“Public health issues in Latin America and the Caribbean are central to the well-being of all of the inhabitants of the region, particularly the vast numbers of people that are poor. Foundations, such as PAHEF, can have lasting impacts on the people that are helped by our efforts and in turn, our efforts can also serve to encourage others to contribute with their resources.”

Enrique E. Figueroa, Ph.D., Former Chairman, Pan American Health and Education Foundation Director of the Roberto Hernandez Center at the University of Wisconsin-Milwaukee

Grants Program » Small Grants Program 2006 

II. Priorities for 2006

Theme A. Enhancing Infection Control Practices

Problem Scope
Infections acquired in health-care settings occur in developed and resource poor countries. The rates of infection in the latter tend to be twice as high as those in developed countries. At any given time, over 1.4 million people worldwide suffer from complications of infections acquired in the health-care setting. These infections are a significant burden both for the patient and for public health systems. They are among the major causes of death and morbidity among hospitalized patients. Infection rates are higher among patients with increased susceptibility because of extremes of age (infants and the elderly), underlying disease, chemotherapy, surgery, instrumentation, or invasive procedures. The highest prevalence of infections acquired in a health-care settings occurs in intensive care units and in acute surgical wards.

The management of health-setting acquired infections has become more complicated because of the emergence of antibiotic-resistant pathogens. Currently, in some countries, 50% or more of these infections are caused by pathogens resistant to common antibiotics.

Despite the high rates of infections acquired in treatment settings and their attendant morbidity, mortality and high cost, about 90% of hospitals in Latin America lack the personnel and/or established structures to prevent and control health-setting acquired infections. And infection control is often not part of the curriculum in medical and nursing schools.

Identified issues of concern in Latin America and the Caribbean:
  • 1. Many hospitals lack access to appropriate microbiologic laboratory facilities or fail to work in a coordinated manner with such facilities. Therefore they lack data on the local patterns of antimicrobial susceptibility that would allow rational selection of appropriate antimicrobial therapy.
  • 2. The initial selection of antimicrobial therapy and subsequent modifications most often rely on experience or observation alone without taking into account systems and theory. The local patterns of practice discourage the use of bacterial cultures to make an appropriate diagnosis that would establish the causative pathogen and its susceptibility pattern. Efforts to guide and control antimicrobial prescribing are therefore very difficult, leading to adverse patient outcomes and more rapid selection of multi-drug resistant pathogens.
  • 3. Many hospitals lack surveillance data on their rates of health-setting acquired infections, main offending pathogens and their modes of transmission. This hinders the selection and application of appropriate infection control practices to prevent those infections.
  • 4. Several countries lack regulations, policies and even uniform definitions of health-setting acquired infections that would allow hospitals to compare similar information to determine the true extent of the problems that they are facing and therefore institute uniform preventive practices.
  • 5. There is very little knowledge as to how the problems of health-setting acquired infections and antimicrobial resistance affect particularly vulnerable populations such as indigenous people, premature babies, neonates, young children, or the elderly.
  • 6. There is little knowledge about the costs of health-setting acquired infections in general and about the costs of health-setting acquired infections caused by multi-resistant organisms in particular. Such knowledge may act as an incentive to the establishment of infection control and prevention programs in health care institutions.

Impact of health-setting acquired infections
Hospital-acquired infections add to the functional disability and emotional stress of the patient and may lead to permanent disabling conditions that reduce the quality of life. Health-setting acquired infections are also one of the leading causes of death. The economic costs are considerable. The increased length of stay for infected patients is the greatest contributor to cost. Prolonged stay not only increases direct costs to patients or payers but also indirect costs due to lost work. The increased use of drugs, the need for isolation, and the use of additional laboratory and other diagnostic studies also contribute to costs. Health-setting acquired infections add to the imbalance between resource allocation for primary and secondary health care by diverting scarce funds to the management of potentially preventable conditions.

The advancing age of patients admitted to health-care settings, the greater prevalence of chronic diseases among admitted patients, and the increased use of diagnostic and therapeutic procedures, which affect the host defenses, will provide continuing pressure that will favor health-setting acquired infections in the future.

In addition, organisms causing health-setting acquired infections can be transmitted to the community through discharged patients, staff and visitors. If organisms are multi-resistant, they may subsequently cause significant disease in the community.

Bacterial resistance
The widespread use of antimicrobial drugs produces pressure on bacteria that favors the selection of multi-drug resistant strains. Such organisms can become endemic within the hospital and complicate the management of health-setting acquired infections. Increasingly, antimicrobial agents are becoming less and less effective because of resistance. This phenomenon has rendered many of the older antibiotics ineffective but is also increasingly negating the efficacy of the newer antibiotics to the point that for certain strains there are few or no effective alternatives. This problem becomes critical in developing countries where newer, more expensive, second line antibiotics may not be available or affordable.

Potential Impact of a PAHEF Initiative
The Pan American Health Organization (PAHO) has been working for several years in trying to establish a network of microbiology laboratories operating under international standards of quality control throughout Latin America. The data from these laboratories are beginning to show the magnitude of the problem of antimicrobial resistance in Latin America. Such efforts should be carried to the next step: the integration of culture data with infection control and antibiotic utilization data to identify the best practices that would allow prevention of infections, while decreasing decrease the risk of antibiotic resistance in hospitals.

Possible Areas of Project Activity
  • Determination of the rates of health-acquired infections and antimicrobial resistance patterns in hospitals with comparison of rates between hospitals in urban versus rural areas. Determination of the extent of the problem and the particular needs of hospitals that primarily serve indigenous populations.
  • Development of programs that support local strategies to control antimicrobial resistance in countries of the Andean region and Paraguay. Such programs should complement the South American Infectious Diseases Initiative (SAIDI).
  • Establishment of programs for the evaluation of the costs of health-setting acquired infections with particular attention to the costs of infections caused by multiresistant organisms such as methicillin resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE) or multi-resistant Gram negative bacilli (such as extended spectrum beta-lactamase [ESBL] producing strains).
  • Determination of the rates of health-acquired infections and antimicrobial resistance patterns in neonatal intensive care units. Institution of infection control and antibiotic utilization control programs in such units to measure their impact on health-setting acquired infection rates, morbidity and mortality and on antibiotic resistance patterns. Determination of the role of methicillin resistant staphylococci and of ESBL producing Gram negative bacilli in neonatal intensive care unit infections.
  • Establishment of pilot programs that aim to integrate the work of the microbiology laboratory with the work of the infection control and the antibiotic utilization committees to improve the prevention and treatment of health-setting acquired infections at the hospital, regional or national levels.
  • Development of teaching programs for the proper utilization of antimicrobials aimed at medical students, residents and practicing physicians. Such programs should incorporate measurable before/after comparisons of results.
  • Development of programs that study the reasons for and offer solutions to the inadequate use of antimicrobials (including the causes of overutilization, unnecessary use and underuse of antimicrobials and their impact on resistance).
  • Development/implementation of pilot programs for the appropriate utilization of antimicrobials in surgical prophylaxis as part of a hospitalís quality improvement initiatives.
  • Studies to document the extent of commercialization of antimicrobials of deficient quality in countries where such antimicrobials can be obtained without prescription.

    Grant Applications:
    Organizations that have the technical and financial resources to design, execute and evaluate a project that can be completed in 12 to 24 months and addresses the issues described above should consider submitting an application to the PAHEF Small Grants Program.