NOSOCOMIAL INFECTIONS

& ITS CONTROL STRATEGIES.

Mentored by:Prof. Sumitra Pattnaik.Presented by:Dr. Subraham Pany.

Nosocomial infection or Healthcare-associated infections

(HAI)"nosus" = disease

"komeion" = to take care of

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 & also occupational infections among staff of the facility.

DEFINITION (WHO):

THE FOLLOWING INFECTIONS ARE

NOT CONSIDERED HAI: * Infections associated with complications or extensions of infections already present on admission, unless a change in pathogen or

symptoms strongly suggests the acquisition of a new infection

* Infections in infants that have been acquired transplacentally (e.g., TORCH, or syphilis) and become evident within 48 hours after birth

* Reactivation of a latent infection (e.g., herpes zoster, herpes simplex, syphilis, or tuberculosis).

THE HISTORY OF HAI’S Hippocrates made the relatively profound statement “Primum non nocere”

that - If you wish to become a physician, always follow the maxim, first do no harm.

It is obviously the case that modern medicine bears little resemblance to that practiced two millennia ago, but the maxim clearly still applies.

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”.

In the context of this dissertation her words were particularly poignant as she was referring to the infections that were rife in her hospital due to the sanitary arrangements.

THE HISTORY OF HAI’S (CONTD. …)

In Europe, Dr Ignaz Semmelweis, 1861 realized that it was hospital staff who were largely responsible for the dreadful death toll of puerperal fever in the maternity units that he was responsible for. His seminal observation was that puerperal fever claimed the lives of 25% of the mothers who delivered in hospital but only 5% of those who delivered at home. (Playfair, 1847). By a complex series of exclusion experiments he was able to discover that by getting the hospital staff to wash their hands between seeing the patients he reduced the death rate by a staggering 96%.

THE HISTORY OF HAI’S (CONTD. …)

HAI IN THE 20TH – 21ST CENTURY

The present era of healthcare- associated infections (HAI) started with the CDC in the USA. It started the National Nosocomial 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 and prevention .

Many guidelines were produced by Healthcare Infection Control Practices Advisory Committee (HICPAC).In 2005, hospitals started contributing data to National Healthcare Safety Network. There are many current Quality Initiatives.Agency for Healthcare Research and Quality (AHRQ) promotes patient safety; improve quality of healthcare & Evidence-based Practice Centres.

HAI IN THE 20TH – 21ST CENTURY (CONTD. ..)

Since 2005, various member countries of the world have signed the pledge of WHO’s 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.

HAI IN THE 20TH – 21ST CENTURY (CONTD. ..)

EPIDEMIOLOGICAL INTERACTION

HOST FACTORS Suppressed immune system due to Age, Poor nutritional status, severity of underlying disease, complicated diagnostic & therapeutic procedure , therapeutic,

THE AGENTVarieties of organismsInstitutional and human Reservoirs & their virulence

THE ENVIRNOMNETEverything that surrounds the patient in the hospital is his environment.Other patientsHospital staff and visitorsEatablesDust and other contaminated articles

NCI

MAGNITUDE OF HAIS Both developed and resource-poor countries are faced with the burden of healthcare-associated infections. In a World Health Organization (WHO) cooperative study (55 hospitals in 14 countries), about 8.7% of hospitalized patients had nosocomial infections.

Overall, 1.4 million people worldwide are suffering from nosocomial infections, & in India alone, the nosocomial infection rate is at over 25-30%.

About 25-36% of these infections are preventable through the adherence to strict guidelines by health care workers when caring for patients.Prolonged stay not only increases direct costs to patients or payers but also indirect costs due to lost work. The increased use of drugs, the need for isolation & the use of additional laboratory & diagnostic studies also contribute to costs.

MAGNITUDE OF HAIS (CONT.…)

A 6-year surveillance study from 2002-2007 involving intensive care units (ICUs) in Latin America, Asia, Africa, and Europe, revealed higher rates of central-line associated blood stream infections (BSI), ventilator associated pneumonias (VAP), and catheter-associated urinary tract infections (CAUTIS) than those of comparable United States ICUs.

MAGNITUDE OF HAIS (CONT.…)

The estimated rate in USA was 4.5% in 2002CDC prevalence of 7.1% in European countries.MOHFW – India is unable to report the burden. In addition the limited number of studies in these settings has been published in the scientific literatureConsolidated data on device associated infection from India has been published as a part of the INICC study (Annals of Internal Medicine 2006). All the hospitals were private, corporate hospitals, and fails to reflect the actual scenario.

