Nosocomial Infections

Epidemiology and key concepts

Doc.D-r Mitova
MU-Sofia
 Nosocomial infection:

It is an infection acquired in a medical setting in

the course of medical treatment. It meets
the following criteria:
• 1 - Not found on admission
• 2 – Temporally associated with admission or
a procedure at a health-care facility
• 3 – Was incubating at admission but related
to a previous procedure or admission to
same or other health-care facility.
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 Definition of Nosocomial infection
The use of uniform definition is crucial if data from one hospital
are to be compared with those of another hospital (inter-
hospital) or with an aggregated database (intra-hospital).
NI is a localized or systemic condition:
1- that results from adverse reaction to the presence of an
infectiuos agent(s) or its toxins and
2- that was not present or incubating at the time of admission to
the hospital.
For most bacterial NI, it become evident 48 hours or more (typical
incubation period) after admission. Because the incubation
period varies with type of pathogen, and extent of the
underlying condition, each infection should be assessed
individually for evidence that links it to hospitalization.

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There are two special situations in which an infection is
considered nosocomial:
a) Infection that is aquired in the hospital but does not become
evident until after hospital discharge.
b) Infection in a neonate that results from passage through the
birth canal.
There are two special situations in which an infection is not
considered nosocomial:
a) Infection that is associated with a complication or extension
of infection already present on admission, unless a change in
pathogen or symptoms strongly suggests the acquisition of
new infection.
b) In an infant, an infection that is known or proved to have
been acquired transpalcentally (e.g congenital rubella,
toxoplasmosis) and become evident at or before 48 hours
after birth

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 There are two conditions that are not infections:

1) Colonization, which is the presence of

microorganisms (on skin, mucous
membranes, in open wounds or in
execretions or secretions) that are not
causing clinical signs or symptoms. .
2) Inflammation, which is a condition that
results from tissue response to injury or
stimulation by noninfectious agnets such as
chemicals.
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 Nosocomial infection
It is an important public health problem because
of their frequency, attributable morbidity and
mortality and cost. In the USA and in Europe,
approximately 5–10% of hospitalized patients
develop an infection during their hospital stay.
Higher incidence rates are reported in
hospitals in developing countries.

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 Nosocomial infection
The patient is exposed to a variety of microorganisms
during hospitalization. Many different bacteria,
viruses, fungi and parasites may cause nosocomial
infections. Infections may be caused by a
microorganism acquired from another person in the
hospital (cross-infection) or may be caused by the
patient’s own flora (endogenous infection). Some
organisms may be acquired from an inanimate
object or substances recently contaminated from
another human source.
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 Nosocomial infection
Important patient factors influencing acquisition of
infection include age, immune status, underlying
disease, and diagnostic and therapeutic
interventions. The extremes of life — infancy and
old age — are associated with a decreased
resistance to infection. Patients with chronic
disease such as malignant tumours, leukaemia,
diabetes mellitus, renal failure, or the acquired
immunodeficiency syndrome (AIDS) have an
increased susceptibility to infections with
opportunistic pathogens. Malnutrition is also a risk.

