PREVENTION & CONTROL OF NOSOCOMIAL INFECTIONS. PART-2

1. PREVENTION & CONTROL OF NOSOCOMIAL INFECTIONS. PART-2 Dr. A K.AVASARALA MBBS, M.D. PROFESSOR & HEAD DEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGY PRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P. INDIA: +91505417 avasarala@yahoo.com

2. PREVENTION

3. PREVENTION OF UTI • AVOID CATHETER • IFCATHETERIZED, PREVENT BACTERURUA(BU), • ONCE BU +, PREVENTION OF BLOOD STREAM INFECTION (BSI)

4. AVOID CATHETER • MINIMIZE THE DURATION, IF CATHETR IS A MUST, EMPLOY CLOSED DRAINAGE SYSTEM. • GOOD HAND WASHING AFTER CARING EACH PATIENT PREVENTS CROSS INFECTION.

5. AVOID CATHETER SAFEST & BEST IF POSSIBLE GENERAL ALTERNATIVES: PATIENT TRAINING TO VOID • BIOFEED BACK, MEDICATIONS, • SURGERY, • USE OF SPECIAL CLOTHES & PADS SPECIFIC APPRPOACHES: INTERMITTANT CATHETERIZATION, EXTERNAL COLLECTION DEVICES (CONDOM CATHETER), SUPRAPUBIC CATHETERIZATION, URUNARY DIVERSIONS

6. PREOPERATIVE PREVENTION OF SWI - 1 Environmental Factors 1. Ultraviolet Light 2. Laminar flow ventilation systems 3. Limit operation theater traffic 4. Pre-operative preparations 5. Avoid antibiotic use except for surgical antibiotic prophylaxis

7. PREOPERATIVE PREVENTION OF SWI - 2 6. Eliminate basal colonization with S.aureus 7. Pre-operative antimicrobial shower 8. Treat distant site infections before elective procedures 9. Hair removal Avoid shaving / hair clipping is recommended as near to the site of surgery as possible 10. Skin preparation Scrubbing for 5 to 7 minutes

8. PREOPERATIVE PREVENTION OF SWI - 3 11. Resolve malnutrition and obesity 12. Discontinue cigarette smoking 13. Optimize diabetic control 14. Antibiotic prophylaxis 15. Choice, timing and duration are critical 16. OT team discipline 17. Vigilance for breaks in aseptic techniques

9. INTRAOPERATIVE PREVENTION 18. GOOD SURGICAL TECHNIQUE 19. LESS DURATION OF SURGERY 20. APPROPRIATE USE OF SURGICAL DRAINS 21. ASEPTIC DRESSINGS 22. FEEDBACK OF SURGEON SPECIFIC INFECTION RATES TO OTHER SURGEONS TO ADOPT THE SAME TECHNIQUES AND TO REDUCE SWI

10. PREVENTION BY ANTIBIOTIC PROPHYLAXIS IN SURGERY • ESSENTIAL PREVENTIVE MEASURE TO PREVENT SWI • MAY BE EXPENSIVE FOR HOSPITAL BUT • COST BENEFIT ANALYSIS OF PROPHYLACTIC ANTIBIOTICS? • WHAT IS THE COST OF WOUND INFECTION? IN MONEY? IN SUFFERING? • HOW EFFECTIVE IS PROPHYLAXIS • HOW MUCH WE CAN SPEND TO PREVENT A CASE OF SWI?

11. PREVENTION OF ANTIBIOTIC ABUSE • To avoid antibiotics abuse, CMC has categorized its antibiotics • The first line of antibiotics can be prescribed by anybody • second line by consultants and • third line to special cases like bone marrow transplant, adds Kang

12. IDEAL REQUIREMENTS FOR PREVENTION • More space per bed • Special air handling provisions for clean air without recirculation • Hand wash area in the wards • Special anti-bacterial methods of flooring • Air curtains, • Isolation wads • Positive air zones and • Hand wash area outside each bed in the ICU

13. PREVENTIVE EPIDEMIOLOGIC STUDIES • To indentify risk factors for endemic infections so that preventive strategies can be formulated and implemented. • These strategies include measures to reduce the risk for infection associated with invasive techniques for intravascular pressure monitoring and hyperalimentation.

