Letters to the editor

Nosocomial infection in China:Management status and solutions

To the Editor:

In China, nosocomial infection is aprominent public health concern and is associated with an annual direct economic burden of $1.5-$2.3 billion (￥10-￥15 billion). Advancesin medical technology, extensive application of novel diagnosticand therapeutic techniques, and increased adoption of traumatic and invasiveinterventions have drastically altered the source, transmission route, andsusceptible population of nosocomial infection. Emergence of multidrug-resistantbacteria has increased the proportion of refractory infections and thechallenges of infection control. China has reinforced legislation to controlnosocomial infection, drawing extensive support from society and medicalcommunity. This transition is reflected in the Chinese governmental response tothe epidemic of Middle East respiratory syndrome.

读者来信——中国医院感染及对策

尊敬的编辑：

医院感染已成为中国突出的公共健康问题，其造成的直接经济损失已到达每年15~23亿美元（100~150亿人民币）。随着医疗技术的进步，新型诊断和治疗技术的广泛应用以及越来越多的侵入性操作，院内感染的传染源、传播途径和易感人群都发生了极大的改变。而多重耐药菌的出现导致难治性感染病例的增加，使得感染控制面临着巨大的挑战。目前中国已经加强立法控制医院感染，此举得到了来自社会和医学各界的广泛支持，特别是在中国政府应对中东呼吸道综合征疫情的时候体现得尤为明显。

In January 2013, 99 out of 120 patientsreceiving treatments for varicosity at Donggang Social Insurance Medical Clinicwere infected with hepatitis C virus. Investigations indicated that this aggressive,multisource, and nosocomial hepatitis C virus infection resulted from repeatedsyringe use among different patients. In July 2011, 15 cataract patientsundergoing surgical treatment at an Ophthalmic Hospital in the Raodu district,Linfen, suffered from endophthalmitis. Investigation showed that patients wereinfected with Pseudomonas aeruginosa endophthalmitis, which resulted from a shortage of surgical equipment andnonstandard disinfection of the surgical instruments. In March 2009, incidenceof neonatal nosocomial infection was reported in a maternal and child careservice center in the Ji County of Tianjin. In a neonatal ward, 5 of the total6 newborns were dead. Investigations revealed a severe nosocomial infectionresulting in deaths attributed to negligence by staff with poor infection prevention andcontrol standards.

2013年1月，东港市社会保险医疗诊所接受静脉曲张治疗的120名患者中，有99名被诊断出感染了丙型病毒性肝炎。据调查表明，该院丙肝病毒的传播是由于医院内不同患者重复使用注射器造成的。2011年7月，临汾市尧都区某眼科医院15名白内障手术患者均感染了眼内炎。经调查，患者罹患绿脓杆菌感染性眼内炎是因为该院手术器械缺乏且手术器械未经过标准的消毒便投入手术使用。2009年3月，天津蓟县一家妇幼保健服务中心被曝出该医院新生儿病房6名新生儿中有5名死亡。通过调查发现，导致该院新生儿高死亡率的原因是该中心医务人员未严格执行感染控制和预防标准。

The ongoing incidence of such seriousevents reflects poor standards of nosocomial infection management.

First, inadequate medical sources and imbalancein hospital development are increasingly serious challenges. Nearly 50 millionof the total 1.3 billion people in China require hospitalization annually because of diseases or trauma. However, theChinese health care system is riddled with long wait lists, shortages, and poorequipment because of funding constraints. The national medical system is not hierarchical in structure. As aresult, most patients are traditionally segregated in large- and medium-sizedhospitals, and hospital wards have become breeding grounds for microbialpathogens, with increased risk of infection.

