Nosocomial infections

1. ‫خدایا‬!‫چیز‬‫هیچ‬‫هایت‬‫داده‬‫تمامی‬‫از‬‫تشکر‬‫جز‬‫ز‬‫و‬‫امر‬
‫نمیخواهم‬‫دیگر‬

2. Dr Hamid Rahman Sabawoon 2

3. Prepared and Presented by: Dr Hamid
Rahman Sabawoon, MD, LMIH,MN,
Supervised by: Dr Wahidullah Formuli, MD,
Trainer of General Surgery
‫افغانســــــــتان‬ ‫اســـــــالمی‬ ‫جمــــــــــهوری‬
‫عـــــــــــــــامه‬ ‫صحـــــت‬ ‫وزارت‬
‫تخــــصـــــص‬ ‫اکمــــــــــال‬ ‫ریاســــت‬
‫بلــــــخی‬ ‫رابعـــــــه‬ ‫کمپــــلکس‬ ‫شفـــــاخانه‬
‫عمــــــومی‬ ‫جــــــراحی‬ ‫دیپــــــارتمنـــت‬

4. Nosocomial Infection
Or
Hospital acquired
infections (HAI)

5. History
 Joseph Lister
 Theodor Kocher
 William S. Halsted
 Ignaz Semmelweis
 Louis Pasteur
 Robert Koch
 Florence knightingale

6. Joseph Lister
 1827-1912British
surgeon
 1867 Used Carbolic Acid
(Phenol) to clean hands,
instruments and wipe on
surgical wounds
drastically decreased
infections.
 father of modern
surgery

7. Theodor Kocher
1841-1917
Introduction and
promotion of aseptic
surgery &scientific
methods in surgery.
mortality rate below 1%
Noble prize 1907.

8. William S. Halsted
1852-1922
Inventing the residency
training system.
Aseptic surgery. Wound
closer, sterility, accurate
dissection,
Mastectomy(radical cncr)
Introduced rubber surgical
gloves.

9. Ignaz Semmelweis
1818-1865 (47) Hungury
Obs&gyn surgeon
Realized that washing
hand with a chlorinated
lime solution decreased
incidence of newborn
death from “puerperal
fever’. (saviour of
mothers)

10. Louis Pasteur
(1822-1895)
 Proved that heat destroys bacteria and
fungi.
 how yeasts (fungi) ferment wine and
beer
 He showed that food spoils because of
microorganisms and invented
Pasteurization Vaccination, microbial
fermentation, and pasteurization
Vaccine for rabies& anthrax, Germ
theory of disease

11. ROBERT KOCH
 Robert Koch(1843-1910)
 German general practitioner
 Grew bacteria in culture
medium.
 Showed which bacteria
caused particular diseases
 tuberculosis, cholera, and anthrax
 Classified most bacteria
 WON NOBLE PRIZE IN 1905

12. Florence nightingale
 1820-1910
 Importance of unsanitary
hospital conditions and
post operative
complications.
 Founder of Modern Nursing
Hospital Hygien & Sanitation
The Lady With The Lump
“ The very first requirement
in a hospital is that it
should do the sick no
harm”

13. Florence nightingale
Importance of unsanitary
hospital conditions and
post operative
complications.
“ The very first requirement
in a hospital is that it
should do the sick no
harm”

15. Nosocomial infection (HAI)
 ANY INFECTION ACQUIRED BY A PATIENT IN HOSPITAL.
Nosocomial infection or Healthcare-associated infections.
 "nosus" = disease "komeion" = to take care of
 (nos-oh-koh-mi-al)
 Nosocomial infections can be defined as infection acquired by
the person in the hospital, manifestation of which may occur
during hospitalization or after discharge from hospital. The
person may be a patient, members of the hospital staff and/
or visitors.

