By Kirstie Ruby

Hospital-acquired infections (HAI) are extremely common, and current estimates show that one out of every 20 hospitalized patients in the United States will develop a HAI. While exact estimates can be hard to pin down, a multistate point-prevalence survey that examined hospital data from 2011 found that 4% of inpatients in U.S. acute care hospitals had at least one health care-associated infection. Applying these findings on a national scale, this study determined that in 2011 alone, 648,000 inpatients acquired a HAI, nationwide.

For years, the Centers for Disease Control and infection control committees have focused their efforts to prevent HAIs primarily on device-associated infections such as central line bloodstream infections, catheter-associated UTIs, ventilator-associated pneumonia, and surgical site infections. However, data from the recent multistate HAI survey, discussed above, points out how device-associated infections accounted for just 25.6% of all health care-associated infections detected in the current survey. 

These findings have renewed attention on the contamination of environmental surfaces, pointing out the important role that they play in the transmission of pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridium difficile (C. diff), Acinetobacter spp., and Norovirus.

To combat these costly, and often life threatening infections, many manufacturers have been developing an ever-broader array of products containing antimicrobials, and many hospitals have turned to these products in the hopes of reducing HAIs. Widely used products such as hand sanitizers, health and beauty products, furnishings, wall coverings, textiles, and many other products are increasingly being offered with added antimicrobials. 

The use of antimicrobials in the clinical setting has a long and important history. As basic tools of modern medicine, antimicrobials are intended to kill or prevent the replication of microorganisms, such as bacteria, viruses, and fungi, and are found in many hospital cleaners. Certain antimicrobial cleaning products are necessary in order to decontaminate shared surfaces and medical products used by multiple patients. However, the introduction of antimicrobials into additional products used throughout the health care setting raises important questions about efficacy, environmental and human health impacts, antimicrobial resistance, and other important tradeoffs. 

The introduction of antimicrobials into additional products used throughout the health care setting raises important questions about efficacy, environmental and human health impacts, antimicrobial resistance, and other important tradeoffs.

At the forefront of this debate is the use of antimicrobial hand soap, which is now widespread in the health care setting, as well as homes, schools, and public buildings. In 2001, 76% of commercial liquid hand soaps contained triclosan, and 80% of all antimicrobial bar soaps sold in the United States in 2011 were found to contain triclocarban. 

The FDA is currently reviewing the widespread use of antimicrobial chemicals in products, but has already found that there is “no evidence that over-the-counter antibacterial soap products are any more effective at preventing illness than washing with plain soap and water.” They go on to say that "… the risks associated with long-term, daily use of antibacterial soaps may outweigh the benefits. There are indications that certain ingredients in these soaps may contribute to bacterial resistance to antibiotics, and may have unanticipated hormonal effects that are of concern to FDA.”

Some hospitals have started to address the issue by no longer using antimicrobial hand soaps in their facilities. In 2010, Kaiser Permanente pulled triclosan from its 37 hospitals across the country, choosing to switch to traditional soaps and alcohol-based hand sanitizers. At the time, Kathy Gerwig, Kaiser Permanente's vice president for workplace safety, said that the hospital chain decided to phase out triclosan as part of its "precautionary approach" to safety issues, stating, "If there is credible evidence that a product we're using might have some disadvantages from a health or environmental standpoint, then it's our obligation to look for a safer alternative." 

In addition to hand soaps, antimicrobials are also being added to health and beauty products, furnishings, wall coverings, deodorants, surgical scrubs, textiles, and various other products. Unfortunately for consumers, the safety of added antimicrobials in many of these applications remains an unanswered question, and significantly more research is needed in order to determine whether the benefit of infection prevention outweighs the potential risks of using such products. 

The concerns discussed in this blog are just some of the issues that Health Care Without Harm is planning to consider in a literature review and analysis expected to be finalized later this year. With manufacturers on the cusp of adding more and more antimicrobials to thousands of products, and hospitals pressured to take every step necessary to address HAIs, both health care providers and manufacturers have been looking for further evidence and guidance on their use. Health Care Without Harm hopes to make a contribution to this important conversation by offering recommendations on current best practices, based on the available evidence.  

^{Images courtesy of Flickr user Wellcomee Images}

Kirstie Ruby provides communications support for our Safer Chemicals program