Assoc. Prof. Dr. Assoc. Prof. Dr. AkeauAkeau UnahalekhakaUnahalekhakaFaculty of NursingFaculty of Nursing

Chiang Mai UniversityChiang Mai University

Prevention of Prevention of NosocomialNosocomial Infection Infection in the in the ImmunocompromisedImmunocompromised

PatientsPatients

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ImmunocompromisedImmunocompromised PatientsPatients

CancerCancerAIDSAIDSNeoplasticNeoplastic disease : disease : leukopenialeukopeniaOrgan transplant recipientsOrgan transplant recipientsUse of corticosteroidsUse of corticosteroidsImpaired cellular immune responseImpaired cellular immune response

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Risk Factors for Infection Risk Factors for Infection

AgeAgeMalnutritionMalnutritionInvasive procedureInvasive procedureAntibiotic therapyAntibiotic therapyImmunocompromiseImmunocompromiseImmunosuppressionImmunosuppressionPresence of colonizing organismsPresence of colonizing organismsSkin and mucous membrane integritySkin and mucous membrane integrity

Chain of InfectionChain of Infection

Portal of entry

Mode of transmission

Host

Infectious agent

Reservoir

Portal of exit

Causative AgentsCausative Agents

BacteriaBacteriaVirusesVirusesFungiFungiProtozoaProtozoaHelminthsHelminthsPrionsPrions

ReservoirReservoir

Definition:Definition:place in which an infectious agent place in which an infectious agent can survive but may or may not can survive but may or may not multiplymultiply

Common reservoirsCommon reservoirshumanshumansanimalsanimalsequipment/equipment/fomitesfomites

Human ReservoirsHuman Reservoirs

Persons with acute Persons with acute or or subclinicalsubclinical illnessillness

CarriersCarriersduring incubationduring incubationconvalescent carriersconvalescent carrierschronic carrierschronic carriersintermittent carriersintermittent carriers

Portal of exitPortal of exit

The path by which an The path by which an infectious agent infectious agent leaves the reservoirleaves the reservoir

respiratory tractrespiratory tractGU tractGU tractGI tractGI tractskin/mucous membraneskin/mucous membranebloodbloodtransplacentaltransplacental

Mode of Transmission of NIMode of Transmission of NIThe mechanism for transfer of anThe mechanism for transfer of aninfectious agent from a reservoirinfectious agent from a reservoirto a susceptible hostto a susceptible host

Contact transmissionContact transmissionDirect contactDirect contactIndirect contactIndirect contactDroplet spreadDroplet spread

Common vehicleCommon vehicleAirborne transmissionAirborne transmissionVector borne transmissionVector borne transmission

Contact transmissionContact transmission

Direct contact Direct contact : person: person--toto--person spread, actual person spread, actual

physical contactphysical contact

Indirect contactIndirect contactcontact with contaminated contact with contaminated

intermediate objectintermediate object

Droplet transmissionDroplet transmission

LLarge droplets are generated by an arge droplets are generated by an infected or colonized person during infected or colonized person during coughing, sneezing, talking, suctioning, coughing, sneezing, talking, suctioning, etc.etc.Droplets propelled a short distance Droplets propelled a short distance

< 3 feet< 3 feet……the the ““spit spacespit space””

Droplets deposited on a susceptible Droplets deposited on a susceptible hosthost’’s eyes, nasal mucosa or mouths eyes, nasal mucosa or mouth

Airborne transmissionAirborne transmission

Droplet nuclei, dust particles or Droplet nuclei, dust particles or skin skin squamessquames containing containing microorganisms are transmitted microorganisms are transmitted to a susceptible host by air to a susceptible host by air currentscurrents

Common Vehicle transmissionCommon Vehicle transmission

Microorganisms are transmitted to susceptible hosts from common items, e.g.

foodwatermedicationsdevices/equipment

VectorVector--borne transmissionborne transmission

Transfer of microorganisms by Transfer of microorganisms by insects, flies, rats, or other insects, flies, rats, or other verminvermin

uncommon mode of transmission uncommon mode of transmission in hospitals in hospitals

