Hospital Acquired Infection (HAI)

A short brief on 'Hospital Acquired Infections' (HAI) or 'Nosocomial Infection' (NI) for M Phil, MPH and Advance Course in Hospital Management/ Administration

1. Brig Gen Dr Zulfiquer Ahmed Amin M Phil, MPH, PGD (Health Economics), Advance Course HA (AIIMS, Delhi), MBBS (DMC) North South University (NSU) HOSPITAL ACQUIRED INFECTION (HAI)

2. Introduction Hospital-Acquired I nfections (HAI) continue to be a source of great medical and economical strain for healthcare facilities across the world. A hospital-acquired infection— also called “ nosocomial infection (NI) ” can be defined as: - An infection acquired in hospital by a patient who was admitted for a reason other than that infection. - 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.

3. For a HAI, the infection must occur: - After 48 hours of hospital admission - Up to 3 days after discharge - Up to 30 days after an operation - Admission in hospital for reasons other than that particular infection - Ideally, it should be less than 1-2% Characteristics of HAI

4. HAI Rate Hospital Acquired Infection = i / d Hospital Acquired Infection Rate = (i / d)×100 Where , i = Total Number of Hospital Infections d = Total Number of Discharges (Including Deaths)

5. Frequency of HAI A prevalence survey conducted by WHO in 55 hospitals of 14 countries representing 4 WHO Regions (Europe, Eastern Mediterranean , South-East Asia and Western Pacific) showed an average of 8.7% of hospital patients had nosocomial infections . The highest frequencies of nosocomial infections were reported from hospitals in the Eastern Mediterranean and South-East Asia Regions ( 11.8 and 10.0% respectively). A study in a tertiary hospital in Dhaka found a prevalence rate of 8.33 % for HAI ( Amin ZA et al, 2015) in ICU, Post Operative Units and selective surgical units.

6. Impact of nosocomial infections - Hospital-acquired infections add to functional disability and emotional stress to the patient. - The increased length of stay (For surgical wound infections average 8.2 days) is the greatest contributor to cost. - The increased use of drugs, the need for isolation , and the use of additional laboratory and other diagnostic studies also contribute to costs . - Organisms causing nosocomial infections can be transmitted to the community through discharged patients , medical staffs, and visitors. - In severe cases ( eg , Septicemia), it may lead to death.

7. COST of HAI in USA

8. Types of HAI (By Methods of Transmission)

9. Routes of Transmission The main routes are: - Airborne infection : I nfection usually occurs by the respiratory route, with the agent present in aerosols (infectious particles <5 μm in diameter). - Droplet infection : L arge droplets carry the infectious agent (>5 μm in diameter). - Infection by direct or indirect contact : infection occurs through direct contact between the source of infection and the recipient or indirectly through contaminated objects.

10. Risk Factors of HAI

11. 1. The microbial agent - Contact between the patient and a microorganism. - Characteristics of the microorganisms, including resistance to antimicrobial agents, intrinsic virulence, and amount (inoculum) of infective material . - Infections may be caused by a microorganism acquired from another person in the hospital (cross-infection) or may be caused by the patient’s own flora (endogenous infection). - Most infections acquired in hospital are common in the general population , in whom they cause no or milder disease than among hospital patients ( Staphylococcus aureus , coagulase-negative staphylococci, enterococci , Enterobacteriaceae ).

12. 2. Patient susceptibility - Age , immune status, underlying disease, and diagnostic & therapeutic interventions . - The extremes of age: Infancy and old age, are associated with a decreased resistance to infection . - Patients with chronic disease such as severe anaemia , malignant tumors, leukemia , diabetes mellitus, renal failure , or AIDS have an increased susceptibility. - Immunosuppressive drugs or irradiation may lower resistance. - Injuries to skin bypass natural defense mechanisms. - Malnutrition. - Diagnostic and therapeutic procedures, ( eg , catheterization , intubation/ventilation and suction and surgical procedures, etc).

13. 3. Environmental factors - Health care settings are an environment where both infected persons and persons at increased risk of infections congregate . - Crowded conditions within the hospital, frequent transfers of patients from one unit to another, and concentration of patients highly susceptible to infection in one area (e.g. newborn infants, burn patients, intensive care). - Contaminated objects , devices, and materials which are subsequently transferred to susceptible patients. Lack of house-keeping and Waste Management services. Inappropriate building design and ventilation.

14. 4. Bacterial resistance - The indiscriminate use of antimicrobials for therapy or prophylaxis. - Many strains of pneumococci , staphylococci , enterococci, and tuberculosis are currently resistant to most or all antimicrobials. - Multi-resistant Klebsiella and Pseudomonas aeruginosa are prevalent in many hospitals . Antibiotic Resistant Organisms in HAI: MRSA: Methicillin Resistant S. aureus VRE: Vancomycin Resistant Enterococci ESBL: Extended Spectrum Beta-Lactamase Producing E coli/ Klebsiella

15. Prevalence of infection as per site

16. Cancer Ward. Operation Theatre. Delivery Rooms. Orthopaedics Dept

17. Sources of Infection

18. Environmental Factors for HAI H ospital environment that significantly contributes to HAI are: - Building features, - Ventilation , - Water , - Food and wastes . - Housekeeping - Medical Devices

19. Buildings feature: - Traffic flow to minimize exposure of high-risk patients and facilitate patient transport - Adequate spatial separation of patients - Adequate number and type of isolation rooms - Appropriate access to hand-washing facilities - Materials (e.g. carpets, floors) that can be adequately cleaned Appropriate potable water systems to limit Legionella spp . Inlets and outlets

20. Ventilation Fresh filtered air, appropriately circulated, will dilute and remove airborne bacterial contamination . It also eliminates smells . Ultra-clean air For minimizing airborne particles, air must be circulated into the room with a velocity of at least 0.25 m/sec through a high-efficiency particulate air (HEPA) filter, which excludes particulate matter of defined size. If particles 0.3 microns in diameter and larger are removed, the air entering the room will be essentially clean and free of bacterial contaminants.

