Hospital Acquired Infection

1. Hospital Acquired Infection Dr. Sudheer Kher Prof & HOD, Dept of Microbiology

2. Adversely affects performance & image of the hospital Prolongation of stay of patient Increase in the morbidity & mortality of the patients Increased bed occupancy Hospital, community & National resources put under severe strain Effects of HAI

4. Synonyms & Definition • Hospital associated infections • Nosocomial infections • Definition- • Infections acquired by a person in the hospital, which was neither present nor incubating at the time of hospitalization. Such infections may manifest during their stay in the hospital, or, sometimes after the person is discharged from the hospital. The person may be a patient, hospital staff or a visitor.

5. Historical • Semmelweiss (1861)- Observed association of puerperal sepsis with attendants like doctors & students. Introduced hand-washing with chlorinated lime. • Florence Nightingale (1863)- “The very first requirement of a hospital is that it does its patients no harm…the actual mortality in hospitals in large crowded city is very much higher than the patients of the same class of diseases treated outside the hospital” • Lord Joseph Lister (1867)- Introduced Antiseptic Surgery with extensive use of carbolic acid.

6. Age – Neonates and elderly have highest risk due to inefficient immunity. Infected patients- Community acquired infection may spread to susceptible patients or attendants Drug resistance- Coliforms & Staph aureus. Drug resistance & increased virulence Susceptible patients- Pre-existing disease e.g. Diabetes, Immuno-suppression, prosthetic implants, special care units. Surgical procedures- Bypassing natural mech of body surface. Diagnostic & therapeutic invasive procedures Factors influencing the HAI

7. Greater exposure of the patients to infective agents Inadequate ventilation, faulty designs of the wards & Depts Non-availability of isolation rooms, toilets, WCs. Overcrowding Spread from undiagnosed infections at the time of admissions Intimate contact between patients, hospital staff & visitors Substandard aseptic procedures Poor kitchen, laundry services Faulty house keeping services What is so special about the hospitals?

8. Endogenous- Patients own flora – auto-infection Exogenous- Accounts for most HAI. Sources :- Contact with other patients/staff Environmental sources like inanimate objects, Air, Food & Water. Mode of transmission Contact Hand & Clothing Inanimate objects Air borne route Droplet from respiratory tract Aerosol by nebulizer, humidifiers, AC system Oral route- Food & water Parenteral route – HIV HBV Sources & Transmission of HAI

9. Common HAI • UTI- Account for 40% of HAI. Associated with catheterization, Instrumentation. Initially E. coli, Staph. epidermidis & enterococcus later Klebsiella, Proteus, Serratia, Pseudomonas & Providentia. • Lower Respiratory Tract Infection: Account for 15-20% of HAI. Leading causes of mortality. Pathogens: GNB, Staph aureus & Strept pneumoniae

10. Common HAI (contd) • Wound & Skin sepsis :- Accounts for 18% of HAI. Common organisms – Staph aureus, Ps. aeruginosa, Other GNBs. • Gastro-intestinal infections :- Food poisoning, Salmonella infections & neonatal septicemia

11. Control & preventionHouse Keeping • Personal hygiene & sanitation to be kept at highest standard • Efficient house keeping, clean bed-linens, patient’s dress, proper bed arrangement • Frequent mopping and periodic washing of wards & Depts • Each ward to have isolation facilities (separate rooms) over and above isolation wards

12. Control & preventionDietary service • Organized kitchen services • Minimum handling of food • Adequate water supply. Proper washing of utensils, food • Sanitation of cook house, distribution centre, provision of food trolleys • Periodic medical exam of food handlers, vaccination.

13. Control & preventionLinen & Laundry • Segregation between clean contaminated & contaminated • Disinfection of linen before washing by chemical agents / boiling / autoclaving • Transportation of linen to & from laundry • Minimum handling while separating / counting • Proper drying • Decontamination & washing of blankets • Decontamination & washing of mattresses

14. Control & preventionCSSD • Highest standard of asepsis & sterilization should be followed • SOP manual for standardization • Testing of efficiency of sterilization procedures

15. Control & prevention • Security – Restricting number of visitors and duration of visits • Engineering aspects particularly AC system • Nursing care • Waste disposal • House hold non-infective • Infected sharp • Infected hospital waste (non-sharp) • Antibiotic policy

16. Hospital Infection Control Committee(HICOM) • Objective • Investigation of all HAI • Establish surveillance programme • Provide guidance & leadership in prevention & control of HAI • Composition – • Chairman – Hospital Suptdt • Secretary – Microbiologist – Also called Hospital Infection Control Officer • Members – All major specialty representatives, Nursing matron, Engineering service representative, House keeping Dept, Dietician, CSSD.

17. Hospital Infection Control Committee(HICOM) • Role & Functions • Establish reporting system thru’ • Nursing unit report • Individual patient report • Bacteriology reports • Autopsy report • Periodical meetings to take decisions • Lay down standards of asepsis, sterilization etc • To distinguish between HAI & Non-HAI • To prepare SOP Manual • To take decision on all reports of HAI control officer

18. Surveillance • AIM : To detect & record methodically all HAI. • Continuous monitoring helps in early detection of outbreak, decide on incidents & trends, know the causative agents, AST and policies • UTI • Lower Respiratory Tract • Post-operative Infections • Systemic Infections

19. Processing of information collected • Information processed by infection control sister • Weekly, monthly and annual reports prepared for the floor/ specialty / hospital for each type of HAI • Incidence rate : No. of new patients developing HAI in a given period compared with No. of patients discharged during the same period • Prevalence rate : No. of new patients and old patients developing HAI in a given period compared with No. of patients discharged during the same period • Analysis helps in revealing true dimension of the problem • Sources & reservoirs can be detected and remedial measures taken

20. Interruption of transmission • The sequence of transmission interrupted at the most vulnerable point • Destruction of the pathogenic agent in the carrier staff / source patient by antibiotic / antiseptic therapy • Isolation of patient / fomite sterilization / disinfection • Disinfection of excreta / infected waste • Control through washing of hands, disinfection of eqpt and change of clothes • Protection of susceptible host by vaccination eg tetanus, gas gangrene

21. High risk procedures • Injections • Surgical procedures • Dressing of wounds • Management of Child birth • Investigation procedures • Laboratory investigations • Dialysis

23. Training & Education • Increasing awareness level • Knowledge, skills & behavioral changes essential • Lectures / workshops / discussions • Target audience – Sister I/C OT, ICUs, Labour rooms, Post-op wards, sanitary inspectors, CSSD, Security, dietician

24. Universal Safety Precautions • They are Universal and for protection of HCW • Routine use of appropriate barrier precautions to prevent skin and mucus membrane exposures when blood and body fluid contact of any patient is anticipated • Gloves, masks, eye shield, face shield, aprons / gowns

25. Legal aspects • Increased ALS (Average Length of Stay) in hospital • Increased cost to the patient / hospital / nation • Increased morbidity / mortality • Loss of daily earning for the patients • Litigation against hospitals / doctors due to negligence