Iatrogenic infections

• ANATOMY OR SYSTEM AFFECTED: All

Definition

Iatrogenic infections are those infections transmitted during medical treatment and care. A study published by Johns Hopkins patient safety experts in the BMJ (formerly the British Medical Journal) reported in 2016 that iatrogenic infection contributed to about 225,000 deaths in the United States each year. They also asserted that, after heart disease and cancer, iatrogenic illness was the third leading cause of death in the United States. However, if these statistics were correct, about one-third of all hospital deaths would have been caused by iatrogenic infections. While these infections are concerning, their prevalence may have been inflated in the literature.

Causes

Iatrogenic infection is complex because it has so many causes, including chance, negligence, medical error, and interactions of prescription drugs. Nosocomial infections, also called healthcare-associated infections (HAIs), are another leading cause of iatrogenic illness that occur during hospitalization or through treatment in another healthcare setting. Vectors for infection in these facilities include vomit, blood, urine, and feces. Some microorganisms can be spread through the air. Postsurgical patients are particularly vulnerable to hospital-acquired infection. Illnesses can be transmitted by healthcare providers who neglect proper methods of sanitation.

HCIs are caused by many pathogens, including viruses, fungi, and bacteria. Gram-negative bacteria that commonly cause these infections include Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Enterobacter species, and Serratia marcescens. Respiratory syncytium virus (RSV) and rotaviruses are common causes of HCIs in children, and the fungi Aspergillus and Zygomycetes occur most commonly as HCIs among organ transplant recipients and patients with hematologic malignancy (blood cancer).

Risk Factors

The risks associated with adverse drug reactions typically occur when healthcare providers lack understanding and education about the prescribed drug. One of the most significant issues in drug-drug interactions resulting in iatrogenic illness is a change in the gastrointestinal tract and liver that leads to metabolic problems. Alcohol intake and smoking can also affect the way drugs are metabolized.

One study of hospitalized patients showed that up to one-half of drug-related problems occur because of errors in prescribing, administering, dispensing, and transcribing records of drugs. Inadequate monitoring of patients was cited in another study, meaning that the appropriate laboratory tests were either not ordered or were incorrectly interpreted.

Also, a lack of sanitation frequently leads to iatrogenic illness. This could happen in a wide range of settings, from food waste and dirty restrooms to devices, such as surgical equipment, catheters, and wound dressings, that are supposed to be sterile.

Rare diseases can be transmitted during corneal transplants, by contaminated dura matter (the layers surrounding the brain and spinal cord), through blood transfusion, and by dental pulp, which has been implicated in the spread of the incurable Creutzfeldt-Jakob disease.

Symptoms

Affected persons experience a wide range of symptoms, illnesses, disorders, and conditions. Some of the most frequently studied include ovarian hyperstimulation syndrome, fat intolerance after cholecystectomy, rupture of the tracheobronchial tree, colitis, hypoglycemia, back pain, neuropathy after hysterectomy, rectourethral fistula, acute estrogen deficiency, temporomandibular joint symptoms, and small perforations of the colon during colonoscopy.

Screening and Diagnosis

By applying rigorous methodology, researchers can study, for example, the epidemiology of drug-induced illnesses. Such research includes a consideration of the frequency of a drug-induced disease, nonmedical contributing factors, the dose and route of administration of all drugs taken by the patient, the time and place of drug-induced diseases, and the specific characteristics of each patient. Other kinds of iatrogenic illnesses, such as nosocomial infections, are often monitored by the medical provider’s risk-management or quality-assurance departments.

Treatment and Therapy

Measures for the treatment of iatrogenic illness include antiseptics, antibiotics, and better surgical techniques. Anesthesia may be used to control pain.

Because there are hundreds of varieties of iatrogenic illness, each requiring individualized treatment, this section will outline the therapeutic course for a patient who is at high risk for developing a common type of iatrogenic, adverse drug reaction: dyspepsia caused by treatment with ibuprofen.

Patients with dyspepsia, or indigestion, have symptoms such as upper abdominal pain, belching, nausea, vomiting, abdominal bloating, and satiety. For patients taking ibuprofen, there is also a risk of internal bleeding, and the medical team will have to screen for this. The patient may also experience warning signs such as weight loss, blood in the stool, fever, and vomiting. The medical team also needs to check the patient’s diet and screen for depression and anxiety. Other factors under consideration should include the patient’s age, medical history, concurrent drug use, use of herbal medicines, and use of food supplements. Treatment cannot safely begin until all differential diagnoses have been excluded.

If the dyspepsia is caused by abnormal function of the gastrointestinal muscles, a smooth muscle relaxant will increase motility and improve symptoms. Dyspepsia with the production of stomach acid may be treated with a proton pump inhibitor or misoprostol (Cytotec). After weighing the risks and benefits, the physician may ask the patient to reduce or stop the ibuprofen.

Prevention and Outcomes

Nosocomial infection can be addressed by decontamination measures such as cleaning, disinfection, sterilization, and ventilation. Vulnerable patients with wounds can be protected with sterile dressings and isolation precautions. Adequate airflow and moisture control helps to limit microorganisms such as bacteria and fungi. Healthcare providers can limit the risk of iatrogenic illness by containing or removing infectious materials, instituting single-use devices, and standardizing drug equipment. Some hospitals are experimenting with financial incentives for handwashing, as studies have shown that medical staff fail to wash their hands more than half of the time.

Many quality improvement approaches to iatrogenic illness focus on the design of systems for the control of hospital infections and adverse drug reactions. Targeting people has been less effective. In a system-focused environment, mechanisms such as medical audits, peer review, and risk management offer valuable feedback to every member of the healthcare team, making it easier to implement evidence-based preventive measures. The evidence-based environment also fosters meta-analysis to improve clinical practice.

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