Portal of entryPortal of entry

The path by which an infectious agent The path by which an infectious agent enters the susceptible hostenters the susceptible host•• Respiratory tractRespiratory tract•• GU tractGU tract•• GI tractGI tract•• Skin/mucous membraneSkin/mucous membrane•• ParenteralParenteral•• TransplacentalTransplacental

Susceptible HostSusceptible Host

A person lacking effective A person lacking effective resistance to a particular resistance to a particular pathogenic organismpathogenic organism

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Mechanism of TransmissionMechanism of Transmission

AgentAgent HostHostEnvironmentEnvironment

Mode of Mode of TransmissionTransmission

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AgentAgent

EndogenousEndogenousExogenousExogenous

FoodFoodAirborneAirborneEnvironmentEnvironmentWaterWaterPersonnelPersonnel

CommensalCommensalOpportunisticOpportunistic

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Causes of Infection in Patients with Causes of Infection in Patients with CancerCancer

FactorFactor Type of InfectionType of Infection

MalignancyMalignancyAcute leukemiaAcute leukemia Bacterial, Bacterial, fungal,viralfungal,viralMultiple Multiple myelomamyeloma S.pneumoniaeS.pneumoniae

H.influenzaeH.influenzaeHodgkinHodgkin’’s diseases disease Viral, fungalViral, fungal

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Causes of Infection in Patients with Causes of Infection in Patients with CancerCancer

FactorFactor Type of InfectionType of Infection

TreatmentTreatmentChemotherapyChemotherapy Bacterial, fungal, viralBacterial, fungal, viral

gram gram ––veve colonizationcolonizationRadiationRadiation Altered skin integrity Altered skin integrity CorticosteroidsCorticosteroids ImmunosuppressionImmunosuppressionBone marrow Bone marrow Bacterial, fungal, viralBacterial, fungal, viral

transplantation transplantation PneumocystisPneumocystis cariniicarinii

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Most Frequent Bacterial Causes Most Frequent Bacterial Causes of Infections in Patients with Cancerof Infections in Patients with Cancer

Gram positiveGram positiveCorynebacteriumCorynebacterium sppspp..EnterococcusEnterococcus fecalisfecalisStaphylococcus Staphylococcus aureusaureusStaphStaph. . CoagulaseCoagulase--negativenegativeStreptococcus Streptococcus pneumoniaepneumoniaeStreptococcus Streptococcus pyogenespyogenes

Streptococcus Streptococcus viridansviridans

Gram negativeGram negativeEnterobacterEnterobacter sppspp..Escherichia coliEscherichia coliHaemophilusHaemophilus influenzaeinfluenzaeKlebsiellaKlebsiella sppspp..Proteus Proteus sppspp..Pseudomonas Pseudomonas aeruginosaaeruginosa

Salmonella Salmonella sppspp..

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NosocomialNosocomial Infection SitesInfection Sites

Primary bloodstream infectionPrimary bloodstream infectionRespiratory tract infectionRespiratory tract infectionUrinary tract infectionUrinary tract infectionSurgical site infectionSurgical site infectionGastrointestinal tract infectionGastrointestinal tract infectionPyrexia cause of unknown originPyrexia cause of unknown origin

Infection Control ProgramInfection Control Program

NI SurveillanceNI Surveillance

Isolation PrecautionsIsolation Precautions

Disinfection & SterilizationDisinfection & Sterilization

Employee Health Employee Health

Patient Care PracticePatient Care Practice

Microbiological ServicesMicrobiological Services

Education and Training Education and Training

Environmental ControlEnvironmental Control

Community CoordinationCommunity Coordination

ResearchResearch

Prevention of Prevention of NosocomialNosocomial Infections Infections in the in the ImmunocompromisedImmunocompromised patientspatients

Assess risk of infection of patientsAssess risk of infection of patientsSurveillanceSurveillanceHand hygieneHand hygieneEnvironmental controlEnvironmental controlEducation of patients and relativesEducation of patients and relativesPatient hygienePatient hygieneEmployee healthEmployee health

Surveillance of Surveillance of Nosocomial InfectionNosocomial Infectionss

SurveillanceSurveillance

The The systematicsystematic,, activeactive,, ongoingongoing

observation of the occurrence and observation of the occurrence and distribution of NI within patients and of distribution of NI within patients and of the events or conditions that increase the the events or conditions that increase the risk of NI occurrencerisk of NI occurrence

