New Delhi: Healthcare-associated infections (HAIs) and the phenomena of antimicrobial resistance (AMR), or diseases caused by pathogens becoming resistant to antimicrobial drugs, are inherently related to each other.
HAIs are typically those infections that one may acquire while being treated at a healthcare facility due to poor infection control practices.
There are mainly four types of HAIs – catheter-associated urinary tract infections (infections caused while inserting a catheter), central line-associated bloodstream infections (infection caused while inserting a central line, a tube put in the neck or chest for medication), surgical site infections (this can happen in a body part after a surgery) and ventilator-associated pneumonia (lung infection while being on a ventilator). All these infections, however, are mostly avoidable.
Although HAIs are a concern worldwide, there are studies which suggest that low- and middle-income countries are “disproportionately affected”.
Several experts and scientists working on HAIs had in September published a paper in The Lancet which found “high HAI and antimicrobial resistance rates in tertiary hospitals” in India.
The paper was published as part of the national HAI surveillance network in which 26 hospitals of the country were initially enrolled.
The Wire caught up with Kamini Walia, one of the authors of the paper, who also leads the antimicrobial research initiative of the Indian Council of Medical Research, on the penultimate day of World Antimicrobial Awareness Week.
The interview has been edited lightly for brevity and clarity.
The Lancet paper clearly seems to be sounding alarm bells as far as HAIs in India are concerned. Can you first explain how serious HAIs can get?
If a patient is coming with, say, myocardial infarction [heart attack], and he ends up getting a urinary tract infection (UTI), that means there is something wrong with the infection control practices of the concerned hospital. If a patient gets a fever 48 hours after she’s admitted, it means it is a hospital-acquired infection. During COVID-19, we saw that a large proportion of secondary infections were hospital-acquired. [Walia, along with others, also authored a paper on this].
For all clean surgeries [in which there are hardly any chances of infection], for example, a C-section or a joint replacement, if a patient gets infected by a hospital-acquired infection, you lose the patient. In the first place, there was no reason for a patient to get the HAI because it was a clean surgery.
Secondly, the patient in all likelihood will acquire a multidrug resistant infection. That will be difficult to treat. Also these infections will extend the patient’s stay in the hospital with the overall health expenses also going up. Mortality, depending on the baseline health condition of the patient and the pathogen causing the infection, can also increase due to these infections.
See, for example, you might hear stories that a patient went to a hospital for a certain disease and suddenly acquired a UTI or a lung infection [which had nothing to do with the disease]. Then, the patient was treated for the infection for a couple or several months but she did not survive. So what I am trying to say is that HAIs are becoming a huge problem in India and just because we don’t have a robust mechanism to capture HAI numbers from across India, the problem is not getting quantified.
And this includes both bacterial and fungal infections.
This is the first paper where we have been able to produce some sort of a snapshot of HAIs in 26 hospitals which are part of the surveillance network across India. But remember, all these hospitals are the top tertiary care hospitals in the country.
In that case, can we infer from this information that the ones [hospitals] which are not as big as them, or even the ones at the district level or below, might be fairing worse?
There is no logic to say no.
The problem is, the investment in infection control is so poor [in Indian hospitals] that doctors are forced to prescribe 2, 3 or 4 antimicrobials [antibiotics] because they don’t want to take a risk with the life of the patients [that is, due to poor infection control practices in hospitals, patients stand a chance of acquiring HAIs, and hence, the doctors are forced to prescribe more and more antibiotics]. Can you blame the doctor?
But here is the vicious circle. Once she is over-prescribing, and if the patient still gets an HAI, it will be mostly a drug-resistant infection [and resistant to some of the antibiotics which have no alternatives]. This is how HAIs further increase the risk of AMR. So we have to clean up the hospitals and make sure much needed investments are done for this.
How does the lack of diagnostics contribute to HAIs?
A doctor has to know what kind of infection it is – which pathogen has caused it – before prescribing an antimicrobial. But getting a test result takes 24 to 72 hours. In the meantime, a doctor may prescribe certain antimicrobials, and at times, even more than one. If the [admitted] patient still gets a fever, one more drug gets added to the list. But it takes a minimum of 48 hours to get a report of culture test for knowing the exact nature of the antimicrobial susceptibility.
