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Hospital infection Control
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Nosocomial infections (hospital –acquired infection):
An infection acquired in [a] hospital by a patient who
was admitted for a reason other than that infection.
OR:
An infection occurring in a patient in a hospital or
other health care facility in whom the infection was
not present or incubating at the time of admission.
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As a general timeline, infections occurring more than 48
hours after admission are usually considered nosocomial.
Frequency of infection:
Nosocomial infection occurs worldwide and affects both
developed and poor countries.
According to studies conducted by WHO, 8.7% of
hospitalized patients had nosocomial infection.
Factors influencing the development of nosocomial infection:
1-The microbial agents and antibiotic-resistance ability: -Patients are exposed to a variety of microorganisms during a hospital stay: A- Endogenous microbes: Part of a patient’s own flora.
B- Exogenous microbes: -Patients, and Visitors. -Medical staff (doctor, nurse, physiotherapist, technician). -Instruments (Endoscopy, catheter, surgical instruments) -Fluids, blood, or food. -Dust, and Insect bite.
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Hospital-dwelling microbes:Bacteria:
Staphylococcus aureus (MRSA), coagulase-negative
Staphylococci, Enterococci (VRE), and Enterobacteriaceae
species.
Viruses:Hepatitis B and C, Rotaviruses, and Enteroviruses.
Fungi:Candida albicans.
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Hospital-dwelling bacteria could develop antibiotics
resistance ability due to conjugation process.
Conjugation: Transfer of bacterial plasmid from one
bacterium to another by sex pili.
Plasmid: Extracircular supercoiled DNA that carry some
important gene such as the reporter genes (CAT gene) .
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2 .Patient susceptibility :Important patient factors influencing acquisition of infection are:
1-Age : infancy and old age .2-Immune status :
chronic diseases like malignant tumor, diabetes, renal failure immunosuppressive therapy and AIDS.
3-Underlying disease : injuries to skin (burn, wound), ischemia.
4-Malnutrition.5-Diagnostic and therapeutic interventions :
biopsies, catheterization, I.V. cannulation, endoscopic examination,
incubation/ventilation.
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3 .Environmental Factors:- Different factors play a role in establishment of
Nosocomial infections: 1-Crowded conditions.
2-Frequent transfer of patients from one unit to another.
3-Concentration of susceptible patients :
( newborn infants, burn patient, intensive care.)
4-Microbial flora may contaminate objects, devices that may come in susceptible site of the patient.
Sources of Hospital-acquired Infections:Nimer
CONTAMINATED HOSPITAL ENVIRONMENT
Instruments, Fluids, Food, Air, Medications
Patient Normal flora
Cutaneous, GIT, Genitourinary,
Respiratory
Invasive medical devices : Iatrogenic
Urinary Catheter, Intravenous catheter, Endotracheal tubes,
Endoscopes
Medical Personnel: Colonized, Infected, Transient, Carriers.
Plasmid transfer
Common Nosocomial Infections:1 .Urinary tract infections (UTI):
This is the most common nosocomial infection it account for 40 % of hospital acquired infections; 80% of infections are associated with the use of an indwelling catheter.
Organisms :
E.coli, multi-resistant Klebsiella, Pseudomonas aeruginosa,
Enterobacter and Candida albicans .Source:
Endogenous flora or exogenous from other patients, health
care provider, instrument, etc.
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Diagnosis:
positive urine culture (1 or 2 species) with at least 105
bacteria/ ml, with or without clinical symptoms.Prevention:
1-Remove the indwelling urinary catheter as soon as possible .
2-Use aseptic technique for inserting or manipulating the catheter.
3-Maintain an unobstructed urinary flow.4-Ensure that the patient is taking sufficient amount of fluids
per day (3-4 L).5-Give proper antibiotic therapy for proper course.
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2.Nosocomial Pneumonia:
Nosocomial pneumonia is the second most common
nosocomial infection accounting for 15 % of all nosocomial
infections .
It is associated with mortality rates that range from
20-50% .
It occurs in several patient groups, the most important are
patients on ventilator in intensive care units (ICU), where
the Incidence rate of pneumonia is 3% per day .
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Organisms:
Staph aureus, Pseudomonas , Enterobacter, Klebsiella
pneumoniae, Candida albicans and Haemophilus
influenzae.
Source: endogenous from upper air way, and exogenous
from contaminated respiratory equipment, patients,
visitors, etc.
Diagnosis: isolation of microbe from clinical specimens,
and presence of signs and symptoms of infect.
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Prevention:
1-Wear gloves; for contact with respiratory
secretions.
2-Wash hands after contact with respiratory secretions,
even if gloves have been worn.
3-Maintain open airway.
4-Isolate patient with potentially transferred
respiratory infections.
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Other hospital-acquired infections:
1-Surgical site infections: Staphylococcus aureus,
Staphylococcus epidermidis (Intravenous catheter).