PurposePurposess ofof SurveillanceSurveillance

Provide data that will guide effortsProvide data that will guide effortsto reduce nosocomial infection rateto reduce nosocomial infection rate

Assess quality of careAssess quality of care

Usefulness of Surveillance systemUsefulness of Surveillance system

1. D1. Detect NI in a timely wayetect NI in a timely way2. P2. Provide estimates of the magnitude of morbidity rovide estimates of the magnitude of morbidity

and mortalityand mortality3. 3. IdentiIdentifyfy factors associated with the eventfactors associated with the event4. D4. Detect trends including outbreaks etect trends including outbreaks 4. A4. Assessment effect of prevention program ssessment effect of prevention program 5. L5. Lead to improved behavioral practicesead to improved behavioral practices6. S6. Stimulate research intended to preventtimulate research intended to prevent NINI

Surveillance

Action

Infection rateWork load

Quality of care

Define the population and typeDefine the population and type((ss)) of infections of infections to be studiedto be studiedCollect data using systematic methodsCollect data using systematic methodsConsolidate data to aid in evaluationConsolidate data to aid in evaluationAnalyze and interpret dataAnalyze and interpret dataReport results to those who can bring about changeReport results to those who can bring about change

Action

Essential ComponentsEssential Componentsof a Surveillance Programof a Surveillance Program

Hand HygieneHand Hygiene

IgnacIgnac SemmelweisSemmelweis18181818--18651865

18401840’’s: General Hospital s: General Hospital of Viennaof ViennaDivided into two clinics, Divided into two clinics, alternating admissions alternating admissions every 24 hours:every 24 hours:

First Clinic: Doctors and First Clinic: Doctors and medical studentsmedical studentsSecond Clinic: MidwivesSecond Clinic: Midwives 0

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First Clinic SecondClinic

The Intervention:The Intervention:Hand scrub with chlorinated lime Hand scrub with chlorinated lime

solutionsolution

Hand hygiene basin at the LyingHand hygiene basin at the Lying--In WomenIn Women’’s Hospital in Vienna, 1847.s Hospital in Vienna, 1847.

Hand Hygiene :Not a New ConceptHand Hygiene :Not a New ConceptMaternal Mortality due to Postpartum Infection

General Hospital, Vienna, Austria, 1841-1850

0

2

4

6

8

10

12

14

16

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1841 1842 1843 1844 1845 1946 1847 1848 1849 1850

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MDs Midwives

Semmelweis’ Hand

Hygiene Intervention

Hand antisepsis reduces the frequency of Hand antisepsis reduces the frequency of patient infections patient infections

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Microorganism on Microorganism on HandsHands

Transient floraTransient floraResident floraResident flora

DefinitionsDefinitionsHand hygieneHand hygiene

Performing Performing handwashinghandwashing, antiseptic , antiseptic handwashhandwash,, alcoholalcohol--based based handrubhandrub, surgical , surgical hand hygiene/antisepsishand hygiene/antisepsis

HandwashingHandwashingWashing hands with plain soap and waterWashing hands with plain soap and water

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Hand decontamination levelsHand decontamination levels

•• Normal Normal handwashinghandwashing

•• Hygienic antisepsis Hygienic antisepsis

•• Surgical antisepsisSurgical antisepsis

Normal Normal handwashinghandwashing

Objective :Objective :

Remove dirt and transient flora Remove dirt and transient flora contaminating skin of medicalcontaminating skin of medical--staff staff hands as a result of contact with hands as a result of contact with infected or colonized patients and/orinfected or colonized patients and/orcontaminated environmental objectscontaminated environmental objects

Hygienic antisepsis of handsHygienic antisepsis of hands(Hygienic (Hygienic handwashinghandwashing))

Objective:Objective:Remove or kill transient micro flora on hands.Remove or kill transient micro flora on hands.

IndicationsIndications::•• Before performing individual proceduresBefore performing individual procedures•• Before working with especially susceptible patients or Before working with especially susceptible patients or

neonatesneonates•• Before and after procedures involving wounds or cathetersBefore and after procedures involving wounds or catheters•• Before and after donning glovesBefore and after donning gloves•• After contact with excreta or objects containing blood or After contact with excreta or objects containing blood or

probably contaminated with microbesprobably contaminated with microbes

Surgical Hand HygieneSurgical Hand Hygiene(Surgical antisepsis)(Surgical antisepsis)

Objective:Objective:Remove or kill transient flora and reduce Remove or kill transient flora and reduce population of resistant flora.population of resistant flora.

