Understanding Health Care Associated Infections (HAIs) in Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

1. HEALTH CARE ASSOCIATED INFECTIONS(HAIs)(NOSOCOMIAL INFECTION) Ida Parwati DjatnikaSetiabudi Komite PIRS RSUP Dr. HasanSadikin Bandung Dr.Hasan Sadikin General Hospital Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216

2. Definition(1) Old concept: • Nosocomial Infection = Hospital acquired infection - An infection that occured during hospitalization (> 3 X 24 hours after admission) which are not present nor incubating upon hospital admission - Infection at the same location but the causative microorganism was different than at addmission OR the same microorganism but different location

3. Definition(2) • Problems of old definition: 1.Focus on infection occuring in the hospital only. What about in other health care system but not hospital?While many home-care are availlable now? 2. Focus on patient’s infection What about healthcare worker?

4. Definition(3) New terminology: nosocomial Infection = Health-careassociated Infection Health-care related Infection

5. Healthcare-associated infection Definition: An infection occurring in a patient during the process of care in a hospital or other healthcare facilitywhich was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility

6. In Indonesia • The term nosocomialinfection still being used • For nosocomialinfection occured in the hospital: Hospital Infection (”InfeksiRumahSakit”) • Control Program of HAIs called: “PencegahandanPengendalianInfeksiRumahSakit” (“PPIRS”)

7. Types of Infections(1) Four categories: Surgical site infections(SSI) Central line-associated bloodstream infections(CLABSI) Ventilator-associated pneumonia(VAP) Catheter-associated urinary tract infections(CAUTI)

8. Types of Infections(2) Others: - Gastroenteritis - Cellulitis -Hepatitis B and C - HIV / AIDS - SARS

9. The most common causative pathogens

10. The 10 most common pathogens (accounting for 84% of any HAIs) Coagulase-negative staphylococci (CONS) (15%), Staphylococcus aureus (15%), Enterococcus species (12%), Candida species (11%), Escherichia coli (10%), Pseudomonas aeruginosa (8%), Klebsiella pneumoniae (6%), Enterobacter species (5%), Acinetobacter baumannii (3%) Klebsiella oxytoca (2%). CDC, April 2013

11. Diseases and Organisms in Healthcare Settings Acinetobacter Burkholderia cepacia Clostridium difficile Clostridium sordellii Enterobacteriaceae (carbapenem-resistance) Hepatitis HIV Influenza Klebsiella MRSA Mycobacterium abscessus Norovirus Pseudomonas aeruginosa Staphylococcus aureus Tuberculosis (TB) VISA and VRSA VRE CDC, April 2013

12. Why does HAIs important?

13. Why does HAIs important? 1.Increase morbidity & mortality 2.Prolong length of stay (LOS) 3.Increase cost 4.Related to ‘image’/ quality of the hospital 5.Important in medicolegaland “patient safety” aspects.

14. Impact of HAIs They lead to functional disability and emotional stress to the patient disabling conditions that reduce the quality of life They are one of the leading causes of death

15. Impact of HAIs (cont’d) • The increased economic costs are high: - Increased length of hospital stay - extra investigations - extra use of drugs - extra health care by doctors and nurses

16. Nosocomial Infections Cost • The cost varies according to the type and severity of these infections • An estimated: 1 - 4 extra days for a UTI 7 – 8 days for a surgical site infections 7 – 21 days for a blood stream infection 7 – 30 days for pneumonia • The CDC has recently reported that US$5 billion are added to US health costs every year as a result of NI

17. Impact of Nosocomial Infections (cont’d) • 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

18. Goals of infection control • To protect the patients from HAIs e.g UTI, SSI, IV line infection, pneumonia (HAP, VAP), Blood stream infection (sepsis) • To protect the patients from others infection which acquire through contact with other patients or healthcare worker whom colonized by contagious microorganisms. • To protect healthcare workers, Visitor, in hospital environtment from infections

19. SIX COMPONENTS OF THE CHAIN OF INFECTION Schaffer SD et al: Infection Prevention and Safe Practice, Mosby, 1996

20. Risk Factors(1) Age: neonatus >> Interuption of anatomical barrier: - Urine catether - Operationprocedure - Respiration intubation - Vein/artery canule - Burn wound and trauma

21. Risk factors(2) Implantation of: - “indwelling catheter” - “surgical suture material” - “cerebrospinal fluid shunts” - “valvular / vascular prostheses” Changes in normal microflora : antibiotics usage

