Hospital Associated Infections & Control

Deptt of Microbiology, Surgery, Anaesthesiologyand critical care UCMS & GTBH

Go Gators!

Nosocomial infections/ HAINosocomial infections/ HAI

Nosocomial infectionsNosocomial infections are infections are infections which are a result of treatment in a hospital which are a result of treatment in a hospital or a healthcare service unit, but secondary or a healthcare service unit, but secondary to the patient's original condition. to the patient's original condition.

Infections are considered nosocomial if they Infections are considered nosocomial if they first appear 48 hours or more after hospital first appear 48 hours or more after hospital admission or within 30 days after discharge.admission or within 30 days after discharge.

PathophysiologyPathophysiology

Within hours of admission, colonies of hospital strains of bacteria develop in the patient's skin, respiratory tract, and genitourinary tract.

Interaction between the contaminating organism and the host.

Not all colonized individuals develop infection .

Persons who have progressed from colonization to infection may represent only the “tip of iceberg” of persons carrying a particular pathogen.

Consequences of Hospital Associated

Infections

Complicate TreatmentCause Additional SufferingIncreased Costs ($4.5

billion/ yr) prolonged hospital stay drug treatment additional surgery

Cause Death

PathophysiologyPathophysiology

Within hours of admission, colonies of hospital strains of bacteria develop in the patient's skin, respiratory tract, and genitourinary tract.

Interaction between the contaminating organism and the host.

Not all colonized individuals develop infection .

Persons who have progressed from colonization to infection may represent only the “tip of iceberg” of persons carrying a particular pathogen.

Classification of Nosocomial Infections Classification of Nosocomial Infections (based on)(based on)

1.1. Source of micro-organismsSource of micro-organisms

2.2. Type of infectionsType of infections

Source of micro-organismsSource of micro-organisms

Endogenous infections Endogenous infections

eg: eg: Klebsiella, E.coliKlebsiella, E.coli

Exogenous infections Exogenous infections

eg: eg: PseudomonasPseudomonas

Type of infectionsType of infections

1.1. Catheter related blood stream infections Catheter related blood stream infections (CR-BSI)(CR-BSI)

2.2. Urinary tract infections Urinary tract infections (UTI)(UTI)

3.3. Ventilator related pneumonia Ventilator related pneumonia (VAP)(VAP)

4.4. Surgical site infections Surgical site infections (SSI)(SSI)

5.5. Burns infectionsBurns infections

Factors

EnvironmentMicrobesHost characteristicsIndwelling devices

Hospital EnvironmentBuildingAirWaterKitchen and food handlingMedical wasteLaundry

High Risk AreasHigh Risk Areas

Nurseries Intensive care unitDialysis unit Organ transplant

Unit

Burns wardCancer wardOperation theatrePost operative

ward

Agent related factorsAgent related factors

Virulence of the organism (S.aureus, Pseudomonas).

Antimicrobial resistance: highly influenced by usage patterns.

Resiliency: Ability to survive in the environment.

Resistance to disinfectants.

MicrobalMicrobal agents:agents:

Bacteria

Viruses

Parasites

Fungus

MRSA/VRSA

VRE

MDR Acinetobacter

MDR Pseudomonas

ESBL K. pneumo

Common bacterial nosocomial infections Common bacterial nosocomial infections causing bloodstream infectionscausing bloodstream infections

Nosocomial UTINosocomial UTI

E. coliE. coli KlebsiellaKlebsiella PseudomonasPseudomonas Entero cocciEntero cocci Candida albicansCandida albicans

Nosocomial PneumoniaNosocomial Pneumonia

Pseudomonas aeruginosaPseudomonas aeruginosa Klebsiella sppKlebsiella spp Staph aureusStaph aureus AcinetobacterAcinetobacter LegionellaLegionella AspergillusAspergillus CandidaCandida Mycoplasma pneumoniaeMycoplasma pneumoniae Chlamydia pneumoniaeChlamydia pneumoniae

Nosocomial SSINosocomial SSI

Staph aureusStaph aureus PseudomonadsPseudomonads CoNSCoNS Gram negative rodsGram negative rods EnterococciEnterococci

Nosocomial VirusesNosocomial Viruses

Hepatitis B & CHepatitis B & C RSVRSV Rotavirus Rotavirus Enterovirus Enterovirus CMVCMV HIVHIV Ebola Ebola Influenza virusInfluenza virus HSV HSV VZVVZV

Nosocomial Parasite & FungiNosocomial Parasite & Fungi

Giardia lambliaGiardia lamblia Cryptosporidium Cryptosporidium Sarcopties scabeiiSarcopties scabeii Candida albicansCandida albicans Aspergillus spp.Aspergillus spp. Cryptococcus neoformansCryptococcus neoformans