16. Nosocomial infection (HAI)
WHEN YOU SAY HOSPITAL ACQUIRED INFECTION
 Infection which was neither present nor incubating at the time
of admission.
 Includes infection which only becomes apparent after discharge
from hospital but which was acquired during hospitalization
(Rcn, 1995)•
Infections are considered nosocomial if they first appear 48hrs
or more after hospital admission or within 30 days after
discharge.

17. EPIDEMIOLOGICAL INTERACTION
HOST FACTORS HOST
• Suppressed immune system due to Age,
• Poor nutritional status,
• Severity of underlying disease,
• Complicated diagnostic & therapeutic procedure,
 THE ENVIRNOMNET
Everything that surrounds the patient.
 THE AGENT in the hospital.
Varieties of organisms
Other patients
Hospital staff and visitors
Eatables Reservoirs
Dust and other contaminated articles

18. Epidemiology
Rise in nosocomial infection as a result of four
factors:
1.Crowded hospital conditions
2.New microorganism
3.increasing number of people with
compromised immune system
4.Increasing Bacterial resistance

19. Nosocomial Infections
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%)}

20. SOURCE OF INFECTION
 Endogenous/direct: (opportunist normal flora)
 Exogenous/indirect (external organism)
• Exposure to hospital personnel, hospital environment,
• Cross- infection from medical personnel
• Organisms in hospital environment
• inanimate objects present as part of air normal flora
• The dust ,
• IV fluids & catheters
• Patient, washbowls, bedpans ,endoscopes ,ventilators &
respiratory equipment, water, disinfectants etc.

21. Nosocomial Infections
Allmicroorganismscan cause nosocomial
infectionsVirusesBacteriaFungiParasites
 BACTERIA
 Gram +ve Staphylococcus aureus
• Staphylococcus epidermidis
 Gram -ve
• Enterobacteriaceae,
• Pseudomonas aeruginosa
• Acinetobacter, baumanni
• Mycobacterium tuberculosis

22. Nosocomial Infections
COMMON BACTERIAL AGENTS:
• Pseudomonas aeruginosa (9%),
• Enterococcus (10%)
• Coag-neg staphylococci (11%),
• E-coli (12%)
• Staphylococcus aureus (13%),
• Other (45%)
 Viruses:
• Blood borne infections : HBV, HCV, HIV
• Others: rubella, varicella, SARS
 Fungi: Candida, Aspergillus

23. Nosocomial Infections
Mode of transmission:
1. Contact/hand borne (most common)
2. Aerial route or air borne
3. Oral route
4. Parenteral route
5. Vector borne

24. Mode of transmission
1. Contact (most common)
 Direct (physical contact) – Hands & clothing –
Droplet contact followed by autoinoculation –
Clinical equipment.
 Indirect via contaminated articles – Bedpans, –
bowls, jugs, – Instruments like needles, – dressings,
– contaminated gloves, etc.

25. Mode of transmission
2. Airborne Transmission:
• Droplet respiratory secretions on surfaces –
• Inhalation of infectious particles e.g. (TB, Varicella)
• 3. Oral route
• 4. Parenteral route
• 5. Vector borne: through mosquitoes, flies, rats

26. Mode of transmission
1.Pathogens transmission
 The hands are the most important vehicle of transmission
of HAI.
SPREAD - ENTRY AND EXIT ROUTES:
• Natural orifices - mouth, nose, ear, eye, urethra, vagina, rectum
• Artificial orifices - such as tracheostomy, ileostomy, colostomy
• Mucous membranes - which line most natural and artificial
orifices
• Skin breaks - either as a result of accidental damage or
deliberate inoculation/incision

27. Nosocomial Infections
SOME STATISTICS:
• Affects approx. 10% of all in-patients RESULTS IN
• Delays discharge
• Increase Medical cost
• Increase Mortality and morbidity HENCE
• HAI costs 2times >no infection
• Direct cause deaths
Socio-economic burden of HAI