MAGNITUDE OF HAIS (CONT.…)

EXOGENOUS INFECTION SITES

THE INANIMATE ENVIRONMENT CAN FACILITATE TRANSMISSION

VirusesBacteriaFungiParasites

ALL MICROORGANISMS CAN CAUSE NOSOCOMIAL INFECTIONS

Gram +veStaphylococcus aureusStaphylococcus epidermidis

Gram -veEnterobacteriaceae Pseudomonas aeruginosaAcinetobacter baumanniMycobacterium tuberculosis

BACTERIA

Pseudomonasaeruginosa

Enterococcus

Coag-neg staphylococcl

E-coli

Staphylococcus aureus

Other

COMMON BACTERIAL AGENTS

(9%)

(10%)

(11%)(12%)

(13%)

(45%)

Viruses• Blood borne infections : HBV, HCV, HIV

• Others: rubella, varicella, SARS

Fungi• Candida • Aspergillus

Urinary tract infections (UTI)Surgical wound infections (SWI)Lower respiratory infectionsTraumatic wounds and burns infectionsPrimary bacteremiaGastrointestinal tract Central nervous system

TYPES OF INFECTIONS

MAJOR TYPES OF NOSOCOMIAL INFECTIONS

0

5

10

15

20

25

30

35

Overall ICU

UTIPneumoniaSWIBloodstreamOther

MODE OF TRANSMISSIONContact/hand borne (most

common)

Aerial route or air borne Oral route

Parenteral route

Vector borne

Direct (physical contact) Hands & clothing Droplet contact followed by

autoinoculation Clinical equipment

Indirect via contaminated articles

Bedpans, bowls, jugs, Instruments like needles, dressings, contaminated gloves, etc.

1.CONTACT (MOST COMMON)

2. Airborne Transmission Droplet respiratory secretions on surfaces Inhalation of infectious particles

e.g. (TB, Varicella)

3. Oral route

4. Parenteral route

5. Vector borne: through mosquitoes, flies, rats.

PATHOGENS TRANSMISSION

COMMON SITES OF INFECTION

COMMON INFECTIONS

Following are the most common nosocomial infections: * Urinary tract infection

* Catheter associated infection

* Pneumonia

* Blood stream infections

PROBLEMS OF NOSOCOMIAL INFECTIONS

Nosocomial infections will become more important as public health problems as it causes,

* Nosocomial suffering

* Prolonged hospital stay

* Increase the cost of care significantly

SURGICAL SITE INFECTIONS

* They are frequent

* The definition is mainly clinical (purulent discharge around wounds or the insertion site of drain, or spreading cellulites from wounds)

* The infections can be exogenously or endogenously

NOSOCOMIAL PNEUMONIA

The most important are patients on ventilators in ICU.

Recent and progressive radiological opacities of the pulmonary parenchyma, purulent sputum and recent onsite fever.

Most commonly caused by acino bacter.

NOSOCOMIAL BACTERAEMIA

The incidence is increasing particularly for certain organisms such as multi resistance coagulase negative staphylococcus and candida.

Infections may occurs at the skin entry site of the IV device or in the sub cutaneous path of catheter.

URINARY TRACT INFECTIONS

It is the most common cause of nosocomial infections

80% of the infections are associated with indwelling catheters.

PREVENTION AND CONTROL Prevention and control of nosocomial infections can be done by the following ways:

ISOLATION Designed to prevent transmission of microorganisms by common routes in hospitals. Because agent and host factors are more difficult to control, interruption of transfer of microorganisms is directed primarily at transmission.

Sterilization Sterilization of all reusable equipment's such as

ventilator,

humidifier and

any device that come in contact with the respiratory tract.

The hands are the most important

vehicle of transmission of Nosocomial Infections

Why Don’t Staff Wash

their Hands? ? ?? ??

WHY NOT? Skin irritation Inaccessible hand washing facilities Wearing gloves Too busy Lack of appropriate staff Being a physician

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

HAND HYGIENE TECHNIQUES

1. Alcohol hand rub

2. Routine hand wash 10-15 seconds

3. Aseptic procedures 1 minute

4. Surgical wash 3-5 minutes

Repeat procedures until hands are clean

ROUTINE HAND WASH

AREAS MOST FREQUENTLY MISSED

HAHS © 1999

HAND CARE Nails

Rings

Hand creams

Cuts & abrasions

“Chapping”

Skin Problems

Hand hygiene is the simplest, most effective measure for preventing hospital-acquired infections.

