Hospital infection and control (dr mms 2017)

1. HOSPITAL ACQUIRED
INFECTION
(NOSOCOMIAL) INFECTION
Dr. Myint Myint SeinDr. Myint Myint Sein
Associate ProfessorAssociate Professor
Department of Public Health LaboratoryDepartment of Public Health Laboratory
ScienceScience
University of Public HealthUniversity of Public Health

2. Definition of HAI
• Infections that arise in hospital
• Infection neither present nor incubating at the
time of admission
• Infection that develops in patients after more
than 48 hours of hospitalization
• May appear after discharge from hospital
eg- post- op wound infection
• Contracted by healthcare staff

3. Hospital Infection
• Hospital Infection
• Hospital Associated Infection
• Hospital Acquired Infection
• Nosocomial Infection
• Health Care Associated Infection

4. DEFINITION:
Any infection acquired by a patient in hospital
A nosocomial infection is an infection that is not
present or incubating when a patient is admitted to a
hospital
Bacterial nosocomial infections generally have an
onset of more than 48 to 72 hours after hospital
admission

5. History of nosocomial outbreaks
• First well-documented outbreak
– Puerperal (child-bed) fever in a hospital in
Vienna, 1847
– Ignác Semmelweis, Hungarian physician
gathered and analysed mortality data
– Autopsy room - Maternity wards
– Hand-washing intervention (chlorine
solution)

6. • Affects approx. 5- 10% of all in-patients
• Delays discharge
• HAI costs 2times >no infection
• direct cause deaths

7. About 9%of all hospitalized pts
As a result of their stay in hospital
Most common
UTI
RTI
Wound infections

8. 1847

9. TYPES OF NOSOCOMIAL INFECTIONS
Urinary tract infection
- most common type
-accounts for 40% of nosocomial infections
Surgical wound infection
-accounts for an additional 20%
Lower respiratory tract infections accounts for
15%
Nosocomial bacteraemia
- accounts for an additional 5%.

10. Urinary tract infection
Related to indwelling catheterization(80%) or
urologic instrumentation such as
cystoscopy(20%)
Catheter associated urinary tract infection
develops in up to 25% of catheterized
patients
Gram negative bacteria- common pathogens

11. Surgical wound infection
Caused by indigenous flora commonly
Staphylococcus epidermidis
(coagulase-negative staphylococci)
Others bacteria:
Staphylococcus aureus,
- Enterococci
- Gram-negative bacilli

12. Lower respiratory tract infection
Related to aspiration
Introduced by respiratory therapy such as
endotracheal suctioning or inhalation therapy
commonly caused by:
Staph aureus,
Pseudomonas spp
Gram negative bacilli

13. Streptococci (Gram positive cocci in long chain)

14. Gram stain – Gram negative rod

15. Nosocomial bacteraemia
Often related use of intravascular devices.
Staphylococcus epidermidis
Staph aureus,
Pseudomonas spp
Acinetobacter

16. Acinetobacter Gram stain

17. Staphylococcus aureus (Gram positive cocci in groups)

18. Factors increasing the risk of hospital-acquired
infections
- Patient risk factors
- Environmental risk factors
- Nature of the organism

19. Factors influencing the HAIFactors influencing the HAI
• Age – Neonates and
elderly have highest risk
due to inefficient
immunity.
• Infected patients-
Community acquired
infection may spread to
susceptible patients or
attendants
• Drug resistance-
Coliforms & Staph
aureus.
• Increased virulence
• Susceptible patients-
Pre-existing disease e.g.
Diabetes,
• Immuno-suppression,
prosthetic implants,
special care units
• Surgical procedures-
Bypassing natural mech
of body surface
Diagnostic /therapeutic
invasive procedures

20. Sources & Transmission of HAI
Endogenous(self-
infection)
- Patients own flora –
auto-infection( pts own
skin, GI, upper
respiratory flora)
Exogenous
Sources :
-Contact with other
patients/staff
-Environmental sources
like inanimate objects,
Mode of transmission
Contact
Hand & Clothing
Inanimate objects
Air borne route
Droplet from
respiratory tract
Aerosol by nebulizer,
humidifiers
Oral route- Food/ water

21. • Susceptible pts
- in neonatal units
- in burn units
- urological wards
- ICU pts

22. Major microbial causes
Gram positive cocci
- Staph aureus ,Staph epidermidis
-Group A & other streptococci
- Enterococci
- Anaerobic cocci
Gram negative bacilli
- Esch. coli & other coliforms
- Proteus-Morganella- Providencia
- Pseudomonas
-Salmonella
- Shigella

23. Anaerobic bacilliAnaerobic bacilli
Gram positive - Clostridium tetani
- Clostridium perfringens
Gram negative – Bacteroides spp
Other bacteria
- Corynebacterium dsiphtheriae
- Listeria
- Mycobacterium tuberculosis
- Atypical mycobacteria
- Bordetella pertussis

24. Notorious Pathogens
• Methicillin-resistant S. aureus (MRSA)
• Vancomycin-resistant enterococcus (VRE)
• Clostridium difficile
• Norovirus
• Multiply-drug resistant (MDR) gram
negative rods
• (e.g., P. aeruginosa, Acinetobacter)
They survive on environmental surfaces for
long periods of time and can be transiently carried on hands.

