Healthcare-associated infections (HAIs) and surgical site infections (SSIs) pose a significant threat to global health for hospitalised patients. A meta-analysis of 41 studies and 223,199 patients revealed a pooled prevalence of healthcare-associated infections (HAIs) of 12.9%. The highest prevalence was observed in 2023 (30.0%), followed by 2019 and 2016. A cyclical pattern in HAI prevalence and mortality rates was observed between 2014 and 2023.

It is important to note that both the incidence and prevention of HAIs and SSIs must be seen within the context of promoting Infection Prevention and Control based on global strategies and guidelines.

HAIs and SSIs affect millions of patients and lead to substantial morbidity and mortality every year. Surgical site infections pose a particularly problematic issue, as they often result in prolonged hospital stays, increased healthcare costs, and even death.

The challenges associated with HAIs and SSIs are acute, especially in resource-limited settings like many parts of rural Africa. Research published in the American Journal of Tropical Medicine and Hygiene (PMID: 10196487) highlights the specific challenges healthcare facilities face in preventing SSIs in Africa, where limited access to clean water, sanitation, and essential medical supplies is a constant struggle.

Although there has been significant progress in preventing certain types of HAIs, the overall burden of these infections remains substantial. SSIs may pose a particularly serious threat in specific surgical procedures, as evidenced by a study published in the Journal of Arthroplasty (PMID: 39290768) which investigated the prevalence of SSIs after hip arthroplasty, a common surgery to replace a damaged hip joint.

SSIs place a particular burden on healthcare systems, and several studies emphasise the need for robust infection prevention protocols.

In this article, we will examine what HAIs and SSIs are, how they are transmitted, their prevalence in Africa, and how JPS Africa aims to help combat their occurrence.

What are HAIs?

Healthcare-associated infections (HAIs) are acquired in healthcare settings like hospitals, clinics or nursing homes. This means that patients would be admitted to hospital with one condition and then acquire another condition while they are there, seeking treatment.

HAIs can be caused by a variety of pathogens, including:

Bacteria are single-celled organisms that can cause HAIs including Staphylococcus aureus (Staph. infection), Escherichia coli (E.coli), and Pseudomonas aeruginosa.

• Viruses are tiny infectious agents that can only replicate inside living cells and cause HAIs like influenza and hepatitis.
• Fungi are eukaryotic (containing a clearly defined nucleus) organisms that can cause fungal infections including Candida albicans (yeast infection) and Aspergillus fumigatus.
• Parasites are organisms that live and feed off of another organism and can cause HAIs including Clostridium difficile (C. diff) and Enterococcus.
• HAIs can be transmitted through:
  • Contact transmission: when an infected person or contaminated object comes into contact with a susceptible host.
  • Airborne transmission: when infectious particles are inhaled.
  • Droplet transmission: when droplets containing infectious agents are expelled into the air and inhaled by another person.
  • Vehicle transmission: when infectious agents are transmitted through a contaminated inanimate object, such as a medical device.

HAIs have a significant impact on patient health and outcomes. They can lead to prolonged hospital stays, increased morbidity and even death.

Patients afflicted with other conditions and seeking care or accessing preventive services such as vaccination in good health, find themselves with the risk of being infected with a HAI. Facilities can be the entry point for outbreaks or become amplifiers of pathogen transmission, with subsequent spread of outbreaks to the community.

Out of 100 patients hospitalised, seven will be infected with an HAI, the risk doubling and being up to 20 times higher in low- and middle-income countries. The more ill and fragile patients get, the higher becomes the risk of HAIs and their deadly consequences. Deaths are increased two to threefold when infections are resistant to antimicrobials. Moreover, the experience accumulated in the past two years during the COVID-19 pandemic unequivocally shows that both patients and health workers can be at high risk of being infected with SARS-CoV-2 during health care delivery and need to be protected.

Out of every 100 patients in acute-care hospitals, seven patients in high-income countries (HICs) and 15 patients in low- and middle-income countries (LMICs) will acquire at least one health care associated infection during their hospital stay. Up to 30% of patients in intensive care can be affected by health care-associated infections, with an incidence that is two to 20 times higher in LMICs than in HICs, in particular among neonates.

Approximately one in four (23.6%) of all hospital-treated sepsis cases are health care associated. Almost half (48.7%) of all cases of sepsis with organ dysfunction treated in adult intensive care units are acquired in hospital.

