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Hospital Infections

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Title: Hospital Infections


1
Hospital Infections
  • The Burden, Prevention and Control
  • Prof. Abdulkarim Al-Aska
  • Infectious Diseases Unit,
  • King Khalid University Hospital

2
Definition
  • Hospital acquired Nosocomial
  • Occurring after admission
  • Neither presenting or incubating at the time of
    admission
  • Occasionally the illness may develop weeks or
    months after discharge.

3
History
  • Earliest Europeans hospitals were established in
    middle ages
  • No resemblance to modern hospitals in either
    structure or function
  • There were lack of space and shifts were ordered
    for patients and occasionally more than one
    patients in beds.

4
  • Consequences
  • Increased physical contact promoting infection
    spread
  • The squalid situations led to the hospitals
    called pest houses

5
  • 19TH century reports
  • Surgery almost always followed by infection
  • 60 of limb amputations resulted in fatal
    infection

6
Observation
  • In 1846 there was differential mortality of
    childbed fever between 2 obstetrics wards 1 2
    at University of Geneva.
  • 11.4 vs 2.7.
  • Investigation was then launched by Ignaz Phillip
    Semmelweis who was the director of Obstetrics
    services

7
  • Then Pathologist doing post mortem died of
    similar illness having nicked his hand with
    scalpel.
  • Conclusion from infectious materials.

8
  • Hospital staff and students were subsequently
    ordered to wash their hands with calcium
    hypochlorite after examining each patients.
  • Mortality rate dropped from 11.4 to 1.3 in ward
    1 decline of 89.

9
  • Hand washing also ordered for ward 2, rate
    declined by 52.
  • This clearly demonstrated the spread and
    prevention of hospital infection
  • Ignaz Phillip Semmelweis was later regarded as
    the Father of Hospital Epidemiology.

10
  • The discovery of penicillins in the 30s and 40s
    led to lower infection rate.
  • Subsequently MRSA became problem.
  • The 1990s saw the emergence of Vancomycin
    resistant Enterococci

11
  • Advancement in medicine also posed new challenges
    like catheter related blood stream infection and
    ventilator associated pneumonia.

12
  • Last two decades, increase number of susceptible
    patients as a result of survival to immune
    modifying disease or effect of therapy.
  • Resulting in patients expose to life threatening
    diseases due to change in natural or acquired
    immunities.

13
Importance of Hosp Infection
  • Estimates in the 70s, 6-8 per 100 patients
    admitted.
  • Additional suffering and mortality for patients
  • Nosocomial infection also increased length of
    hospital stay and extra costs to authorities.

14
Prolongation of Hospital Stay due to Nosocomial
Infections in the USA
15
Annual Costs and Benefits of Infection Control
Program in a Hypothetical 250-bed Hospital
Each 1000 invested in infection control will
return 3000 in net direct cost savings
16
Hospital-acquired Infectionwhy worry?
  • 10-15 of patients will get infected during a
    stay in hospital
  • Costs gt1 billion per year in UK
  • A single large outbreak can cost 10-100K

17
  • Effects of nosocomial infection
  • Increased mortality morbidity
  • Prolonged hospital stay
  • Increased drugs bill
  • Increased staffing costs
  • Demoralising for staff patients
  • Decreased public confidence in hospitals
    doctors

18
Why is hospital-acquired infection different from
community-acquired infection?
  • Many vulnerable patients in close proximity to
    each other for prolonged periods of time
  • Many patients have impaired immunity
  • After anti-cancer chemotherapy
  • After transplants
  • Extremes of age

19
  • Many patients have impaired normal physiological
    defences
  • Breaches in skin
  • Implanted foreign bodies (biofilms)
  • Impaired physiology (Peristalsis, mucociliary
    escalator)

20
Antibiotic-Resistant Infections
  • Associated with extended illness
  • Longer hospital stay
  • Higher risk for death
  • Increased costs to health system
  • Microbes with mutation for resistance has a
    selective advantage to
  • Survive, proliferate and spread.

21
  • Controlling antibiotic prescriptions within
    hospitals had helped in reduction of resistant
    organism emergence.
  • Contact precautions with gowns and gloves had
    prevented the spread of MRSA and VRE.

