PREVENTION OF HOSPITAL ACQUIRED INFECTIONS

S. VIVEK ADHISH Professor NIHFW

Definition
An infection acquired in hospital by a patient who was admitted for a reason other than infection. 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. This includes infections acquired in a hospital but appearing after discharge

Significance
Leading Cause of Death
Economic Costs Increased length of stay Loss of livelihood Increased use of drugs

Drug Resistance

A Study in US in 1995 revealed that : Rate of hospital acquired infection: 1 in every 10 admitted patients. Resulted in 88,000 deaths. Annual cost: 4.5 billion to 11 billion$. Deaths because of HAI: 5%. Over last 25 years Nosocomial Infection rates have remained stable at 5-6 HAI per 100 admissions (CDC). However, in terms of infections per 1000 patient days it has increased by 36% from 7.2 in 1975 to 9.8 in 1995.

Global Scenario
Major cause of death and increased morbidity. A prevalence study by WHO in 55 hospitals in 14 countries across globe representing 4 regions showed that : Average rate of HAI 8.7% At any given point of time 1.4 million people world wide suffer from infections complication acquired in hospital

RATES OF HAI IN DIFFERENT REGIONS:

East Mediterranean region: 11.8% South East Asia region: Western Pacific Region: European Region: 10% 9.0% 7.7%

Highest rate of HAI in ICU, acute surgical ward and orthopedic wards. Rates highest among susceptible patients i.e. old age with underlying disease, chemotherapy.

Studies in India
Hospital Infection Rates: 2-15% Contributory mortality rate: 3%

Post Op. wound infection rate: 10-32%

Commission Set-up by British Parliament in 1996 to review Nosocomial Infection reported: Nosocomial Infection cannot be eradicated. 30% could be avoided by better application of existing knowledge and realistic operation control practices. 50 -70% of surgical would infection occur post discharge (UK) but only a quarter of infection control team doing post discharge surveillance. No written policies for use of catheters hand washing. Nosocomial Infection National Surveillance Scheme developed in 1996. National Programme on Hospital Infection Control may be initiated.

Sources of HAI
Endogenous:
These would be from the patient himself.

Exogenous:
Other patients Hospital staff Environment I/V medicines Blood Air Apparatus

1. Hospital pathogen drug resistant

10. Impaired defense

9. Transplantation

2. Poor hygiene

Hospital Infections

8. malignancy

3. Crowding of Patients

7. Burns

4. Instrumentation and surgery

5. Extreme of age

6. Implanted Prostheses

Risk Factors For HAI

Low resistance of patients to infections. Contact with infectious persons. Invasive procedures/ interventions. Inappropriate antimicrobial usage. Drug resistance of endemic microbes. Contaminated environment.

 Patient susceptibility Age Immune status Underlying disease Diagnostic and therapeutic intervention

Environmental factors Bacterial resistance

Wash bowls

Air

Dust and other dry environment

Food

Surfaces contaminated with patients secretions, excretions, body fluids, etc.

Water, disinfectants, solu tions, etc.,

IV fluid equipment Urinals, bed pan

Ventilators

Surgical instruments (endoscope, cystoscope, bronchoscope, etc.

Nosocomial Infection Site

(In order of frequency ) Urinary tract Lower respiratory tract Surgical site Skin and soft tissue Bacteraemia Catheter site Other

High Risk Areas in Hospitals

Nurseries Intensive Care Units Dialysis Units Organ Transplant Units Oncology Wards Operation Theatres Delivery Rooms & Post Op Wards.

The spread of infection within the hospital requires three essential elements:
A source of infecting organisms. A means of transmission of the organism A susceptible host

The transmission may occur:

By direct or indirect contact Through airborne, vehicle, or vector means

Nosocomial infection rate equation

# of nosocomial infections for the month X 100 # of discharges for the month

Reservoirs and Transmission

Endogenous:
Transmission to site outside natural habitat e.g. Urinary tract, wound (damage to skin) Inappropriate antibiotic therapy allowing over growth

Exogenous Cross Infection:

(from other patient or member of staff): Microorganisms are transmitted between patients

Strategies
Risk Stratification:
All patients are not at equal risk. We should assess risk of HAI and accordingly practice patient care practices. Aseptic measure should be appropriate to the level of risk.

Differential Nosocomial Infection risk by patient and intervention

Risk of Infection Type of Patients Type of Procedures 1. Minimal Not immuno-compromised ; no significant underlying disease Infected patients, or patients with some risk factors (age, neoplasm) Non-invasive No exposure to biological fluids Exposure to biological or High risk invasive procedures (e.g. peripheral venous catheter, introduction of urinary catheter)

2. Medium

3. High

Severely immuno-compromised Surgery or patients, (<500 WBC per ml); High risk procedures (e.g. central venous multiple trauma, severe burns, organ catheter, endotracheal intubation transplant

Aseptic Measures Appropriate for Different Levels of Risk of Infection

Risk of Infection 1. Minimal Asepsis Clean Antiseptics None Hands Simple hand washing or disinfection by rubbing Hygienic hand washing or hand disinfection by rubbing Surgical hand washing or surgical hand disinfection by rubbing Clothes Street clothes Devices Clean or disinfected at intermediate or low level Disinfected at sterile or high level

2. Medium

Asepsis

Standard antiseptic products

Protection against blood and biological fluids, as appropriate Surgical clothes: dress, mask, caps, sterile gloves

3. High

Surgical asepsis

Specific major products

Disinfected at sterile or high level

Reducing Person To Person Contamination : Hand Washing Is Key.

