|Year : 2018 | Volume
| Issue : 2 | Page : 155-162
Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach'
Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||7-Aug-2018|
Prof. Purva Mathur
Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background: Healthcare-associated infections (HCAI/HAIs) are one of the most common adverse events in patient care and account for substantial morbidity and mortality. The high rates of HCAIs in a facility are an indicator of poor quality of healthcare services. According to the World Health Organization, at any time, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI. These infections also present a significant economic burden at the societal level. However, a large percentage of HAIs are preventable through effective infection prevention and control measures. Objectives: Prevention of these infections also needs to be prioritised in view of the growing antimicrobial resistance in HAIs. The bundle approach to the prevention of HAIs is a relatively new concept that is revolutionising the care of high-risk patients in the Intensive Care Units. This report details the bundle approach for the prevention of HAIs, particularly the device-associated infections, for low- and middle-income countries. Conclusion: With the escalating armamentarium of antimicrobial resistance, healthcare sector has to go back to the very basics of hospital infection control; develop, assess and implement bundles of prevention. These are cost-effective and easily adaptable, to cater to the increasing HCAIs and MDR infections in the LMICs.
Keywords: Bundle approach, healthcare-associated infections, patient care
|How to cite this article:|
Mathur P. Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach'. Indian J Med Microbiol 2018;36:155-62
|How to cite this URL:|
Mathur P. Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach'. Indian J Med Microbiol [serial online] 2018 [cited 2019 Feb 23];36:155-62. Available from: http://www.ijmm.org/text.asp?2018/36/2/155/238689
| ~ Introduction|| |
Healthcare-associated infections (HCAIs/HAIs) are increasingly driving the outcomes of patients in both acute- and long-term care health facilities. Device-associated infections (DAIs) such as ventilator-associated pneumonia (VAP), central line-associated bloodstream infections (CLA-BSIs), catheter-associated urinary tract infections (CA-UTIs) and surgical-site infections (SSIs) together account for most of the HAIs across the world.,
HAIs have tremendous implications in terms of associated mortality, morbidity, increased cost of treatment, adverse patient outcomes and social impact. Apart from their escalating rates, HAIs are now frequently being caused by multi- and pan-drug-resistant organisms, causing therapeutic dilemma. DAIs continue to be one of the main threats to the patient safety, particularly in Intensive Care Units (ICUs) of low-and middle-income countries (LMICs).,,,
Of the annual 12 million deaths, 95% occur in LMICs, where infection prevention and control (IPC) policies are non-existent, poorly adapted or insufficiently funded by governments., There is paucity of basic life-saving equipment and drugs; the priority given to HCAIs is even lesser. Of the many causes of higher prevalence of HCAIs in LMICs, the most important are the lack of financial resources, workforce and policies for infection control; lack of surveillance systems; poor hygiene and sanitation; paucity of induction and continuous training for healthcare workers on infection control; limitations in sterilisation/disinfection and aseptic practices (especially in primary-level acute care facilities of low-income countries); limited access to microbiology services in many hospitals and lack of regulations for use of antimicrobials.,, In these countries, there is a dearth of literature available on the prevalence of HCAIs and the best preventive practices which can be adopted and implemented in their hospitals.
High morbidity, preventable deaths and expenditure which HAIs cause should be reason enough to upscale infection control efforts in all healthcare facilities (HCFs). A growing body of evidence from well-designed studies indicate that up to 10%–70% of HAIs can be prevented by implementation of appropriate infection control protocols. Most studies support the observations that at least 1/3rd of HAIs can be prevented in HCFs by surveillance and implementation of evidence-based guidelines for prevention of infections (especially device-related infections and SSIs)., Some of the most effective infection prevention measures are the most basic, easy and cost-effective practices that can be incorporated in routine patient care workflows.
'Bundle approach' to prevention of infections
Observational studies confirm that evidence-based approaches can reduce infections., For this reason, the care bundle approach was introduced by the Institute for Healthcare Improvement (IHI). One of the five goals of the 'saving 100,000 lives' campaign, launched by the IHI, was to prevent VAP and deaths associated with it by implementing a set of interventions known as the 'Ventilator Bundle'. A care bundle is defined as the implementation of a set of evidence-based practices such that, when each element is executed individually, it improves the patient recovery process and outcomes; when all of the practices are executed together, they provide better outcomes than when implemented individually. The ventilator and central line bundles were the first two bundles developed by IHI. Care bundles have now been applied for VAP, CLA-BSI, CA-UTI and SSIs.