HOSPITAL INFECTION PREVENTION STRATEGIES

STANDARD PRECAUTIONS Guidelines recommended by the CDC and

Prevention for reducing the risk of

transmission of blood-borne and other

pathogens in hospitals.

OCCUPATIONAL HEALTH PROGRAM

All health care workers should be assessed by an occupational heath team prior to commencing work. This assessment should include: Immunisations- hep B vaccine.screening HCW’s who perform exposure prone procedures for blood borne viruses.

PATIENT PLACEMENT HCW’s should include the potential for transmission of infectious agents in patient placement decisions

Where possible, place patients who contaminate the environment or cannot maintain appropriate hygiene in isolation rooms with en suite toilet facilities etc.

USE OR PERSONAL PROTECTIVE EQUIPMENT

Face protection mask

gloves

Aprons/ gowns

Eye wear

shoes

BARRIER NURSING The aim is to erect a barrier to the passage of infectious pathogenic organisms between the contagious patient & other patients & staff in the hospital, and hence to the outside world.

The nurses, attending consultants as also any visitors must wear gowns, masks, and sometimes rubber gloves and they observe strict rules that minimize the risk of passing on infectious agents.

PREVENTION OF ENVIRONMENT TO PATIENT TRANSMISSION-

ENVIRONMENT DECONTAMINATION Cleaning of hospital environment. This may be achieved by classifying areas into one of four hospital zones-

Zone A: no patient contact. Normal domestic cleaning (e.g. administration, library).

Zone B: care of patients who are not infected, and not highly susceptible. Cleaning with detergent solutions.

Zone C: infected patients (isolation wards). Clean with a detergent/disinfectant solution, with separate cleaning equipment for each room.

Zone D: highly-susceptible patients (protective

isolation) or protected areas such as operating suites, delivery rooms, intensive care units, premature baby units, casualty departments and haemodialysis units.

PATIENT CARE EQUIPMENT & DECONTAMINATION OF MEDICAL

DEVICES: All patient equipments must be thoroughly cleaned prior to use on another patient/resident. They can be disinfected or sterilised as per hospital guidelines.

Disinfection procedures must meet criteria for killing of organisms have a detergent effect act independently of the number of micro-organisms present

MANAGEMENT OF HEALTH CARE RISK WASTE

Ensure safe waste management.Treat waste contaminated with blood, body fluids, secretions and excretions as clinical waste, in accordance with local regulations. Human tissues and laboratory waste that is directly associated with specimen processing should also be treated as clinical waste.Discard single use items properly.

MANAGEMENT OF NEEDLE STICK INJURIES (NSI) AND BLOOD AND BODY FLUID

EXPOSURE: Use care when:Handling needles, scalpels, and other sharp instruments or devices.Cleaning used instruments.Disposing of used needles and other sharp instruments.Follow universal precautions while handling blood and body fluids

SAFE INJECTION PRACTICES All injections should be prepared in a clean area. This area must not be used for disposing of used needles and syringes, handling blood samples, or any material contaminated with blood or body fluids An aseptic technique must be used when drawing up injections Needles, syringes and cannula are sterile, single use items; they must not be reused for another patient.

Use single dose vials wherever possible Do not use single dose vials for multiple patients Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space

SAFE INJECTION PRACTICES (CONT..)

MANAGEMENT FOR PREVENTION OF HIV AFTER NEEDLE STICKS

(POST EXPOSURE PROPHYLAXIS)It is most effective if started 1- 2 hours after exposureCan be given up to 72 hours after exposureShould NEVER be given without medical follow-up and filing an incident report because of the serious side effects, and the need to try to prevent similar injuriesMust be taken for 28 days.Pregnant staff can take PEP drugs.Staff member on PEP should avoid sex or practice safe sex.

RESPIRATORY HYGIENE AND COUGH ETIQUETTE

Persons with respiratory symptoms should use source control measures:Cover their nose and mouth when coughing/sneezing with tissue or mask, dispose of used tissues and masks, and perform hand hygiene after contact with respiratory secretions.

Health-care facilities should:Place acute febrile respiratory symptomatic patients at least 1 metre away from others in common waiting areas, if possible.

Post visual alerts at the entrance to health-care facilities instructing persons with respiratory symptoms to practise respiratory hygiene/cough etiquette.Consider making hand hygiene resources, tissues and masks available in common areas and areas used for the evaluation of patients with respiratory illnesses.

