Chapter 5
Infection prevention strategies and hygiene measures
5.1
This chapter addresses the effectiveness of the implementation of the
JETACAR recommendations relating to regulatory control of antimicrobials. The WHO
identified poor infection prevention and control practices as one of the six
underlying factors that drive AMR.[1]
The actions taken since JETACAR are summarised, along with current
arrangements. While a range of activities are underway the committee heard
concerns about issues including: whether sufficient effort is being put into
alternatives to antibiotics, lack of single patient rooms in hospitals, the
need for further work on the hand hygiene program and non-clinical use of power
antimicrobials, such as nano-silver. The chapter concludes with a discussion on
ways to ensure appropriate hospital responses to AMR.
Implementation of the JETACAR recommendations
5.2
JETACAR commented that the overall bacterial 'load' to humans is reduced
if high standards of hygiene are maintained in the food supply, and
precautionary measures are taken to reduce contamination of humans with animal
bacteria. JETACAR recommended (recommendation 12) that food safety procedures
be implemented as a means of reducing the contamination of food products with
foodborne organisms, including antibiotic resistant organisms, and that these
programs also address on-farm infection control.
5.3
In relation to food-producing animals, JETACAR commented that the need
for antibiotics will be reduced if disease is reduced through improved
veterinary care and animal husbandry. JETACAR recommended (recommendation 13)
that cost-effective non-antibiotic methods to increase productivity and prevent
disease should be developed by intensive animal industries.
5.4
JETACAR also noted that a nationally coordinated system of human
infection control practice and outbreak management is also required. JETACAR recommended
that DoHA examine current surveillance activities for hospital-acquired (nosocomial)
infections and that it work with stakeholders (including the states and territories)
to further develop a comprehensive and standardised national system for
monitoring nosocomial infections (recommendation 14). This would facilitate
improvements in infection control and hygiene measures and development of
national standards and guidelines for both surveillance and infection control
in healthcare settings.[2]
The Government response
5.5
The Government supported recommendation 12 including the role of
industry based codes of practice in addressing identified risk factors in food
animal production systems. It was also noted that the Australia and New Zealand
Food Authority (ANZFA) and other bodies were already progressing relevant
strategies and policies.[3]
5.6
In relation to recommendation 13, the Government response noted that the
Government encouraged research and development activities through established
research and development corporations to develop cost effective and safe food
animal production systems. Further research efforts to help decrease food
animal industry dependence on antibiotic use would be encouraged. The
Government indicated in its response to recommendation 14, that it was already
taking action, pointing to the initiation of a national scoping study to
examine existing surveillance of nosocomial infections in Australia. The study
was intended to provide vital information for future national planning of
nosocomial surveillance. Findings from the scoping study would be referred to
the DoHA and DAFF and to the Working Party on Antibiotics or its successor.[4]
The CIJIG progress report
5.7
In March 2003, the CIJIG released a progress report on the
implementation of the JETACAR recommendations. In relation to infection prevention
strategies and hygiene measures, the progress report noted that for
recommendations 12 and 13:
- actions to examine and improve existing procedures and industry
based quality assurance to reduce microbial contamination in the production
chain were continuing;
- meat hygiene standards had been developed with implementation to
be undertaken the Australian Quarantine Inspection Service and states and
territories;
- FSANZ had assumed responsibility for primary production and processing
standards for Australia; and
- EAGAR had published outputs from a workshop on priorities for
antimicrobial research in epidemiology, human health impacts and interventions
to limit the emergence and spread of antimicrobial resistance.[5]
Actions since the CIJIG progress
report
5.8
The DoHA submission noted that a range of measures had been funded to
address recommendations 12 to 14, including the development of national
infection control guidelines and programs to specifically monitor healthcare-acquired
infections.[6]
These include:
- Monitoring healthcare associated infections – a National
Surveillance of Healthcare Associated Infection in Australia study was
conducted and provided to the then Australian Council for Safety and Quality in
Healthcare. This resulted in a national strategy to address healthcare
associated infections, which contained nine recommendations endorsed by all
Health Ministers in 2003.[7]
In July 2004 the Australian Council
for Safety and Quality in Health Care's Health Care Associated Infections
Advisory Committee reported that a national snapshot was being developed to
draw together all work being undertaken in the jurisdictions on healthcare
associated infections.[8]
- Safety and quality in healthcare – Standard 3 of the National
Safety and Quality Health Service Standards, 'Preventing and Controlling Health