Indications:Indications:Before all surgical operations.Before all surgical operations.

Surgical Hand HygieneSurgical Hand Hygiene

Use either an antimicrobial soap or alcoholUse either an antimicrobial soap or alcohol--based based handrubhandrubAntimicrobial soap: scrub hands and forearms for length Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturerof time recommended by manufacturerAlcoholAlcohol--based based handrubhandrub: follow manufacturer: follow manufacturer’’s s recommendations. Before applying, prerecommendations. Before applying, pre--wash hands wash hands and forearms with nonand forearms with non--antimicrobial soapantimicrobial soap

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

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Isolation PrecautionsIsolation Precautions

Standard precautionsStandard precautionsTransmissionTransmission--based precautionsbased precautions

•• Contact precautionsContact precautions•• Droplet precautionsDroplet precautions•• Airborne precautionsAirborne precautions

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Hospital PersonnelHospital Personnel

Hand hygiene with antiseptic soap or alcoholHand hygiene with antiseptic soap or alcohol--based hand rubbased hand rubDaily screening or selfDaily screening or self--screening for symptoms screening for symptoms of communicable diseaseof communicable diseaseVaccination of Vaccination of HCWsHCWs for influenza for influenza

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EnvironmentEnvironment

Environmental surfaceEnvironmental surfaceLinenLinenPlants and flowersPlants and flowersFood and drinking waterFood and drinking waterWater systemsWater systemsDialysisDialysisToysToysAirAirConstructionConstruction

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Environmental ControlEnvironmental Control

Cleaning should be performed by trained Cleaning should be performed by trained personnelpersonnelDaily cleaning of frequently touched horizontal Daily cleaning of frequently touched horizontal surfaces (avoid dry dusting and mopping)surfaces (avoid dry dusting and mopping)Reduce personal belongings or provide other Reduce personal belongings or provide other storage areasstorage areas

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LinenLinen

Using standard linen handling Using standard linen handling and managementand managementUnnecessary to provide sterile linen Unnecessary to provide sterile linen for for immunocompromisedimmunocompromised patients patients

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Plants and FlowersPlants and Flowers

Flowers and plants are known to harbor Flowers and plants are known to harbor microorganismsmicroorganismsVast water from fresh flowers has yielded Vast water from fresh flowers has yielded gram negative bacilli, e.g. P. gram negative bacilli, e.g. P. aeruginosaaeruginosaDried and fresh flowers and potted plants Dried and fresh flowers and potted plants can harbor fungi e.g. can harbor fungi e.g. aspergillusaspergillusExclude plants and flowers, both fresh and Exclude plants and flowers, both fresh and dried from dried from immunocompromisedimmunocompromised patient units patient units

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Food and Drinking WaterFood and Drinking Water

••Immunosuppressive Immunosuppressive therapytherapy

•• ChemotherapyChemotherapy•• RadiationRadiation•• Antimicrobial TherapyAntimicrobial Therapy•• H2 blockersH2 blockers•• Impaired intestinal Impaired intestinal motilitymotility

•• HematopoieticHematopoietic Stem Stem Cell transplantationCell transplantation

•• Solid organ transplantSolid organ transplant

Increased Risk of Food-borne Illness

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Food and Drinking WaterFood and Drinking Water

Low microbial dietsLow microbial diets-- Restricting raw fruits and vegetablesRestricting raw fruits and vegetables-- Concern about contamination with gram Concern about contamination with gram

negative bacillinegative bacilli

Safe food preparation at homeSafe food preparation at home-- HandwashingHandwashing before handling foodbefore handling food-- Using clean utensilsUsing clean utensils-- Cooking to temperature recommendedCooking to temperature recommended

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Food and Drinking WaterFood and Drinking Water

EnteralEnteral feedingsfeedings•• Has potential to become contaminated by Has potential to become contaminated by

bacteriabacteria•• Capable of causing severe infection, Capable of causing severe infection,

gastrointestinal colonization, gastrointestinal colonization, nosocomialnosocomialpneumoniapneumonia

•• Organisms cultured from Organisms cultured from enteralenteral feeding feeding included included S.epidermidisS.epidermidis, S. , S. aureusaureus and gram and gram negative bacilli such as negative bacilli such as SerratiaSerratia, , klebsiellaklebsiella,,and and Pseudomonas Pseudomonas sppspp..

