6. Nosocomial_Prof. Hari Kusnanto

8/12/2019 6. Nosocomial_Prof. Hari Kusnanto

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NOSOCOMIAL INFECTION

Hari Kusnanto


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"It may seem a strange principle toenunciate as the very first requirementin a hospital that it should do the sick

no harm"

Florence Nightingale


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Nosocomial infection =

Any infection that is not present orincubating at the time the patient isadmitted to the hospital


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Nos oc om ial in fec t ion :

It is an infection acquired in a medicalsetting in the course of medical care. Itmeets the following criteria:

Not found on admissionTemporally associated with admission or aprocedure at a health-care facilityWas incubating at admission but related to aprevious procedure or admission to same orother health-care facility.


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How hazardous is healthcare?Dr. Lucien Leape Harvard Medical School. USA

Dangerous Regulated Ultrasafe

(>1/1000 ) (< 1/100,000 Total lives

lost peryear

1

10

100

1000

10,000

100,000

1 10 100 1000 10,000 100,000 1M 10M

Bungee jumping

Mountainclimbing

Healthcare

Driving

Chemicalmanufacturing

Chartered

flights

Scheduled airlines European

railroads

Nuclear power

Number of encounters for each fatality


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At any time, over 1.4 million people worldwide are sufferingfrom infections acquired in hospital.Between 5% and 10% of patients admitted to modern

hospitals in the developed world acquire one or moreinfections.The risk of health care-associated infection in developingcountries is 2 to 20 times higher than in developed countries.In some developing countries, the proportion of patientsaffected by a health care acquired infection can exceed 25%.

In the United States, 1 out of every 136 hospital patientsbecomes seriously ill as a result of acquiring an infection inhospital; this is equivalent to 2 million cases and about 80000 deaths a year.In England, more than 100 000 cases of health care-associated infection lead to over 5000 deaths directlyattributed to infection each year.A NZ study of hospital-acquired infectionestimated prevalence rate of 9.5% (Graves 2003)


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History of infection control and hospital epidemiology

Pre 1800: Early efforts at wound prophylaxis

1800-1940: Nightingale, Semmelweis, Lister, Pasteur1940-1960: Antibiotic era begins, Staph. aureus nurseryoutbreaks, hygiene focus1960- 1970s: Documenting need for infection control

programs, surveillance begins1980s: focus on patient care practices, intensive careunits, resistant organisms, HIV1990s: Hospital Epidemiology = Infection control, quality

improvement and economics2000s: ??Healthcare system epidemiology

modified from McGowan, SHEA/CDC/AHA training course


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Opportunities and Problems

Hospitals are complex institutions wherepatients go to have the i r heal th pro blemdiagno sed and t reated

But,

hospitals and medical/surgicalinterventions in t rodu ce r i sks that mayharm a patients health


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Additional morbidityProlonged hospitalizationLong-term physical, developmentaland neurological sequelaeIncreased cost of hospitalizationDeath

Consequences of Nosocomial Infections


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Challenges

Make a hospital safe Prevent harm to the patient and

employees initial focus on infectious diseases increasingly all adverse (harmful) events

are targets

Improve hospital efficiency Eliminate unnecessary costs Eliminate wasteful practices


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Responsibilities of the Infection Control Program

Surveillance of nosocomialinfectionsOutbreak investigationDevelop written policies forisolation of patients

Develop written policies toreduce risk from patientcare practicesCooperation with

occupational healthCooperation with qualityimprovement program

Education of hospitalstaff on infection controlOngoing review of allaseptic, isolation andsanitation techniques

Monitoring of antibioticutilizationMonitoring of antibioticresistant organisms

Eliminate wasteful orunnecessary practices


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Monthly incidence of febrile episodes and associated BSI rates per1000 discharges in the pediatric inpatient units from January to

December 1999

0

100

200

300400

500

600

700

800

J a n

F e b

M a

r c h

A p r i l

M a

y

J u n e

J u l y

A u g u s t

S e p t .