Care Associated Infection' is being implemented. Standard 3 ensures that health
services take active steps in relation to governance and systems for infection
prevention, control and surveillance; infection prevention and control
strategies; managing patients with infections or colonisations; antimicrobial
stewardship; cleaning, disinfection and sterilisation; and communication with
patients and carers.[9]
- Infection prevention and control guidelines – The Australian
Guidelines for the Prevention and Control of Infection in Healthcare were
released by the NHMRC in October 2010. The guidelines aim to establish a
nationally accepted approach to infection prevention and control and provide an
evidence base on which healthcare workers and healthcare facilities can develop
detailed protocols and processes for infection prevention and control.[10]
Therapeutic guidelines for
antibiotics are produced by the Antibiotic Expert Group of Therapeutic Guidelines
Limited, which is an independent non-for-profit organisation. The purpose of
the guidelines is to provide prescribers with clear, practical, succinct and
up-to-date therapeutic information for a range of diseases. The guidelines were
updated in 2010.[11]
- Food safety – in July 2008, all jurisdictions signed up to a Food
Regulation Agreement aimed at providing safe food controls for the purpose of
protecting public health and safety. The agreement and introduction of the food
standards code addresses JETACAR recommendation 12.[12]
FSANZ now has oversight of
Maximum Residue Limits for pesticides in imported food. FSANZ provides risk
assessment advice to DAFF for food imports that represent a medium of high food
safety risk.[13]
5.9
In addition, DoHA indicated that to reflect the new opportunities for
national coordination and improvement, two new priority areas, including
'nationally coordinated action to address health care associated infection and
antimicrobial resistance', have been added to the ACSQHC's 2013–16 work plan.
This will be funded through joint arrangements with the Commonwealth, states
and territories. DoHA stated that this priority builds on the success of the
Commission's existing healthcare associated infection (HAI) program to address
AMR and HAI, to identify, assess and communicate current and emerging threats
to human health posed by infectious diseases. The Commission is proposing to
coordinate national action to address HAI and AMR in alignment with initiatives
under development by the Australian Health Protection Principal Committee. This
provides an integrative approach to the prevention of AMR and HAI through
coordination of national activities such as surveillance, response to emerging
health threats, scientific opinions, scientific and technical assistance,
collection of data and identification of emerging health threats, and provision
of public information.[14]
Industry actions
5.10
Industry associations provided information on actions that industry has
undertaken to address the JETACAR recommendations, including projects on
pre-weaning techniques, low stress stock handling methods, commingling methods,
promotion of direct consignments, methods for the introduction of cattle to
grain, vaccines,
animal health diagnostics, cost-effective animal husbandry that focusses on
disease prevention, and simple treatments. The Hazard Analysis Critical Control
Points (HACCP)-based food safety procedure has been implemented and evaluated.
Advice is also given to farmers with strict program requirements for use of livestock
treatment according to label and veterinary directions.[15]
The Australia Lot Feeders' Association also informed the committee that:
A number of vaccines have become available since 2000, and
are being used commercially, for the control of bovine respiratory disease
(BRD) in feedlot cattle. These include Rhinogard® for control of bovine
herpesvirus, Pestigard® for control of bovine pestivirus, and Bovilis Mh® for
control of Mannheimia haemolytica, an important secondary bacterial
infection agent in cases of BRD. The viral infections are important precursors
to bacterial infections, so they are relevant in the context of reducing the
need for antibiotic use.[16]
5.11
The ACMF submitted to the committee that the Australian chicken industry
has taken AMR very seriously and achieved very low rates of resistance when
compared to other countries. The ACMF argued that the low resistance rates have
been achieved through 'a combination of high levels of bird health associated
with infection prevention programs (including continuous attention to
biosecurity and the use of vaccination), highly nutritious diets, cutting edge
genetic selection and high standards of bird husbandry'.[17]
5.12
The ACMF noted that in a five year period it had spent 10.5 per
cent of its total budget on projects aimed at developing alternatives to
antibiotics. The ACMF also stated that the chicken meat industry had worked
closely with FSANZ in the development and implementation of the Primary
Production and Processing (PPP) Standard for Poultry Meat. The PPP Standard aims
to strengthen food safety and traceability throughout the food supply chain
from paddock to plate. The standard introduces new legal safeguards for growing
live poultry and requires poultry growers to identify and control food safety
hazards associated with poultry growing.[18]
Concerns about the implementation of the recommendations
5.13
Submitters raised concerns about infection prevention programs,
particularly in hospitals settings such as hygiene measures, alternatives to
the use of antibiotics in the food production sector and non-clinical use of
antibiotics.