Bundles help healthcare workers translate evidence into practice by summarising and simplifying the best evidence and providing reminders to adhere to evidence-based practices. Moreover, the goal-oriented and multifaceted nature of bundles also provides opportunities to providers to adapt the health delivery system, such as implementing structural changes and improving teamwork, resulting in improved patient outcomes.
Requirements for a 'good care bundle'
The bundle approach to prevention has been found to be highly effective in reducing the incidence of DAIs and in reducing the mortality and ICU stay. However, to be effective, the interventions selected in a preventive care bundle should have scientific support of effectiveness, based on randomised controlled trials. All the elements of the bundles must be executed at the same time. The management of hospital-acquired pneumonia (HAP) using a preventive bundle typically exemplifies a multidisciplinary approach. The responsibilities of this multidisciplinary group include setting prevention benchmarks, establishing goals and timelines and providing appropriate education, training, audits and feedback to the staff and, at the same time, continually updating themselves on the relevant clinical and prevention strategies.
Central line-associated bloodstream infections
CLABSIs are associated with increased morbidity, mortality and healthcare costs. In a recent study, the rates of CLABSIs in the International Nosocomial Infection Control Consortium (INICC) ICUs (i.e. in Africa, Asia, Europe and Latin America) were reported to be 4.9 infections per 1000 central-line-days, which was almost five times higher than that reported from ICUs in the USA. Prevention of CLABSIs represents a complex challenge for the infection control teams and the healthcare providers in general. It is important to understand the pathogenesis of CLABSIs in order to devise preventive bundles. In a patient with a central vascular catheter (CVC), pathogens can enter the blood via the following routes:
Organisms can be carried hematogenously to the indwelling catheter from the remote sources of local infection (e.g., pneumonia).
Microorganisms can contaminate the catheter hub (and lumen) when the catheter is inserted over a percutaneous guide wire or later manipulated in a variety of ways. Inadequate disinfection of access sites (i.e., needleless connectors), incorrect use of stopcocks and other types of connectors and inadvertent contamination of intravenous (IV) administration sets and tubing facilitate the microbial entry into an otherwise sterile system. Intraluminal colonisation becomes a significant risk in the pathogenesis of CLABSI with increasing dwell time. This risk is one of the reasons for the genesis of CLABSI maintenance bundles. This is also the reason why the CVCs must be removed as early as possible.
The core measures for reducing the risk of intraluminal contamination include the following:,,
- Careful and meticulous hand hygiene
- Attention to aseptic technique with all infusion-related procedures
- Minimal manipulation of the central catheter and adjunct administration components
- Rigorous disinfection practices when the system must be manipulated (SCRUB THE HUBS).
Extraluminal spread occurs when skin organisms, most commonly coagulase-negative staphylococci and Staphylococcus aureus, incite an infection through portals of entry, including skin at the insertion site and catheter hubs. This is the mostly likely source of an incubating infection for catheters in place for <14 days.
Infusates, such as parenteral fluids, blood products or IV medications, can also potentially become contaminated and lead to device-associated BSIs. Most healthcare-associated epidemics of infusion-associated BSIs have been traced to contamination of infusate by Gram-negative bacilli, introduced during manufacturing (intrinsic contamination) or during preparation and administration in the healthcare settings (extrinsic contamination). This is however an uncommon cause of endemic BSIs.
Bundle approach to prevention of central line-associated bloodstream infection
Research indicates that 65%–70% of CLABSIs are preventable by implementing evidence-based strategies currently available to healthcare professionals. In comparison to other HAIs, CLABSIs are associated with the highest number of preventable deaths. The use of CLABSI bundle, the first one introduced by the IHI, has been associated with a sustained decrease in the incidence of CLABSI globally., In a landmark study, Pronovost et al. demonstrated that an intervention including care bundles in 103 ICUs decreased infection rates by up to 66%. The individual elements included hand washing, using full-barrier precautions during the insertion of central venous lines, cleaning the skin with chlorhexidine, avoiding the femoral site if possible and rapidly removing unnecessary catheters. Subsequently, many studies have supported the role of bundle approach in the prevention of CLA-BSIs in adults and children.,,,, Thus, the CLABSI bundle identified a group of interventions supported by the highest level of research, which when used together would ideally produce better outcomes than if one or more had been used separately.