Host Characteristics:Influence susceptibility and

severity of disease

Age Socioeconomic status

Disease historyLife styleNutritional statusImmunization

U nfortunate 5%

Patients at high risk for NI Transplant patients

Chemotherapy patients

Other I mmunocompromisedpatients

Diagnostic and therapeutic Diagnostic and therapeutic interventionsinterventions

Foley Catheters

Ventilators

Other tubes

IVs/CVLs

Implants

Transmission of Nosocomial Infections

Patient to patient

Patient to healthcare worker

Healthcare worker to patient

CHAIN OF INFECTIONCHAIN OF INFECTION

SOURCESOURCEHOSTHOST

PATIENT

EMPLOYEE

ENVIRONMENT

EQUIPMENT

VISITORSVISITORS

Method of Transmission

Direct Indirect

AGEAGE

Nutrition

Socioeconomics

DISEASE

Immunity

Skin Injury

Treatment

Life Style

VehicleVector

MAGNITUDE OF PROBLEMMAGNITUDE OF PROBLEM

WHO: Eastern Mediterranean Region

(11.8%)

South-East Asia, (10%).

At any time over 1.4 million people worldwide suffer from hospital infections

Cost more than US$ 40 million every year in Thailand alone.

In our hospital ????

Our Experience in GTBHOur Experience in GTBH

Emergence of Multidrug resistant Acinetobacter in Burns unit

(1993-1997-1%-1997-2002-9.5%)

Increased prevalence of Kpneumoniae harbouring ESBL (87%)

NICU: Clinical and environmental ESBL K.pneumoniae

Increase in MRSA isolation(40-60%)

Increase in concomitant HLAG resistance in Enterococci (61%)

Infection Control:Basic Elements

The Infection Control Team

Hospital EpidemiologistInfection Control Committee

ChairmanInfection Control DirectorInfection Control PractitionersGTB Healthcare Staff

YOU!!

Infection Control is E veryone’s Business

Fam ily/ V isitors

C N A /P C A /C M A

Reduce transmission of infectious diseases in the health care setting

Improve quality of health care services through promotion of infection control

Goals of Infection control

Prevention

Reduce person to person transmission of organisms

Prevent transmission from environment

Appropriate use of antimicrobials, nutrition and vaccination

Limit invasive procedures to prevent endogenous infections

Prevention

Surveillance of infections, identifying and controlling outbreaks

Prevention of infection in staff members

Enhancing staff patient care practices and continuing staff education

Standard Precautions

Designed to reduce risk of transmission of pathogens

Apply to all patients Apply to:

blood (including plasma, platelets, serosanguinous fluids, and medications derived from blood such as immune globulins, albumin, and factor VIII and IX)

All body fluids, excretions, secretions - - regardless of visible presence of blood

Standard Precautions (cont’d)

HandwashingPersonal protective equipmentsSafe handling of sharpsSafe handling of blood and body

fluid spillsUse of sterile instrumentsControl of hospital waste

Proper handwashing is VITAL to infection prevention

Before patient contact After contact with anything contaminated Between contact with different patients During patient care (per procedures)

before and after invasive procedurebefore and after contact with woundbetween procedures on different body parts of the

same patientBetween glove changesImmediately, if skin is contaminated or an injury

occurs

Wash Your Hands!!Wash Your Hands!!

Studies have shown that healthcare worker compliance with handwashing recommendations is 42% ---- What is your percentage?

WASH YOUR HANDS

It has also been reported that even when healthcare workers do wash their hands, they do not

always use proper technique.

How should I wash my hands?

For general patient care wash hands thoroughly with soap in running water without missing any area.

For high risk patients use hospital-approved antimicrobial soap.(2-4% chlorhexidine gluconate / detergent solution)

For surgical scrub scrub for 3-5 minutes

.

Personal Protective Equipment (PPE)

GlovesGownProtective Eye

and Face ShieldMasksOthers

Boots, shoe covers CPR shield

B E C A R E F U L W I T H S H A R P S

D o n o t r e c a p b y h a n d U s e o n e - h a n d t e c h n i q u e o r a r e c a p p i n g

d e v i c e - - o n l y i f r e c a p p i n g i s u n a v o i d a b l e .

D o n ' t b e n d , b r e a k o r r e m o v e n e e d l e s f r o m s y r i n g e .

