Developing Tailored Infection-Control Practices and More Accurate HAI Outcome Measures

"AHRQ has funded work that would never have been funded by other agencies. We think it’s important work that has moved the field ahead and that would not have been possible without AHRQ filling that void."

Hospitals have come a long way in routinely using evidence-based interventions and bundled protocols to combat dangerous and costly antibiotic-resistant infections.

However, the organisms that cause these healthcare-associated infections (HAIs) often behave in different ways, making one protocol potentially more effective for one organism, but less so for another. By understanding which protocol is most effective for an antibiotic-resistant bacteria and which protocol is most effective for each HAI, hospitals can tailor their infection-control practices in the safest and most cost-effective manner.

The work of AHRQ-funded researcher Anthony Harris, M.D., M.P.H., has shed light on this key distinction.

A professor of public health and epidemiology at the University of Maryland, Baltimore, Dr. Harris recently completed an AHRQ-funded grant that examined whether an intervention – the universal use of gloves and gowns to combat MRSA (Methicillin-resistant Staphylococcus aureus) – could also reduce transmission of antibiotic-resistant gram-negative bacteria, including Acinetobacter, Pseudomonas, E. coli and Klebsiella. These bacteria are a major infection-control concern because they often cannot be treated effectively with existing antibiotics, putting patients at greater risk of serious illness and death.

Dr. Harris’ recent study builds on a 2013 investigation, funded in part by AHRQ and published in JAMA

, that found that the intervention of universal glove and gown use in ICUs reduced MRSA acquisition, one of the most common antibiotic-resistant bacteria, by 40 percent. The intervention had no impact on vancomycin-resistant enterococcus (VRE) rates compared with standard recommended use of contact precautions.

Preliminary results from Dr. Harris’ study show that the universal glove and gown protocol did, in fact, lower infection rates for antibiotic-resistant gram-negative bacteria, but not by as large of a margin as the intervention showed for MRSA. The protocol “seems to have an effect for most, but not all organisms. And the effect size depends on the type of organism,” he said.

Taken as a whole, this emerging body of knowledge will allow hospitals to more carefully assess, depending on their ICU infection rates, “whether it’s worth using the universal glove and gown intervention,” Dr. Harris said. The work also provides important information relative to the use of contact precautions.

In addition to helping hospitals better protect patients against specific types of HAIs, Dr. Harris’ AHRQ-funded research is identifying the types of pre-existing medical conditions that put patients at higher risk of developing HAIs.

Using data from hospital diagnostic codes, Dr. Harris found that patients with diabetes, kidney disease, obesity, and other chronic conditions had a higher risk of developing a central line-associated bloodstream infection (CLABSI) or surgical site infection (SSI). He also found that hospital rankings based on these hospitals’ CLABSI and SSI rates would change if these hospital rankings took into account the type of patients these hospitals were seeing based on these chronic conditions. Establishing this connection has important policy implications, because current pay-for-performance efforts reduce payments to hospitals if patients develop an HAI as a result of their care and do not currently adjust for many chronic conditions. Thus, hospitals taking care of more patients with chronic conditions may be unfairly ranked based on current methodology.

Dr. Harris’ current AHRQ-funded project is looking more closely to analyze antibiotic utilization practices across hospitals. He is using data that 550 hospitals submit to the Centers for Disease Control and Prevention to determine which risk factors or conditions are risk factors for increased antibiotic use.

“We want hospitals to be striving to improve performance, but we want them to strive based on rankings of outcome measures that are sound,” he said. Sound rankings will require using more precise outcome measures that can identify and adjust for treating more patients who are more vulnerable to HAIs.

Dr. Harris, who is a former president of the Society for Healthcare Epidemiology of America (SHEA), credits AHRQ-funded research with having had a far-reaching effect on HAI prevention.

“It has led to a better understanding of how to prevent HAIs and thus led to fewer HAIs,” he said. AHRQ-funded interventions have also reduced the spread of antibiotic-resistant bacteria, which in turn, has lowered the transmission of HAIs. And finally, the Agency’s support of informatics-driven research is leading to better outcome measures “that are more meaningful for patients and hospitals.”

Dr. Harris was the founder of the SHEA Research Network and served as its director from 2009 to 2013. He also serves on the editorial board of the journal Infection Control and Hospital Epidemiology.

Principal Investigator: Anthony Harris, M.D., M.P.H.
Institution: University of Maryland, Baltimore
Grantee Since: 2013
Type of Grant: Various