25th February 2021

To celebrate our 50th anniversary, we’re inviting a select number of experts to share what they see as being the 21st-century solutions to one of the biggest and most complex challenges of our generation: antimicrobial resistance. In this post, Andreas Voss, Professor of Infection Control at Radboud University, explores the future of infection prevention and control...

COVID-19 is the first global pandemic any of us has experienced, finding ourselves on common but unpredictable ground. I have never seen so many infection prevention and control (IPC) dogmas being torn apart, guidelines changed at lightning speed, cooperation and interest from other medical specialties, and whole nations becoming IPC specialists – or at least having strong opinions on what to do. While many believe that this should be a time for international cooperation and guidance (with the obvious advantage of high-level collaboration on vaccine research, for example), I have also experienced the benefit of focusing on national policies and regional proficiencies and harmonization, respecting local circumstances, and cultural differences.

In the post-COVID era, hospitals will have a new role within their region. Part of the way they deliver care will change thanks to good prevention (with the help of general practitioners), early diagnostics, and an efficiency driven change of the patient-mix (adequate patients in the correct domain). More care will also be delivered digitally, instead of face-to-face, leaving patients with more complex needs in more specialized hospitals – leading to certain groups of healthcare professionals working in different, physical places.

Long-term care will receive a certain part of the hospital population, which makes cooperation between acute and long-term care even more important. IPC has already anticipated the need to cooperate across different healthcare settings (switching from hospital infections to healthcare infections), but should furthermore implement a regional network, that shares data without restriction, harmonizes guidelines, and is a sounding board for professionals, truly solving problems instead of “discharging” them to a different setting.  This type of cross-setting cooperation will become essential with changing health policies, leaving only the sickest patients in hospital beds and pushing complex care into other settings. Consequently, IPC teams will no longer act within their “silo”.

In some countries, infection control, microbiology, and infectious diseases are still seen as three different specialties, with a difference in the perceived “added value” and acceptance among other medical specialists. Integration of these subspecialities in one team, where all members cover all aspects (obviously to a different degree depending on their background) will change the perception of the IPC advice given, most certainly in view of other medical specialists.

While some believe that the future will bring far-reaching disruptive changes, I believe that all of us presently working in IPC, need to ensure that we anticipate or join the emerging changes now.  Health policies and economic restrictions, societal expectations with regard to prevention (“from cure and care to health and lifestyle”), involvement of non-healthcare stakeholders (not limited to implementing technology and engineering solutions but disrupting current health delivery), have already started to change our healthcare system. The new players in healthcare, such as tech giants (Google, Apple), retailers (Amazon, Walmart), and financials (JP Morgan Chase) will direct their activities toward data (collection, connection, and safety), data-analysis, and personalized interventions. In general, new care solutions will not only come from people working in care-related fields thinking out of the box, but from totally different boxes altogether.  If the COVID-pandemic has taught us one thing, it is that simple technology (such as that of supporting “digital first” which has been talked about for years), has become “the new normal” in less than a year.  “Virtual Healthcare” is not limited to how we contact our patients or give/receive training but will change patient-mix and -population in our hospitals and will influence the architecture (“more bytes – less bricks”), and thereby the places, in which patients actually receive their care – and its complications. As a consequence, IPC has to adapt and transform (with regard to key activities like surveillance, for example).

In addition, classic surveillance will be taken over by AI and cognitive automatization and will – combined with rapid diagnostics and sophisticated typing systems – broaden surveillance to include more and other endpoints as well as allow for real-time interventions. At some point we not only need to redefine “nosocomial” but might need new definitions of nosocomial infections and other outcome indicators, better geared to AI and automatization.  These changes, as well as the analysis of “big data” create the need for a different skillset within the IPC team to include more sophisticated data analysis and epidemiology.

