Hospital Aquired Infections - a primer

1. HOSPITAL AQUIREDINFECTIONS
Dr.S.K.Varma, MS,FRCS(Ed.),MCh,DNB,FIACS
CardiothoracicSurgeon
K.G.Hospital

3. Goals of InfectionControl
Training
• Ensure that health professionals understand how pathogens can
be transmitted in the work environment (patient to healthcare
worker, healthcare worker to patient and patient to patient )
• Apply current scientifically accepted infectioncontrol principles
• Minimize opportunity for transmission of pathogens to patients
and healthcareworkers

4. History of
Hygiene
Greek Era :Aristotle
recommended Boiling water
to armies. Advised the
Alexander
Semmelweis: Practiced & emphasizes
the importance of washing handswith
chlorinated water in Obstetrics to
reduce maternal mortality

5. Historical AspectsChanged
the History
1867 –Dr. JosephLister first
identifies airborne bacteriaand
uses Carbolic acid spray insurgical
areas
1880– Johnson and Johnson
introduce antisepticsurgical
dressings.
Reduction of Hospitalassociated
infections
Mortality reduced
Morbidity reduced

6. What are Hospital AcquiredInfections
?
Any infection that is not present
or incubating at the time the
patient is admitted to the hospital
This includes infections acquired
in the hospital but appearing
after discharge, and also
occupational infections among
staff ofthe facility

7. Other definitions
CommunityAcquired Infection
An infection Present or Incubating at the time of admission to
ahealth care facility without any association to previous
hospitalization at the same facility
Colonization
The presence of microorganism in or on ahost, with growth
and multiplication but without tissue invasion or damage
Contamination
The presence of microorganism on inanimate objects
(Clothing, surgical instruments, water, food, milk ) or in
substances

8. Public Health
Importance
Major public healthproblem
Incidence- 2%to1
2% in the developed countries
The overall incidence in various hospitals in India varies
between 10 - 20 %(inadequately reported/ underreported)
The incidence depends on type of hospital, type of patients and
the type of surgeries performed.

9. Consequencesof HospitalInfections
Prolongs hospital stay. An estimated 1to 4 extra days for a urinary tract
infection, 7– 8 days for asurgical site infection, 7– 21days for ablood
stream infection, and 7– 30 days forpneumonia.
Extra expenses US$5billion are added to UShealth costs every year asa
result of NI
The patient suffers bodily mentally and economically.
Increase in mortalityrate
Law suits
Technical competence of experienced doctors turned into disaster
Quality of care suffers and it leads to bad public image
Infected patients are twice as likely to die, twice as likely to spend timein
ICU and five times more likely to be readmitted afterdischarge

10. Sources of HAI
Endogenous: normal flora of the patient- About 50%of N.I.
Exogenous :
1. Other patients andenvironment
2. Hospital personnel (surgicalteam/staff)
3. Inanimate objects-Tools, instruments, and materials used
4. Seeding from distant focus of infection (prosthetic
device, implants)
Goodinfrastructure does not always mean asafe
environment

11. Routes of Transmission
Transmission
ContactTransmission
Direct
Indirect
Droplet Transmission Airborne
Transmission
CommonVehicleTransmission(uncommon)
Vector-borneTransmission(uncommon)

12. The microbial agent
Patient susceptibility
Environmental factors

13. Urinary tract infection: most common type of N I (30- 40%
of reported cases), associated with an indwelling urinary
catheter or instrumentation
Lower respiratory tract
surgical wound infections
Bacteraemia ,
Intravenous site infection, g
Gastrointestinal tract and
Skin infections.
Nosocomial Infection Sites

14. Criteria of NosocomialInfections
S u r g i c a l site i n f e c ti on
U r i n a r y i n f e c ti on
R e s p i r a t o r y i n f e c tio n
A n y p u r u l e n t d i s c h a r g e , a b s c e s s o r
s p r e a d i n g cellulitis a t t h e s u r g i c a l
site d u r i n g t h e m o n t h after o p e r a t i o n
P o s i t i v e u r i n e c u l t u r e ( 1 o r 2
s p e c i e s ) wi t h a t l e a s t 1 0 0 0 0 0
b a c t e r i a / ml , wi t h o r wi t h o u t clinical
s y m p t o m s
R e s p i r a t o r y s y m p t o m s wi t h a t l e a s t
2 s i g n s : c o u g h ; p u r u l e n t s p u t u m ;
n e w infiltrate o n c h e s t , a p p e a r i n g
d u r i n g h o s p i t a l i z a t i o n
I n f l a m m a t i o n , l y m p h a n g i t i s o r
p u r u l e n t d i s c h a r g e a t t h e i n s e r ti on
site
F e v e r o r r i g o u r s a n d a t l e a s t o n e
p o s i t i v e b l o o d c u l t u r e
Va s c u l a r c a t h e t e r
i n f e c ti on
S e p t i c a e m i a

15. The chain of infection.
Sourceof
infection
Method of
spreading
Person at risk Point of entry
Breaking this chain by removing any part of it will control or stop
the spread ofinfection

16. Control of Hospital
Infections
Infection control is an essential component of care and one which has
too often beenundervalued
Prevention of HAI require amultifaceted approach
Three main principles :
Remove source of infection
Block route of transfer
Increase in resistance of host
prevent
infection,
one must
break the
chain of
To
infection.

