The role of Infection control in improving quality and safety in primary healthcare in Nigeria

The primary healthcare system which provides basic clinical and public health to one fifth of the global population has a notable history. The primary care institutions faced substantial challenges in the health care sector, including limited development, inadequate government funding and weakening of the support by public health care providers. This led to surging costs, poor quality, and diminished access to care in primary healthcare. Even though Nigeria has made remarkable efforts and achievements following reforms over the years, the service quality of primary health care in Nigeria is still poor.

Healthcare-associated infection (HAI) is responsible for a substantial burden of diseases on patients and healthcare workers, especially in primary health care institutions with poor resources. For primary healthcare institutions, poor social environment, deficient infrastructures, rudimentary equipment, the lack of national and local infection control policies and the co-existence of other major health problems are the main determinants of the poor quality of care and a two to twenty times higher risk of acquiring HAI.1

In developing countries, surveillance systems providing reliable and regularly collected data are non-existent and the burden of HAI is underestimated to a large extent and unknown by healthcare professionals and policy makers more especially at the primary healthcare level. Infection control should be prioritized at every level of the healthcare system to achieve an improved quality of care. The HAI rate can be reduced effectively and the compliance rate of health workers can be improved in the daily work by the efficient management, regular training, and setting a strong organization and surveillance system at the national level. Patient Safety and Service Quality Units in Hospitals have been established in many institutions globally to monitor patient care and facilitate the development of clinical protocols for patient safety. However, it is regrettable that most hospitals in Nigeria and Africa are yet to establish such units to improve healthcare delivery as well as checkmate medical errors. According to a study conducted among health workers in a tertiary hospital in Nigeria, it was revealed that patient safety awareness and practice are low and most hospitals in Nigeria do not have an effective institutional protocol for preventing medical errors.

Medical advances have brought lifesaving care to patients in need. These advances in healthcare involves variety of invasive procedures and devices to treat patients to help them recover but this devices and procedures exposes the patient to a significant risk of infections refers to as healthcare associated infections.2

HAIs is a global concern: however, in developing where the burden of HAIs is presumed to be higher compared to the developed nations, yet information on the surveillance of HAIs is not sufficiently available because of lack of countrywide surveillance programs and data.3 HAIs are infections that first appear 48 hours or more after hospitalization or within 30 days after having received health care.4 The term HAIs initially referred to those infections linked with admission to an acute-care hospital (earlier called nosocomial infections), but the term now includes infections developed in various settings where patients obtain health care (eg, long-term care, family medicine clinics, home care, and ambulatory care).3

World Health Organization (WHO) defined Health care-associated infections, or “nosocomial” and “hospital” as infections that affect patients in a hospital or other healthcare facility, and are not present or incubating at the time of admission. They also include infections acquired by patients in the hospital or facility but appearing after discharge, and occupational infections among staff.5

Health care-associated infections, or infections acquired in health-care settings are the most frequent adverse event in health-care delivery worldwide.5 the report further stated that of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection.5

The prevalence of health care-associated infection varies between 5.7% and 19.1% in low- and middle-income countries. Average prevalence is significantly higher in high- than in low-quality studies (15.5% vs 8.5%, respectively). WHO reported that HAIs only receive public attention when there is epidemic even though no institution or country can claim to have solved the endemic HAIs burden.5. WHO estimates that out of every 100 hospitalized patients, at any given time, seven in high-income countries and 10 in low- and middle-income countries will acquire one or more healthcare-associated infections (HAIs). People with methicillin-resistant Staphylococcus aureus (MRSA), a bacterium increasingly found in hospital settings that is resistant to most antibiotics, are estimated to be 64% more likely to die than people with a non-resistant form of the infection.

Types of healthcare associated infection

Contaminated hands of health workers, use of medical devices, and improper procedures techniques could be responsible for infections known as healthcare associated infections. These infections include central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTIs), Ventilator-associated pneumonia (VAP), and surgical site infections (SSIs).

Central Line Blood Stream Infections (CLABSI)

Central line is universally used to deliver parenteral medications and fluids and for hemodialysis. However, its use may cause a great risk of infection to the patients with increased potential for prolonged hospital stay, significant economic burden and mortality.6 Central line associated blood stream infection have caused thousands of deaths each year and billions of dollars in added cost to the US healthcare.7 According to studies, CLABSI accounts for 12% – 15% mortality rate which makes it an import and deadly HAI. 8A study reported that CLABSI in developing countries is linked with high morbidity and mortality with infection rate of up to 62% high.9

Healthcare providers must follow a strict protocol when inserting the line to make sure the line remains sterile and a CLABSI does not occur. In addition to inserting the central line properly, healthcare providers must use stringent infection control practices each time they check the line or change the dressing. Patients who get a CLABSI have a fever, and might also have red skin and soreness around the central line.10

Catheter associated urinary tract infection (CAUTI)

Between 15% – 25% of patients in the hospital receive catheterization during their hospital stay11. Catheter associated urinary tract infection is the most commonly occurring healthcare associated infection in hospital setting representing about 40% of HAI rate with significant cost implication and high potential for morbidity and mortality.12Unnecessary catherization should be avoided at all cost and catheter should not allowed in place for a prolonged period of time. Studies have shown that systemic antibiotics use in catheter-related asymptomatic bacteriuria increases the risk of antibiotic resistant with insignificant clinical improvement. The study further indicated that the use of systemic prophylactic antibiotics in indwelling catheterization is not recommended. However, systemic antibiotic use may be recommended in symptomatic CAUTI.12

In addition to avoiding unnecessary catherization and prolonged indwelling catheter, the use of catheter checklist has been identified as one of the effective way of preventing CAUTI in a health setting.13

Ventilator associated pneumonia (VAP)

Ventilator-associated pneumonia is the most common healthcare associated infection in patients receiving mechanical ventilation14. VAP is the second most common healthcare associated infection accounting for about 9-27% of infections and a major cause of mortality in the intensive care unit13. Modern devices such as ventilator and catheter used in treating patients in the healthcare settings are associated with higher risk of infection14. Ventilator-associated pneumonia is a lung infection that occur in a patient that is on ventilator. Infection can occur when a micro-organism enters the ventilator tubes and gets to the patient’s lungs.14

It is recommended that, to prevent ventilator-associated pneumonia, oro-tracheal instead of naso-tracheal tubes should be used on patients receiving mechanical ventilation. Other preventive measures include the use of endo-tracheal tube with a dorsal lumen to allow free drainage of respiratory secretions, and changing the breathing circuit when visibly contaminated15.

Surgical Site Infection (SSI)

Surgical site infection is an infection occurring in patients who had surgery or days after a surgical intervention. SSI is the most common complication in post-operative patients associated with high morbidity and responsible high financial burden.13SSI that occur in post-operative surgical patients accounts for 14% mortality and is responsible for prolonged hospital stay16. SSI is the most commonly occurring HAIs following cardiac and orthopedic surgery which usually presents with sepsis and multiple organ failure17. A study in Nigerian tertiary hospital reported SSI as the second most prevalent HAIs with the incidence rate of 30.7% after UTI (43.9) and Staphylococcus specie as the predominant isolate (20.1%)4. The CDC provided an exclusive guide to prevent surgical site infections including hand hygiene up to elbow with antiseptics before surgery, wash hands with soap and water after caring for surgical patient, shave immediately before the surgery, wear special hair covers, mask, gown and gloves during surgery, clean skin with antiseptics before surgery and if indicated, administer antibiotics 60 minutes before surgery18.

Muhammad Ahmad Saddiq is an infection control practitioner (ICP) at Federal Teaching Hospital Gombe, Nigeria.