28. Many Personnel Don’t Realize When They Have
Germs onTheir Hands

29. Classification of surgical procedures
Clean
no entry into GI/GU/Respiratory tract
low risk
infection usually exogenous
Clean contaminated
no significant spillage
e.g. cholecystectomy
infection rates 5-10 %
Contaminated
Significant spillage of bacteria expected Infection rate
18-20%
Dirty
Perforated viscus drainage of
abscess Infection rate often >30%

30. Common Hospital-Acquired
infection
 Urinary Tract
 Pulmonary
 SSI (Wound Infection)
 Devices and instruments
 Intra-abdominal
 Empyema
 Foreign-body associated
 Fungal infection
 Multiple organ failure

31. Common Hospital-Acquired
infection
1. URINARY TRACT INFECTIONS: It is the most
common cause of nosocomial infections 80% of the
infections are associated with indwelling catheters :
Catheter associated infection, Blood stream infections.
2. SURGICAL SITE INFECTIONS: clinical purulent
discharge around wounds or the insertion site of drain,
or spreading cellulites from wounds) The infections can
be exogenously or endogenously.

33. Common Hospital-Acquired
infection
3. NOSOCOMIAL PNEUMONIA: patients on ventilators
in ICU. Recent and progressive radiological opacities of the
pulmonary parenchyma, purulent sputum and recent onsit
fever. Most commonly caused by Acinetobacter
4. NOSOCOMIAL BACTERAEMIA: The incidence is
increasing particularly for certain organisms such as multi
resistance coagulase negative staphylococcus and candida.
Infections may occurs at the skin entry site of the IV device or
in the subcutaneous path of catheter.

35. Etiology
Wind--- pneumonia, atelectasis at 1st 24- 48 hours
Water--- urinary tract infection at Anytime after post op day 3
Wound--- wound infections at Anytime after post op day 5
Wonder drugs--- drug fever on postoperative day>7 especially anesthesia
Walking--- deep venous thrombosis/thrombophlebitis/ pulmonary embolus on
postoperative usually occurs at Day 7-10
5Ws

36. 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.

37. RESISTANT GRAM
NEGATIVE ORGANISMS
 Resistance to multiple antibiotics
Organisms:
E .coli
Proteus
Enterobacter
Acinetobacter
Pseudomonas aeruginosa
TUBERCULOSIS
Open pulmonary TB (Sputum smear positive for AFB)
VIRAL INFECTIONS
Chicken Pox

38. Cause:
Bacteraemia
U.T.I.
Pneumonia
Wound infection
Control:
Antibiotic Policy
Control of Infection Guidelines
Prevention of Cross Infection especially on high
risk areas ( hospital, Clinics, vaccination center,
family planning center)
RESISTANT GRAM
NEGATIVE ORGANISMS

40. 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%

42.  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
Case well MW et al. Br Med J 1977;2:1315

43. Second part

45. Case well MW et al. Br Med J 1977;2:1315
ISOLATION:
Designed to prevent transmission of microorganisms by common
routes in hospitals. Because agent and host factors are more
difficult to control, interruption of transfer of microorganisms is
directed primarily at transmission.
PREVENTION AND CONTROL
Sterilization:
Sterilization of all reusable equipments such as ventilator,
humidifier and any device that come in contact with the
respiratory tract

46. Wear Gloves:
They are worn for two reasons: Provide a protective barrier and
prevent contamination of hands Reduce the liklihood that
microorganism present on the hands will be transmitted to the
patients during invasive and other patient care procedure
Wear Aprons:
Wearing an apron during patient care reduces the risk of
infections. Apron is must for preventing yourself from getting
disease
There is no official national approach and no real managerial
support from authorities for nosocomial infection. Only thing is
proper asepsis, proper hand washing and sterilization
PREVENTION AND CONTROL

