Journal of Hospital Infection (2001) 49: 94–98

doi:10.1053/jhin.2001.1026, available online at http://www.idealibrary.com on

INFECTION CONTROL IN EUROPE

Hospital infection control in Poland

W. Hryniewicz*†‡, P. Grzesiowski†‡ and T. Ozorowski†
*National Consultant for Medical Microbiology, †Hospital Infection National Working Group of the National
Consultant for Medical Microbiology and ‡Sera and Vaccines Central Research Laboratory,Warsaw,
00-725 Warsaw, Chelmska Str. 30/34, Poland

Summary: During the last 10 years, as in other areas of the public sector in Poland, the healthcare system
has undergone important changes presenting a challenge for medical staff and healthcare managers alike.
Since 1997, the Polish Government has undertaken important healthcare reforms. New regulations have
introduced decentralization of management and a financing system for hospitals. These changes have pro-
vided favourable conditions in which to implement an infection control system for hospitals. The most
important recent initiatives are training courses and workshops for hospital staff organized in co-operation
with microbiologists and epidemiologists as well as preparation of recommendations and guidelines for
hospitals. Several non-governmental organizations have been set up to improve hospital hygiene, infection
control and monitoring of antimicrobial resistance.
© 2001 The Hospital Infection Society
Keywords: Hospital infections; Infection control; Poland.

Introduction inhabitants, 750 hospitals with about 250 000 beds

Before the political and economic changes of the
early 1990’s, all hospitals in Poland were public and
the national health insurance system was fully cen-
tralized. Hospital services were paid for by the
Ministry of Health from a fixed general budget
based on historical expenditures with no regard
for cost-effectiveness and quality control studies.
During the last 10 years, as in other areas of the
public sector, the healthcare system has undergone
important changes presenting a challenge for med-
ical staff and healthcare managers alike. Quality of
care is the primary goal of the new system with
infection control emerging as a priority issue.
Socio-economic conditions of Polish
healthcare system
The Polish healthcare system is one of the largest
in Central Europe and covers around 40 million
Received 25 April 2001; manuscript accepted
2 May 2001; published online 13 July 2001.
Author for correspondence: Dr. P. Grzesiowski, Chelmska Str.
30/34, 00-725 Warsaw, Poland. Tel.: ;48(22) 841 33 67;
Fax: ;48(22) 841 29 49; E-mail: paolo@il.waw.pl
and 5 million hospital admissions a year. The dis-
tribution of medical services varies significantly
between urban and non-urban areas. Most primary
care hospitals are located in non-urban areas and
have less than 250 beds, whereas secondary and ter-
tiary care hospitals are situated in major cities and
usually have more than 350 beds. However, there is
a discrepancy between the public’s need for quality
in the healthcare system and economic reality, since
only 7.75% of total national income is directed into
this sector, clearly making the situation difficult.
Past government initiatives
The first central regulation for a modern infection
control system in hospitals was established in 1983
by the Polish Ministry of Health.1 According to
this, every medical centre was obliged to introduce
several infection control measures. The most impor-
tant were the hospital infection control committee,
mandatory notification of hospital-acquired infec-
tions to regional Public Health Authorities and the
Central Register, training for hospital staff and stan-
dards of isolation, hospital hygiene and disinfection.
The infection control programme including passive