25. Methicillin resistantMethicillin resistant Staphylococcus aureusStaphylococcus aureus
((MRSA)MRSA)
Resistant to Flucoxacillin and usually others
May cause -
Wound infection
Bacteraemia
Skin/soft tissue infection
UTI
Pneumonia etc.

26. Colonisation common:
Nose, Axilla ,Perineum
- Wounds/Lesions
Spread By:
Hands
Fomites
Aerosols
Becoming more common in Community
Control:
Eradication of carriage
Barrier nursing
Screening of other patients Staff

27. VRE (vancomycin resistant enterococci)
Enterococcus faecalis and E. faecium
• Normal inhabitants of bowel
•UTI and wound infections in seriously ill patients
•Cross infection via contaminated equipment
•Patients with VRE are placed on contact isolation

28. Tuberculosis
Open pulmonary TB
(Sputum smear positive for AFB)

29. Drug Resistant Gram negative bacteria
Resistance to multiple antibiotics
Organisms:
Escherichia coli
Extended spectrum beta lactamase producing
Klebsiella
Proteus
Enterobacter
Acinetobacter
Pseudomonas aeruginosa

30. Cause:
Bacteraemia
UTI
Pneumonia
Wound infection
Control:
Antibiotic Policy
Control of Infection Guidelines
Prevention of Cross Infection especially on
high risk areas

31. Viral infections
SARS(Severe Acute resparatory Syndrome)
Merburg and Ebola viruses
- viral haemmorrhage fever
Norovirus - diarrhoea

32. The Inanimate Environment Can FacilitateThe Inanimate Environment Can Facilitate
TransmissionTransmission
Contaminated surfaces increase cross-transmission~
The Risk of Hand and Glove Contamination after Contact with a
VRE (+) Patient Environment..
X represents VRE culture positive
sitesz

33. HAI

34. Burn patient

35. SSISSI: Superficial wound Deep Wound: Superficial wound Deep Wound

36. Up to 85% of patients with C. difficile-associated disease
have antibiotic exposure in the 28 days before infection
Antibiotic exposure is
the single most
important risk factor
for the development
of Clostridium difficile
associated
Pseudomembranous
colitis

37. Toxic Colon from C Difficile

38. HOSPITAL ACQUIRED
INFECTIONHospital Acquired RTI
•Micro-aspiration of upper
airway secretions
•Ventilator associated,
•ET intubation associated
•Pseudomonas aeruginosa,
E coli, Klebsiella spp.,
Acinetobacter baumannii,
Haemophilus infleunzae, etc.
•Usually multidrug resistant
isolates

39. The CVC- is one of the most
commonly used catheters in
medicine
The CVC is typically
placed through a central
vein such as the IJ,
Subclavian or femoral
Central Venous Catheter (CVC)
These serve as
direct line for
microbial
bloodstream
invasion

40. Areas Most Frequently Missed
HAHS © 1999

41. INFECTION CONTROL

42. Infection Control
The process by which health care facilities
develop and implement specific policies and
procedures to prevent the spread of infections
among health care staff and patients

43. HAI increasing in :
• Compromised patients
• Ward and inter-hospital transfers
• Antibiotic resistance
(MRSA, resistant Gram negative bacteria)
• Increasing workload
•staff pressures
•lack of facilities

44. High risks : Healthcare workers
They 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

45. Hospital Infection Control Committee
(HICOM)
Objective
– Investigation of all HAI
– Establish surveillance programme
– Provide guidance & leadership in prevention
& control of HAI

46. Hospital Infection Control Committee
Composition :Chairman – Hospital Suptdt
Membership:
Doctors
General physician
Infectious disease specialist
Surgeon
Clinical microbiologist
Members –All major specialty representatives,
Nursing matron, Infection control nurse
Engineering service representative,

47. Hospital Infection Control Committee
• Role & FunctionsRole & Functions
– Establish reporting system thru’
• Nursing unit report
• Individual patient report
• Bacteriology reports
• Autopsy report
– Periodical meetings to take decisions
– Lay down standards of asepsis, sterilization etc
– To prepare SOP Manual
– To take decision on all reports of HAI control officer

48. Surveillance
• Important means of monitoring HAI
Early detection of trends outbreaks
1. Laboratory Based
Microbiology Laboratory lists +ve organisms
‘Alert organisms’ reported
2. Ward Based
Ward staff monitor patients

49. Drug-resistant pattern recording at
hospital

50. Drug-resistant pattern recording at
hospital

51. Drug-resistant pattern recording at
hospital

52. Disc Diffusion susceptibility test

53. Root Causes of Nosocomial Infections
Lack of training in basic IC
Lack of an IC infrastructure and poor IC practices
(procedures)
Inadequate facilities and techniques for hand
hygiene
Lack of isolation precautions and procedures
Inadequate sterilization and disinfection practices
and inadequate cleaning of hospital