Other important changes may come due to more attention and possibilities with regard to the built environment. With the gaining knowledge of water as a source of nosocomial infections or transmission of drug-resistant micro-organisms, and the importance of ventilation with regard to the prevention of SARS-CoV-2 transmission or operating theatre air quality, engineering out problems with water and air safety must be a high priority.  Over time, an important part of the built environment discussion has been focused on the number of beds in a patient room. Starting from Nightingalian halls to four-bed rooms, and initially single-bed ICU cubicles to now single-bedroom-only hospitals, my feeling is that many people have had different ideas about what the patients want and what the finances allow, but few did what should be most logical, namely to involve the patients in hospital design.  While the advantages of single-bed rooms are clearly visible at present with regard to patient admittance and cohorting during the COVID-19 pandemic, I believe that in some circumstances patients might need a roommate as an example and a motivation of how to behave e.g. after arthroplasty.  Still, built environment goes further than just water and air and the number of single bedrooms. Surface treatment and surface characteristics can possibly influence the contamination (and consequently transmission) of micro-organisms but can certainly affect cleaning budgets. By influencing the workflow, chances for contamination can be avoided and/or hand hygiene moments reduced. Colour, light, and even the smell of the building, do not only contribute to the feeling of wellbeing of patients, but can be used to nudge healthcare workers into certain positive behaviours.  In general, influencing healthcare workers’ behaviour has been, is, and will be an important part of IPC.  On a personal note, given the chance of improving healthcare workers’ behaviour by using technology, engineering, and structural solutions to help and guide them might be a safer and less cumbersome choice, than trying to change their behaviour through training and education alone.

In order to be prepared for the future, IPC teams need to expand their physical boundaries, their knowledge of different healthcare settings, their skill-set, and the type of professionals they employ, while simultaneously reducing the kinds of activities they do today as some of their present problems will be automated or engineered out.  I realize that this is a limited view on a future of IPC that will hold so many more details such as cleaning robots, self-disinfecting storage rooms, IPC training in virtual reality, sensor- and CVC-based “observations” of procedures, etc.  What will remain and what will always be needed, are highly trained and motivated professionals who are able to see what is going wrong, to recognize what is going well, and who are masters in communication with their clinical colleagues.

Andreas Voss, MD, PhD, is Professor of Infection Control, Radboudumc, Medical Manager Clinical Microbiology, CWZ, Nijmegen, The Netherlands

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Initial response from BSAC

The in-patient treatment of infections makes a large contribution to the emergence and spread of antimicrobial resistance. Consequently, a vital element of tacking resistance is the prevention of nosocomial infection. It’s clear from Andreas Voss’s thought-provoking article, that fundamental shifts in how we prevent and control infection could have a significant and long-lasting impact on our ability to neutralise the growing threat of antimicrobial resistance.

The response to the COVID-19 pandemic has already shown that with the right resources and the freedom to do things differently, infection can be managed more effectively and efficiently – leading to better outcomes for patients. The high rates of nosocomial COVID-19 (around 15% of patients in English hospital with COVID-19 caught infection in hospital) shows we have much more work to do.

By teaming-up infection control specialists, microbiologists, antimicrobial pharmacists and infectious disease physicians, for example, we might stand a better chance of: harnessing all available technology, harmonsising guidelines and standards, and improving hospital design.

This way of working could have positive implications for a body like the Federation of Infection Societies – but also for initiatives like BSAC’s Outpatient Parenteral Antimicrobial Therapy programme, which seeks to deliver care closer to home (thereby increasing targeted treatments while reducing secondary infections).

Andreas’s vision is coherent and cohesive, and could go a long way to inspiring the range of infection specialists to integrate approaches to education, training, standards, guidelines, and advocacy – in the collective effort to counter the growing threat of drug-resistant infection.

But first, we want to hear your thoughts on Andreas’s article. What you say could inform the recommendations we make in the Vanguard Report itself, which will be published at the end of the year.

You can join the conversation by emailing mcorley@bsac.org.uk or tweeting our @BSACandJAC account.

 

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