The practices described in the IHI CLABSI bundle include the following:
- Hand hygiene
- Maximal sterile barrier precautions upon insertion
- Chlorhexidine skin antisepsis
- Optimal site selection (avoidance of femoral vein in adults)
- Daily review of central line necessity and prompt removal of unnecessary lines.
These five evidence-based interventions remain the cornerstone of CLABSI prevention, especially at the time of catheter insertion. Growing evidence suggests that addition of a maintenance bundle to a central-line insertion bundle might be even more effective in the prevention of CLABSIs in children and infants. [Figure 1], [Figure 2], [Figure 3] show the insertion and maintenance practices recommended for prevention of CLABSIs.
In a recently published meta-analysis by Ista et al., on the effectiveness of preventive bundles for CLABSI, encompassing neonatal to adult ICUs, the baseline CLABSI incidence ranged from 1.2 to 46.3/1000 catheter-days in adult ICUs, from 2.6 to 31.1 in paediatric ICUs (PICUs) and from 2.6 to 24.1 in neonatal ICU (NICU). After implementation of the central-line bundles, the incidences ranged from 0.3 to 19.5/1000 catheter-days in adult ICUs, from 0.1 to 16.5 in PICUs and from 0.1 to 14.9 in NICUs. All studies reported cost savings in high-income countries. For the insertion bundle, addition of hand hygiene significantly reduced CLABSIs in adult ICUs. Other important elements included a CVC kit and proper selection of insertion vein in PICUs. The effectiveness of the CLABSI bundle was also reiterated in the Keystone ICU project in Michigan ICUs. The CLABSI bundle has now been adopted by most hospitals across the US; the bundle is an essential requirement for all accredited hospitals by The Joint Commission as part of its National Patient Safety Goal to prevent CLABSIs.
Prevention of catheter-associated-urinary tract infections
CA-UTIs are the most common HCAIs;, it is estimated that 65%–70% of CA-UTIs may be prevented by following evidence-based strategies. Due to the high cost associated with CAUTIs, the Centers for Medicare and Medicaid Services have included CAUTI as a penalty in the value-based purchasing model, causing it to be a focus for improvement among acute care institutions. As compared to intravascular catheters, preventive developments for urinary catheter-related infections have been slow. This is largely due to the difference in the pathogenesis of CAUTIs as compared to CLABSIs. Urinary catheters are bathed in static urine in contrast to the turbulent flow of blood in vascular catheters. The urinary catheters get coated with Tamm–Horsfall proteins, which in turn facilitates the attachment of uropathogens. Urinary catheters traverse through a natural orifice, heavily colonised with bowel flora, making microbial catheter colonisation inevitable after a few days. Moreover, in contrast to short-term use of vascular catheters, urinary catheters are often used for years.,, The reason for the inevitable failure to suppress bacteriuria in chronically catheterised patients is thus related to the pathogenesis of infections in such patients: the nearby bowel flora is numerous, diverse and frequently resistant to antimicrobials. This microbial mass also readily receives or transmits resistance plasmids in its small ecological niche. In this scenario, the catheters provide a route for organisms to enter the bladder and also serve as a foreign body for colonisation.
Preventing CAUTI thus begins with using catheters only for appropriate indications and using alternatives when possible. Once the decision has been made to use an indwelling catheter, appropriate insertion with sterile equipment and aseptic techniques should be used. Moreover, proper maintenance and early discontinuation reduces exposure and CAUTI risk. The health providers must be engaged in appropriate patient selection for catheterisation; there should be optimisation of insertion and maintenance techniques, a system should be in place for prospective audits with evaluation for ongoing indications and there should be emphasis on early discontinuation. Nurses need to empowered to remind clinicians about unwarranted/prolonged catheterisation.,
Preventive bundles for CAUTI are an important strategy, as part of a multimodal approach that focuses efforts on high-yield interventions. One such strategy implemented by the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality included several components from the bladder bundle, called 'ABCDE' approach  as follows:
- Adherence to general infection control principles is important (e.g., hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance and education)
- Bladder ultrasound may avoid indwelling catheterisation
- Condom catheters or other alternatives to an indwelling catheter such as intermittent catheterisation should be considered in appropriate patients
- Do not use the indwelling catheter unless you must!
