1. 1 HEALTH CARE ASSOCIATED INFECTIONS BY DR SABA M MANSOOR
GUIDED BY DR HEMANT KUMAR Department of Community Medicine,AJIMS
&RC , Mangalore
2. 1. INTRODUCTION 2. HISTORY 3. DEFINITION 4. MAGNITUDE OFTHE
PROBLEM 5. EPIDEMIOLOGICAL FACTORS 6. PREVENTION AND CONTROL OF
HAIS 7. SURVEILLANCE 8. HAICC 9. UPDATE ON NEWERTECHNOLOGIES 10.
SUMMARY 11. CONCLUSION 2
3. 3 The very first requirement in a hospital is that it should
do the sick no harm (Nightingale F 1859).
4. INTRODUCTION 4
5. Health Care-Associated Infections (HCAI) were earlier known
as Noso- comial infections and the term was derived from Greek
words nosus meaning disease and komeion meaning to take care of
HEALTH CARE-ASSOCIATED INFECTIONS (HCAI) 5
6. Contd Health Care-Associated Infections (HCAI) are acquired
during hospital care which are not present or incubating at the
time of hospital admission. HAI are a significant cause of
increased morbidity and mortality in hospitalized patients. In
addition, HAI lead to prolonged hospital stay, are inconvenient for
the patients, and constitute huge economic burden on health care
system. 6
7. Studies have shown that HAI prevalence varies from 3.8% to
19.6% depending on the population surveyed with a pooled global
prevalence of 10.1%. At any given time, out of every 100
hospitalized patients, 7 in developed and 10 in developing
countries will acquire at least one health care- associated
infection. The fight against HCAI as a public health priority was
promoted through the World Health Organization's 'Clean Care is
Safer Care' campaign. Source: BMC Proceedings 2011,Volume 5 Suppl
6http://www.biomedcentral.com 7
8. HCAIs are multi-factorial, which are related to healthcare
systems and procedures as well as behavioral practices. Although
eradication of HAI is impossible, a well- conducted prospective
surveillance is the gold standard and may significantly reduce HAI
and associated costs. However, this approach requires comprehensive
resources and well coordinated prevention programs. 8
9. HISTORICAL PERSPECTIVES OF HOSPITAL ACQUIRED INFECTIONS
9
10. 10
11. Hippocrates made the relatively profound statement Primum
non nocere that is If you wish to become a physician, always follow
the maxim, first do no harm. Nearer to the present day, Florence
Nightingale paraphrased Hippocrates words with the phrase It may
seem a strange principle to enunciate as the very first requirement
in a hospital that it should do the sick no harm. (Nightingale F
1859) 11
http://www.apiindia.org/pdf/medicine_update_2012/infectious
disease_14.pdf
12. In 1854, during the Crimean War she demonstrated that
hygiene could make a difference. She demonstrated that cleaning up
the military hospital with fresh linens, rat poisons and
scrubbrushed floors would result in a reduction of the combat
wounded death rates from 40% to 2% in a matter of six months.
12http://www.apiindia.org/pdf/medicine_update_2012/infectious_disease_14.pdf
13. Contd.. At the same time Joseph Lister, a British Surgeon
also demonstrated that limb amputations became infected 47% of the
time before hand washing and carbolic acid antisepsis, and only 15%
of the time after this ritual was introduced. 13
14. HAI INTHE 20TH 21ST CENTURY The present era of healthcare-
associated infections (HAI) started with the Center for Disease
Control and Prevention (CDC) in the USA. It started the National
Noso-comial Infection Surveillance System (NNIS) in 1950s and the
SENIC project in 1974. It was observed that one-third of
healthcare- associated infections were preventable through
effective infection control . Many guidelines were produced by
Healthcare Infection Control Practices Advisory Committee (HICPAC).
14http://www.apiindia.org/pdf/medicine_update_2012/infectious_disease_14.pdf
15. Since 2005, various member countries of the world have
signed the pledge of WHOs First Global Patient Safety Challenge.
