EPIDEMIOLOGY OF

HEALTHCARE ASSOCIATED INFECTION

(HAI)
BOERHAN HIDAYAT
PERHIMPUNAN PENGENDALIAN INFEKSI (PERDALIN)
CABANG JAWA TIMUR

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 LEARNING OBJECTIVES

1. Describe the epidemiology of healthcare

associated infections (HAI).
2. Summarise how agent, host and
environmental factors affect the occurrence
of HAIs.
3. Outline the types of epidemiologic studies
that can be used in HAI epidemiology.
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Dalin Pradik 2018 02/08/2019 3
 It may seem a strange principle
to enunciate as the very first
requirement of a hospital
that it do the sick no
harm

Patients Safety!
HAI

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 HEALTHCARE - ASSOCIATED INFECTIONS

• Definition
A localised or systemic infection that results from
an adverse reaction to the presence of an
infectious agent(s) or its toxin(s), for which there
is no evidence of infection on admission to a
health care facility
• An infection is frequently considered an HAI if
it appears ≥48 hours after admission
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 The Healthcare System 
More than Just Hospitals

Nosocomial
infection

Acute Care Facility

Home Outpatient/ Health Care

Care Ambulatory
Facility Associated
Tranquil Gardens
Nursing Home
Infection
(HAI)
Long Term Care
Facility
 HOSPITAL ACQUIRED INFECTIONS
(NOSOCOMIAL INFECTION)

 Two types of infections you find in

the hospital
 Hospital-acquired infections
 Community-acquired infections
 How can we distinguish them?
 By latency period
 CDC definition for HAIs:
development of infections after
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48 hours of admission
 EPIDEMIOLOGY

• Study of the dynamic occurrence, distribution,

and determinants of health-related events in
specified populations
• Defines the relationship of a disease to the
population at risk
• Involves the determination, analysis, and
interpretation of rates
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Intervention & Prevention Plan

 HAI SURVEILLANCE

• Systematic, active, on-going observation of

the occurrence and distribution of HAIs and
of the events or conditions that increase the
risk of HAI occurrence

Analysis by Time , Place and Person

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 TYPES OF STUDIES

• Epidemiological studies can be classified as either

observational or experimental
• The most commonly used types of epidemiological
studies are:
• Descriptive study
• Analytic study
• Experimental study

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 EPIDEMILOGIC FACTORS

Host Defens Mech.

• Susceptible
• Unsusceptible

PIC PIC

Agents Environment
• Source PIC • Biological
• Pathogenicity • Non-biological
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• Mode of transmission
• Quantity
 KEY PREVENTION STRATEGIES

 Prevent infection
 Diagnose and treat
infection effectively
 Use antimicrobials
wisely

 Prevent transmission

Clinicians hold the solution!

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CHANGING LANDSCAPE OF HEALTHCARE

 Organizational factors affect HAI prevention

• Administrative policies

• Antimicrobial utilization
• Staffing

• Education

 Increasing prevalence of antimicrobial-resistant

pathogens
 CHANGING LANDSCAPE OF HEALTHCARE
 Growing populations at risk
• Immunocompromised individuals
• Low birthweight, premature neonates
• Transplant recipients on immunosuppressive therapy

 Special environments
• Intensive care and burn units
• Long-term care
• Ambulatory surgery, endoscopy, and infusion services
 CHAIN OF INFECTION
Causative agent

Susceptible host Reservoir

Inoculating dose Portal of exit

Portal of entry Environmental

survival
Mode of transmission
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 CHAIN OF INFECTION

contact

+ Droplet

Airborne

Quantity of Virulence Route of Port

pathogen transmission Sensitive
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host
02/08/2019 16

Isolation Precaution
 TRANSMISSION IN HOSPITAL SETTING

Patients

Hospital
Source of
Environ HCW
ment
Infections

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Devices
 AGENT FACTORS

• An infectious agent can be bacteria, virus, fungus, or parasite

• The majority of HAIs are caused by bacteria or viruses
• Two major types of bacteria that cause HAIs
• Gram-positive cocci (e.g., Staphylococci and Streptococci)
• Gram-negative bacilli (e.g., Acinetobacter, Pseudomonas,
Klebsiella)

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 RESERVOIR

Definition:
• Place in which an infectious agent can survive but may or may not multiply
Common reservoirs:
• humans
• animals
• equipment/fomites

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 SOURCES OF PATHOGENS

• People
• Endogenous: Normal flora or reactivation
• Exogenous: People (staff, visitors) or environment
• Animals
• Arthropods (insects)
• Environment

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 NORMAL SKIN MICRO-FLORA

Numbers of bacteria that colonize different parts of the body

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Numbers per square centimeter of skin surface (cfu/cm2).
ICU Setting: Multiple Sources of Pathogens
 HUMAN RESERVOIRS

