Hospital acquired (HAI) or Health care -

associated infections (HCAI) or

Nosocomial (NI) infections
 Nosocomial infection: Derived from two Greek words "nosos"
(disease) and "komeion“ (to take care of) . Also known as Hospital-
acquired infection (HAI)
— is an infection that is contracted from the environment or staff of a
healthcare facility.
— Infection is spread to the susceptible patient in the clinical setting
by a number of means, Health care staff can spread infection, in
addition to contaminated equipment, bed linens, or air droplets.
— The infection can originate from another infected patient.
Frequency of Nosocomial Infection (N.I.)
 Nosocomial infections occur worldwide. Every year, between 1.75 and 3
million (5-10%) of the 35 million patients admitted to hospital in US acquire
nosocomial infection. Approximately 88,000 deaths (3-5%) were related to
nosocomial infections In 1995
ü The highest frequencies are in East Mediterranean and South-East Asia.
 A high frequency of N.I. is evidence of poor quality health service delivered.

Impact of Nosocomial Infections

They lead to functional disability and emotional stress to the patient
They are one of the leading causes of death.
The increased economic costs are high:- Increased length of hospital stay (5-
10 days), extra investigations, extra use of drugs and extra health care by
doctors and nurses.
 Organisms causing N.I. can be transmitted to the community through
discharged patients, staff and visitors.
If organisms are multi-resistant they may cause significant disease in the
community.
 Nosocomial Infections Cost
 The cost varies according to the type and severity of these
infections.
 An estimated 1 to 4 extra days for a urinary tract infection,
7 – 8 days for a surgical site infection (SSI), 7 – 21 days for a
blood stream infection, and 7 – 30 days for pneumonia.
 Treatment of nosocomial infections is estimated to add
between 4.5$ and 15$ billion annually to the cost of health care
problem and represent huge economic problem in today's
environment of cost containment.
The CDC has recently reported that US $5 billion are added to
US health costs every year as a result of N.I.
 World Bank studies have shown that two-thirds of developing
countries spend more than 50% of their health care budgets on
hospitals .
 healthcare-associated infections (HAIs)
• Central line-associated bloodstream infections (CLABSIs) result in
thousands of deaths/year and billions of dollars in added costs to the
healthcare system, yet these infections are preventable.
• A urinary tract infection (UTI) is an infection involving any part of
the urinary system, including urethra, bladder, ureters, and kidney.
UTIs are the most common type of healthcare-associated infection
reported.
 Among UTIs acquired in the hospital, 75% are associated with a
urinary catheter, which is a tube inserted into the bladder through the
urethra to drain urine. Between 15-25% of hospitalized patients
receive urinary catheters during their hospital stay.
 The most important risk factor for developing a catheter-associated
UTI (CAUTI) is prolonged use of the urinary catheter.--- Therefore,
catheters should only be used for appropriate indications and should be
removed as soon as they are no longer needed.
 healthcare-associated infections (HAIs)

• A surgical site infection (SSI) is an infection that occurs after

surgery in the part of the body where the surgery took place.
 SSIs can sometimes be superficial infections involving the skin
only. Other SSIs are more serious and can involve tissues under
the skin, organs, or implanted material.
• Ventilator-associated pneumonia is a lung infection that
develops in a person who is on a ventilator.
 A ventilator is a machine that is used to help a patient breathe by
giving oxygen through a tube placed in a patient’s mouth or nose,
or through a hole in the front of the neck.
 An infection may occur if germs enter through the tube and get
into the patient’s lungs.
Factors Influencing N.I.:
The hospital is an environment in which several factors are present
increasing the risk of infection , include:
1. Susceptible host
2. The microbial agent
3. Environmental factors
Susceptible host :
Most hospital pateint are in poor state of health :
1. extremes of age e.g. neonates and the old are vulnerable to infection
2.Lowered host resistance due to:
 disease e.g. diabetes and burns , or
 those under immunosuppressive therapy e.g. transplant or cancer
patients (receiving treatment with steroids, anticancer drugs, and
radiation) .
3.Instrumentation e.g. urinary ,venous or arterial catheters, endoscopy.
Mechanical ventilation or dental procedures.
4.subject to invasive procedures such as surgery, which breaches the
intact skin that would otherwise help prevent infection.

The highest nosocomial infection rates are in intensive care unit (ICU)
patients, 3 times higher in adult and pediatric ICUs than elsewhere in the
hospital.
Microbial Agent :
The hospital setting harbors many pathogens and potential pathogens.
They live on and in healthcare workers, employees, visitors to the hospital,
and patients themselves.
Some live in dust, whereas others live in wet or moist areas like sink drains,
shower heads, whirlpool baths, mop buckets, flower pots, and even food
from the kitchen.
A. The bacterial pathogens in hospital settings are usually drug-resistant
strains and, quite often, are multi-drug resistant.
the most common causes of N.I. are :
■ Gram-positive cocci (caused 34% of the N.I. ):
Staphylococcus aureus , Coagulase-negative staphylococci , Enterococcus spp.
■ Gram-negative bacilli (caused 32% of the N.I.):
Escherichia coli , Pseudomonas aeruginosa , Enterobacter spp. Klebsiella spp.
Approximately 70% of N.I. involve drug-resistant bacteria, which are
common in hospitals and nursing homes as a result of the many
antimicrobial agents that are used there.
The drugs place selective pressure on the microbes, meaning that only
those that are resistant to the drugs will survive. --- These resistant
organisms then multiply and predominate.
Patient's normal flora changes quickly after hospitalization from
Viridans streptococci, saprophytic Neisseria spp and diphtheroids to
potentially resistant microorganisms found in the hospital
environment, -then, their colonized nares, skin, GIT or GUT can serve
as reservoir for endogenously acquired infections.

