NOSOCOMIAL INFECTION

Nosocomial infections (NCI)

"nosus" = disease "komeion" = to take care of

Infections that occur during hospitalization but are not present nor incubating upon hospital admission

History of Nosocomial Infection

Ignaz Semmelweis, (1840s) demonstrated importance of hand hygiene No progress for next century 1976, the Joint Commission on Accreditation of Healthcare Organizations - standards for infection control Nosocomial infection still on the increase - emerging infection

Nosocomial Infections
5-10% of patients admitted to acute care hospitals acquire infections 2 million patients/year of nosocomial infections occur in ICUs 90,000 deaths/year Attributable annual cost: $4.5 $5.7 billion
Cost is largely borne by the healthcare facility not 3rd party payors
Weinstein RA. Emerg Infect Dis 1998;4:416-420. Weinstein Jarvis RA. WR.Emerg EmergInfect InfectDis Dis1998;4:416-420. 2001;7:170-173. Jarvis WR. Emerg Infect Dis 2001;7:170-173.

Nosocomial Infections
70% are due to antibiotic-resistant organisms Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection
Burke JP. New Engl J Med 2003;348:651-656. Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

Major Sites of Nosocomial Infections

Urinary tract infection Bloodstream infection Pneumonia (ventilator-associated) Surgical site infection

CAUSES OF HCAI
Virtually all microorganisms can cause nosocomial infections Viruses Bacteria Fungi Parasites

BACTERIA
Bacteria Gram +
Staphylococcus aureus Staphylococcus epidermidis

Gram Enterobacteriaceae Pseudomonas aeruginosa Acinetobacter baumanni

Mycobacterium tuberculosis

NOSOCOMIAL PATHOGENS
Viruses
Blood borne infections : HBV, HCV, HIV Others: CMV, rubella, varicella, SARS

Fungi
Candida Aspergillus

SOURCES OF INFECTION
Endogenous
source is the normal flora or colonisers of skin and other epithelial surfaces

Exogenous
other persons (cross-infection) inanimate objects (fomites)

TYPES BY ORIGIN
1.Endogenous:
Caused by the organisms that are present as part of normal flora of the patient

2. Exogenous:
caused by organisms acquiring by exposure to hospital personnel, medical devices or hospital environment

Up to 20% of skin-associated bacteria in skin appendages (hair follicles, sebaceous glands) & are not eliminated by topical antisepsis. Transection of these skin structures by surgical incision may carry the patient's resident bacteria deep into the wound and set the stage for subsequent infection.
Downloaded from: Principles and Practice of Infectious Diseases

2004 Elsevier

The inanimate environment is a reservoir of pathogens

X represents a positive Enterococcus culture

The pathogens are ubiquitous

~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, C.diff CNS and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

SPREAD OF INFECTONS
Air-borne
Skin scales, droplet nuclei

Contact
Direct Hands & clothing Droplet contact followed by autoinoculation Clinical equipment Indirect Bedpans, bowls, jugs, etc

SPREAD OF INFECTONS

The hands are the most important vehicle of transmission of HCAI

Nosocomial Infections

Compromised Hosts

Compromised Hosts

Nosocomial Infections

Exogenous Infections

Exogenous Infections

Endogenous Infections

Nosocomial Infections

Chain of Transmission

Universal Precautions

Universal Precautions

PRACTISE STANDARD PRECAUTIONS

CONTROL OF HCAI
Hand hygiene is the single most important measure for control of nosocomial infections

TYPES OF HAND HYGIENE PROCEDURES

Hand washing
Hand washing is usually limited to hands and wrists Hands are washed for a minimum of 10 15 seconds with soap (plain or antimicrobial) and water Transient micro-organisms are mechanically removed by rinsing.

Hand antisepsis/decontamination
Hand antisepsis removes or destroys transient micro-organisms and confers a prolonged effect. Two ways: Wash hands and forearms with antimicrobial soap and water, for 15-30 seconds Decontaminate hands with a waterless, alcohol-based hand gel or hand rub for 15-30 seconds. Appropriate for hands that are not soiled with protein matter or fat.

