Nosocomial infections

Important cause of Additional morbidity

Prolonged hospitalization

Mortality &Increased cost of hospitalization

Can occur in all hospitalised children but most common in PICU & NICU

Any infection that is not present or incubating at the time the patient is admitted to the hospital

INFECTIONS THAT OCCUR AS CONSEQUENCE OF medical care whether or not they arise during hospitalisation

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

According to NNIS system of USA 14/100 Discharges in NICU’S

6/100 Discharges in PICU’S

• Portal of Entry• Susceptible Host• Causative Agent• Reservoir• Portal of Exit• Mode of Transmission

6

7

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

2. Urinary tract infections (UTI)

3. Ventilator related pneumonia (VAP)

4. Surgical site infections (SSI)

5. Burns infections

host factors, prior invasive procedures , use of catheters and other

devices, use of antibiotics and exposure to other patients

visitors, or health care providers with contagious diseases

LENGTH OF HOSPITALISATION INFECTION CONTROL PROGRAMM IN

THE HOSPITAL

Factors

EnvironmentMicrobesHost characteristicsIndwelling devices

URTI GIT INFECTIONS SKIN & SOFT TISSUE INFECTIONS VARIOUS EXANTHEMAS As consequence of invasive procedures UTI’S ; PNEUMONIA;

BACTEREMIA;SURGICAL SITE

AIR BORNE DROPLET CONTACT TRANSMISSION COMMON VEHICLE VECTORS AUTO INFECTION

AIR BORNE TINY DROPLETS pTB,

measles,varicella,legionnaires,aspirgillosis & mucormycosis

Droplet transmission pertusis,meningococcal infections, Contact transmission gram+ cocci, RSV, C.difficile,

enterovirus,hepatitis A

VEHICLE TRANSMISSIONGram- bacteremia, due contaminated iv

medications,post transfusion infections, Auto infection patients own flora

Host factors that increase the risk for infection include

anatomic abnormalities (dermoid sinuses, cleft palate, obstructive uropathy),

damage to skin, organ dysfunction, malnutrition, and underlying diseases or co-

morbidities

Diseases and therapies that alter immunity are most likely to predispose to infection

Intravenous and other catheters bypass host defenses, provide direct access to sterile sites, provide adherence sites for microbes, and may occlude normal ostia such as the eustachian tubes.

Antibiotics often alter normal bowel flora and encourage colonization by resistant flora,

and they may suppress hematopoiesis.

Exposure to adults or children with contagious diseases is a clear risk for nosocomial transmission of disease..

Transmission of infectious agents occurs by various routes, but by far the most common and important route is via the hands

Fungi and resistant bacteria are frequent causes of infection in immunocompromised children

and in those who require intensive care and prolonged hospitalization

Most effective strategy A good hospital infection control program

is must to orchestrate effective infection control programme

The most important measure in any infection control programme

the important component of handwashing is placement of the hands under water and use of friction with or without soap.

Studies show that a 15-second scrub removes the majority of transient flora but does not alter the permanent flora.

Alcohol-containing antiseptic hand rubs preferred except when hands visibly are soiled with blood or other proteinaceous materials or if exposure to spores (e.g., Clostridium difficile, Bacillus anthracis) is likely to have occurred

A chlorhexidine based hand rub has been recommended as the most suitable for this purpose

After touching blood, body fluids, secretions, excretions, or contaminated items;

immediately after removing gloves;

between patient contacts.

Compliance < 40%

Handwashing …an action of the past(except when hands are visibly soiled)

Alcohol-based hand rub is standard of care

Alcohol-based handrub at point of

care

Access to safe, continuous water supply, soap and

towels

2. Training and Education

3. Observation and feedback

4. Reminders in the hospital

5. Hospital safety climate

+

+

+

+

The 5 core components of the WHO Multimodal Hand Hygiene Improvement Strategy

1. System change

- Team and multidisciplinary team work- Successful interventions- Adaptability of actions- Scaling up - Sustainability of actions / interventions- Leadership commitment / Governance

SAVE LIVES: Clean YOUR Hands

5 May 2009-2020

A WHO Patient Safety Initiative 2009

formerly known as universal precautions, are intended to protect health care workers from blood and body fluids and should be used whenever providing care

Standard precautions involve the use of barriers—gloves, gowns, masks, goggles, and face shields—as needed to prevent transmission of microbes associated with contact with blood or body fluids

Restriction of visitors Cleaning Rigorous sterilisation Disinfection procedures Appropriate waste disposal Limiting antibiotic therapy less invasive procedures Preventing hyperglycemia Education &training of health workers in

inf control is mandatory

Good surveillance programme to detect prevailing pattern of pathogens

Antimicrobial susceptability

Isolation of patients infected with certain pathogens decreases the risk for nosocomial transmission

Contact transmission

Droplet transmission

Airborne transmission

RTI rsv influenza parainfluenza virusGIT infections viruses c.difficileVaricella, measles

Use and care of vascular access lines

Use and care of urinary catheters

Therapy and support of pulmonary functions

Experience with surgical procedures

Sources of the catheter-associated bloodstream infection

SkinVein

Intraluminal from tubes and hubs

Intraluminal from tubes and hubs

Hematogenous from distant sites

Hematogenous from distant sites

Extraluminal from skin

Extraluminal from skin

Multimodal intervention strategies to reduce catheter-associated bloodstream infections:

- Hand hygiene- Maximal sterile barrier precaution at insertion- Skin antisepsis with alcohol-based chlorhexidine-

containing products- Subclavian access as the preferred insertion site- Daily review of line necessity- Standardized catheter care using a non-touch technique- Respecting the recommendations for dressing change

Chlorhexidine gluconate-

impregnated sponge

Chlorhexidine gluconate-

impregnated sponge

Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults

Multi-centre randomized controlled trial

- 3’778 catheters- 28’931 catheter-days- Baseline rate of major catheter-related infections: 1.4/1000 catheter-days!

