HOSPITAL ACQUIRED (NOSOCOMIAL) INFECTION

jschangco,icn 2003

DEFINITION:

ANY INFECTION ACQUIRED BY A PATIENT IN HOSPITAL.

SOME STATISTICS:

• Affects approx. 10% of all in-patients • (KFHUrate the last 5 years 1.14%)• delays discharge • HAI costs 2times >no infection• direct cause deaths

Socio-economic burden of HAI

SOURCES:

1.Patients own flora - Endogenous (50%) Auto-Infection ( Greatest source of potential danger)2.Environment - Exogenous(15%) (Air-5%; Instruments-10%) 3.Another Patient/Staff - Cross Infection (35%)

Classification of surgical procedures

Cleanno entry into GI/GU/Resp tractlow riskinfection usually exogenous

Clean contaminatedno significant spillagee.g. cholecystectomy

infection rates 5-10 %

Contaminated Significant spillage of bacteria expected Infection rate 18-20%

DirtyPerforated viscus drainage of abscess Infection rate often >30%

IMPORTANT CROSS-INFECTION ORGANISMS

METHICILLIN RESISTANT STAPH AUREUS (MRSA)

Resistant to Flucoxacillin and usually others

May cause - Wound infection Bacteraemia Skin/soft tissue infection U.T.I. Pneumonia etc.

Colonisation common:

Nose Axilla Perineum Wounds/Lesions

Spread By:

Hands Fomites Aerosols Becoming more common in the Community

Control:

Eradication of carriage Barrier nursing Screening of other patients Staff

TUBERCULOSIS Open pulmonary TB (Sputum smear positive for AFB)

VIRAL INFECTIONS

Chicken Pox (Hepatitis B HIV)

RESISTANT GRAM NEGATIVE ORGANISMS

Resistance to multiple antibiotics

Organisms:E .coli Proteus Enterobacter Acinetobacter Pseudomonas aeruginosa

Cause: Bacteraemia U.T.I. Pneumonia Wound infection

Control: Antibiotic Policy Control of Infection Guidelines Prevention of Cross Infection especially on high risk areas

SURVEILLANCE

Important means of monitoring HAI Early detection of trends outbreaks 1. Laboratory Based Microbiology Laboratory lists +ve organisms ICN reviews ‘Alert organisms’ reported 2. Ward Based Ward staff monitor patientsICN reviews ICN visits wards

H.A.I. IS INCREASING: compromised patients ward and inter-hospital transfers antibiotic resistance (MRSA, resistant Gram negatives) increasing workload

staff pressures lack of facilities ? lack of concern

HAI is inevitable but some is preventable (irreducible minimum)

realistically reducible by 10-30%

Many Personnel Don’t Realize When

They Have Germs on Their Hands• Healthcare workers can get 100s to 1000s of

bacteria on their hands by doing simple tasks like: – pulling patients up in bed

– taking a blood pressure or pulse

– touching a patient’s hand

– rolling patients over in bed

– touching the patient’s gown or bed sheets

– touching equipment like bedside rails, overbed tables, IV pumps

Casewell MW et al. Br Med J 1977;2:1315Ojajarvi J J Hyg 1980;85:193

GENERAL PRINCIPLES

Good general ward hygiene: - No overcrowding - Good ventilation - Regular removal of dust - Wound dressing early in day - Disposable equipment

HAND WASHING

most important - Before and after patient contact

before invasive procedures

Why

Don’t Staff Wash their Hands

(Compliance estimated at less than 50%)

Why Not?• Skin irritation• Inaccessible hand washing facilities• Wearing gloves• Too busy• Lack of appropriate staff• Being a physician

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

Why Not?• Working in high-risk areas

• Lack of hand hygiene promotion

• Lack of role model

• Lack of institutional priority

• Lack of sanction of non-compliers

Successful Promotion • Education• Routine observation & feedback• Engineering controls

– Location of hand basins– Possible, easy & convenient– Alcohol-based hand rubs available

• Patient education(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

Successful Promotion • Reminders in the workplace

• Promote and facilitate skin care

• Avoid understaffing and excessive workload; Nursing shortages have caused

Hand Hygiene

Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene.

A study by Pittet showed a 20% increase in compliance by using feedback and encouraging the use of alcohol hand rubs

Hand Hygiene Techniques1. Alcohol hand rub

2. Routine hand wash 10-15 seconds

3. Aseptic procedures 1 minute

4. Surgical wash 3-5 minutes

Repeat procedures until hands are clean

Routine Hand Wash

Alcohol Hand Rubs

• Require less time

• Can be strategically placed

• Readily accessible

• Multiple sites

• All patient care areas

Alcohol Hand Rubs• Acts faster

• Excellent bactericidal activity

• Less irritating (??)

• Sustained improvement

Alcohol Hand RubsChoose agent carefully:

– Adequate antimicrobial efficacy

– Compatibility with other hand hygiene products

Visible soiling

Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material MUST by washed with liquid soap and water

Areas Most Frequently Missed

HAHS © 1999

Hand Care• Nails

• Rings

• Hand creams

• Cuts & abrasions

• “Chapping”

• Skin Problems

Hand hygiene is the simplest, most effective measure for preventing

hospital-acquired infections.

PREVENTING CROSS INFECTION

If known or suspected on admission to hospital, or detected following admission:

- Isolation (barrier precautions) - Inform Infection Control team - Treatment - if appropriate - Regular surveillance

Any Questions???

• Thank you for not asking!!!

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