HOSPITAL INFECTION EPIDEMIOLOGICAL CONCEPTS AND INDICATORS Ms. Prof.

Carlos Alberto da Silva e Souza INTERACTION OF MICROORGANISMS - HOST Infectious agent in sufficient numbers INFECTIOUS PROCESS ACCESS ROUTE TO HOST PORT OF ENTRY susceptible host ANY MICROORGANISMS CAN CAUSE DISEASE, SINCE THERE FOR TRANSMISSION VIA, entrance door and a susceptible host. MEETING OF THE AGENT WITH THE HOST SPECIFIC RECEPTORS FIXING MICROORGANISMS RECEIVERS ARE LIMITED IN NUMBER OF MICROORGANISMS FOR A SAME KIND. MEETING OF THE AGENT WITH THE HOST OCCUPIED AFTER THE RECEIVERS, host colonization by other microorganisms can be g iven only in three situations: • RELEASE • AMENDMENT OF THE EVEN DUE TO USE DE POR ANTIMICROBIAL; receptors causes CERTAIN MEDICAL CONDITIONS; • COLONY FORMATION O F MIXED BY ACCESSION OF ANOTHER microorganisms by ADHESINS MEMBER OF glycocalyx of the microorganism. MEETING OF THE AGENT WITH THE HOST The TO MICROORGANISMS IN CONTACT WITH THE HOST EPITHELIAL CELLS CAN: • NOT to fi x them FOR LACK OF RECEIVERS, BEING REMOVED • • EASILY, WHAT HAPPENS IN MOST CAS ES, fix it and be colonized without SIGNALS INFECTION fix it, BE STARTED coloniz ers and destroyed, that infectious processes, Depending on conditions of the host, the infectious agent and the environment.

CONCEPTS AND DIAGNOSTIC CRITERIA POLLUTION SETTLEMENT INFECTION (DISEASE)

CONCEPTS AND DIAGNOSTIC CRITERIA COMMUNITY INFECTION: Having ascertained or incubation period at time of admiss ion, provided they do not related to previous hospitalization; Associated comp lication or extension of infection already present on admission, provided there is no exchange of microorganisms; In the RN, transplacentally acquired form; In the RN associates ruptured membranes for more than 24 hours. CONCEPTS AND DIAGNOSTIC CRITERIA HOSPITAL INFECTION (infectious complication): Acquired after admission the pat ient and that manifests itself during hospitalization or after discharge, while it may be related to hospitalization or invasive procedures. Every infection i s acquired after 72 hours of hospitalization, the when know the period incubation microorganism. Those raised before 72 hours of admission, since it relates to diagnostic or therapeutic procedures performed during this period. FACTORS THAT INTERFERE IN RATES OF HOSPITAL INFECTION Severely ill patients, •, • AVAILABILITY invasive techniques; • METHODOLOGY OF D ATA COLLECTION; • DEGREE OF ACTION AND UPDATE HICC; • TECHNICAL QUALITY AND LEVE L OF COMMITMENT TO HEALTH TEAM; • UNDERSTAND THAT HOSPITAL HYGIENE Hand hygiene, PROCESSING AND CLEANING ENVIRONMENTAL ARTICLES. Community Infection • Infection detected or incubated in patient hospitalization, since unrelated to a previous admission in the same hospital. • They are also considered guideline s: - Associated infection complication or extension of infection already present at admission - infection in a patient from another hospital, unless there is an ex change of germ or strong indication of acquiring new infection. - Congenital inf ection in newborn - infection in infants born to mothers with ruptured membranes for more than 24 hours. Infection • Infection acquired after admission or even after discharge, while it may be re lated to hospitalization or hospital procedures. • hospital are also considered: - Infection manifested after 72 hours of admission, when they do not know the in cubation period of the germ or not there is clinical evidence and / or laborator y evidence of infection at admission. - Infection manifest 72 hours before admis sion, when associated diagnostic procedures and / or treatment undertaken after admission. Infection - Infection arising in the same location where community infection was diagnosed when a germ is isolated and there is worsening of different clinical conditions . - Infection in the newborn, with the exception of congenital and mother with r