TYPES OF HAND HYGIENE PROCEDURES

Surgical hand antisepsis
Removes or destroys transient micro-organisms and confers a prolonged effect. Hands and forearms are washed thoroughly with an antiseptic soap for a minimum of 2-3 minutes. Hands are dried using a sterile towel. Required before performing invasive procedures.

Alcohol based hand hygiene Easy to use Quick solutions

Very effective antisepsis due to bactericidal properties of alcohol

Hand Hygiene
Single most important method to limit cross transmission of nosocomial pathogens Multiple opportunities exist for HCW hand contamination
Direct patient care Inanimate environment

Alcohol based hand sanitizers are ubiquitous

USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

HAND WASHING TECHNIQUE

Source: World Health Organization. Regional Office for Western Pacific.

PROTECT YOURSELF THROUGH IMMUNISATION

Immunisation
BCG Hepatitis B Tetanus Rubella Varicella Influenza

Chemical Antimicrobials

Agent Surfactants Quats (cationic detergent) Organic acids and bases Heavy Metals Halogens Alcohols Phenolics

Mechanisms of Action Membrane Disruption; increased penetration Denature proteins; Disrupts lipids High/low pH Denature protein Oxidizing agent Disrupts cell membrane Denatures proteins; Disrupts lipids Disrupts cell membrane

Comments Soaps; detergents Antiseptic - benzalconium chloride, Cepacol; Disinfectant Mold and Fungi inhibitors; e.g., benzoate of soda Antiseptic & Disinfectant; Silver Nitrate Antiseptic - Iodine (Betadine) Disinfectant - Chlorine (Chlorox) Antiseptic & Disinfectant Ethanol and isopropyl Disinfectant Irritating odor

Aldehydes

Denature proteins

Gluteraldehyde - disinfectant (Cidex); Formaldehyde disinfectant

Used in a closed chamber to sterilize

Ethylene Oxide

Denaturing proteins

Oxidizing agents

Denature proteins

Hydrogen peroxide antiseptic; Hydrogen peroxide disinfectan; Benzoyl peroxide antiseptic

Agent

Mechanisms of Action
Denatures proteins Denatures proteins Denatures proteins Incineration of contaminants Oxidation & Denatures proteins

Comments
Kills vegetative bacterial cells and viruses Endospores survive 121C at 15 p.s.i. for 30 min kills everything Kills pathogens in food products Used for inoculating loop 170C for 2 hours; Used for glassware & instrument sterilization

Physical Antimicrobials

Moist Heat, boiling Moist Heat, Autoclaving Moist Heat, Pasteurization Dry Heat, Flaming Dry Heat, Hot air oven Filtration

Separation of bacteria Used for heat sensitive liquids from liquid (HEPA: from air)

Cold, Lyophilization (also desiccation)

Cold, Refrigeration Osmotic Pressure, Addition of salt or sugar Radiation, UV Radiation, X-rays Strong vis. Light

Desiccation and low temperature

Decreased chemical reaction rate Plasmolysis of contaminants

Used for food & drug preservation; Does not necessarily kill so used for Long-term storage of bacterial cultures
Bacteriostatic Used in food preservation (less effective against fungi) Limited penetration Used for sterilizing medical supplies Line-drying laundry

DNA damage (thymine dimers) DNA damage

Conclusion

Hospital

Pathogen

Unhappy patients

Unhappy director

Hospital

Surveillance Happy Patients

Happy director

Hands Spread Disease

Why disinfection and sterilization?

Contagious diseases Hospital infection (e.g., OR, ID ward) or other opportunistic infection Lab contamination, etc. Microbes:
- usually easy to grow in environment; - but also can be inhibited or killed by certain environmental (physical or chemical) factors/conditions.

Terminology

Disinfection Sterilization Bacteriostasis Antisepsis Asepsis

Disinfection
Process of reducing or eliminating living pathogenic microorganisms in or on materials, so they are no longer a health hazard.
For example: use of alcohol before drug injection.