2-Nosocomial Bacteremia.
3-Skin and soft tissue infections:
Open sores (ulcers, burns and bedsores).
4-Gastroenteritis : The most common nosocomial infection in the children, where rotavirus is a chief pathogen.
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5-Nosocomial Bloodborne diseases: A-Hepatitis B virus: -Transmission rate was 25%, reduced due to application of vaccination, the practice of not recapping needle, and Hepatitis B surface antigen screening test.
B-Hepatitis C: Rate is 3%. Anti-viral drugs at first 8 hrs reduce the infection by 60%.
C-HIV: Rate is 0.3%
Infection Control :
-Biological safety precautions.
-Hand hygiene.
-Clean & contaminated area.
-Management of blood & body fluid spillage.
-Immunization of health care workers.
-Post exposure management for health care
workers.
Biological safety precautions:
1-All clinical specimens should be considered as
potentially hazardous.
2-Wear Lab coat, gloves, shoes (Protective purpose).
3- Remove gloves when using the telephone or
photocopier.
4- Skin cuts on the hands, must be covered with a
waterproof dressing prior to start working.
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5-Never perform any action which may bring your hands
into contact with your face, eyes or mouth, such as
eating, smoking or adjusting contact lenses.
6-Remove laboratory coat and
gloves and wash hands
before leaving your
working area.
Hand hygiene:
When Do We Need to Wash Our Hands?-Before eating-Before starting work-Before and after any patient contact-After contact with potentially contaminated materials like blood, urine, CSF.
-Before wearing gloves.-After removing gloves.-Before and after performing any medical procedure-Before leaving work.
When Do We Need to Wash Our Hands?N
Types of Hand Hygiene (Decontamination):
1-Routine care (minimal): -Hand washing with non antiseptic soap. -Or quick hygienic hand disinfection by rubbing with alcoholic solution.2-Antiseptic hand cleaning (moderate) – aseptic care of infected patients: -Hygienic hand washing with antiseptic soap. -Quick hand disinfection by rubbing with alcoholic solution.
3-Surgical scrub (surgical care):Surgical hand and forearm washing with antiseptic soap and sufficient time and duration of contact (3 – 5 minutes).
Clean & contaminated area:
Control of spreading of infection could be achieved by classifying hospital environment into one of four zones:Zone A: no patient contact. Normal cleaning.
( e.g. administration, library.)
Zone B: Care of patients, who are not infected and not highly susceptible. Wet disinfection with detergent.
Zone C: infected patients (isolation wards) . Clean with a detergent/disinfectant solution ,
with separate cleaning equipment for each room.
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Zone D: High–susceptible patient (protective isolation) or protected areas such as: Operating room, delivery rooms, intensive care units, premature baby units, and haemodialysis unit.
-Clean using a detergent/disinfectant solution and separate cleaning equipment.
Blood and body fluid spillage, and contaminationmanagement :
PURPOSE: To protect healthcare workers, patients and
visitors from unnecessary exposures to bloodborne
pathogens and other potentially infectious body fluids.
Three types:
1-Low grade disinfection:
Quaternary ammonium: Bactericidal effect.
used for low amount- blood spillage.
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2-Intermediate grade disinfection: Phenol and 70-90% alcohol ;Bactericidal and Virucidal effect. Used for low amount -blood spillage (less than 50ml).
3-High grade disinfection: Formaldehyde ,Glutaraldehyde, Sodium hydrochlorite , and hydrogen peroxide. : Sporicidal ,Mycobactericidal, Fungicidal, and bactericidal effect. Used for: high blood spillage (more than 50ml), and fungal decontamination.
NOSOCOMIAL INFECTION SURVEILLANCE:
The development of a surveillance is an essential first step
to identify local problems , and evaluate the effectiveness
of the infection control activity.
Objectives:
The purpose of surveillance program is to detect, record,
and report hospital acquired infection aiming to reduce
them and their costs.
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2 .Strategy of Surveillance :A surveillance system must meet the following criteria:Simplicity: to minimize costs and work load, and promote
unit participation by feedback.Flexibility: to allow changes when appropriate.
Acceptability: Evaluated by ICC according to data analysis .
Consistency: use standardized definitions and methodology
Sensitivity .Specificity.
Infection Control Committee:
1-Management2-Epidemiologist 3-Physicians
4-Other health care workers(Laboratory, or Nurse).5-Clinical microbiologist 6-Pharmacy
7-Central supply 8-Maintenance
Tasks (most important) of the committee -To review and approve a yearly program of activity
for surveillance and prevention.-To review epidemiological surveillance data and identify
areas for intervention.
Role of the physician:1-Direct patient care using practices which minimize
infection.2-Appropriate practice of hygiene:
( hand washing, and isolation.)3-Supporting the infection control team.
4-Protecting their own patients from other infected patients and from hospital staff who may be infected.
5-Obtaining appropriate microbiological specimens when an infection is present or suspected.