What are SSIs?

Surgical site infections (SSIs) occur at the site of a surgical incision. These infections are caused by pathogens, including bacteria, viruses, and fungi that are introduced by the surgical procedure and they range in severity from:

• Superficial infections that involve only the skin or subcutaneous tissue.
• Deep infections that involve the fascia or deeper tissues.
• Organ space infections that involve the internal organs or cavities.
  Surgical site infections (SSIs) typically occur within 30 days of surgery or up to one year after implant surgery. They can lead to significant morbidity and increase the risk of other complications, such as sepsis, pneumonia, and mortality. The most common pathogens that cause SSIs are:
• Staphylococcus aureus
• coagulase-negative staphylococci
• Enterococcus spp. and
• Escherichia coli

Patient characteristics and surgical procedures are two of the many factors that can influence the risk of patients contracting SSIs. Effective prevention requires a multifaceted approach to address multiple risk factors to reduce bacterial contamination and enhance patient defences by boosting their immune systems.

The incidence of SSIs can be as high as 20%, depending on the:

• surgical procedure
• surveillance methods
• and data quality.

The CDC’s guidelines for SSI prevention emphasise the importance of proper patient preparation, aseptic techniques and surgical technique. Antimicrobial prophylaxis might be recommended in specific circumstances.

Emerging technologies, like microbial sealants, can potentially reduce the risk of SSIs by sealing and immobilising skin flora during surgical procedures.

HAIs and SSIs remain a significant global health challenge. While progress has been made, ongoing efforts are needed to:

• improve prevention strategies
• reduce the burden of these infections
• and enhance patient outcomes

Healthcare providers can implement comprehensive approaches that address multiple risk factors by using innovative technologies, working towards mitigating the impact of HAIs and SSIs and ensuring safer patient care. In addition, HAIs and SSIs can also place a heavy burden on healthcare resources.

Common Ways in Which HAIs and SSIs are Contracted

Healthcare-associated infections (HAIs) and surgical site infections (SSIs) can be transmitted through several means. Health care facilities can implement effective infection prevention and control measures by understanding how they are transmitted. Common ways in which hospital acquired infections and surgical site infections are transmitted include:

Contact Transmission

• Direct contact transmission occurs when an infected person directly touches a susceptible host, such as a healthcare worker or another patient. For example, a healthcare worker who does not wear gloves while caring for an infected patient can transmit an infection through direct contact.
• Indirect contact transmission occurs when an infected person contaminates an inanimate object, such as a medical device or bed linen, which is then touched by a susceptible host. For example, when a patient coughs on a medical device, this can transmit the infection through indirect contact to another patient who later comes into contact with the contaminated device.

Good hand hygiene is key to helping minimise or even prevent contact transmission. Frequently washing your hands with soap and water or using an alcohol-based hand sanitiser can go a long way to preventing contact transmission. Regularly cleaning and disinfecting of frequently touched surfaces like doorknobs, countertops, and medical equipment can also help eliminate infectious agents.
Healthcare workers should wear appropriate personal protective equipment (PPE), such as gloves and gowns, always to protect themselves and their patients. Additionally, we can prevent the spread of infection through proper disposal of contaminated materials and medical waste.

IPC is a proven solution that can avoid most of this harm and incalculable suffering and costs to people and the health system. Compelling evidence shows that up to 70% of HAIs can be prevented by scaling up an array of effective IPC interventions. Investing in IPC is one of the most effective and cost-saving interventions available. In particular, hand hygiene and environmental hygiene in health care facilities were found to be able to more than halve the risk of dying because of infections with AMR pathogens, as well as to decrease the associated long-term complications and health burden by at least 40%.

Improving hand hygiene in health care settings could save about US$ 16.50 in reduced health care expenditure for every dollar invested. It is also shocking to understand that, during the first six months of the COVID-19 pandemic, access to appropriate personal protective equipment combined with rapid IPC training would have had the potential to avert SARS-CoV-2 infections and related deaths among health care workers globally, while generating substantial net savings across countries worldwide, independently from their income.

