Different types of nosocomial infection and treatment protocol. Infection control committee

1. NOSOCOMIAL
INFECTION(nosos= disease; komeion= to take care of)
DySP Dr. Samriddhi Karki
MD Pathology
Nepal Police Hospital
11th May 2017

2. OUTLINES
• Introduction
• Epidemiology
• Sources of infection
• Microorganisms
• Common nosocomial infections
• Diagnosis
• Treatment
• Prevention
• Hospital infection control committee

3. INTRODUCTION
• An infection occurring in a patient in a hospital or
other health care facility in whom the infection was
not present or incubating at the time of admission.
• This includes infections acquired in the hospital but
appearing after discharge, as well as occupational
infections among staff of the facility.
World Health Organization

4. EPIDEMIOLOGY
• About 2 million patients suffer from hospital acquired
infections (HAI) every year with around 100,000
deaths.
Reed D, Kemmerly SA. Infection Control and Prevention: A Review of Hospital-Acquired
Infections and the Economic Implications. Ochsner J. 2009;9(1):27-31.
• WHO report has shown that frequency of HAI in South
East Asia is 10%.
WHO/CDS/CSR/EPH. Prevention of hospitalacquired infections: A practical guide, 2nd edition;
2002.12.
• A study done in Nepal has shown overall point
prevalence of HAI to be 2.4%
Lamichhane DR, Shrestha P. Prevention of nosocomial infection in TUTH. A report submitted
to Nepal Health Research Council, 2001

5. SOURCES OF INFECTION
• ENDOGENOUS
– Patient’s own flora
• EXOGENOUS
– Cross infection from medical personnel
– Cross infection from patient to patient
– Hospital environment
• Air
• Water
• Dust
• IV fluids and catheters
• Bed pans
• Endoscopes
• Ventilators and respiratory equipment

6. MICROORGANISMS
• Any pathogen that are able to survive in
hospital environment and develop resistance
to antibiotics & disinfectants.
Bacteria
Virus Fungi
Protozoa

7. Gram positive bacteria
• Staphylococcus aureus is one of the commonest
pathogens associated with HAI.
• It colonize the skin, nose, throat of patients and
hospital staff.
• Causes wide variety of infections and are
frequently resistant to antibiotics.
• A study conducted by Pandey et. al. shows
26.12% of S.aureus isolates to be MRSA.7
Pandey S, Raza MS, Bhatta CP. Prevalence and Antibiotic Sensitivity Pattern of Methicillin-Resistant-
Staphylococcus aureus in Kathmandu Medical College Teaching Hospital. Journal of Institute of Medicine. 2013 Jan
11.

9. Gram negative bacteria
• Most important group of hospital pathogens
• Enterobacteriaceae:
– E.coli; Proteus; Kliebsiella
– Immunocompromised host
• Pseudomonas spp:
– Often isolated in water and damp areas
– Transmitted via inanimate objects (improper disinfection of
instruments: endoscope, bronchoscope, cystoscope) and airborne
route (dust from bedding, floors, wound exudates)
• Acinetobacter:
– Widely distributed in soil and water

10. Cont…
• In a study conducted by Pant et. al. , most
common isolates from ICU was:
– Acinetobacter baumannii (40%) followed by
– Pseudomonas aeruginosa (36%),
– members of Enterobacteriaceae,
– Staphylococcus aureus,
– Staphylococcus epidermidis,
– Aspergillus fumigatus,
– Candida albicans and Bacillus cereus
Pant ND, Sharma M. Environmental screening for microorganisms of patient’s surrounding as the possible source of
nosocomial infections in a hospital in Nepal. Journal of Biomedical Sciences. 2015;2(3):21-3.