uptured membranes. Surveillance of Hospital Infections • Hospital: • passive method 'Data obtained from the mains HICC' retrospective, depends on the notification, subject to limitations. • ICU, Neonatology, Oncology, Neurology • method NNISS - active search »Daily prospective" allows comparisons between sectors with the same severity sc ore 'evaluates length of stay, procedures, and their relationship to infection' patient day 'SVD-day€Catheter-days, Resp-day Indicators for hospital infection control, • Rate of patients with nosocomial infection • Rate of hospital infection • noso comial infection rate by wards or sectors • The rate of nosocomial infections by topographies • Rate of hospital infection by invasive procedures • Death rate f or hospital infection • Case fatality rate by hospital infection • Is there any procedure in which cutting of skin or mucous membranes and for wh ich the patient is taken to the surgical ward. • Excludes: • • • • • myelogram endoscopy bronchoscopy drainage venous thoracic dissection Surgeries • Includes: • orthopedic procedures performed in minor surgery • surgery performed at the Su rgical Center with patient discharge the same day. Types of Surgery • Surgery clean: performed in sterile tissue or easily decontaminated in the absence of local sup puration. with the presence of bacterial decontamination difficult or impossible in the absence of local suppuration. • Surgery is not clean: Made in tissue • Surgery held in any court in the presence of local suppuration. infected: Antibiotic prophylaxis in surgery: • Its objective is to reduce surgical wound infection; • Recommended single dose at induction of anesthesia, repeat only if surgery lasts more than two half liv es of the drug. • Used Intravenous • In most cases using the Cefazolin, which ha s a half life of 1.5 h, and must be repeated if the surgery lasts more than thre e hours. LIST OF PROBLEMS • Not washing hands. • Do not use gloves for venipuncture procedure or patient c are with secretions. • Do not reporting accidents with organic secretion. • Powe r wards for health professionals. • Not washing hands after removing gloves. • P icking up pens and charts using gloves. • Do not fill the form of the HICC. • Do not fill in all fields of prescription antibiotics and requests for examination s. TREATMENT OF HOSPITAL INFECTIONS

TREATMENT OF HOSPITAL INFECTIONS Treatment of Hospital Infection is facing many challenges within the health inst itutions: • the terms of implementation and evaluation of antibiotic • the issue of inform ation on infectious agents, • correct use of antimicrobials. TREATMENT OF HOSPITAL INFECTIONS Hand washing: a simple thing but undervalued. Hand washing with soap and water is one of the more simple and more effective in the prevention and control of Hospital Infections. Causes of Emergence and Spread of Antimicrobial Resistance dissemination of resistant strains or patient-patient transmission Inconsisten t application of basic measures and control techniques by health professionals ( handwashing, gloves, etc..) Units, particularly intensive care, overcrowded and understaffed Environmental contamination Patients colonized with multidrug-resis tant bacteria (VRE) Causes of Emergence and Spread of Antimicrobial Resistance Selection of resistant strains, resistance becomes more prevalent → doctor a nxious will rely only on antibiotics more potent and broader spectrum of action to prevent and treat Increasing numbers of critically ill patients and immunoc ompromised "Overinterpretation" the implications of colonization colonization • upper respiratory tract by multiresistant gram-negative bacteria in intubated patients Selective pressure The use of antimicrobials leads to: • Elimination of sensitive pathogens and recolonization by strains / species res istant - no empty ecological • "Induction" Gens inducible resistance • Resista nce to cephalosporins of third. generation Gene Mutation - The chance of selec ting resistant mutants will be greater: • The larger the inoculum (bacterial pne umonia, abscesses) • The closer the MIC is the concentration of atb. Molecular typing of multidrug-resistant strains Allow assessment of the mode of spread of resistance and direct control measures to be imposed Strains with molecular profile or pattern of identical or similar clones resista nce ↓ ↓ Dissemination Implementation of measures for barrier Large genetic variation among strains resistant ↓ independent selection of resis tance by selective pressure ↓ Reassessment of policy for antimicrobial use TREATMENT OF HOSPITAL INFECTIONS The bacterial ability to resist antibiotics is more agile than the human capacit y to develop new antibiotics. Investigation of Outbreaks of Infection and Implementation of Control Measures Objectives • Recognition, investigation and control of outbreaks of hospital infection • Re view steps in conducting an investigation of hospital outbreak • Discuss impleme ntation of control measures in a real situation and its impact