54. Functions
 Addressing food handling, laundry handling, cleaning
procedures, visitation policies
 Obtaining and managing critical bacteriological data
and information
 Developing and recommending policies and
procedures pertaining to infection control
 Recognizing and investigating outbreaks of infections
in the hospital and community
 Intervening directly to prevent infections
 Educating and training health care workers, patients,
and nonmedical caregivers

55. Core Strategies to Reduce Nosocomial
Infections-Hand Hygiene
To ensure appropriate hand washing techniques—
 Provide sinks, clean water, and soap at
convenient locations
 alcohol-based products
 Use gloves when necessary
 Hand hygiene is the simplest, most effective
measure for preventing hospital-acquired
infections.

56. Repeat procedures until hands are clean
Routine Hand Wash

57. Ensuring a Clean Environment
 Establish policies and procedures to prevent
food and water contamination
 Establish a regular schedule of hospital
cleaning with appropriate disinfectants in, for
example, wards, operating theaters, laundry
 Dispose of medical waste safely

58. Cleaning, Disinfection, and Sterilization of
Instruments and Supplies
Sterile Invasive Procedures and Intravenous
Medications-Intravascular devices ,Urinary catheter
Mechanical ventilation ,respiratory equipment
Ensure proper handling of inhalation medications
and supplies
Use antibiotic prophylaxis only when indicated
and according to established protocols.

59. Antimicrobial Use and Monitoring
 Therapeutic guidelines
 Prophylactic guidelines
 Guidelines for surgical prophylaxis

60. http://www.oneandonlycampaign.org/

61. ANTIBIOTIC POLICY

62. ANTIBIOTIC POLICY
Antibiotic policy deals with recommendations for
specific antibiotic treatments and is usually derived from
a consensus view reached by detailed discussion among
a group experts in the field.

63. ANTIBIOTIC POLICY
• The aim of implementing this policy is to ensure that
antibiotics are used appropriately.
• This should result in more effective treatment of
infections so that patient outcomes are optimized.
• In addition, appropriate antibiotic use should minimise
the risk of healthcare-associated infections occurring and
• It produces benefits for patients and staff and for service
delivery and clinical outcomes.

64. ANTIBIOTIC POLICY
• Required in all hospitals
• Promote the practice of good medicine.
• Ensure the used of appropriate antibiotic for a specific
disease at optimal doses for correct duration
• Helps to limit the unnecessary use so that will avoid
exposure to side effects of the drug as well as decrease
emergence of resistance amongst the bacterial population.
• Reduce hospital cost.
• Improve education of junior doctors by providing
guidelines.

65. COMPONENTS OF
ANTIBIOTIC POLICY
• Educational
• Prescribing strategies
• Antibiotic Audit

66. COMPONENTS OF
ANTIBIOTIC POLICY
1. Educational
Most important component
- continuously informing the doctors regarding the use
of antibiotics, any new agents
- resistance pattern, etc
- lectures, clinical meeting, newsletters

67. COMPONENTS OF
ANTIBIOTIC POLICY
2. Prescribing strategies
- designed to limit inappropriate use of antibiotics
- restrict drug list
- The need of authorization by physician
- AST results
- stop

68. COMPONENTS OF
ANTIBIOTIC POLICY
3. Antibiotic audit
To improve antibiotic prescribing
- improve quality of health care
- improve cost-effectiveness
- reduce or control levels of antibiotic resistance
Integral part of an antibiotic policy
- Regularly done
- Poor compliance – find out why
- Review the policy if necessary.

69. COMPONENTS OF
ANTIBIOTIC POLICY
Antibiotic audit (cont’)
1. Universal audit of all antibiotic prescriptions
2. Targetted Audit
- of specific situations
- of specific antibiotics
- for specific infections
- in selected units/areas
- for surgical prophylaxis
Depends on the needs and resources of the institution
- necessity for antibiotic usage
- correct choice, dose, duration, route
- cost-effectiveness
- outcome of treatment

70. COMPONENTS OF
ANTIBIOTIC POLICY
3. Antibiotic audit
To improve antibiotic prescribing
- improve quality of health care
- improve cost-effectiveness
- reduce or control levels of antibiotic resistance
Integral part of an antibiotic policy
- Regularly done
- Poor compliance – find out why
- Review the policy if necessary.

71. COMPONENTS OF
ANTIBIOTIC POLICY
Antibiotic audit (cont’)
1. Universal audit of all antibiotic prescriptions
2. Targetted Audit
- of specific situations
- of specific antibiotics
- for specific infections
- in selected units/areas
- for surgical prophylaxis
Depends on the needs and resources of the institution
- necessity for antibiotic usage
- correct choice, dose, duration, route
- cost-effectiveness
- outcome of treatment