REVIEW
The preventable proportion of nosocomial infections: an overview of published reports

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Abstract

The proportion of nosocomial infections potentially preventable under routine working conditions remains unclear. We performed a systematic review to describe multi-modal intervention studies, as well as studies assessing exogenous cross-infection published during the last decade, in order to give a crude estimate of the proportion of potentially preventable nosocomial infections. The evaluation of 30 reports suggests that great potential exists to decrease nosocomial infection rates, from a minimum reduction effect of 10% to a maximum effect of 70%, depending on the setting, study design, baseline infection rates and type of infection. The most important reduction effect was identified for catheter-related bacteraemia, whereas a smaller, but still substantial potential for prevention seems to exist for other types of infections. Based on these estimates, we consider at least 20% of all nosocomial infections as probably preventable, and hope that this overview will stimulate further research on feasible and cost-effective prevention of nosocomial infections for daily practice.

Introduction

For the last 30 years, there has been great interest in understanding the causes and impact of hospital-acquired infections.1 Many experimental studies and randomized trials have examined various methods to prevent nosocomial infections.2., 3., 4., 5. Uncertainty remains, however, about the proportion of nosocomial infections that could potentially be prevented by infection control measures applied under routine working conditions.

Most estimates about the proportion of potentially preventable nosocomial infections were collected almost three decades ago during the SENIC study, which was performed between 1971 and 1976 and published 10 years later.6 This interventional cohort study showed that about 6% of all nosocomial infections could be prevented by minimal infection control efforts, and that 32% of all nosocomial infections could be prevented by well-organized and highly effective infection control programmes.6

It remains unclear whether these frequently mentioned results are still applicable today,7 as no other systematic, nationwide cohort study has attempted to replicate these findings. However, several large-scale prevalence studies have suggested that great potential may exist to reduce the prevalence of nosocomial infections on a regional or national scale.8., 9., 10., 11., 12., 13. Moreover, a number of single-centre intervention studies published during the last decade compared infection rates during two consecutive observation periods before and after implementation of multi-modal intervention measures (hereafter called intervention studies) and demonstrated the impact of standardized infection control policies and procedures under real-life conditions.14., 15.

Due to advanced molecular biology and typing methods, it is possible to identify cross-transmission between patients and to distinguish endogenous from exogenous nosocomial infections. Transmission studies may enable conclusions to be drawn about the potential preventability of exogenous nosocomial infections by avoiding cross-transmission.

The aim of this paper was to conduct a systematic review of the published literature to describe multi-modal intervention studies and transmission studies performed during the last decade, in order to give a crude estimate of the proportion of potentially preventable nosocomial infections under current healthcare conditions.

Section snippets

Methods

To identify intervention studies, we performed a MEDLINE search using combinations of the index terms ‘nosocomial, hospital, infection, intervention, incidence, survey and reduction’ for the period between January 1990 and October 2002. The search for intervention studies focussed on studies applying a multi-modal prevention strategy under real-life working conditions. To search for transmission studies the index terms ‘cross infection’ or ‘transmission’ or ‘typing’ were used. We excluded

Results

We identified 25 relevant intervention studies, which were performed in different parts of the world. The settings and patient populations were extremely diverse, offering a sample of the multi-farious nature of current medical care. Ten of the included studies investigated the influence of multi-modal interventions on all types of nosocomial infections (Table I),11., 14., 32., 33., 34., 35., 36., 37., 38., 39. whereas 15 studies focused on specific types of nosocomial infections (Table II).15.

Discussion

By definition, any infection not present or incubating at the time of admission to the hospital is classified as a nosocomial infection.58 To date, it remains unclear to what extent these nosocomial infections are avoidable under real-life hospital conditions and what represents the irreducible minimum.59 The simplest way to answer this question is to document infection rates before and after a multi-modal quality improvement intervention, adopting standardized policies, and if necessary,

References (68)

  • S.J. Raine

    Quality assurance and the role of infection control: a retrospective study of hospital-acquired infection in a District General Hospital based on three sites, 1978–1988

    J Hosp Infect

    (1991)
  • N. Malone et al.

    Factors associated with a significant reduction in hospital-wide infection rates

    Am J Infect Control

    (1996)
  • M. Delgado-Rodriguez et al.

    Efficacy of surveillance in nosocomial infection control in a surgical service

    Am J Infect Control

    (2001)
  • S.I. Kelleghan et al.

    An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia

    Am J Infect Control

    (1993)
  • J. Cohran et al.

    Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections

    Heart Lung

    (1996)
  • A. Maas et al.

    Central venous catheter-related bacteraemia in critically ill neonates: risk factors and impact of a prevention programme

    J Hosp Infect

    (1998)
  • J. Kaye et al.

    Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia

    Am J Infect Control

    (2000)
  • H. Grundmann et al.

    Detection of cross-transmission of multiresistant Gram-negative bacilli and Staphylococcus aureus in adult intensive care units by routine typing of clinical isolates

    Clin Microbiol Infect

    (1999)
  • C.A. Webster et al.

    Use of RAPD-ALF analysis for investigating the frequency of bacterial cross-transmission in an adult intensive care unit

    J Hosp Infect

    (2000)
  • J.S. Garner et al.

    CDC definitions for nosocomial infections

    Am J Infect Control

    (1988)
  • P. Eggimann et al.

    Overview of catheter-related infections with special emphasis on prevention based on educational programs

    Clin Microbiol Infect

    (2002)
  • A.P. Wilson et al.

    Meta-analysis and systematic review of antibiotic trials

    J Hosp Infect

    (1999)
  • J.L. Gerberding

    Hospital-onset infections: a patient safety issue

    Ann Intern Med

    (2002)
  • A. Kurz et al.

    Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization

    N Engl J Med

    (1996)
  • T.M. Perl et al.

    Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections

    N Engl J Med

    (2002)
  • W.A. Krueger et al.

    Selective decontamination of the digestive tract

    Curr Opin Crit Care

    (2002)
  • S. Harbarth et al.

    Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance

    Pediatr Infect Dis J

    (2002)
  • R.W. Haley et al.

    The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals

    Am J Epidemiol

    (1985)
  • H. Sax et al.

    Interhospital differences in nosocomial infection rates: importance of case-mix adjustment

    Arch Intern Med

    (2002)
  • S. Harbarth et al.

    Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices

    Infect Control Hosp Epidemiol

    (1999)
  • W.E. Bischoff et al.

    Handwashing compliance by healthcare workers: the impact of introducing an accessible, alcohol-based hand antiseptic

    Arch Intern Med

    (2000)
  • R.J. Sherertz et al.

    Education of physicians-in-training can decrease the risk for vascular catheter infection

    Ann Intern Med

    (2000)
  • M. Weinberg et al.

    Reducing infections among women undergoing cesarean section in Colombia by means of continuous quality improvement methods

    Arch Intern Med

    (2001)
  • S. Harbarth et al.

    Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus

    Antimicrob Agents Chemother

    (1999)
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