Introducing low- cost measures, such as hand hygiene, staff
education and inclusion of basic principles of infection control in
medical and paramedical curricula can reduce health care associated
infections. 15
16. DEFINITION 16
17. DEFINITION World Health Organization (WHO) defines HCAI
as:- An infection occurring in a patient during the process of care
in a hospital or other health- care facility which was not present
or incubating at the time of admission. This includes infections
acquired in the hospital, but appearing after discharge, and also
occupational infections among staff of the facility
www.who.int/bulletin/volumes/89/10/11-088179/en/ 17
18. Contd.. These includes infections which are Not present nor
incubating at admission. That appear more than 48 hours after
admission. Those acquired in the hospital but appear after
discharge. Occupational infections among staff as a result of
Needle Stick Injury / exposure to blood & body fluids e.g. HBV,
HCV & HIV. 18
19. The following conditions are not infections Colonization,
which means the presence of microorganisms on skin, on mucous
membranes, in open wounds, or in excretions or secretions but are
not causing adverse clinical signs or symptoms. Inflammation that
results from tissue response to injury or stimulation by
noninfectious agents, such as chemicals. 19
20. MAGNITUDE OF PROBLEM 20
21. DEVELOPED COUNTRIES In developed countries, even with
sophisticated treatments and technologies, HAI continues to account
for complications in 5-10% of admissions to acute-care hospitals.
HCAI pooled prevalence in mixed patient populations in high-income
countries: 7.6%. In the U.S. alone there are at least 80,000
fatalities each year (about 200 deaths/day) from HAI. More than 4
million patients affected by HCAI every year in Europe .
Approximately 30% of ICU patients are affected by at least one
episode of HCAI. (WHO 2013) 21
22. Adults 1-3 3-5 5-10 >10 Number of national and
multicentre studies reporting health care-associated infection in
high-income countries, 1995-2010 Lowest France :4.4% Highest New
Zealand :12.0%Source: Report on the burden of endemic health
care-associated infection worldwide.World Health Organization 2011
22 Neonates and pediatrics 1-3 3-5 5-10 >10
23. DEVELOPING COUNTRIES In low- and middle-income countries
the frequency of ICU-acquired infection is at least 23 fold higher
than in high-income countries; device-associated infection
densities are up to 13 times higher than in the USA. The impact of
HAI is far greater than developed countries, the prevalence studies
report hospital-wide infection rates usually higher than 15%. In
these countries, over 4000 children die of HAI every day.