RESPIRATORY HYGIENE AND COUGH ETIQUETTE

(CONT.…)

LAUNDRY CARELaundry should be handled and transported in a manner that prevents transmission of micro-organisms to other patients, or the environment Staff handling soiled linen should wear gloves and a disposable plastic apron.Segregation and transportation of used laundry should be in accordance with the biomedical waste management norms.

ENVIRONMENT

Health services — including public and private hospital services — must meet quality standards (ISO 9000 and ISO 14000 series).An infection control team member should participate on the planning team for any new hospital construction or renovation of existing facilities. The role of infection control in this process is to review and approve construction plans to ensure they meet standards for minimizing nosocomial infections.

SURVEILLANCE

WHY SURVEILLANCE?NCI cause of morbidity and mortalityOne third may be preventableSurveillance = key factor

an infection control measureoverview of the burden and distribution of NCIallocate preventive resources

Surveillance is cost-efficient ! !

OBJECTIVESReducing infection rates

Establishing endemic baseline rates

Identifying outbreaks

Identifying risk factors

Persuading medical

personnel

Evaluate control measures

Satisfying regulators

Document quality of care

Compare hospitals’ NCI rates.

THE SURVEILLANCE LOOP

Event

Action

Data

Information

Health care system

Surveillance centre

Reporting

Feedback, recommendations

Analysis,

interpretation

CONSIDERATIONS WHEN CREATING A SURVEILLANCE

SYSTEMGoal of the surveillance system (why)Engage the stakeholders (who)Available resources

Surveillance method (what, how, when)definitionwhat to collecthow to collect (operation of system)

WHO All hospitals?

All departments?

All specialties?

Other health institutions?

Control of NCI

There are 3 principal goals for hospital infection control & 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.

.

GOALS FOR INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY

The purpose of standard precautions is to break the chain of infection focusing particularly but not exclusively on the mode of transmission, portal of entry and susceptible host sections of the chain.

observance of aseptic technique frequent hand washing especially between

patients careful handling, cleaning, and disinfection of

fomites where possible use of single-use disposable items patient isolation avoidance where possible of medical procedures

that can lead with high probability to nosocomial infection (urinary catheter).

PREVENTION & CONTROL OF NOSOCOMIAL INFECTIONS

Various institutional methods such as air filtration within the hospital.Appropriate isolation precautions to protect patients, visitors and HCWs.Surveillance for common infections, monitoring of high risk patients, and hospital area to identify outbreaks, document incidence and prevalence rate of specific infections and set goal for improvement.

PREVENTION & CONTROL OF NOSOCOMIAL INFECTIONS (CONT.)

UTTERMOST CARE SHOULD BE TAKEN IN FOLLOWING SERVICES:

House keepingDietary servicesLinen and laundryCentral sterile supply departmentNursing careWaste disposalAntibiotic policyHygiene and sanitation

THE 5 PILLARS OF INFECTION CONTROL

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INFECTION CONTROL COMMITTEE

INFECTION CONTROL COMMITTEE (ICC):

The hospital ICC is charged with the responsibility for the planning, evaluation of evidenced-based practice and implementation, prioritization and resource allocation of all matters relating to infection control.

INFECTION CONTROL TEAMInfection Control Nurse

(ICN)Infection Control Doctor (ICD)

INFECTION CONTROL TEAM Should consist of individuals who are specialists in infection control or contributing to it in any way.

public health specialists,

microbiologists,

epidemiologists,

nursing administration &

infection control physicians.

ROLE OF INFECTION CONTROL TEAMS

surveillance and research,developing and assessing policies and practical supervision, evaluation of material and products,control of sterilization and disinfection, Implementation of training programmes. support and participate in research and assessment programmes at the national and international levels

INFECTION CONTROL RESPONSIBILITY

Role of hospital management- LeadershipEstablishing HICCIdentify appropriate resources & apply them for prevention of HAIs

Education and training of staff

Role of the physiciancomplying with the practices approved by the ICC.

notifying cases of HAI.obtaining appropriate microbiological specimens when an infection is present or suspected

Appropriate use of antimicrobials.

Role of microbiologistdeveloping guidelines for appropriate collection, transport, and handling of specimens ensuring laboratory practices meet appropriate standardsperforming antimicrobial susceptibility testing following internationally recognized methods.monitoring sterilization, disinfection and the environment where necessary

Role of the pharmacistdispensing anti-infectious drugs and maintaining records

obtaining and storing and dispensing vaccines or sera,

providing the Antimicrobial Use Committee and Infection

Control Committee with summary reports and trends of

antimicrobial use

having available the information on disinfectants, antiseptics

and other anti-infectious agents

Role of nursing staff- maintaining hygiene, consistent with hospital

policies and good nursing practice on the ward

monitoring aseptic techniques.

reporting infection in patients

limiting patient exposure to infections from

visitors, hospital staff, other patients,

maintaining a safe and adequate supply of

ward patient care supplies.