O c t .

N o v .

D e

c .

Month

R a

t e / 1 0 0 0

d i s c

h a r g e

Febrile episodesBSI


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Staphylococcus aureus

Common Many sites esp blood, wounds

Bacteraemia

50% hospital onset 1/3 of community onset are health care related

High mortality in bacteraemia

Pre-antibiotics 82% MSSA median 25% MRSA median 35%


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Blood stream infections: seriousmorbidity

Blood stream infections Renal failure, osteomyelitis, prolonged antibiotic

therapy etc


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Many primary sites for BSI;but IV catheters main site at all major hospitals

Body system(TCH data) 1998 1999 2000 2001 2002 2003 2004 Total

IV Device 109 72 81 54 39 45 42 442

Respiratory 50 36 54 31 41 49 47 308

GIT 47 38 46 43 40 41 59 314

Genito-urinary 43 38 38 43 45 54 70 331

Skin 24 22 22 19 18 27 35 167

Unknown 19 39 32 37 32 28 27 214

Cardiovascular 13 9 10 12 8 19 14 85

Musculo-skeletal 10 14 5 13 12 20 19 93

Haematology 9 17 10 15 16 15 20 102

Maternal 9 4 5 5 6 3 2 34

Neurology 4 13 8 7 6 5 5 48

Other 0 0 2 1 1 1 0 5

Prim Bacteraemia 0 5 7 8 7 9 14 50


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IV catheter infections can be reduced

Too many used

In for too longPoor selection of most appropriate cathetersPoor selection of sites

Almost every doctor inserts them

including CVCs - even if little trainingCVCs used instead of peripheral catheters

for convenience BUT much higher per day risk

W h i t ll t


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We can have an impact on all typesof infections

Surgical site Infection rates can be decreased

Blood stream infections

Especially IV catheterUrinary tractPneumonia

All types If you recognize there is a problem


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QI versus Regulatory Strategies inInfection Control

Regulatory approachExternal organizationsestablish rules andregulations

Data collection forcomparison with outsidestandardsInspections forcompliancePenalties for non-compliance

TQM/QI approachInternal organization ofhospital staff to developgoals and methods

Data collection for internalreviewContinuous efforts toimproveFailure belongs to theentire system, not anindividual


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Organizing for Infection Control

Requires cooperation, understanding andsupport of hospital administration andmedical/surgical/nursing leadership

There is no simple formula: Every hospital is different Every hospitals problems are different Every hospitals personnel are different The hospital must develop its own uniqueprogram


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Changes in Nosocomial Infection Rates inHospitals with or without Effective Programs

Infection site andpatient risk

Hospitals with veryeffective programs

Hospitals withineffective programs

Surgical Wound % %High risk -48.0 +13.8Low risk -23.6 +21.3

Urinary TractHigh risk -35.8 +18.5Low risk -41.6 +30.7

PneumoniaSurgical patients -7.3 +9.3Medical patients -7.7 +10.0

Bloodstream All patients -27.6 +25.5

SENIC Study, CDC


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Essential Components of an EffectiveInfection Control Program (after SENIC)

One full time infection control practitionerper 250 beds optimal ratio may be different

A physician with training and expertise ininfection controlSurveillance and feedback of rates toclinicians

Control activities (interventions, policies,training)


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Personnel Hospital Epidemiologist MD with clinical training Usually part time salaried by the hospital for

infection control duties and part time asinfectious diseases clinician

Training in infection control

Infection Control Practitioner Usually a nurse but can be a microbiologist Has clinical experience before entering infection

control

Full time in infection control, no other clinical oradministrative duties Training in infection control