Human reservoir: Persons with

acute or subclinical illness

Carriers
• convalescent carriers
• chronic carriers
• intermittent carriers

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 PORTAL OF EXIT

The path by which an infectious

agent leaves the reservoir
• Respiratory tract
• Genitourinary tract
• Gastrointestinal tract
• Skin/mucous membrane
• Blood
• Transplacental
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 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
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 MODE OF TRANSMISSION
Contact transmission
• Direct – organism is transferred directly from one person to
another, e.g. scabies or herpetic whitlow
• Indirect- organism is transferred through contaminated
intermediate object or person, e.g. hands or contaminated
patient care equipment
Droplet Transmission- relatively large ( >5 microns) droplet heavy
with moisture that are propelled relatively short distances from the
source (3-6 feet) onto the mucous membranes of the nose, mouth or
eyes, of the host and environmental surfaces
Airborne Transmission- droplet nuclei (<5 microns) that remain
suspended in the air for long periods, that may be inhaled by the
host into the alveoli of lungs
• Vehicle transmission
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• Vector-borne transmission
 AIRBORNE PRECAUTIONS

• Used for patients with known or suspected diseases transmitted

by airborne droplet nuclei (<5 microns)
• Private room
• Negative air pressure in relation to the corridor
• >6 air exchanges per hour
• Direct discharge of air to the outside
• Personnel: Respiratory protection required
• N-95 respirator
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• Limit transport of patient to essential purposes
 AIRBORNE PRECAUTIONS

Representative pathogens
• M. tuberculosis
• Varicella
• Zoster
• Measles
HCWs required to wear a
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respirator to enter room 02/08/2019 28
 SPECIAL AIRBORNE PRECAUTIONS

• Used for patients with known or suspected diseases transmitted

by airborne droplet nuclei and contact
• Private room (must meet airborne isolation guidelines)
• Personnel: Respiratory protection required
• N-95 respirator
• Eye protection: Shield or goggles
• Gowns and gloves when entering room
• Limit transport of patient to essential purposes
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 SPECIAL AIRBORNE PRECAUTIONS

Representative pathogens
• Avian influenza
• Monkey pox
• SARS Co-V
• Smallpox
• Viral hemorrhagic fever (e.g.,
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Ebola, Lassa) 02/08/2019 30
 Recent classification for airborne transmission

Obligate airborne: initiate solely through aerosols:

TB
Preferential airborne: initiate through multiple
routes but predominately by aerosols: Chicken pox
and measles
Opportunistic airborne: typically through other
routes but by aerosols in favorable conditions (as
high-risk procedures such as intubation): Influenza
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and SARS 02/08/2019 Pradik
2018
 DROPLET PRECAUTIONS

• Large droplets generated by an

infected or colonised person during
coughing, sneezing, talking,
suctioning, etc.
• Droplets propelled a short distance
<3m
• Droplets deposited on a susceptible
host’s eyes, nasal mucosa or mouth
• Private room
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Special air handling not required

• Personnel
 DROPLET PRECAUTIONS

Representative pathogens
• Invasive N. meningitidis
• RSV
• Bordetella pertussis
• Rubella
• Mumps
• Group A streptococcal
pharyngitis
• Influenza
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• Diphtheria
H1NI Precautions
 CONTACT PRECAUTIONS

• Used for pathogens that

can easily be transmitted by
contact with patient and/or items
in the patient’s environment
• Private room
• Gloves and gown when entering room
• Careful hand hygiene
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 COMMON VEHICLE TRANSMISSION

Microorganisms are transmitted to

susceptible hosts from common
items:
• Food
• Water
• Medications
• Devices/equipment
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 VECTOR-BORNE TRANSMISSION

 Transfer of microorganisms by
insects, flies, rats, or other vermin

 Uncommon mode of transmission in

hospitals

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 ENVIRONMENTAL FACTORS

 Healthcare settings are environment where both

infected persons and persons at high risk of infection
congregate.
 Crowded conditions within hospital, frequent transfers of
patients between units.
 Microbial flora may contaminate objects, devices and
materials which subsequently contact susceptible body
sites of patients.
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 Transmission

• Where do HAI come from?

Endogenous infection: When normal patient flora change
to pathogenic bacteria because of change of normal habitat,
damage of skin and inappropriate antibiotic use. About 50%
of N.I. Are caused by this way.
Exogenous cross-infection: Mainly through hands of
healthcare workers, visitors, patients.
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 Exogenous environmental infections: several types
of micro-organisms survive well in the hospital environment
(hospital flora):
* In water, damp areas and occasionally in sterile products or
disinfectants eg pseudomonas, Acinetobacter, Mycobacterium.
* On items such as linen, equipment and supplies
* In food.
* In fine dust and droplet nuclei
Some procedures that save life may increase risk of
infection e.g urinary catheters, I.V.L inhalation therapy,
surgery.
Inappropriate use of antibiotics.

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 WHAT KINDS OF HOSPITAL INFECTIONS EXIT?