Role of CSSD-clean,

decontaminate,

test,

prepare for use, sterilize,

and

store aseptically all sterile

hospital equipment.BMW management.

Role of the food service defining the criteria for the purchase of foodstuffs, equipment use, and cleaning procedures

ensuring that the equipment used and all working and storage areas are kept clean

issuing written policies and instructions for handwashing, clothing, staff responsibilities and daily disinfection duties

Role of laundry serviceensuring appropriate flow of linen, separation of “clean” and “dirty” areas

recommending washing conditions (e.g. temperature, duration)

ensuring safety of laundry staff through prevention of exposure to sharps or laundry contaminated with potential pathogens.

INITIATIVES IN INDIA

HOSPITAL INFECTIONS SOCIETY(HIS) The HIS-India (HISI) is an association of medical professionals with a special interest in the prevention & control of hospital infection. It is registered with Registrar of Societies at Delhi.

Founded in 1991, the society presently has 450 members.

Vision- Every Indian hospital has a functioning infection control programme.

Mission statement- HISI provides the essential tools, education materials & communication that unite HISI members and foster development of Hospital Infection Control programmes based on evidence based medicine.

OBJECTIVES:Advance medical knowledge and disseminate information on the subject of Hospital Infections and their prevention

Provide individuals and institutions with information and assistance to form hospital Infection control programmes and similar activities.Gather and disseminate information about Hospital Infections and their prevention in both technical and practical aspects.Hold training courses and educational symposia, seminars on all aspects of Hospital Infections.Form liaison with similar associations at national and international levels.Do all such things as are incidental or conductive to the attainment of the above objectives, or any one of them.

CURRENT CHALLENGES AND

RECOMMENDATIONS FOR THE FUTURE

Indian ICUs show high HAI rates; possible reasons for this include the absence of a legal framework for infection control programs or their implementation, restricted funds, low nurse-to-patient ratios, overcrowded wards and insufficient supplies.Only a small part of the Indian healthcare industry is advanced enough to incorporate effective solutions to prevent HAIs in their setup, the general population having negligible information about the same.

CURENT CHALLENGES

CURRENT CHALLENGES (CONT…)

The Government can be most effective in controlling HAI by implementing mandatory surveillance of HAI for the entire country, updating guidelines for the accreditation of hospitals, and requiring a mandatory presence of infection control teams in hospitals.All hospitals should have software and forms to collate data, which can be analysed by a set of immunologists and statisticians.

There should be separate team of  doctors and nurses to diagnose all of the cases of HAI.Every health care facility should have an antimicrobial use programme.

The goal should be to ensure effective and economical prescribing to minimize the selection of resistant microorganisms.

CURRENT CHALLENGES (CONT…)

This committee should involve in prescribing policies, reviews and approves practice guidelines, audits antibiotic use, oversees education, and interacts with pharmaceutical representatives.As far as the availability of equipment is concerned, India has most of it. But, the need is to properly utilize available resources.

CURRENT CHALLENGES (CONT.…)

CONCLUSIONWe must change the culture of clinical care in India.This will come by mandatory reporting of HAI and it is the consumer who must push for it. Clinicians, health system leaders, payers, purchasers, and above all, patients need to demand care that is proven to be effective as a condition of delivering, paying for, or receiving it. A time has come, when we need to move together, move towards preventive medicine than curative medicine.

REFERENCESCentre for disease control and prevention. Hospital associated infections. http://www.cdc.gov/HAI/prevent/prevention.htmlInternational nosocomial infection control consortium. www.inicc.orgPrevention of hospital-acquired infections: A practical guide. 2nd edition. WHO/CDS/CSR/EPH/2002.12Hospital infection society of India. High prevalence of multidrug-resistant MRSA in a tertiary care hospital of northern India. Hare Krishna Tiwari, Darshan Sapkota, Malaya Ranjan Sen.November 2008, 2008:1 57 – 61.http://www.apiindia.org/pdf/medicine_update_2012/infectious_disease_14.pdfAm J Infect Control. 2010 Mar;38(2):95-104.e2. doi: 10.1016/j.ajic.2009.12.004. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009.

Chemotherapy. 1988;34(6):553-61. Study on the efficacy of nosocomial infection control (SENIC Project): results and implications for the future.

Hughes JM1.

Thank you