Approximately half of all patients admitted to neonatal intensive
care units acquire an infection, and over half of them die. 23
Source: Report on the burden of endemic health care-associated
infection worldwide.World Health Organization 2011
24. Number of studies* reporting health care-associated
infection in low- and middle-income countries, 1995-2010 Neonates
and pediatrics 1-3 3-5 5-10 >10 Adults 1-3 3-5 5-10 >10
Source: Report on the burden of endemic health care-associated
infection worldwide.World Health Organization 2011 Lowest Mongolia
: 5.4% Highest Albania : 19.1% 24
25. INDIAN SCENARIO 25
26. INCIDENCE Average Incidence - 10% to 30%, but may be still
higher in ICU Urinary Tract Infection - usually catheter related -
28% Surgical Site Infection or wound infection -19% Pneumonia -17%
Blood Stream infection - 7% to 16% 26
https://www.google.co.in/?gfe_rd=cr&ei=sVdhVbf2LuXH8Afkj4GIDg&gwsr
d=ssl#q=EPIDEMIOLOGY+OF+NOSOCOMIAL+INFECTIONS+(NCI
27. HAI control programme is at a nascent stage in Indian
hospitals, with some yet to establish a central sterilization and
supply department (CSSD) and appoint an infection control team
Suggestions to strengthen the infection control programme is turned
down by the management of most hospitals as spending on infection
control does not generate revenue. 27
28. What is the impact of health care- associated infections?
Annual financial losses due to health care-associated infections
are also significant: they are estimated at approximately 7 billion
in Europe, including direct costs only and reflecting 16 million
extra days of hospital stay, and at about US$ 30 billion in the
USA. In Mexican ICUs, the overall cost of one single health
care-associated infection episode was US$ 12 155. In several ICUs
in Argentina, the overall extra-cost estimates for catheter-related
bloodstream infection and health care-associated pneumonia averaged
US$ 4 888 and US$ 2 255 per case, respectively. 28
http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
29. Contd Antibiotic resistant infections due to Superbugs are
on the rise. One superbug, called MRSA, affecting over 100,000
patients a year, caused the death of more than 18,600 patients in
2010. This number supersedes the death rate for breast cancer,AIDS
and SARS combined.
29http://www.livescience.com/36674-superbugs-drug-resistant-bacteria-infections.html
31. RISK FACTORS FOR HAI Admission as an emergency and to the
intensive care unit (ICU); Hospital stay longer than seven days;
Placement of a central venous catheter, indwelling urinary
catheter, or an endo-tracheal tube; undergoing surgery; Patients on
immuno-suppressants; Neutropenia; a rapidly or ultimately fatal
disease and impaired functional or coma status. 31
32. SETTINGS WITH LIMITED RESOURCES Inadequate environmental
hygienic conditions and waste disposal; poor infrastructure;
insufficient equipment understaffing; overcrowding; poor knowledge
and application of basic infection control measures; lack of
sophisticated procedures; lack of knowledge of injection and blood
transfusion safety; absence of local and national guidelines and
policies. 32
33. EPIDEMIOLOGICAL FACTORS 33
34. There are 3 main factors related to development of HAIs
Host factors Agent factors Environmental factors 34
35. Host Factors Coma HIV infection Malignancies Diabetes
mellitus Severe malnutrition Circulatory impairment Open wound or
trauma Bronchopulmonary disease 35 Advanced age or premature birth
severe burns and certain skin diseases Chronic obstructive
pulmonary disease Immunodeficiency (due to drug, or
irradiation)
36. AGENT FACTORS Infectious agents may be from endogenous or
exogenous sources: Endogenous sources are body sites, such as the
skin, nose, mouth, gastrointestinal (GI) tract, or vagina that are
normally inhabited by microorganisms. Exogenous sources are those
external to the patient, such as patient care personnel, visitors,
patient care equipment, medical devices, or the healthcare
environment. 36
37. Contd.. These may be broadly classified into the following
categories: 1. Conventional:- pathogens that could cause disease in
healthy persons in the absence of any specific immunity to them. 2.
Conditional:- pathogens that could cause disease (other than simple
localized infections) only in persons with lowered resistance to
infection or when implanted directly into tissue or normally
sterile area. 3. Opportunistic:- pathogens that could cause severe
disease only in patients with greatly diminished resistance to
infection 37
http://whqlibdoc.who.int/euro/es/EURO_SERIES_4.pdf
38. COMMON ORGANISMS Urinary tract infection: E. coli,
enterococci, and P. aeruginosa. Surgical wound infection: S.
aureus, enterococci and coagulase-negative staphylococci.
Bloodstream: coagulase-negative staphylococci, S. aureus,
enterococci, E. coli, and Candida spp. Lower respiratory tract
infection: S. aureus. P. aeruginosa and Enterobacter spp. 38
39. Contd.. Among patients in the intensive care unit (ICU) the
commonest pathogens were: P. aeruginosa (124%). S. aureus (123%).
coagulase-negative staphylococci (102%). Candida spp. (101%).
Enterobacter spp. and enterococci (86% each).