13. Other pathogens…
• Viruses:
– HIV and Hepatitis B & C
– CMV, HSV, Influenza, Enteroviruses,
• Fungi:
– Candida albicans, Aspergillus, Mucor
• Protozoa:
– Entamoeba histolytica, Plasmodia, Toxoplasma
gondii, Pneumocyctis carinnii

14. • Retrospective study : Prevalence of
microorganisms and their antibiotic
resistant pattern
– Nepal Police Hospital, central laboratory
(microbiology unit)
– Time period: 15th Falgun, 2073 to 15th Chaitra,
2073
– Inclusion criteria: All samples received in central
laboratory for culture/sensitivity
– Total cases: 554

15. 61%
14%
13%
5%
2%
Types of sample
urine
sputum
blood
pus
ascitic fluid
throat swab
tissue
stool
wound
synovial fluid
HVS
pleural fluid
catheter tip
peritoneal fluid
cerebrospinal fluid

16. STERILE
GROWTH
MIXED GROWTH
NO SIGNIFICANT GROWTH
TOTAL
382
59(10.5 %)
33
80
554
RESULT

17. 49%
15%
10%
7%
3%
3%
3%
2% 2% 2%
2%
2%
FREQUENCY OF MICROORGANISMS
E.coli
S.aureus
Pseudomonas
aeruginosa
Enterococcus faecalis
S.typhi
Yeast cell
Citrobacter freundii
Klebsiella oxytoca
E.coli + Enterococcus faecalis
E.coli + S.aureus
beta hemolytic streptococcus

18. None E.coli
S.
typhi
E.
faecalis
Yeast cell
S.
aureus
P.
aeruginosa
K.
oxytoca
C.
freundii
E.coli +
Enterococ
cus
faecalis
E.coli +
S.aureus
beta
hemolytic
streptococ
cus
Acenobacter Total
urine 307 22 0 3 1 1 2 1 0 0 0 0 1 334
blood 72 0 2 0 0 0 0 0 0 0 0 0 0 74
sputum 72 0 0 0 1 2 3 0 0 0 0 0 0 78
pus 15 4 0 0 0 6 0 0 2 0 0 0 0 27
throat swab 5 1 0 0 0 0 0 0 0 0 1 1 0 8
HVS 2 0 0 0 0 0 0 0 0 0 0 0 0 2
wound 2 0 0 0 0 0 1 0 0 0 0 0 0 3
tissue 2 0 0 1 0 0 0 0 0 1 0 0 0 4
stool 4 0 0 0 0 0 0 0 0 0 0 0 0 4
catheter tip 0 1 0 0 0 0 0 0 0 0 0 0 0 1
ascitic fluid 7 1 0 0 0 0 0 0 0 0 0 0 0 8
synovial fluid 3 0 0 0 0 0 0 0 0 0 0 0 0 3
pleural fluid 2 0 0 0 0 0 0 0 0 0 0 0 0 2
peritoneal
fluid
1 0 0 0 0 0 0 0 0 0 0 0 0 1
cerebrospinal
fluid
1 0 0 0 0 0 0 0 0 0 0 0 0 1
495 29 2 4 2 9 6 1 2 1 1 1 1 554

19. E.coli S.typhi E. faecalis S.aureus
P.
aeruginosa
urine 22 0 3 1 2
blood 0 2 0 0 0
sputum 0 0 0 2 3
pus 4 0 0 6 0

20. COMMON NOSOCOMIAL
INFECTIONS
1. Urinary tract infection (UTI)
2. Lower respiratory tract infection (LRTI)
3. Surgical site infection (SSI)
4. Ventilator associated pneumonia (VAP)
5. Septicemia
Sah MK, Mishra SK, Ohora H, Kirikae T, Sherchan JB, Rijal BP, Pokhrel BM. Nosocomial Bacterial Infection and Antimicrobial
Resistant Pattern in a Tertiary Care Hospital in Nepal. Journal of Institute of Medicine. 2014 Dec 1;36(3).

21. Nosocomial UTI
• Diagnosis:
– Clinical signs/symptoms (e.g. Dysuria, urgency frequency, suprapubic
pain)
– Pyuria (>10 WBC/hpf )
– Positive urine culture (1 or 2 species) with at least 105 CFU/ml
• Risk stratification:
– Uncomplicated: female, no urologic abnormalities, no stones, no
catheter
– Complicated: male gender, possible stones, urologic abnormalities,
pregnancy

