NOSOCOMIAL INFECTIONS

Dr. MANISHA NAGPAL PG Resident Deptt. Of Community Medicine

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Definition

A Nosocomial Infection also called as Hospital Acquired Infection (HAI) is defined asAn infection acquired in hospital by a patient who was admitted for a reason other than that infection. OR 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. OR This includes infections acquired in the hospital but appearing after discharge, and also occupation infections among staff of the facility.
http://www.who.int/csr

Burden of HAI

At any time over 1.4 million people worldwide suffer from HAI 1.7 million people are affected annually in US Lead to prolonged hospital stay 5-10 infections/100 admissions Cost: $6.7 billion/yr Mortality: 99,000 deaths / year
Wallace/Maxcy-Public health and Preventive Med.
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In India, nosocomial infections contribute: 57% extra hospital days 42% extra cost Incidence of post- operative infections : 10-25% Studies conducted in hospitals in Delhi & Mumbai report figures as high as 30%. If such figures are representative, around 300,000 of the 1 million hospital beds would be occupied by people falling sick from hospital acquired infections.
IJCM 2004.11(1).38-40 national newspaper The Hindu. 21June; 2007
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Epidemiology of Nosocomial Infections

Three elements are needed for transmission of infection in health care:

Source of infection: may be human or environment

Susceptible host: susceptibility influenced by age, nutritional status, co morbidities & severity of underlying disease
Mode of transmission: 3 primary routes- contact (direct or indirect) - respiratory droplet - air-borne
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Factors influencing the development of Nosocomial Infections

The microbial agent: many bacteria, viruses, fungi & parasites cause nosocomial infections. It maybe: - cross-infection: by a microorganism acquired from another person in the hospital. - endogenous infection: by the patients own flora - environmental infection: acquired from an inanimate object or substances recently contaminated from another human source. Patient susceptibility: patient factors include age, immune status, underlying disease & diagnostic and therapeutic interventions.
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Environmental factors: these include crowding,

frequent transfers of patients from one unit to another & concentration of patients highly susceptible to infection in one area e.g. newborn infants, burn pts.,& intensive care.

Bacterial resistance: arises due to the widespread use of

antimicrobials for therapy or prophylaxis . -MRSA (Methicillin resistant S. aureus), first recognized in 1960s, became endemic in many countries in 1990s - Ist clinical isolate of vancomycin-resistant S. aureus (VRSA) was identified in June 2004 & by Feb.2005, two additional cases had been reported in the US.
Wallace/Maxcy-Public health and Preventive Med.
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Common Hospital acquired infections

UTI
BACTERAEMIAS

PNEUMONIAS
POST OPERATIVE WOUND INFECTION

Other infections include burn infections, gastrointestinal, eye infections & HBV/HCV/HIV
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Urinary Tract Infections (UTI)

Most common nosocomial infection 80% infections associated with urinary catheters Typical UTI prolongs hospital stay by an average of 1.2 days Infections are usually defined by microbiological criteriapositive quantitative urine culture (>105 microorganism/ml, with a maximum of 2 isolated microbial species). Common organisms responsible are: E. coli, Candida albicans, Enterococcus spp., pseudomonas aeruginosa, klebsiella pneumonae, staph. aureus.

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Surgical site infections (SSIs)

Second largest category Incidence varies from 0.5-15% depending on the type of operation The impact on hospital costs & post operative length of stay (between 3-20 additional days) is considerable Infection is defined as purulent discharge around the wound or the insertion site of the drain or spreading cellulitis from the wound Guidelines for preventing SSIs have been developed by the Healthcare Infection Control Practices Advisory Committee ( HICPAC)
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Risk of SSIs depend on: - wound classification (clean, clean- contaminated, contaminated or dirty- infected) - physical status of the patient (using the American Society of Anesthesiology score ranging from 1 or healthy to 5 or moribund) - duration of the operative procedure
Common organisms involved are: S.aureus, Enterococcus spp., coagulase negative staph., P. aeruginosa, Enterobacter spp., E. coli & C. albicans
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Nosocomial Pneumonia

Most important are patients on ventilators in intensive care units (ICU), where the rate of pneumonia is 3%/day The infection is defined as: recent & progressive radiological opacities of the pulmonary parenchyma, purulent sputum and recent onset of fever In the US, ventilator- associated pneumonia (VAP) occurs at a mean rate ranging from 4.4-15.4 infections/1000 ventilator days in adult ICU; in pediatric ICUs, the mean rate is lower i.e. 2.9 infections/1000 ventilator days

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Risk factors for VAP include the type & duration of ventilation, quality of respiratory care, severity of patients condition (organ failure) and previous use of antibiotics Apart from VAP, viral bronchiolitis ( respiratory syncytial virus, RSV) is common in childrens unit & influenza and secondary bacterial pneumonia may occur in institutions for the elderly Two pathogens commonly associated with VAP are S. aureus & P. aeruginosa; others less frequent are Enterococcus spp., K. pneumonia, Acinetobactor spp., S.marcescens, C. albicans, E.coli and H.influenzae
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Bloodstream infections (BSI)

Almost one- half of all BSIs are health care associated During 2002-2004 in NNIS hospitals, mean rates of centralline associated BSI ranged from2.7-7.4 infections/ 1000 catheter days Mean cost of a BSI is $35,000 Mortality is high: an estimated 14% of hospital deaths are associated with BSI Infection may occur at the skin entry site of the intravascular device, or in the subcutaneous path of the catheter (tunnel infection) Incidence is increasing for organisms like multiresistent 15 coagulase negative staphylococcus and candida spp.

