hospital acquired infection ( nosocomial infection )

NOSOCOMIALINFECTION

YASH RAMAWATM.Sc. NsgRAJ KUMARI AMRIT KAUR COLLEGE OF NURSING DELHI

Meaning

Cro

mial

"komeion"

"to take care of."

Noso-

"nosus“

"disease"

MAGNITUDE OF HAIS

In a World Health Organization (WHO) cooperative study (55 hospitals in 14 countries), about 8.7% of hospitalized patients had nosocomial infections.in India the nosocomial infection rate is at over 25-30%.

About 25-36% of these infections are preventable through the adherence to strict guidelines by health care workers when caring for patients.

MAGNITUDE OF HAIS (CONT.…)

Slide Title• A prospective study of 71 burn patients at Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh found that up to 59 patients (83 per cent) had hospital-acquired infections: 35 % S. aureus

24 % P. aeruginosa 16 % haemolytic streptococci.

http://pgimer.nic.in/

http://pgimer.nic.in/

S. aureusP. aeruginosa

haemolytic streptococci

0%

5%

10%

15%

20%

25%

30%

35%

Series 1

A six-month study conducted in the intensive care units (ICUs) at All India Institute of Medical Sciences (AIIMS) in New Delhi, found that 140 of 1,253 patients (11 per cent) had hospital-acquired infections, where P. aeruginosa made up 21 per cent of isolates, 23 per cent were S. aureus, 16 per cent Klebsiella spp., 15 percent Acinetobacter baumannii and 8 per cent Escherichia coli.

http://www.aiims.edu/

25%

28%19%

18%

10%

SalesP. aeruginosa S. aureus Klebsiella sppAcinetobacter baumannii Escherichia coli

11

H.A.I. INCREASING: in

· 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%

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HAI - common bacteria Staphylococci - wound, respiratory and

gastro-intestinal infections Escherichia coli - wound and urinary tract

infections Salmonella - food poisoning Streptococci - wound, throat and urinary

tract infections Proteus - wound and urinary tract

infections (Peto, 1998)

13

HAI - common viruses Hepatitis A -

infectious hepatitis Hepatitis B - serum

hepatitis Human

immunodeficiency virus [HIV] - acquired immunodeficiency syndrome [AIDS] (Peto, 1998)

SOURCE OF INFECTIONEndogenous/

direct: Caused by the

organisms that are present as part of normal flora of the patient (50 %)

Exogenous/indirect Caused by organisms acquiring

by exposure to hospital personnel, medical devices or hospital environment, cross-infection from medical personnel (35 %)

hospital environment- inanimate objects 15%· air , dust , IV fluids & catheters · Washbowls, bedpans ,

endoscopes · ventilators & respiratory

equipment · water, disinfectants etc

Exogenous source15

16

CDC estimates major infections are caused common microbes

According to the CDC, the most common pathogens that cause nosocomial infections are Staphylococcus aureus, Pseudomonas aeruginosa, and E. coli. Some of the common nosocomial infections are urinary tract infections, respiratory pneumonia, surgical site wound infections, bacteremia, gastrointestinal and skin infections.

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Strategies to control nosocomial infection


REDUCING PERSON-TO-PERSON TRANSMISSION

PREVENTING TRANSMISSION FROM THE ENVIRONMENT


REDUCING PERSON-TO-PERSON TRANSMISSION

Hand decontamination Mask, eye protection/face shieldGownClothing Gloves


HAND DECONTAMINATION


Many Personnel Don’t Realize When They Have microbes 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


Hand washingSingle most effective action to prevent HAI -

resident/transient bacteriaCorrect method - ensuring all surfaces are cleaned -

more important than agent used or length of time taken

No recommended frequency - should be determined by intended/completed actions

Research indicates:◦poor techniques - not all surfaces cleaned◦frequency diminishes with workload/distance◦poor compliance with guidelines/training


Before touching a patient

Before aseptic procedures

After body fluid exposure/risk

After touching the patient

After touching the patient's surrounding




PREVENT TRANSMISSION FROM THE ENVIRONMENT

• CLEANING OF ENVIRONMENT• CLEANING OF EQUIPMENT• FOLLOW TRANSMISSION BASED PRECAUTION• SPECIFIC STRATEGIES• CONTROL OF ENVIROMENT FACTOR• ADMINISTRATIVE MEASURE

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PREVENTION OF ENVIRONMENT TO PATIENT TRANSMISSION

ENVIRONMENT DECONTAMINATION

Cleaning of hospital environment. This may be achieved by classifying areas into one of four hospital zones-

Zone A: no patient contact. Normal

domestic cleaning (e.g. administration, library).

Zone B: care of patients who are not

infected, and not highly susceptible. Cleaning with detergent solutions.


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Zone C: infected patients (isolation wards).

Clean with a detergent/disinfectant solution, with separate cleaning equipment for each room.

Zone D: highly-susceptible patients

(protective isolation) or protected areas such as operating suites, delivery rooms, intensive care units, premature baby units, casualty departments and haemodialysis units.