- Early removal of the catheter using a reminder or nurse-initiated removal protocol appears warranted.
After bundle implementation, the CAUTI rate reduced over one-third (from 4.07 to 2.5). However, it was felt that optimisation of culturing practices is essential to prevent the CAUTI rate from increasing from a reduced denominator.,
The most commonly tried elements to prevent CAUTI include the following: catheterisation only if absolutely necessary, reducing the duration of catheterisation, closed drainage, intermittent catheterisation, use of external collection devices, ensuring dependent drainage, using systemic antimicrobials only if the patient is symptomatic with a suggestive urine culture and catheter removal as early as possible. A common preventive bundle for CA-UTI, which can be adopted in hospitals of LMICs, includes the following four elements:
- Aseptic insertion and proper maintenance
- Dependent drainage
- Condom or intermittent catheterisation in appropriate patients
- Daily assessment of catheter requirement and prompt removal.
In contrast to the central-line and ventilator bundles, studies need to validate the effectiveness of a urinary catheter bundle. [Figure 4] depicts the elements of the urinary catheter bundle.
VAP is a potentially fatal, morbid and costly HCAI in the ICU. Between 10% and 20% of patients ventilated for a duration of over 48 h develop VAP. In addition, VAP is associated with a longer duration of mechanical ventilation, hospital length of stay (LOS) and ICU LOS., According to the INICC, the overall rate of VAP in ICUs of LMICs is 13.6/1000 ventilator days. In contrast to the rates of 1–4/1000 ventilator days in the developed world, the incidence in LMICs varies according to the patient group and hospital setting, ranging from 13 to 51/1000 ventilation days. The mortality associated with VAP ranges from 24% to 76%, and is higher among critically ill patients., [Figure 5] depicts the pathogenesis of HAP/VAP. Considering the risk factors associated with VAP, evidence-based guidelines have been published to reduce the incidence of VAP incidence. Since the pathogenesis of VAP starts with colonisation of the upper respiratory tract, restraining this colonisation is the first step in the prevention of VAP. Prevention strategies for VAP include hand hygiene, reduction of cross-contamination by appropriate care of respiratory equipment, elevation of head position, oral hygiene with chlorhexidine, surveillance and utilisation of endotracheal tube which allows the aspiration of subglottic secretions and monitoring the cuff pressure. As with other DAIs, the Ventilator Bundle is a set of evidence-based clinical practice interventions for patients on mechanical ventilation, and it has become an important component of care of critically ill patients in ICU. The VAP prevention bundles may include many possible measures; most institutions select four to six of them. Several reports have demonstrated the reduction of VAP rates after implementation of Ventilator Bundle.,,,,
The VAP bundle: IHI Ventilator Bundle includes the following components:
- Elevation of head of bed
- Daily 'sedation vacations' and assessment for readiness to extubate
- Peptic ulcer disease prophylaxis
- Deep-venous thrombosis prophylaxis
- Daily oral care with chlorhexidine.
However, many researchers have added other evidence-based interventions to the IHI VAP bundle and created their own customised VAP bundle for decreasing VAP rates. Studies have reported that the implementation of a customised VAP bundle results in better patient and clinical outcomes. In a study by Al-Tawfiq and Abed implementation of the IHI VAP bundle resulted in a reduction of VAP from 9.3/1000 ventilator days to 2.3/1000 ventilator days.
The most commonly added elements to the IHI bundle include:
- Avoid unnecessary antibiotics
- Avoid unnecessary stress ulcer prophylaxis
- Sucralfate for stress ulcer prophylaxis
- Oral intubation
- Chlorhexidine oral rinse
- Selective digestive decontamination
- Short-course parenteral antibiotics
- Appropriate hand disinfection
- Appropriate staffing
- Avoid tracheal intubation
- Shortened duration of mechanical ventilation
- Semi-recumbent positioning
- Avoid gastric overdistention
- Subglottic suctioning
- Avoid ventilator circuit changes/manipulation
- Drain ventilator circuit condensate
- Prevent accidental extubation
- [Figure 6] shows the elements of the Ventilator Bundle.
