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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
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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