14. PREVENTION OF LRI • GENERAL MEASURES: • HAND WASHING, • BARRIER ISOLATION, • ROUTINE DECONTAMINATION OF EQUIPMENT, • SPECIFIC MEASURES: • AVOID H2 BLOCKERS AS THEY REDUCE THE PROTECTIVE EFFECT OF GASTRICACID • USING TOPICAL ANTIBIOTICS, • IMMUNOSYSTEM MODULATION - INFLUENZA VACCINE

15. RISK REDUCTION OF PNEUMONIAS • Hand washing during patient care and after glove removal • Change gloves after coming into contact with respiratory secretions, in between patients • Change tubing, masks and suction catheters between patients • Anti-stress ulcer prophylaxis with sucralfate • Early enteral feeding • Elevate head end of patient to a 30 to 45 degree angle • Prevention of atelectasis • No routine antimicrobial prophylaxis

16. RISK ALGORITHM CAN BE PREPARED • TO PREDICT RISK OF WOUND GETTING INFECTED. BASING ON 1) PATIENT FACTORS 2) TYPE OF PROCEDURE

17. SURVEILLANCE

18. SURVEILLANCE DEFINITION A dynamic process of gathering, managing, analyzing and reporting data on events that occur in a specific population

19. OBJECTIVES OF THE SURVEILLANCE • Reducing the infection rate within a hospital. • Establishing baseline rates. • Identifying outbreaks. • Comparing infection rates among hospitals.

20. FIVE COMPONENTS OF SURVEILLANCE • CASE DEFINITION: DEFINE THE HEALTH PROBLEM TO BE SURVEYED AS PRECISELY AS POSSIBLE • DATA COLLECTION: SYSTEMATIC AND VALID • DATA PRESENTATION IN A USEFUL MANNER • DATA ANALYSIS AND INTERPRETATION • FEED BACK TO BRING ABOUT THE CHANGE IN CAUSATIVE FACTORS

21. SURVEILLANCE INDIACTORS • Overall rate=No. Of NCIs / TOTAL NO. OF ADMITTED OR DISCHARGEDPATIENTS • INFECTION RATES BY INFECTED SITES • INFECTION RATES BY PATHOGEN • INFECTION RATES BY SERVICE SPECIALITY • INFECTION RATES PER PATIENT CARE AREA • SURGEON-SPECIFIC WOUND INFECTION RATES • PROCEDURE -SPECIFIC WOUND INFECTION RATES

22. FEEDBACK “Surveillance is not complete until the results are disseminated to those who use it to prevent and control”

23. SENIC STUDY INFERENCE • SURVEILLANCE WAS THE MAIN COMPONENT ESSENTIAL FOR REDUCING SWI, PNEUMONIA, UTI & BACTEREMIA.

24. INFECTION SURVEILLANCE 1.SURVEILLANCE OF PATIENT CARE PRACTICES 2. REGULAR, FREQUENT VISIT TO PATIENT CARE AREAS 3. REVIEWING PATIENT CARE PLANS& LAB CHARTS 4. WATCHING LIST OF PATIENTS TAKING ANTIBIOTICS 5. WATCHING PATIENTS IN ISOLATION PROCEDURES

25. SURVEILANCE LIMITS • ROUTINE MICROBIOLOGICAL SURVEILLANCE OF INANIMATE HOSPITAL ENVIRONMENT – IS NOT RECOMMENDED

26. HOSPITAL WIDE SURVEILLANCE (HWS) • Hospital wide • Periodic • Targeted • Defining the threshold limit • Post discharge

27. DATA SOURCES (HWS) COLLECTION • Daily reports of microbiology labs • Medical records of febrile patients • Medical records of patients taking antibiotics • Medical records of isolated patients • Daily interview with nurses & patients • Periodic review of autopsy reports • Periodic review of medical records of staff

28. PERIODIC SURVEILLANCE 1.Hospital wide surveillance (HWS) during specified periods and 2. Targeted Surveillance during alternate periods or 3. Rotating from one unit to the other