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• Many modern diagnostic and therapeutic
procedures, such as biopsies, endoscopic
examinations, catheterization, intubation/ventilation
and suction and surgical procedures increase the risk
of infection. Contaminated objects or substances
may be introduced directly into tissues or normally
sterile sites such as the urinary tract and the lower
respiratory tract.
Health care settings are an environment where both
infected persons and persons at increased risk of
infection congregate. Patients with infections or
carriers of pathogenic microorganisms admitted to
hospital are potential sources of infection for
patients and staff.
Patients who become infected in the hospital are a
further source of infection. Crowded conditions
within the hospital, frequent transfers of patients
from one unit to another, and concentration of
patients highly susceptible to infection in one area
(e.g. newborn infants, burn patients, intensive the
development of nosocomial infections.
In addition, new infections associated with bacteria
such as waterborne bacteria (atypical mycobacteria)
and/or viruses and parasites continue to be
identified.
• Nosocomial pathogens
Pathogens responsible for nosocomial infections
are bacteria, viruses and fungal parasites. These
microorganisms vary depending upon different
patient populations, medical facilities and even
difference in the environment in which the care
is given.
 Bacteria
• Bacteria are the most common pathogens responsible for nosocomial
infections. Some belong to natural flora of the patient and cause
infection only when the immune system of the patient becomes prone to
infections.
• S. aureus is one of the most common human pathogens, usually
opportunists and capable of causing a wide range of infection in the
immunocompromised
• Methicillin-resistant S. aureus (MRSA) transmit through direct contact,
open wounds and contaminated hands. It is highly resistant towards
antibiotics called beta-lactams .
• The data from European Centre for Disease Prevention and Control
(ECDC) for the countries from the European Union (EU) regarding the
resistance of S. aureus to Methicillin (MRSA) for 2017 shows that
Bulgaria is with 13.7% resistant isolated proportions. The highest relative
weight of MRSA could be found in Roumania – 44.4% and in Malta –
42.1%
 Bacteria
• Enterobacteriaceae
E.coli has been reported to be the most
common nosocomial pathogen. It causes 16% of
the etiologically confirmed cases of NIs in
Bulgaria for the period 2009-2018. Klebsiella
spp. are responsible for 11.82% of the infections
in the Bulgarian hospitals for the period 2009-
2018.
 Bacteria
• Pseudomonas aeruginosa is a nonfermentative Gram-
negative bacteria causing diseases in immunity-hampered
people. It has an extensive role of a pathogen in relation
to nosocomial pneumonia.
• Acinetobacter spp. are gram-negative nonfermentative
bacterias. Their role in the nosocomial pathology in
Bulgaria as well as in the world increases constantly. They
are the cause for 9.94% of the NIs in our country for the
period 2009-2018 and are the fifth most common
pathogen. They are the most frequent causative agent for
pneumonia/LRTIs (24.82% of the cases).
 Bacteria
• Еnterococcus species are the second most significant
gram-positive causes for NIs in Bulgaria and around
the world.
• Their health and social importance is determined by
their frequent resistance to a huge variety of
antibiotics including Vancomycin.
• According to the data of ECDC for the countries of the
EU for 2017, the Vancomycin resistant isolates E.
faecalis in Bulgaria are 2.3% and the Vancomycin
resistant isolates E. faecium are 19%.
 VRE (vancomycin resistant enterococci)
• Enterococcus faecalis and E. faecium
• normal inhabitants of bowel
• can cause infections in seriously ill patients
• enterococci now becoming more resistant to many antibiotics
• this includes vancomycin
• therefore a serious clinical problem
• cross infection via contaminated equipment documented
• Patients with VRE are placed on contact isolation.

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 Viruses
• Besides bacteria, viruses are also an important cause of
nosocomial infection. Usual monitoring revealed that
5% of all the nosocomial infections are because of
viruses .They can be transmitted through respiratory
route and fecal-oral route . Hepatitis is the chronic
disease caused by viruses. Healthcare delivery can
transmit hepatitis viruses to both patients and workers.
Hepatitis B and C are commonly transmitted through
unsafe injection practices. Other viruses include
influenza, HIV, rotavirus, and herpes-simplex virus.
 Fungal parasites
• Fungal parasites act as opportunistic pathogens causing
nosocomial infections in immune-compromised
individuals. Aspergillus spp. can cause infections through
environmental contamination. Candida albicans,
Cryptococcus neoformans are also responsible for infection
during hospital stay. Candida infections arise from patient's
endogenous microflora while Aspergillus infections are
caused by inhalation of fungal spores from contaminated
air during construction or renovation of health care facility.
Bacterial resistance
Many patients receive antimicrobial drugs. Through
selection and exchange of genetic resistance elements,
antibiotics promote the emergence of multidrugresistant
strains of bacteria; microorganisms in the
normal human flora sensitive to the given drug are
suppressed, while resistant strains persist and may
become endemic in the hospital. The widespread use
of antimicrobials for therapy or prophylaxis (including
topical) is the major determinant of resistance.