22. • Empiric treatment:
–Uncomplicated:
• Nitrofurantoin 100 mg PO Q12H X 5 days (not in patient
with CrCl <50ml/min), OR
• Cephalexin 500 mg PO Q6H X 5 days, OR
• Cefpodoxime 100 mg PO Q12H X 5 days, OR
• TMP/SMX 1DS tab PO Q12H X 3 days, OR
• IV option: Cefazolin 1g IV Q8H X 3 days
–Complicated:
• Same as above except duration is 7-14 days
CIPROFLOXACIN is not recommended for
empiric treatment for in-patients with non-
catheter associated UTI at JHH due to the low
rate of E. coli
susceptibility (71%)
Treatment Recommendations For Adult Inpatients at John Hopkins Hospital, 2015-2016.
Web address: insidehopkinsmedicine.org/amp

23. Sah MK, Mishra SK, Ohora H, Kirikae T, Sherchan JB, Rijal BP, Pokhrel BM. Nosocomial Bacterial Infection and Antimicrobial
Resistant Pattern in a Tertiary Care Hospital in Nepal. Journal of Institute of Medicine. 2014 Dec 1;36(3).

24. Antibiotic resistant pattern
Antibiotics E.Coli
(n=29)
S.Aureus
(n=9)
P.Aeruginosa
(n=6)
Amoxicillin 79.3% 66.7% 100%
Ciprofloxaxin 55.2% 55.6% 16.7%
Cefexime 48.3% 55.6% 66.7%
Ceftriaxone 48.3% 11.1% 33.3%

25. Prevention
• Avoiding catheter when possible and
discontinue ASAP- MOST IMPORTANT
• Aseptic insertion by trained HCWs
• Maintaining closed system of drainage
• Ensuring dependent drainage
• Silver coated catheters

26. Nosocomial LRTI
• Clinical diagnosis
– Symptoms with at least two of the following signs
appearing during hospitalization:
 Cough
 Purulent sputum
 New infiltrate on chest radiograph consistent with
infection
• Microbiologic Confirmation
– Suctioned Sputum sample

27. • Risk stratification:
– Mild to moderate illness
• Not in the ICU, no or minimal oxygen requirement, no hypotension
– Severe illness
• In the ICU, concern for sepsis, significant oxygen requirement, multi-
lobar consolidation
– History of or risk factors for Pseudomonas and
other resistant Gram-negative organisms

28. Cont…
• Mild to moderate:
– Ceftriaxone 1g IV Q24H
• Severe:
– Cefepime 2g IV Q8H +/- vancomycin, OR
– Piperacillin/tazobactum 4.5g IVQ6H +/- vanco, OR
– Severe penicillin allergy: Vancomycin + Ciprofloxacin +/- Gentamicin
• H/O or risk factors for Pseudo and other
resistant GNB:
– Treated as severe illness with tailoring of antibiotic based on past
culture data

29. Surgical site infection
• Diagnosis:
– Any purulent discharge, abscess, or spreading
cellulitis at the surgical site during the month after
the operation
• Risk stratification:
– Infections following clean procedures
– Infections following contaminated procedures
– Deep fascia involvement

30. Cont…
• Infections following clean procedures
– Oxacillin 1-2gIV Q4H, OR
– Cefazolin 1g IV Q8H, OR
– Clindamycin 600 mg IV Q8H (PCN allergy),

31. Cont…
• Infections following contaminated procedures:
– Patients not on broad-spectrum antibiotics at time of
surgery and not severely ill
• Ertapenem 1g IV Q24H, OR
• If PCN allergy, (Ciprofloxacin 500mg PO BID or Ciprofloxacin 400 mg IV
Q12H) + Clindamycin 600 mg IV Q8H
– Patients on broad-spectrum antibiotics at time of
surgery or severely ill
• Piperacillin/tazobactam 3.375 g IV Q6H +/- Vancomycin

32. Cont…
• Deep fascia involvement:
– Surgical emergencies
– Antibiotics are only an adjunct to prompt
debridement
– Vancomycin + Piperacillin/tazobactam 3.375 g IVQ6H, OR
– Cefepime 1g IV Q8H + Clindamycin 600-900mg IV Q8H

33. Prevention
• Limiting pre-op hospitalization
• Stabilizing underlying diseases
• Avoiding hair removal by shaving
– Clipping of skin is preferred
• Skin decolonization
– Chlorhexidine
– Intranasal Mupirocin for S.aureus carriers
• Impermeable drapes