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Food and Drinking WaterFood and Drinking Water

Contamination of Contamination of EnteralEnteral feedingfeeding•• Manipulation of the Manipulation of the enteralenteral feeding product and feeding product and

system during preparation and administration.system during preparation and administration.•• Mixing Mixing enteralenteral feeding on site results in more highly feeding on site results in more highly

contaminated solutions compared with premixed contaminated solutions compared with premixed feeds.feeds.

•• Colony counts in Colony counts in enteralenteral feedings increase with feedings increase with the hang time of product and the administration set.the hang time of product and the administration set.

•• High risk patients should receive readyHigh risk patients should receive ready--to feed to feed enteralenteral feeding via closed systems and feeding via closed systems and administration sets should be changed every 24 hrs.administration sets should be changed every 24 hrs.

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Water SystemsWater Systems

Water quality can pose different risks for Water quality can pose different risks for acquisition of infectious diseaseacquisition of infectious diseaseInterventions for testing and treatment of Interventions for testing and treatment of hospital water depend upon the water supply, hospital water depend upon the water supply, susceptibility of patients, and historical outbreak susceptibility of patients, and historical outbreak information information

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ToysToys

Risk of personRisk of person--toto--person transmissionperson transmissionIt is essential that all toys are cleaned and It is essential that all toys are cleaned and disinfected regularly and when visibly soiled or disinfected regularly and when visibly soiled or mouthedmouthedOnly toys that are easily cleaned and disinfected Only toys that are easily cleaned and disinfected are appropriate are appropriate Appropriate toy cleaning involves scrubbing with Appropriate toy cleaning involves scrubbing with soap and water to remove secretions and soap and water to remove secretions and surface dirt, followed by disinfection with non surface dirt, followed by disinfection with non toxic disinfectant and need to be thoroughly toxic disinfectant and need to be thoroughly rinsed with waterrinsed with water

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AirAir

Private rooms with air filtration and positive Private rooms with air filtration and positive pressure pressure Well sealed windowsWell sealed windowsAt least 12 air changes per hourAt least 12 air changes per hourA HEPA (high efficiency particulate air) filtrationA HEPA (high efficiency particulate air) filtrationsystem removes up to 99.97% of particles system removes up to 99.97% of particles measuring measuring >> 0.30.3 micron from the air micron from the air

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ConstructionConstruction

Substantial planning is required to protect Substantial planning is required to protect patients from the fungal infections, primarily patients from the fungal infections, primarily aspergillosisaspergillosisContainment measures necessary to protect Containment measures necessary to protect atat--risk populations include adequate barriers risk populations include adequate barriers and negative pressure inside the construction and negative pressure inside the construction sitesite

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PatientsPatientsMany infections are caused by patientMany infections are caused by patient’’s s endogenous floraendogenous floraMaintaining good personal hygieneMaintaining good personal hygieneGood oral and dental hygieneGood oral and dental hygieneChanging cleaned clothes regularlyChanging cleaned clothes regularlyDaily showers using mild soapDaily showers using mild soapInspection of skin integrity, especially perineum, Inspection of skin integrity, especially perineum, periperi--anal area and intravascular access sitesanal area and intravascular access sitesHand hygiene (both patients and family Hand hygiene (both patients and family members)members)

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VisitorsVisitorsWellWell--developed and strongly enforced policiesdeveloped and strongly enforced policiesto screen all visitors for symptoms of to screen all visitors for symptoms of communicable illness, including communicable illness, including

DiarrheaDiarrhea VomitingVomitingFeverFever ConjunctivitisConjunctivitisUndiagnosed rash Undiagnosed rash Upper respiratory tract symptomsUpper respiratory tract symptoms

Decisions make on a caseDecisions make on a case--byby--case basiscase basis(taking the patient(taking the patient’’s medical status and emotional s medical status and emotional needs into account, as well as the family memberneeds into account, as well as the family member’’s s ability to implement isolation techniques well enough ability to implement isolation techniques well enough to protect the patient)to protect the patient)

