MMWR 1999 / 48(29);621-629 Slide - Dr Paul Tambyah
2004: Annual, intensive, project-based control programs introducedChuang YC et al. Secular trends of healthcare-associated infections at a teaching hospital in Taiwan,1981-2007. J Hosp Infect 2010.
‘nosocomial infections’ ◦ Greek nosos ‘disease’, komien ‘to care for’ ◦ Roman military hospital orderlies were called nosocomi ‘hospital-acquired infections’ ◦ Introduced by James Simpson (England) in 1830s ◦ Called the problem ‘Hospitalism’ ‘healthcare-associated infections’ (HAI) ◦ Increasing complexity of healthcare delivery
Louis Pasteur: 1822- 1895, French chemist & microbiologistRobert Koch: 1843-1910, German physician
Bacteriological era PostMiasma theory: origin of Germ theory: infections dueepidemic diseases due to to microorganismsnoxious form of ‘bad air’HAIs due to poor HAIs recognized in obstetric,ventilation & NOT direct surgical patients and later,contact medical patients
• Surgeon at obstetric clinic in Vienna in 1848 Divided into two clinics, alternating admissions every 24 hours: ◦ First Clinic: Doctors and medical students ◦ Second Clinic: Midwives doctors taught anatomy in the mornings, midwives came from home http://www.cdc.gov/handhygiene/materials.htm
Suggested handwashingand use of antisepticsolution for hands andsurgical instruments forphysicians Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847. http://www.cdc.gov/handhygiene/materials.htm Adapted Slide - Dr Paul Tambyah
Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850 18 16 Semmelweis’ Hand Within 2 years ofMaternal Mortality (%) 14 Hygiene Intervention 12 his idea, forced 10 to quit medicine 8 6 4 Died in asylum 2 0 for the mentally 1841 1842 1843 1844 1845 1946 1847 1848 1849 1850 unstable MDs Midwives ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999. http://www.cdc.gov/handhygiene/materials.htm
Florence Nightingale (1820- 1910, founder of modern nursing) – promoted hospital reform Joseph Lister (1827-1912, British surgeon) ◦ Introduced hand washing and carbolic acid antisepsis ◦ Infections post limb amputations 47% 15%
You do not find what you are not looking for… You need to know your baseline You need to know before someone else does! You want to improve outcomes for your patients Slide - Dr Paul Tambyah
• Effectiveness has to be measured• We want to objectively assess the impact of interventions• Measurement is not neutral• Questions asked are different: – Patient: which is the best hospital? • What are my chances of getting bettter? Worse? – Doctor: how am I doing? – Administrator: What is the bottom line? Slide - Dr Paul Tambyah
To establish baseline rates of HAI To identify outbreaks To evaluate the effectiveness of IC prevention activities To identify preventable infections in high-risk areas To help limited resources be more effectively targeted to high priority areas Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.
National level, surveillance should be standardized with ◦ standardized case definitions & ◦ surveillance methods Local level, surveillance should include ◦ assessment of the local situation ◦ selection of appropriate methods ◦ reporting Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.
Alert microorganism surveillance can be done if: ◦ there is a good microbiology laboratory ◦ support from the clinicians ◦ support from senior management Simplest forms of surveillance: ◦ Mortality, a very crude measure of quality ◦ Readmission rates per surgical procedure or per ICU admission ◦ Periodic point prevalence surveillance can be used to monitor the effectiveness of IC measures Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.
US CDC’s National Health and Safety Network (NHSN) definition: ◦ Widely used as most widely disseminated and readily available ◦ interpretation and application may not be easy International Nosocomial Infection Control Consortium (INICC) ◦ first multinational, collaborative HAI control program ◦ established to control HAIs in hospitals in limited resource countries ◦ founded in Argentina in 1998 ◦ network of 173 ICUs in 25 countries Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.
“…a healthcare associated infection (HAI) is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility.” ◦ All factors satisfying CDC/NHSN site-specific infection criterion 1st present on or after 3rd day of hospitalization ◦ Purpose of definition: NHSN surveillance CDC. Identifying Healthcare-associated Infections (HAI) in NHSN. Jan 2013
CDC/NHSN major and specific types of HAI ◦ Bone and joint infection ◦ Bloodstream infection ◦ CNS ◦ CVS infection ◦ Eye, ear, nose, throat or mouth infection ◦ GI system infection ◦ Lower respiratory infection, other than pneumonia ◦ Pneumonia ◦ Reproductive tract infection ◦ SSI ◦ Skin and soft tissue infection ◦ Systemic infection ◦ UTI ◦ Ventilator-associated eventCDC. CDC/NHSN Surveillance Definition of Healthcare-associated Infection and Criteria for Specific Types of Infectionsin the Acute Care Setting. Jan 2013.
Goal of NHSN AUR module:- “…to provide a mechanism for facilities to report and analyze antimicrobial use and/or resistance as part of local or regional efforts to reduce antimicrobial resistant infections through antimicrobial stewardship efforts or interruption of transmission of resistant pathogens at their facility” CDC. Antimicrobial Use and Resistance Module. Jan 2013
HAIs can be caused by endogenous or exogenous sources: ◦ Endogenous – body sites eg. skin, nose, mouth, GIT or vagina ◦ Exogenous – external to patient eg. patient care personnel, visitors, patient care equipment, medical devices or healthcare environment CDC. Identifying Healthcare-associated Infections (HAI) in NHSN. Jan 2013
Features of the International Nosocomial InfectionControl Consortium Hospitals and Intensive Care Units* Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591
Ventilator-Associated Pneumonia in theInternational Nosocomial Infection Control Consortium Intensive Care Units* Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591
Central Venous Catheter-Associated Bloodstream Infections in the International Nosocomial Infection Control Consortium Intensive Care Units* Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591
Comparison of Device Use and Rates of Device-Associated Infection in the Intensive Care Units of the International Nosocomial Infection ControlConsortium and of the U.S. National Nosocomial Infection Surveillance System* Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591
173 ICUs in Latin America, Asia, Africa and Europe. 6 year study, data from 155,358 patients Device utilization in the developing countries’ ICUs remarkably similar to US Some HAIs markedly higher in the ICUs of the INICC hospitals: ◦ CLABSIs: 7.6% vs 2.0 per 1000 central line days ◦ VAP: 13.6 vs 3.3 per 1000 ventilator days Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.
Hospitals were originally set up for the sick and dying among the poor The wealthy had physicians go to their homes to provide care Hospitals were widely and correctly perceived as dangerous places Pittet et al http://www.hopisafe.ch Slide - Dr Paul Tambyah
7 year old boy with acute leukemia, finishing chemotherapy in remission Was admitted after his last course of chemotherapy with fever Had Clostridium difficile infection (Antibiotic associated colitis) Also developed bloodstream and soft tissue infection Slide - Dr Paul Tambyah
Blood cultures persistently positive Debrided in ICU as he was too sick for surgery Slide - Dr Paul Tambyah
Hsu LY et al,Emerg Infect Dis2007;13:1944-7 Slide - Dr Paul Tambyah
Hsu LY et al, Emerg Infect Dis 2007;13:1944-7 Slide - Dr Paul Tambyah
‘…no evidence that financial disincentives reduced infection rates. As CMS continues to expand this policy to cover Medicaid through the Affordable Care Act, require public reporting of NHSN data through the Hospital Compare website, and impose greater financial penalties on hospitals that perform poorly on these measures, careful evaluation is needed to determine when these programs work, when they have unintended consequences and what might be done to improve patient outcomes.’ Lee GM et al. NEJM 2012