22
  • Transmission facilitated by hospital staff who
    rarely
  • Wash their hands
  • Disinfect or dispose their clothing
  • Disinfect their equipment

23
Hand washing
24
  • Method
  • Wet hands with clean (not hot) water
  • Apply soap
  • Rub hands together for about 20 seconds
  • Rinse with clean water
  • Dry with disposable towel or air dry
  • Use towel to turn off faucet

25
Alcohol-based Hand Rubs
  • Effective if hands not visibly soiled
  • More costly than soap water
  • Method
  • Apply appropriate (3ml) amount to palms
  • Rub hands together, covering all surfaces until
    dry

26
  • How consistent are we in washing hands between
    attending patients?

27
  • Recent studies
  • Forty per cent (40) wash their hands after
    contact with a patient before the next.
  • Nurses comply more than doctors
  • Worst compliance regrettably in ICUs.

28
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29
UTI
  • Thirty per cent of all nosocomial infections
  • Rate of 1 with single in-out catheterisation
  • Risk of 3 to 6 per catheter-day for prolonged
    usage.
  • Higher for females than males
  • Post 10-14 days, half of pateints have
    bacteriuria.

30
NNIS Data (CDC).
  • E coli Coagulase -ve Staph
  • Enterococcus spp Other fungi
  • P aeruginosa Citrobacter spp
  • Candida spp S aureus
  • K pneumoniae
  • Enterobacter spp
  • Proteus mirabilis

31
  • Preventive measures have confirmed the advantage
    of closed drainage system.
  • Also the use of silver alloy urinary catheter

32
Pneumonia
  • Mainly from aspirated gastric contents.
  • Also from microbes-laden secretions of upper
    respiratory tract.
  • Septic emboli from infected CVP or A-V fistula
  • Rarely, inhalation of pathogens from the air for
    example M tuberculosis and Aspergillus fumigatus

33
  • S aureus
  • P aeruginosa
  • Enterobacter spp
  • K pneumoniae
  • E coli

34
  • Most patients are ventilated in ICU.
  • Rates from 6 to 30.
  • Risk of 1 to 3 per day.
  • Higher inocula with patients on either H2
    blocker or antacid therapy.
  • Less with sucralfate.

35
  • Preventive measures
  • Keeping patients at an angle of 45 degrees.
  • Use of device for subglottic suction to reduce
    the pooling of secretions.
  • Led to less clinical aspirations and lower
    pneumonia rates.

36
Surgical Site Infections
  • Still occur despite aseptic techniques
  • Clearly the obese and diabetic patients require
    adequate preparations.
  • Use of dry shaving a day before surgery is better
    than clippers hours before.
  • Emergent surgery on inherently contaminated
    organs like the colon.

37
  • S aureus
  • Coagulase ve Staph
  • Enterococci
  • E coli
  • Enterobacter
  • Klebsiella
  • Candida

38
Blood Stream Infections
  • Primary 80 mainly from infected vascular
    catheter.
  • Secondary 20 local infection in another organ.
  • Catheter-related BI begins with colonization of
    the catheter with microbes.
  • Femoral more prone than IJ and SC

39
  • Cultured tips of catheter in cardiac surgery are
    infected within 1-2 hours of insertion.
  • Earlier on tackled by the bodys immune system.
  • Subsequently microbes moved through the catheter
    tract to enter the blood stream.

40
  • By 10 days there is an increasing frequency of
    intra-luminal contamination.
  • Multiple randomised trials had shown that
    antiseptic preparation with chlorhexidine is far
    superior in risk reduction of colonisation as
    compared with alcohol or povidone-iodine
    preparations.

41
  • Chlorhexidine-silver sulphadiazine treated
    catheter has been shown to reduce colonization
    and blood stream infection by about half.
  • Cotton gauze covered by tape were associated with
    lower risk of colonization versus transparent
    dressings.

42
  • Antibiotic-coated catheter reduced colonization
    by 55 as compared with standard catheters.
  • Comparative study had shown that the capacity of
    minocycline/rifampicin coated catheter were
    superior in resisting infection versus
    chlorhexidine-silver sulfadiazine catheter.

43
Organization for Infection Control
  • Surveillance
  • Outbreak investigations
  • Education
  • Hospital employee health
  • Antimicrobial utilization
  • Policy development
  • Quality assessment

44
Infection Control Programs
  • Size and intensity of program predicts infection
    rates.
  • Most effective associated with 32 reduction
    compared with hospital without program.
  • One hospital with effective program in 1985
    reported saving costs of 2million for the year.