0195-6701/01/020094;05 $35.00/0 © 2001 The Hospital Infection Society

Hospital Infection control in Poland
monitoring activities, was performed by a physician
and co-ordinated by the infection control committee.
The committee consisted of physicians and nurses,
and was managed by the medical director of the hos-
pital. Identification of hospital epidemics, standards
and control of disinfection, sterilization and waste
disposal remained in the hands of the nurse respon-
sible. In response to these regulations, hospital infec-
tion control committees existed solely on paper and
consisted of untrained hospital staff. In practice,
most of the measures ordered by the ministerial cir-
cular were never implemented in hospitals and most
standards existed only in theory for the purpose of
official statistics. At that time, the only body
involved in some aspects of infection control was a
network of public health laboratories (Sanitary-
Epidemiologial Stations – SESs). They had the
power to inspect hospitals, but only within the lim-
ited fields of hospital hygiene and sterilization/disin-
fection and some outbreak investigation. Notification
of hospital-acquired infections by the SESs resulted
in inspections that lacked expertise and often
resulted in a fine for the hospital. This meant that
official data on the prevalence of hospital infections
registered by regional SES’s and the National
Institute of Hygiene was never reported to exceed
0.1%. No other documented national data on infec-
tion control in hospitals were available.
Present government initiatives
The main objections to the introduction of the
ministerial guidelines from 1983 were: lack of pro-
motion, resources, knowledge and co-operation
between regional SES’s and hospitals in the field of
infection control; a limited number of trained
microbiologists and an inadequate use of microbio-
logical diagnostics in clinical practice. An impor-
tant step in the improvement of the central
healthcare administration was a survey organized in
1995 by the National Centre for Economisation and
Organization in Health Care. All hospitals were
reviewed in accordance with existing infection con-
trol practices. Of the more than 700 hospitals
involved, 77% of institutions had no system for the
registration of hospital infections and 75% had no
epidemiological nurse employed on a full time
basis. The results of this survey highlighted the gap
between administrative regulations, official statis-
tics and hospital practice.2
In 1996, the National Commission for Nosocomial
Infections was appointed by the Ministry of Health
95
and consisted of national experts in microbiology,
epidemiology and infectious diseases. After a year
of intense research, the Commission prepared a
report for the Ministry, resulting in an obligation
for all hospitals to employ a hospital epidemiolo-
gist. The report has never been published, however
it has encouraged health authorities to stimulate
changes in hospitals.3
Since 1997, the Polish Government has under-
taken important healthcare reforms. New regulations
have introduced decentralization of management
and a financing system for hospitals. The following
changes have been the most important for infection
control:
a) Hospitals have become self-financing entities
with a strong motivation to reduce the costs of
care e.g. expenditure for antibiotics.
b) Hospitals are now held fully responsible by law
for malpractice e.g. hospital-acquired infection
due to mistakes in procedures.
c) A network of 16 regional funding centres has
been set-up (Regional Health Care Insurance
Authorities – RHCIA), signing contracts with
hospitals based on a prospective payment system
related to the number of hospitalized patients.
In this system all costs of hospital-acquired
infection are covered by hospital budgets and
cannot be reimbursed. A department of quality
care control is included in the structure of
RHCIAs. In the near future there will probably
be appointments to positions similar to that of
the Consultant in Communicable Disease Control
(CCDC) in local health authorities in the UK.
d) A Centre for Hospital Accreditation has been
established and infection control measures have
been included as a part of the accreditation
process for hospitals: preventive procedures,
staff education, monitoring and isolation. This
organization has created a system of external
audits, certification for hospitals based on guide-
lines and procedures similar to the American
Joint Commission of Hospital Accreditation. To
date, about 0.5% of all Polish hospitals have
obtained certificates of accreditation and met
