Healthcare associated infections
February 2006
The present position
HCAIs remain a high priority and a significant problem throughout the United Kingdom (UK), important both in terms of the safety and wellbeing of patients and of the resources consumed by potentially avoidable infections. The National Audit Office (NAO) estimates that HCAIs contribute to the death of up to 5,000 people each year and cost the NHS up to £1 billion per year in the UK. [Go to note 3] In England, 300,000 patients acquire infections in hospitals every year and at any given time some 9 per cent of hospital patients are infected with a HCAI. [Go to notes 3,4]. A report from NHS Quality Improvement Scotland (NHS QIS) in 2004 found that HCAIs were a major factor in 457 deaths each year and a contributory factor in 1,372 infections, at a cost to the health service in Scotland of over £186 million per year.
With the significant increase in the proportion of S.aureus bacteraemias resistant to methicillin, much of the intense media interest in HCAIs has focused on methicillin-resistant Staphylococcus aureus (MRSA). According to the NAO, the proportion of S.aureus that is methicillin-resistant increased from 2 per cent in 1994 to 35 per cent in 2001. [Go to note 2] The UK now has one of the highest levels of antimicrobial resistance in Europe with respect to MRSA (see box 2). [Go to note 1] In 2004, there were 7,684 cases of MRSA bacteraemia in the UK, [Go to note 6]. and according to the Office of National Statistics (ONS), MRSA contributed to 955 deaths in 2003. [Go to note 7] While MRSA is the commonest multi-resistant bacteria, the majority of HCAIs result from infections by other pathogens. In 2004, the number of reported cases of C.difficile in England, Wales and Northern Ireland was 43,672, while in 2003 it was mentioned on 1,748 death certificates in England and Wales and in 934 of those cases it was identified as the underlying cause of death. [Go to note 8] In 2005, an epidemic of C.difficile was responsible for at least 12 deaths at Stoke Mandeville Hospital. The causative strain was found to be closely related to that isolated during outbreaks in Canada and North America of C.difficile-associated disease with increased morbidity and mortality. [Go to note 9]
Box 2: Proportion of S.aureus blood isolates resistant to methicillin.
| • Denmark | 1% | • France | 33% | |
| • Netherlands | 1% | • Portugal | 38% | |
| • Austria | 11% | • Italy | 38% | |
| • Germany | 19% | • Greece | 44% | |
| • Spain | 23% | • United Kingdom | 44% |
Source: Winning ways – working together to reduce healthcare associated infections in England (DH, 2003)
In 2003 there were 7,992 reported cases of streptococcal bacteraemia, 6,036 reported cases of Enterococcus spp bacteraemia and 1,087 reported cases of Acinetobacter spp bacteraemia in England, Wales and Northern Ireland. [Go to notes 10. 11. 12] Of the two main enterococcal species, 16 per cent of E.faecuim reports were resistant to vancomycin and 14 per cent were resistant to teicoplanin, while 2 per cent and 4 per cent of E.faecalis reports found resistance to vancomycin and teicoplanin respectively. [Go to note 11] In 2003 there were 1,380 reports of the fungal Candida species in England, Wales and Northern Ireland, of which 54 per cent were identified as Candida albicans. Health Protection Agency (2004) Candidaemia reports, England, Wales and Northern Ireland: 2003. London: Health Protection Agency. In England and Wales, there are on average between 130 and 250 outbreaks of norovirus gastroenteritis annually, of which 79 per cent occur in healthcare settings, either in hospitals or residential care homes. [Go to note 14]
The prevalence of HCAIs in patients in primary and community care settings in the UK is not known. Many infections in these patients may have been acquired in hospital and only identified following early discharge into the community. In reducing the length of hospital stay, care which was previously delivered only in hospitals has progressively shifted to outpatient and home settings. Healthcare practitioners are increasingly working across the boundaries of acute and community care, and invasive procedures are performed in outpatient clinics, nursing home and home settings. These factors create the potential for patients to be at greater risk of acquiring HCAIs in a diverse range of environments and outside the hospital setting. As complex care is increasingly performed in primary and community care settings (eg minor surgery), the risk of infections associated with healthcare interventions increases. Community-acquired MRSA infection (C-MRSA) is when a MRSA infection occurs in a previously healthy individual who has no recognised risk factors associated with MRSA (eg no previous hospitalisation). In the UK, the term community-acquired MRSA may refer to infections in residential homes that are caused by hospital strains of MRSA. Some other countries (eg the USA) are describing strains of MRSA that have arisen in the community ('true' community MRSA) and are very different from hospital MRSA strains. There have been no systematic studies to establish how common C-MRSA infection is in the UK, but routine surveillance of MRSA isolates has identified approximately 100 cases over the last three years. [Go to note 15]
In the UK, the Health Protection Agency (HPA) is responsible for developing strategies to prevent, control and monitor all HCAIs. The HPA has established a Steering Group on Healthcare Associated Infections that advises the DH on all matters relating to HCAIs and provides recommendations on developments required in the field. The DH recently undertook a consultation on proposed legislation to support the prevention and control of HCAIs, which included a draft Code of Practice incorporating clinical care protocols. The consultation, Action on health care associated infection in England (DH, 2005) closed in September 2005. [Go to note 16] In Scotland, the HAI Task Force was established in 2003 to coordinate the development and implementation of the Ministerial HAI Action Plan Preventing infections acquired while receiving health care (Scottish Executive, 2002), to monitor progress in its implementation across NHSScotland, to monitor levels of HCAIs and to report on progress to the Scottish Executive Health Department (SEHD). The Scottish Executive has already developed and implemented the NHSScotland code of practice for the local management of hygiene and healthcare associated infection (Scottish Executive, 2004). The Welsh Healthcare Associated Infection Programme (WHAIP) established the Healthcare Associated Infection Sub Group (WHAISG) to develop an evidential base for control of HCAIs in Wales, to identify preventable aspects and audit compliance with agreed practices. The Communicable Disease Surveillance Centre Northern Ireland (CDSC (NI)), which forms part of the HPA, is responsible for monitoring changes in the incidence, prevalence and patterns of HCAIs in Northern Ireland.