21. Operating theatres - The operating room is usually under positive pressure relative to the surrounding corridors, to minimize inflow of air into the room. - Modern operating rooms which meet current air standards are virtually free of particles larger than 0.5 μm (including bacteria) when no people are in the room. - operating rooms are ventilated with 20 to 25 changes per hour of high-efficiency filtered air

22. Food The most common errors related to food which contribute to outbreaks include: — Preparing food more than a half day in advance of needs — Storage at room temperature — Inadequate cooling — Inadequate reheating — Use of contaminated processed food (cooked meats and poultry, pies and take-away meals) prepared in premises other than those in which the food was consumed — Undercooking — Cross-contamination from raw to cooked food — Contamination from food handlers .

23. Water The physical, chemical and bacteriological characteristics of water used in health care institutions must meet local regulations. Waste Health care waste is a potential reservoir of pathogenic microorganisms , and requires appropriate handling . Appropriate colour -coding for waste segregation, transportation, handling and disposal should be ensured.

24. Housekeeping: Proper supervision. Regular cleaning. Proper Linen and Laundry Services. Adoption of 5S (5s-CQI-TQM) system of hospital- quality improvement. Medical Equipment: Proper CSSD Services. Avoid unnecessary instrumentation. Aseptic condition (Including sterilization) Policy on use of medical devices (Including duration of use).

25. Standards to be maintained at hospitals

26. Rodac Plates ( RODAC = Replicate Organism Detection And Counting) can be used for microbiological control of all surfaces.

27. Antimicrobial resistance Currently many microorganisms have become resistant to different antimicrobial agents , and in some cases to nearly all agents . Some strains of methicillin-resistant Staphylococcus aureus (MRSA) have a particular affinity for nosocomial transmission . MRSA strains are often resistant to several antibiotics in addition to the penicillinase -resistant penicillins and cephalosporins , and occasionally are sensitive only to vancomycin and teicoplanin .

28. Infection control programs - National or regional programs The responsible health authority should develop a national (or regional) program to support hospitals in reducing the risk of nosocomial infections . - Hospital programs Risk prevention for patients and staff is a concern of everyone in the facility, and must be supported at the level of senior administration . - Infection Control Committee

29. Composition of Infection Control Committee - Hospital director as chairman - Chief of Infection control team (Microbiology staff) - Heads of all the major clinical departments - Chief Nurse. - Chief Pharmacist. - Head of the maintenance and cleaning department. - Head of CSSD.

30. Functions of Hospital Infection Control Committee - Formulates infection control guidelines and procedures - Monitors implementation of infection control practices. - Conducts a hospital wide surveillance and identifies prevalent microorganisms and nosocomial infections and makes appropriate action. - Facilitates/recommends risk reduction strategies to prevent hospital acquired infections among patients , families and health care providers - Recommends appropriate advices on issues and problems related to infection control practices.

31. - Plans/facilitates for the educational training of all hospital employees on infection control practices. - Conducts risk assessment activities for patients who are likely to develop hospital acquired infections. - Collates/analyzes statistical data on hospital infection and makes prompt action and recommendations. - Reviews the use of antibiotics as they relate to patient care. - Conducts regular meeting or as the need arises .

32. Role of Infection Control Committee Education and Training Development and dissemination of infection control policy Monitoring and audit of hygiene practices Clinical Audit

33. Nosocomial Infection surveillance Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice . The development of a surveillance process to monitor HAI rate is an essential first step to identify local problems and priorities, and evaluate the effectiveness of infection control activity .

34. Prevention of Nosocomial I nfection 1. Risk stratification Vulnerability to nosocomial infection is determined by both patient factors, such as degree of immuno -compromise, and interventions performed. Thus categorize patients and plan infection control interventions . 2. Reducing person-to-person transmission Hand decontamination: Compliance with hand-washing is frequently suboptimal, due to: - Lack of appropriate accessible equipment. - Insufficient knowledge of staff about risks and procedures . - Too long a duration recommended for washing . - Lack of washing facilities. - Leniency of the management.

35. Personal hygiene: All staff must maintain good personal hygiene. Nails must be clean and kept short . Clothing: - Clothes covered by a white coat. - In special areas such as burn or ICU, uniform trousers and a short-sleeved gown - The working-cloths must be made of a material easy to wash and decontaminate . - Use of shoes and caps. Masks Gloves

36. Safe injection practices - Eliminate unnecessary injections. - Use sterile needle and syringe. - Use disposable needle and syringes (If possible). - Prevent contamination of medications. - Follow safe sharps disposal practices. 3. Preventing transmission from the environment - Adequate methods for cleaning, disinfecting and sterilizing. - Ninety per cent of microorganisms are present within “visible dirt”, and the purpose of routine cleaning is to eliminate this dirt . - Safe disposal of Hospital W aste .

37. 4. Establishing Infection Control Committee 5. Establishment of Infection C ontrol P rogram . 6. Provision of safe blood. 7 . Proper hospital building and design. 8 . HAI Surveillance . 9 . Commitment of administrators and clinicians. 10. Financing infection control programs. 11. Raising awareness among the staffs, patients and attendants. 12. Special care to bed-ridden and unconscious patients for bed-sore and septicemia. 13. Justify use of medical devices and duration of use.

38. 13. Control of Antimicrobial Resistance:

39. 5 Pillars of Infection Control

40. Conclusion