Selecting for drug resistant organisms. (A) Indigenous microflora of a patient before initiation of
antibiotic therapy. Most members of the population are susceptible (indicated by S) to the antibiotic
to be administered; very few are resistant (indicated by R).
B. Viruses:
• HIV, HBV, HCV can be transmitted through blood & Body Fluids
(transfusion, injections, dialysis)
• respiratory syncytial virus, rota virus, infleunza, herpes simplex
viruses.
C. Parasites & Fungi: e.g. Giardia lamblia is easily transmitted
between adults or children,
• Scabies an ectoparasite causing outbreak.
• Aspergillus sp. affecting imunocompromised.
Environmental Factors
Ø Hospital environment where both infected persons and persons
at high risk of infection congregate.
 Crowded conditions within hospital, frequent transfers of patients
between units.
 Increased use of less-highly trained healthcare workers, who are
often unaware of infection control procedures.
 Microbial flora may contaminate objects, devices and materials which
subsequently contact susceptible body sites of patients.

** Although some of the pathogens that cause N.I. come from the external
environment, most come from the patients themselves—their own
indigenous microflora that enter a surgical incision or otherwise gain
entrance to the body.
Urinary catheters, for example, provide a “superhighway” for indigenous
microflora organisms to gain access to the urinary bladder.
 Mode of transmission of pathogens in hospitals:
Vary by type of organism and some may be transmitted by more than
one route.
Routes of Pathogen transmission :
1.Direct Contact transmission: from one infected person to another
person without a contaminated intermediate object or person.
• HBV, HCV and HIV transmission through direct contact of patient's
blood or blood--containing body fluids to mucous membrane or
breaks (i.e., cuts, abrasions) in the skin of caregiver,
• mites from a scabies-infested patient are transferred to the skin of a
caregiver while he/she is having direct ungloved contact with the
patient’s skin
• Healthcare provider develops herpetic whitlow on a finger after
contact with HSV when providing oral care to a patient without using
gloves or HSV is transmitted to a patient from a herpetic whitlow on
an ungloved hand of a HCWs.
 Mode of transmission of pathogens in hospitals:

2. indirect contact transmission:

• From patient to patient on the hands of HCWs ,
• if devices (e.g., electronic thermometers, glucose monitoring
devices) contaminated with blood or body fluids are shared between
patients (MRSA ,rotavirus).
• Instruments (e.g., endoscopes or surgical instruments) that are
inadequately cleaned between patients before disinfection or
sterilization
• Shared toys among pediatric patients may become a vehicle for
transmitting respiratory viruses (e.g., respiratory syncytial virus) or
bacteria (e.g., P.aeruginosa)
 Mode of transmission of pathogens in hospitals:
3. Airborne transmission: e,g, aerosols, inhalation of droplets
nuclei (≤5um) that can travel large distance on air currents and
remain infective over time.
Examples (Tuberculosis), rubeola virus (measles), and varicella-
zoster virus (chickenpox).
4. Droplets transmission :
Respiratory droplets are generated when an infected person coughs,
sneezes, or talks, or during procedures such as suctioning,
endotracheal intubation, cough induction by chest physiotherapy
and cardiopulmonary resuscitation.
• inhalation of droplets (>5um) that cannot travel more than 3 feet
on air.
• Examples (influenza virus, pertussis). adenovirus , rhinovirus,
SARS-CoV , group A streptococcus, and Neisseria meningitidis )
 Source of infection:
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 sources:
• Infected patients transmit virulent organisms to other patient
• Carriers e.g. hospital personnel and medical staff.
• Environmental sources e.g. Water, surgical instruments,
urinals, anesthesia, apparatus, ventilators, bed pans, blankets
and air conditioning.
• Blood and its products can be the source of HIV,HBV,HCV
infections
• Intravenous manipulations; cannulae, shunts for haemodialysis
may cause bacteraemia and septicaemia.
Infection Sites
UTI : most common type of N I (30-40% of reported cases),
associated with an indwelling urinary catheter or
instrumentation.
Lower respiratory and surgical wound infections are the next
( each about 15%).
Less frequent include bacteraemia (5-13%), intravenous site
infection, gastrointestinal tract and skin infections.

Of individuals with hospital acquired blood stream or lung infections,

40 to 60% die each year. Likewise , patients with indwelling catheters
have a threefold increases chance of dying from urosepsis,
bloodstream infection that is complication of UTI, than those do not
have one.
Criteria of Nosocomial Infections
 Surgical site infection: Any purulent discharge, abscess or
spreading cellulitis at the surgical site during the month after
operation
 Urinary infection : Positive urine culture (1 or 2 species) with
at least 105 bacteria/ml, with or without clinical symptoms.
 Respiratory infection : Respiratory symptoms with at least 2
signs: cough; purulent sputum; new infiltrate on chest,
appearing during hospitalization
 Vascular catheter infection: Inflammation, lymphangitis or
purulent discharge at the insertion site
 Septicaemia : Fever or rigours and at least one positive blood
culture
Most common pathogens causing N.I.:
• UTIs by E. coli, Klebsiella, pseudomonas and proteus.
• Surgical wound infection by staphylococci, anaerobes and
Gram negative bacilli.
• Lower respiratory tract infection especially pneumonia by
S.aureus and gram negative bacilli.
• Bacteremia or septicaemia by Bacteroids, S.aureus,
Serratia..etc
• Gastrointestinal infections e,g, Pseudomonas colitis by
CL.difficile