39www.ncbi.nlm.nih.gov NCBI Literature PubMed Central (PMC)
40. Contd.. There is the possibility of HAI transmission of
many viruses, including: The hepatitis B and C viruses
(transfusions, dialysis, injections, endoscopy). Respiratory
syncytial virus (RSV), rotavirus, and enteroviruses (transmitted by
hand-to-mouth contact and via the faecal-oral route). Other viruses
such as cytomegalovirus, HIV, Ebola, influenza viruses, herpes
simplex virus, and varicella- zoster virus, may also be
transmitted. 40
41. COMMON SITES OF INFECTION 41www.ncbi.nlm.nih.gov NCBI
Literature PubMed Central (PMC)
42. Reservoir Definition: Place in which an infectious agent
can survive but may or may not multiply Common reservoirs: humans
animals equipment/fomites 42
43. 43
44. Portal of Exit The path by which an infectious agent leaves
the reservoir Respiratory tract Genitourinary tract
Gastrointestinal tract Skin/mucous membrane Blood Transplacental
44
45. Portal of Entry The path by which an infectious agent
enters the susceptible host Respiratory tract GU tract GI tract
Skin/mucous membrane Parenteral Transplacental 45
46. MODES OFTRANSMISSION There are five main modes of
transmission Contact Vector borne Air borne Droplet Common vehicle
46
47. Contact Transmission Direct contact person-to-person
spread, actual physical contact Indirect contact contact with
contaminated intermediate object 47
48. Vector-borne Transmission 48 Vectors are small organisms
such as mosquitoes or ticks that can carry pathogens from person to
person and place to place. Diseases like Malaria, Dengue, Lymphatic
Filariasis, Kala-azar, Japanese Encephalitis and Chikungunya are
widely prevalent in India and can be transmitted in poor hospital
settings .
49. Airborne Transmission Droplet nuclei, dust particles or
skin containing microorganisms are transmitted to a susceptible
host by air currents 49 TB or not TB?
50. CommonVehicle Transmission Microorganisms are transmitted
to susceptible hosts from common items: Food Water Medications
Devices/equipment 50
51. MAJOR TYPES OF HAIS The four most common HAIs are :-
Catheter-associated urinary tract infection (CAUTI)
Ventilator-associated pneumonia (VAP) Surgical site infection (SSI)
Catheter related bloodstream infection (CR-BSI) Each of these is
associated with an invasive medical device or invasive procedure
51
52. URINARYTRACT INFECTIONS Urinary tract infections (UTIs) are
commonest followed by SSI and pneumonia UTIs account for more than
15% of infections reported by acute care hospitals. Virtually all
healthcare-associated UTIs are caused by instrumentation of the
urinary tract. CAUTI can lead to such complications as cystitis,
pyelonephritis, gram-negative bacteremia, prostatitis,
epididymitis, and orchitis in males and, less commonly,
endocarditis, vertebral osteomyelitis, septic
arthritis,endophthalmitis, and meningitis in all patients. 52
53. SURGICAL SITE INFECTIONS SSIs were the most common
healthcare- associated infection, accounting for 10-13% of all HAIs
among hospitalized patients. with a mortality rate of 3%, and 75%
of SSI- associated deaths are directly attributable to the SSIs.
While advances have been made in infection control practices,
including improved operating room ventilation, sterilization
methods, barriers, surgical technique, and availability of
antimicrobial prophylaxis, SSIs remain a substantial cause of
morbidity, prolonged hospitalization, and death.
53www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
54. PNEUMONIA Health care associated pneumonias are the second
most common type of HAIs, second only to UTIs. They are associated
with a high rate of mortality and morbidity. Patients with
mechanically-assisted ventilation have a high risk of developing
healthcare-associated pneumonia. Most commonly caused by
acinetobacter.