17. Thusthe Control maybe
through:
General measures
Special Control measures
InfectionControl Organisation in Hospitals
Surveillance and control programmes
Prevention of infections like HIV, Hepatitis B,Cin Health Care
setting and Health careworkers
Proper management of waste in hospital

18. GeneralMeasures
Personal hygiene
Standard Precautions
Environmental sanitation
Efficient house keepingservices
Provision of ancillary facilities (Good and efficient CSSD,Mechanised
laundry, waste disposal , Minimum handling of food , Isolation and reverse isolation
facilities, Procedure manuals, Regular health check-up of theworkers, Checkon visitors)

19. Personal hygiene
The most important person in this organisation is
YOU.
You get it right and both you and the organisation will
meet all thelegal requirements.
You get it wrong and someone could become ill: That
someone could beYOU.

20. Isolation Precautions (CDCRecommendations)
Four types of precautions, evidence-based
recommendations based on the mode of
transmission of the organism known or suspected
to bepresent.
1.StandardPrecautions
Transmission BasedPrecautions:
2.ContactPrecautions
3.Airborne Precautions
4. Droplet Precautions

21. Standard -Apply for Blood,All body fluids, Non-intact skin, Mucous
membranes
Transmission-Based Precautions-
Contact Precautions-Apply for Gastrointestinal, respiratory, skin, or wound
infections, Skin infections that are highly contagious
Airborne Precautions-Apply to Tuberculosis ,Measles, Varicella (including
disseminated zoster),
Droplet Precautions- Apply to Haemophilus influenzae type b, Neisseria
meningitidis, Diphtheria (pharyngeal), Mycoplasma pneumonia,
Pertussis,Pneumonic plague, Streptococcal,, pharyngitis, pneumonia, or
scarlet fever, Serious viral infections eg.Adenovirus , Influenza, Mumps,
Parvovirus B19,Rubella
Theseguidelines were developed for hospitalized inpatients, and the
principles can be applied in outpatient settings

22. Standard Precautions
Standard Precautions are to be usedwith all patients, regardless of diagnosis.
formerly known asUniversalPrecautions
#1: Handwashing
#2: Gloves
#3: Mask, EyeProtection, FaceShield
#4: Gown
# 5: Patient-careEquipment
#6: Environmental Control
#7: Linen
#8: Sharps
#9: VentilationDevices
#10:Patient Placement
All our patients should be treated asthough they have potential bloodborninfections

23. #1:Handwashing
Hand hygiene is still the single most
important procedure for preventing the
spread of infection!
(Wash hands with plain soap or waterless
antiseptic agent, alcohol-basedproduct)

25. Words ofWisdom on Hand Washing
Soap, water and
Common sense arestill
the Best Antiseptics
William Osler

26. Personnel safety devices
The use of protective gears should be made mandatory f or a l l
the personnel i f chances o f contact with Blood or Body f l u i d
i s anticipated/inevitable

27. #5:Patient-careEquipment
Clean or reprocess reusable equipment before using it
for the care of anotherpatient.
Ensure that single- use items are discarded properly.
# 6: Environmental Control
Routine care, cleaning, and disinfection of
environmental surfaces, beds, bedrails, bedside
equipment, and other frequently touched surfaces.
#7:Linen
Handle, transport, and process used linen soiled with
blood or bodyfluids

28. #8: Sharps
All used needles and sharps should be
deposited in puncture resistant containers.
Bending, Reshaping, should beprohibited.
Do not recap the needles .
All used Disposable syringes and needles
should be discarded into Bleach solution at
the work station before final disposal.

29. DISPOSAL OF USED NEEDLES AND SYRINGESOF
DestS
ro
H
y
ARPS
needle
Cut syringe
tip
Decontaminate in twin
bucket having 1% bleach
SHARPS including
catheter guide wires

30. Dealing with Needle stick
Injuries
Consider all Needle stick injuries asaserious health hazard in
the era ofAIDS
All events of Needle stick injuries to be reported to the
supervisory staff.
Washthe injured areas with soap and water.
Encourage bleeding if any.
Prophylaxis for prevention of HIV/HBVis toppriority.