29. TARGETED SURVEILLANCE • SELECTED GEOGRAPHIC AREA (E.G. ICU) • SELECTED SERVICE (E.G. CARDIO THORACIC SURGERY) • SPECIFIC POPULATIONS OF PATIENTS OR INFECTIONS: • AT HIGH RISK OF ACQUIRING INFECTION ( E.G. TRANSPLANTATION) • UNDERGOING SPECIFIC INTERVENTIONS (E.G. DIALYSIS) • AT SPECIFIC SITE (E.G. BLOOD STREAM)

30. CONTROL PROGRAM

31. INFECTION CONTROL PROGRAM • INFECTION CONTROL TEAM

32. INFECTION CONTROL TEAM • HOSPITAL EPIDEMIOLOGIST • INFECTION CONTROL PRACTITIONER/S • MICROBILOGIST • HOSPITAL PHYSICIAN/SURGEON • ICU STAFF NURSE

33. HOSPITAL EPIDEMIOLOGIST USUALLY A COMMUNITY PHYSICIAN DUTIES -PROVIDES LIASON WITH OTHER MEMBERS OF MEDICAL STAFF & ADVISES ABOUT THE CLINICAL IMPLICATIONS OF PATIENT CARE PRACTICES, INFECTION PROBLEMS AND PREVENTION & CONTROL MESURES. -PROVIDES ADVICE ABOUT SURVEILLANCE METHODS, ANALYSIS OF SURVEILLANCE DATA, METHODS OF CONDUCTING EPIDEMIOLOGICAL STUDIES -DEVELOPMENT OF CONTROL MEASURES -SUPERVISES THE INFECTION CONTROL PRACTITIONERS AND NURSES -DEVELOPING POLICIES AND PROCEDURES OF COMMITTEE

34. DUTIES OF HOSPITAL EPIDEMIOLOGIST-1 • SURVEILLANCE OF NCIS • OBSERVES THE PATTERNS OF TRANSMISSION OF NCI • OUTBREAK INVESTIGATION • ISOLATION PRECAUTIONS • EVALUATION OF EXPOSURES • EMPLOYEE’S HEALTH • DISINFECTION & STERILIZATION • HOSPITAL ENGINEERING & ENVIRONMENT • REVIEWING POLICIES & PROCEDURES FOR PATIENT CARE

35. INFECTION CONTROL PRACTITIONERS • CAN BE A LAB TECHNICIAN, A NURSE, SANITARY INSPECTOR, • DUTIES • TO PROVIDE DAY TO DAY CO-ORDINATION OF SURVEILLANCE AND CONTROL PROGRAMMES • TO COLLECT AND ANALYZE SURVEILLANCE DATA • ASSISTING IN DEVELOPMENT OF INFECTION CONTROL POLICIES • PROVIDING EDUCATION AND CONSULTATION TO HOSPITAL PESONNEL

36. CONTROL POLICIES DEVELOP AND IMPLEMENT POLICIES FOR • ISOLATION WITH POTENTIALLY COMMUNICABLE DISEASES, • USE OF ANTIBIOTICS, • CONTROL OF HOSPITAL ENVIRONMENT

37. SENIC PROJECT(CDC) YEAR 1970 IN 338 HOSPITALS • STRATIFIED BY SIZE, MEDICAL SCHOOL AFFILIATION, TYPE OF INFECTION CONTROL TEAM • OBJECTIVE TO KNOW RATES OF UTI, LRI, BSI, SWI IN ADULTS • RESULTS: 1) HOSPITALS WITH ICC (INFECTION CONTROL COMMITTEE) HAVE FEWER NCIs COMPARED TO THOSE WITHOUT ICC

38. FUNCTIONS OF INFECTION CONTROL PROGRAM (SENIC) 1. SURVEILLANCE OF NCIs 2. DEVELOP WRITTEN POLICIES FOR ISOLATION OF PATIENTS 3. DEVELOPMENT OF WRITTEN POLICIES TO REDUCE RISK FROM PATIENT CARE PRACTICES 4. ELIMINATION OF ALL WASTEFUL & UNNECESSARY PRACTICES 5. EDUCATION OF HOSPITAL STAFF ON INFECTION CONTROL