Steps Research Hospital Outbreak Preliminary Investigation and Research Studies descriptive and definitive compar ative studies

Steps Research Hospital Outbreak Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the laboratory store samples / strains of suspected cases Curve Listing and epidemic cases To establish th e existence of an outbreak Implement and evaluate control measures, emergency Steps Research Hospital Outbreak Final research and comparative studies Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct additional studies as necessary: - Observational - Surveys - Experimental Im plement control measures communicate the results Steps Research Hospital Outbreak Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the laboratory store samples / strains of suspected cases Curve Listing and epidemic cases To establish th e existence of an outbreak Implement and evaluate control measures, emergency Steps in Outbreak Investigation Hopital Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the lab to save the samples / strains of suspected cases Curve Listing and epidemic cases To establish the existence of an outbreak Implement and evaluate control measures, emergency Hospital A USA state on the West Coast Center global reference for bone marrow transpla ntation (BMT) BMT ~ 400's by 60 beds for years Regime transplant hospitali zation and outpatient ~ 150 BMT patients in outpatients Request Information laboratory tests? that had been done? Microorganisms isolated? The characteristics of cases

Existing Information ICS per gram negative Pseudomonas spp. Strenotrophomonas spp. bacter spp.

Klebsiella spp.

E.

coli Entero

More frequent in patients from outpatient All patients with central access c atheters Use of venous access devices without needle started in July 1998

Patients Bone Marrow Transplantation • More susceptible to infections • Prolonged treatment • Recent changes in BMT - High early hospital - outpatient - intermittent hospitalization if necessary of infusion therapy at home Venous Access Devices for No-Needle • Used to access intravenous systems without needles • Reduces accidents piercin g-cutting in health care • USA • Widely used in combination with ICS Reports • I mpact of these devices in patient safety? Steps in Outbreak Investigation Hopital Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the lab to save the samples / strains of suspected cases Curve Listing and epidemic cases To establish the existence of an outbreak Implement and evaluate control measures, emergency Confirmation of diagnosis • Clinical - Review medical notes - review and discussion with patients • • Surveillance Laboratory - - - - Identify misdiagnosis Review laboratory methodology change in the type o r routine? Request the laboratory to keep strains Steps in Outbreak Investigation Hopital Descriptive studies and preliminary investigation Review existing information Determine nature,€location and severity of the pro blem to confirm the diagnosis Establish a case definition (time / place / pe rson) Identify and quantify cases request the lab to save the samples / stra ins of suspected cases epidemic curve and listing cases Establish the existe nce of an outbreak Implement and evaluate control measures, emergency Identifying and Counting Cases Case definition • • • • • • Simple and easy to Include time, place and person or refined Compreh ensive Amendment as Applied unbiased research progress in all investigated crite ria include clinical or laboratory Definitions Case Definition CDC definition for primary bloodstream infection (BSI) ICS primary gram-nega tive BMT patients in outpatient settings, with central access catheter during th e epidemic period Epidemic period August 1 - 30 October 1998 Steps Research Hospital Outbreak Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the lab to save the samples / strains of suspected cases Curve Listing and epidemic cases To establish the existence of an outbreak Implement and evaluate control measures, emergency

Information Sources Identify and Quantify Cases • Systematic • Several sources Laboratory registration record HICC Nursing records (ICU, surgical center, etc.) Worksheets dept. billing / costs of hospital admission records Steps Research Hospital Outbreak Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the lab to save the samples / strains of suspected cases Curve Listing and epidemic cases To establish the existence of an outbreak Implement and evaluate control measures, emergency Investigation of Outbreaks organize data by time • epidemic curve (histogram) Simple Number of cases by early symptoms of the outbreak nds Allows inferences about the incubation periods Distribution of Patients with ICS by Gram-negative BMT outpatient clinic, The Hospital in January - October 1998 No. of cases 12 13 Use of device 6 3 1 JAN FEB MAR APR April 3 April 3 2 MAI JUN JUL AGO SET OUT 1998 Steps Research Hospital Outbreak Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the lab to save the samples / strains of suspected cases Curve Listing and epidemic cases To establish the existence of an outbreak Implement and evaluate control measures, emergency Establish the Existence of an Outbreak • Determine the number of cases observed • Determine expected number of cases • To calculate incidence rates of BSI in the periods pre-epidemic and epidemic • D emonstrate that there was an increase in the incidence of ICS in the epidemic pe riod than expected Establish the Existence of an Outbreak • Incidence of ICS in the pre-epidemic (January 1 - July 31, 1998) 0.7 / 1,000 catheter-days

