AMR and HAI

Healthcare-associated infections (HCAIs) are any infections that develop as a direct result of contact with the healthcare system. This could be care provided in your own home or care provided in a hospital, in a GP surgery or nursing home and which was not present or incubating at the time of admission. HCAIs include infections that occur after surgery and infections which occur due to the prolonged use of inserted medical devices like drips or catheters. You have probably heard of some healthcare-associated infections in the media, such as Methicillin-Resistant Staphylococcus aureus (MRSA), the so-called 'superbug'.

However, HCAIs also include infections caused by medicines like antibiotics affecting the balance of harmless bacteria in the gut. This allows some bacteria like C. difficile which can be found in people’s intestines (their “digestive tract” or “gut”), which normally does not cause a problem, to grow to unusually high levels. This, in turn, allows the toxin they produce to reach levels where it attacks the intestine and causes diarrhoea and fever.

HCAIs are a major concern for patients when entering hospitals or other environments providing healthcare and they can affect both patients and healthcare workers.


Healthcare associated infections

What causes healthcare associated infections?

From the earliest days of healthcare, organisms have found opportunities to cause infection at the sites of wounds and in weakened patients fighting other diseases. While modern medicine has done a lot to reduce the impact of infection, some of the procedures and treatments which are now available carry with them an increased risk of infection. There are also a number of other key factors which play a part, including the behaviours of both patients and healthcare workers.

Modern medicine has meant that complex and invasive surgery such as caesarian sections are now fairly routine. There are now treatments for chest infections, skin infections, cancer and leukaemia. However while these advanced therapies improve patient survival, some of them are dependent on the use of drugs that deliberately weaken the body's defence system to prevent rejection of a donated organ, or are dependent on other drugs that weaken the body's defences against infection. This results in patients who have these treatments occasionally developing infections in the healthcare setting, which increases the numbers of HCAIs.

The increased use of medical devices such as urinary catheters, drips and other machines which save lives, such as kidney dialysis and ventilators to assist breathing also provide an entry point into the body for infection and increasing the likelihood of disease. Routine use of antibiotics in healthcare is vital for preventing some infections but can cause other infections by disturbing the balance of harmless bacteria in the gut, allowing some resistant bacteria to multiply to a number where they cause illness.

People with chronic diseases like asthma and older people can also be at greater risk of infection in general, so when they receive healthcare, they will be at a higher risk of acquiring infections. The spread of infection, particularly in hospitals, is not helped by current pressures on hospital beds resulting in more crowded wards and increased patient movement around and between hospitals.

In addition to this, transmission of infections between patients can be caused by contaminated medical devices and by healthcare workers, visitors and others not properly washing their hands and not following policy and guidelines around the safe and clean provision of care. In places where resources are limited such as developing countries, heathcare associated infection for some groups, like newborns, is 20 times higher than in developed countries. This is often made worse by poor infrastructure, insufficient medical equipment and understaffing.

How serious are the effects of healthcare associated infections?

The World Health Organization estimates that each year, hundreds of millions of people around the world are affected by HCAIs. For every 100 hospitalised patients at any given time, seven in developed countries and ten in developing countries, will acquire at least one HCAI.

In countries with high incomes, approximately 30% of patients in intensive care units (ICU) are affected by at least one health care-associated infection. In low- and middle-income countries, the frequency of ICU-acquired infection is at least 2-3 times higher. Among hospital-born babies in developing countries, health care-associated infections are responsible for between 4% and 56% of all causes of death in the early days after birth and these figures rise to 75% in South-East Asia and Sub-Saharan Africa. As is the case for many other patient safety issues, healthcare-associated infections create additional suffering and come at a high cost for patients and their families. Infections cause longer hospital stays, may worsen the patient’s existing medical condition, may create long-term disability, and can increase resistance to drugs.

HCAIs also represent a huge financial burden for health systems and cause unnecessary deaths. In Europe, they cause 37,000 deaths. The Office of National Statistics estimates that up to 5,000 patients die of hospital acquired infection every year in England & Wales and it is one of the factors in another 15,000 deaths. HCAIs are a serious burden on the NHS with a cost estimated at £1 billion a year, with infected patients costing three times more to treat than uninfected patients. They also have a major impact on the availability of beds because infected patients have to spend, on average, an extra 11 days in the hospital.

The Antimicrobial Resistance Report 2016 found that across developed countries, between 7 and 10% of all hospital inpatients will contract some form of healthcare-associated infection and this figure rises to one in three patients in intensive care units. These figures are higher in low- and middle-income settings.

How are we tackling healthcare associated infections?

Global efforts to deal with the issue of healthcare-associated infections are being undertaken by the World Health Organization. Their Patient Safety Alliance is actively working towards establishing effective ways of improving global health care and to save lives lost to health care-associated infections. Their “Clean Care is Safer Care” programme is aimed at reducing HCAIs globally and has placed improving hand hygiene practices at the core of achieving this.

At a National level, the Labour government of the 2000s set hospital targets to reduce the level of HCAIs and required hospitals to report levels of infection. Public Health England ( an executive agency of the Department of Health) monitors the numbers of certain infections that occur in healthcare settings and advises on how to prevent and control infection in establishments such as hospitals, care homes and schools. They currently monitor Staphylococcus aureus (Methicillin-Resistant Staphylococcus aureus or MRSA and Methicillin-Sensitive Staphylococcus aureus or MSSA), Escherichia coli, Clostridium difficile infection, and surgical site infections.

The introduction of these targets stimulated a greater emphasis in hospitals, on hand hygiene, and the better use of antimicrobials.

The National Institute for Health and Care Excellence (NICE) has also issued guidelines about HCAI in primary and community care. There is a useful lay summary of these provided under Healthcare-associated infections: prevention and control in primary and community care on the NICE website.