American College of Physicians: Internal Medicine — Doctors for Adults ®

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Get the germs where they live—in the hospital

From the June ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Stacey Butterfield

There is good news and bad news about hospital-acquired infections, according to Dennis G. Maki, MACP, head of infectious diseases at the University of Wisconsin.

Get the germs where they live—in the hospital

The bad news is that there are increasing and novel drug-resistant pathogens being found in hospitals. “Traditional infection control practices that we have followed over the last 30 or 35 years are starting to fail us,” said Dr. Maki during a session at Internal Medicine 2009.

Drug-resistance rates are skyrocketing, especially in the intensive care unit (ICU), and sicker patients, nursing shortages, and limited surveillance aren’t helping the situation.

“We need a new paradigm if we’re going to successfully protect patients from these infections,” Dr. Maki said. “The good news is it’s very clear that the vast majority of nosocomial infections are device- or procedure-related. It’s good news because we’ve got a very good grasp of the pathophysiology of most device-related infections.”

There are new paradigms and technologies for preventing these infections, Dr. Maki told session attendees, and he urged them to put the concepts to work in their own hospitals. “A lot of progress is being made here. Our challenge is to implement it on a significant scale.”

The first concept in the new paradigm is actually an ancient one—hand hygiene. The statistics on compliance with handwashing are bad (25% to 50% at best, said Dr. Maki), and research has actually found more microorganisms on the hands of ICU personnel after they wash their hands than before.

To increase compliance and kill those microbes, many hospitals have gone over to waterless alcohol gels, but Dr. Maki is not with them, mainly because of Clostridium difficile. “My concern about waterless alcohol gels is that they don’t remove spores and they don’t kill spores, whereas running water and vigorous friction will help remove them,” he said. He favors conventional washing of hands and stethoscope with chlorhexidine.

Patients are even less likely to pick up germs off your hands if they have no contact with them. Barrier precautions are the standard in patients known to be carrying methicillin-resistant Staphylococcus aureus (MRSA), but the problem is that those patients are only the tip of the infectious iceberg.

“For every patient that you know is MRSA-positive because somebody serendipitously did a culture, I can guarantee you there are three or four patients in your hospital who are carrying MRSA that you don’t know about,” Dr. Maki said.

Some hospitals have tried universal screening, but there’s still a delay in getting the results; also, the process is expensive and covers only one type of infection. That’s why Dr. Maki has used preemptive barrier isolation for all high-risk patients to quell disease outbreaks in his hospital. “It’s something that really deserves to be studied better and used more widely,” he said.

There are also some new technologies and tools available to help in the fight against infections. Dr. Maki was excited about a new washcloth that is impregnated with chlorhexidine. In a recent study, giving patients a sponge bath with the washcloth and letting the residue dry on the skin resulted in a 60% reduction in central line infections compared to a traditional soap bath.

“If this is validated and looks to be as effective as they found, it will be a major advance in helping to prevent the spread of MRSA and other organisms,” Dr. Maki said.

Chlorhexidine is also an asset in protecting patients from intravascular device-related infections. About 15 years ago, Dr. Maki found that prepping skin with the antiseptic reduced central line infections. There’s also evidence support for the effectiveness of a chlorhexidine-impregnated patch for venous and arterial catheters and chlorhexidine oral care for ventilated patients.

Not that chlorhexidine is the end-all, be-all of antiseptics. “I’m convinced there are better disinfectants out there than chlorhexidine. We need better cutaneous antiseptics that last longer,” said Dr. Maki.

The search for the best antiseptic is also under way for patients with long-term intravascular devices, such as premature infants and dialysis patients. Dr. Maki supports the use of flush/lock solutions. He has had success with vancomycin-heparin in the pediatric ICU, methylene blue/citrate for hemodialysis patients, and ethanol for a woman with short-bowel syndrome. “As far as I’m concerned, there’s enough published data that it’s ready for prime time,” Dr. Maki said.

Cleaning a facility’s air and water can also reduce hospital-acquired infections, Dr. Maki noted. Ever since his hospital had a couple of outbreaks of legionellosis, they’ve had copper-silver ionization of the water. The technology costs about $35,000 to start up, plus $3,000 to 4,000 per year in maintenance, and has eliminated the disease from the hospital.

Much of the air at the University of Wisconsin is also filtered, in an effort to prevent ventilator-associated pneumonia. “In my hospital, where we do huge numbers of transplants, we have over 200 HEPA-filtered beds,” Dr. Maki said.

He offered some additional simple advice for pneumonia prevention. First, don’t intubate if you don’t absolutely have to. “If you don’t intubate people, you have much, much less pneumonia and there’s actually a survival advantage,” said Dr. Maki.

And everyone knows the advice about positioning ventilated patients at a semi-recumbent angle, but it turns out that putting the bed at exactly 45 degrees is critical. A recent study compared flat beds to having nurses position beds at the angle they usually do, which turned out to be around 30 degrees. “They almost never got to 45 and they had no differences [in outcomes],” Dr. Maki said.

He also offered a few quick tips for post-surgical infection prevention. Keeping patients warm, by using bed warmers, and hyperoxygenated, by giving them 80% oxygen during and for two hours after surgery, appears to reduce infection rates, Dr. Maki said.

The application of all these techniques and technologies across hospitals would be a major step forward in the battle against hospital-acquired infections. Although ICUs have the worst rates of infection and drug resistance, infection prevention efforts are absolutely necessary in the entire hospital, Dr. Maki warned his audience in closing.

“I’m very concerned that everybody’s so happy they got their rates down in the ICU. Can you tell me what progress you’ve made outside your ICU?”

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