0.60 per 1000 catheter-days

1.40 per 1000 catheter-days

HR = 0.39; p=0.03

Chlorhexidine-gluconate impregnated dressingsdecreased major catheter-related infections:

Catheter-days

Cu

mu

lativ

e R

isk

Control dressings

Control dressings

ChGdressings

ChGdressings

Use and care of vascular access lines

Use and care of urinary catheters

Therapy and support of pulmonary functions

Experience with surgical procedures

• Urinary tract infection (UTI) causes ~ 40% of hospital-acquired infections

• Most infections due to urinary catheters

• 25% of inpatients are catheterized

• Leads to increased morbidity and costs

Avoid unnecessary catheterization

Two main principles

Limit the duration of catheterization

Practice hand hygiene before insertion of the catheter before and after any

manipulation of the catheter site

http://www.who.int/gpsc/tools/en/

Insert catheters by use of aseptic technique and sterile equipment

Cleanse the meatal area with antiseptic solutions is unnecessary routine hygiene is appropriate

Properly secure indwelling catheters after insertion to prevent movement and urethral traction

Maintain a sterile, continuously closed drainage system

Do not disconnect the catheter and drainage tube unless the catheter must be irrigated

Do not use (avoid) catheter irrigation

Do not use systemic antimicrobials

routinely as prophylaxis

Do not change catheters routinely

Use and care of vascular access lines

Use and care of urinary catheters

Therapy and support of pulmonary functions

Experience with surgical procedures

Patient Age Burns Coma Lung disease Immunosuppressi

on Malnutrition Blunt trauma

Devices Invasive ventilation Duration of invasive

ventilation Reintubation Medication Prior antiobiotic

treatment Sedation

Staff education, hand hygiene, isolation precautions

Surveillance of infection and resistance with timely feedback

Adequate staffing levels

Effect of staffing level in late onset VAP

Avoid intubation and reintubation Prefer non-invasive ventilation Prefer orotracheal intubation &

orogastric tubes - Continous subglottic aspiration Cuff pressure > 20 cm H2O Avoid entering of contaminate

consendate into tube/nebulizer Use sedation and weaning protocols to

reduce duration Use daily interruption of sedation and

avoid paralytic agents -

Oral chlorhexidine application reduces VAP in one study but not for general use

Selective decontamination of the digestive tract (SDD) reduces the incidence of VAP & helps to contain MDR outbreaks

But SDD not recommended for routine use

Prior systemic antibiotics helps to reduce VAP in selected patient groups but increases MDR

24-hour AB prophylaxis helps in one study but not for routine use

1. Adherence to hand hygiene

2. Adherence to glove and gown use

3. Backrest elevation maintenance

4. Correct tracheal-cuff maintenance

5. Orogastric tube use

6. Gastric overdistention avoidance

7. Good oral hygiene

8. Elimination of non-essential tracheal suction

2 year intervention study:

Compliance with preventive measures increased

VAP prevalence rate decreased

by 51%

1. Hand hygiene before and after patient contact, preferably using alcohol-based handrubbing

2. Avoid endotracheal intubation if possible

3. Use of oral, rather than nasal, endotracheal tubes

4. Minimize the duration of mechanical ventilation

5. Promote tracheostomy when ventilation is needed for a longer term

6. Glove and gown use for endotracheal tube manip

Use and care of vascular access lines

Use and care of urinary catheters

Therapy and support of pulmonary functions

Experience with surgical procedures

ObjectivesReduce the inoculum of bacteria at the surgical site

Surgical Site Preparation Antibiotic Prophylaxis Strategies

Optimize the microenvironment of the surgical siteEnhance the physiology of the host (host defenses)

In relation to risk factors, classified as Patient-related (intrinsic)Pre-operativeOperative

Diabetes - Recommendation Preoperative

Control serum blood glucose; reduce HbA1C levels to <7% before surgery if possible

Post-operative (cardiac surgery patients only) Maintain the postoperative blood glucose level at less than

200 mg/dL (A-I)

• Smoking- Rationale– Nicotine delays wound healing– Cigarette smoking = independent RF for SSI after cardiac surgery

- Studies: None

- Recommendation– Encourage smoking cessation within 30 days before procedure

Hair removal techniquePreoperative infectionsSurgical scrubSkin preparationAntimicrobial prophylaxisSurgeon skill/techniqueAsepsisOperative time Operating room characteristics

Recommendations

Administer within 1 hour of incision to maximize tissue concentration Once the incision is made, delivery to the wound

is impaired

Duration of prophylaxis (A-I)Stop prophylaxis

within 24 hours after the procedure within 48 hours after cardiac surgery

To: Decrease selection of antibiotic resistance Contain costs Limit adverse events

Excellent surgical technique reduces the risk of SSI

IncludesGentle traction and handling of

tissuesEffective hemostasisRemoval of devitalized tissuesObliteration of dead spaces Irrigation of tissues with saline

during long proceduresUse of fine, non-absorbed

monofilament suture materialWound closure without tensionAdherence to principles of asepsis

ryryry

Making healthcare

safer

THANK YOU