Infection Prevention and Control in Resource-Limited Settings

Anucha Apisarnthanarak

Anucha Thatrimontrichai

Linda M. Mundy

Infection prevention and control (IPC) in developing countries and in resource-limited settings (RLSs) of developed countries is a challenging issue for healthcare providers and healthcare systems (Table 33-1). Similar to safety controls for air transportation, basic universal standards for IPC are fundamentally linked to the expectation of service provision. In 2016, the World Health Organization (WHO) published core component recommendations for IPC, yet there are noteworthy pragmatic challenges for implementation, and variance of these standards, in RLSs. Subsequent international debate ensues for whether or not the core standards for IPC in developing countries, and RLSs in developed countries, should be similar to recommendations for resource-adequate settings in developed countries.¹

In 2006, “get to zero” was proposed as an attainable goal for the prevention of healthcare-associated infections (HAIs) in the United States.² This goal, set over a decade ago, was perhaps unrealistic, as a portion of HAI episodes are not likely preventable.³ Often, the healthcare system’s resources in RLSs are either not available or limited for a prioritized focus on a national or institutional agenda for IPC of HAI, relative to priorities and policies directed toward prevention of maternal or infant mortality, promotion of vaccination programs, and other population health initiatives. Nonetheless, global public health inclusive of healthcare safety is a recognized component of the Millennium Development Goals endorsed by leading industrialized countries and established foundations.⁴

In 2016, the WHO established a lead role in endorsement of global patient safety initiatives, inclusive of core components for IPC programs. Critical elements of IPC are recommended for all countries as a practical framework for IPC in national and acute healthcare facilities (Table 33-2).⁵ These recommendations provide a stepwise approach to IPC in RLSs for all countries, and eight core components from the WHO take into account principles of behavioral change, and two key components from a systematic review for engaging champions in prevention programs and the role of a positive organizational culture were deemed crucial to effective IPC programs.⁶

Infection prevention and control is a priority for the goal of patients’ safety and should involve healthcare providers at all levels. Staffing must meet task requirements without excessive workload. Program initiatives should be made readily available with user-friendly documents prepared by multidisciplinary groups and which take into account local guidelines, follow a multimodal intervention strategy with emphasis on experiential training, and are regularly assessed and adjusted per local context if necessary.⁶ Moreover, hand hygiene is an extremely cost-effective IPC practice in RLSs, together with HAI surveillance, interventions to reduce HAIs and multidrug-resistant (MDR) organisms, and building of infection control networks.⁷^,⁸

SURVEILLANCE AND EPIDEMIOLOGY OF HEALTHCARE-ASSOCIATED INFECTION IN RLS

Surveillance is an essential component of strategic global and national IPC programs. The three main objectives of surveillance are (1) to identify the endemic baseline epidemiology of device-associated HAI (DA-HAI) including estimated rates of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI); (2) to identify and monitor outbreaks and the effectiveness of IPC programs; and (3) to identify preventable infections and cost-effective interventions. These interventions in RLSs require prioritization for the targeted population and are contingent upon administrative support, existing infrastructure, and resource allocation.

To establish credible, point prevalence estimates of HAI from surveillance, the involved healthcare teams must be well trained in standardized definitions, protocols, and data management. Most healthcare institutions use the survey definitions from the United States Centers for Disease Control and Prevention (CDC)’s National Health and Safety Network (NHSN) because there are the most widely disseminated and standardized metrics readily available. However, benchmarking overall or crude HAI surveillance without risk-adjusted metrics, for example, stratification, restrictions, indirect standardization, and multivariate logistic regression analysis, can result in misleading conclusions.⁹

TABLE 33-1 Key Strategies and Challenges in Implementation of Infection Prevention and Control in Resource-Limited Settings