22. Routes of Transmission of Infection A susceptible host and appropriate inoculum of infecting microorganism with an appropriate route of transmission contributed in majority of case • Airborne (resp tract, aerosols from equipment etc) • Contact spread (person to person) • Food borne spread • Blood borne spread • Self infections (endogenous) and cross infections

23. Transmission(1) • Contact transmission: - Direct: body contact physically causative microorganism transfer  physical examination, patients bathing - Indirect: most of the time !!! contact through objects (tools) instrumentation, needle, bandage  unwashed hand

24. Transmission(2) • Droplet transmission : - droplet particles > 5 μm - coughing, sneezing, talking - short transmission distance, and only short time in the air - “deposit” at conjungtival mucous, nose, mouth - e.g.: Diphteria, Pertussis, Hib, Mycoplasma Influenza Virus , mumps, rubella

25. Transmission(3) • Airborne transmission : - small particles < 5 μm - long standing in the air - long transmission distance - easy inhaled - e.g : Mycobacterium tuberculosis varicella virus, morbilli, fungi spore.

26. Pathophysiology Within hours of admission, colonies of hospital strains of bacteria develop in the patient's skin, respiratory tract, and genitourinary tract. Risks factors for the invasion of colonizing pathogens can be categorized into 3 areas: iatrogenic, organizational, and patient-related

27. Iatrogenic risk • Iatrogenic risk factors: include pathogens on the hands of medical personnel, invasive procedures (intubation and extended ventilation, indwelling vascular lines, urine catheterization), and antibiotic use and prophylaxis.

28. Organizational • Organizational risk factors include:contaminated air-conditioning systems, contaminated water systems, and staffing and physical layout of the facility (eg, nurse-to-patient ratio, open beds close together).

29. Patient associated • Patient risk factors include the severity of illness, underlying immunocompromised state, and length of stay. • Prolonged stay in the hospital is a Major contributing factor

30. Blood stream infections • Most important pathogen: coagulase negative Staphylococcus (CONS): 39.3% • 10 – 15% of patients with HAI have a BSI • Needle sticks may offer a path of entry for the microbes

31. Pneumonia • Most important pathogens • Staphylococcus aureus: 16.8% • Pseudomonas aeruginosa: 16.1% • 10 – 15% of patients with a HAI get pneumonia • 20 – 50% mortality rate • Intubation and mechanical ventilation increase the risk of pneumonia by S. aureus • Pneumonia usually caused by aspiration of bacteria clusters found in resp. Tract/GI tract

32. Urinary tract infection • Most important pathogens • Escherichia coli – 18.2% • Candida albicans – 15.3% • Up to 40% of patients with HAIs get a UTI • E. coli is a natural inhabitant of the GI tract it is commonly found near the anterior urethra • Candida albicans is a natural inhabitant of the GI and genital tract • Normal urination clears the urethra of harmful microbes while catheterization may allow microbes to colonize and infect the urinary tract

34. Surgical site infection • Most important pathogens • Enterococci spp. – 14.5% • Coagulase negative Staphylococcus (CoNS)– 13.5% • Up to 54% of patients with HAI who have also had surgery get a SSI: 500,000 infections/year • Enterococci spp. are a natural inhabitant of the GI tract • Urinary catheterizations and antimicrobial use during hospital stays increases risk of infection

35. 3 Major players in HAIs 1. Antimicrobial use in hospitals and long-term care facilities: has produced resistant strains that are often found colonizing health care workers. These strains can be transferred to patients by normal human contact • Medical devices such as catheters and sutures offer a portal of entry for the microbes 2. Failure of hospital personnel to follow basic infection control: Handwashing, PPE etc. 3. Hospital patients are increasingly immunocompromised

36. Prevention and Control • The basic responsibility of any good hospital remain with establishment of good infection control policies, which can always be achieved with • 1. An infection control committee • 2. An Infection team • The Functions of the Committee: • To do surveillance and infection monitoring of hygiene practices. • Educate the Medical and Paramedical staff on policies relating to prevention of infection, and safe procedures

37. Infection Control Nurse • Is the key member of the team • Maintain the close working relations between Microbiology Laboratory, different clinical services and supportive services like laundry, pharmacy and engineering • Collect information and document on HAIs

40. Universal Precautions!

41. Correlation between Handsrub usageand MRSA botol MDRO in the Hospital, Al Ichsan Bandung 21 August 2013

43. Thank you