Issues in infection control: a potpourri

August 2004

Since the special emphasis in this issue of Infectious Disease News is nosocomial infection, it seems an appropriate opportunity to comment on some loose ends and unfinished business in infection control that have been discussed in the past. There are four such topics that merit comment: conflicting guidelines, hand washing issues, patient safety issues and Occupational Safety and Health Administration (OSHA) activities.

HICPAC vs. SHEA guidelines

First, conflicting guidelines. Publication (in draft form for public comment) of the CDC Hospital Infection Control Practices Advisory Committee (HICPAC) Guidelines for Isolation Precautions in Hospitals has served to underscore the confusion in the infection control community on how best to limit the spread of multiply resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). This is well illustrated in the report elsewhere in this issue of IDN describing the role of active surveillance cultures debated at the recent Association for Professionals in Infection Control and Epidemiology meeting in Phoenix by Drs. Bill Jarvis and Bill Scheckler. It seems most likely that most of the audience didn’t fully understand the differences between the Society for Healthcare Epidemiology of America (SHEA) and HICPAC guidelines, and wound up feeling that since the “experts” couldn’t agree, it probably didn’t matter too much what they did.

I have expressed my opinions of the SHEA guidelines, at least as pertains to VRE, previously in this column (August 2003) and have no wish to comment further at this time. Briefly, however, the SHEA guidelines call for active surveillance cultures in high-risk areas to detect MRSA and VRE under any circumstances. The HICPAC guidelines, on the other hand, call for a two-tiered approach, recommending less stringent measures in settings where little or no transmission of MRSA or VRE is occurring and more stringent precautions, including active surveillance cultures, in circumstances where transmission is out of control.

Without debating the merits of either set of guidelines, it is unfortunate there are now two sets of disparate guidelines out there, leading inevitably to debates among infection controllers and hospital epidemiologists about whose guidelines should be followed. When these kinds of conflicting recommendations have occurred with vaccines, as for example when there have been differences in what the American Academy of Pediatrics and the CDC’s Advisory Committee on Immunization Practices have recommended, the result has inevitably been widespread confusion among health care providers. For this reason, those two bodies now very carefully see to it that their recommendations are harmonized, if not exactly identical. One hopes that SHEA and HICPAC will amicably resolve their differences as soon as possible and come up with coordinated, science-based guidelines.

Hand hygiene

This leads directly to the second topic, hand washing and hand hygiene issues. Several articles have been published in the last several months that underscore our (meaning all health care personnel’s) continuing failure to practice the basic tenets of hand hygiene.

I would call your attention particularly to the article by Didier Pittet and his colleagues in the July issue of the Annals of Internal Medicine, along with the accompanying editorial by Bob Weinstein. Pittet et al carried out a cross-sectional survey among 163 faculty physicians at the University of Geneva Hospital. Adherence to hand hygiene recommendations averaged 57% and was positively associated with awareness of being observed, perception of being a role model for colleagues, a positive attitude toward hand hygiene after patient contact and easy access to alcohol-based hand gels.

Nonadherence, on the other hand, was associated with high workload, activities associated with a high risk of transmission and the medical specialties of surgery, anesthesiology, emergency medicine and intensive care medicine. These four areas account for as much as 60% or more of many modern hospitals! This will not be cheerful reading. It is, in fact, a major disgrace in health care that these kinds of deficiencies continue to be documented whenever someone takes the trouble to look.

A recent editorial (N Engl J Med. 350(13):1283-1286) by Atul Gawande, entitled “On Washing Hands,” provided a much-needed insight. This surgeon commented about his feelings when one of his patients encountered problems with MRSA and VRE; it is well worth reading. A surgeon such as this on a hospital infection control committee could work wonders among his surgical colleagues. If we were all 100% compliant in practicing good hand hygiene, there would likely be no need even to think about contact precautions for multiply resistant organisms, much less worry about conflicting guidelines.

Patient safety

Third, patient safety issues. Ever since publication in 1999 of the Institute of Medicine report “To Err is Human,” many in the infection control community recognized that the tools needed to address patient safety issues were, in fact, the tools of hospital epidemiology, ie, surveillance, investigation, data collection and analysis and feedback. Thus, many of us applauded efforts by many leaders, notably Julie Gerberding, then director of what was formerly known as the CDC’s Hospital Infections Program, to place the patient safety program into the mainstream of hospital epidemiology, since it seemed so clearly to be our “turf.”

Other leaders in the field who wrote of the need for input of hospital epidemiology in the patient safety movement included Bill Scheckler (Infect Control Hosp Epidemiol. 2002;23:48-52) and most recently, John Burke (N Engl J Med. 2003;348:651-656). Five years later, however, nothing like that has happened. The patient safety movement seems to be firmly in the hands of bureaucrats, industrial safety leaders and the payers. Julie Gerberding has other things on her mind these days. SHEA, the obvious organization to lead such a movement, has been noticeably silent on the issue.

Thus, almost by default, we seem to have lost that battle, at least for the time being.

OSHA activities

Finally, OSHA activities. Most recently, as of July 1, OSHA has lifted its temporary suspension of enforcement of the respiratory protection rule. Among other things, perhaps, the most ridiculous requirement is that fit testing be carried out annually, as if facial dimensions were continuously undergoing sculpturing so significant as to require repetitive fit testing.

Evidently, this is another organization that needs input from hospital epidemiology; lacking that, or at least failing to heed the available science, they seem to continue to shoot themselves in the foot. Rumor has it that there is legislation afoot in Congress to prevent OSHA from going even further off the deep end, but, judging from the past, don’t hold your breath!

More will surely follow!