It's only infection prevention, but infection prevention is all we have.

Abstract

Catheter associated urinary tract infections (CAUTI) are supposedly a very common cause of nosocomial infection in the Intensive Care Unit (ICU).[1] Pyuria and bacteruria are, however, inevitable in every patient who has a Foley's Catheter in place for a few days. It is, therefore, difficult to separate catheter associated bacteruria from true CAUTI.[2] In our country, ventilator associated pneumonia and central line associated blood stream infections (CLABSI) remain the main bug bears in the ICU. Many of the episodes of CAUTI occur after the patient has been transferred out of the ICU after removal of the catheter (especially if the catheter has been removed prematurely and the patient needs re catheterization). Even so, the incidence of true CAUTI is probably over estimated. In this Issue Jain et al.[3] have studied the knowledge and attitude of doctors and nurses towards prevention of CAUTI in a Tertiary Care Hospital. Irrespective of the true incidence of CAUTI, this is an important study. The focus of this study was CAUTI, but the findings of this study are a reflection of the knowledge and attitudes of Health Care Workers (HCW) toward prevention of any nosocomial infection. If a similar study were done about hospital acquired pneumonia or about CLABSI, it is unlikely that the results would be any less depressing. It is interesting to note that the HCW were reasonably good at identifying effective methods of preventing urinary tract infections. They however were very poor at identifying the noneffective methods (metal cleaning, bladder wash, prophylactic antibiotics, etc.). Many useless, expensive and potentially harmful practices are unfortunately therefore still being followed in many ICUs in our country. This is also probably the reason why many other useless practices such as fumigation, removal of foot wear, restriction of visitors, etc., continue to be popular. This study was conducted in a tertiary care hospital, one shudders to think of the results of a similar survey in smaller hospitals. It is a small mercy that HCW in the ICU performed slightly better than the others. This is probably because intensive care is the only speciality, which gives some importance to infection prevention. It is also heartening to note that most of those surveyed recognized that infection prevention should be a priority. They also recognized the importance of education. Preventive medicine has never got the importance it deserves in the medical and nursing curriculum. It is the “Cinderella,” the neglected step sister. This needs to change. Preventive medicine needs a godmother, “Cinderella” needs to be transformed. Infection prevention should be part of the curriculum at both under graduate and postgraduate level (irrespective of specialty). There should be at least one question related to infection control in the qualifying examinations. While seeking renewal of registration, it must become mandatory for a physician to have attended at least one continuing medical education on infection prevention each year. Hospitals must dedicate a minimum of 1-day each year to re-educating and re training their staff in infection prevention. Unfortunately, increased knowledge does not always translate into better practice. In a study performed in a premier teaching hospital in India, doctors scored better than nurses in knowledge of infection prevention practices, but performed much worse when it came to practice of these measures.[4] In a study from South India, after an education program, in spite of an increase in knowledge scores, doctors were the least compliant of the HCW in infection control practices. Several studies have shown that doctors are the worst offenders when it comes to hand washing.[5] Why do doctors have such a poor attitude towards infection control? A major share of the blame must go to the senior doctors. The average age of the respondents in this study was quite low, the results would probably have been more dismal if more senior personnel had been surveyed. Junior doctors and even other HCW tend to copy the behavior and attitudes of the Senior doctors. Unfortunately until recently Senior doctors have been very poor role models at least as far as infection prevention is concerned. Fortunately, intensive care is a relatively young specialty with relatively younger more enlightened leaders. It is their responsibility to lead by example.[6] In these days of “Bad Bugs, No Drugs,” infection prevention is all we have.