Antimicrobial agents are, in some cases, becoming

less effective because of resistance. As an antimicrobial
agent becomes widely used, bacteria resistant
to this drug eventually emerge and may spread in
the health care setting. Many strains of pneumococci,
staphylococci, enterococci, and tuberculosis are
currently resistant to most or all antimicrobials which
were once effective. Multiresistant Klebsiella spp. and
Pseudomonas aeruginosa are prevalent in many
hospitals.
Causative agents of nosocomial (health care-associated)
infections in Bulgaria for the period 2009-2018
16
16

14
12.06 11.82
12
10.3
9.94
10 9.05
8.27

6 4.91 5.06
4.39

4 2.94

1.27 1.21 1.19

2 0.74
0.43 0.43

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 Types of nosocomial infections
Nosocomial bacteraemia
These infections represent a small proportion of
nosocomial infections (approximately 5%) but casefatality
rates are high — more than 50% for some
microorganisms. The incidence is increasing, particularly
for certain organisms such as multiresistant
coagulase-negative Staphylococcus and Candida spp.
Infection may occur at the skin entry site of the
intravascular device, or in the subcutaneous path of
the catheter (tunnel infection). Organisms colonizing
the catheter within the vessel may produce
bacteraemia without visible external infection. The
resident or transient cutaneous flora is the source of
infection. The main risk factors are the length of
catheterization
 Types of nosocomial infections
• Central line-associated bloodstream
infections (CLABSI)
CLABSIs are deadly nosocomial infections with
the death incidence rate of 12%–25%. Catheters
are placed in central line to provide fluid and
medicines but prolonged use can cause serious
bloodstream infections resulting in
compromised health and increase in care cost.
 The major risk factor is the Central Venous Catheter
(CVC)

The CVC- is one of the most

commonly used catheters in These serve as
medicine direct line for
microbial
bloodstream
The CVC is typically placed invasion
through a central vein such as
the IJ, Subclavian or Femoral.

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BSIs, Bulgaria, 2009-2018

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• Catheter associated urinary tract infections
(CAUTI)
CAUTI is the most usual type of nosocomial infection
globally. CAUTIs are caused by endogenous native
microflora of the patients. Catheters placed inside serves
as a conduit for entry of bacteria whereas the imperfect
drainage from catheter retains some volume of urine in
the bladder providing stability to bacterial residence.
CAUTI can develop to complications such as, orchitis,
epididymitis and prostatitis in males, and pyelonephritis,
cystitis and meningitis in all patients
UTIs, Bulgaria, 2009-2018

28.80
30.00

25.00

20.00
16.24
15.51

15.00

8.48
10.00 7.22
5.99
5.03
3.04 3.15
5.00 2.53
0.92 1.16 0.97
0.14 0.53 0.30

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• Surgical site infections (SSI)
These are the second most common type of
nosocomial infections mainly caused by
Staphylococcus aureus resulting in prolonged
hospitalization and risk of death. The pathogens
causing SSI arise from endogenous microflora of
the patient. The incidence may be as high as 20%
depending upon procedure and surveillance
criteria used
 Superficial Incisional SSI

Infection occurs within 30

days after the operation
and involves only skin or
subcutaneous tissue Skin
Superficial
of the incision incisional SSI

Subcutaneous
tissue

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

 Deep Incisional SSI
Infection occurs within 30
days after the operation if
no implant is left in place
or within 1 year if implant
is in place and the
infection appears to be Superficial
incisional SSI
related to the operation
and the infection involves
the deep soft tissue (e.g.,
fascia and muscle layers)
Deep soft tissue Deep incisional SSI
(fascia & muscle)

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Organ/Space SSI
Infection occurs within 30 days
after the operation if no implant Superficial
is left in place or within 1 year if incisional SSI
implant is in place and the
infection appears to be related
to the operation and the
infection involves any part of
the anatomy, other than the Deep incisional SSI
incision, which was opened or
manipulated during the
operation

