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Healthcare-associated sepsis and the role of clean hands: When we do not see the trees for the forest
PETERS, Alexandra, MASSON-ROY, Sarah, PITTET, Didier
PETERS, Alexandra, MASSON-ROY, Sarah, PITTET, Didier. Healthcare-associated sepsis and the role of clean hands: When we do not see the trees for the forest. International Journal of Infectious Diseases , 2018, vol. 70, p. 101-103
DOI : 10.1016/j.ijid.2018.02.017 PMID : 29501872
Available at:
http://archive-ouverte.unige.ch/unige:115820
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Editorial
Healthcare-associated sepsis and the role of clean hands: When we do not see the trees for the forest
Asofthispastyear,sepsishasbeenredefinedasa“lifethreatening organ dysfunction caused by a deregulated host response to infection”,whichoftenleadstohighratesofmorbidityandmortality (Singeretal.,2016).Althoughtherealburdenofthischallenging conditionisunknown,asystematicreviewestimatedthatthereare around30millioncasesand6milliondeathsattributedtosepsisper year(Fleischmannetal.,2016).Thereisadistinctpossibilitythatthis estimate,although immense,is low, astheconditiondispropor- tionallyaffectsthedevelopingworld.Inareaswhereinformation gatheringisoftenlimited,therealincidenceofsepsisisdifficultto quantify.(“RecognizingSepsisasaGlobalHealthPriority—AWHO Resolution|NEJM,”n.d.).“Theburdenofsepsisinthedeveloping worldisenormous,outcomesareoftenpoor,andsocioeconomic consequencesaredire”(Shresthaetal.,2017).IntheGlobalBurdenof Diseasestatistics,itsburdenisnotaccuratelyrepresented,asdeaths duetosepsisareclassifiedaccordingtotheunderlyinginfection (“RecognizingSepsisasaGlobalHealthPriority—A WHOResolution
|NEJM,”n.d.).
Butsepsis isfarfrombeinganeglectedtropicaldiseasethat onlyaffectsthedevelopingworld.Eveninhigh-incomecountries, withmodernhospitalsandstate-ofthe-artequipment,itremainsa major cause of death in children (Dellinger et al., 2008).
Furthermore,its burden is increasingrapidly. In thedeveloped world, sepsis is increasing at a rate of 8%-13% annually, with attributedhospitalizationsmorethandoublingbetween2000and 2008(Reinhartetal.,2013),(Halletal.,2011).OnestudyintheU.S.
foundittobea contributingfactor inbetween33%- 50%ofall hospitaldeaths(“HospitalDeathsinPatientsWithSepsis|Critical CareMedicine|JAMA|TheJAMANetwork,”n.d.).
Althoughfamiliartoacademicsandclinicians,theconditionhas remainedlargelyignoredbygoverningbodiesand international healthcaresystems(“RecognizingSepsisasaGlobalHealthPriority
— AWHO Resolution |NEJM,” n.d.).As a result of therecent renewedinterestinsepsis,andduetoadvancesinunderstanding itspathophysiology,management,andepidemiology,therewere reasonstore-examinethecondition,updatetheguidelinesand redefinethetermitself(Singeretal.,2016).In 2017,theWorld Health Assembly (WHA) adopted a resolution focusing on preventing, diagnosing and managing sepsis (“WHA Adopts ResolutiononSepsis,”n.d.).
Becausemostof thecases are ofcommunity origin,current literaturetendstofocusonhowtorecognize,preventandtreat
sepsisinthecommunity.Forexample,amongpatientswithsepsis incriticalcare,60%alreadydevelopedtheconditionpriortotheir admission(Vincentetal.,2014).Wetendtostrivetoseethebig pictureinthisepidemic;afterall,mostofthesepatientsalready havesepsiswhentheyareadmitted.Theinstanceswhensepsisisa direct consequence of healthcare itself, as a complication of healthcare-associated infection (HAI), are largey ignored. Little attention hasbeenfocused on howto prevent theepisodes of sepsis thatarecausedbycare,inbothinpatientand outpatient settings. Thismightbe inpartdue tothelack of moreprecise epidemiologicalstudies,whichwouldhelpclarifytheextentofthe issue.Itcouldalsobeinfluencedbythecomparativelylownumber ofhealthcare-associatedsepsiscomparedtothetotalnumberof sepsis cases globally. This means that campaigns targeting healthcare-associatedsepsiswouldlikelyhavelessofameasure- ableimpactwhencomparedtothelarger-scalecampaigns,which are already known tobe effective.For example,pneumococcal vaccineswereshowntodrasticallyreducethenumbersofsepsisin the community (Thorrington et al., 2018). In order to reduce healthcare-associated sepsis, the focus must be on changing healthcareworker(HCW)behaviourregardinginfectionpreven- tion and control (IPC) measures. It comes as no surprise that modifying human behaviour is more difficult than vaccinating peopleandneedstoincorporateelementsfrombehaviouraland implementation science. We tend to want to concentrate our resourcesinthemajorareas(suchasvaccinationstopreventsepsis inthecommunity),essentiallymakingsurethatwedonotfallinto thetrapof“notseeingtheforestforthetrees”.Butwhatthisadage doesnottakeintoaccount istherelativeinfluencethat canbe exerted directlyby HCWs onthecomparatively minorissue of reducinghealthcare-associatedsepsis.