这一系列严重的事件反映了医院感染管理标准的缺失。

首先，我们正面临医疗资源匮乏和医院间发展不平衡这两个日益严峻的挑战。每年由于各种疾病或创伤，13亿中国人中有将近50万人需住院治疗。然而中国医疗体系由于资金紧张，导致其发展缓慢、医疗设备缺乏。同时我国尚未建立多层次医疗卫生体系。因此，大多数病人选择在大、中型医院就诊，医院病房成为了病原微生物的温床，使得感染风险增加。

Second, the under-reporting of nosocomialinfection and the number of full-time staff experienced in infection controlhave been highlighted by health administrators during the performance appraisalof health care institutions. In some hospitals, hospital leaders neglect poststandardization training and continuing education of the managers involved incontrolling infection. Full-time professional staff members fail to undergotraining in nosocomial infection and occupational health. In most hospitals,target and prospective monitoring are rare, which results in delayed discoveryof high-risk areas.

Third, hospitals lack expertise and humanresources skilled in infection management. Senior managers fail to considerqualified personnel. A few health care institutions simply fill availablevacancies with retired nurses to ensure the number of required personnel in thedepartment of nosocomial infection.

其次，卫生行政人员指出，在医疗卫生机构绩效考核中，存在院感案例和专职感控人员数量漏报的情况。医院的院领导往往忽视了感染控制管理人员的岗位规范化培育和继续教育，使得其不能参与医院感染和职业卫生培训。大多数医院尚未实施医院感染的目标性监测，为医院感染高发区域埋下了隐患。

再次，医院缺少感染管理专业知识及人力资源。高层管理人员对感控人员的资格认证并未考虑。一些医疗机构甚至聘用退休护士以填补职位空缺，从而达到感染管理部门要求的感控人员数量。

Forth, drug-resistant bacteria as a resultof antibiotic abuse and unreasonable use are still important factors leading tonosocomial infection. Epidemiology studies suggest that the usage rate ofantibiotics in hospitalized patients in some regions and hospitals is still >60%,reaching a rate of 74.67%, or even exceeding 90% in the neonatal ward.Inadequate catheterization and subsequent care along with poor concept ofasepsis are other factors. Failure to comply with standard regulations of handhygiene or even handwashing after examining patients with infections, lack ofstandardized or complete disinfection of surgical instruments, failure to implementsurgical standards, failure to consider oxygen humidifiers as an important sourceof lower respiratory infection, and inappropriate measures of disinfection andisolation are some of the factors that artificially increase nosocomial infection.

最后，抗生素的滥用产生的耐药菌也是引起院感的重要因素。流行病学研究表明，我国部分地区的医院，患者抗生素使用率高于60%，达74.67%，在新生儿病房甚至超过了90%。导尿术操作不当以及术后缺乏无菌观念护理也是引起院感的其他因素。未严格执行手卫生规范、接触有感染病灶患者后未洗手、缺少标准完整的手术器械消毒、不遵循手术标准、未将氧气加湿器作为下呼吸道感染重要来源以及不恰当的消毒隔离措施等，都是增加院感的人为因素。

A solution for improved nosocomial infection management in China has been proposed. The overall goal of the Chinese Action Plan on Prevention and Control of Nosocomial Infection (2012-2015) includes enhanced prevention and control of nosocomial infection, insisting on“scientific prevention and control, standard management, highlighting the key points, and enforcing the implementation.”The solutions are designed to improve the related technicalcriteria, upgrade and implement prevention and control measures, raise the professionalskills and capacities, and increase the quality and safety of medicines.

目前，我国已提出改进院感管理的解决方案。《预防和控制医院感染行动计划（2012-2015年）》以加强院感预防和控制工作为主导，坚持“科学防控、规范管理、突出重点、强化落实”的原则。该计划旨在提高相关技术标准，完善并落实感染防控措施、提高专业技能与能力和药物质量安全。

The following additional steps arerecommended to address the challenges of nosocomial infection:

•Governmentsat all levels must invest increasingly to improve hospital conditions. Publichospitals should be transformed into not-for-profit organizations in thenational health care system.