Sterilization
Process of destroying all microbial forms. A sterile object is one free of all microbial forms, including bacterial spores. More thorough than disinfection

Bacteriostasis
Process of inhibiting the growth of microorganisms, in vivo (mostly) or in vitro For example: bacteriostatic antibiotics

Antisepsis
Process of inhibiting or preventing growth of microbes, mostly in vitro and not bactericidal or sporicidal For example: use of chemical agents on skin, other living tissues or food/beverage.

Asepsis
A state where no living microorganism exists. For example: OR (Operating Room)

Controlling Microorganisms with Physical Conditions

High Temperature (heat) Radiation Ultrasound Filtration Low Temperature Desiccation

High Temperature
Dry heat and Moist heat protein denaturation and clotting; DNA strand breakdown

static action

cidal action

Dry heatprotein oxidation

Incineration
most thorough (>500) disposals and corpes

Flaming (burner)
test tube opening, transferring loop

Hot air sterilization/Baking

160-170, 2h Glassware, syringes, needles, etc

Infrared heat: similar to baking

Moist heatdenaturing proteins and melt lipids

Autoclaving
Most commonly used and effective 121 (103.4kPa), 15-20min killing both vegetative organisms and endospores

Boiling
100 (105 with 2% Na2CO2) , 15-20min cidal for vegetative cells but not necessarily spores

Regular Steam (Arnold Sterilizer)

100 , 15-20min cidal for vegetative cells but not necessarily spores

 Pasteurization
to kill pathogens in readily perishable objects (milk, wine) flash method : 71.6, 15s holding method : 62.9, 30 min

Fractional sterilization
alternating exposure and cooling time for a consecutive period: Steam heating (100, 30 min) 30 for endospores to germinate 100, 30 min to kill germinated endospores 30-37 overnight for remaining endospores to germinate 100, 60 min to kill last remaining germinated endospores for sugar- or milk-containing culture media

Moist Heat vs Dry Heat

Moist heat
Penetrating potency Temp for protein clotting Extra heat released from condensation higher lower yes

Dry heat
lower higher no

Sterilizing potency: Moist heat >> Dry heat

Radiation
Ultraviolet (UV) radiation
mechanism: blockage of DNA replication by forming thymidine dimmers microbicidal activity of UV depends on:
length of exposure wavelength: 200-300 nm, with the best effect of 265-266nm bulb life (4000hr)

very poor penetrating power for air or surface disinfection (OR, ID ward, labs) causing eye damage, burns and mutation in skin cells

 Ionizing Radiation
X-rays, gamma rays and high-speed electrons generating more energy and penetrating power than UV to sterilize pharmaceuticals, disposable medical supplies (e.g., syringes, gloves, catheters, sutures) and foods

Microwave
penetrating non-metal materials (glass, plastics)

 Ultrasound
more effective for gram-negative bacteria Lack of thoroughness survivors remain

Filtration
sterilize heat- or chemical-sensitive solutions not effective for virus, ricketia, mycoplasma

Seitz filter

 Desiccation
static effect by inhibiting microbial enzymes not effective against endospores mainly for food reservation

Low Temperature (-20 -70)

inhibits microbial growth by slowing down microbial metabolism a special form: lyophalization (freeze-drying), used for long-term (years) reservation of bacteria stocks
fast freezing + drying protecting agents (glycerol, serum)

Control Microorganisms with Chemical Agents (Disinfectants and Antiseptics)

Antimicrobial modes of action of disinfectants and antiseptics

Denaturation of bacterial proteins by disrupting hydrogen and disulfide bonds phenol (high conc.), alcohol, heavy-metal (high conc.), acids, alkalies, aldehydes)
Damage to bacterial membrane (lipids and/or proteins), causing leakage of intracellular molecules phenol (low conc.), surfactants, dyes Interference of bacterial enzyme and metabolism oxidants, heavy-metals (low conc.), alkylating agents