45
Infection Control in hospital
  • Interrupt transmission
  • Human-to-human
  • Hand washing
  • Ward routine (e.g. wet mopping)
  • Aseptic technique
  • Sterilisation disinfection
  • Isolation procedures
  • Environment
  • Food hygiene, pest control, theatre design

46
Precautions
  • Standard
  • Specific ----Airborne
  • ----Droplets
  • ----Contact

47
Standard Precautions
  • Perform hand hygiene
  • Wear gloves
  • Wear gowns
  • Wear a mask and goggles and glasses

48
Standard Precautions
  • Hand hygiene
  • Respiratory hygiene and cough etiquette
  • Personal protective equipment (PPE)
  • Based on risk assessment to avoid contact with
    blood, body fluids, excretions, secretions
  • Safe injection practices
  • Environmental control
  • Patient placement

49
  • Specific Isolation Categories

50
Airborne precautions
  • Use a negative-pressure room
  • Keep doors closed
  • Wear grade N95 or better mask
  • If patient transport is necessary, then patient
    to wear surgical mask
  • TB, Measles, Chickenpox

51
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52
Droplet precautions
  • Keep doors closed
  • Wear a surgical mask if entering the room
  • Discard mask after leaving the room
  • If patient transport is necessary, patient to
    wear surgical mask
  • Meningitis, Mumps, Pertussis, Rubella

53
Contact precautions
  • Wear a gown and gloves to enter the room
  • Use a dedicated stethoscope and thermometer
  • Remove gown and gloves before leaving the room
  • Acute infectious diarrhea, Abscess/draining wound

54
  • Occupational Exposures

55
Occupational Risk for Hepatitis
  • Hepatitis B is much more frequent occupational
    infection and a cause of deaths among HCWs.
  • Standard precautions and vaccination had reduced
    infection.
  • Ten per cent of HCWs do not respond to
    vaccination.
  • No vaccine yet for Hepatitis C

56
  • Occupational exposures
  • General steps in management
  • Wash and clean wounds
  • Flush mucous membranes immediately

57
  • Unvaccinated Exposed HCW
  • Injury from HBsAg ve source, give HBIG 0.06mL
    per Kg and initiate HB vaccine
  • Injury from HBsAg -ve source, initiate HB
    vaccine
  • Injury from unknown status of HBsAg initiate HB
    vaccine and determine HBsAg of source.

58
  • Vaccinated HCW/unknown Ab status
  • Injury from HBsAg ve source, do anti- HBS on
    exposed person
  • --If titergt10milli-IU/ml no treatment.
  • --If titerlt10milli-IU/ml, give HBIG 0.06mL per Kg
    1 dose of HB vaccine

59
  • Injury from HBsAg -ve source, no treatment is
    necessary.
  • Injury from unknown status of HBsAg do anti-HBS
    on exposed person
  • --If titer gt10milli-IU/ml no treatment.
  • --If titer lt10milli-IU/ml, give 1 dose of HB
    vaccine plus HBIG if source high risk

60
Hepatitis C exposure
  • Determine anti-HCV from both exposed person and
    source.
  • If source known ve and exposed ve follow up HCV
    testing advised.
  • Baseline and serial LFTs
  • HCV RNA after 2 weeks of exposure.

61
  • No recommended prophylaxis immune globulin not
    effective.
  • Monitor for early infection as therapy may reduce
    risk of progression to chronic hepatitis.

62
  • Risk factors from case control study.
  • Needle from artery and veins.
  • Deep injury.
  • Male HCW.
  • Source 6 million copies/mL.

63
Occupational Risk for HIV Infection
  • Approximately 1 in 300-400 needle sticks injuries
    will transmit HIV.
  • Chances increased with large-bore hollow needle
  • Wash wounds and flush mucous membranes.

64
  • Baseline HIV test, CBC, renal and hepatic tests
  • Viral load of source.
  • HIV testing should be repeated as follows
  • 3-4 weeks and 3 6 months
  • PEP should be started within hours

65
  • Regimens
  • Treat for 4 weeks
  • Monitor drug side-effects fortnightly
  • Basic regime
  • Zidovudine Lamivudine or Stavudine Lamivudine
  • Expanded regime
  • Above Lopinavir Ritonavir

66
Occupational Risk for T B
  • Infection occurs in setting lacking isolation
    techniques
  • These are
  • Absence of negative-pressure ventilation rooms
  • Lack of administrative control measures

67
  • Further recommendations
  • Annual and semi-annual PPD testing
  • Training and retraining of staff

68
  • An extract from the work book of Dr Fester, aged
    24, newly qualified house officer...
  • 50 lines as punishment for poor hand hygiene
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients
  • I promise to wash my hands between patients...

69
  • Thank you
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