TYPES OF HAND WASH
Simple Hand Wash Hygienic Hand Wash Surgical Hand Washing Hand Disinfection by Rubbing Surgical Hand Disinfection by Rubbing

Simple Hand Wash

Hand washing limited to hands and wrist Use non-antiseptic soap

Hygienic Hand Wash

Area as above. Use antiseptic soap (follow manufacturer instructions e.g.. one minute)

Surgical Hand Washing

Area includes hands and forearms With antiseptic soap 3-5 minutes

Hand Disinfection By Rubbing

Use alcohol, rub on hand and wrist (alcohol rubs consists of antiseptics and emollient gels) as per manufacturers instruction

Surgical Hand Disinfection By Rubbing

Hand and forearm Simple hand wash followed by drying Two application of alcoholic rub and rub to dry for duration as per manufacturers recommendations.

PREVENTING TRANSMISSION FROM ENVIRONMENT

Cleaning of Hospital Environment
Routine cleaning is very essential. 90% of microorganism in visible dust and routine cleaning remove this. Hospital housekeeping services should have schedule of cleaning which has frequency and use of agents specified. It should include schedule for cleaning floor, walls, windows, beds, curtain, screen, fixture, furniture, bath toilet and all reusable medical devices

Cleaning of Hospital Environment (Cont.)

Proper method Appropriate levels of cleanliness. For this we may classify hospital into zones Zone A : No patient contact : Administration Office Zone B : Patients not infected Zone C : Patient infected : Isolation Room Zone D : Highly susceptible patient : OT, ICU

Level of Cleaning
Zone A : Domestic cleaning Zone B : No dry mopping/vacuum Wet mopping Disinfect before mopping Use detergent Zone C : Ideally separate equipment for each room Use detergent/disinfectant solution Zone D : Ideally separate equipment for each room Use detergent/disinfectant solution All horizontal surface and toilets to be cleaned daily in zone B, C and D.

 Use of Hot Water Sanitary Equipment: Cooking Utensil: Linen:

80 C 1 Min. 80 C 1 Min. 70 C 25 Min. 95 C 10 Min.

Disinfection of Patient Equipment Remove micro-organisms without complete sterilization to prevent transmission of organism

Infection Control Committee

Chairman: Director/ Medical Superintendent
Members : Heads of Major Departments Operation Theater Nursing Chief Infection Control Officers Nurse CSSD ICU OPD Casualty Kitchen Laundry Cleaning services Purchasing Equipment Committee Making Alterations and Letting Agencies.

 Infection Control Team

ICO IC Nurse Microbiologist Epidemiologist Software Clerk

1 Full Time Practitioner 1/200 Teaching Referral; 1/300 Community Hospital

Functions of the Infection Control Nurse

Experienced nurses are appointed full time on this position

Regular visit to all wards and high risk units.

Checking nursing supervisors register & records suggestive of infection. Collection and tabulation of daily data of incidence of hosp infection
Identification and location of pt Date of admission Date of infection Type of infection Cultures taken, antibiotics taken Name of treating physician

Surveillance of HAI
Reducing infection rates in the hospital Establishing endemic baseline rates Identifying & containing outbreaks Evaluating & monitoring all infection control measures Monitoring antimicrobial susceptibility patterns Dept of Microbiology carries out surveillance of HAI with the help of infection control team.

Prevention of Nosocomial Infection

Key components are : Limiting transmission of organism between patient
Hand washing Gloves Aseptic practice Isolation Disinfection and sterilization

Controlling environment risk for infection

 Appropriate use of prophylactic antimicrobials nutrition and vaccination Limiting endogenous infection by
Minimising invasive procedure Appropriate use of antibiotics

Surveillance Prevention of infection in staff Enhancing staff patient care practices and continuing staff education.

Disinfection
Critical Items
Sterilization

Semi-critical Items
High level disinfection Intermediate level disinfections

Non-critical Items
Low level disinfection

Universal Precautions
Blood and fluids visibly contaminated with blood. Also semen and vaginal secretions, tissues and body fluids

Body Substance Isolation

Faces, urine, sputum , saliva, wound drainage etc.

Success Factors
Leadership Co-ordination Partnerships Communication Consistency of information Sharing

HEALTHCARE ACQUIRED INFECTION

Needs to be managed across health and social care systems as an integral part of patient safety

The Way Forward

Protocols for all procedures Guidelines for handwashing, cleaning, disinfection etc Functional Infection Control Committees and Infection Control Teams Surveillance

 National Progamme or prevention of hospital acquired Infections