The Impact of Hospital-Acquired Bloodstream Infections

Richard P. Wenzel, Michael B. Edmond, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, USA


Emerging Infectious Diseases. 2001;7(2) 

In This Article


The arguments above justify a major effort with substantial resources for preventing and controlling serious hospital-acquired infections. We suggest a quality assessment approach for hospital-based programs of infection control: structure, process, and outcome. The Study of the Efficacy of Nosocomial Infection Control (SENIC), published in 1985, showed that both structure (expertise) and process (surveillance, feedback and protocols) predicted lower infection rates[9]. A subsequent analysis suggested that infection control programs represented one of the most cost effective of current public health efforts[10].

Access to improved infection-control technology is one of the promises at the dawn of the 21st century. Another is improved handwashing compliance associated with more attractive and accessible products. Two recent factors influencing infection control are use of antibiotic-bonded vascular catheters and access to alcohol hand-cleansing materials that improve handwashing compliance. In a multicenter study reported by Darouiche and colleagues, bloodstream infections were significantly reduced when patients received catheters bonded with rifampin and minocycline[11]. Estimates of nosocomial bloodstream infections from the SCOPE database indicate that 70% occur in patients with central venous catheters[12]. Furthermore, the study by Darouiche et al. showed that 90% of central venous catheter-associated infections could be prevented by antibiotic-bonded catheters. Assuming 200,000 total nosocomial bloodstream infections of which 35% are attributable to central venous catheters and assuming that 45% could be prevented with a catheter bonded with minocycline and rifampin, the number of lives saved according to varying attributable mortality rate estimates would be 4,745 to 9,450 (Table 2).

In a study of handwashing compliance by Bishoff and colleagues, handwashing frequency in a medical intensive-care unit (ICU) increased with access to an alcohol-based product[13]. Previously, Doebbeling and colleagues showed that medicated soap solutions were more popular than alcohol preparations and thus were associated with reduced infection in intensive care units[14]. The study by Doebbeling et al. showed that a 28% increase in handwashing frequency (with a higher volume of use of antiseptic soap) resulted in a substantial reduction in the rate of nosocomial bloodstream infections of 56/10,000 ICU admissions, by 45% for the attack rate and by 22% when incidence density was calculated (Table 3). In SCOPE, 49.4% of all nosocomial bloodstream infections occurred in intensive-care units. However, if 25%-50% of all bloodstream infections occur in intensive-care units and a 25% increase in handwashing would prevent 25% of bloodstream infections in ICUs, the number of lives saved would be 469 to 1,874, depending on assumptions of attributable death rate (Table 3). The emerging concept is that increased handwashing frequency will result in an improved outcome. Perhaps most striking is that in this selected comparison of the impact of changes in technology with changes in behavior, the former will likely be 5 to 10 times more effective, but at substantially increased cost. Neither, however, is mutually exclusive, and both need to be in place.

In summary, vital statistics list the major causes of death yet give little insight into environmental risk factors for disease or outcomes. Estimates of hospital-acquired bloodstream infections derived from the attributable mortality rate show the impact of the specific environment where many life-threatening infections occur. By modifying the institutional environment to improve hospital care and infection control, the outcomes for patients will greatly improve. Technological advances will likely have a greater impact on health than theoretical advances in behavior, such as improved handwashing frequency.


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