Magnitude and tre

• Incidence of ICS in the epidemic period (August 1 - 30 Outubro1998) 2.1 / 1,000 catheter-days • Increased incidence of ICS than expected in the epidemic period RR = 3.17 (p-value <0.001) Rate ICS by Gram-negative Patients Undergoing BMT outpatient, Hospital In January - October 1998 outbreak 3 2.5 2 1.5 1 0.5 0 F air M ai ja n Ju l br / 98 Ju n Fe v ut TO GO A If t rates of BSI / 1,000 catheter-days p-value <0.001 Steps Research Hospital Outbreak Descriptive studies and preliminary investigation Review existing information Determine the nature, location and severity of the problem Confirm the diagnosis Establishing a case definition (time / place / person) Identify and quantify cases request the lab to save the samples / strains of suspected cases Curve Listing and epidemic cases To establish the existence of an outbreak Implement and evaluate control measures, emergency Descriptive Epidemiology Examination of patients evaluated Features age sex mortality clinical complications such conduct medication received BMT pr esence of other invasive procedures Descriptive Data • 31 episodes of primary BSI in 29 patients 10 (32%) polymicrobial 20 (64%) symptomatic (48%) lost the central access catheter

21 (67%) admitted by ICS

13

• 52 bacterial strains isolated from blood cultures • All episodes were identifi ed in patients with venous access devices without needle Bodies Identified Other Gram-positive Staphylococcus (7.7%), coagulase negative (11.5%) Enterobacteria (38.5%) Gram negative hydrophilic (42.3%) Steps Research Hospital Outbreak Final research and comparative studies Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct additional studies as necessary: - Observational - Surveys - Experimental Im plement control measures communicate the results Steps Research Hospital Outbreak Final research and comparative studies

Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct additional studies as necessary: - Observational - Surveys - Experimental Im plement control measures communicate the results Formulating and Testing Hypotheses • Objective: • Explain the problem should address the source of the outbreak and mode of transmission • Hypothesis must be consistent with observed facts and sc ientific knowledge • Analytic Studies - Comparative Studies - If control - Cohort Hypothesis • ICS polymicrobial with a predominance of gram-negative organisms hydrophilic B MT Patients • outpatient • Patients with central catheter (Hickman), receiving h ome infusion therapy • All cases with venous access devices without needle Exposure to tap water? Steps Research Hospital Outbreak Final research and comparative studies Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct additional studies as necessary: - Observational - Surveys - Experimental Im plement control measures communicate the results Investigation of Outbreaks Testing Hypotheses Table Matrix: 2x2 B patients exposed to Healthy Total Total non-exposed C D Epidemiology Analytical Methods • Rates of ICS before and after the introduction of venous access devices withou t needle • Case-control I - Initial analysis of risk factors • case-control II Detailed analysis of exposure to water and care of the catheter at home Analytic Studies Case-Control I • 31 cases, 31 controls • Potential risk factors evaluated demographic characteristics of transplant immunosuppression days of catheter man ipulation access central venous access medications outpatient visits / admission s • Result: Average number of manipulation of venous access (24 h pre-ICS) 11.3 fo r cases / 9.3 for controls - not significant • Telephone interviews • 17 cases, 34 controls • detailed evaluation of risk fac tors - Exposure to water Analytic Studies Case-Control II tap water / ice / bath / swimming other - Care of the catheter wash hands / protection areas catheter infusion PVC / use filter frequency of ex change of the device