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Main elements Develop an effective surveillance system Establish policies and regulations to

reduce risks Develop with clinicians (physicians and

nurses) Develop and maintain a program of

continuing education for hospitalpersonnel

Use scientific (epidemiologic) method tostudy problems and test hypotheses


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Additional elements of an effectiveprogram Antibiotic monitoring and control Microbiologic laboratory liaison Antibiotic susceptibility data

dissemination Occupational health

Provide resource to other departmentsfor quality improvement study designand data analysis


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Key elements of surveillance

Defining as precisely as possible theevent to be surveyed (case definition)Collecting the relevant data in asystematic, valid way

Consolidating the data into meaningfularrangementsAnalyzing and interpreting the dataUsing the information to bring aboutchange

adapted from R. Haley


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Infection Control Committee Purpose Advisory

Review ideas from infection control team Review surveillance data

Expert resource Help understand hospital systems and policies

Decision making Review and approve policies and surveillance

plans Policies binding throughout hospital

Education Help disseminate information and influence

others


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Infection Control Committee

Committee Representatives

Hospital Epidemiologist Infection Control Practitioners Administrator

Ward, ICU and Operating room Nurses Medicine/Surgery/Obstetrics/Pediatrics Central Sterilization Hospital Engineer Microbiologist Pharmacist


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Infection Control Committee

Qualifications to be on the committee Interest Represent group in hospital

Experts in their field Diplomatic Good communicators

Resources : Where to get more information or help


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Resources : Where to get more information or help Training Courses Society of Hospital Epidemiologists of America (SHEA) Association of Professionals in Infection Control

(APIC) National courses and congressesBooks Textbooks: Bennett and Brachman - Wenzel - Mayhall APIC Curriculum and Guidelines CDC GuidelinesJournals Infection Control and Hospital Epidemiology Journal of Hospital Infections American Journal of Infection ControlConsulting services National: CDC, Ministry of Health Colleagues


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Risk factors for surgical wound infection

AgeObesityMalnutrition (low albumin)

DiabetesSteroids/immunosuppressionProlonged pre-ophospitalization

Infection at anothersiteProlonged procedure

DrainsUrgency of surgeryForeign bodySkill of surgeon


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Strategies to develop effectivepatient care practices

Team collaborationStaff educationCommunication

Identify problems with polices and procedures


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Identify problems with polices and proceduresExample: Pre- and Post-Operative Care

Skin shaved the nightbefore surgeryInappropriate peri-op

antibiotic prophylaxisInstruments used fordressing changessubmerged disinfectantLarge containers ofantiseptics, no routinefor cleaning and refilling

Eliminate shaving of skinthe night before surgerySingle dose peri-opantibiotic prophylaxisguidelinesUse individual sterile packsof wound care instrumentsUse small containers ofantiseptics; clean and drycontainers before refilling

RecommendationProblem Area


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Methods to reduce cost ofnosocomial infections

Reduce incidenceReduce morbidityShorten hospital stayReduce costs of treating infectionsReduce costs of preventative measuresStop ineffective control measures

Eli i t t


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Eliminate wasteExample: Unnecessary nursing techniques

Dressing change of aseptic woundsDaily dressing change of venous catheterdressingsDaily change of intravenous infusion sets

Preoperative shavingRoutine changing of urinary cathetersTwice daily urinary catheter careProtective gowns except for care of infectedpatients

Daschner, F. J Hosp Infect (1991) 18, 73-78)

Eliminate waste:


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Eliminate waste:Unnecessary microbiologic monitoring

Routine environmental cultures of walls,floors, air, sinks, or other hospital surfacesRoutine cultures of healthcare workers noseand hands

Clinical cultures which are not available toclinicians in time to help with decisionmaking

Also: Failure to generate annual summary ofculture data to provide clinicians with datafor empirical selection of antibiotics

Cultures of Walls Floors and Other Smooth


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Cultures of Walls, Floors and Other SmoothSurfaces: Not Necessary

All hospitals have some bacterial colonization ofenvironmentWhat is the evidence that the environmentdirectly infects the patient?