Infection prevention in human
health
5.14
Infection prevention is crucial to decreasing the use of antibiotics,
particularly in hospitals. Professor Cooper provided evidence on outcomes when
infection prevention and control is poor. He pointed to countries where clinical
practices are inconsistent and overburdened, causing the problem of infection
to be significantly larger. Professor Cooper noted that a three year study in
four Mexican public hospital intensive care units revealed device associated
nosocomial infection rates of 24.4 per cent. However, where hospitals have
implemented programs with a focus on prevention and control of infections,
there has been a decline in the incidence of hospital acquired infections.[19]
5.15
Professor Grayson pointed to the example of golden staph which developed
as a problem in the early 1980s. He suggested that the lack of effective
infection control measures at that time has resulted in golden staph becoming a
major health issue. He stated:
The attitude was it was too hard and after a couple of years
everyone gave up and said, 'We'll just have to live with it.' It is now our No.
1 pathogen 20 years later. We did not do anything about it and it is now a
key issue in our healthcare system which has cost us enormously, whereas a few
preventative measures at the start would not have stopped it but would have
slowed it up so that it was containable and manageable. I suppose that is what
I am talking about here. We are not going to stop the emergence of resistance.
It is about Darwinian selection, which is that, while you have an antibiotic,
bugs will learn to become resistant to it. It is about controlling it in a way
such that we can continue our healthcare systems and standards of living.[20]
5.16
In recognition of the need for infection prevention and control, standard
3 of the National Safety and Quality Health Service Standards now applies to
every hospital and day procedure centre in Australia. In part, standard 3
requires systems for infection prevention, control and surveillance, including
infection prevention and control strategies, managing patients with infections
or colonisations, antimicrobial stewardship, cleaning, disinfection and
sterilisation of hospitals. Professor Debora Picone, Chief Executive Officer,
ACSQHC, commented that the changes in relation to infection control are
significant.[21]
5.17
Witnesses agreed that some progress had been made in relation to
infection prevention. Dr Looke, suggested that ACSQHC had made good progress on
infection control to date.[22]
However, NPS MedicineWise supported the need for better management of infection
control procedures.[23]
Professor Collignon also commented that, in his view, infection control in
hospitals is less than optimal, particularly for areas such as hand hygiene.[24]
5.18
Professor Grayson argued that there should be a greatly enhanced focus
on infection control measures to limit the transmission of superbugs,
particularly for hospital in-patients. He stated that crucial steps include:
- further improvements hand hygiene among healthcare workers;
- establishing a national standard for hospital cleaning, including
better training of cleaners; and
- establishing national standards for insertion and maintenance of
invasive devices.[25]
5.19
Dr Looke considered that further research is required to identify new
ways of managing or preventing infections that are 'innovative and lateral'. He
recommended that incentives should be given to academic centres to undertake
this research. Dr Looke further stated 'this is something that will stand
the country in great stead. We have always punched above our weight in doing
things like that.'[26]
Hand hygiene
5.20
In March 2008, Austin Health, Victoria, was contracted by the ACSQHC to
deliver the National Hand Hygiene Initiative. The Director of Hand Hygiene
Australia, Professor Grayson, informed the committee that prior to the
initiative there was a great deal of variation in how hand hygiene was managed
across hospitals. The initiative has delivered improvements in hygiene
through standardised arrangements:
By way of example, each hospital had its own attitudes and
personalities thinking about different systems for hand hygiene. My own
hospital had a different system. Now we have one system that is in almost 700
hospitals around Australia with reporting three times a year and all using a standardised
measure and tools using validated assessors so that when a hospital gets a bad