*Interventions*	*Expected performance*	*Challenges*
Standard care (hand hygiene and contact precautions)	Before and after every patient contact	Availability of alcohol hand rub/soap and sinks
Antimicrobial stewardship program	Reduction in antibiotics consumption of key antibiotics (eg, carbapenems)	Lack of team and administration support, doctor-nurse champion
Environmental cleaning	Improve daily and terminal cleaning practices, reduction in multidrug-resistant pathogens	Lack of awareness in this issue, lack of knowledge and know how to do it
Source control	Daily chlorhexidine bathing and/or chlorhexidine oral care in certain at-risk populations (eg, intensive care unit)	Massive workload for laboratory personnel and heathcare team, fiscal resources
Reduce device-associated infection	Comply with central line-associated bloodstream infection, ventilator-associated pneumonia, and catheter-associated urinary tract infection bundles	Inadequate knowledge on appropriate device care (eg, maintenance bundle on central line-associated bloodstream infection), lack of process and outcome monitorings for bundle compliance

TABLE 33-2 Guidelines for the Core Components of Infection Prevention and Control (IPC) Programs at the National and Acute Healthcare Facility Level

*Core component*	*Recommendation or good practice statement*	*Strength of recommendation and quality of evidence*
1. IPC programs	1a. Healthcare facility level: IPC program with a dedicated, trained team at each acute healthcare facility to prevent healthcare-associated infection (HAI) and combat antimicrobial resistance (AMR).	Strong, very low quality
	1b. National level: Active, stand alone, national IPC programs with clearly defined objectives, functions, and activities established for the purpose of preventing HAI and combating AMR; national IPC programs should be linked with other relevant national programs and professional organizations.	Good practice statement
2. IPC guidelines	Evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and AMR. The education and training of relevant healthcare workers on the guideline recommendations and the monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation.	Strong, very low quality
3. IPC education and training	3a. Healthcare facility level: IPC education should be in place for all healthcare workers by utilizing team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR.	Strong, moderate quality
	3b. National level: IPC program should support the education and training of the healthcare work force.	Good practice statement
4. Surveillance	4a. Healthcare facility level: Facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance with timely feedback of results to healthcare workers and stakeholders and through national networks.	Strong, very low quality
	4b. National level: HAI surveillance programs and networks that include mechanisms for timely data feedback and with the potential to be used for benchmarking purposes should be established to reduce HAI and AMR.	Strong, very low quality
5. Multimodal strategies	5a. Healthcare facility level: IPC activities using multimodal strategies should be implemented to improve practices and reduce HAI and AMR.	Strong, low quality
	5b. National level: IPC programs should coordinate and facilitate the implementation of IPC activities through multimodal strategies on a nationwide or subnational level.	Strong, low quality
6. Monitoring/audit of IPC practices and feedback	6a. Healthcare facility level: Regular monitoring/audit and timely feedback of healthcare practices according to IPC standards should be performed to prevent and control HAI and AMR at the healthcare facility level. Feedback should be provided to all audited persons and relevant staff.	Strong, low quality
	6b. National level: IPC monitoring and evaluation program should be established to assess the extent to which standards are being met and activities are being performed according to the program’s goals and objectives. Hand hygiene monitoring with feedback should be considered as a key performance indicator at the national level.	Strong, moderate quality
7. Workload, staffing and bed occupancy (acute healthcare facility only)	Elements should be adhered to in order to reduce the risk of HAI and the spread of AMR: (1) bed occupancy should not exceed the standard capacity of the facility; (2) healthcare worker staffing levels should be adequately assigned according to patient workload.	Strong, very low quality
8. Built environment, materials and equipment for IPC at the facility level (acute healthcare facility only)	8a. Patient care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR, including all elements around the water, sanitation and health infrastructure and services and the availability of appropriate IPC materials and equipment.	Good practice statement
	8b. Materials and equipment to perform appropriate hand hygiene should be readily available at the point of care.	Strong, very low quality