Airborne Transmission

Airborne transmission happens when infectious particles (bacteria or viruses) are suspended in the air and inhaled by a susceptible host. Medical facilities have a high concentration of infectious agents, especially in isolation rooms or during certain medical procedures that generate airborne pathogens. That’s why medical personnel often wear masks in these situations. Examples of airborne transmission include:

• Aerosol transmission, which is when infectious particles are generated by medical procedures, such as suctioning or bronchoscopy.
• Dust-borne transmission occurs when infectious particles attach to dust particles that are inhaled.

Adequate ventilation (including HEPA filters) can help remove airborne particles and prevent transmission. Patients with airborne diseases should be isolated in negative pressure rooms. Regular cleaning and disinfection of surfaces, especially in isolation rooms, can further reduce the risk of airborne transmission.

Respiratory hygiene practices, such as covering the mouth and nose when coughing or sneezing, can reduce the spread of bacteria and viruses. Healthcare workers should be trained to wear appropriate PPE, like N95 respirators, to protect themselves and patients from HAIs.

Droplet Transmission

Droplet transmission happens when droplets containing infectious pathogens are expelled into the air through coughing, sneezing, or talking and are then inhaled by a susceptible host. Examples of diseases caused by droplet transmission includ:

• Influenza (flu)
• Meningitis

Droplet transmission can be prevented through practising good respiratory hygiene and properly disposing of used tissues. As usual, washing your hands regularly and using hand sanitizer can help remove respiratory droplets and prevent their spread.

Wearing a mask, especially in healthcare settings, can significantly reduce the spread of respiratory droplets. Additionally, social distancing around sick people can minimise exposure to respiratory droplets and significantly reduce the risk of contracting and spreading airborne infections through droplet transmission.

Vehicle Transmission

Vehicle transmission happens when infectious agents are transmitted through a contaminated inanimate object, such as a medical device or bed linen. Examples of vehicle transmission include:

• Central line-associated bloodstream infections (CLABSIs) that are transmitted through contaminated central lines. (A central venous catheter (a drip) is a thin, flexible tube inserted into a large vein in the neck, chest, or groin.)
• Catheter-associated urinary tract infections (CAUTIs) that are transmitted through contaminated urinary catheters.

Medical personnel should be trained to practise proper hygiene and sterilisation practices to prevent vehicle transmission. Frequent handwashing, especially before and after patient contact, and regular cleaning and disinfection of medical equipment and surfaces will go a long way to preventing vehicle transmission.

Healthcare workers should also adhere to strict aseptic techniques during procedures; this includes using sterile gloves and instruments at all times. Additionally, medical personnel can significantly reduce the risk of HAIs and SSIs by adhering to the appropriate use and maintenance of medical devices, especially catheters and central lines.

By understanding how these diseases are spread, healthcare facilities can implement effective infection prevention and control measures that will help reduce the risk of HAIs and SSIs.

Prevention of HAIs and SSIs & Potential Treatment Options

All healthcare facilities should implement comprehensive infection prevention and control programs to prevent HAIs and SSIs. Prevention programs should include the following safety and prevention measures:

According to OECD, the implementation of a package including improved hand hygiene, antibiotic stewardship programmes and enhanced environmental hygiene in health care settings would reduce the health burden of AMR by 85%, while producing savings of 0.7 euros per capita per year.

The effectiveness of IPC interventions to reduce AMR is very well illustrated. According to data from ECDC, there is a significant inverse association between the composite index of AMR (which mostly includes pathogens transmitted in health care settings) and the percentage of beds equipped with alcohol handrub dispensers at point of care, of beds in single rooms (for isolating patients with microorganisms resistant to antimicrobials) and the percentage of hospitals with at least 0.4 full time-equivalent IPC nurse for 250 beds.

Whether implemented as a stand-alone intervention or integrated into multifaceted interventions, hand hygiene has been highlighted as the most effective single measure to reduce the transmission of microorganisms/pathogens and reduce infection in health care settings.

Hand and respiratory hygiene: Regular hand and respiratory hygiene is essential to prevent the spread of infections. Healthcare workers should follow these practices and teach it to patients.