result they do not say, 'You didn't score us properly.' They accept that it was
scored properly and that they have a problem.[27]
5.21
DoHA commented that in 2011 the National Hand Hygiene Initiative was
awarded a WHO 'Centre of Excellence Award', one of only four sites worldwide to
receive such an honour. In 2012 over 90 per cent of public hospitals and over
50 per cent of private hospitals contributed data to the initiative. Compliance
has risen from 64 per cent when data was first collected in 2009 to 73 per cent
in 2012. DoHA indicated that the future direction of the hand hygiene
initiative is to focus on:
- national hand hygiene data standardisation and validity;
- national hand hygiene database, analysis and efficiency;
- national hand hygiene education resources and credentialing;
- private sector hand hygiene support and coordination; and
- research and development.[28]
5.22
The Pharmaceutical Society of Australia (PSA) informed the committee of
its Self Care program, aimed at providing reliable health information to
Australians. The information provided includes simple hand and body hygiene
advice in an easy to read fact card. Along with Friends of the Earth Australia,
the PSA discourages the use of antibacterial and antimicrobial hand wash
lotions and cleaning products unless advised to do so by a health professional:
If used frequently, many of these products can contribute to
the development of resistant bacteria. In most situations, washing with plain
non-bactericidal soap/detergent, rinsing with running water and thorough drying
is effective cleaning and is cheaper.[29]
5.23
The importance of hand hygiene was also noted for people working with
animals, including pigs, raw seafood, and raw meat.[30]
The potential risks for the community associated with the use of antibiotics in
imported ornamental fish were also brought to the committee's attention.[31]
Single patient rooms
5.24
Another issue highlighted by Professor Grayson was increased infection
transmission problems arising from having multi-patient rooms in hospitals.
Antibiotics were used to combat the resulting increases in infections when more
patients were put into large rooms. Professor Grayson argued that it may be
appropriate to reduce the transmission of infections by having single patient
rooms:
Why were you going to get sick in the first place? Was it
because in the hospital there were four of you in a room potentially spreading
germs between the four of you? Should we be moving to single rooms and being
separated from each other, which was the situation before antibiotics were
invented? Fairfield Hospital and other isolation hospitals all had single rooms
because they did not have antibiotics. They separated a sick person from
another. It is not rocket science. In a way we have become lazy or dependent on
antibiotics and said: 'With antibiotics we do not need to worry about that. We
can put people together and we will get around the problem by giving them
antibiotics.' I do not think we can afford to do that any more.[32]
5.25
DoHA commented that research in the UK has shown that improved designs
in National Health Service buildings can have a significant impact on the
control of infection in clinical areas and help to reduce the more than £1 billion annual cost
burden of healthcare associated infections. A number of recently designed
Australian hospitals (for example, the new Royal Perth Hospital and the Royal
Adelaide Hospital) have incorporated these key principles in their designs such
that they each have about 80 per cent single rooms, each with their own
bathroom, to avoid sharing of toilet facilities.[33]
Aged care
5.26
Submitters and witnesses indicated that AMR was also a problem in aged care
facilities.[34]
In response to committee questions on the impact that AMR is having in the aged
care sector, NPS MedicineWise indicated that while some projects had been
undertaken in Victoria, there was little specific information available.[35]
DoHA advised the committee that the Australian Government has responsibility
for the surveillance and management of infection in aged care.[36]
5.27
The committee notes that the Quality of Care Principles 1997
require an 'an effective infection control program' to be implemented.[37]
The relevant aged care standards provide further detail on policies, practices
and considerations required of an effective infection control program, under
standard 4.[38]
However these standards and the related guidelines do not explicitly cover AMR.
