Hospital acquired infections

HAIS, NOSOCOMIAL INFECTIONS,PREVENTION AND SURVEILLANCE

1. Hospital-Acquired Infections Dr. Neelam Gupta M.D. MICROBIOLOGY

2. Also called as “ NOSOCOMIAL INFECTIONS .” ‘ Nosus ’ means disease . ‘ Kameion ’ means to take care of

3. DEFINITION Hospital-acquired infections ( HAls ) can be defined as the infections acquired in the hospital by a patient: Who was admitted for a reason other than that infection. • In whom the infection was not present or incubating at the time of admission Symptoms should appear at least after 48 hours after Admission. This also includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the hospital care facility.

4. It is estimated that 5-10% of patients admitted to acute care hospitals develop HAIs. Treatment of these HAIs adds a huge economic burden to the patient and hospital.

5. Factors Affecting HAIs Immune status Hospital environment: Hospital organisms: Diagnostic or therapeutic interventions such as insertion of intravenous or urinary catheters, or endotrachealTube Transfusion: Blood, blood products and intravenous Fluids Poor hospital administration: Strong administrative support is essential to control the HAIs

6. HOST FACTORS THE AGENT EP I DEMI O - LOGICAL INTERACT- ION ENVIRONMENT

7. SOURCES OF INFECTION ENDOGENOUS 2 SOURCES : EXO G ENOUS

8. Endogenous T hey involve patient's own microbial flora which may invade the patient's body during some surgical or instrumental manipulations.

9. Exogenous Source Exogenous sources are from hospital environment, staff, or patients. Environmental sources include inanimate objects, air, water and food in the hospital. Inanimate objects in the hospital are medical equipment (endoscopes, catheters, etc.), bed pans, surfaces contaminated by patients’ excretions, blood and body fluids Healthcare workers may be potential carriers, harboring many organisms; which may be multidrug resistant , e.g. nasal carriers of Methicillin-resistant Staphylococcus aureus (MRSA) Other patients of the hospital may also be the source of infection.

10. Microorganisms Implicated in HAIs The ESKAPE pathogens: Enterococcus faecium (DAIs). Staphylococcus aureus Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa Enterobacter species. Other infections that can spread in hospitals include: Escherichia coli Nosocomially -acquired Mycobacterium tuberculosis Legionella pneumophila Candida albicans Clostridium difficile diarrhea. Blood-borne infections transmitted through contaminated needle prick injury or mucocutaneous exposure of blood includes HIV; hepatitis B and hep C viral infections.

11. MODES OF TRANSM I SSION ROUTES OF SPREAD CONTACT AIR BORNE EXOGENOUS

12. CONTACT TRANSMI S SION ( MOST COMMON MODE OF TRANSMISSION) CO N T ACT DIRECT HANDS, A U TOINO C UL A TION, EQUIPMENT. INDIRECT BED P AN S , DRE S SINGS, CONTAMINATED GLOVES

13. AIR BORNE TRANSMISSION DROPLET NUCLEI IN THE ATMOSPHERE RESPIRATORY SECRECTIONS ON SURFACE (FOMITES)

14. EXOGENOUS INFECTIONS SITES IN HOSPITAL-INFECTIONS

15. Urinary Tract Infection Catheter associated (CAUTI) and non-catheter associated; Risk factors that predispose patients to acquire a nosocomial UTI include: i ) advanced age, ii) female gender, iii) severe underlying disease, iv) placement of a urinary catheter for >2 days Organisms: Gram-negative rods cause the majority of hospital-acquired UTis and E. coli is the most common organism implicated. Gram-positive bacteria such as S. aureus, enterococci can occasionally cause CAUTI.

16. Central Line Associated Blood Stream Infection Central line associated blood stream infection ( CLABSI) is the fourth common cause of HAIs. Organisms: Coagulase negative staphylococci, and S. aureus are increasingly reported to cause CLABSI recently, followed by gram-negative rods and Candida Risk factors that predispose to acquire a CLABSI include: • Patient related : • Age ( < 1 year and >60 years.) Malnutrition • Low immunity • Severe underlying disease • Loss of skin integrity (burn or bed sore) • Prolonged stay in ICUs. • Device related : Presence of central line • HCW related: Poor infection control practices such as hand hygiene.

17. Ventilator-associated Pneumonia Ventilator-associated pneumonia (VAP) are the second common cause of HAIs next to UTI. Risk factors include: • Device related : Endotracheal intubation • Patient related : ( i ) prolonged ICU stay leading to increased risk of colonization of hospital MDROs, (iii) aspiration of oropharyngeal flora due to various reasons such as semiconscious state, supine position, etc . • HCW related : Poor infection control practices such as poor hand hygiene. Organisms: Gram-negative rods such as Acinetobacter species and Pseudomonas species account for majority ofVAP .

18. Surgical Site Infection (SSI) Surgical site infection is defined as infection that develops at the surgical site within 30 days of surgery ( within 90 days for breast, cardiac and joint surgeries). Though SSI is a major threat in the hospitals, it is often under reported because 50% of SSis develop after the discharge Organisms: Surgical site wounds are classified as clean, clean -contaminated, contaminated or dirty. • For clean wound : The skin flora of the surgery team or the environmental organisms are the major pathogens; most common being S. aureus.