So broad-spectrum medicines continue till then, some of which might not even have been needed had the doctor got a report in time. [The more the over-prescription, the more the chances of AMR.]
What are the investments required to have proper infection control practices at hospitals?
We need nurses to do infection control, who can monitor patients, central line inserted in patients, check the number of days for which the catheter is being used, ensure hand-hygiene among healthcare providers, see that the devices are inserted properly in patients, so on and so forth. [While inserting devices, pathogens may travel inside the body through the area exposed to the device.]
We need dedicated nurses to do so. Besides, there has to be infection control committees in every hospital comprising microbiologists and infectious disease specialists, who can monitor HAI outbreaks, which are not uncommon. Not all hospitals at the tertiary level or beyond have them. And wherever they exist, they have to work routinely and not in an ad-hoc fashion.
Do these nurses require any special training?
No, all nurses, as part of regular training, are trained in infection control. But a certain number [of nurses], even if small, has to be dedicated to this job specifically. So far, we have had a tough time in making hospitals, even those where we are working as part of surveillance, to do this.
Out of 20 hospitals, which are part of the antimicrobial stewardship programme, only two have created the post of clinical pharmacists. But those two hospitals realised the importance of having a trained pharmacist to supervise the antimicrobial prescriptions in terms of duration, dosage, etc.
These people are trained to monitor the antimicrobial prescription [to see if there is no over-prescription], hence, it is important to have them. But these posts have to be created in the first place, in both government and private hospitals.
ICUs, where patients have one or more devices inserted, are literally hotbeds of HAIs. Why?
There is a lack of awareness among healthcare providers. Much needs to be done in terms of hand-hygiene, for example. They need to have simple yet important HAI-customised infra. For example, there should be taps which can be operated with elbows, so that healthcare providers themselves don’t use their hands to touch the taps.
We have to make infra changes, get supplies, and you need a person who will monitor the central line and caterers, including how the central line is inserted, so that we minimise the chances of infection.
The Lancet paper also clearly mentioned which pathogens are responsible for HAIs in India. How important was this understanding?
This was very important to know. If you see in western countries, most of these infections are caused by gram-positive bacteria. In India we have huge gram-negative bacteria causing HAIs. [Gram-negative bacteria are much more difficult to treat.]
And, even some of them have peculiar mechanisms of developing resistance against antimicrobial drugs. And the treatment is guided only after identifying the disease-causing pathogens. Candida auris [a fungal infection], for example, can only be treated with specific anti-fungals.
The right identification also helps in other observations. For instance, wherever you find Acinetobacter, [a group of bacteria usually found in a certain environment], which The Lancet paper mentions, means there was a clear breach in infection control. It is straight away a pointer to the fact that there was an environmental pathogen that has acquired the ability to cause infections in your ICUs.
That is why constant vigil is required to know what pathogens are causing infections in your hospital, how many patients are acquiring them, what can you do to reduce these infections. Otherwise how do you frame hospital guidelines?
Moreover, you cannot work on AMR unless you work on HAIs and infection control. If infection control is poor in a hospital, doctors will have to prescribe more and more antibiotics [which in turn leads to AMR].
But today whatever data we have, it’s mostly from tertiary hospitals. Should we really worry that we hardly know anything beyond that?
We have started working with 94 private nursing homes and district hospitals, too, though the project is starting to build up. We realised in the course of our work that tertiary hospitals receive a lot of sick patients with drug-resistant infections acquired from previous hospitalisations.
Hence, to make any difference one has to go beyond tertiary care and work with smaller hospitals at the secondary level which are referring patients to tertiary care.
What should be the incentive for a small hospital to launch an HAI-control programme because it means investing in a few things?
If they are going for accreditation, say from NABH, then they have to show they have good infection control practices. Besides, it obviously saves the lives of patients and reduces AMR.
Are there any countries which provide a legal backing or make some standardisation in this regard?
England has a system of HAI audits. We also have guidelines in India but they are not mandatory.
As a scientist working in this field, would you like to be provided with legal backing?
That would definitely help in AMR containment. Making deaths due to infections with some drug-resistant pathogens notifiable, mandatory publishing of HAI rates, and making HAI rates a strict part of its accreditation exercise are some of the measures that will help the cause.