The estimated rates of CLABSI and VAP in developing countries are reported to be 5-10 fold higher than rates reported in a developed country (Table 33-3).¹⁰ Moreover, the crude excess mortality rates, length of stay (LOS), and antimicrobial resistant rates (AMR; the percentage of pathogenic isolates are resistant from pooled intensive care units [ICUs]) among neonatal, pediatric, and adult patients with DA-HAI are reportedly higher than those reported in developed countries (Table 33-3).¹⁰ In the ICUs of International Nosocomial Infection Control Consortium (INICC) hospitals, the AMR rates reported from blood cultures were higher than NHSN rates reported for several gram-negative bacteria (GNB) including Klebsiella pneumoniae, Pseudomonas spp., Escherichia coli, and Acinetobacter baumannii.¹⁰ Furthermore, the greatest proportion of DA-HAI attributed to carbapenem-resistant A baumannii
were reported from ICUs participating in the NHSN (63%) and the INICC (85%-90%), especially in the Southeast Asia region.¹⁰ Notably, besides the limited IPC capabilities in RLSs, the warm, humid tropical climate of Southeast Asia may contribute to the environmental growth of A baumannii colonization and infection.¹¹

TABLE 33-3 Comparing the Incidence Density, Pooled Crude Excess Mortality Rate, and Length of Stay of Device-Associated Infection (DAI) From INICC Report 2010-2015^a With NHSN Report 2013^b

*DAI*	*Adult and pediatric patients (INICC:NHSN ratio)*	*Level III neonatal patients (INICC:NHSN ratio)*
Incidence density
CLABSI	3-5	10-20
VAP	5-10	5-10
CAUTI	1-2	Not available
Pooled crude excess mortality rate
CLABSI or VAP	2.5	1.5
CAUTI	1.7	Not available
Pooled average excess length of stay, days
CLABSI or VAP	10	20
CAUTI	3	Not available
CAUTI, catheter-associated urinary tract infection; CLABSI, central line-associated bloodstream infection; VAP, ventilator-associated pneumonia.
^aInternational Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: device-associated module. Am J Infect Control. 2016;44(12):1495-1504.
^bNational Healthcare Safety Network report, data summary for 2013, device-associated module. Am J Infect Control. 2015;43(3):206-221.

SUPPORTING PROGRAMS FOR INFECTION PREVENTION AND CONTROL IN RLS

An effective IPC program requires a multidisciplinary team in all healthcare delivery systems. In developed countries, there are agencies, professional societies, and nongovernmental organizations focused on IPC policies, procedures, and practices (Table 33-4). At the local hospital level, a hospital may link with public health authorities for reporting of HAIs and to support any outbreak investigations. At the national level, the regional offices of the WHO have links with health authorities for IPC programs, in addition to the reporting of internationally notifiable diseases such as Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola virus disease, and influenza. The WHO maintains and regularly updates a Web site with postings to Disease Outbreak News from a network of electronically interconnected WHO member countries.¹²

TABLE 33-4 Key International Organizations Focused on Infection Prevention and Control and Healthcare Epidemiology

*Organizations*	*Web site*	*Scope of work*
Association of Professionals in Infection Control (APIC)	Home	To create a safer world through the prevention of infection and advance toward healthcare without infection
Asia Pacific Society of Infection Control (APSIC)	Home	To facilitate and encourage quality improvement initiatives and infection control research to promote cost-effective evidence-based practices throughout the Asia Pacific region
European Centre for Disease Prevention and Control (ECDC)	https://www.ecdc.europa.eu/en/home	To identify, assess, and communicate current and emerging threats to human health posed by infectious diseases across Europe
European Society of Clinical Microbiology and Infectious Diseases (ESCMID)	https://www.escmid.org/	To become Europe’s leading society in clinical microbiology and infectious diseases with members from all European countries and all continents
Hospital Infections Society (HIS)	https://www.his.org.uk/about/	Focuses on activities that support their members to overcome the challenges they face, and advance research that underpins excellence in clinical practice of healthcareassociated infections
Institute for Healthcare Improvement (IHI)	http://www.ihi.org/Pages/default.aspx	To improve health and healthcare worldwide
Joint Commission	https://www.jointcommission.org/	To continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value
Society for Healthcare Epidemiology of America (SHEA)	http://www.shea-online.org/	To promote the prevention of healthcare-associated infections and antibiotic resistance and to advance the fields of healthcare epidemiology and antibiotic stewardship
US Centers for Disease Control and Prevention (US CDC)	https://www.cdc.gov/	To protect America from health, safety, and security threats, both foreign and in the United States
World Health Organization (WHO)	https://www.who.int/infection-prevention/en/	To strengthen national and international capacity, improve practices and behavior to make healthcare safer and free from avoidable infections