Although the total numberof sepsiscases due to HAI is much lower thanthenumberofcommunity-onsetsepsis,theyaresignificant additional and preventable infections. If HCW behaviorcannot reduce the occurrence of sepsis in the community, it makes sense to focus our efforts onwhere itcan.Sepsisinhealthcare can belinked to exogenous cross-transmission,andthistransmissioncouldbereducedbyHCW adherence to IPC measures, especially hand hygiene. HCWs’hands are consideredthemostimportantvehicleformicrobialcross-transmis- siontopatients;50-70%ofHAIsarelinkedtopoorhandhygiene.Itis logicalthatincreasinghandhygienecompliancecouldplayapivotal roleinpreventinghealthcare-associatedsepsisinbothdeveloping
https://doi.org/10.1016/j.ijid.2018.02.017
1201-9712/©2018TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
InternationalJournalofInfectiousDiseases70(2018)101–103
ContentslistsavailableatScienceDirect
International Journal of Infectious Diseases
j o u r n a l h o m ep a g e : w w w . e l s e v i e r . c o m / l o c a te / i j i d
and developed countries. In low and middle income countries (LMICs),38%ofhealthcarefacilities donothaveanadequatesourceof cleanwater,whichcompromisestheirabilitytopreventandcontrol infectionsbyhandwashing(WorldHealthOrganizationandUnited Nations’Children’sFund,2015).Thislackofclean waterincreasesthe riskforHAIandsepsis.Theuseofalcohol-basedhandrub(ABHR)for handhygienegreatlyreducestheneedforcleanwaterinprovidinga hygienicstandardofcare.
Because improved compliance with hand hygiene has been shown to drastically reduce HAI (Pittet et al., 2000), it could ostensiblyalsoreducethethreatofsepsis.Areducednumberof infections also means that there is less need for prescribing antibiotics,which inturncanlowerantibiotic consumptionand helpreduce thespread of resistantorganisms. Thereis a clear correlationbetween infections and sepsis caused bymultidrug resistantorganismsandtheabilitytosuccessfullytreatthem.For example, methicillin resistant Staphylococcus aureus (MRSA) infections are associated with a 50% higher mortality than infections caused by Staphylococcus aureus susceptible strains (Hanbergeretal.,2011).
The5May2018WHO“SAVELIVES:CleanYourHands”campaign (WorldHealthOrganizaiton,n.d.)targetssepsisinhealthcare;itis especiallytimelyconsideringtheincreasedglobalawarenessofHAI and the concern towards the increasing number of multidrug resistantorganismsworldwide.The“SAVELIVES:CleanYourHands” campaignwaslaunchedin2009,andiscelebratedannuallyon5
Maytopromotehandhygieneinhealthcarearoundtheworld.Each yearthereisadifferentfocusandcalltoactionspecifictohand hygiene,andthisyearitfocusesonhealthcare-associatedsepsis.
“It’sin yourhands;preventsepsisinhealthcare”(seeFigure1).Calls toactionhighlightconcretestrategiesthatindividualHCWsand theirinstitutionscanimplementinordertoincreasecompliance andreducetheburdenofHAI(seeTable1).Thecampaignendeavors to gather every possibleactor among healthcare professionals, hospitaladministrators,politicians,patientsandpatientgroups,as wellasallstakeholdersinordertopromoteaglobaladvocacyeffort for the critical role of hand hygiene in healthcare. Tools for campaigningandparticipationareavailableathttp://www.who.
int/gpsc/5may/en/.Healthfacilitiesthatwouldliketobeapartof thisinternationaleffortcanregisterthroughtheWHOdedicated website: http://www.who.int/gpsc/5may/register/en/. Join the over200000facilitiesaroundtheworldthatparticipate!