5.28
Professor Rood called for an integrated response to AMR that covers all
sectors, including aged care. The ASID/ASA antimicrobial resistance summit in
2011 recommended that 'national evidence-based standards for multi-resistant
organism control in aged care facilities should be developed, implemented and
robustly enforced and monitored.'[39]
Incentives
5.29
In order to ensure that hospitals make every effort to decrease AMR
rates, Professor Cooper suggested that incentives be provided to hospitals.
He noted a program in the United Kingdom in which hospital chief executive
officer bonuses were linked to performance on AMR. As a result, year-on-year
reductions in MRSA incidence rates have been reported from the late 2000s.[40]
5.30
NPS MedicineWise supported using incentives in hospitals as long as the
incentives were carefully thought out so that unintended consequences were
avoided:
I think you have to be very sure you have the right indicator
and the right incentive, that you are measuring the right thing. If you are
not, of course, you have unintended consequences. If you get the measure right
it can be very powerful. It is a very powerful signal that you care about it...
So it can be very useful in that way. It focuses people's mind on that
particular issue.[41]
5.31
The importance of carefully selecting the incentives was highlighted by
data from the United Kingdom in which the rates of targeted AMR fell, while
rates for other types of AMR rose:
Based on results from a selection of hospitals
across England, the report indicates that there have been large reductions in
both MRSA and C. difficile rates since the last survey was conducted in
2006. C. difficile infections fell from 2% of patients becoming infected in
2006 to 0.4% in the 2012 report. MRSA fell even more sharply, from 1.8% of
patients affected to less than 0.1%.
However, infections with other organisms, such
as E. coli and salmonella, are increasing.[42]
5.32
Dr Jenny Firman, DoHA, indicated that some incentives already exist in
the Australian healthcare system in relation to prescribing in general
practice. While there are a small percentage of prescriptions are private
prescriptions, it is simpler and cheaper for patients to use the Pharmaceutical
Benefits Scheme. The use of the authority also makes it more difficult to
prescribe certain drugs. Dr Firman commented that is a very effective method.
In addition, clinicians are provided with feedback on prescribing patterns and
comparisons with peers can be made.[43]
5.33
In relation to general practice, the current Practice Incentives Program
(PIP) provides payments to support general practice activities that encourage
continuing improvements, quality care, enhance capacity, and improve access and
health outcomes for patients.[44]
5.34
Professor Picone, ACSQHC, was less enthusiastic about incentives in
hospital settings, citing a lack of evidence for the effectiveness of financial
and other incentives, instead suggesting that mandating standards, such as
standard 3, was a preferable approach to changing behaviour.[45]
5.35
However, Australian Society for Antimicrobials and the Public Health
Association of Australia submitted to the committee that the 2001 WHO Global
Strategy for Containment of Antimicrobial Resistance includes the creation of
economic incentives for the appropriate use of antimicrobials.[46]
Control of infections imported from
overseas
5.36
The issue of control of infections in overseas countries that may impact
on Australia was also noted. Professor Grayson commented on control at the
border to prevent diseases being brought into Australia:
The whole reason we have things in place in airports is to
prevent the importation of diseases and they have been incredibly effective. In
the case of specific infectious diseases, we know that in the past when steps
were instituted to control importation of swine flu or avian flu, more
importantly, they were incredibly effective at preventing the importation of
these diseases. We have a very robust public health system that can cope with
this if the right directions are given to them in terms of screening and
awareness amongst returned travellers about these issues.[47]
5.37
Professor Baggoley, DoHA, also informed the committee of Australia's
international work to promote infection control.[48]
Alternatives to antibiotics in the
food production sector
5.38
One of the central messages from JETACAR was the need to develop
approaches to alternative infection prevention, particularly in the food animal
sector, so that the antibiotic usage could be decreased and thus resistance is
decreased. Professor Collignon summed this up in his comments to the committee:
I am not saying that animals should never get antibiotics to
prevent them getting disease. My argument is that if you routinely have to add
antibiotics to feed or water to prevent animals getting disease there is
something wrong with your production system...In my view, continuous use of
antibiotics is an example of a practice that is inherently not sustainable and
needs to change so that you prevent disease by means other than antibiotics.[49]
5.39
The committee was informed by the ASID that innovation and ways of
preventing infections are needed. Possible approaches suggested include vaccine
development, ways of preventing the common infections, reactivating Staph Aureus
prevention and treatment with a staphylococcal vaccine.[50]
Dr Looke noted that the agricultural sector is attempting to identify ways of
producing food without antibiotics. Dr Looke stated:
I note that there was some work done in aquaculture, with
trying to do prawn farming without adding antimicrobials, and it was quite
successful. There has been work in the chicken industry with breeding different
types of chicken stock that are resistant to the common infections that spread
through the high-intensity chicken breeding industries and they do need to put
antibiotics in the feed and the water for those types of things.
