et al. 2010, p. 234). However, the research does not document the prevalence of the MRSA in the community in which it was carried out. In addition, it postulates constant factors in the spread of the microorganisms. It also did not incorporate all the other methods of prevention of infection. An assumption was that there were no changes in these methods. An adjustment to the same research was made and carried out by Cheng et al. when they conducted their research in a different country, China, including patient isolation as a mode of prevention of the spread of the infection (2009, p. 289). Some of the other researchers on the use of hand hygiene in the prevention of MRSA spread over the past decade found the act of hand hygiene and use of patient isolation to be effective (Davis 2010: Fowler, et al. 2010: Gagné et al. 2010: Goodman et al. 2008).

Holder and Zellinger suggested an ambitious method of preventing the spread of MRSA by the use of chlorhexidine baths (2009, p. 512). This method is however expensive. Holder and Zellinger say, “The cost of the chlorhexidine cloths is greater than for the non-chlorhexidine” (p. 512). Therefore, it would prove to be less sustainable in most of the health institutions. The concentrations that are required for the effectiveness of the chemical were not defined. It is therefore erroneous to claim that all surfaces are infected with the bacteria before an effective method of determining this infection is developed. Patient isolation is also a measure that is suggested to be effective in the prevention of the spread of MRSA-related infection. Several researches have demonstrated its efficacy (Kho et al. 2008, Kurup et al. 2010). Some of the limitations of this method include the unavailability of space in most of the health facilities for the isolation of such patients with the isolation spaces being preserved for conditions perceived to be more life threatening.

Some other methods of infection prevention against the spread of MRSA have also been suggested. However, they have their weaknesses. One of these methods is the use of patient screening. O’Brien et al conducted a study on the effectiveness of the same on infection prevention (2008, p. 2456). The results of their study showed a reduction in the infection. They observed an “Overall decrease in the rate of MRSA acquisition in the pre-IT period compared with the post-IT period” (O’Brien et al. 2008, p. 2456) that was statistically significant to their research. The major weakness of the use of this method in the prevention of MRSA infection is that patient screening is expensive and that the tests used are not absolutely sensitive and specific. The method cannot therefore be used as the basic measure to prevent the infection. Therefore, it does not solve the problem.

Audits in Infection Prevention and Control

Infections associated with MRSA have a multifactorial origin. Prevention may be undertaken through the application of the strategies and measures highlighted above. Various policies, guidelines, and procedures for carrying out infection prevention and control exist. The existing practices are gauged and compared against these guidelines. Auditing allows the establishment of whether the healthcare workers or the infection prevention teams are compliant with the methods of prevention of infections (Gould, & Brooker, 2008, p. 11). In most of the instances, the results of the audit are used to improve the methods of prevention of the spread of MRSA. A health institution can carry out internal audits where the results are compared against the objectives set within the facility and against the external guidelines and standards.

An audit is usually carried out in the areas that are perceived to be important to the success of the preventive measures. According to Gould and Brooker, “An effective audit should include a description of the physical layout, review of traffic flow, protocols and policies, supplies and equipment, and observation of appropriate IPC practice” (2008, p. 11). An effective audit should be able to assess the knowledge of the team involved in the infection control. A report should be prepared with recommendations on the areas to be improved. However, in most of the health institutions with prevention strategies in place for MRSA, there exists no definitive audit process and or procedures in place. Most of the recommendations are not acted upon. The cost of carrying out an audit on the preventive measures is also reported to be high (Fraise, & Bradley, 2009, p. 28). Institutions are not willing to commit their resources towards the objective. In auditing the effects of infection prevention and control strategies, it is important to monitor the behavioural changes that are because of the measures. Some of them include hand washing. When this monitoring is done, auditors must then make recommendations based on the capabilities of the institution to make the recommended changes. For any intervention to be successful, it must be easy to implement, effective, and affordable for the institutions.

Effectiveness and respect for cultural values

Various authors and researchers have described the effectiveness of the measures described above with each stating his or her observations and inferences. In the isolation of patients, one of the drawbacks to the use of this method for infection prevention is that the healthcare givers often spend a little time in the isolation room examining the patient. As Fowler, et al report, “isolated patients are less likely to have their vital signs recorded, have fewer physician progress notes, are more likely to complain about their care, and are more likely to experience an adverse event” (2010, p. 233). This case is a challenge to the use of isolation as a means of preventing the spread of MRSA. It may be prevented trough educating the health care providers and promoting the use of hand hygiene.

The use of personal protective equipment is reported to be effective against the spread of MRSA. Gowning and mask protection are among the preferred methods. However, the compliance to the use of these items in the prevention of MRSA spread is inhibited by the amount of investing in the item that is required against the outcome. Some studies describing the effectiveness of these methods have found an overall reduction in the infection spread by about 17% (Fraise, & Bradley, 2009, p. 29). However, the studies do not take into consideration the methods of using the personal protective items, which may be significant contributing factors. Hand and environmental hygiene are reported to be the most effective in the prevention of the spread of MRSA infection with some studies quoting a significant reduction on the same (Fowler et al. 2010). Health workers especially nursing staff people are therefore encouraged to use hand hygiene whenever they encounter patients or their environs. Cleaning of patient environments should be carried out regularly.