the criteria of the quality control measures,
including the infection control system.
The new system of contracts for medical services,
which is funded by the RHCIAs, creates competi-
tion between healthcare institutions, stimulates
quality improvement and the implementation of
96
recommendations and guidelines for hospital prac-
tice formulated by scientific and medical consultants.
These changes have provided favourable conditions
in which to implement an infection control system
for hospitals.
Non-government initiatives
Between 1983 and 1995, several limited studies
on hospital-acquired infections were undertaken,
mainly in surgery and paediatric wards, but these
incidental and casual activities had no influence on
the organization and efficacy of hospital epidemiol-
ogy for the country as a whole.4–6 Some local initia-
tives were undertaken to improve preventive
standards and control measures, albeit on a very
limited scale. In order to overcome this situation,
the Polish Society for Hospital Infections was esta-
blished in 1994 to improve co-operation between epi-
demiologists, microbiologists and hospital staff. The
main activities of the Society are the organization of
meetings and conferences, publishing a journal of
hospital infections and the promotion of infection
control guidelines.
The first national survey on hospital-acquired
infections was set up by the Ministry of Health and
conducted by the Polish Society for Nosocomial
Infections during 1997–1999. Of the more than 200
hospitals surveyed by passive monitoring, only 40%
completed the questionnaires and the overall
reported hospital-acquired infection rate was 1.5%
of all hospitalized patients.7 This poor compliance
once again confirmed the need for the implementa-
tion of complex infection control programmes
based on well-defined standards and procedures
and well-trained personnel.
In the last few years, several other non-
governmental organizations have been set up to
improve hospital hygiene and infection control
standards. Two autonomous groups which have
had a major impact are the Society for Hospital
Sterilisation Managers and the Polish Association
of Epidemiological Nurses. Their major goals are
the education of medical staff in the field of hospi-
tal-acquired infections and the implementation of
guidelines and standards in hospital hygiene, disin-
fection and sterilization, as well as monitoring the
quality of medical procedures. The most important
initiatives are training courses and workshops for
hospital staff organized in co-operation with micro-
biologists and epidemiologists as well as preparations
of recommendations and guidelines for hospitals.
W. Hryniewicz et al.
Recent advances in infection control
In response to the growing interest of healthcare
professionals and hospital management staff in
infection control and antimicrobial resistance, seve-
ral initiatives have been undertaken by the National
Consultant for Medical Microbiology. In 1997, the
Reference Centre for Antimicrobial Resistance, the
Centre for Quality Control in Microbiology and
the Hospital Infection Working Group were estab-
lished as the three most important elements of a
complex programme designed to improve the infec-
tion control system for the whole country. The activ-
ities of these bodies are focused on:
a) The organization of infection control in hospi-
tals on a local and national level.
b) The education and training of medical person-
nel in infection control.
c) Improving diagnostics and monitoring antimi-
crobial resistance and consumption of antibi-
otics in hospitals.
d) The implementation of recommendations and
standards of infection control and good antimi-
crobial practice in hospitals (GAP).
e) Early diagnostics and management of hospital
outbreaks.
f ) Multi-disciplinary co-operation and exchange
of knowledge in the field of hospital-acquired
infections and preventive measures.
Between 1997 and 1999 this independent group
of experts published the first Polish guidelines for
the empirical treatment of respiratory and urinary
tract infections, and in 2000, in co-operation with
the Ministry of Health, the first Polish guidelines
on standards and procedures of infection control
in hospitals covering all important issues, such as
organization, education, epidemiology, microbiol-
ogy, GAP, monitoring and preventive procedures
of hospital-acquired infections.8–10 The Working
Group provides regular training for hospital infec-
tion control teams and workshops for epidemiology
nurses and infection control physicians.
In 2000, the first national hospital network
(OPTY) to be founded by the Ministry of Health was