39. FUNCTIONS OF INFECTION CONTROL PROGRAM - (SENIC) 6. ONGOING REVIEW OF ALL ASEPTIC, ISOLATION & SANITATION TECHNIQUES 7. MONITORING OF ANTIBIOTIC UTILIZATION 8. MONITORING OF ANTIBIOTIC RESISTANT ORGANISMS

40. RELATED TASKS (SENIC) • OUTBREAK INVESTIGATION • COOOPERATION WITH OCCUPATIONAL HEALTH • COOPERATION WITH QUALITY IMPROVEMENT PROGRAM

41. SENIC RECOMMENDATIONS • ACTIVE INFECTION SURVILLANCE SYSTEM WITH REPORTING OF RESULTS TO STAFF MEMBERS • PRESENCE OF VIGOROUS CONTROL MEASURES DESIGNATED TO ELIMINATE RECOGNIZED HAZARDS • ATLEAST ONE FULL TIME INFECTION CONTROL PRACTITIONER FOR EVERY 250 BEDS • A PHYSICIAN ON THE STAFF KNOWLEDGEBLE ABOUT NCI (SENIC PROJECT)

42. CONTROL MEASURES • RELATED TO SPECIFIC PATIENT CARE PRACTICES • GUIDELINES TO MINIMIZE THE RISK OF INSTRUMENTATION TO BE DEVELOPED

43. COST-EFFECTIVE CONTROL • Reducing incidence • Reduce morbidity • Shorten hospital stay • Reduce cost of treating infections • Reduce cost of preventive measures • Stop infective control measures

44. HOSPITAL INFECTIONS SYSTEM, INDIA • Says Dr Ajita Mehta, President, HIS, India • While simple chores like regular washing of hands and proper sterilization of instruments prevent nosocomial infection, the awareness of medicos about these is far from encouraging. • “While nosocomial infection is high in the operation theatre, it’s the surgeons who do not pay attention to the basic guidelines. • Awareness of other medicos is also low.” • She, however, added that the awareness level is improving following the scare created by TB and AIDS.

45. ROLE OF MICROBIOLOGISTS • As many skin barriers are transgressed in the form of IV lines, urinary tract catheters central lines used in specialised ICU exist infection control is the only way in which a check can be kept on infection and in all this micriobiologist has an important role to play.

46. WASTE MANAGEMENT PRACTICES Dr Vijay D Silva, Director, Critical care, Asian Heart Institute (AHI) says • It’s the improper waste management practices which has resulted in the high infection rate in India, • “Washing hands before touching the patients is crucial in checking nosocomial infection. • To minimize transmission of microorganisms from equipment and environment, adequate method of cleaning, disinfecting and sterilization should be made,”

47. EPIDEMIOLOGICAL INVESTIGATION • Itis necessary to carry out Epidemiological investigation in the management of acute outbreaks of nosocomial infection. • Most outbreaks require only local assistance with technically trained personals of that area. • Onsite Epidemiological assistance will help in early identification of the cause and source of the infection and the appropriate measures to control and prevent it.

48. ICU STUDIES • Recently epidemiologic studies have been focussed more on intensive care units, where the nosocomial infection with resistant strains of pathogens in causing havoc among the old, debilitated patients as well as patients with chronic illnesses. • It has increased the morbidity and mortality among those patients admitted to the ICU's.

49. REFERENCES • Maxcy - Rosenau- Last, Public health & Preventive medicine, Robert B. Wallace, Bradley N .Doebbeling, 14th edition • Epidemiology of Nosocomial infections , James M. Hughes & William R. Jarvis Manual of clinical Microbiology, fourth edition,1985 • Surveillance methods of nosocomial infections by Masud Yunesian,M.D., Epidemiologist, super course lecture at www.pitt.edu/~super1/lecture/lec2041/index.htm • WHO Country Profile & Practical manual -2 edition on Nosocomial infections