 Phenol and phenol derivatives

altering membrane permeability and denaturing proteins
0.01% - 0.05% Chlorhexidine vaginal wash, OR hand-wash 3% - 5% carbonic acid or 2% Lysol floor or surface disinfection

 Alcohols
denaturing bacterial proteins and membranes
70% - 75% ethyl or isopropyl alcohol skin and thermometer disinfection ineffective against endospores and nonenveloped viruses

 Heavy metals (Hg2+Ag+) denaturing proteins and inactivating enzymes

2% mercurochrome or 0.1% merthiolate skin, mucosa and wound bacteriostatic, ineffective against endospores

1% silver nitrate eye drops for newborns to prevent gonococcal ophthalmia

 Oxidants
oxidation, protein precipitation
0.1% potassium permanganate skin, fruits/vegetables

3% peroxiden small trauma wound, skin, mucosa

0.2% - 1% peroxyacetic acid plastics, glassware 0.2 0.5 ppm cholorines water and swimming pool

 Surfactants
damaging bacterial membranes, inactivating enzymes, protein precipitation
0.05-0.1% bromogeramine OR hand-wash, skin, surgical instruments

 Alkylating agent
alkylating proteins and nucleic acids
formalin (formaldehyde) surface disinfection, air, surgical instruments

glutaric dialdehyde high-precision instruments, endoscopes

50mg/L epoxy ethane surgical instruments and dressing

 Dyes
inhibiting bacterial growth by interfering with
oxidation
2% - 4% methyl violet wound disinfection

 Acids and alkalies

destroying cell membrane and cell wall,
denaturing proteins
5-10ml/m3 acetic acid evaporation air disinfection
quicklime [Ca(OH)2] floor and excretion (feces, urine, sputum, pus) disinfection

Effectiveness of antimicrobial agents are affected by :

The concentration/intensity and nature of the disinfectant; Length of exposure; Species and number of the microbe(s); Temperature and humidity; Acidity (pH); Presence of organic substances; Presence of chemical antagonists The nature of the material bearing the microbes

Summary 1. Application of chemical disinfectants

Patient excretion Chlorines, 5% carbonic acid, 2% Lysol
Skin (hands) 2% Lysol, 0.2-0.4% peroxyacetic acid for HBV, 70% ethyl alcohol, 2% mercurochrome oral - 3% peroxide; uri-reproductive - 0.01-0.05%Chlorhexidine, 0.1% potassium permanganate ; newborn eyes - 1% silver nitrate

Mucosa

Drinking water

Chlorines

Toilets, sewage

quicklime [Ca(OH)2]

Air (OR, ID ward)

formalin steam (12.5-25ml/m3,12-24h), formalin 40ml + potassium permanganate 30g/m3; HBV ward- peroxyacetic acid 3g/m3 90min

Glassware, china, Rubber, metal devices

0.5% iodophores, 0.2-0.4% peroxyacetic acid

Summary 2. Potency levels of chemical disinfectants

Potency
High

Definition
Killing all microbes including endospores and TB

Examples
glutaric dialdehyde formaldehyde peroxyacetic acid epoxy ethane

Medium

Killing all non-spore microbes alcohol, chlorines, including TB iodophores Killing vegetative bacteria chlorhexidine and lipophilic (enveloped) bromogeramine viruses, but resisted by endospores, TB and hydrophilic (non-enveloped) viruses

Low

Summary 3. Spore-killing effects of chemical disinfectants

Spore-killing disinfectants
glutaric dialdehyde, formaldehyde, Iodines,

H2O2, epoxy ethane

Non spore-killing disinfectants

alcohols, phenols, chlorhexidine,
bromogeramine

Medical Microbiology

Disinfection and Sterilization

For the course of Medical Microbiology for MBBS foreign students, Class 2006/2011, SYSU

September 18, 2007

Mengfeng Li , M.D. Department of Microbiology, Zhongshan School of Medicine, SYSU, Guangzhou, China limf@mail.sysu.edu.cn