Hospitalized patients infect the environment Poor technique, poor handwashing, poordisinfection have all been shown to infect thepatients but these are all related to poor practicenot the environment directly

Floors, Walls, Tables, Beds etc. should becleaned properly but not cultured

Prolongation of Hospital Stay due to


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Prolongation of Hospital Stay due toNosocomial Infections in the USA

Infection Site Excess Days

Surgical Wound 6.0

Urinary tract 1.2

Pneumonia 4.0

Bacteremia 7.0

Other sites 4.2 Adapted from Dixon, Ann Int Med 89:749, 1978


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Annual Costs and Benefits of Infection ControlProgram in a Hypothetical 250-bed Hospital

Estimated reduction of directcosts from infectionsprevented

$246,700

Estimated infection controlprogram expenses

$60,000

Hospital savings $186,700

Each $1000 invested in infection controlwill return $3000 in net direct cost savings

Annual Nosocomial Infection Cost Savings by Introducing


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Annual Nosocomial Infection Cost Savings by IntroducingEffective Infection Control Program to a 250-bed Hospital

Infection site Infectionswithout

anyprogram

Infectionswith

effectiveprogram

Infectionsprevented

Averagecost per infection

$

Totalsavings

$

Surgical wound 186 120 66 1944 128,3Urinary tract 283 195 88 318 29,5Respiratory 74 58 16 1540 24,64Bacteremia 34 22 12 2268 15,2Other sites 136 92 44 1113 48,97

TOTAL 713 487 226 $246


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Antibiotic Prophylaxis in Surgery

Potentially an important part of surgical woundinfection preventionMay also be a significant expense for the hospitalWhat is the cost-benefit of prophylactic antibiotics? What is cost of wound infection? In money? In

suffering? How effective is prophylaxis? How much can we spend to prevent a case of wound

infection ?

Cost of Surgical Prophylaxis with Cefonocid


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Cost of Surgical Prophylaxis with Cefonocidin a Boston Teaching Hospital

Assuming $10 per course: $178 to prevent one breast infection $539 to prevent one herniorrhaphy infection

$1,515 to prevent one readmission for breastinfection $622 to prevent one readmission for

herniorrhaphy

From: Platt et al. NEJM 322:153, 1990.

Impact of Cefonocid Prophylaxis


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p p y(per 1,000 patients)

Routine use for breast surgery wouldprevent 56 infections 23 definite wound infections

16 UTIsRoutine use for herniorrhaphy wouldprevent: 19 infections 13 definite wound infections

from: Platt et al. NEJM. 322:153,1990.


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Organization and support

A. Institutional support Infection control as a department Placement in the organization

Authority Personnel Other resources


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B. Infection control committee membership support by the medical staff

participation by other disciplines annual planning



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C. Infection Control Program

quality assessment information for clinicians educational/informational resource surveillance data

outbreak investigation assurance of appropriate asepsis, sterilization,

disinfection minimize risk from invasive procedures/devices

use of isolation occupational health

Therapy


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Therapy

Ideally directed toward organisms detected byculturesEmpiric therapy may have to be given know your hospitals antibiogram

choose drugs that should be -cidal Beta-lactam drugs Cephalosporins Glycopeptides Aminoglycosides

Therapy


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Therapy

Ideally directed toward organisms detected byculturesEmpiric therapy may have to be given know your hospitals antibiogram

choose drugs that should be -cidal Beta-lactam drugs Cephalosporins Glycopeptides Aminoglycosides

h d


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Drugs that treat Pseudomonas

CiprofloxacinCeftazidimeCefepimeTimentinPiperacillin/Tazobactam (Zosyn)Imipenem

Fi l P i


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Final Point

Three day rule: You can treat a patient with broad spectrum antibiotics

for three days, but need to narrow spectrum of antibioticcoverage at three days when culture and susceptibilityresults come back!

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6. Nosocomial_Prof. Hari Kusnanto