54www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
55. BACTERAEMIA Primary bloodstream infection (BSI) is a
leading, infectious complication among critically ill patients. It
represents about 6-9 % of all HAIs and affects approximately 1% of
all hospitalized patients. The impact on patient outcome is
tremendous; BSI increases the mortality rate, prolongs patient stay
in an intensive care unit (ICU) and in the hospital and generates
substantial extra costs. 55
56. PROBLEMS OF NOSOCOMIAL INFECTIONS HAIs cause :- Increased
suffering Prolonged hospital stay Increase the cost of care
significantly Increased morbidity and Mortality. Extra financial
burden on Health system 56
57. PREVENTION OF HAIs 57
58. GOALS FOR INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY There
are three principal goals for HAI control and prevention programs:
1. Protect the patients 2. Protect the health care workers,
visitors, and others in the healthcare environment. 3. Accomplish
the previous two goals in a cost effective and cost efficient
manner, whenever possible. . 58
59. GENERAL MEASURES 59
60. Contd.. Assess the need for isolation.Screen all intensive
care unit (ICU) patients for the following: Neutropenia and
immunological disorder Diarrhea Skin rashes Known communicable
disease Known carriers of an epidemic strain of bacterium. 60
ISOLATION www.ijccm.org/article.asp?issn=0972-5229;year=2014;
61. IDENTIFY THETYPE OF ISOLATION NEEDED. There are two types
of isolation in the ICU Protective isolation for neutropenic or
other immunocompromised patients to reduce the chances of acquiring
opportunistic infections Source isolation of colonized or infected
patients to minimize potential transmission to other patients or
staff. 61
62. FOLLOW STANDARD PRECAUTIONS Standard precautions include
prudent preventive measures to be used at all times, regardless of
a patient's infection status:- Gloves Sterile gloves should be worn
after hand hygiene procedure while touching mucous membrane and
non-intact skin and performing sterile procedures e.g. arterial,
central line and Foley catheter insertion 62
63. Contd.. Clean, non-sterile gloves are safe for touching
blood, other body fluids, contaminated items and any other
potentially infectious materials Change gloves between tasks and
procedures in the same patient especially when moving from a
contaminated body area to a clean body area. Never wear the same
pair of gloves for the care of more than one patient . Remove
gloves after caring for a patient Practice hand hygiene whenever
gloves are removed. 63
64. GOWN Wear a gown to prevent soiling of clothing and skin
during procedures that are likely to generate splashes of blood,
body fluids, secretions or excretions. The sterile gown is required
only for aseptic procedures and for the rest, a clean, non- sterile
gown is sufficient . Remove the soiled gown as soon as possible,
with care to avoid contamination. 64
65. MASK, EYE PROTECTION/FACE SHIELD Wear a mask and adequate
eye protection (eyeglasses are not enough), or a face shield to
protect mucous membranes of the eyes, nose and mouth during
procedures and patient care activities that are likely to generate
splashes/sprays of blood and body fluids, etc. Patients, relatives
and health care workers (HCWs) presenting with respiratory symptoms
should also use masks (e.g. cough) Shoe and head coverings are not
required in routine care . 65
66. PATIENT-CARE EQUIPMENT Used patient-care equipment soiled
with blood, body fluids, secretions, or excretions should be
handled carefully to prevent skin and mucous membrane exposures,
contamination of clothing and transfer of microorganisms to HCWs,
other patients or the environment . Ensure that reusable equipment
is not used for the care of another patient until it has been
cleaned and sterilized appropriately . Ensure that single use items
and sharps are discarded properly 66
67. Utmost care should be taken in following services:- 1.
House keeping 2. Dietary services 3. Linen and laundry 4. Central
sterile supply department 5. Nursing care 6. Waste disposal 7.
Antibiotic policy 8. Hygiene and sanitation 67
68. The 5 pillars of infection control
Isolation&barrierprecautions Decontaminationofequipment
Prudentuseofantibiotics Handwashing Decontaminationofenvironment
68
69. CDC Recommendations to Prevent Healthcare-Associated
Infections 69
70. To Prevent Catheter-Associated UrinaryTract Infections
(CAUTIs:) 70 1. Insert catheters only for appropriate indications
2. Leave catheters in place only as long as needed 3. Ensure that
only properly trained persons insert and maintain catheters 4.
