HEALTH CARE ASSOCIATED HEALTH CARE ASSOCIATED INFECTIONS AND ITS CONTROLINFECTIONS AND ITS CONTROL

Prof Victor LimProf Victor Lim

International Medical International Medical UniversityUniversity

• DefinitionDefinition

• Any infection acquired by patients or Any infection acquired by patients or members of staff while in a heath care settingmembers of staff while in a heath care setting

• Does not include infections which manifest in Does not include infections which manifest in a health care setting but acquired outside the a health care setting but acquired outside the health care settinghealth care setting

• Includes infections acquired in a health care Includes infections acquired in a health care setting but manifest after dischargesetting but manifest after discharge

HEALTH CARE HEALTH CARE ASSOCIATED INFECTIONASSOCIATED INFECTION

NOSOCOMIAL OR HOSPITAL ACQUIRED INFECTION

• Old term• Nosocomium = Hospital• Increasing day-care and ambulatory

care in modern medical practice• Chronic care facilities, nursing homes• Confining definitions to hospitals only

may not reflect the true situation• Infection control is also important in

non-hospital settings – hence health-care associated infections

History of Nosocomial InfectionHistory of Nosocomial Infection

• Ignaz Semmelweis, (1840s) Ignaz Semmelweis, (1840s) demonstrated importance of hand demonstrated importance of hand hygiene hygiene

• No progress for next centuryNo progress for next century• 1976, the Joint Commission on 1976, the Joint Commission on

Accreditation of Healthcare Accreditation of Healthcare Organizations - standards for infection Organizations - standards for infection controlcontrol

• Nosocomial infection still on the Nosocomial infection still on the increase - emerging infection increase - emerging infection

Reasons for Re-emergenceReasons for Re-emergence

• Antibiotic resistance : HCAI Antibiotic resistance : HCAI becoming more difficult to treatbecoming more difficult to treat

• Increased numbers of vulnerable Increased numbers of vulnerable patientspatients– progress in medical managementprogress in medical management

– increasing day-care & ambulatory careincreasing day-care & ambulatory care

• Failure of staff to comply with Failure of staff to comply with infection control proceduresinfection control procedures

• Virtually all microorganisms can cause Virtually all microorganisms can cause nosocomial infectionsnosocomial infections

• VirusesViruses

• BacteriaBacteria

• FungiFungi

• ParasitesParasites

CAUSES OF HCAICAUSES OF HCAI

• BacteriaBacteria

• Gram +Gram +– Staphylococcus aureusStaphylococcus aureus

– Staphylococcus epidermidisStaphylococcus epidermidis

• Gram -Gram -– Enterobacteriaceae Enterobacteriaceae

– Pseudomonas aeruginosaPseudomonas aeruginosa

– Acinetobacter baumanniAcinetobacter baumanni

• Mycobacterium tuberculosisMycobacterium tuberculosis

BACTERIABACTERIA

• VirusesViruses– Blood borne Blood borne

infections : HBV, infections : HBV, HCV, HIVHCV, HIV

– Others: CMV, rubella, Others: CMV, rubella, varicella, SARSvaricella, SARS

• FungiFungi– Candida Candida

– AspergillusAspergillus

NOSOCOMIAL PATHOGENSNOSOCOMIAL PATHOGENS

SOURCES OF INFECTIONSOURCES OF INFECTION

EndogenousEndogenoussource is the normal flora or source is the normal flora or

colonisers of skin and other colonisers of skin and other epithelial surfacesepithelial surfaces

ExogenousExogenousother persons (cross-infection)other persons (cross-infection)

inanimate objects (fomites)inanimate objects (fomites)

SPREAD OF INFECTONSSPREAD OF INFECTONS

Air-borneAir-borneSkin scales, droplet nucleiSkin scales, droplet nuclei

ContactContactDirectDirect

HandsHands & clothing & clothing

Droplet contact followed by autoinoculationDroplet contact followed by autoinoculation

Clinical equipmentClinical equipment

IndirectIndirect

Bedpans, bowls, jugs, etcBedpans, bowls, jugs, etc

SPREAD OF INFECTONSSPREAD OF INFECTONS

The hands are the most importantvehicle of transmission of HCAI

National NI prevalence rates : Ministry of Health and Teaching Hospitals

0

1

2

3

4

5

6

7

8

03/1 03/2 04/1 04/2 05/1 05/2 06/1

• Common infectionsCommon infections–Urinary tract infectionsUrinary tract infections

