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INTRODUCTION

Health care–associated infections affect at least 2 million patients at a cost of billions of dollars and 100,000 or more lives in U.S. hospitals annually. Guidelines from the Centers for Disease Control and Prevention (CDC) (www.cdc.gov/hicpac/), the Agency for Healthcare Research and Quality (www.ahrq.gov), and professional societies (e.g., www.shea-online.org; www.idsociety.org; www.apic.org; www.his.org.uk) have led to marked reductions in occurrence of most device-related infections (https://www.cdc.gov/hai/data/portal/progress-report.html)—historically, the largest drivers of nosocomial infection risk. Despite these successes, there is the seemingly unending threat of antimicrobial-resistant infections and novel pathogens. This chapter reviews the epidemiology, prevention, and control of health care–associated infections and newer challenges.

ORGANIZATION, RESPONSIBILITIES, AND SCRUTINY OF HEALTH CARE–ASSOCIATED INFECTION PROGRAMS

Over the past several decades, hospitals have refined programs for surveillance, prevention, and control of health care–associated infections. The successful deployment of these activities has been driven by accrediting agencies, primarily The Joint Commission (www.jointcommission.org); by payers and regulators, primarily the U.S. Centers for Medicare and Medicaid Services (CMS) (www.cms.hhs.gov); by quality assurance groups that grade hospitals and health care performance (e.g., www.leapfroggroup.org; www.ihi.org); and by federal agencies such as the CDC that provide landmark guidelines and recommendations. Although neither the carrot (pay-for-performance) nor the stick (nonpayment for preventable infections) appears to have had a major impact on infection rates in U.S. hospitals, the specter of public attention to infection rates has been more powerful.

SURVEILLANCE

Traditionally, infection preventionists surveyed inpatients for infections acquired in hospitals (some of which only appear after hospital discharge, i.e., community-onset, health care–associated infections). Many infection-control programs leverage electronic surveillance (e.g., for vascular catheter, surgical wound, or even clustered infections inferred from clinical microbiology data) to complement “shoe-leather” epidemiology on nursing wards. Such approaches show the increasing value of newer computer techniques, such as machine learning and artificial intelligence, and can facilitate “house-wide” surveillance, remove observer bias, and free personnel time for health care worker education and adherence monitoring. Infection control programs and surveillance activities in many nursing homes and some long-term acute-care hospitals (LTACHs) are still in formative stages, highlighting a key opportunity for intervention by regulators, advisory agencies, and payers, given the role of long-term care facilities in the transmission of antimicrobial-resistant pathogens (Fig. 142-1).

FIGURE 142-1

Regional spread and control of antimicrobial-resistance. (From www.cdc.gov/vitalsigns/stop-spread.)

In the spirit of “what is measured improves,” most states require public reporting of health care–associated infection. Thirty-six states require health care facilities in their jurisdictions to report to CDC’s National Healthcare Safety Network (NHSN) (https://www.cdc.gov/nhsn/index.html) reporting system, which provides uniform definitions and facilitates transmission of data. Beginning in 2011, CMS required hospitals to report health care–associated infection data to NHSN to qualify for their full ...

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