Organ/space Organ/space SSI

 SSIs, Bulgaria, 2009-2018

19.96
% 19.24
20

18

16

14

12 10.1

10 8.65 8.67
7.42
6.97
8
5.68
5.19
6

4 2.35
1.1 1.47
0.57 0.84 0.84 0.95
2

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• Nosocomial pneumonia
Nosocomial pneumonia occurs in several different patient
groups. The most important are patients on ventilators in
intensive care units, where the rate of pneumonia is 3% per
day. There is a high casefatality rate associated with
ventilator-associated pneumonia, although the attributable
risk is difficult to determine because patient comorbidity is
so high. Microorganisms colonize the stomach, upper
airway and bronchi, and cause infection in the lungs
(pneumonia): they are often endogenous (digestive system
or nose and throat), but may be exogenous, often from
contaminated respiratory equipment.
• Ventilator associated pneumonia (VAP)
VAP is nosocomial pneumonia found in 9–27%
of patients on mechanically assisted ventilator. It
usually occurs within 48 h after tracheal
incubation. 86% of nosocomial pneumonia is
associated with ventilation. Fever, leucopenia,
and bronchial sounds are common symptoms of
VAP .
Causative Agents of LRTI /Pneum (%),
Bulgaria (2009-2018)

% 24.82
25

20.06
20

14.53
15

10
7.32
6.3
5.54 5.42

5 3.34 3.23 3.26

2.05 1.82
1.21
0.13 0.48 0.11 0.4

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 Reservoirs and transmission

• Microflora of patient - bacteria belonging to the endogenous

flora of the patient can cause infections if they are transferred to
tissue wound or surgical site. Gram negative bacteria in the
digestive tract cause SSI after abdominal surgery.
• Patient and staff - transmission of pathogens during the
treatment through direct contacts with the patients (hands,
saliva, other body fluids etc.) and by the staff through direct
contact or other environmental sources (water, food, other body
fluids).
 Main routes of transmission
Route Description
Contact transmission The most important and frequent mode of
transmission of nosocomial infections is by
direct contact.
Droplet transmission Transmission occurs when droplets containing
microbes from the infected person are
propelled a short distance through the air and
deposited on the host's body; droplets are
generated from the source person mainly by
coughing, sneezing, and talking, and during
the performance of certain procedures, such as
bronchoscopy.
Airborne transmission Dissemination can be either airborne droplet
nuclei (small-particle residue {5 μm or smaller
in size} of evaporated droplets containing
microorganisms that remain suspended in the
air for long periods of time) or dust particles
containing the infectious agent.
 Prevention of nosocomial infection
Being a significant cause of illness and death, nosocomial infections need to be
prevented from the base line so that their spread can be controlled.
• Infections can be transferred from healthcare staff. It is the duty of healthcare
professionals to take role in infection control. Personal hygiene is necessary
for everyone so staff should maintain it. Hand decontamination is required
with proper hand disinfectants after being in contact with infected patients.
Safe injection practices and sterilized equipments should be used. Use of
masks, gloves, head covers or a proper uniform is essential for healthcare
delivery
• Waste from hospitals can act as a potential reservoir for pathogens that
needs proper handling. Infectious healthcare waste should be stored in the
area with restricted approach. Waste containing high content of heavy metals
and waste from surgeries, infected individuals, contaminated with blood and
sputum and that of diagnostic laboratories must be disposed off separately.
 Control of nosocomial infections
• Healthcare Institutes should devise control programs against
these infections.
• Appropriate antimicrobial use. Antibiotic control policy.
 Hand Hygiene is the single most effective
intervention to reduce the cross transmission
of nosocomial infections

Handwashing
• must be "bacteriologically effective"
• wash hands before any procedure in which gloves and forceps
are necessary
• after contact with infected patient or one colonised with multi-
resistant bacteria
• after touching infective material
• use soap and water (preferably disinfectant soap)

DISINFECTION OF HANDS
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