–Surgical wound infectionsSurgical wound infections

–Lower respiratory infectionsLower respiratory infections

–Traumatic wounds and burns Traumatic wounds and burns infectionsinfections

–Primary bacteraemiaPrimary bacteraemia

TYPES OF INFECTIONSTYPES OF INFECTIONS

Types of infections : National Surveillance

0102030405060708090

100

03/1 03/2 04/1 04/2 05/1 06/1

OTHER

CS

SSI

BSI

PNE

UTI

Pe

rcen

tag

e

COST OF INFECTIONSCOST OF INFECTIONS

United KingdomUnited Kingdom

115 million pounds (1988)115 million pounds (1988)

United States of AmericaUnited States of America

5 billion dollars (1987)5 billion dollars (1987)

4.5 billion dollars (1995)4.5 billion dollars (1995)

MalaysiaMalaysia

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CONTROL OF HCAI

Hand hygiene is thesingle most importantmeasure for controlof nosocomial infections

TYPES OF HAND HYGIENE PROCEDURES

• Hand washing– Hand washing is usually limited to hands and wrists– Hands are washed for a minimum of 10 – 15 seconds with soap (plain

or antimicrobial) and water– Transient micro-organisms are mechanically removed by rinsing.

• Hand antisepsis/decontamination– Hand antisepsis removes or destroys transient micro-organisms and

confers a prolonged effect. – Two ways:

» Wash hands and forearms with antimicrobial soap and water, for 15-30 seconds

» Decontaminate hands with a waterless, alcohol-based hand gel or hand rub for 15-30 seconds. Appropriate for hands that are not soiled with protein matter or fat.

TYPES OF HAND HYGIENE PROCEDURES

• Surgical hand antisepsis– Removes or destroys transient micro-

organisms and confers a prolonged effect.

– Hands and forearms are washed thoroughly with an antiseptic soap for a minimum of 2-3 minutes.

– Hands are dried using a sterile towel.– Required before performing invasive

procedures.

HAND WASHING TECHNIQUE

Source: World Health Organization. Regional Office for Western Pacific.

COMPOUNDS FOR HAND ANTI-SEPSIS

• Recommended by WHO–2%-4% chlorhexidine,

–5%-7.5% povidone iodine,

–1% triclosan, or

–70% alcoholic hand rubs.

WHO FIRST GLOBAL PATIENT SAFETY CHALLENGE

• Clean care is safer care

• Alcohol-based hand rubs must be available at the point of care

• As effective as washing with soap or antiseptic and water

• More convenient and less time consuming

THE SWISS EXPERIENCE

• A hand hygiene campaign was launched in January 2006, in 116 hospitals nationwide.

• Alcohol-based hand rubs were available at the patient bedside or carried by staff in their pocket.

• Overall hand hygiene compliance increased from 54% to 68% - a 25% boost in patient safety.

• Nurses’ compliance is 72%. Doctors’ compliance showed an increase of 33% to an encouraging 60%

• Prevented 17,000 infections and saved CHF 60 million nationwide.

• Hand rubbing now accounts for up to 97% of all hand hygiene actions in Swiss hospitals

Source : WHOSource : WHO

OTHER MEASURES

• Practise aseptic techniques when performing procedures

• Limit the duration of in-situ catheters (urinary and intravascular) to shortest possible

• Meticulous care of lines, ventilator tubing, catheters and wounds

OTHER MEASURES

• Isolation of infectious patients and immuno-compromised patients

– Source isolation

– Protective isolation

– Use of single rooms with bathroom attached

– Use of positive or negative pressure rooms

• Protect yourself appropriately through good practices and using personal protective equipment (STANDARD PRECAUTIONS)

PRACTISE STANDARD PRECAUTIONS

PROTECT YOURSELF PROTECT YOURSELF THROUGH IMMUNISATIONTHROUGH IMMUNISATION

ImmunisationImmunisationBCGBCG

Hepatitis BHepatitis B

TetanusTetanus

RubellaRubella

VaricellaVaricella

InfluenzaInfluenza

CONCLUSIONS

• Preventing HCAI is a very important aspect of patient safety

• All health care personnel must practise the highest standards of infection control as HCAIs

– Cause significant morbidity and mortality to patients and health care staff

– Contribute to increasing prevalence of antibiotic resistance

– Are difficult and expensive to manage

– Can result in medical litigation