Dr. Nasia Safdar: Hospital acquired infections
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Rates of hospital-acquired infections (also called healthcare-associated infections) that are resistant to multiple antibiotics are significantly higher now than before the COVID-19 pandemic.
On June 17, 2024, SciLine interviewed: Dr. Nasia Safdar, a professor of medicine at the University of Wisconsin—Madison. See the footage and transcript from the interview below, or select ‘Contents’ on the left to skip to specific questions.
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Introduction
[0:00:20]
NASIA SAFDAR: My name is Nasia Safdar. I’m a professor in infectious diseases at the University of Wisconsin-Madison. And I study the prevention and treatment of health care-associated infections, many of which are resistant to anti-infectives.
Interview with SciLine
What are health care-associated infections?
[0:00:42]
NASIA SAFDAR: Health care-associated infections are infections that occur as a result of exposure to the health system. And the reason that they happen is because within the health system, there’s a lot of devices use, antibiotic use. People that are coming in are typically quite sick with other things. And so, they’re at risk of acquiring a bacteria that can then cause infection while they’re in the hospital or shortly after they are discharged from the hospital.
Why do infections, particularly antibiotic-resistant ones, spread so easily in hospitals and other health care settings?
[0:01:15]
NASIA SAFDAR: There is a certain profile of bacteria and germs that develop in health care facilities. And that profile is typically bacteria that are resistant to many commonly used antibiotics. It’s because within the health care system environment, there are patients who are typically quite sick. They’re vulnerable. Their immune systems might be compromised. You take that, and on top of that you add heavy-duty antibiotic usage, surgeries, procedures, devices, this leads to you know, a vulnerable population then at risk for acquiring these bacteria that are circulating in the environment of the system. And many of them happen to be antibiotic resistant. And so that’s why these are high risk settings for health care-associated infections.
What does it mean for an infection to be antibiotic-resistant?
[0:02:10]
NASIA SAFDAR: What that means is that for any typical infection, there might be a range of choices for treatment. There is what’s called first-line treatment, which is the first antibiotic you would go to. These are typically the most narrow antibiotics can treat the infections really well but without harming other things in the system, like the good bacteria that live in your intestine. But when bacteria get resistant to antibiotics, and we have fewer of those first-line choices, we have to go to more broad-spectrum antibiotics, which are those that might still be effective for treatment but also might have more side effects or might be able to destroy some of the good bacteria in the intestine. So, it is a trade off. And then ultimately, you also have bacteria where you lose treatment choices because they are resistant to whatever is available, meaning that those antibiotics are no longer effective. The bacteria has found a way to get around that antibiotic such that it can still multiply and grow. And the antibiotic is essentially not doing anything in that case.
What can health systems do to prevent or reduce the spread of infections?
[0:02:28]
NASIA SAFDAR: When we think about the two big categories of interventions that can be done: One is infection prevention, and the other is antibiotic stewardship, or the judicious or correct use of antibiotics. And both of these categories are really important together because they work synergistically with each other. So, within the infection prevention category, you have things like hand hygiene, which is important and critical, not just for health care personnel, but also for patients themselves. There is also the use of gowns and gloves when necessary to make sure that if one patient has a particular condition that is able to be transmitted from person to person, that that pathway is interrupted by health care workers wearing the right what’s called PPE, or personal protective equipment, which typically is gowns and gloves. And then monitoring to make sure that those processes are followed with care, with a lot of fidelity, such that there’s not a lot of variation in these best practices. I think using devices only when essential is another way to prevent the patients from becoming an unnecessary or avoidable risk for for health care-associated infections. And then within the antibiotic stewardship category, there’s a lot of overuse of antibiotics still that happens in health care systems. And even though there have been many advances made in recent years, or people are being very careful, there still is a lot of room for growth. And that’s the other biggest driver of antibiotic resistance is overuse of antibiotics.
What has been happening with rates of health care-associated infections in recent years?
[0:04:51]
NASIA SAFDAR: So, before the pandemic, I think that the field was quite optimistic because we were seeing some real gains in reduced rates of antibiotic-resistant infections. And when we say antibiotic-resistant infections, there is a big spectrum of them. You know, there’s about 20 different types of bacteria that are on the watch list, for instance, as strains go up and down. So, it’s not just one homogenous category. But within those, we had seen gains and people were quite pleased with the way things were going. And then I think that a lot of those gains were reversed with the arrival of the pandemic. Patients were sicker. There was a lot of overuse, unnecessary use of antibiotics, a lot of intensive care that was needed to be provided. And so, a lot of those gains were reversed, and we see sharp increases in many of those antibiotic-resistant bacteria. And that led to a lot of concern that whatever success we might have had was pretty fragile and short-lived. And we want to make sure that we’re not as vulnerable as we became during the pandemic.