19. PREVENTING NOS O COMIAL INFECTIONS The preventive measures for HAIs can be broadly categorized into ( i ) standard precautions and (ii) transmission-based or specific precautions.

20. HAND WASHING

21. CONTRO L OF DROPLET INFECTION Use of face-mask Proper bed-spacing Prevention of overcrowding Ensure adequate ventilation

22. COLOR WASTE TREATMENT YELLOW Human & animal anatomical waste/Microbiology waste and soiled cotton/dressings/linen/bedding etc. INCINERATION/ DEEP BURIAL RED Tubing/catheters/i.v. sets etc. A U TOCL A VE/MI C RO WAVE/CHEMICAL TREATMENT BLUE / Waste sharps AUTOCLAVE/MICRO WHITE (needles,syringes,scalpels,blades etc.) WAVE/CHEMICAL TREATMENT/ DESTRUCTION BLACK Discarded medicines/ cytotoxic drugs/incineration ash/chemical waste DISPOSAL IN LAND FIELDS PROPER DISPOSA L OF HOSPITAL WASTE

23. DISINFECTION Disinfection prevents transmission of organisms between patients. LEVELS OF DISINFECTION: HIGH LEVEL - destroys all the microorganisms except heavy contamination by bacterial spores. INTERMEDIATE LEVEL – inactivates M.tuberculosis, vegetative bacteria, most viruses & fungi. LOW LEVEL – kills most bacteria, some viruses & some fungi.

24. HOSPITAL INFECTION CONTROL COMMITTEE The hospital infection control program is organized and run by the Medical Superintendent (MS), for which he /she constitutes the Hospital Infection Control Committee (HICC). The HICC provides a forum for multidisciplinary input and cooperation, and information sharing, required for hospital infection control and prevention. The HICC is advisory to the MS and makes its recommendations to the MS.

25. Functions of HICC The HICC supervises the implementation of the hospital infection control program. The various functions of the committee include: HAI surveillance : Maintains surveillance of hospitalacquired infections. The four key parameters used for HAI surveillance are as follows 1. CA-UTI ( Catheter-associated urinary tract infection). 2. CLABSI (Central line -ass ociated bloo dstream infection). 3. VAP (Ventilator-associated pneumonia). 4. SSI (Surgical site infection).

26. Develops a system for identifying, reporting, analyzing investigating and controlling hospital-acquired infections. Antimicrobial stewardship program (AMSP): Develops antibiotic policies, monitors the antibiotic usage, advises the MS on matters related to the proper use of antibiotics, and also recommends remedial measures when antibiotic resistant strains are detected. Policies: Reviews and updates the hospital infection control policies and guidelines from time to time. Education : Conducts teaching sessions for healthcare workers regarding matters related to HAIs.

27. Staff health : Monitors employee health activities regarding matters related to HAIs such as needle stick injury prevention, hepatitis B vaccination, etc. Outbreak m anagement : Develops strategies to identify infectious outbreaks, their source and implements preventive and corrective measures Reviews risks associated with new technologies, and monitor infectious risks of new devices and products, prior to their approval for use HICC Meetings : meet regularly not less than once a month and as often as required. Other departm ents : Central Sterile Supplies department (CSSD) , Biomedical Safety Committee • Blood Transfusion Committee.

28. HOSPITAL-ACQUIRED INFECTION SURVEILLANCE healthcare-associated infections (HAIs) surveillance is a system that monitors the HAIs in a hospital. Main objectives of HAI surveillance include: Provides endemic or baseline HAI rate and information on type of HAIs in the hospital. Helps in comparing HAI rates within and between hospitals. Identifies the problem area; based on which root cause analysis can be conducted to find out the breakdowns in infection control measures and then the appropriate corrective measures are implemented. Provides timely feedback to the clinicians; thus, reinforces them to adopt best practices.

29. Targeted Surveillance Where to conduct : intensive care units (ICUs) What type of HAIs to be monitored : only the major type of HAI to be monitored such as: • Catheter-associated urinary tract infection (CAUTI) • Central line-associated blood stream infection ( CLABSI) • Ventilator-associated event (VAE) • Surgical site infection (SSI). Who will conduct : The infection control nurses (ICNs) under the supervision of the officer in-charge of HICC conduct HAI surveillance

30. Method of Conducting HAI Surveillance The HAI surveillance cycle consists of data collection – data analysis – data interpretation – data dissemination.

31. PREVENTION OF MAJOR TYPES OF HAIs Prevention of Device-associated Infections ( DAls ): CAUTI, CLABSI and YAP. Presence of device itself is a major risk factor for developing such infection. This is because of various reasons: ( i ) risk of introduction of patients own flora, (ii) risk of introduction of HCW's hand flora due to improper handling during insertion or daily maintenance of the device; (iii) ability of the invading organism to produce biofilm over the device; (iv) persistence of organisms as majority of them are MDROs (multi-drug resistant organisms) Strict aseptic techniques must be followed while insertion and daily maintenance of the devices. The preventive measures for each of the DAis are grouped as bundle care approach

32. Bundle Care Approach Most hospitals follow bundle care approach for the prevention of DAIs. Bundle care comprises of 3 to 5 evidence-based elements with strong clinician agreement; each of the component must be followed during the insertion or maintenance of the device. Compliance to the bundle care is calculated as all or-none way, i.e. failure of compliance to any of the component leads to non-compliance to the whole bundle.

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