set up and co-ordinated by the National Consultant
for Medical Microbiology in co-operation with the
National Reference Centre for Antimicrobial
Resistance of Sera and Vaccine Central Research
Laboratory (SVCRL). The aims of the network are
the standardization of diagnostic procedures and
the identification of important pathogens and new
Hospital Infection control in Poland
antimicrobial resistance mechanisms, the elabora-
tion of recommendations and guidelines for hospi-
tal infection control teams and microbiology
laboratories, the education and clinical training of
hospital personnel responsible for infection control,
the monitoring and analysis of the regional and
country-wide spread of multi-resistant pathogens,
early warning systems for emerging pathogens and
resistance mechanisms and the rapid control of
hospital outbreaks with the use of molecular biol-
ogy diagnostic methods.11
Currently, 25 hospitals with certified hospital
microbiology laboratories participate in the net-
work, all working with standardized methodology
and sending data through the internet to the co-
ordinating centre in SVCRL. The hospital laborato-
ries have participated in the European quality
control programme (NEQAS) organized by CPHL,
Colindale London, UK as a requirement for joining
the European Antimicrobial Resistance Surveillance
System (EARSS). Preliminary results from the first
year of OPTY project indicate significant differences
between hospitals in utilization of microbiology diag-
nostics and antimicrobial policies, however rather
low overall prevalence of multi-resistant pathogens,
e.g. methicillin-resistant S. aureus (MRSA) (12%)
high level aminoglycoside-resistant enterococci
(HLAR) (19%), Enterobacteriaceae producing
extended-spectrum beta-lactamases (ESBL’s) (15%).
In all monitored hospitals, several control proce-
dures, such as infection control teams, training pro-
grammes for hospital staff and recommendations
for rational empirical therapy and antimicrobial
prophylaxis have been introduced. For the 14 000
hospital beds surveyed there were 400 000 hospital-
izations with an average length of stay of 9 days.
The mean number of microbiology tests performed
for the whole group was eight per hospital bed,
per year with the total cost of antibiotics between
15 and 35% of the total hospital budget for medi-
cines. Antimicrobial resistance monitoring identi-
fied ‘alert’ multi-resistant pathogens as well as
emerging resistance mechanisms in all participating
hospitals.
This ongoing programme has generated impor-
tant epidemiological data for the creation of new
regulations, in co-operation with RHCIA’s, in order
to promote infection control systems in all public
and private hospitals. A joint commission made up
of representatives from epidemiology, clinical
microbiology and RHCIAs will be created in the
near future in order to develop training programmes
97
for hospital staff and to promote and encourage
hospitals to implement infection control standards
and good antimicrobial practice.
In 1996, the National Centre for Quality Control
in Microbiology headed by the National Consultant
for Medical Microbiology was set up. The first
training programme for hospital microbiologists
and External Quality Scheme (POLMICRO) for
hospital microbiology laboratories was intro-
duced.12 This programme began a countrywide
promotional and educational campaign in the field
of antimicrobial resistance and the monitoring of
antimicrobial drugs consumption. In co-operation
with the National Reference Centre for Anti-
microbial Resistance representative isolates of the
main hospital-acquired pathogens, such as MRSA,
vancomycin-resistant enterococci (VRE), ESBL-
producing Enterobacteriaceae and nonfermenting
Gram-negative rods were collected, characterized
by phenotypic and genotypic methods and a
national collection of alert pathogens was estab-
lished. The advanced molecular epidemiology meth-
ods were used also to assist several hospital during
outbreaks caused by multi-resistant pathogens, espe-
cially MRSA, Enterobacteriaceae-producing ESBLs
and Acinetobacter baumanni.13–22
Conclusion
Despite several initiatives, the current situation in
hospital infection control in Poland is still provisional
and evolving. All categories of institutions involved
in the field of infection control, central and regional
administration, Regional Health Care Insurance
Authorities, non-government and scientific organiza-
tions and hospitals, must intensify efforts to establish
an effective and multi-disciplinary programme for
the monitoring and prevention of hospital-acquired
