SYMPOSIUM


tions, SBT, and VTE appear beneficial, whereas daily oral care with chlorhex- idine and stress ulcer prophylaxis appeared to be harmful in some pa- tients.31


Further, CDC’s Wake Up and


Breathe Collaborative demonstrated that minimizing sedation, paired with daily spontaneous breathing tri- als and spontaneous awakening trials, early exercise and mobility, low tidal volume ventilation, and conservative fluid management along with mini- mization of blood transfusions can decrease VAE rates. Further decrease in duration of mechanical ventilation and targeting the primary conditions associated with VAEs can reduce them, as well.32


SURGICAL SITE INFECTIONS


SSIs can be superficial, deep, or organ space-related to the implantation of a prosthesis.33


a health organization anywhere from $18,902 to $22,667.16


If the infection is


related to an implanted hip or knee prosthesis, the costs could be substan- tially more expensive. The new Comprehensive Care for


Joint Replacement model aims to sup- port better and more efficient care for Medicare beneficiaries undergoing the most common inpatient surger- ies: hip and knee replacements (also called lower extremity joint replace- ments). The bundled payment and quality measurement associated with this model for hip and knee replace- ments encourages hospitals, physi- cians, and post-acute care providers to work together to improve the quality and coordination of care from initial hospitalization through recovery. The penalties associated with this model are severe and potentially crippling to a health care system that may not be practicing good prevention strategies when it comes to SSIs associated with hips and knees.34 Initiatives such as preoperative


showering of patients with an anti- septic soap the day before or day of surgery, keeping staff movements in and out of the operating area to a


A typical SSI may cost


minimum, selecting appropriate an- tibiotic prophylaxis with appropriate timing of administration before sur- gery, appropriate hand decontamina- tion for the first operation of the day using an aqueous antiseptic surgical solution (with a pick for the nails) and for subsequent surgeries (us- ing either an alcoholic hand rub or an antiseptic surgical solution), use of sterile gowns and gloves during surgery, antiseptic skin prep with an alcohol containing povidone-iodine or chlorhexidine, and maintaining patient homeostasis along with ap- propriate wound care have all been shown to prevent surgical site infec- tions. Maintenance of normothermia, supplemental oxygenation, and con- trol of blood glucose levels during the immediate postoperative period are additional measures that prevent SSIs.35,36


CLOSTRIDIUM DIFFICILE INFECTIONS


In 2013, CDC classified the antibi- otic resistance threat as urgent (the highest level) for C. difficile.37


These


threats, although currently not wide- spread, have the potential to become so and require urgent public health attention to limit transmission. It is estimated that the number of CDIs in the United States is about 500,000 in- fections per year, with 29,000 deaths and $4.5 billion in excess health care costs.37,38


Each infection costs about


$13,500 and potentially more if the in- fections are serious.16


During 2000-07,


deaths related to C. difficile increased 400 percent because of a more viru- lent bacteria strain that emerged. A majority of the deaths occur in people who are aged 65 and older. Lack of antibiotic stewardship and


environmental transmission of spores have been attributed as main causes for occurrence of C. difficile.37


Other


risk factors include immunosuppres- sion, proton pump inhibitor usage, age over 65, hospitalization, severe illness, enteral feeding, and gastroin- testinal surgery.39


It is recommended that patients with active C. difficile


diarrhea be placed in contact isola- tion rooms and proper hand hygiene be performed with soap and running water instead of alcohol-based hand gel, which has been found to be inef- fective. Similarly, CDC also recom- mends hospital cleaning be performed thoroughly and augmented using an Environmental Protection Agency- approved spore-killing disinfectant in rooms where C. difficile patients are treated.37


HOSPITAL ENVIRONMENT AND ITS RELATION TO HAI


Patients admitted to rooms where previous patients were infected with MRSA, vancomycin-resistant Entero- coccus (VRE), or C. difficile are at in- creased risk (two to three times high- er) for acquiring these organisms dur- ing their stay due to the persistence of these organisms in the patient’s envi- ronment.39-41


The full extent to which


hospital surfaces influence the trans- mission of HAIs is unknown, but it is widely accepted that surface contami- nation plays a major role in the spread of disease.6,7,42


Contaminated hands of health care


workers, which can come from con- tact with infected surfaces or persons, have been outlined as a potential fac- tor in the acquisition of HAIs, which, in turn, results in direct and indirect exposure of other patients to the in- fectious agent. Scientific evidence has clearly


supported the need to enforce hand- washing in order to minimize the risk of surface and hand contamination.6 The pervasiveness of these pathogens coupled with their survivability on health care surfaces presents a diffi- cult obstacle in the fight against HAIs and implies a high degree of responsi- bility for surface-mediated transmis- sion in the natural ecology of HAIs.43 The longevity and prevalence of some of the most common nosocomial pathogens emphasize the important need to incorporate preventive sur- face disinfection into health care set- tings.42,43


This implication is supported February 2017 TEXAS MEDICINE 45


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