Best Practices in Infection Prevention and Control: An International Perspective

Abstract

This is the second edition of this book and is a project supported by the Society of Healthcare Epidemiology of America (SHEA) and the Joint Commission international (JCI) and is designed to ‘provide practical strategies for creating a learning and performance environment for health care-associated infection (HAI) prevention that is centred on patient care’. It takes a worldwide perspective with contributions from all continents and includes hospital-acquired infections, epidemics, and pandemics and even bioterrorism. What this book does well is bringing together the institutional processes from various sources which might provide strategy for managing outbreaks and crises. What it is less good at is providing scientific evidence to justify recommendations. Providers of healthcare, whether at an institutional or national level, are understandably very worried about infection. The approach in recent years has therefore been to institute processes and governance structures for the management of HAIs through the development of infection control professionals and teams. These teams are multidisciplinary and although may differ in structure around the world, they may be given great resource and influence. Each time there is an event, locally or nationally, a series of procedures, precautions, and rules are introduced to overcome the problem. When done well, they can be very successful and real reductions in HAIs can be observed. A good example of this has been in the management of central venous catheters where bundles of care have been reproducibly shown to decrease the risk of serious bacteraemia. The difficulty, however, is that it is impossible to tease out of these systems what is important or indeed vital for success and what is superfluous effort and expense. Of course, it can be argued that so long as it works, does understanding what works matter? In these days of austerity, perhaps this will matter more than it did before. Some actions do not need any further justification, for example, hand washing, this was shown to be important so long ago it is difficult to see how anyone can justify not including this is in their routine management of every patient, nevertheless, 100% adherence to hand washing is still to be achieved. Other actions may appear logical and obvious, but may not be so. An illustration of this may be cohorting patients in one part of a ward with, for example, methicillin-resistant Staphylococcus aureus (MRSA). There is in fact very little evidence that this is necessary for MRSA and indeed in my own institution we actually observed a decrease in cross-contamination when we stopped cohorting all patients with MRSA in one part of our intensive care unit. Of course, this is not proof against cohorting patients and indeed for highly infectious diseases, isolation and cohorting may be entirely logical and necessary, but if the literature is reviewed, there is little proof that it is important for some HAIs. Cohorting is often justified but always in the context of an infection control bundle and it has not been tested as a single measure, although this would be difficult to achieve. The book is full of examples where individual measures are included on the assumption that they are proven necessities and infection control teams will insist on them as proven necessities. I had hoped the book would discuss some of the individual measures in detail but it kept to systems and strategies. It may now be virtually impossible to unpick what is important and what is not from many of the bundles described and indeed this is one of my main criticisms. In a number of chapters, the authors have provided case studies. Many of these are interesting to read, but they do not constitute evidence and I do think that this is overlooked. Most of them would not achieve the grade for publication in a peer-reviewed journal. For the majority of scenarios, the lack of real evidence may not matter but in the worst case, a seemingly good idea may actually do harm. There are many examples of this in medical practice and infection control is not immune to this pitfall. I am not sure that this book is of great relevance to individual clinicians managing patients on a day-to-day basis, but all healthcare workers need to be very aware of HAIs and potential methods for their prevention. This book should prove useful to anyone setting up an HAI prevention programme.