That is the sort of thing that we should be trying to promote
as innovation and ways of preventing infections.[51]
5.40
The Australian Veterinarian Association (AVA) indicated its support for
the development and use of alternatives to antibiotics. Whenever possible the
use of non-antibiotic options is recommended prior to decision to employ
antimicrobial interventions. The AVA annual conference and the Australian
Veterinary Journal both regularly include information on research on
alternatives to antibiotics, such as dietary manipulation, natural products,
probiotics and immunological stimulants.
5.41
The AVA Guidelines for veterinary personal biosecurity also set out a
comprehensive approach to protecting verterinary personnel from zoonotic
infections. The AVA's Therapeutic subcommittee published a review on the
prevention and treatment of Ruminal Acidosis, that noted that forward planning
and preventative management can frequently avoid the onset of fermentative
acidosis.[52]
5.42
The ASID/ASA antimicrobial resistance summit in 2011 also recommended as
one of its top five priorities, the development of enhanced infection
prevention strategies with investigation of ways of circumventing the need for
antimicrobials in all sectors of human and animal health, and agriculture.[53]
5.43
The pork industry stated that it has been working with research bodies
on a range projects, including reduction of antibiotic usage through herd
management, diagnostic tools and alternative treatments, such as gene based
vaccines.[54]
However, Australian Pork Limited noted some concerns about the process for
getting new vaccines registered:
APL believes industry endeavours in this regard are being
stifled by what is typically a protracted registration process experienced by a
number of companies that wish to import efficacious and safe vaccines. APL
would urge the APVMA to rationalize the registration process for imported
vaccines.[55]
Non-clinical use of nano-silver and
other antimicrobials
5.44
Friends of the Earth Australia and the Australia Institute raised
concerns about the increased use of antimicrobials in consumer goods,
particularly nano-silver and triclosan.
5.45
Compounds such as alcohol, mercury, silver and bleach act as antimicrobials.
Silver can be manipulated into small nanoparticles which allow it to spread
further and to increase its efficiency. Friends of the Earth noted nanosilver
has 'important clinical applications: lining wound dressings, catheters,
stents—places where bacteria can infect compromised people in hospitals and,
ultimately, nanosilver can help save lives'.[56]
However, nano-silver is being increasingly used in consumer goods such as dish
cloths, hair brushes, baby mattresses, toothbrushes and computer keyboards.[57]
5.46
Triclosan was first developed and introduced as an antimicrobial
and preservative in the 1960s. Since this time, triclosan has been used in clinical
settings as an antiseptic. However, like nano-silver it is also used in a 'vast
range of domestic products under trade names such as Microban and
Ultrafresh, including hand soaps, pillows, toothpastes, cosmetics,
mouthwash, deodorants, cutting boards, wound disinfectants, facial tissues,
plastic utensils, socks and toys'. Friends of the Earth went on to note that
both nano-silver and triclosan are non-specific antimicrobials and have the
ability to kill good microbes as well as the bad.[58]
5.47
Dr Crocetti, Friends of the Earth, concluded:
So we have two classic examples of antimicrobials that could
form vital weapons in our ongoing battle against multidrug-resistant
bacterials—superbugs—in hospitals, but at the current rate of this frivolous
use in consumer goods we will inevitably lose effectiveness. Also, the
widespread use of these antimicrobials will lead to an even greater problem.[59]
5.48
Dr Crocetti also raised the dangers of co-selection if these
antimicrobials are used unnecessarily in household products. Co-selection
means, in simple terms, that if microbes or bacteria becomes resistant, the
resistance can be passed on to successive microbes or bacteria for not just the
initial antimicrobial but for other similar antimicrobials. Dr Crocetti
explained this in more detail in evidence.[60]
5.49
Similarly, Dr Liz Frazer noted that exposure to mercury can contribute
to co-selection for resistance. Dr Frazer also pointed out that contact with
mercury, through food sources, such as fish, or older dental amalgams could
contribute to resistance.[61]
5.50
The Public Health Association of Australia[62]
and Friends of the Earth Australia suggested that usage of antimicrobials such
as nano-silver and triclosan should be restricted to their clinical
applications:
Experts agree that regulators need to halt the excessive and
unnecessary use of powerful antimicrobials in every day products. This kind of
regulation is critical in order to maintain the effective clinical uses of
those antimicrobials, as well as the continued effectiveness of antibiotics.[63]
5.51
DoHA responded to concerns about the use of nano-silver and stated it
has not taken any specific actions relating to nano-silver. DoHA went on to note
that there is very limited data to support human toxicological risk assessment.