AHCWcannotcontrolmuchofwhathappensinthecommunity before a patient arrives in a hospital, with the exception of community and nurse practitioners and emergency and ambu- lance departments’ staff.However, HCWs do have controlover whathappensassoonasthepatientisseekingcare.Itiskeythat weengageinanefforttocombathealthcare-associatedsepsis– notjustforthehealthofthepatients,butalsoforthefaiththatthey haveinthehealthcaresystem.
Improvinghandhygiene,andthusreducingHAIingeneral,isa straightforward, cost-effective, and proven strategy that hospitals and
Figure1.“It’sinyourhands;preventsepsisinhealthcare”.
5May2018WorldHealthOrganizationSAVELIVES:CleanYourHandscampaignsloganandmainpromotionalimage(2018hashtags:#HandHygiene#Sepsis).Campaign participantsareinvitedtosubmitphotos/selfiesofthemholdingaboardwiththesloganandhashtagsatwww.CleanHandsSaveLives.org.
102 A.Petersetal./InternationalJournalofInfectiousDiseases70(2018)101–103
healthcareinstitutionscanimplementtoimprovepatientoutcomes.
Theevidencesuggeststhatimplementingsuchmeasurescouldalso drasticallyreducetheratesofhealthcare-associatedsepsis.Although sepsisremains oneofthe worstpossible outcomesfora routine hospitalization,itisalsoonethatHCWhavealargedegreeofdirect controlover.Pleasejointhecampaign,andhelpmakesurethatwedo notmissseeingthetreesfortheforest.
Funding
InfectionControlProgramme&WHOCollaboratingCentreon Patient Safety (SPCI/WCC), University of Geneva Hospitals and FacultyofMedicine,Geneva,Switzerland;handhygieneresearch activitiesattheSPCI/WCCsupportedbytheSwissNationalScience Foundation(32003B_163262).
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AlexandraPeters InfectionControlProgrammeandWHOCollaboratingCentreon PatientSafety-InfectionControl&ImprovingPractices,Universityof GenevaHospitalsandFacultyofMedicine,Geneva,Switzerland SarahMasson-Roya,b
aInfectionControlProgrammeandWHOCollaboratingCentreon PatientSafety-InfectionControl&ImprovingPractices,Universityof GenevaHospitalsandFacultyofMedicine,Geneva,Switzerland
bDépartementdeMicrobiologieetd'Infectiologie,CentreHospitalier AffiliéUniversitaireHôtel-DieudeLévis,Lévis,Québec,Canada DidierPittet*
InfectionControlProgrammeandWHOCollaboratingCentreon PatientSafety-InfectionControl&ImprovingPractices,Universityof GenevaHospitalsandFacultyofMedicine,4RueGabrielle-Perret- Gentil,1211Geneva,Switzerland
*Correspondingauthor.
E-mailaddress:didier.pittet@hcuge.ch(D.Pittet).
CorrespondingEditor:EskildPetersen,Aarhus,Denmark Received20February2018 Table1
5May2018WorldHealthOrganizationSAVELIVES:CleanYourHandscampaigncallstoactions.
Healthworkers “Take5Momentsatocleanyourhandstopreventsepsisinhealthcare”
IPCbleaders “Beachampioninpromotinghandhygienetopreventsepsisinhealthcare”
Healthfacilityleaders “Preventsepsisinhealthcare,makehandhygieneaqualityindicatorinyourhospital”
Ministriesofhealth “Implementthe2017WHAcsepsisresolution.Makehandhygieneanationalmarkerofhealthcarequality”
Patientadvocacygroups “Askfor5Momentsaofcleanhandstopreventsepsisinhealthcare”
aReferstothe“My5MomentsforHandHygiene”aspublishedintheWHOGuidelinesonHandHygieneinHealthCare”(WorldHealthOrganization,2009).
b IPC:Infectionpreventionandcontrol.
cWHA:WorldHealthAssembly.
A.Petersetal./InternationalJournalofInfectiousDiseases70(2018)101–103 103
