In the past few years, national surveillance data and public health research have demonstrated that healthcare-associated infections (HAIs) take a major human toll on society. The overall morbidity and mortality associated with HAI are enormous. Five to 10% of all hospital admissions are complicated by HAI, in both the United States and Western Europe.1
In the United States, an estimated 1.7–2 million people per year develop an HAI, and nearly 100,000 die.2
By these estimates, HAIs are among the top 10 leading causes of death in the United States.2
The economic burden of HAIs is substantial and increasing. The total cost of HAIs has been estimated at $20 billion per year. The healthcare costs of hospital-acquired catheter-associated bloodstream infections in the United States have been estimated to be $10,000–$20,000 per case,3
and the cost of each episode of Clostridium difficile
infection has been estimated to be approximately $5,000.4
These figures do not reflect the loss of productivity and other less quantifiable human and economic costs associated with a serious HAI. Finally, HAIs result in another, less tangible toll on the healthcare system: loss of consumer confidence in the healthcare system. In response to the realization of the magnitude of the problem, consumer advocacy groups, federal and state governments, and professional societies have stepped up pressure to make reduction of HAIs a national priority. In a notable example, the Centers for Medicare and Medicaid Services have engaged in “payment reform” in the battle against HAIs and have ceased reimbursing hospitals for expenses related to certain HAIs. By placing that economic burden on the shoulders of hospitals, the Centers for Medicare and Medicaid Services have given hospitals a very concrete incentive to enhance efforts to prevent HAIs.
Healthcare costs continue to spiral upward at an alarming rate, virtually mandating substantial healthcare reform in the United States. President Barack Obama and his new administration have identified healthcare reform as one of their highest priority projects. Improved understanding of the pathogenesis, epidemiology, prevention, and treatment of HAIs should be an integral part of any discussion of healthcare reform. Because of the substantial and unnecessary costs associated with HAIs, addressing the problem of HAIs will improve healthcare quality while simultaneously resulting in substantial cost savings.
The past decade has witnessed increasing national and international momentum for addressing HAIs. In December 2008, the European Union declared HAI prevention a top policy priority. In the United States, national and state consumer groups have raised public and media awareness of both HAIs and multidrug-resistant organisms. Prevention of HAI has become a major patient safety initiative; indeed, the 2 objectives are inextricably linked, both within and outside healthcare settings.5,6
In the spirit of patient safety, one-half of all states have, in the past 7 years, established mandatory reporting of HAIs, and some have required screening for certain multidrug-resistant organisms. Legislatures and consumer advocacy groups argue that mandatory screening and reporting will reduce the incidence of HAIs, although no data yet support this assertion. A major shortcoming of this approach is that it is based on inadequate scientific data. Much of what has been recommended for infection control interventions over the past 2 decades has been based on experience, empiricism, and common sense. Often such approaches seem rational on the basis of our limited science base. Unfortunately, the evidence base is inadequate to support the mandatory implementation of many of these interventions or to guide the manner of their implementation. The Department of Health and Human Services, in a multiagency effort, has developed a National Action Plan to Prevent Healthcare-Associated Infections. This aggressive plan focuses on reporting rates of HAI and enforcing existing guidelines, but it pays insufficient attention to shoring up the research foundation that would, if available, provide the critical underpinnings for science-based guidelines. An approach that mandates the implementation of practices based on inadequate scientific understanding may prove ineffective or, worse, may have unintended consequences, in addition to depleting critical infection control resources.
Professional organizations, such as the Society for Healthcare Epidemiology of America (SHEA), which is a major scientific organization dedicated to healthcare epidemiology and infection prevention,7–9
the Infectious Diseases Society of America,9,10
and the Association of Professionals in Infection Control,7,11
have developed policy statements recommending prioritization of research on the pathogenesis and prevention of HAIs. Any national effort designed to address the problem of HAIs should begin with the following priorities: scrutinizing the science base, developing a prioritized research agenda, conducting studies that address the questions that have been identified, creating and deploying guidelines that are based on the outcomes of these studies, and then initiating studies that assess the efficacy of the interventions.