Hospital Acquired

HOSPITAL INFECTIONS illustrated Dr.T.V.Rao MD

What are Hospital acquired infections  An infection acquired in hospital by a

patient who was admitted for a reason other than that infection . An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational

Nosocomial Infections  Nosocomial

comes from the Greek word nosokomeion meaning hospital (nosos = disease, komeo = to take care of). This type of infection is also known as a hospital-acquired infection (or more generically healthcare-associated infections).

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Nosocomial Infections on Public Health 

Nosocomial infections are widespread. They are important contributors to morbidity and mortality. They will become even more important as a public health problem with increasing economic and human impact

Crowding a Major Factor 

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Increasing numbers and crowding of people. More frequent impaired immunity (age, illness, treatments). New microorganisms. Increasing bacterial resistance to antibiotics

When the Nosocomial infections manifest  Majority

of such infections become evident during their stay in the Hospital or some times only after their discharge from the patient.

How and When Hospital acquired infections occur.  Nosocomial

infections are infections which are a result of treatment in a hospital or a healthcare service unit, but secondary to the patient's original condition. Infections are considered Nosocomial if they first appear 48 hours or more after hospital admission or within 30 days after discharge.

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Commonly occurring Microorganisms in Hospital Infections

Microorganisms and Nosocomial Infections 

The patient is exposed to a variety of microorganisms during hospitalization. Contact between the patient and a microorganisms does not by itself necessarily result in the development of clinical disease — other factors influence the nature and frequency of

Urinary tract Infections     

Escherichia coli Klebsiella, Serratia,Proteus spp Pseudomonas aeruginosa Enterococcus spp Candida albicans

Respiratory Infections       

Haemophilus influenzae Streptococcus pneumonia Staphylococcus aureus Enterobacteriaceae Respiratory viruses Fungi, Candida spp Aspergillus's spp

Skin sepsis and Wounds       

Staph aureus Streptococcus pyogenes E.coli Proteus spp Anaerobic bacteria Enterococcus spp Coagulase negative Staphylococcus

Gastro Intestinal Infections  Salmonella

serotypes  Clostridium difficile  Norwalk like viruses

Drug Resistance – Nosocomial Infection 

The likelihood of exposure leading to infection depends partly on the characteristics of the microorganisms, including resistance to antimicrobial agents, intrinsic virulence, and amount (inoculum) of infective material.

Pathophysiology  Within

hours of admission, colonies of hospital strains of bacteria develop in the patient's skin, respiratory tract, and genitourinary tract. Risks factors for the invasion of colonizing pathogens can be categorized into 3 areas: iatrogenic, organizational, and patient-related

Iatrogenic risk 

Iatrogenic risk factors include pathogens on the hands of medical personnel, invasive procedures (eg, incubation and extended ventilation, indwelling vascular lines, urine catheterization), and antibiotic use and prophylaxis.

Organizational 

Organizational risk factors include contaminated airconditioning systems, contaminated water systems, and staffing and physical layout of the facility (eg, nurse-to-patient ratio, open beds

Patient associated 

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Patient risk factors include the severity of illness, underlying immunocompromise d state, and length of stay. Prolonged stay in the hospital is a Major contributing factor

Routes of Transmission of Infection 

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A susceptible host and appropriate inoculum of infecting microorganism with an appropriate route of transmission contributed in majority of cases Doctorrao’s ‘e’ learning series

Air – borne route 

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From respiratory tract via talking, coughing, sneezing From the skin by natural shedding of the skin scales during would dressing or bed making. From aerosols from equipment, respiratory apparatus, air-conditioning plants. Doctorrao’s ‘e’ learning series

Contact spread 

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In direct contact spread from person to person By indirect contact spread via contaminated hands or equipment. Clothing of staff, Urinary catheters, contaminated with hands of the operator may introduce organisms, or patients own flora from urethra may contribute to infection. Doctorrao’s ‘e’ learning series

Food borne spread 

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From hospital kitchen, or in special diets, infant feeds, kitchen, or commercial supplies Mechanical vectors flies, cockroaches or insects, or rodents act as carriers of infection. Doctorrao’s ‘e’ learning series

Blood borne spread 

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The accidental transmission of infections as HIV, HBV,and HCV by needle stick injuries is documented Syphilis and malaria a concern in high prevalence areas

Self Infections and Cross infections  

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Lower bowel surgery, Self infection may occur due to flora from nose, Staphylococcus may be introduced into wounds. Cross infection between patients occur due to spread of Staphylococcus or coli forms

Other contributing factors 

Surgeons punctured surgical gloves, or moistened gown, imperfectly sterilized surgical instruments, or by airborne theatre dust. Faulty wound dressings may cause infections.

Patients own flora too infective  Self

infection from patient’s own flora from Bowel can be major contributor of infections in bowel surgery.