Can you give us some background on Candida auris?
[0:05:59]
NASIA SAFDAR: Candida auris is an emerging pathogen. Unlike some of the other antibiotic resistant germs that are in health care systems, this one is a fungus—or a yeast is the other terminology for it. And the reason that it’s concerning is that it spreads quite fast in health care systems. It has been responsible for a number of outbreaks, and the treatment options for that are much more limited compared to some of the other organisms or germs that we see causing infections in the health care environment. Over the past several years, it’s been percolating with little pockets of infections here and there but didn’t reach the level of high concern because people were keeping a close eye on it, and it seemed like it was smoldering. But then with the arrival of the pandemic—and for the couple of years during that—there was a sharp increase in it. And the thing that drives it is much like the other things is also antibiotic use. And so, it rose by several hundred percent nationwide, after having smoldered for a while. And so, that’s the thing that concerns us that when these things rise in numbers, it’s typically not subtle. There’s a sharp spike.
What can health care systems do to manage C. auris specifically?
[0:07:18]
NASIA SAFDAR: So, for C. auris, I think one of the biggest things is to have a sense of great vigilance, and to know what your rates are. There are challenges in diagnosing Candida auris, so health systems should make sure that the necessary equipment and the resources to diagnose it. There are other things that can be done beyond the standard gowning and gloving of health care workers when taking care of patients with Candida auris. And one of those is that if you see a single case in the facility, it might be an indication or a reason to do cultures from other patients in that same area who might also be vulnerable to getting this fungus. So, it should raise quite a bit of alarm if one were to see Candida auris—and then keeping a close eye on those rates to make sure that they are not continuing to rise.
Is it possible to reduce the spread of health care-associated infections by manipulating the gut microbiome?
[0:08:13]
NASIA SAFDAR: We know that many of these germs that occur in health care systems and then cause infections live in the intestine. They are generally kept at bay by the good bacteria that we all have in our intestines. But sometimes when we use antibiotics, or there is devices, or there is surgeries, those good bacteria are destroyed. And then these germs can find hospitable niche in their environment, and they can grow and cause infections. We know that diet plays a pretty important role in keeping our gut microbiome healthy. And while we don’t know exactly what the specific aspects of diet are that will help, we know that fiber, for instance, is one component of a healthy diet that is used very little by the national U.S. population, speaking generally. But a high-fiber diet is generally beneficial for you, including keeping your gut biome microbiota, or gut bacteria healthy, so that they can put up more of a resistance to germs when they try to invade.
What can patients or their families do to reduce the odds of contracting an infection in the hospital or other health care setting.
[0:09:16]
NASIA SAFDAR: I think for patients, some of the core things that are beneficial for a healthy life in general is to try and do whatever one can to prevent chronic illnesses. Now, of course, not everything is preventable. But in terms of your diet, your exercise routine, sleep—those are all things that keep our learning systems healthy and make us less vulnerable. Having said that, patients will get conditions that will require them to seek care in a health care system. And so, if you happen to need that, the things that you can do is make sure that patient hand hygiene is followed, that you ask about the health care system’s rates of infections, rates of hand hygiene. Those are things that are typically closely tracked by health care systems and are often even publicly available. And then it’s also a good idea to ask your health care treatment team what you’re getting for treatments, particularly if they’re antibiotics, so that you can ask the right questions about how long you should be taking them, what side effects to anticipate, and what the effect they will have on your gut bacteria.
What can patients or their families do to reduce their odds of contracting an infection in the hospital or other health care setting?
[0:10:33]
NASIA SAFDAR: In the vast majority of incidences, yes. Hand sanitizer because it’s effective, it’s convenient, it’s readily available, is a really great idea to prevent infections in health care systems. There are some instances where you would want to use soap and water instead. And so, example of that would be a particular infection called Clostridium difficile. This causes diarrhea, and so the hand sanitizer doesn’t work for that. And so, you want soap and water. There’s also instances where there’s gross soilage—so evidence of blood, stool, other body secretions. For those kinds of things, you would want to use soap and water for hand hygiene instead.