47. • PPE when contamination
or splashing with blood
or body fluids is
anticipated
• Disposable gloves
• Face masks
• Safety glasses,
• goggles,
• visors
• Head protection
• Foot protection
• Fluid repellent gowns
• Prevention
• Correct disposal in
appropriate container
• Avoid re-sheathing needle
• Avoid removing needle
• discard syringes as single
unit
• avoid over-filling sharps
container
• Management
• follow local policy for
sharps injury
PREVENTION AND CONTROL
1. PERSONAL PROTECTIVE
EQUIPMENT
2. SHARPS INJURIES

49. 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

50. Hand hygiene is the
simplest, most
effective measure
for preventing
hospital-acquired
infections!

51. Why
Don’t Staff Wash
their Hands
(Compliance estimated at less than 50%)

52. Why Not?
 Skin irritation
 Inaccessible hand washing facilities
 Wearing gloves
 Too busy
 Lack of appropriate staff
 Being a physician
 Working in high-risk areas
 Lack of hand hygiene promotion
 Lack of role model
 Lack of institutional priority
 Lack of sanction of non-compliers

53. Successful Promotion 
 Education
 Routine observation & feedback
 Engineering controls
 Location of hand basins
 Possible, easy & convenient
 Alcohol-based hand rubs available
 Patient education
 Reminders in the workplace
 Promote and facilitate skin care
 Avoid understaffing and excessive workload;

54. Successful Promotion 

55. 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

56. Hand Hygiene Techniques
1. Alcohol hand rub
2. Routine hand wash 10-15 seconds
3. Aseptic procedures 1 minute
4. Surgical wash 3-5 minutes

57. Repeat procedures until hands are clean
Routine Hand Wash

58. Alcohol Hand Rubs
 Require less time
 Can be strategically placed
 Readily accessible
 Multiple sites
 All patient care areas
 Acts faster
 Excellent bactericidal activity
 Less irritating (??)
 Sustained improvement

59. Alcohol Hand Rubs
Choose agent carefully:
 Adequate antimicrobial
efficacy.
 Compatibility with other hand
hygiene products.

60. Areas Most Frequently Missed

61. Hand Care
 Nails
 Rings
 Hand creams
 Cuts & abrasions
 “Chapping”
 Skin Problems

62. 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

64. Surveillance
Why surveillance???
• NCI cause of morbidity and mortality
• One third may be preventable
• Surveillance = key factor
• An infection control measure
• Overview of the burden and distribution of NCI
• Allocate preventive resources
• Surveillance is cost-efficient!!

65. Surveillance
• Objectives:
 Reducing infection rates
 Establishing endemic baseline rates
 Identifying outbreaks
 Identifying risk factors
 Persuading medical personnel
 Evaluate control measures
 Satisfying regulators
 Document quality of care
 Compare hospitals’ NCI rates

66. Surveillance
 The surveillance loop
 Health care Surveillance center
system Reporting.
 Event Data interpretation & Analysis
 Action Information Feedback,
 Recommendations
 Conclusions

67. Surveillance
Considerations when creating a surveillance
system
 Goal of the surveillance system (why)
 Engage the stakeholders (who)
 Surveillance method (what, how, when)
 Definition – What to collect – How to collect
(operation of system)
 Available Resources

68. Surveillance
1. Who?
 All hospitals?•
 All departments?•
 All specialties?•
 Other health institutions? •
2. Stakeholders
 Central administration.
 Local administration.
 Public Health ICP institute
 Directorate of Surveillance of department.
 Surgical site infections Ministry Of health wards of Surgical Services
 Lab Patients

69. Control of NCI
Goals for infection control and hospital epidemiology:
There are three principal goals for hospital infection control and
prevention programs:
1. Protect the patients
2. Protect the health care workers, visitors, and others in the
healthcare environment.
3. Accomplish the previous two goals in a cost effective and
cost efficient manner, whenever possible…

70. Control of NCI
1. To control the nosocomial infection we need to consider
the chain of infection and the transmission of an
infectious agent

71. Any Questions???
Thank you for not asking!!!