Nosocomial Infections Epidemiology and key concepts

1. Nosocomial Infections Epidemiology and key concepts Nelly Hassan Ali ElDin Department of Cancer Epidemiology & Biostatistics

2. It is an infection acquired in a medical setting in the course of medical treatment. It meets the following criteria: 1 - Not found on admission 2 – Temporally associated with admission or a procedure at a health-care facility 3 – Was incubating at admission but related to a previous procedure or admission to same or other health-care facility. Nosocomial infection:

3. It is an important public health problem because of their frequency, attributable morbidity and mortality and cost. In the USA and in Europe, approximately 5–10% of hospitalized patients develop an infection during their hospital stay. Higher incidence rates are reported in hospitals in developing countries. In our hospital (National cancer Institute,), blood stream infections among pediatric patients accounted for 87.6/1000 discharges at 1999).Hospital acquired infection HAI contributed to 37.5% of these episodes. Why Nosocomial infection ?

4. Monthly incidence of febrile episodes and associated BSI rates per 1000 discharges in the pediatric inpatient units from January to December 1999

5. Increased morbidity (serious consequences and permanent disability ) The length of hospital stay is prolonged, on average by 5–10 days. The risk of death approximately doubles in patients who acquire hospital infection. Hospital-acquired infections are very expensive and contribute significantly to the escalating costs of health care. It has been argued that, even if moderately effective, a hospital infection control program is one of the most cost-effective and cost-beneficial preventative medical interventions currently available. Impact of nosocomial infection?

6. The use of uniform definition is crucial if data from one hospital are to be compared with those of another hospital (inter-hospital) or with an aggregated database (intra-hospital). NI is a localized or systemic condition: 1- that results from adverse reaction to the presence of an infectiuos agent(s) or its toxins and 2- that was not present or incubating at the time of admission to the hospital. For most bacterial NI, it become evident 48 hours or more (typical incubation period) after admission. Because the incubation period varies with type of pathogen, and extent of the underlying condition, each infection should be assessed individually for evidence that links it to hospitalization. Definition of Nosocomial infection

7. In superficial incisional surgical site infections (SSI) which involve only the skin or subcutaneuos tissues, it occurs within 30days after the operation. In deep incisional SSI which involves deep soft tissues (fascia and muscles) and organ/space SSI which involves anatomic structures not opened or manipulated during operation, in both conditions; it occurs 30days of operation or within one year if an implant is present. Specific situations of NI

8. First (available information): The information used to determine the presence and classification of an infection should be a combination of clinical findings, laboratory evidence and supportive data. Clinical evidence is derived from direct observation of the infection site or review of other pertinent sources of data such as the patient’s chart or medical record. Laboratory evidence includes results of cultures, antigens or antibody detection or microscopic examination. Supportive data are derived from other diagnostic studies such as: X-ray, US, CT, MRI, BAL, Endoscopy, ..etc Important principles upon which NI definitions are based

9. Second, (a physician’s or surgeon’s diagnosis) The diagnosis of infection by the surgeon or physician is derived from direct observation during a surgical operation, endoscopic examination or other diagnostic study or from clinical judgment. This diagnosis could be an acceptable criterion for an infection unless there is compelling evidence to the contrary. For certain sites of infections, however, a physician’s clinical diagnosis in the absence of supportive data must be accompanied by initiation of appropriate or empirical antimicrobial therapy to satisfy the criterion.

10. There are two special situations in which an infection is considered nosocomial: a) Infection that is aquired in the hospital but does not become evident until after hospital discharge. b) Infection in a neonate that results from passage through the birth canal. There are two special situations in which an infection is not considered nosocomial: Infection that is associated with a complication or extension of infection already present on admission, unless a change in pathogen or symptoms strongly suggests the acquisition of new infection. In an infant, an infection that is known or proved to have been acquired transpalcentally (e.g congenital rubella, toxoplasmosis) and become evident at or before 48 hours after birth

11. 1) Colonization, which is the presence of microorganisms (on skin, mucous membranes, in open wounds or in execretions or secretions) that are not causing clinical signs or symptoms. . 2) Inflammation, which is a condition that results from tissue response to injury or stimulation by noninfectious agnets such as chemicals. There are two conditions that are not infections:

12. There are two additional points that are important to understand regarding the definition of NI: Fisrt) the preventability of an infection is not a consideration when determining whether it is nosocomial. For example, preventing the development of nosocomial C. difficle pseudomembraneous colitis after extensive antibiotic treatment may not be possible (i.e inevitable in some immunocompromised patients) Another example some would argue that neonatal infections acquired during vaginal delivery are inevitable and, therefore, should not be counted as nosocomial.

13. However, these neonatal infections are nosocomial, they can be identified as maternally acquired, and the analysis of their incidence can be dissiminated to obestetricians for interventional strategies (i.e preventable). Second), surveillance definitions are not intended to define clinical disease for the purpose of making therapeutic decisions. Some true infections (HIV infection) will, therefore, be missed while other conditions (asymptomatic bacteruria) may erroneously be counted as infections.

14. There are three principal goals for hospital infection control and prevention programs: Protect the patients Protect the health care workers, visitors, and others in the healthcare environment. Accomplish the previous two goals in a cost effective and cost efficient manner, whenever possible. . Goals for infection control and hospital epidemiology

15. Function and organization of the infection control program The provision of an effective infection control program (ICP) is a key to the quality and a reflection of the overall standard of care provided by the health care institution. Major differences among countries in their health care resources and organization, and medical cultures explain the diversity of approaches to the organization of hospital hygiene and infection control programs. The growth in ICP has been paralleled by the establishment and growth of a number of professional and governmental organizations which focus on NI prevention and control such as (APIC, SHEA, CDC, HICPAC).