• Environmental cleaning: Healthcare facilities should implement environmental cleaning programs to ensure they are cleaned and disinfected regularly to remove infectious agents from surfaces. Adherence to waste management protocols is a critical component in contributing to a safe and clean environment both within and outside health facilities.
• Isolation precautions: Patients with infectious diseases should be isolated to prevent the spread of infection to other patients and healthcare workers.
• Antibiotic and antifungal stewardship: Antibiotics and antifungals should be carefully managed to prevent the development of resistance by administering antibiotics only when necessary, selecting the appropriate antibiotic for the infection, and ensuring that medications are taken correctly.
• Surgical site preparation: Proper surgical site preparation can help to reduce the risk of SSIs. This is done by cleaning the surgical site with an antiseptic solution and using sterile drapes to cover the surgical site.

Healthcare facilities that implement these strategies can significantly reduce the risk of HAIs and SSIs, which will inevitably improve patient safety and outcomes.

Treatment

Treatment of healthcare-associated infections (HAIs) and surgical site infections (SSIs) depends on the specific type of infection and the pathogen that caused it. Treating HAIs and SSIs usually requires antibiotics or antifungal medications.

• Bacterial infections: Antibiotics are often used to treat bacterial infections. The choice of antibiotic depends on the specific type of bacteria causing the infection and its susceptibility to different antibiotics. In the case of severe infections, multiple antibiotics may be used to effectively treat a patient.
• Fungal infections: Antifungal medications are used to treat fungal infections. The choice of medication depends on the specific type of fungus causing the infection and its susceptibility to different antifungal agents.

Treating HAIs and SSIs is often challenging, as these infections can be caused by a variety of pathogens and may be resistant to certain antibiotics or antifungal medications.

Overuse or incorrect administration of these medications can lead to antibiotic and antifungal resistance, which means that the pathogen causing the infection becomes less responsive to treatment. This makes infections even harder to cure. Antibiotics and antifungals must be used appropriately and only when necessary to prevent drug resistance.

Statistics on HAIs and SSIs in Africa

Reliable data on the prevalence of these HAI and SSI infections in Africa remains limited, despite the significant impact they have on global health and that of the people of our continent. This is probably due to the:

• Limited healthcare infrastructure and access to healthcare facilities, particularly in rural areas of Africa. A lack of infrastructure leads to delayed diagnosis and treatment of infections, and inadequate infection prevention and control measures, which make it hard to quantify its impact.
• Inadequate sanitation and hygiene practices due to poor water quality and lack of access to basic sanitation facilities can contribute to the spread of infectious diseases, HAIs, and SSIs.
• Overcrowding in understaffed, low-infrastructure healthcare facilities can increase the risk of transmission of infections, causing patients to come into contact with each other and with contaminated surfaces more easily.

Out of every 100 patients in acute-care hospitals, seven patients in high-income countries (HICs) and 15 patients in low- and middle-income countries (LMICs) will acquire at least one health care associated infection during their hospital stay. Up to 30% of patients in intensive care can be affected by health care-associated infections, with an incidence that is two to 20 times higher in LMICs than in HICs, in particular among neonates. Approximately one in four (23.6%) of all hospital-treated sepsis cases are health care associated. Almost half (48.7%) of all cases of sepsis with organ dysfunction treated in adult intensive care units are acquired in hospital.

Many healthcare facilities in Africa may not have adequate infection prevention and control measures such as hand hygiene protocols, environmental cleaning practices, and isolation procedures in place.

eClinicalMedicine published a study titled The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis, which emphasises the urgent need for improved infection prevention and control practices with the aim to reduce the burden of HAIs and improve patient outcomes. This extensive study provides a comprehensive overview of the burden of healthcare-associated infections (HAIs) in healthcare facilities across sub-Saharan Africa. Key findings of this insightful study include:

• The pooled prevalence of HAIs in the region was estimated at 12.9%, with significant variations among subregions.
• East and West Africa showed a higher HAI prevalence compared to Southern and Central Africa.
• The estimated mortality rate associated with HAIs was 22.2%, which highlights the severe potential consequences of these infections going unchecked.
• HAIs disproportionately affect vulnerable populations, which include neonates, children, the elderly, and patients in intensive care units.
• Bloodstream infections, urinary tract infections, surgical site infections, and lower respiratory tract infections were the most prevalent types of HAIs in the region.
• The lack of robust surveillance systems and data collection efforts in many African countries limits the understanding of the true burden of HAIs.

The study emphasises the urgent need for improved infection prevention and control practices in healthcare facilities across sub-Saharan Africa to reduce the burden of HAIs and improve patient outcomes.

