Dr. Ignaz Semmelweis, one of the fathers of modern hygiene, proposed in the 19th century that the hands could carry particles or “cadaveric matter.” This would be the cause of the high number of women who died of puerperal fever in the Vienna general hospital, where Semmelweis worked.
He then established the use of chlorine solutions for hand washing by doctors and medical students, before and after caring for and examining their patients. The results were spectacular: mortality from puerperal fever dropped from 12.11% in 1842 to 1.28% in 1848.
As far back in time as it may be, Semmelweis’ discovery is an important precedent for examining what happened in January at the 10 de Octubre Gyno-Obstetric Hospital in Havana. The death of eight newborns due to presumed sepsis was an unfortunate episode for Cuban public health.
The official note released by the Ministry of Public Health reported it was due to “the presence of an outbreak of Healthcare Associated Infection (HAI) in the neonatal intensive care room.” As a consequence of this, six of the ten babies who died had signs of sepsis with positive blood cultures where Gram-negative bacteria were identified. The others died due to other causes, caused by their delicate state of health. They were premature and underweight patients.
The most unfortunate thing is that the outbreak was linked to “violations of hygienic-sanitary measures,” according to the note. They added to “resource guaranteeing problems” that the center was presenting at that time. They implied “effects on the quality of patient care processes.”
Top 10 causes of hospital infections
Currently, one hundred and seventy years after Semmelweis’s discoveries, an old axiom, which emerged after his death, is fully valid: “the first ten causes of hospital infections are the ten fingers of the hands.” Of course, now no one would speak of “cadaverous particles,” but of “germs.” And instead of “puerperal fever,” we use terms like Health Care Associated Infections (HAIs). But what are we talking about?
HAIs are understood to be those related to the presence of an infectious agent, in association with exposure to health centers. In other words: infections that are acquired in polyclinics, hospitals, dental clinics, etc.
It is one of the main causes of hospital mortality. According to data from the European Center for Disease Prevention and Control (ECDPC), some 4 million patients acquire an HAI each year in the European Union and approximately 37,000 deaths result directly from these infections.
Critical patients and HAIs
It is important to point out that HAIs reach their highest expression in patients hospitalized in intensive care services or units, whether they are neonatal — as is the case of the mentioned deaths —, pediatric and adult.
A series of factors come together for the development of these infections, which we will see below.
The alteration of defensive barriers is one of them. Hospitalized patients usually have a feeding tube and urine collection; endotracheal tubes for ventilation; multiple venous punctures to administer food or medication…. All this decreases the effectiveness of that “shield” that is our skin.
Another phenomenon is the so-called “cross-transmission of microorganisms.” It consists of the transmission of infectious agents between patients and health personnel, by direct contact or through fomites. These are lifeless elements that, when contaminated, can transport and transmit a germ, for example, a forceps…
To this must be added “the selected ecosystem.” What does this mean? Well, the germs in these intensive therapy services are the most aggressive and the most resistant to antimicrobial therapy. This occurs through a biological process of natural selection.
If we add that they are vulnerable patients, especially newborns; the long hospital stays, due to the complexity of their conditions; and that, in order to save their lives, are undergoing invasive procedures, it will be understood that the risk of death from the infection is very high.
Incidence rate in Cuba
In the largest study that has been carried out in the country on this subject, it was determined that the incidence rate of HAIs was 1.3 per 100 discharged patients.1 When this same rate is evaluated in relation to the type of service, we will see that the neonatal care units presented 8.2 HAIs for every 100 discharges. More than twice the rate for adult and pediatric ICUs, with 3.5 and 3.7 per 100 discharges, respectively, and 6.3 times the overall rate.
Hence, in order to reduce the risk of HAI to acceptable levels, hygiene measures must be impeccable in this type of unit. Otherwise, many things can go wrong, with catastrophic results.
Problems with ensuring resources
An important element when it comes to HAIs is related to “problems with ensuring resources.” Even though correct handwashing continues to be the cornerstone of HAI prevention and control, it cannot be claimed that this measure alone will solve all problems. Many inputs are needed to prevent HAIs, some of them very expensive. For example, a box of surgical gloves, with 70 units, cost 73.23 euros and sanitary regulations require that they be discarded after each use.
On the other hand, excellent medical care, which is what all human beings deserve — especially children — requires having different types of hospital disinfectants for different types of patients, surfaces, and equipment. Five liters of high-level instrument disinfectants cost 98.01 euros. This is probably not even enough for a week of work in a small provincial hospital.
Obviously, Cuba is not in the economic conditions to provide all the necessary resources to prevent HAIs. Even though neonatal care is one of the most protected areas, if unjustifiable violations of hygienic standards are added to the lack of resources, it is relatively easy for misfortunes such as those of the Gyno-Obstetrics hospital to occur in a group of patients as vulnerable as newborns, with low birth weight and prematurity.
Newborns have an immature defensive system. They lack immunological memory; that is, their defense system is not capable of recognizing and attacking germs as an adult would because they have not yet been exposed to them. The only antibodies a newborn possesses are those given by the mother through lactation. Hence, it is imperative to maximize care in neonatal units, because the risk of infection and death in this type of patient is the highest; this is what the data shows.
Primum non nocere
The first principle of medical ethics is primum non nocere: “first do no harm.” If a newborn is infected due to mishandling or a hospital outbreak, it is being harmed. Of course, it does not occur to me that someone would want the unfortunate deaths to happen; on the contrary. Nor has it been reported that in this case there was negligence on the part of those involved, which would have criminal consequences.
On the other hand, HAIs are also a significant cause of hospital mortality worldwide, an inevitable phenomenon that derives from institutionalized medical care. Eliminating them is impossible even in high-income countries with all the necessary resources at their disposal. The challenge is to keep them under control and this is precisely what did not happen at the 10 de Octubre hospital.
The lack of resources does not justify not respecting the protocols, especially when it comes to children. Consequently, the collective unease is understandable and I share it: the death of these patients is unfortunate. It is imperative that everything possible be done so that it does not happen again. There is too much at stake and the consequences are irreversible.
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1 For all the variables that measure the quality of hospital services, the number of discharges and not admissions is taken as a reference. There are two fundamental reasons for this. The first is that the discharge indicates that the patient has completed his cycle in the hospital and has died or has recovered from his condition. The second is to avoid bias. Not all patients admitted to hospital units are discharged, some simply leave without any record of it.
Author
Carlos Alberto González