CLEANING OF EQUIPMENTS Disinfection procedures must_ Meet criteria for killing of organisms_ Have a detergent effect_ Act independently of the number of bacteria present, the degree of hardness of the

water, or the presence of soap and proteins (that inhibit some disinfectants). To be acceptable in the hospital environment, they must also be:_ Easy to use_ non-volatile_ not harmful to equipment, staff or patients_ free from unpleasant smells_ effective within a relatively short time.


levels of disinfectionHigh-level disinfection (critical) — this will destroyall microorganisms, with the exception of heavy contamination by

bacterial spores.Intermediate disinfection (semi-critical) — this inactivates

Mycobacterium tuberculosis, vegetative bacteria, most viruses and most fungi, but does not necessarily kill bacterial spores.

Low-level disinfection (non-critical) — this can kill most bacteria, some viruses and some fungi, but cannot be relied on for killing more resistant bacteria such as M. tuberculosis or bacterial spores.

These levels of disinfection are attained by using the appropriate chemical product in the manner appropriate for the desired level of disinfection.Disinfection of patient equipment


SterilizationAnd

Disinfection

Definitions: Sterilisation :

– It is a process by which an article, surface or medium is made free of all microorganisms either in vegetative or spore form.

Disinfection :– Destruction of all pathogens or organisms capable of

producing infections but not necessarily spores.– All organisms may not be killed but the number is

reduced to a level that is no longer harmful to health.


Antiseptics :– Chemical disinfectants which can safely

applied to living tissues and are used to prevent infection by inhibiting the growth of microorganisms.

Asepsis :– Technique by which the occurrence of

infection into an uninfected tissue is prevented.


Methods

1.Physical methods

2.Chemical methods


Physical methods:• Physical

methods:1.Sunlight 2.Heat

1.Dry heat2.Moist heat

3.Filtration 4.Radiation


Chemical methods• Chemical methods:

1. Alcohols2. Aldehydes3. Phenols4. Halogens5. Oxidizing agents6. Salts7. Surface active agents8. Dyes9. Vapor phase disinfectants


Physical Methods


Sun light:

• Sun light:– Active germicidal

effect due to its content of ultraviolet rays .

– Natural method of sterilisation of water in tanks, rivers and lakes.


HEAT

• two type– DRY HEAT– MOIST HEAT


Dry heat:1.Red heat2.Flaming 3.Incineration 4.Hot air oven


Red heat: Materials are held

in the flame of a bunsen burner till they become red hot.» Inoculating

wires or loops» Tips of forceps» Needles


FlamingMaterials are passed

through the flame of a bunsen burner without allowing them to become red hot.

» Glass slides» scalpels» Mouths of culture

tubes


Incineration: • Materials are

reduced to ashes by burning.

• Instrument used was incinerator.

• Soiled dressings• Bedding • Pathological material


Hot air oven: • Most widely used method• Electrically heated and fitted with a fan to

even distribution of air in the chamber.• Fitted with a thermostat that maintains

the chamber air at a chosen temperature.• Temperature and time:

» 160 C for 2 hours.» 170 C for 1 hour» 180 C for 30 minutes.


MOIST HEAT STERILIZING

• below 100° – pasteurization – Vaccine bath

• At 100°– boiling– Tyndalization

• Above 100°– autoclave


TEMPERATURE BELOW 100o C (PASTEURISATION)

Uses – for serum or other

body fluids containing

proteins.

HOLDER METHOD – Heating

at 63o C for 30 minutes.

FLASH PROCESS – Heating at

72o C for 15-20 seconds.Wednesday, May 3, 2023 46YaSh

Principle of Pasteurization


INSPISSATION.

Inspissation is done between 75°C to 80°C. Inspissation means stiffening of protein without coagulation as the temperature is below coagulation temperature. Media containing serum or egg is sterilized by heating for 3 successive days. It is done in 'Serum Inspissator'.


A temperature at 100°C

II. A temperature at 100°C

1. Boiling 2. Tyndallisation


1 Boiling for 10 – 30 minutes may kill most of vegetative forms but spores with stand boiling.2. Tyndallisation :

Steam at 100C for 20 minutes on three successive days

Used for egg , serum and sugar containing media.


Temperatures above 100°CIII. A temperature

above 100°CAutoclave : -Steam above

100°C has a better killing power than dry heat.

-Bacteria are more susceptible to moist heat.


Components of autoclave:

• Components of autoclave:– Consists of vertical or horizontal cylinder of

gunmetal or stainless steel.– Lid is fastened by screw clamps and

rendered air tight by an asbestos washer.– Lid bears a discharge tap for air and steam,

a pressure gauge and a safety valve.


Figure 9.6 Autoclave-overview


Autoclave: Closed Chamber with High Temperature and Pressure

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Temperature (°C)

Time (min) Pressure (kPa)

121°C 30MIN 15LBS

126°C 10MIN 20LBS

131°C 30LBS 3 MIN

Uses of Autoclaves:

• Uses :1. Useful for

materials which can not withstand high temp.