Other Source of Hospital Infections 

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Hospital environment, includes defective constructions, People their behaviour has great impact. Objects, food, water, Air in the hospital too contribute to infections.

Cross Infection 

Many different bacteria, viruses, fungi and parasites may cause Nosocomial infections. Infections may be caused by micro organism acquired from another person in the hospital (cross-infection) or may be caused by the patient’s own flora (endogenous infection).

Used/Contaminated Syringes a great threat in Developing world 

Some organisms may be acquired from an inanimate object or substances recently contaminated from another human source (environmental infection).

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Primary Etiological agents causing Hospital Infections 

Nosocomial infections are primarily caused by opportunists , particularly by Staphylococcus aureus Enterococcus spp.

Changing trends in infection etiology 

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With advances in more elaborate surgery and intensive care, with combined use of broad spectrum antibiotics and immunosuppresevive drugs, Gram Negative bacteria increased in importance Pseudomonas aeruginosa gained importance in causing infection in compromised patients. They exhibit natural resistance to antibiotics and antiseptics

Emerging Infectious Agents 

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A group of Microbes that played no role in the past have emerged. 1 Coagulase negative Staphylococci 2 Acinetobacter baumanii

Microbes from Environment 

The dissemination from environment such as cooling towers and hot water system is proving a threat with Legionella pneumophila causing infections of respiratory systems

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Virus too play a Important role 

Awareness on risk of Blood born viruses including Hepatitis B, C and HIV essential CMV virus in association with organ and cellular transmission

Iatrogenic Spread a Concern 

The possible risk of iatrogenic spread of Prions causing Cruetzfeldt-Jacob disease is a concern

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Common sites associated with etiological agents        

Urinary tract Surgical wounds Respiratory tract Skin (especially burns) Blood (bacteraemia) Gastrointestinal tract Central nervous system Doctorrao’s ‘e’ learning series

Collection of Data in Cross Infections 

Always collect information and document information on 1 Patient details 2 Site and extent of infection 3 Date of admission – operative procedure first recognition of infection 4 Specimen and laboratory isolates and typing results 5 Ward and staff details.

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Prevention and Control  The

basic responsibility of any good hospital remain with establishment of good infection control policies, which can always be achieved with 1 An infection control committee 2 An Infection team

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Infection control committee 

Should meet regularly to formulate and update policies for the whole hospital on all matter which have bearing on infection control and to mange outbreaks of Nosocomial infection

Infection Control Team 

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Which will function under the guidance of Infection control Doctor. A Medically qualified Microbiologist, who will take responsibility of day to day for the policies formulated Doctorrao’s ‘e’ learning series

The Functions of the Committee  To

do surveillance and infection monitoring of hygiene practices.  Educate the Medical and Paramedical staff on policies relating to prevention of infection, and safe procedures

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Infection Control Nurse  

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Is the key member of the team Maintain the close working relations between Microbiology Laboratory, different clinical services and supportive services like laundry, pharmacy and engineering Doctorrao’s ‘e’ learning series

All are campaigners of Safe practices 

It is the minimal responsibility of the members to campaign on issues related to safe practices including Hand washing

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Decontamination and Sterilization

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Fundamental importance lies with supply of sterile instruments, dressings and fluids. A availability of single use syringes, needles, catheters and drainage bags to be assured and planned for the regular supplies .

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Aseptic techniques 

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A no touch technique when dealing with sterile equipment coupled with strict personal hygiene. A strict rules laid when dealing the patients in the operation theatre and other procedures such as wound dressing and insertion of IV and urinary catheters.

Cleaning and Disinfection 

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Basic cleaning, waste disposal, and laundry carry priority. The use of chemical disinfectants for wall floors, and furniture is warranted in special circumstances, such as spillages, of body fluids from patients with blood born viral infections Doctorrao’s ‘e’ learning series

Care of Mop Heads and other items 

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All the Mop heads and cloths used in crucial areas should be heat disinfected and stored in dry places after use. Bed pans washers and disinfectants and dishwashers should be monitored to ensure reliable performance

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Skin disinfection and Antiseptics 

Hand washing is a most important procedure which should be practiced by health care worker, gram – ve bacteria on the hands of the staff is an important factor in the spread of hospital infection

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Hand washing 

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Thorough hand washing after any procedure involving nursing care or close contact with the patient is essential. Alchool based hand antiseptics gaining importance where washing with water and soap are not practicable.

Wearing a Glove 

Gloves may be worn for any dirty contact procedure such as emptying a urinary cans, or bed pans, however it should not be forgotten gloved hand may also become colonized by transient hospital flora.