16. Infection control program(ICP) In the majority of countries ICP, typically operates on two levels: an executive body – the infection control team(ICT)– and an advisory body to the hospital management – the infection control committee(ICC)– which adopts the ‘legislative’ role of policy making.

17. Infection Control Committee

18. Infection control Committee (ICC): The hospital ICC is charged with the responsibility for the planning, evaluation of evidenced-based practice and implementation, prioritization and resource allocation of all matters relating to infection control. The ICC must have a reporting relationship directly to either administration or the medical staff to promote ICP visibility and effectiveness. The ICC should meet regularly (monthly) according to local need

19. Infection Control Committee (cont): The membership of the hospital ICC should reflect the spectrum of clinical services and administrative arrangements of the health care facility. As a minimum, the committee should include: • Chief executive, or hospital administrator or his/her nominated representative. • ICD or hospital microbiologist (chairperson). • Infection Control Nurse (ICN). • Infectious Diseases Physician (if available) • Director of nursing or his representative. • Occupational Health Physician (if available). • Representative from the major clinical specialities. • Additionally representatives of any other department (pharmacy, central supply, maintenance, housekeeping…etc) may be invited as necessary

20. The ICC has the following tasks: • To review and approve the annual plan for infection control • To review and approve the infection control policies. • To support the IC team and direct resources to address problems as identified • To ensure availability of appropriate supplies • To review epidemiological surveillance data and identify area for intervention.

21. The ICC has the following tasks (cont): • To assess and promote improved practice at all levels of the health care facility • To ensure appropriate training in infection control and safety. • To review risks associated with new technology and new devices prior to their approval for use. • To review and provide input into an outbreak investigation • To communicate and cooperate with other committees with common interests such as antibiotic committee, occupational health committee….etc.

22. Infection Control Team (ICT): It comprises the infection control doctor ICD and infection control nurse ICN. The ICT is responsible for the day-to-day running of ICPs. It is important that all hospitals should have an ICT. The optimal structure of ICT will vary with needs and resources of the facility. The ICT must have the authority to manage an effective ICP. In large hospitals, this usually means a direct reporting relationship with senior administration

23. Role of Infection Control Team : The role of ICT is to: Ensure that an effective ICP has been planned, co-ordinate its implementation, and evaluate the impact of such measures. It is important to ensure that there is a 24-hour access to the ICT for advice on infection prevention and control which would include both medical and nursing advice.

24. The role of Infection Control Team : • To develop an annual infection control plan with clearly defined objective. • To develop written policies and procedures including regular evaluation and update. • To supervise and monitor daily practices of patient care designed to prevent infection. • To ensure availability of appropriate supplies • To organize an epidemiological surveillance program (particularly in high risk areas for early detection of outbreak). • To educate all grades of staff in infection control policy, practice and procedures

25. The Role of Infection Control Team (cont): • To develop and implement annual training plan for all health care workers. • To have scientific and technical support role in purchasing and monitoring of equipment and supplies. • To participate with the pharmacy and antibiotic committee in developing a program for supervising the use of antibiotics. • To participate in the audit activity. • To submit monthly reports on activities to ICC.

26. Infection Control Doctor (ICD):

27. Infection Control Doctor (ICD): The infection control physician should be a medically qualified senior staff of the facility who is interested in and who spends the majority of his time involved in hospital infection control. He could be a medical microbiologist, an epidemiologist or infectious disease physician Irrespective of his professional background, the ICD should have the interest, knowledge and experience in different aspects of infection control.

28. The role and responsibilities of the ICD: • Serves as a specialist advisor and takes a leading role in effective functioning of the ICT. • An active member of ICC may be the chairman. • Assist the ICC in drawing the annual plan, policies and long-term program for prevention & control of hospital infection. • Advises the hospital administrator directly on all aspects of infection control • Participates in the preparation of tender documents for support services • Must be involved in setting quality standards, surveillance and audit with regard to hospital infection.

29. Infection Control Nurse (ICN)

30. Infection Control Nurse (ICN) An ICN or practitioner is a registered nurse with an additional academic education and practical training which enables her to act as a specialist advisor in all aspects relating to infection control. The ICN is usually the only full-time practitioner in the ICT and therefore takes the key role in day-to-day infection control activities with the ICD providing the leading role

31. The role of Infection Control Nurse The role and responsibilities of the ICN are summarized as follows: • Has an ongoing contribution to the development and implementation of IC policies and procedures, participate in auditing and monitoring tools related to IC and infectious diseases. • Provide specialist nursing input in the identification, prevention, monitoring and control of infections within the hospital • Participate in surveillance and outbreak investigation

32. The role of ICN (cont) • Identify, investigate and monitor infections, hazardous practice and procedures • Participate in the preparation of documents relating to service specifications and quality standards. • Participate in training and educational programs and in membership of relevant committees where infection control input is needed

33. Infection control is a quality management function Quality is defined by its attributes: effectiveness, efficiency, optimality, acceptability, legitimacy, and equity. Quality is also the relationship of structure, process and outcome. Quality is “hassle elimination” Quality is the result of planning, monitoring (through measurement) and improvement (through team effort).. How to achieve in infection control

34. Quality Scientific approach Teamwork (Joiner traingle) Improvements in quality are achieved by understanding processes, and variations and are supported by teamwork and scientific approach

35. Thank you