31. #9: Ventilation Devices
Use mouthpieces, resuscitation bags, or other
ventilation devices asan alternative tomouth-to-
mouth resuscitationmethods.
#10:Patient Placement
Place apatient who contaminatesthe
environment in aprivate room.

32. SpecialMeasures
Proper planning of OT
sand monitoring of its functioning
Monitoring Functioning of Nurseries and ICUs
Isolation facilities,daily washing, asepsis
Infection Oriented training to hospital staff to assessthe
standards of asepsis,personal hygiene and cleanliness

33. ORGANIZATION
Hospital administrator/head
should establish
ICC (provides resources for ICP)
ICT
IC Officer IC Nurse Microbiologist

34. HospitalSurveillanceandControlProgramme
Weekly OPDReports
Report
Bacteriological
Reports
Discharge
Reports
Personal
Clinics
Ward Visits Autopsies
Training
Programme
Regular
Reports
Infection Committee
Investigations
CONTROL

35. Handling of Spills & Surface Disinfection
• Notify people in the area
• Don appropriatePPE
• Place absorbent materialon spill
• Apply appropriate disinfectant 1%hypochlorite– min contact
time (30min)
• Pick up material;dispose
• Reapply disinfectant andwipe
• For large/high hazard spillsuse 5%hypochlorite

36. CATEGORIES OF BIO-MEDICALWASTE
Cat
e
gor
y
Waste type Colourcoding Treatment &Disposal
1. Human
anatomica
l
Yellow Incineration / deepburial
2. Animal waste Yellow Incineration / deepburial
3 Microbiology &
Biotechnology
Waste
Yellow/ Red Autoclaving/microwaving/ Incineration
4 Waste Sharps White / blue /
Translucent
puncture proof
containers
Disinfection by chemical
treatment/autoclaving/ Microwaving &
mutilation/shredding
5 Discarded
medicines and
Cytotoxic drugs
Black Destruction/ neutralization & disposal in
secured landfills

37. Catego
r y
Waste type Colour coding Treatment & Disposal
6 Soiled
waste
Yellow/red Incineration / autoclaving/ microwaving
7 Solid (
plastic
)
Blue/ White/ Red Disinfection by chemical
treatment/autoclaving/ Microwaving &
mutilation/shredding
8 Liquid
waste
------- Disinfection by chemical treatment and
discharge into drains
9 Incineratio
n Ash
Black Disposal in municipallandfill
10 Chemical Black Chemical treatment and discharge intodrains
for liquids and secured landfill for solids

38. Prevention of Urinary tract Infection
CDC:Guidelines
Avoid catheterization
Useintermittent catheterization
Decreaseduration of catheterization
Insert catheters aseptically
Maintain aclosesterile drainagesystem
Usecondomcatheter in cooperative patients
Maintain gravitydrainage
Apply topical meatal antimicrobials inwomen
Separate infected and non-infected patients

39. Prevention ofSurgical site infections
 Pre-operative
 Intra-operative
 Post-operative

40. Preoperative preventivemeasures
Preparation of the patient
Hand/ forearm antisepsis for surgical team
Antimicrobial prophylaxis

41. Intra-operative preventive measures
Ventilation
Cleaning & disinfection of surfaces
Sterilization ofsurgical instruments
Surgical attire &drapes
Asepsis & surgical technique
Normothermia and glucosecontrol

42. Post-operative incisioncare
Protect with a sterile dressing for 24-48 hrs
Washhands before & after dressing changes & any contact
with thesurgical site
Use aseptic technique when an incision dressing mustbe
changed

43. Prevention of ventilatorassociated
pneumonia
• Standard Precautions (Hand hygiene,Gloving)
• Aseptic technique for performing or changing tracheostomy tube
• Sterile fluid to remove secretion
• Sterile single use catheter if open system suction
• Elevation of the head end of bed 30°-45°
• Care of oralcavity
• Sedationvacation
• Spontaneous breathing trial
• Oral access totrachea and stomach
• EV
ACtube for drainage of subglottic secretion

44. Prevention ofBlood Stream Infections
CDC:Guidelinesfor the Prevention of Intravascular Catheter-Related Infections,
Hand hygiene
Maximal barrier precautions
Chlorhexidine skinantisepsis
Optimal catheter site selection, with Subclavian vein asthe
preferred site for non-tunneled catheters in adults
Daily review of line necessity with prompt removal of
unnecessarylines
Line secure and dressing clean and intact

45. Staff health promotion and education:
1.HCW are at risk of acquiring infection, they can also
transmit infection to patients and other employee.
2.Employee health history must be reviewed,
immunizations recommendations to be considered.
3. Release from work if sick, occupation injury
must be notified.
4.Continuous education to improve practice, better
performance of new techniques.

46. InfectionControl is
Responsibility Of

47. Everyone