11^th Global Infections Conference

Biography

Biography: Anil Batta

Abstract

Surveillance of healthcare associated infections in India: current gaps

In India, accurate estimates of the burden of healthcare associated infections are limited by the absence of reliable and routine standardized surveillance data. Published reports of healthcare associated infections are mostly from individual health facilities and include short term prospective studies and point prevalence surveys conducted in selected patient units of large hospitals. These indicate a prevalence of healthcare associated infections ranging from 7 to 18 per 100 patients, which is similar to that reported from other low and middle income countries. As in other settings, healthcare associated infections in India are associated with longer hospital stays, increased mortality, and added costs. The frequent use of indwelling devices is also reported, particularly in intensive care units, where one centre reported that over 70% of patients had indwelling devices in its intensive care unit for more than 48 hours. While microbiological confirmation of the healthcare associated infections was not a requirement in each of these reports, the data indicate that many of these infections were due to multidrug resistant pathogens, including meticillin resistant Staphylococcus aureus (MRSA) and extended spectrum β-lactamase producing and carbapenem resistant Enterobacteriaceae, Pseudomonas spp, and Acinetobacter spp.  Over the past several years, 40 private sector and academic hospitals in 20 cities in India have participated in surveillance through the International Nosocomial Infection Control Consortium, which uses a standardized method, and case definitions for surveillance of healthcare associated infections. Their recent publication gives pooled rates of healthcare associated infections at participating sites for the years 2004-13 and compares these rates with reported benchmarks.

Infection prevention and control in India:

Although hospital accreditation is not mandatory in India, groups like the autonomous National Accreditation Board of Hospitals and the National Health Mission’s National Health Systems Resource Centre have incorporated programmes on infection prevention and control, including surveillance of healthcare associated infections, as a core part of the review and certification process. At the national level, there has been growing recognition of the need for policy and guidance documents, and in 2016 the Indian Council of Medical Research released guidelines on infection prevention and control. In addition, as part of the national Swacch Bharat Abhiyan (clean India mission) the National Health Mission launched Kayakalp (clean hospital initiative), which aims to promote and reward cleanliness, hygiene, and infection control practices in public healthcare facilities.

Despite these initiatives, the successful implementation of an infection prevention and control programme in Indian healthcare settings faces some important challenges, including insufficient funding and human resources, hospital overcrowding, and low nurse-to-patient ratios even in intensive care units. Nevertheless, there is clear interest among doctors and other providers in healthcare facilities to improve infection prevention and control. Many facilities have started hospital infection control committees, although with varying effectiveness. Some institutes have also begun targeted infection control interventions, such as the use of infection prevention and control bundles to prevent surgical site infections and infections from indwelling devices. Data from a few facilities in India suggest that the implementation of such bundles is feasible and can reduce infection rates. Long term implementation of recommended procedures will require concerted efforts to strengthen infection prevention and control capacity among staff in healthcare settings. Thus, it is important to find ways to support standardized surveillance of healthcare associated infections in India .

New initiatives to address gaps in India:

As part of the national response to AMR, the Indian Council of Medical Research and the National Centre for Disease Control started AMR surveillance networks in 2013 and 2014, respectively. These surveillance efforts are an important part of the Indian Ministry of Health and Family Welfare’s recently launched five year national action plan on AMR. The networks currently comprise 25 public and private sector hospital laboratories across the country that report antibiotic susceptibility data on important resistant pathogens. In 2015 the Indian Council of Medical Research and the National Centre for Disease Control, with technical support from the US Centers for Disease Control and Prevention (CDC), helped their existing AMR networks begin programmes for the systematic assessment and improvement of infection prevention and control practices and the implementation of standardized surveillance of healthcare associated infection. The aim is to develop models that can serve as the basis for a sustainable Indian national network for standardised implementation, strengthening, and reporting of healthcare associated infections and infection prevention and control practices for the purposes of public health action.

In the current collaborations, a phased approach is being used to implement healthcare associated infection surveillance that is tied to strengthening related infection prevention and control practices and characterisation of resistance patterns among these infections. The expertise at facilities that are already conducting systematic surveillance of healthcare associated infections, such as the Jai Prakash Narayan Apex Trauma Centre of the All India Institute of Medical Sciences, has been used to develop protocols that will be applied across all network sites.

Way forward

Tackling AMR requires a multipronged effort. Healthcare associated infections and infection control are linked with other factors associated with the emergence of AMR. Inadequate infection prevention and control practices provide greater opportunities for new drug resistant infections to emerge in healthcare settings. In turn, a high incidence of such infections results in an increased demand for broad spectrum and reserve antibiotics, which also contributes to increased drug resistance. This inter-relation highlights the importance of strengthening infection prevention and control systems to control AMR.

The newly introduced activities for surveillance of healthcare associated infection and strengthening infection prevention and control are currently being conducted in a limited number of referral hospitals. As the AMR networks of the National Centre for Disease Control and the Indian Council of Medical Research expand these activities will be the basis of more robust and representative national surveillance of healthcare associated infections in public and private sector healthcare facilities across India. The data can be used to develop benchmarks for healthcare associated infections for India and to promote standardized reporting of healthcare associated infections from more healthcare facilities. In addition, there is scope to adapt these measures to establish and implement infection prevention and control programmes in regional and district hospitals in semi-urban and rural settings, where it is equally important to understand the burden and pattern of AMR.

Surveillance of healthcare associated infections and infection prevention and control programmes not only help tackle AMR but also contribute to overall patient safety. Incorporating the initiatives started by the Indian Council of Medical Research and the National Centre for Disease Control within broader clinical care and patient safety initiatives—including accreditation and certification programmes implemented by the National Accreditation Board of Hospitals and the National Health Mission in India—provides a way to sustain surveillance of healthcare associated infections and infection prevention and control programmes as a routine part of clinical care. Data from many countries have shown that when governments and health system leaders take a leadership role in prioritizing healthcare associated infection surveillance and infection prevention and control efforts, major change can be achieved.