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Disinfection policies 

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All the hospitals should create disinfection policies which suit circumstances and economic resources. The procedures and products should have a limited range of options, and chemicals to be used only in desired circumstances. The policies should take into consideration surgical instruments, heat disinfection, Laundry, crockery and cleaning of floors and furniture Doctorrao’s ‘e’ learning series

Importance of Staff 

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Staff should have well understood responsibilities. Effective implementation of policy requires , motivated staff, with training, Regular updating as new methods become available Doctorrao’s ‘e’ learning series

Prophylactic antibiotics 

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Wide spread and haphazard use of antibiotics hasten emergence of antibiotic resistant bacteria. Rational antibiotic prophylaxis plays an important role in infection control Antibiotic policy limits the use of broad spectrum agents, and is important in both prophylaxis and treatment.

Protective Clothing 

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Different activities within the hospital require different degrees of protection to staff and patients. In operation theatre the wearing of sterile gowns, gloves, head gear and face mask minimizes the shedding of microorganisms.

Barrier Nursing 

Barrier nursing is highly essential when soiling of clothing is anticipated, and dealing with communicable diseases, eg in EBOLA and MARBURG infections.

Other Measures 

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Gloves, face mask, and goggles are indicated in specific procedures. The use of the above should confirm to international standards and the staff should be trained in their proper use and disposal

Isolation in Infectious Diseases 

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Practiced as a source isolation and to protect the susceptible or immunocompromised. It needs a highly disciplined approach by all staff to ensure that none of the barriers to transmission are breached.

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Cubicle Isolation 

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In which patient nursed alone in a room separated by door and corridor from other patients confers a substantial measures of protection. Desirable to supply clean, filtered air is supplied to room with facilities for own toilet and washing facilities

Critical Situations 

In some critical situations such as bone marrow transplant units, where air borne contamination with environmental fungal spores is a problem the efficiency of an air filtration may be increased and laminar airflow maintained as barrier around the patient

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Trexler isolator 

Stringent isolation such as a plastic tent or Trexler isolator, is required only for patients with highly contagious infections.

Hospital building and Design 

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Routine maintenance of the Hospital building is important, ensuring that surfaces wherever possible are smooth, impervious and easy to clean. All constructions around the existsting Hospitals generate fungal spores and bacterial spores with have impact on specialized units serving

Legionnaires’ disease prevention 

The risk of Legionnaires’ disease is reduced by regular flushing all outlets and installing water supplies that circulate below 200c for the cold and above 600c for the hot circuit

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Equipment 

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All the equipment in contact with patients need decontamination and sterilization Heat is a preferred method. However heat sensitive to the sterilized with chemical and other newer emerging methods

Personnel care of Health Care Workers 

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All health care workers should screened for possible communicable diseases before employment, and offered immunization against Hepatitis B Viral infection. An education on Universal Health Precautions is highly essential Doctorrao’s ‘e’ learning series

Needle Stick Injuries 

Who sustain needle stick injuries from potentially contaminated sources should have access to advise and post exposure prophylaxis with antiviral agents or immunization.

Monitoring of the Environment ? 

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Routine Microbiological monitoring of the environment is of little benefit, But monitoring of the Air conditioning plants, and machinery used for disinfection and sterilization is essential series

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Screening of Staff or Patients 

Microbiological screening of staff and patients not undertaken routinely but it may be needed for specific purpose to detect carriers or MRSA and Hepatitis viruses in those performing some types of surgery or where transmission to patients has occurred.

Surveillance and Role of Microbiology Laboratories  The

detection and identification of hospital infection incidents or outbreaks rely on the laboratory data that alert the infection control team to unusual cluster of infection, called as ‘alert organism’ system.

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Surveillance 

Identification of MRSA & ESBL and timely information to clinicians will help the ongoing events in the Hospital warrant to track the events on source of outbreaks and action to control the similar situations in future

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Practical Teaching to Staff 

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Regular visits to wards are also important to record data on infected patients from whom no specimens have been received and to respond to problems as they occur. Such visits will bring in grater human interaction with paramedical staff and deliver the practical teaching.

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Efficacy of Infection control 

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The Following measures will certainly control the infections 1 Sterilization 2 Hand washing 3 Closed drainage systems for urinary catheters. 4 Intravenous catheter care 5 Peri operative antibiotic prophylaxis for contaminated wounds, and care of equipment used in respiratory therapy.

Measures proved to be ineffective 

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Chemical disinfection of floors, walls, and sinks Routine environmental monitoring is losing its concerns.

What is most Important 

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Effective surveillance and action by the infection control team have shown to reduce infection rates. One important role of the team is to monitor compliance and practices known to be

Saving the Costs in prevention if Infections 

With raising economic costs in running safe hospitals eliminate the many rituals or less effective practices that they may even increase the incidence or cost of cross infection.

Created for benefit of Health care workers in the Devloping World Doctorrao’s ‘e’ learning series Dr.T.V.Rao MD Email [email protected]