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Infection control in hospitals—sink or swim?

BMJ 1997; 315 doi: (Published 15 November 1997) Cite this as: BMJ 1997;315:1315
  1. Keith F Barker, consultant microbiologist
  1. London

    It is questionable how many newly appointed consultant microbiologists relish the prospect of also acquiring the role of infection control doctor for their trusts. Recognised outbreaks are only a small proportion of hospital acquired infection but inevitably attract more attention. Indeed it was two major outbreaks and associated deaths in the mid-1980s and the adverse publicity concerning the hospital management that provided the impetus for the 1988 guidance, which was revised in 1995. As a result, the concept of an infection control doctor, usually a medical microbiologist, and infection control nurse is now well established. Published standards for infection control in hospitals exist, and yet it is estimated that still around one in 10 hospital patients will acquire an infection.

    It was an American study, now 20 years old, that showed a strong association between the establishment of intensive infection surveillance and control programmes and reduction of the rates of hospital acquired infection over a five year period. Most studies, however, accept that even with optimal infection control procedures there is an irreducible, but unfortunately often undefined, minimum number of infections associated with, for example, mechanical ventilation, lines, and catheters.

    The objective to reduce infection must be adequately resourced. This is usually translated into effective manpower, and specifically infection control nurses. The figure of one nurse for every 250 beds for effective surveillance and control programmes is constantly quoted, yet in Britain the figures are often less impressive.

    As an infection control doctor I am faced with three fundamental problems. Firstly, there is the hospital itself. The new NHS requires rapid turnover of patients and operates under considerable financial pressures. The concept of designated wards for designated specialties is disappearing. Patients are sicker and more vulnerable to hospital acquired infection. They are slotted into any bed, and often move through several different wards during their admission.

    These factors, coupled with increasingly shorter inpatient stays, complicate surveillance, epidemiological investigations, and, when they exist, effective control measures. There are both insufficient and inadequate side rooms in which to isolate patients. Cleaning contracts, levels of basic cleanliness, and the general fabric of clinical areas can be poor. Ward closures are now, more than ever, unpopular and difficult to justify. In essence the new management of the NHS negates effective infection control. It is not surprising that the government deliberately chose not to select hospital acquired infection as a key area to address in The Health of the Nation.

    The second frustration is the overprescribing of antibiotics. The pressure to keep patients out of hospital beds plays a major part. If antibiotics really moved these patients out of hospital beds more quickly then I could not object. The result is the exponential rise in isolates of methicillin resistant Staphylococcus aureus(MRSA), vancomycin/teicoplanin resistant enterococci, multiresistant gram negative organisms, and Clostridium difficile associated diarrhoea that now literally plague our hospitals. Although the patients are most likely to be asymptomatic carriers, managing MRSA easily occupies the full time of the single infection control nurse and can represent over 10% of a laboratory's workload. The existing guidelines, essentially an obsessive “search and destroy,” are now unworkable and ineffective. Some have already given up. Drafts of the new guidelines are circulating. I wonder how many of the people writing these guidelines actually deal with MRSA in our hospitals on a day to day basis. MRSA now bores microbiologists and clinicians alike, and, damagingly, is seen by too many people as synonymous with infection control. But as flucloxacillin (methicillin) begins to disappear from our antistaphylococcal armoury, as has penicillin, microbiologists anxiously await further clinical isolates of MRSA with reduced vancomycin susceptibility as recently reported in Japan. The race is on to be the first to report in Britain.

    The third and most frustrating problem is that even though hand hygiene is the most important factor in preventing hospital acquired infection staff remain reluctant to comply with any guidelines. Even on an intensive care unit appropriate hand hygiene techniques are rarely practised by medical and nursing staff. Insufficient washbasins or supplies of liquid soap and paper towels do not help matters. Worse still are the grubby bars of soap that still turn up occasionally.

    None of these problems is readily solved. Staff education may achieve, at least in the short term, improvement in antibiotic prescribing and hand hygiene. Maintaining such change is far more difficult. Much of our time is spent designing and producing written guidance and policies of good practice. Unfortunately, current resources often permit negligible policing and audit of these policies. Their existence merely lulls us into a false sense of security. Pressure from purchasers may focus attention on the problem, but I doubt that they would pay for it. Protocol driven care and heightened patient awareness of hospital acquired infection may force change. Litigious patients winning significant compensation might dampen enthusiasm for the crisis management that often pervades infection control at present. While the concept of patients demanding that the examining doctor or nurse wash their hands is an attractive one, the patients most at risk are, unfortunately, rarely able to make such demands. Televised monitoring and recording of handwashing practices is another possibility.

    At the end of the day infection control teams will continue to advise, educate, and manage hospital acquired infection to the best of their ability. Sustainable and significant falls in infection will be difficult to achieve and increasingly unlikely. The position may get worse. What is required is first a sufficient number of staff in clinical areas who then use commonsense and employ good clinical practice. Cooperation and commitment from all healthcare workers and managers is vital.

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