A recent prevalence study found that SSIs were the most common HCAI, accounting for 31% of all HAIs among hospitalised patients. Although SSI incidence is much lower in high-income countries, it remains the second-most frequent type of HAI in Europe and the USA. While advances have been made in infection control practices, including improved operating room ventilation, sterilisation methods, barriers, surgical techniques and availability of antimicrobial prophylaxis, SSIs remain a substantial cause of morbidity, prolonged hospitalisation and death. SSI is associated with a mortality of 3%; 75% of SSI-associated deaths are directly attributable to the SSI. A multifaceted approach is essential to prevent SSIs. As for other HCAIs, implementation of evidence-based bundled interventions has also been piloted for SSIs, which has been reported to reduce the number of SSIs.,, Specific actions which have been included in the SSI bundles in various studies include the following:,,,,,,,
- Pre-operative nasal screening for methicillin-resistant S. aureus (MRSA)
- Intranasal mupirocin ointment for MRSA carriers
- Intraoperative hair clipping immediately before the operation, if necessary
- Surgical hand antisepsis: hand rubbing with 0.2% chlorhexidine-alcohol solution
- Patient skin preparation: 0.5% chlorhexidine-alcohol solution applied repeatedly 3–4 times, as with a lacquer coating, with the last coat applied using sterile gloves. Finally, 10% povidone-iodine applied to the skin using several pieces of cellulose sponge
- Administration of prophylactic antibiotics 30 min before the skin is incised
- Re-administration of prophylactic antibiotics every 4 h
- Discontinuation of prophylactic antibiotics during surgery (intraoperatively only)
- Ensure double-gloving for all surgical team members
- Scheduled glove change after draping the patient, scratching the bone wax, harvesting the graft, tying the suture of the prosthetic valve and sternal closure
- Check blood glucose levels; if >140 mg/dL, start insulin infusion
- Post-operative maintenance of blood glucose levels.
Recently, a bundle was evaluated for 'zero SSI', which includes the following:
- Removal of body hair with clippers
- Pre-operative showering with chlorhexidine soap
- Preparation of the surgical field with alcoholic chlorhexidine 2%
- Adequacy of antimicrobial prophylaxis
- Intraoperative and post-operative glycaemic and central temperature control.
High-infection-risk surgeries are also coming under the ambit of preventive bundles. Colorectal surgeries are highly prone to SSI. In a recent study on SSI prevention bundle for colorectal surgeries, 14 pre-operative, intraoperative and post-operative measures were found to be highly effective for reducing SSI.
Monitoring the compliance to implementation of preventive bundles
Monitoring of compliance and providing feedbacks to the stakeholders is an essential component of IPC activities. Compliance is defined as the percentage of ICU patients on a particular device (central line/ventilator/urinary catheter) for whom all the elements of the preventive bundle are documented on daily goals sheets and/or elsewhere in the medical record. This is an 'all-or-nothing' indicator. If any of the selected elements are not documented, do not count the patient in the numerator. If a bundle element is contraindicated for a particular patient and this is documented appropriately in the medical record, then the patient is considered compliant with regard to that measure. The goal should be that 95% of all patients in the ICU should receive all the elements of the preventive bundle.
Collection of data
On a given day, select all patients on a device and assess them for compliance with the Bundle. If even one element is missing, it is considered that the case is not in compliance with the bundle. For example, if there are ten ventilated patients and six patients have all the five bundle elements completed, then there is 60% compliance with the Ventilator Bundle. If all the ten patients had all the five elements completed, compliance would be 100%. Conduct the assessment 1 day/week.
Calculation of compliance rate
The compliance rate is calculated as follows:
The number of ICU patients on a particular device who received all the elements of the bundle)/total number of ICU patients on that device on the day of week of sample × 100 to obtain percentage.
| ~ Conclusion|| |
The increasing rates of multidrug-resistant (MDR) infections are counterproductive to highly sophisticated and life-saving medical-surgical advancements. With the ever-increasing armamentarium of antimicrobial resistance, healthcare fraternity has to go back to the basics of infection control; develop, evaluate and implement bundles of prevention, which are cost-effective and easily adaptable to LMICs, who are facing the brunt of escalating HCAIs and MDR infections.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]