Results • Cases were more manipulation of venous access (24 h pre-ICS) that controls - Average of 11.3 for cases - Average of 9.3 for the controls - Not Meaningful • Hypothesis of exposure to water and manipulation of the catheter at home as a risk factor Risk Factors for ICS Categorical variables, number n = 17 Cases Self-IV infusion tub baths (only) Continuous variables, mean number of showers / week 4.8 Number of exchanges of device / week 2.0 6.3 2.4 0.01 0.01 13 3 Contro ls n = 34 April 14 OR 6.8 3.4 p-value <0.01 NS Risk Factors for ICS Multivariate Analysis Variables Self Yes No Minor IV infusion frequency of exchange of devices once a week> sinc e a number of baths (bath) per week Odds Ratio 6.2 Ref p-value 0016 Ref 15.2 1.4 0028 12:05 Conclusions Venous access devices without needle Temporal association with increased rates of ICS Infection control practices regarding the use of these devices Risk factors for ICS Showering habits Associated with increased risk for development of ICS Steps Research Hospital Outbreak Final research and comparative studies Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct additional studies as necessary: - Observational - Surveys - Experimental Im plement control measures communicate the results Laboratory studies • Crops - Solution "flushing" pre-prepared - Hickman catheters - devices for vascular ac cess without needle • Studies of biofilms - Hickman catheters - devices for vascular access without needle Steps Research Hospital Outbreak Final research and comparative studies Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct

additional studies as necessary: - Observational - Surveys - Experimental plement control measures communicate the results

Im

Practice Note • Handling • Placement of catheters and catheter exchange for access and central venous access devices without needle • Training of patients regarding the handl ing of the catheter and infusion pump • Practice at home and frequency of flushi ng • Preparation and administration of IV medication • Use in the clinic to prot ect the catheter exit Steps Research Hospital Outbreak Final research and comparative studies Reviewing medical records of Formulating hypothesis Test hypothesis in compa rative studies (case-control or cohort) Conduct laboratory studies Conduct a dditional studies as necessary: - Observational - Surveys - Experimental Imple ment control measures and evaluate impact Communicate results Initial Implementation of Control Measures • Exchange systematic device at least two times a week and every time there is b lood collection catheter • Standardize a method to protect the catheter tip duri ng the bath / shower • Encourage showers instead of tub baths • Material didacti c for patients should include risks associated with exposure to water, showering habits and frequency of exchange of devices • education classes for patients an d their home caregivers mandatory Rate ICS by Gram-negative Patients Undergoing BMT outpatient, Hospital A January 1998 - March 1999 outbreak rates of BSI / 1,000 catheter-days interventions 3 2.5 2 1.5 1 0.5 0 ja n / Fe v M 1998 The air br M ai Ju n Ju l If you go t the ut N ov D ez ja n / v Fe 99 M air Control Measures - Institutional Program for the Prevention of ICS • systematic and regular education of patients and caregivers • Replacing the de vice two times a week Impact Assessment - Institutional Program for the Prevention of ICS • Fall in rates of ICS / catheters days - Health professionals - patients - home caregivers Impact of the Institutional Program for the Prevention of ICS • Incidence of ICS in the pre-epidemic (January 1 - July 31, 1998) 0.7 / 1,000 catheter-days • Incidence of ICS in the post-epidemic (01 November 1998 - December 31, 1999) 0.35 / 1,000 catheter-days RR = 0.41 (p-value <0.01) Rate ICS by Gram-negative Patients Undergoing BMT

outpatient, Hospital A January 1998 - December 1999 interventions rates of BSI / 1,000 catheter-days 3 2.5 2 1.5 1 0.5 0 M ai M ai air F air M n Ju l ja / ja 98 n / 99 Ju l If t If t ov ov NN Steps in Outbreak Investigation Hopital Final research and comparative studies Reviewing medical records of Formulate hypothesis hypothesis testing in comp arative studies (case-control or cohort) Conduct laboratory studies Conduct additional studies as necessary: - Observational - Surveys - Experimental Im plement control measures communicate the results Public Health Implications • Control of epidemics with high morbidity and mortality • Use of preventive mea sures that are efficient, easy and cheap • Reference Guideline for Prevention of Opportunistic Infections in Patients Undergoing Stem-Cell Transplantation (MMWR , 20 Oct 2000)