Further studies are needed to understand the many forms of nano-silver and
their effects. Concerns that exposure to nano-silver may potentially lead to
AMR are not supported by evidence of any increased bacterial resistance to
silver in the medical literature.[64]
Conclusions
5.52
It is acknowledged that infection prevention strategies and hygiene
measures are an important aspect of controlling the antibiotic use and
therefore the incidence of AMR. The committee acknowledges that progress has
been made for infection prevention and hygiene, such as the development and
implementation of standards and national guidelines, covering areas including
healthcare associated infections, food standards, and industry based quality
assurance programs.
5.53
In relation to infection control in hospital settings, the committee
notes the work of ACSQHC in the implementation of standard 3 of the National
Safety and Quality Health Service Standards.
5.54
The National Hand Hygiene Initiative is another important program which
has resulted in increased compliance from 64 per cent in 2009 to 73 per cent in
2012. The committee considers that further work on hand hygiene as outlined by
DoHA should be progressed as a priority. In addition, the committee considers
that more private hospitals should be encouraged to contribute data to the
initiative.
5.55
While the implementation of standard 3 and the success of the Hand
Hygiene Initiative are welcome, there other areas that have been poorly
addressed. These areas include national standards for hospital cleaning and cleaning
training, and national standards for the insertion and maintenance of invasive
devices. The problem of infection transmission in multi-patient hospital rooms
was also highlighted to the committee.
5.56
The committee has noted the comments received in relation to incentives
for hospitals to ensure that every effort is to improve infection control and
thus decrease AMR rates. The committee does not consider that incentives are
required at this point in time. The need to comply with standard 3, which in
part requires infection control and prevention strategies to gain and maintain
accreditation, is a significant mechanism to ensure that hospitals meet the
standards required. In addition, publication of hand hygiene rates and cases of
golden staph for each hospital on the MyHospitals website acts as a further
incentive to improve infection control and hygiene. However, the committee
considers that further investigation of means to implement effective infection
control in community medical practices is warranted.
5.57
The committee also considers that, while infection control programs are
required under the Standards and Guidelines for Residential Aged Care Services
Manual, it would be appropriate for those standards to explicitly address AMR aspects
of infection prevention and control. In addition, the committee considers that
the standards should substantially reflect the standards contained in standard
3 of the National Safety and Quality Health Service Standards.
Recommendation 8
5.58
The committee recommends that Australian Commission on Safety and
Quality in Health Care coordinate the development of a national system of
enhanced infection control including minimum hospital inpatient infection
control standards, and standards for community health practices and aged care
facilities.
Recommendation 9
5.59
The committee further recommends that the Commonwealth consider further
support for research and development in infection control in farmed animals
with the goal of reducing the need for the use of antibiotics in agriculture,
taking into account the costs and impacts of proposed measures on animal health
and farming practices.
5.60
The increasing non-clinical use of powerful antimicrobials in consumer
products was brought to the committee's attention. Some witnesses suggested
that such uses can contribute to significant multi-drug resistance and
undermine the use of these antimicrobials in clinical settings. The committee
considers that this issue is worthy of further monitoring of research outcomes
in relation to nano-silver.
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