• Device-related
• Catheter-associated blood stream infections (CLABSI)
• Catheter-associated urinary tract infections (CAUTI)
• Ventilator-associated pneumonia (VAP)
• Procedure-related
• Surgical site infections (SSI)
• Environmental contamination
• Water, disinfectant, etc.
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 DISTRIBUTION OF HOSPITAL INFECTIONS BY
SITES, SENIC STUDY

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 DISTRIBUTION OF HOSPITAL INFECTIONS BY INFECTION
SITES AND ENDEMIC/OUTBREAK STATUS

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Endemic 02/08/2019 42

Outbreak
 HEALTHCARE-ASSOCIATED URINARY TRACT
INFECTION
• Urinary tract infection (UTI) causes ~ 40% of
hospital-acquired infections

• Most infections due to urinary catheters

• 25% of inpatients are catheterized

• Leads to increased morbidity and costs

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 INDICATIONS FOR THE USE OF
INDWELLING URETHRAL CATHETERS
• Indications
• Perioperative use for selected surgical procedures
• Urine output monitoring in critically ill patients
• Management of acute urinary retention and urinary obstruction
• Assistance in pressure ulcer healing for incontinent residents
• As an exception, at patient request to improve comfort

• Urinary incontinence is not an accepted indication for urinary

catheterization
• 21 to 50 percent of urinary catheters not indicated
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Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50

 PREVENTION OF CATHETER-ASSOCIATED
URINARY TRACT INFECTION (CA-UTI)

Two main principles

Avoid unnecessary catheterization

Limit the duration of catheterization

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 WHY DO WE NEED TO STUDY HOSPITAL
INFECTIONS?

Not all hospital infections are preventable, but they

are associated with
• Excess length of hospital stay
• Excess cost
• Excess mortality
• Law suits
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 WHO ARE AT RISK FOR ACQUIRING HOSPITAL
INFECTIONS?

• Patients in Intensive Care Units

• ICU （medical, surgical, burn, Neonatal ICU、
Pediatric ICU)
• Surgery department
• Immunocompromised patients
• Cancer treatment, transplant, HIV infections
• Other factors
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• Age, smoking, chronic diseases 02/08/2019 47
NOSOCOMIAL PATHOGENS BY INFECTION TYPE

Pneumonia UTI BSI SSI

S. Aureus 19% 2% 16% 20%
Coag (-) staph 2% 4% 31% 14%
Enterococcus 2% 16% 9% 12%
Pseudomonas 17% 11% 3% 8%
Other gram (-) 29% 45% 17% 23%
C. albicans <5% 8% 5% 3%

Jernigan, J. Cecil’s Textbook of Medicine

 Isolation Precaution
ISOLATION PRECAUTIONS ARE USED TO REDUCE
TRANSMISSION OF MICROORGANISMS IN
HEALTHCARE AND RESIDENTIAL SETTINGS.
DESIGNED TO PROTECT PATIENTS/RESIDENTS, STAFF,
AND VISITORS FROM CONTACT WITH INFECTIOUS
AGENTS.

THERE ARE TWO CATEGORIES OF ISOLATION

PRECAUTIONS: STANDARD PRECAUTIONS AND
TRANSMISSION-BASED
49
PRECAUTIONS
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 Standard Precautions
 Prevents contact with blood or other potentially infectious materials.

Hand
Patient hygiene
PPE
placement

Three new elements added to standard precautions (2007)

Patient
Respiratory hygiene/cough etiquette
Transport Standard Routine and
Safe injection practices Terminal
Precautions
Use of masks for insertion of catheters or injection into spinal
Cleaning
or epidural areas
Linen &
laundry Patient care
equipment
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And articles 50

02/08/2019
 TRANSMISSION-BASED PRECAUTIONS -
PATIENT PLACEMENT

• Single patient rooms - always

indicated for patients placed on
airborne precautions and
preferable for those who require
contact of droplet precautions

• Cohort patients with same

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organism 02/08/2019 51
 TRANSMISSION-BASED PRECAUTIONS-
MANAGEMENT OF VISITORS

• Visitors as sources of healthcare associated

infections – e.g., pertussis, influenza,
tuberculosis
• Cough etiquette
• Use of barrier precautions by visitors
• Educate patients and family members
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 NEGATIVE PRESSURE ISOLATION ROOM

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 Infection Control and Quality Healthcare in the New Millenium
Where are we going ?
Multidisciplinary team approach
1. Recognize
1847
2. Explain Healthcare system:
1863
3. Act
1958
-Hospitals
1970
-Ambulatory services
1980 -Nursing homes
1990 -Long-term care facilities
2000 -Home care delivery
systems

International Financing Patient safety

State/country
surveillance bodies promotion
epidemiology
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Pittet & Sax, Infectious Diseases. Cohen textbook (2nd ed.), chap.85, 2004
 ry

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 SUMMARY - 1

• HAIs can cause serious complications and

greatly impact patients, their families, and
health care personnel
• Health care personnel need to understand
the epidemiology of HAIs to prevent them in
their own settings
• Understanding the chain of infection and
epidemiology of HAIs can lead to effective
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prevention and control intervention
 SUMMARY - 2

• The epidemiology of HAIs can explain what

happens to whom, and where and when it
happens
• i.e., the occurrence and distribution of HAIs
• Using evidence-based recommendations can
reduce infection rates
• This information supports effective planning
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HAIs
 THANK YOU

Perhimpunan Pengendalian Infeksi (Perdalin)

Cabang Jawa Timur
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