• Healthcare quality improvement
• Infection control
• Nosocomial infections

Healthcare-associated infections, particularly ones caused by antibiotic-resistant bacteria, are associated with high morbidity, mortality and economic costs. In the USA, on average, 2 out of 10 patients admitted to a hospital contract a healthcare-associated infection and their mortality is estimated to exceed breast and prostate cancers, combined.1 Antibiotic-resistant pathogens are responsible for more than two million infections and 23 000 deaths each year in the USA, at a direct cost of $20 billion and additional productivity losses of $35 billion.2 In the European Union, an estimated 37 000 deaths are attributable to antibiotic-resistant infections, costing €1.5 billion annually in direct and indirect costs.3 Although these numbers are well known to hospital epidemiologists and infection preventionists, the magnitude of these numbers is often not appreciated by other clinicians and healthcare executives. Importantly, a large proportion of these infections are preventable. For example, a recent systematic review indicated that up to 70% of central line-associated bloodstream infections and catheter-associated urinary tract infections and up to 55% of surgical site infections and ventilator-associated pneumonias are preventable.4 Since the 1970s, infection prevention programmes have been recognised as an essential component for infection prevention in hospitals.5 These programmes generally consist of one or more hospital epidemiologists and infection prevention nurses and are tasked with internal and external tracking and reporting, developing and revising infection prevention policies, training staff, monitoring and surveillance, outbreak investigation, product management and evaluation, device processing, employee health, emergency preparedness and environmental cleaning methods in addition to regular meetings.5 ,6

Over the past decade, research funding for interventions targeting the prevention of healthcare-associated infections has increased. In 2015, the White House released the US National Strategy for Combating Antibiotic-Resistant Bacteria initiative which proposes increased research funding to target antibiotic-resistant bacteria.7 These investments have led to an increase in the number of evidence-based interventions and greater understanding of the epidemiology of healthcare-associated infections and antibiotic resistance. A sample of these interventions is outlined in table 1. We hope that these investments continue so that continued progress can be made against emergent threats while improving efficiency.

It is clear that despite these advances, the proportion of hospital-acquired infections (HAI) caused by antibiotic resistance remains high and bacteria containing new resistant mechanisms continue to emerge. Thus, there are many important questions that remain unanswered.8 For example, the following are important areas of need: (a) novel barrier methods to prevent patient-to-patient transmission of antibiotic-resistant bacteria while making it easier to use personal protective equipment; (b) novel technology and devices that do not require behaviour change interventions, for example, antibiotic-coated or antimicrobial hardware that would decrease device-associated infections; (c) advances in implementation science targeting HAI prevention processes and (d) improved automated surveillance methods for tracking HAI using electronic medical record (EMR) and other existing databases. In recent years, healthcare-associated infections and antibiotic resistance have received increasing public attention and healthcare policy, leading to changes in national reporting requirements, reimbursement based on HAI and other legislative mandates. For example, 35 US states mandate collection and reporting of HAI through the CDC's National Healthcare Surveillance Network,9 while the adoption of mandatory surveillance and reporting has been variably implemented in Europe. Financially, both public and private insurers are withholding payment for HAIs. As the financial and regulatory burdens increase, infection prevention programmes are becoming increasingly strained.

Although hospital epidemiology and infection prevention programmes are being tasked with more, this increase in demand has not been met with a commensurate increase in compensation or personnel. Increased surveillance and reporting requirements combined with flat or decreasing budgets creates the unintended consequence of taking the focus away from patient-focused infection prevention duties. This unfortunate situation could jeopardise critical local prevention efforts. To emphasise this point, we only need to point to the USA, where conditions for federal reimbursement include a requirement for an infection control programme and will soon require antimicrobial stewardship as well. The government provides no guidance on staffing, manpower or reimbursement for these programmes. The Society for Healthcare Epidemiology of America (SHEA) recently has tried to fill that void by providing recommendations on infection prevention manpower issues for academic and non-academic facilities.10 Other less formal recommendations have been made in other countries.11–13

This is a situation not unknown to quality improvement (QI) experts, who have seen increased demands without commensurate funding increases. Going forward, it will be critical for infection prevention and QI programmes to partner together not only on implementation efforts but also on proving the cost-effectiveness of their programmes to local and national administrators who set internal and external support for these critical programmes. We must work together to make the business case for high-quality care, devoid of HAI.

Part of this lack of funding is because infection control programmes are seen as cost centres and not as revenue generators. Modifications to how Centers for Medicare & Medicaid Services (CMS) and others reimburse for infection prevention are essential. The current delivery-of-care structure in healthcare systems reinforces underinvestment in preventative measures such as infection control, which places patients at risk. It is time to alter delivery models and properly fund infection prevention and partner QI programmes along with the necessary research to guide the continued advancement of these programmes.

How can we move infection prevention programmes forward? The current hospital funding mechanism is undergoing major changes in the USA and throughout the world. However, further modifications are needed to mandate specific resources for infection prevention programmes and continue to improve patient outcomes. We suggest that organisations such as SHEA, Association for Professionals in Infection Control and Epidemiology (APIC) and European Society of Clinical Microbiology and Infectious Disease (ECSMID) work with government agencies to create comprehensive recommendations for infection prevention programmes. Potential ideas include the following: (a) guidelines by major organisations outlining the optimal reimbursement and full time employee (FTE) of hospital epidemiologists and infection preventionists for healthcare facilities in various settings. Currently, agencies such as CMS list certain conditions of participation for institutions relative to infection control and soon to be antibiotic stewardship; however, details of these requirements are vague and should be expanded; (b) as reimbursement moves away from fee per service and more towards quality outcomes driving reimbursement and penalties, we need more effective and novel methods of directing resources for day-to-day infection prevention. For example, an infection prevention fee could be imposed on all procedures that require significant infection prevention resources such as surgery or central line insertion and maintenance; (c) funding for state health departments to assist individual hospitals in establishing effective infection prevention programmes; (d) novel reimbursement models such as a fixed fee per surveillance culture reviewed, a fee for each chart reviewed to assess the appropriateness of antibiotic selection or an hourly fee for performing outbreak investigation may be warranted and (e) certification requirements for hospital epidemiology and QI experts that will help recruit and establish more experts to the field.

As the bacteria continue to evolve new mechanisms of resistance that push us closer to a postantibiotic era, we must continue to evolve our healthcare systems so that QI and infection prevention programmes keep pace. We must all partner together to maintain our advanced, high-quality healthcare systems and reduce the threat of healthcare-associated infections.