hospital infection and control

1. Hospital Infections HEALTH CARE solutions Dr.T.V.Rao MD Dr.T.V.Rao MD

2. Anton van Leeuwenhoek (1632-1722) Dutch linen draper Amateur scientist Grinding lenses, magnifying glasses, hobby First to see bacteria “little beasties” No link between bacteria and disease Microbiology - scientific erainfection Dr.T.V.Rao MD

3. Scientific era continued . . . . . Ignaz Semmelweis (1818-1865) • Obstetrician, practised in Vienna • Studied puerperal (childbed) fever • Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems • Reduced maternal mortality by 90% • Ignored and ridiculed by colleagues Dr.T.V.Rao MD

4. Louis Pasteur (1822-1895) French professor of chemistry Studied how yeasts (fungi) ferment wine and beer Proved that heat destroys bacteria and fungi Proved that bacteria can cause infection - the “germ theory” of disease Scientific era continued . . . . . Dr.T.V.Rao MD

5. Robert Koch (1843-1910) German general practitioner Grew bacteria in culture medium Showed which bacteria caused particular diseases Classified most bacteria by 1900 Scientific era continued Dr.T.V.Rao MD

6. Infection which was neither present nor incubating at the time of admission Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation. Also called nosocomial infection Hospital acquired infection Dr.T.V.Rao MD

7. What are health care associated infections • Healthcare associated infections (HCAIs) are infections transmitted to patients (and healthcare workers) as a result of healthcare procedures, in hospital and other healthcare settings. Recent years have seen an increase in the awareness of HCAIs, in particular those caused by antibiotic-resistant ‘superbugs Dr.T.V.Rao MD

8. What are Health care associated infections ??? • A wide variety of micro-organisms can cause HCAIs, leading to an extensive range of different diseases. • Experts estimate that 9% of in-patients have an HCAI at any one time. Dr.T.V.Rao MD

9. Health care associated infections and microbes • HCAIs are mostly caused by bacteria. Bacteria can exist harmlessly in people, for example on the skin or in the gut. However, some types of bacteria can cause HCAIs when they enter the body, for example through wounds and the use of surgical devices, or when the body’s natural balance is disturbed. HCAIs occur in the lungs (23% of all HCAIs), urinary tract (23%), blood (6%), skin (11%) and gut. Infections are usually treated with antibiotics. However, many bacteria have developed resistance to antibiotics This can make infections harder to treat. Dr.T.V.Rao MD

10. Increased use of antibiotics • Increasing antibiotic use. The more antibiotics are being used, the more likely bacteria become resistant to them. Antibiotics are sometimes prescribed for conditions that are not treatable with antibiotics, such as colds and the ‘flu. Dr.T.V.Rao MD

11. Not a new problem - Penicillin in 1944 Hospital “superbugs” Methicillin Resistant Staphylococcus Aureus [MRSA] Vancomycin Intermediate Staphylococcus Aureus [VISA] Tuberculosis - antibiotic resistant form Antibiotic resistance Dr.T.V.Rao MD

12. Irregular use of antibiotics • Patterns of antibiotic use. Many people do not finish their courses of antibiotics because they start feeling better. This means that bacteria are not killed off, so they multiply, become resistant and transmit to others. Dr.T.V.Rao MD

13. Micro-organisms - bacteria, fungi, viruses, protozoa and worms Most are harmless [non-pathogenic] Pathogenic organisms can cause infection Infection exists when pathogenic organisms enter the body, reproduce and cause disease The nature of infection Dr.T.V.Rao MD

14. Infection which was neither present nor incubating at the time of admission Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation Also called Nosocomialinfection Hospital acquired infection Dr.T.V.Rao MD

15. Two sources of infection: Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998) Modes of spread Dr.T.V.Rao MD

16. Use of leftover antibiotics • Using leftover antibiotics to self-medicate against a fresh infection can exacerbate the problem, as specific bacterial infections require specific antibiotics Dr.T.V.Rao MD

17. Use of antibiotics in livestock • The indiscriminate use of antibiotics in livestock has further compounded the problem by increasing the likelihood of resistance factors emerging. Dr.T.V.Rao MD

18. Concerns with staphylococcus • Methicillin-resistant S. aureus (MRSA) is resistant to several antibiotics. Another form of S. aureus, vancomycin-resistant S. aureus (VRSA), is resistant to one of the most powerful, last line of defence antibiotics, vancomycin Dr.T.V.Rao MD

19. RESISTANT GRAM NEGATIVE ORGANISMSResistance to multiple antibiotics Organisms: E .coli Proteus Enterobacter Acinetobacter Pseudomonas aeruginosa

20. E.Coli and emerging resistance • Escherichia coli (E. coli) has gradually become resistant to different types of antibiotics. In 2003, the overall resistance of E. coli to common amino penicillin antibiotics reached 47% across Europe Dr.T.V.Rao MD