In contrast to resource-adequate settings in most developed countries, an IPC team in an RLS may have a single doctor-nurse dyad who work as a team toward risk minimization of the spread of drug-resistant pathogens. In developing countries, this small team may benefit from networking with regional teams in order to share the infection rates and build infrastructure for reporting AMR rates in support of local epidemiology. Nowadays, AMR as well as multidrug-resistant (MDR) pathogens are very worrisome, especially in RLSs, and there are several organizations in Asia and in Africa which support IPC networks and surveillance, for example, the Asia Pacific Society of Infection Control (APSIC) and the Infection Control Africa Network (ICAN). The major international organizations of AMR for IPC include the WHO Collaborating Centre for Reference and Research in AMR or IPC and AMR, Baltic Antibiotic Resistance collaborative Network (BARN), and the National Antimicrobial Resistance Surveillance Thailand (NARST). After the emergence and detection of MDR-GNB in Southeast Asia and Thailand, NARST was established in 1998 to strengthen the surveillance programs for antimicrobial-resistant pathogens and to standardize the laboratory practices and reporting of AMR pathogens in Thailand. This collaborative network was funded by the WHO and involved 33 hospitals throughout
Thailand.¹³ This program is an example of a regional and global collaboration that was established to meet the IPC needs of hospitals in RLSs.

INTERVENTIONS TO REDUCE THE INCIDENCE OF HEALTHCARE-ASSOCIATED INFECTIONS

Reducing the incidence of major nosocomial infections, such as VAP, CAUTI, CLABSI, and surgical site infection (SSI), is achievable with implementation of simple, affordable, nondevice interventions that are feasible and associated with cost saving in various RLSs.¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰ Reducing the incidence of VAP can be achieved by educational interventions, use of continuous quality improvement models to create a multidisciplinary nosocomial pneumonia team, and implementation of a VAP prevention “bundle” (ie, a combined group of prevention measures).²¹^,²²^,²³ Notably, although these interventions have been shown to be effective in preventing VAP,²¹^,²²^,²³ they are not widely implemented. Three key factors associated with successful implementation of VAP IPC interventions are active participation by respiratory therapists, physicians, nurses, and other key leaders; the use of evidence-based educational programs with the VAP prevention bundle; and continuous monitoring of nursing care practices to prevent VAP.²¹^,²²^,²³ Together, these findings emphasize the importance of improving the management and care of ventilated patients, rather than eliminating a particular nosocomial reservoir of infection.

Several educational and behavioral interventions have been shown to be effective in reducing the incidence of CAUTI.²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹ These simple approaches include providing education, performance feedback to physicians and nurses about catheter care, written reminders for physicians about catheter indications, antibiotic guidelines tailored to specific units, and reminders to physicians to remove unnecessary catheters.²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹ A recent meta-analysis revealed that these nondevice interventions had a significant impact on the duration of catheter use, with 2.6 fewer catheter days in the case group than in the control group.³⁰ Additionally, the relative risk of CAUTI was 0.68 (95% confident interval, 0.45-1.01; P = .06), suggesting a trend toward fewer cases of CAUTI after these interventions.³⁰ As these reminder systems appear to significantly reduce the duration of urinary catheter use and possibly even the incidence of CAUTI, without evidence of harm, they can be readily adopted for implementation in RLSs.

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