34. Ventilator-associated pneumonia
(VAP)
• Difficult to diagnose.
• Quantitative cultures of BAL fluid can help
distinguish between colonization and infection;
>=104 cfu/ml is considered significant growth.
• Optimal treatment based on Severity of illness
as determined by the Clinical Pulmonary
Infection Score (CPIS)

36. • Empiric treatment
–CPIS <= 6, VAP is unlikely.
–CPIS >6
• Early onset VAP
–Ceftriaxone 1g IV Q24H
• Late onset VAP
–Vancomycin + Piperacillin/tazobactam +/-
genta

37. Prevention
• Change position q 2 hours
–Elevate head to 30-45 degrees
• Deep breathing, incentive spirometry
• Frequent suctioning
• Bronchoscopy to remove mucous
plugging

38. Prevention
• Reducing person-to-person transmission
– Hand decontamination
– Personal hygiene
– Clothing
• Working clothes
• Shoes
• Caps
– Masks
– Gloves
– Safe injection practice
• Preventing transmission from the environment
– Cleaning of the hospital environment
– Use of hot/ superheated water
– Disinfection of patient’s equipment
– Sterilization

40. Hospital Infection Control Committee
(HICC)
• Every hospital must have effective
Hospital Infection Control
Committee.
• Responsible for control of HAI
• The first HICC in Nepal was
established in 1988 at TUTH.
Ohara H, Pokhrel BM, Dahal RK, Mishra SK, Kattel HP, Shrestha DL et al. Fact-finding Survey of Nosocomial Infection Control in Hospitals in
Kathmandu, Nepal-A Basis for Improvement. Tropical Medicine and Health. 2013;41(3):113-9.

41. Members of HICC
• Chairperson: Hospital director
• Infection control officer: Clinical microbiologist
• Infection control nurse
• Infectious disease physician
• Chief of nursing services
• Medical record officer (if available)
• Representative from the major clinical specialties
• Additionally, representatives from any other department (pharmacy,
maintenance, housekeeping, etc) may be invited as necessary

42. CONCLUSION
• HAIs are global problem and are important contributors
to morbidity and mortality.
• HAIs are often caused by antibiotic- resistant organisms
• Empirical antimicrobial therapy must be based on
careful clinical evaluation and local epidemiological data
regarding potential pathogens and antibiotic
susceptibility.
• Proper disinfection of the vicinity of the patients along
with strict implementation of the hand hygiene program
is very necessary to reduce the rate of HAIs.
• Every hospital must have effective Hospital Infection
Control Committee to control HAIs

43. REFERENCES
1. Reed D, Kemmerly SA. Infection Control and Prevention: A Review of Hospital-Acquired
Infections and the Economic Implications. Ochsner J. 2009;9(1):27-31.
2. WHO/CDS/CSR/EPH. Prevention of hospitalacquired infections: A practical guide, 2nd
edition; 2002.12.
3. Lamichhane DR, Shrestha P. Prevention of nosocomial infection in TUTH. A report submitted
to Nepal Health Research Council, 2001
4. Pant ND, Sharma M. Environmental screening for microorganisms of patient’s surrounding as
the possible source of nosocomial infections in a hospital in Nepal. Journal of Biomedical
Sciences. 2015;2(3):21-3.
5. Sah MK, Mishra SK, Ohora H, Kirikae T, Sherchan JB, Rijal BP, Pokhrel BM. Nosocomial
Bacterial Infection and Antimicrobial Resistant Pattern in a Tertiary Care Hospital in Nepal.
Journal of Institute of Medicine. 2014 Dec 1;36(3)
6. Treatment Recommendations For Adult Inpatients at John Hopkins Hospital, 2015-2016. Web
address: insidehopkinsmedicine.org/amp
7. Pandey S, Raza MS, Bhatta CP. Prevalence and Antibiotic Sensitivity Pattern of Methicillin-
Resistant-Staphylococcus aureus in Kathmandu Medical College Teaching Hospital. Journal
of Institute of Medicine. 2013 Jan 11.
8. Ohara H, Pokhrel BM, Dahal RK, Mishra SK, Kattel HP, Shrestha DL et al. Fact-finding
Survey of Nosocomial Infection Control in Hospitals in Kathmandu, Nepal-A Basis for
Improvement. Tropical Medicine and Health. 2013;41(3):113-9.

44. THANK- YOU

Hospital Infection Control
Committee