•Todisseminate the knowledge of nosocomial infection, the government and healthworkers should popularize and publicize new techniques and know-hows forinfection prevention and control.

•To improveenvironmental hygiene, a national system of sanitation should be created toprovide population access to adequate sanitation measures given the currentunsanitary conditions in hospitals.

•To emphasizeappropriate hospital layout, a well-developed, scientifically planned hospitalinfrastructure is essential to ensure sustainable care and development andnosocomial infection management. The government and the director of thehospital should emphasize the role of rational design of the wards and hospitallayout and balance the costs and benefits in prevention of infection.

笔者建议采取以下措施以应对院感挑战：

•各级政府应加大投入以改善医院条件。在国家医疗服务系统中，公立医院应转变为非营利性组织。

•宣传院感知识。政府和卫生工作人员应向公众普及感染预防和控制的新技术和进展。

•为改善环境卫生。鉴于目前恶劣的医疗环境，应建立国家卫生系统以为公众提供保健措施。

•为强调合理医院布局，科学规划的医院基础设施对保证可持续照护、发展以及院感管理不可或缺。政府及医院领导应重视病房和医院布局的合理设计并平衡院感预防的成本和收益。

•The hospitalinformation system (HIS) enables the control of infection by regulating all ofthe operational aspects, such as medical, administrative, financial, and legalissues and the corresponding services. The HIS is the essential technologicbackup of the environment and infrastructure in a modernized hospital system.Information sources related to nosocomial infection may be enriched using theHIS and enhance the ability of health care professionals. The HIS facilitatesorganizations in nosocomial infection management, official documentation, andensures data security.

•Evidence-basedmedicine (EBM) is intended to optimize decision-making by emphasizing the useof evidence from welldesigned research studies. According to the theory of EBM,the strongest evidence based on meta-analyses, systematic reviews, andrandomized controlled trials yields strong recommendations. Combined with thedata of epidemiologic survey and analysis, EBM may provide useful strategies toimprove nosocomial infection management. However, the inadequacy of clinical application of EBM in nosocomial infectionmanagement in China needs to be addressed.

•A no-paypolicy by the government and medical insurance organizations must beimplemented rigorously for items of nosocomial infection that are not coveredby medical insurance. This policy will encourage awareness of prevention and controlmeasures that reduce the incidence of hospital infection.

•医院信息系统（HIS）通过调节医院当前医疗、行政、财务、法律问题及相关服务等各方面来实施感控工作。该系统能为医院提供必不可少的环境和基础设施信息备份。通过使用该系统，可补充院感相关信息资源，提高医护人员的感控知识掌握能力。并且该系统便于院感管理组织、保存官方文件，并能确保数据的安全性。

•对于医疗保险不能覆盖的院感项目，政府和医疗保险机构应严格执行免费政策。这一政策将会增强人们采取感染防控措施的的意识，从而降低院感发生率。

The quality of infection control is animportant indicator balancing quality of management and medical administration.During the early period of the severe acute respiratory syndrome epidemic in2002, the nosocomial infection rate of medical staff reportedly exceeded 10%because of inadequate disease knowledge. However, this rate does not representall the data because there were several hospitals or wards with a zeroinfection rate among the medical staff during the outbreak. The discrepancy isassociated with different attitudes toward infection. Overall, nosocomial infectionmanagement in China and worldwide has a long way to go.

医院感染管理已成为衡量医院管理水平及医疗质量的重要标志之一。2002年，严重急性呼吸道综合征（非典）疫情爆发的早期，医务人员由于对该疾病认识不足，其院感发生率超过了10%。但这样的感染速度并不能代表所有的数据，因为期间仍有几家医院医务人员达到了零感染率。这种差距与各医院对待感控采取不同态度有关。总之，中国和全球的院感管理工作任重道远。

上述文章是选自《美国感染控制杂志》一篇读者来信

主题为中国医院感染，并对当下严峻的院感现状提出了建议对策。