2. To sterilize culture media, rubber material, gowns, dressings, gloves etc.


Sterilisation controls:• Sterilisation controls:

1. Thermocouples2. Bacterial spores-

Bacillus stearothermophilus

3. Browne’s tube4. Autoclave tapes


Filtration:• . Filtration:

• Useful for substances which get damaged by heat.

• To sterilize sera, sugars and antibiotic solutions.

• To obtain bacteria free filtrates of clinical samples.

• Purification of water.Wednesday, May 3, 2023

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FILTERS


60YaSh

Filtration Sterilize solutions

that may be damaged or denatured by high temperatures or chemical agents.


Candle filters


CANDLE FILTERS Hollow ‘Candle’ form

Principle – Fluid is forced by suction or

pressure from the inside to outside or vice

versa.


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SINTERED GLASS FILTERS Made from finely ground glass fused

sufficiently to make small particles adhere

Cleaning – After use, they are washed with

running water in reverse direction and cleaned

with warm, strong sulphuric acid.


64YaSh

The roles of HEPA filters in biological flow safety cabinets

Exhaust HEPAfilter

Blower

Supply HEPAfilter

Light

High-velocityair barrier

Safety glassviewscreen


RADIATION

IONISINGNON-IONISING


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IONISING RADIATION• Lethal action – breakdown of single stranded

or sometimes double-stranded DNA and effect

on other vital cell components.

• Cold sterilisation.

• X-rays, gamma rays and beta rays


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NON-IONISING RADIATION

Electromagnetic rays with wavelengths

longer than those of visible light are used.

Ultraviolet and infrared rays


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Ultraviolet rays kills

microorganisms by

chemical reaction.

Low penetrating capacity

Infrared rays have no

penetrating capacity.


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CHEMICAL METHOD

• TWO TYPE LIQUID AND GAS• LIQUID

1. ALCOHOL2. PHENOLS3. HALOGENS4. OXIDANT5. SURFACTANTS

• GAS1. ETHYLENE OXIDE2. ALDEHYDES


TRANSMISSION BASED PRECSUTION

• AIRBONE PRECAUTION• CONTACT PRECAUTION• DROPLET PRECAUTION• ENTERIC PRECAUTION

USE SPECIFIC STRATEGIES

VAPCRBSICAUTI

VAP (VENTILATOR-ASSOCIATED PNEUMONIA

)

https://en.wikipedia.org/wiki/Ventilator-associated_pneumonia

INTUBATION •AVOID•ORAL•REINTUBATION•CUFF PRESSURE•USE SUBGLOTTIC SUCTION PORT ET TUBEVENTILATOR NONINVASIVE ROUTINE CHANGE OF CIRCUIT AVOID

SUCTIONCLOSE ENDOTRACHEAL SUCTIONING

CRBSI

•Prefer the upper extremity •If the catheter is inserted in a lower extremity site, replace to an upper extremity site as soon as possible

•Use maximal sterile barrier precautions •Clean skin with more than 0.5% chlorhexidine preparation with alcohol (usually 2% chlorhexidine with 70% w/v ethanol)

•Use ultrasound-guided insertion if technology and expertise are available

•dressing sterile transparent semipermeable Replace site dressing only when the dressing becomes damp, loosened, or visibly soiled

be changed frequently (every 72 h)

Evaluate the catheter insertionInsertion date should be put on all vascular access devices Use needleless intravascular catheter access systems and avoid stopcocks. Clean injection ports with an appropriate antiseptic Assess the need for the intravascular catheter daily and remove when not required Peripheral lines should not be replaced more frequently than 72-96 h.Replace administration sets, including secondary sets and add-on devices, every day in patients receiving blood, blood products, or fat emulsionsIf other intravenous fluids are used, change no <96-h intervals and at least every 7 days Needleless connectors should

CAUTI

•ENVIRONMENTAL FACTORS•High-quality cleaning and disinfection •EPA-registered disinfectants •Frequency of cleaning•The unit situated•Central air-conditioning systems WITH PROPER filters •It is recommended that all air should be filtered to 99% efficiency down to 5 μm

•Suitable and safe air quality must be maintained at all times. Air movement should always be from clean to dirty areas

•It is recommended to have a minimum of six total air changes per room per hour, with two air changes per hour composed of outside air

•Isolation facility should be with both negative- and positive-pressure ventilations

•Clearly demarcated routes of traffic flow through the ICU are required

•Adequate space around beds is ideally 2.5-3 m

•Electricity, air, vacuum outlets/connections should not hamper access around the bed

•Adequate number of washbasins should be installed

•Alcohol gel dispensers are required at the ICU entry, exits, every bed space and every workstation

•There should be separate medication preparation area

•separate areas for clean storage and soiled and waste storage and disposal

•Adequate toilet facilities should be provided

ORGANIZATIONAL AND ADMINISTRATIVE MEASURESpatient to nurse ratio Policies for controlling traffic flow to and from the unit to reduce sources of contamination from visitors, staff and equipmentWaste and sharp disposal policy Education and training for staff about prevention of nosocomial infections Protocols for prevention of nosocomial infections Audit and surveillance of infections and infection control practices Infection control team (multidisciplinary approach) Antibiotic stewardship Vaccination of health care personnel