Other nosocomial infections

Skin & soft tissue infections: ulcers, burns and bedsores encourage bacterial colonization and may lead to systemic infection Gastroenteritis: rotavirus is the chief pathogen in children & Cl. defficile in adults Sinusitis and other enteric infections Infections of eye and conjunctiva Endometritis and other infections of the reproductive organs following childbirth

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Reservoirs of infection

Colonized or infected patients - wound drainage - urine bags - stools - respiratory secretions Health care workers/ visitors - S.aureus: gram positive bacteria that colonize nose & hands

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Ventilating system - External source: fungal spores - Re-circulated air: Aspergillus - Central humidifiers: Legionella
Water: rare source - Ventilator reservoirs: Pseudomonas - Faucets/sinks/flower vases: gram-negative bacilli

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Medical devices - Contamination during manufacturing - Contamination during use

Solutions - Dextrose solutions: Aeromonas hydrophila - Lipids solutions: Malassezia - Disinfectants: Pseudomonas cepacia

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Other health care settings

Long term care facilities: specially for care of elderly pts. having multiple risk factors i.e. age, decrease immunity, co morbidities & decreased functional status (urinary & fecal incontinence or immobility) Outpatient Dialysis Centre: risk factors for dialysis patients are- antimicrobial resistance and vascular access. There is possibility of nosocomial transmission of viruses like hepatitis B & C Home care and other outpatient settings: unsafe injection practices, reuse of syringes and needles and contamination of multiple-dose medication vials have been associated with transmission of infections in out patient settings
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Nosocomial infections in children

Newborn is an immuno compromised host Most common age of onset of nosocomial infection -4th day of neonate NICU-highest proportion of infection Nosocomial infection can occur in both, the well baby clinic and special care nurseries, but incidence is higher in the latter Well baby clinics should be separate from the pediatric OPD where chances of cross-infection & environmental infection are higher
Ind. J of paed;73.2006
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Antimicrobial resistance and emerging infections

Nosocomial infections are often caused by antibiotic resistant organisms Resistant infections are associated with increased mortality, morbidity and cost Prevalence of resistance is highest in US To control resistance guidelines for control of antimicrobial use and appropriate implementation of infection control is necessary

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Nosocomial infection control

Components of hospital infection control policy are:

Infection control committee (ICC) Antibiotic policy Outbreak policy Surveillance Hospital personnel education & immunization Hospital visitor policy Biomedical waste management

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Infection control committee (ICC) Members

Headed by Medical superintendent ICC Chairman- Senior medical Microbiologist ICC coordinator-Physician/Pediatrician ICC surveillant- Staff nurse Head of medicine Head of surgery Head nurse ICU Head nurse of OT Director of nursing House keeping man Head of laundry & food supply department
http://www.who.int/csr
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Functions of ICC

Monthly meeting to formulate & update policy for hospital infection control & to manage outbreaks Continued surveillance of HAI Develop an antibiotic policy System of identifying ,reporting, investigating & controlling Hospital acquired infections Formulate & update patient care policies from time to time Educate health workers on infection control policies Protocols on methods of sterilization & disinfection Guidelines for segregation & disposal of hospital waste
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Antibiotic policy

Choice of antibiotics purely on antimicrobial sensitivity report Trend of resistance in hospital setting should be known. Restricted antibiotic sale Give antibiotic only when required & no antibiotics for viral infections Reconsider the choice of antibiotic & secondary infection, if no clinical response in 72 hrs.

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Hospital visitor policy

Visiting hours to be specified

Visitors allowed only on visitors pass.

Visitors with cough, coryza, fever, sore throat should be discouraged.

Children less than 12 years should not be allowed. Maintenance of quiet environment
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Role of microbiology laboratory

Identify causative organism

Antimicrobial susceptibility testing and reporting Monitor MDR organisms by tabulating data on antimicrobial susceptibility of common isolates. Study trends indicating emerging resistance
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Out break policies

Definition- An increase in the isolation rate of an organism or clustering of clinical cases in the same time frame.
Factors suggesting an outbreak Laboratory report of bacteriology specimen grows an altering organism

Two or more patients are found to have infection by a species not previously documented
Clinicians reports multiple infection of similar nature
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Investigation of an outbreak

An outbreak is an infection control emergency; measures should be taken as soon as an outbreak is suspected. To confirm the existence & diagnosis using microbiological methods. Identify all cases of outbreak Who are at risk Investigate the reservoir of infection, where it exits & means of transmission
Implement measures for control & prevention.
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Surveillance

It is defined as continuous scrutiny of all aspects of occurrence & spread of disease that are pertinent to effective control. Lab record scrutiny by ICC nurse daily To send samples of suspected patients. Identify cross infection & outbreaks Rate of nosocomial infections Periodical tests for potability of water every fortnight & pre & post fumigation swab culture from various site of different OT, ICU, Nursery & Oncology every week along with air sampling

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Hand hygiene
All visitors and staff should wash their hands Before and after any pt contact Before performing any invasive procedures Before the use of multidose vials Before administration of IV fluids or medications After touching the environmental surfaces After removing gloves

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Proper IV Care Practices

Use aseptic techniques & PPE for CVC or guide wire exchange

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Accidental HIV exposures

Needle stick injury wash with soap & water & don't put the pricked finger into mouth.
Splashes to nose, mouth, skin & eyes flush with plenty of water. Report the exposure to appropriate authority. Degree of exposure & HIV status of source forms the basis of starting the post exposure prophylaxis (PEP) Post exposure prophylaxis should be started within few hours preferably within 8hrs. ( Not effective after 72 hrs)
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Conclusions

Optimal infection control practices are essential Good hand hygiene is the simplest most effective way to reduce HAI. One study showed that proper hand washing and other simple procedures can decrease the rate of catheter-related bloodstream infections by 66 percent. Judicious use of antimicrobial agents, with an emphasis on targeted antibiotics and appropriate indications can limit the emergence of MDR organisms
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