Hospital infections can cause death or serious conditions in hospitalized patients. Following a series of procedures is essential to both prevent spread of infections and treat them. As the Nov. 18-24 World Antimicrobial Awareness Week begins, a doctor, a nurse, and a patient from the Hospital Maciel, in Montevideo, Uruguay, describe coping with hospital infections.
November 17, 2021 - Procedures such as wearing masks, gowns, gloves, as well as hand washing before and after entering the inpatient rooms, and cleaning the screens of respirators, monitors, and infusion pumps, are the regular tasks that intensive care teams carry out to prevent the spread of pathogens, particularly multidrug-resistant pathogens that are increasingly difficult to combat.
Antimicrobial resistance (AMR) is a natural phenomenon of microorganisms such as bacteria, viruses, parasites, and fungi. AMR allows microorganisms to become resistant to drugs such as antibiotics, antifungals, and antiparasitics. The misuse of drugs has accelerated the emergence AMR and makes diseases increasingly difficult to cure. Hospital infections kill 700,000 people a year worldwide, and it is estimated that if action is not taken, the number will rise to 10 million people by 2050, according to a 2016 global report for the UK government.
Prevent, care, and educate
Part of a nurse’s role is to control and educate nurses’ assistants, ancillary services, and families to follow the procedures that prevent the spread of multi-resistant pathogens, explained Inés Lavega, a nurse who worked for more than eight years in the intensive care unit (ICU) of Hospital Maciel, Uruguay's first public hospital.
Contagion between patients is a latent risk, especially in ICUs, where several people share the same room. Multiple strategies have been developed to minimize this risk. One is preventive isolation of patients who were hospitalized in emergency units for more than 72 hours, or who come from long-term care facilities, where they may have been infected by multidrug-resistant pathogens.
The epidemiological surveillance of ICUs is a permanent task. If a patient is found to have a multidrug-resistant pathogen, she or he is isolated, and extreme care is taken to avoid an outbreak of infection.
Lavega does not feel at risk for infection: "We have no risk if we follow all the measures," she said. Instead, "The person at risk is the one who is admitted to the ICU, because we, with our actions, can transmit the pathogens to her or him," she said. Hence the insistence on compliance with all measures that contribute to providing care in a safe environment.
Affected, recovered and grateful
Modesto Parra, a Cuban doctor who has lived in Uruguay for three years, participated in this story not as a doctor but as a patient affected by multidrug-resistant pathogens. In May, he contracted COVID-19. Pneumonia caused by the disease led him to be admitted to an ICU, where he had to be intubated. His case grew even more complicated when he contracted resistant pathogens. "I was gravely ill," he said.
Except for the period of time when he was in a coma, Dr. Parra was aware of his situation. Doctors informed him about his diagnosis and treatments, based on modern antibiotics and antifungals. He gradually got better: his lungs recovered function and with the help of physiotherapists, he regained muscle tone little by little. At 56 years old, he is grateful for his care, his medical team, and the support and respect he received during his stay.
Prevent, control, and treat
As in all spheres of patient safety, work is being done on preventing, controlling, or mitigating and treating,”, said Marcelo Barbato, intensive care doctor and director of Hospital Maciel’s ICU
In the field of prevention, "a central element is the good use of antibiotics – prescribing them only when strictly necessary, for the number of days necessary and with the greatest possible specificity." At the same time, Dr. Barbato pointed out the importance of trying to reduce the length of time patients spend in ICUs through diagnosis and timely treatment. "The greatest appearance of antimicrobial resistance occurs in patients who spend many days in intensive care units, who undergo many invasive procedures, and who are the most immunosuppressed,” he said.
In the event that resistant bacteria appear, their spread is prevented through isolation, protective equipment, hand washing and tests on unoccupied beds to confirm that whoever occupies them is not at risk of contracting an infection. "We have to be permanently focused on details because we can design many processes but 'the devil is in the details,'" Dr. Barbato explained.
Dr. Barbato, who has a long trajectory in infection control, measures results in terms of controlling infection and uses them to evaluate management. “If there are a lot of outbreaks or the cases spread quickly and take a long time to control, that means there is less awareness.” He added that behavior related to infection varies from place to place. “Each place has its different culture and that is why it is so important to measure the results,” he said. Although health staff is aware of resistant bacteria, the level of awareness is not as developed as with diseases such as COVID-19, to which workers feel exposed on a personal level.
"Handwashing is perhaps the cheapest safe practice, with evidence that has been proven for more than 150 years, and yet, it has been extremely difficult to get people to do it," he lamented, adding that workers often forget when they are about to treat a patient. It is important to strengthen education as well as supervision and control. "Health workers have to regulate behavior," he said.
Joint work: "One Health"
The inappropriate and excessive use of antimicrobials occurs not only with regard to human health but also with animals and plants. As such, adoption of the “One Health” approach – which takes into consideration the interrelationship between people, animals, plants, and the environment – is recommended.
PAHO offers technical support and leadership to Member States to combat AMR and implement national action plans against antimicrobial resistance according to the “One Health” approach. In addition, PAHO promotes the exchange of experiences and advocates adoption of best practices and implementation of collaborative actions between countries.
Under this approach, Uruguay, Argentina, Brazil, Chile, Colombia, Paraguay, and Peru are participating in Working Together to Fight Antimicrobial Resistance, a project implemented by PAHO, the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE) and the European Union.
From 2020 to 2023, this project aims to facilitate implementation of national action plans in each of the seven countries participating in the project to address AMR. The initiative is expected to strengthen surveillance of antimicrobial resistance in people and animals, establish public-private alliances to contribute to the responsible and prudent use of drugs, and strengthen research on the subject, as well as on alternatives to the use of antibiotics.
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