Dr Madhumanee Abeywardena

Consultant Clinical Microbiologist

District General Hospital Nuwara Eliya

07/07/2015

HOSPITAL-ACQUIRED INFECTIONS/NOSOCOMIAL INFECTIONS

An infection contracted by a patient or staff

member while in a hospital or health care facility

(and not present or incubating on admission)

Hospital acquired infections are a common

problem

Hundreds of millions of patients are affected by

health care-associated infections worldwide

each year, leading to significant mortality and

financial losses for health systems.

Of every 100 hospitalized patients at any given

time, 7 in developed and 10 in developing

countries will acquire at least one health care-

associated infection

1 in 10!

EPIDEMIOLOGY OF NOSOCOMIAL INFECTIONS

Most common sites for nosocomial infections

Surgical incisions

Urinary tract (i.e., catheter-related)

Lower respiratory tract

Bloodstream (i.e., catheter-related)

Surgical incisions

Urinary tract (i.e., catheter-related)

Lower respiratory tract Ventilator associated pneumonia

The CVC- is one of the most commonly used catheters in medicine

The CVC is typically placed through a central vein such

as the IJ, Subclavian or femoral

Bloodstream (i.e., catheter-related)

These serve as direct line for microbial bloodstream invasion

Bloodstream (i.e., catheter-related)

stream (i.e., catheter-related)

COMMON MICROORGANISMS

Gram-positive cocci

(Staphylococcus aureas [MRSA],

enterococci [vancomycin-

resistant]),

Gram-negative bacilli (Escherichia coli,

P. aeruginosa, Enterobacter spp., and Klebsiella

pneumoniae

NOSOCOMIAL TRANSMISSION OF COMMUNITY ACQUIRED, MULTIDRUG-RESISTANT ORGANISMS

M. tuberculosis Salmonella spp. Shigella spp. V. cholerae

ROOT CAUSES OF NOSOCOMIAL INFECTIONS

Lack of training in basic Infection Control

Lack of an IC infrastructure and poor IC practices (procedures)

Inadequate facilities and techniques for hand hygiene

Lack of isolation precautions and procedures

Use of advanced and complex treatments without adequate training and supporting infrastructure, including— Invasive devices and procedures Complex surgical procedures Interventional obstetric practices Intravenous catheters, fluids, and medications Urinary catheters Mechanical ventilators

Inadequate sterilization and disinfection practices and inadequate cleaning of hospital

CORE STRATEGIES TO REDUCE NOSOCOMIAL INFECTIONS—HAND HYGIENE

To ensure appropriate hand washing techniques—

Provide sinks, clean water, and soap at convenient locations

Where sinks, clean water, and hand washing supplies are unavailable, use alcohol-based products which are inexpensive, produced locally, convenient, and effective for hand hygiene.

Monitor compliance Use gloves when necessary

ISOLATION AND STANDARD PRECAUTIONS

Whenever possible, avoid crowding wards.

Implement specific policies and procedures for patients

with communicable diseases:

Private rooms and wards for patients with specific diseases

Visitation policies

Hand washing and use of gloves

Gowns, when appropriate

Masks, eye protection, gowns

Precautions with sharp instruments and needles

ENSURING A CLEAN ENVIRONMENT

Establish policies and procedures to prevent food and water contamination

Establish a regular schedule of hospital cleaning with appropriate

disinfectants in, for example, wards, operating theaters, and laundry

Dispose of medical waste safely

Needles and syringes should be incinerated

Other infected waste can be incinerated or autoclaved for landfill

disposal

Bag and isolate soiled linen from normal hospital traffic

CLEANING, DISINFECTION, AND STERILIZATION OF INSTRUMENTS AND SUPPLIES

Written policies and procedures are needed

All objects to be disinfected or sterilized should first be thoroughly cleaned

Use stream sterilization whenever possible

Quality control in reprocessing is essential

Monitor and record sterilization parameters (i.e., time, temperature, pressure)

Biological indicators should be used to ensure sterilization

Chemical indicators are necessary for chemical sterilization

Sterilized items must be stored in enclosed clean areas

Items or devices that are manufactured for single use should not be reprocessed

(e.g., disposable syringes and needles)

STANDARD PRECAUTIONS

Masks, eye protection, face shield: Wear during activities likely to generate

splashes or sprays Gowns

Protect skin and soiling of clothing Wear during activities likely to generate

splashes or sprays Sharps

Avoid recapping of needles Avoid removing needles from syringes by

hand Place used sharps in puncture –resistant

containers

AIRBORNE PRECAUTIONS Designed to prevent airborne transmission of

droplet nuclei or dust particles containing infectious agents

For patient with documented or suspected: Measles Tuberculosis (primary or lanryngeal) Varicella (airborne + contact) Zoster (disseminated or immunocompromised

patient; (airborne and contact) SARS (Contact+airborne)

DROPLET PRECAUTIONS

Designed to prevent droplet (larger particle)

transmission of infectious agents when the

patient talks, coughs, or sneezes

For documented or suspected:

Adenovirus (droplet+contact)

Group A step pharyngitis, pneumonia, scarler fever

(in infants, young children)

H. Influenza meningitis, epiglottitis

Infleunza, Mumps, Rubella

Meningococcal infections

SUMMARY

IC procedures are vital to preventing nosocomial infections and for controlling hospital

costs.

Simple, inexpensive strategies can prevent many infections.

Hand washing and use of appropriate antiseptics and disinfectants

Monitoring IV and injection preparation and administration

Policy for Antibiotics

Guidelines for treatment and surgical prophylaxis

Selection of appropriate antimicrobials for the formulary

Antimicrobial use reviews

Infection Control Committees or programs,

when functioning effectively, will

Reduce the spread of infectious diseases

Decrease morbidity and mortality due to nosocomial

infections

Maintain employee health and morale

Decrease the incidence of AMR

Decrease health care costs

Hand Hygiene is the single most effective intervention to reduce the cross transmission

of nosocomial infections

RECENT EXAMPLE OF HAI

Outbreak of multiresistant Klebsiella pneumoniaein PBU of DGH Nuwara Eliya

WHY? HOW??

Poor hand hygiene? Contaminated infusates? Lack of general cleanliness?

REGULAR VISITS TO PBU

IS OUR HAND-RUB GIVES EXPECTED RESULTS?

CHECK THE IN-HOUSE HAND-RUB!

Formulation I To produce final concentrations of ethanol

80% v/v, glycerol 1.45% v/v, hydrogen peroxide (H2O2) 0.125% v/v.

Pour into a 1000 ml graduated flask: ethanol 96% v/v, 833.3 ml H2O2 3%, 41.7 ml glycerol 98%,14.5 ml

Formulation II To produce final concentrations of isopropyl

alcohol 75% v/v, glycerol 1.45% v/v, hydrogen peroxide 0.125% v/v:

Pour into a 1000 ml graduated flask: isopropyl alcohol (with a purity of 99.8%),

751.5 ml H2O2 3%, 41.7 ml glycerol 98%, 14.5 ml

TO STOP OR CONTROL HAI

Hand hygiene – Properly done “hand hygiene”