While the exact prevalence of HAIs and SSIs in Africa is difficult to quantify, it is evident that these infections are a significant public health burden in the region.

Measures to Address the Occurrence of HAIs and SSIs in Africa

HAIs and SSIs significantly impact hospitals and healthcare facilities by causing increased healthcare costs due to longer hospital stays, additional diagnostic tests, and the need for specialised treatments. These infections can also strain hospital resources, such as beds and staff, as more patients require care.

Additionally, outbreaks of HAIs and SSIs can damage a hospital’s reputation and lead to decreased patient trust. Increased mortality rates that stem from these infections often lead to a higher number of deaths among hospitalised patients, which can have a profound impact on the overall health of a community and the healthcare system as a whole.

HAIs and SSIs in Africa can be effectively addressed by implementing a multi-faceted approach to:

• strengthen the healthcare infrastructure
• implement effective infection prevention and control measures
• and investing in research and data collection

Strengthening healthcare infrastructure involves improving sanitation and hygiene practices by ensuring access to clean water, adequate sanitation facilities, and promoting hand, respiratory, and environmental hygiene among healthcare workers and patients. Upgrading healthcare facilities with modern infrastructure, ensuring adequate space, ventilation, and infection control equipment is crucial, but it’s not always possible.

In facilities where upgrades are more prohibitive, comprehensive training on infection prevention and control practices, aseptic techniques, and proper use of PPE can be increased to help healthcare workers reduce the risk of transmission.

• Implementing effective infection prevention and control measures includes following standard disease prevention precautions, such as consistently wearing gloves, masks, and gowns to prevent the spread of infections.
• Rigorous environmental cleaning and disinfection protocols for medical equipment, surfaces, and common areas helps eliminate infectious agents.
• Implementing antibiotic stewardship programs promotes the appropriate use of antibiotics to prevent antibiotic resistance.
• Establishing robust surveillance systems are important in helping facilities to track the incidence of HAIs and SSIs and identify outbreaks promptly to help with effective infection control.

The World Bank report found that adherence to IPC guidelines was partial or poor overall and pointed out that improvement of both IPC-related structural factors and health care processes are needed to reduce the burden of HAIs and AMR.

Research and data collection is a worthwhile investment that can help combat the occurrence of HAIs and SSIs. Conducting epidemiological studies to gather data on the prevalence, risk factors, and outcomes of infections helps identify trends and inform targeted interventions. Evaluating the effectiveness of various infection prevention and control strategies allows healthcare facilities to optimise their practices. It is also advisable that healthcare facilities support research to develop innovative technologies and approaches to prevent and treat HAIs and SSIs.

These strategies can significantly improve patient outcomes while at the same time reducing the overall burden of hospital acquired infections and surgical site infections. By prioritising these strategies and fostering collaboration between healthcare providers, policymakers, and researchers, stakeholders can significantly reduce the burden of HAIs and SSIs in Africa and improve patient outcomes.

JPS Africa’s Role in Combating HAIs and SSIs

While JPS Africa focuses mainly on fighting HIV and AIDS, their commitment to improving healthcare delivery in South Africa can indirectly contribute to reducing the burden of healthcare-associated infections (HAIs) and surgical site infections (SSIs) in the region they serve.
Here’s how JPS Africa’s work can impact infection prevention:

• MMC Training and Infection Control: The MMC training program emphasises aseptic techniques and infection prevention measures, which helps prevent the spread of infections. By training healthcare providers in these practices, JPS Africa contributes to a culture of infection prevention within healthcare settings. JPSA embarked on a process by having converted all MMC and IPC training material into MicroLearning modules.
• Community Outreach and Education: Community outreach programs help raise awareness about the importance of hygiene, sanitation, and seeking healthcare services early to help reduce the transmission of infectious diseases and improve health outcomes.
• Partnership with Healthcare Facilities: Partnering and collaborating with healthcare facilities to provide training on infection prevention and control measures, support the implementation of infection prevention and control programs, and improve access to essential medical supplies.
• Data Collection and Analysis: Collecting data on the prevalence of HAIs and SSIs in the communities they serve can help identify areas for improvement and inform evidence-based interventions.

JPS Africa plays a valuable role in combating HAIs and SSIs, improving patient safety, and promoting overall health in Africa.