D i s p o s e y o u r o w n s h a r p s i n s h a r p s c o n t a i n e r

R e p l a c e s h a r p s c o n t a i n e r s w h e n 3 / 4 f u l l

Safe handling of Blood /Body fluid spills

•Cover spill with paper towel/ blotting paper/newspaper

•Pour 1% sodium hypochlorite solution on and around for minimum 30 min

•Remove with brush and discard

Key Points for Cleaning, Sterilisation& Disinfection of Patient Care Equipment/

Environmental Surfaces

Firstremove gross debris and organic matter by cleaning

Recommendations for sterilisationand disinfectionof patient care equipments and environmental surfacesw3.whosea.org/bct/pdf/HLM-343.pdf

Heat is the best sterilant Only use disinfectants approved by Hospital

Be sure to follow the manufacturer’s directions for use on the container’s label

Bleach is the cheapest & best disinfectant For 1:10 dilution: make fresh daily For 1:5 dilution: use for 30 days

Commonly used disinfectantsCommonly used disinfectants Skin Disinfection (Antiseptic):Skin Disinfection (Antiseptic):Isopropyl alcohol (70-80%)Isopropyl alcohol (70-80%)Halogens (iodine, iodophores)Halogens (iodine, iodophores)Quarternary ammonium compounds (cetrimide)Quarternary ammonium compounds (cetrimide)Biguanides (chlorhexidine)Biguanides (chlorhexidine)Phenolics (hexachlorophene, choroxylenols like Phenolics (hexachlorophene, choroxylenols like

dettol)dettol)Savlon (cetrimide + chlorhexidine)Savlon (cetrimide + chlorhexidine)   Heat sensitive instruments:Heat sensitive instruments:   Glutaraldehyde 2%, hydrogen peroxide 6%Glutaraldehyde 2%, hydrogen peroxide 6%

Environmental DisinfectionEnvironmental Disinfection

Clean surfacesClean surfacesEthyl alcohol (70%) is good for trolley top and Ethyl alcohol (70%) is good for trolley top and

thermometers.thermometers.Hypochlorite for surfaces with blood spills, viruses, Hypochlorite for surfaces with blood spills, viruses,

food preparation surfaces.food preparation surfaces. Dirty surfaces Dirty surfaces Phenolics (Lysol)Phenolics (Lysol)Sodium hypochloriteSodium hypochlorite  

BacteriologicalMonitoring Bacteriological testing of the environment is not

recommended except in selected circumstances

such as:

epidemic investigation where there is a suspected environmental source

dialysis water monitoring for bacterial counts

quality control when changing cleaning practices.

Isolationand containment (in addition to Standard Universal Precautions)

Airborne precautions: droplet nuclei <5 µm e.g.tuberculosis, chickenpox, measles

requires negative air pressure room

Droplet precautions: droplet nuclei >5 µm e.g. bacterial meningitis, diphtheria, respiratorysyncytial virus

Contact precautions: enteric infections diarrhoea , skin lesions

Strict isolation:haemorrhagic fever, SARS

Biohazardous

vs.

Regular

Waste Management

Red Bag(Cat 3,4,7)

All plastic waste (infected andnoninfected)SyringesUsed blood bagUrinary bag, cathetersEmpty plastic containersIV setsEmptyglucose bottlesSurgical glovesSharps: collect in puncture proof containers

Y ellow Bag(Cat 1,2,3,5,6)

soiled wasteCotton dressingPlastic castMaterial contaminatd with blood, body fluidsOutdated discarded medicines Human and animal tissue Body partswhole bloodPlacenta, pus

Black Bag(Cat9,10)

MCD wasteCard boardsPlastics after autoclaveAsh of Biomedical wasteWrappers of Biomedical waste

Report These Conditions To Occupational Health

“Weeping” dermatitis and draining lesions

“Pink eye”/conjunctivitisRash (no known reason)Fever/nausea/vomiting/diarrhea

Blood/body fluid exposuresfor post exposure prophylaxis

Other infectious disease exposures

IMMUNIZATIONSIMMUNIZATIONS

Required:MMRHepatitis B Recommended:Hepatitis AInfluenza

What should I do if an What should I do if an exposure occursexposure occurs?

Thoroughly wash exposed areaContact supervisor/access Occupational Health

Specific postexposurepoliciesHIV, hepatitis A virus, hepatitis B virus, hepatitis C virus, N.meningitidis, M.tuberculosis,VZvirus, hepatitis E virus, C.diphtheriae, B.pertussis, and Rabies

Antibiotic UseAntibiotic Use

Justify antibiotic use

clinical diagnosis

expected infecting microorganisms.

sensitivity pattern, patient tolerance and cost.

Select a narrow spectrum agent as far as possible

Avoid antibiotic combinations if possible.

SurviellanceSurviellance

Site oriented: Ventilator associated pneumonia, surgical site infections, blood stream infections, infections with MDR bacteria

Unit oriented: for high risk units, eg. Burns, ICU, etc.

Priority oriented: For specific issues,eg. UTI in catheterized patients

Training and capacity building Training and capacity building Training MethodologyTraining Methodology

Combination of:Combination of:– LecturesLectures– Practical exercisesPractical exercises– 5 month course5 month course– Series of five 1-week Series of five 1-week

coursescourses– Practical applicationPractical application

Remember:Remember: everything you touch everything you touch has been touched by someone elsehas been touched by someone else

Thanks for washing your hands

Any Questions?????

Talk to your supervisor

Contact Infection Control committee