2. Health Care-Associated Infections (HAI)
According to WHO:
■ HAI is also called “nosocomial”.
■ “nosus” = disease
■ “komeion” = to take care
■ HAI is 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
nor in the incubation period at the time of admission.
– the symptom should appear at least 48 hrs of admission
3. This also includes :-
■ Infections that are acquired in the Hospital but
symptoms appear after discharge.
■ Occupational infections among staff of the healthcare
facility ( e.g. needle stick injury transmitted infections)
4. ■ Opportunistic infection:- Infection with organisms that
are normally commensals in the Human but become
pathogenic when the body’s immunological defenses are
compromised like in AIDs patients.
■ Iatrogenic disease:- It is “doctor-generated” that
occurs due to adverse effects of treatment,
prevention, diagnosis, surgical procedures, etc
5. Factors Affecting HAI
■ Immune status
■ Hospital environment
■ Hospital organisms
■ Diagnostic or therapeutic interventions
■ Transfusion
■ Poor hospital administration
6. Sources of HAIs
■ Endogenous source- Caused by the organisms that are
present as part of normal flora of the patient
■ Exogenous source-
o Environmental sources
o Health care workers
o Other patients
7. Microorganisms implicated in HAIs
■ The ESKAPE pathogens-
o Enterococcus faecium
o Staphylococcus aureus
o Klebsiella pneumoniae
o Acinetobacter baumannii
o Pseudomonas aeruginosa
o Enterobacter species and Escherichia coli
8. Other infections that can spread in hospitals include:-
■ SARS-CoV-2
■ Nosocomially acquired Mycobacterium tuberculosis
■ Legionella pneumophila
■ Clostridium difficile diarrhoea
Blood Borne infection
■ HIV
■ Hepatitis B
■ Hepatitis C viruses
Transmitted by
o Blood Transfusion
o Needle /Other Sharp Injury /Splash
9. MAJOR TYPES OF HAIs
■ Catheter-associated urinary tract infection (CAUTI)
■ Central line-associated blood stream infection (CLABSI)
■ Ventilator-associated pneumonia (VAP)
■ Surgical site infection (SSI).
11. CDC definition of CAUTI
Catheter associated urinary tract infection is defined when all the
following criteria is present.
1. Patient had an indwelling urinary catheter that had been in place for >
2 consecutive days in an inpatient location on the date of event AND was
either present for any portion of the calendar day on the date of event
or removed the day before the date of event.
2. Patient has at least one of the following signs or symptoms: Fever
(>38.0°C), Suprapubic tenderness, Costovertebral angle pain or
tenderness, Urinary urgency, Urinary frequency, Dysuria
3. Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of ≥105 CFU/ml
12.
13. Causative organisms
■ Escherichia coli, Candida spp, Enterococcus spp,
Pseudomonas aeruginosa , Klebsiella
pneumoniae, Enterobacter spp.
■ A smaller proportion was caused by other gram-
negative bacteria and Staphylococcus spp.
14. Risk factors
■ Advanced age
■ Female gender
■ Severe underlying disease
■ Placement of a urinary catheter for > 2 days.
16. “Laboratory-confirmed bloodstream infection
with a Central Line in place for >2calendar
days on the date of event (DOE) AND the line
was in place on the DOE or the
day before = CLABSI”
Definition of CLABSI
18. Source of CLABSI
■ Migration of skin organisms at the insertion site into the
cutaneous catheter tract and along the surface of the
catheter with colonisation of the catheter tip. This is
the most common route of infection for short term
catheters
■ Direct contamination of the catheter or catheter hub by
contact with hands or contaminated fluids or devices
■ Contaminated infusate may lead to CLABSI though this
is rare.
20. Risk factors
■ Patient related:
o Age (<1 yr and >60 yrs), malnutrition
o Low immunity
o Severe underlying disease
o Loss of skin integrity (burn or bed sore)
o Prolonged stay in ICUs
■ Device related: presence of central line : multi-lumen, non-
tunnelled
■ HCW related: poor IC practices such as Hand Hygiene
22. Superficial incisional SSI: Must meet the following
criteria:
■ Date of event occurs within 30 days after any operative
procedure (where day 1 = the procedure date) AND involves only
skin and subcutaneous tissue of the incision
AND
■ patient has at least one of the following:
■ Purulent drainage from the superficial incision.
■ Organism(s) identified from an aseptically-obtained specimen
from the superficial incision or subcutaneous tissue by a culture
testing method which is performed for purposes of clinical
diagnosis or treatment.
■ In case culture not done…..at least one of the following signs or
symptoms: localized pain or tenderness; localized swelling;
erythema; or heat.
■ Diagnosis of a superficial incisional.
23. Deep incisional SSI must meet the following criteria:
■ The date of event occurs within 30 or 90 days after operative procedure
(where day 1 = the procedure date)
■ involves deep soft tissues of the incision (for example, fascial and
muscle layers) AND
■ Patient has at least one of the following:-
■ Purulent drainage from the deep incision.
■ Deep incision that spontaneously dehisces, or is deliberately opened or
aspirated by a surgeon, AND organism(s) identified from the deep soft
tissues of the incision by a culture testing method which is performed
for purposes of clinical diagnosis or treatment
■ A culture that has a negative finding does not meet this criterion.
AND
■ patient has at least one of the following signs or symptoms: fever
(>38°C); localized pain or tenderness.
■ An abscess or other evidence of infection involving the deep incision
that is detected on gross anatomical or histopathologic exam, or imaging
24. ■ Pathogenesis:
■ Endogenous:
– Patient flora: skin ,mucous membranes, GI tract
– Seeding from a distant focus of infection
■
■ Exogenous
■ Surgical Personnel (surgeon and team)
■ Soiled attire
■ Breaks in aseptic technique
■ Inadequate hand hygiene
■ Physical environment and ventilation
■ Tools, equipment, materials brought to the operative
field
26. ■ Risk factors for nosocomial wound infection include:
o Advanced age, obesity, malnutrition, diabetes
o Infection at a remote site that spread through blood
stream
o Preoperative shaving of the site
o Inappropriate timing of prophylactic antimicrobial
agent.
o Note: -The antimicrobial prophylaxis is usually
given to the patient to prevent the seeding of
organisms on the surgical site. It is given 1 hour
prior to the incision, usually along with the
induction of anesthesia.
28. What is VAP?
■ A pneumonia where the patient is on
mechanical ventilation for >2 calendar days
on the date of event, with day of ventilator
placement being Day 1, AND Ventilator was in
place on the date of event or the day before.
29. Pathogenesis
■ Exogenous source:- Hands of health care
worker, Contaminated ventilator circuit,
endotracheal intubation.
■ Endogenous source:- Colonization of oropharynx
and nasopharynx
33. Risk factors for VAP
■ Patient related:
– Prolonged ICU stay leading to colonization of
hospital MDROs
– Aspiration of oropharyngeal flora due to various
reasons such as semiconscious state, supine
position etc
■ HCW related: poor IC practices such as Hand
34. Impacts of Health Care-Associated
Infections (HAI)
HAI can:
Increase patients’ suffering.
Lead to permanent disability.
Lead to death.
Prolong hospital stay.
Increase need for a higher level of care.
Increase the costs to patients and hospitals.
35. How can HAI prevented?
Requires health care providers who have:-
Knowledge of common infections and their vectors
An attitude of cooperation and commitment
Skills necessary to provide safe care
36. Required Skills
Apply universal precautions
Use personal protection methods
Know what to do if exposed
Encourage others to use universal precautions
Report breaks in technique that increase patient risks
Observe patients for signs and symptoms of infection
37. Universal precautions:-
"Universal precautions," as defined by CDC, are a set of
precautions designed to prevent transmission of human
immunodeficiency virus (HIV), hepatitis B virus (HBV), and other
bloodborne pathogens when providing first aid or health care.
Under universal precautions, blood and certain body fluids of all
patients are considered potentially infectious for HIV, HBV and
other bloodborne pathogens
38. Use of Personal Protective Equipment
Gloves
aprons
Gowns
eye protection
face masks
Health care workers should wear a face mask,
eye protection and a gown if there is the
potential for blood or other bodily fluids to splash.
39. One more important thing!
Protect Yourself
Be sure you have been immunized
against Hepatitis B since it is very easy
to transmit!
40. Ways to Prevent HAI
1. Maintain cleanliness of the hospital.
2. Personal attention to handwashing before and after every
contact with a patient or object.
3. Use personal protective equipment whenever indicated.
4. Use and dispose of sharps safely.
5. Sterilization of reusable equipments
6. judicious use of antibiotics may reduce the prevalence of
multidrug-resistant organisms in health care facilities.
41. Prevention of Catheter-Associated Urinary
Tract Infection (CA-UTI)
Avoid unnecessary catheterization
Two main principles
Limit the duration of catheterization
42. Prevention through Handwashing
Hands are the most common vehicle for transmission of
organism and “hand hygiene” is the single most effective
means of preventing the horizontal transmission of
infections among hospital patients and health care personnel.
43. World Health Organizations (WHO′s) five moments for
hand hygiene:-
Before patient contact
Before an aseptic task
After body fluid exposure even if wearing gloves!
After patient contact
After contact with patient surroundings
45. How to Clean Hands
Remove all wrist and hand jewelry.
Cover cuts and abrasions with waterproof dressings.
Keep fingernails short, clean, and free from nail
polish.
46. Alcohol-based
handrub at point of
care
Access to safe,
continuous water
supply, soap and
towels
2. Training and Education
3. Observation and feedback
4. Reminders in the hospital
5. Hospital safety climate
+
+
+
+
■ The 5 core
components of the
WHO Multimodal
Hand Hygiene
Improvement
Strategy
1. System change
48. Campaigns to Decrease Infection Rates
WHO “Clean hands are safer hands” campaign
Centers for Disease Control and Prevention (CDC)
“prevent antimicrobial resistance’’ campaign in
health-care settings
Institute for Healthcare Improvement (IHI) “5 million
lives” campaign
Developing country focuses
WHO [12] defines a health care-associated infection (also called “nosocomial”) 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. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.
Environmental sources include inanimate objects, air, water and food, medical equipments ( catheter, endoscopes, bedpan, contaminated surfaces by patients body fluids and blood.
HCWs are potential carrier of MDR organisms MRSA, ESBL, etc
In the United States, 1 out of every 136 hospital patients becomes seriously ill as a result of acquiring an infection in hospital; this is equivalent to two million cases and about 80 000 deaths a year.
In England, more than 100 000 cases of health care-associated infection lead to over 5000 deaths directly attributed to infection each year.
In Mexico, an estimated 450 000 cases of health care-associated infection cause 32 deaths per 100 000 inhabitants each year.
Health care-associated infections in England are estimated to cost £1 billion a year. In the United States, the estimate is between US$ 4.5 billion and US$ 5.7 billion per year. In Mexico, the annual cost approaches US$ 1.5 billion.
Universal precautions: "Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Retrieved from CDC web site http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html
Personal protective equipment includes the use of gowns, gloves, aprons, eye protection and face masks.
The use of these equipment is usually based on assessment of the risk of micro-organism transmission to the patient or to the carer as well as the risk of contamination of the health-care practitioner’s clothing and skin by the patient’s blood, bodily fluids, secretions or excretions.
Students should approach every situation as having the potential to infect a patient or a health-care worker or themselves.
Infections are preventable when health-care workers use the right techniques and remain on the look out for unclean and unsafe situations.
Handwashing today is the single most important intervention before and after patient contact.
Every health-care worker is required to act responsibly and without fail to apply the techniques for handwashing at every patient encounter. They also should advise patients and families of the importance of handwashing and give them permission to remind the staff.
Decontamination refers to the process for physical removal of blood, bodily fluids and the removal or destruction of micro-organisms from the hands.
• limited studies available to test the technique of hand decontamination;
• methods based on expert opinion:
- before clinical shift begins remove all wrist and hand jewelry;
- cuts and abrasions covered with waterproof dressings;
- fingernails kept short clean and free from nail polish.
Clean hands are safer hands
prevent antimicrobial resistance
5 million lives
Developing country focus
Recognizing this worldwide crisis, WHO established the campaign Clean hands are safer hands and joins other campaigns by addressing the high infection rates through the implementation of endorsed guidelines aimed at reducing death from transmission of health care-associated infections.
The CDC’s campaign to Prevent antimicrobial resistance aims to prevent antimicrobial resistance in health-care settings by a range of strategies aimed at preventing infection, diagnosing and treating infection, using antimicrobials wisely and preventing infection transmission. The campaign is targeting clinicians who treat particular patient groups such as hospitalized adults, dialysis patients, surgical patients, hospitalized children and long-term care patients.
The IHI campaign called the 5 million lives aims to reduce MRSA infections through the implementation of five key interventions:
1. hand hygiene;
2. decontamination of environment, equipment;
3. active surveillance cultures;
4. contact precautions for infected and colonized patients;
5. compliance with central venous catheter and ventilator bundles.