Insert catheters using aseptic technique and sterile equipment
(acute care setting) 5. Follow aseptic insertion, maintain a closed
drainage system 6. Maintain unobstructed urine flow 7. Comply with
CDC hand hygiene recommendations and Standard Precautions
http://www.cdc.gov/HAI/prevent/top-cdc-recs- prevent-hai.html
71. To Prevent Surgical Site Infections (SSIs): 71 Before
surgery 1. Administer antimicrobial prophylaxis in accordance with
evidence-based standards and guidelines 2. Treat remote
infections-whenever possible before elective operations 3. Avoid
hair removal at the operative site unless it will interfere with
the operation; do not use razors 4. Use appropriate antiseptic
agent and technique for skin preparation
72. During Surgery /After Surgery 72 During Surgery Keep OR
doors closed during surgery except as needed for passage of
equipment, personnel, and the patient After Surgery Maintain
immediate postoperative normo thermia Protect primary closure
incisions with sterile dressing Control blood glucose level during
the immediate post-operative period (cardiac) Discontinue
antibiotics according to evidence- based standards and
guidelines
73. To Prevent Central Line-Associated Bloodstream Infections
(CLABSIs) Outside ICUs: 73 1. Remove unnecessary central lines 2.
Follow proper insertion practices 3. Facilitate proper insertion
practices 4. Comply with CDC hand hygiene recommendations 5. Use
appropriate agent for skin antisepsis 6. Choose proper central line
insertion sites 7. Perform adequate hub/access port disinfection 8.
Provide staff education on central line maintenance and
insertion
74. To Prevent Clostridium difficile Infections (CDI) 74 1.
Contact Precautions for duration of diarrhea 2. Comply with CDC
hand hygiene recommendations 3. Adequate cleaning and disinfection
of equipment and environment 4. Laboratory-based alert system for
immediate notification of positive test results 5. Educate about C.
diff infection: healthcare personnel, housekeeping, administration,
patients, families
75. To Prevent MRSA Infections 75 1. Comply with CDC hand
hygiene recommendations 2. Implement Contact Precautions for MRSA
colonized and infected patients 3. Recognize previously MRSA
colonized and infected patients 4. Rapidly report MRSA lab results
5. Provide MRSA education for healthcare providers. Active
surveillance testing screening of patients to detect colonization
even if no evidence of infection Other novel strategies
Decolonization Chlorhexidine bathing
76. 76 WHOS RESPONSE WHO Patient Safety is actively working
towards establishing effective ways of improving global health care
and save lives lost to health care-associated infections. Within
WHO Patient Safety, the Clean Care is Safer Care programme is aimed
at reducing health care-associated infections globally and works in
collaboration with other WHO programmes, and has placed improving
hand hygiene practices at the core of achieving this. by assisting
with the assessment, planning, and implementation of infection
prevention and control policies, and timely actions at national and
institutional levels.
77. 77
78. Hand Hygiene Hands are the most common vehicle to transmit
health care- associated pathogens Transmission of health
care-associated pathogens from one patient to another via
health-care workers hands requires 5 sequential steps
79. 5 stages of hand transmission Germs present on patient skin
and immediate environment surfaces Germ transfer onto health-care
workers hands Germs survive on hands for several minutes Suboptimal
or omitted hand cleansing results in hands remaining contaminated
Contaminated hands transmit germs via direct contact with patient
or patients immediate environment one two three four five 79
80. The My 5 Moments for Hand Hygiene approach 80
www.who.int/gpsc/5may/background/5moments/
81. To effectively reduce the growth of germs on hands,
handrubbing must be performed by following all of the illustrated
steps. This takes only 2030 seconds! EIGHT STEPS FOR HANDWASH
81www.who.int/gpsc/5may/How_To_HandWash
82. How to handwash To effectively reduce the growth of germs
on hands, handwashing must last 4060 secs and should be performed
by following all of the illustrated steps 82
83. Hand hygiene and glove use The use of gloves does not
replace the need to clean your hands! You should remove gloves to
perform hand hygiene, when an indication occurs while wearing
gloves You should wear gloves only when indicated (see the Pyramid
in the Hand Hygiene Why, How and When Brochure and in the Glove Use
Information Leaflet) otherwise they become a major risk for germ
transmission 83
84. Compliance with hand hygiene Compliance with hand hygiene
differs across facilities and countries, but is globally