infections. Dynamic changes in the epidemiology of
hospital-acquired infections and the spread of new
mechanism of antimicrobial resistance should be
resolved by the close co-operation of all the parties
involved.
References
1. Polish Ministry of Health, National Guidelines for
infection control in hospitals, Dziennik Ustaw, 1983,
Warsaw, Poland.
2. Report by the National Centre for Economisation and
Organisation in Health Care, 1995. Warsaw, Poland.
3. Juszczyk J, Gladysz A, Hryniewicz W et al.
Nosocomial Infections. Report for the Ministry of
Health, 1996, Warsaw, Poland.
98
4. Hryniewicz W, Zareiba T, Kawalec M. Susceptibility
patterns of Enterococcus spp. isolated in Poland dur-
ing 1996. Int J Antimicrob Ag 1998; 10: 303–307.
5. Trzciński K, van Leeuwen W, van Belkum A et al.
Two clones of methicillin-resistant Staphylococcus
aureus in Poland. Clin Microb Infect 1997; 3: 198–207.
6. Trzciński K, Hryniewicz W, Kluytmans J et al.
Simultaneous persistence of methicillin-resistant and
methicillin-susceptible clones of Staphylococcus
aureus in a neonatal ward of a Warsaw Hospital.
J Hosp Infect 1997; 36: 291–303.
7. Wójkowska-Mach J, Bulanda M, Adamski P, Heczko P.
Preliminary analysis of data on hospital infections in
Polish hospitals. Terapia 1999; 7: 3–6.
8. Hryniewicz W, Radzikowski A, Meszaros J,
Grzesiowski P. Guidelines for treatment of respi-
ratory infections. 1997, Fundacja Centrum
Mikrobiologii, Warszawa, Poland.
9. Hryniewicz W, Grzesiowski P, Radzikowski A,
Meszaros J, Ozorowski T. Guidelines for the treat-
ment of urinary tract infections. 1999, Fundacja
Centrum Mikrobiologii, Warsaw, Poland.
10. Staszkiewicz W, Hryniewicz W, Grzesiowski P,
Ozorowski T. Practical Guidelines for Infection
Control in Hospital, 2000, MZ i GIS, Warsaw,
Poland.
11. Hryniewicz W, Grzesiowski P. National Network for
antimicrobial resistance monitoring (OPTY). Nowa
Medycyna 1999; 9: 3–5.
·
12. Chmylak B, Szczypa K, Zurek E, Matynia B,
Hryniewicz W. The sixth National External Quality
Assesment Scheme in microbiology in Poland-
POLMICRO’99. The 10th European Congress of
Clinical Microbiology and Infectious Diseases,
Sztokholm, 28–31.05.2000r.
13. Gniadkowski M, Palucha A, Grzesiowski P,
Hryniewicz W. Outbreak of ceftazidime-resistant
Klebsiella pneumoniae in a pediatric hospital in
Warsaw, Poland: clonal spread of the TEM-47
extended-spectrum beta-lactamase-producing strain
and transfer of a plasmid carrying the SHV-5-like
ESBL-encoding gene. Antimicrob Ag Chemother
1998; 42: 3079–3085.
14. Gniadkowski M, Schneider I, Jungwirth R,
Hryniewicz W, Bauernfeind A. Ceftazidime-resistant
W. Hryniewicz et al.
Enterobacteriaceae isolates from three Polish hospi-
tals: identification of three novel TEM- and SHV-5-
type extended-spectrum beta-lactamases. Antimicrob
Ag Chemother 1998; 42: 514–520.
15. Grzesiowski P, Trzciński K, Bober K et al.
Usefulness of molecular methods in epidemiology of
hospital outbreak caused by Serratia marcescens in
pediatric ICU. Ped Pol 1998; 72: 369–376.
16. Leι ski T., Gniadkowski M, Skoczyńska A, Stefaniuk
E, Trzciński K, Hryniewicz W, Outbreak of
mupirocin-resistant Staphylococci in a hospital War-
saw, Poland, due to plasmid transmission and clonal
spread of several strains J Clin Microbiol 1999; 37:
2781–2788.
17. Palucha A, Mikiewicz B, Hryniewicz W, Gniadkowki
M. Concurrent outbreaks of extended-spectrum lac-
tamase-producing organisms of the family
Enterobacteriaceae in a Warsaw hospital.
J Antimicrob Chemother 1999; 44: 489–499.
18. Hryniewicz W, Szczypa K, Bronk M, Samet A,
Hellmann A, Trzciński K. First report of van-
comycin-resistant Enterococcus faecium isolated in
Poland. Clin Microbiol Infection 1999; 5: 503–505.
19. Fiett J, Palucha A, Maczyńska B et al. A novel com-
plex mutant ␤-lactamase,  TEM-68, identified in a
Klebsiella pneumoniae isolate from an outbreak of
extended-spectrum ␤-lactamase-producing klebsiel-
lae. Antimicrob Ag Chemother 2000; 44: 1499–1505.
20. Kawalec M, Gniadkowski M, Hryniewicz W.
Outbreak of vancomycin-resistant enterococci in a
hospital in Gdańsk, Poland, due to horizontal trans-
fer of different Tnl546-like transposon variants and
clonal spread of several strains. J Clin Microbiol
2000; 38: 3317–3322.
21. Mlynarczyk G, Mlynarczyk A, Luczak M,
Jeljaszewicz J. Sensitivity to vancomycin and
teicoplanin of coagulase-negative Staphylococci iso-
lated from clinical specimens. Med Dosw Mikrobiol
1999; 51: 17–23.
22. Samet A, Bronk M, Hellmann A, Kur J. Isolation
and epidemiological study of vancomycin-resistant
Enterococcus faecium from patients of a haematologi-
cal unit in Poland. J Hosp Infect. 1999; 41: 137–43.