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AnimalsAnimals

Rehabilitation medicine has advocated animalRehabilitation medicine has advocated animal--assisted therapy to enhance physical, cognitive, assisted therapy to enhance physical, cognitive, and emotional participation in treatmentsand emotional participation in treatmentsPet therapy programs should be carefully Pet therapy programs should be carefully considered considered

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Solid Organ Transplant (SOT)Solid Organ Transplant (SOT)

SOT patients are at risk for both HAI and SOT patients are at risk for both HAI and opportunistic infectionsopportunistic infectionsType of organ transplant, Type of organ transplant, immunosuppressionimmunosuppressionlevel and time lapsed postlevel and time lapsed post--transplant are factors transplant are factors that influence infection riskthat influence infection riskThorough preThorough pre--operative history and assessment operative history and assessment may predict opportunistic infection riskmay predict opportunistic infection riskStandard precautions, including hand hygiene, Standard precautions, including hand hygiene, and isolation precautions are key to preventing and isolation precautions are key to preventing HAI HAI

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PostPost--Transplant Transplant Risk Factors for InfectionRisk Factors for Infection

Bacterial or fungal colonization of the Bacterial or fungal colonization of the respiratory tractrespiratory tractFrequent or prolonged exposure in the Frequent or prolonged exposure in the healthcare systemhealthcare systemSeverity of illness prior to surgerySeverity of illness prior to surgeryLongstanding malnutritionLongstanding malnutritionPatient agePatient ageDisruption of physical barriers Disruption of physical barriers (e.g. surgery, intravascular catheters)(e.g. surgery, intravascular catheters)

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Infections in SOT PatientsInfections in SOT PatientsBacterialBacterial MRSA, VRE, Clostridium MRSA, VRE, Clostridium difficiledifficile, ,

LegionellaLegionella, , M.tuberculosisM.tuberculosis, atypical , atypical mycobacterium, pseudomonasmycobacterium, pseudomonas

FungiFungi Candida, Candida, AspergillusAspergillus, , Cryptococcus, Cryptococcus, PneumocystisPneumocystis cariniicarinii

Endemic mycosesEndemic mycoses HistoplasmosisHistoplasmosis, , BlastomycosisBlastomycosis, , coccidioidomycosiscoccidioidomycosis

VirusesViruses Cytomegalovirus, Herpes simplex virus, Cytomegalovirus, Herpes simplex virus, VaricellaVaricella zoster virus, Epsteinzoster virus, Epstein--Barr virus, Barr virus, HepHep B , B , HepHep C, Adenovirus, respiratory C, Adenovirus, respiratory syncitialsyncitial virus, Influenzavirus, Influenza

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Infection ControlInfection Control

Monitoring infection ratesMonitoring infection ratesPostPost--transplant immunizationstransplant immunizationsEnvironmental control measuresEnvironmental control measuresPatient educationPatient education

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Monitoring InfectionsMonitoring Infections

Bloodstream infectionBloodstream infectionSurgical site infectionSurgical site infectionPneumoniaPneumoniaUrinary tract infectionUrinary tract infection

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PostPost--transplant immunizationstransplant immunizations

LiveLive--virus vaccines are not recommended virus vaccines are not recommended Killed immunizations are recommended for Killed immunizations are recommended for both adult and pediatric transplant recipients : both adult and pediatric transplant recipients : Hepatitis A and B if negative Hepatitis A and B if negative serostatusserostatus, , InfluenzaInfluenzaSOT recipients should receive influenza vaccine SOT recipients should receive influenza vaccine annuallyannually

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Patient educationPatient education

Avoid contact with persons with URIAvoid contact with persons with URIFood preparation safelyFood preparation safelyAvoid raw seafoodAvoid raw seafoodAvoid construction sitesAvoid construction sitesDecreasing molds in householdDecreasing molds in householdMonitoring of infectionMonitoring of infectionGood Good handwashinghandwashing techniquestechniques

Infection control education to prevent Infection control education to prevent opportunistic infection should be addressed opportunistic infection should be addressed

with SOT recipients prior to discharge.with SOT recipients prior to discharge.

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