Recommendations to improve practice

From the review of methods of infection, prevention and control applied for the case of MRSA, several recommendations are evident. The institutions wishing to control the microorganisms need to support the initiative by having administrative support directed towards the prevention of the spread. This strategy should then be focused on educating the staff and patients besides collaborating with bodies with the same intentions and provision of adequate funding. The institutions also need to develop policies directed towards the prevention of the spread of infection and or invest in education. The institutions should then encourage the use of personal protective items when handling patients. They should promote hand hygiene and provide the necessary equipment for this task. Some of the other measures that can be implemented include screening of patients and proper environmental hygiene.

Conclusion

In conclusion, Methicillin Resistant Staphylococcus Aureous (MRSA) continues to pose a challenge to the delivery of health services. Several methods of preventing the spread of the microorganism have been described with the efficacy of these methods being analysed by various authors and researchers. Health care workers should ensure that they put the right measures in place to prevent the spread of the microorganism, as the management of infections caused by it is costly to the health sector.

References

Baldwin, S, Gilpin, F, Tunney, M, Kearney, P, Crymble, L, Cardwell, C, & Hughes, M 2010, ‘Cluster randomised controlled trial of an infection controleducation and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people’, Journal of Hospital Infection, vol. 76 no. 1, pp. 36-41.

Bassetti, M, Righi, E, Ansaldi, F, Molinari, P, Rebesco, B, McDermott, L, Fasce, R, Mussap, M, Icardi, G, Pallavicini, B, & Viscoli, C 2009, ‘Impact of limited cephalosporin use on prevalence of methicillin-resistant Staphylococcus aureus inthe intensive care unit’, Journal of Chemotherapy, vol. 21 no. 6, pp. 633-638.

Boyce, M, Havill, L, Dumigan, G, Golebiewske, M, Balogun, O, Risvani, R 2009, ‘Monitoring the effectiveness of hospital cleaning practices by use of an adenoisetriphosphate bioluminescence assay’, Infection Control and Hospital Epidemiology, vol. 30 no. 7, pp. 678-684.

Burkitt, H, Sinkowitz-Cochran, L, Obrosky, S, Cuerdon, T, Miller, J, Jain, R, Jernigan, A, & Fine, J 2010, ‘Survey of employee knowledge and attitudesbefore and after a multicenter Veterans’ Administration quality improvement initiative to reduce nosocomial methicillin-resistant Staphylococcus aureus infections’, American Journal of Infection Control, vol. 38 no. 4, pp. 274-282.

Carboneau, C, Benge, E, Jaco, T, & Robinson, M 2010, ‘A lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%’, Journal for healthcare quality: official publication of the National Association for Healthcare Quality, vol. 32 no. 4, pp. 61-70.

Cheng, C, Tai, M, Chan, M, Lau, Y, Chan, W, To, W, Li, S, Ho, L, & Yuen, Y 2009, ‘Sequential introduction of single room isolation and hand hygiene campaign in the control of methicillin-resistant Staphylococcus aureus in intensive care unit’, BMC Infectious Diseases, vol. 10 no. 1, p. 263.

Davis, R 2010, ‘Infection-free surgery: How to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards’, Annals of the Royal College of Surgeons of England, vol. 92 no. 4, pp. 316-319.

Fowler, S, Webber, A, Cooper, S, Phimister, A, Price, K, Carter, Y, Kibbler, C, Simpson, H, & Stone, P 2010, ‘Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series’, Journal of Antimicrobial Chemotherapy, vol. 59 vol. 5, pp. 990-995.

Fraise, P & Bradley, C 2009, Ayliffe’s Control of healthcare-associated infection: Hodder Arnold, London.

Gagné, D, Bédard, G, & Maziade, J 2010, ‘Systematic patients’ hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital’, Journal of Hospital Infection, vol. 75 no. 4, pp. 269-272.

Goodman, R, Platt, R, Bass, R, Onderdonk, B, Yokoe, S, & Huang, S 2008, ‘Impact of an environmental cleaning intervention on the presence of methicill in resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms’, Infection Control and Hospital Epidemiology, vol. 29 no. 7, pp. 593-599.

Gould, D, & Brooker, C 2008, Infection Prevention and Control: Applied Microbiology for Healthcare, Palgrave Macmillan: UK.

Holder, C & Zellinger, M 2009, ‘Daily bathing with chlorhexidine in the ICU to prevent central line-associated bloodstream infections’, Journal of Clinical Outcomes Management, vol. 16 no. 11, pp. 509-513.

Kho, N, Dexter, R, Warvel, S, Belsito, W, Commiskey, M, Wilson, J, Hui, L, & McDonald, J 2008, ‘An effective computerised reminder for contact isolation of patients colonised or infected with resistant organisms’, International Journal of Medical Informatics, vol. 77 no. 3, pp. 194-198.

Kurup, A, Chlebicka, N, Tan, Y, Chen, X, Oon, L, Ling, A, Ling, L, & Hong, G 2010, ‘Active surveillance testing and decontamination strategies in intensive care units to reduce methicillin-resistant Staphylococcus aureus infections’, American Journal of Infection Control, vol. 38 no. 5, pp. 361-367.

O’Brien, M, Greenhouse, K, Schafer, J, Wheeler, A, Titus, A, Pontzer, E, O’Neill, M, & Wolf, D 2008, ‘Implementing and improving the efficiency of amethicillin-resistant Staphylococcus aureus active surveillance program using information technology’, American Journal of Infection Control, vol. 36 no. 3, p. 2456.

Verhoeven, F, Steehouder, F, Hendrix, G, & van Gemert-Pijnen, C 2009, ‘Factors affecting health care workers’ adoption of a website with infection control guidelines’, International Journal of Medical Informatics, vol. 78 no. 10, pp. 663-678.

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