21. Pseudomonas aeruginosa • Pseudomonas aeruginosa (P. aeruginosa) and Extended Spectrum Beta Lactamase (ESBL) -producing bacteria are increasingly becoming resistant to antibiotics. Dr.T.V.Rao MD

22. Reducing infection rates Establishing endemic baseline rates Identifying outbreaks Identifying risk factors Persuading medical personnel Evaluate control measures Satisfying regulators Document quality of care Compare hospitals’ NCI rates Objectives – reducing infections Dr.T.V.Rao MD

23. SURVEILLANCE • Important means of monitoring HAI Early detection of trends outbreaks • . Laboratory Based Microbiology Laboratory lists +ve organisms ICN reviews ‘Alert organisms’ reported • 2. Ward Based Ward staff monitor patientsICN reviews ICN visits wards Dr.T.V.Rao MD

24. Who will practice preventive measures • All hospitals? • All departments? • All specialties? • Other health institutions? Dr.T.V.Rao MD

25. Stakeholders Dr.T.V.Rao MD

26. PPE when contamination or splashing with blood or body fluids is anticipated Disposable gloves Plastic aprons Face masks Safety glasses, goggles, visors Head protection Foot protection Fluid repellent gowns Personal protective equipment Dr.T.V.Rao MD

27. Hand washing Personal protective equipment [PPE] Preventing/managing sharps injuries Aseptic technique Isolation Staff health Linen handling and disposal Waste disposal Spillages of body fluids Environmental cleaning Risk management/assessment Universal precautions Dr.T.V.Rao MD

28. Why Don’tStaff Wash their Hands (Compliance estimated at less than 50%) Dr.T.V.Rao MD

29. Single most effective action to prevent HAI - resident/transient bacteria Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken No recommended frequency - should be determined by intended/completed actions Research indicates: poor techniques - not all surfaces cleaned frequency diminishes with workload/distance poor compliance with guidelines/training Hand washing Dr.T.V.Rao MD

30. Skin irritation Inaccessible hand washing facilities Wearing gloves Too busy Lack of appropriate staff Being a physician (“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381) Why Not? Dr.T.V.Rao MD

31. Working in high-risk areas Lack of hand hygiene promotion Lack of role model Lack of institutional priority Lack of sanction of non-compliers Why Not? Dr.T.V.Rao MD

32. Education Routine observation & feedback Engineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs available Patient education (Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381) Successful Promotion  Dr.T.V.Rao MD

33. Successful Promotion  • Reminders in the workplace • Promote and facilitate skin care • Avoid understaffing and excessive workload; Nursing shortages have caused Dr.T.V.Rao MD

34. Areas Most Frequently Missed HAHS © 1999 Dr.T.V.Rao MD

35. Nails Rings Hand creams Cuts & abrasions “Chapping” Skin Problems Hand Care Dr.T.V.Rao MD

36. Hand hygiene • Hand hygiene is the simplest, most effective measure for preventing hospital-acquired infections. Dr.T.V.Rao MD

37. Sharps injuries • Prevention • correct disposal in appropriate container • avoid re-sheathing needle • avoid removing needle • discard syringes as single unit • avoid over-filling sharps container • Management • follow local policy for sharps injury (May, 2000) Dr.T.V.Rao MD

38. Clinical waste - HIGH risk potentially/actually contaminated waste including body fluids and human tissue yellow plastic sack, tied prior to incineration Household waste - LOW risk paper towels, packaging, dead flowers, other waste which is not dangerously contaminated black plastic sack, tied prior to incineration Follow local policy (May, 2000) Waste disposal Dr.T.V.Rao MD

39. PPE - disposable gloves, apron Soak up with paper towels, kitchen roll Cover area with hypochlorite solution e.g., Milton, for several minutes Clean area with warm water and detergent, then dry Treat waste as clinical waste - yellow plastic sack Follow local policy Spillage of body fluids Dr.T.V.Rao MD

40. H.A.I. IS INCREASING: compromised patients ward and inter-hospital transfers antibiotic resistance (MRSA, resistant Gram negatives) increasing workload staff pressures lack of facilities ? lack of concernHAI is inevitable but some is preventable (irreducible minimum) realistically reducible by 10-30%

41. Journal of Infection Prevention • Journal of Infection Preventionis the professional publication of the Infection Prevention Society. The aim of the journal is to advance the evidence base in infection prevention and control, and to provide a publishing platform for all health professionals interested in this field of practice. The journal is a bi-monthly peer-reviewed publication containing a wide range of articles: Original primary research studies, Qualitative and quantitative studies,. Dr.T.V.Rao MD

42. Consequences of hospital infections ??? Pathogen Unhappy patients Unhappy director Hospital Surveillance Happy Patients Happy director Hospital Dr.T.V.Rao MD

43. Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD