A short brief on 'Hospital Acquired Infections' (HAI) or 'Nosocomial Infection' (NI) for M Phil, MPH and Advance Course in Hospital Management/ Administration

1. Brig Gen Dr Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), Advance Course HA (AIIMS, Delhi), MBBS (DMC)
North South University (NSU)

2. Introduction
Hospital-Acquired Infections (HAI) continue to be a source of great
medical and economical strain for healthcare facilities across the
world. A hospital-acquired infection— also called “nosocomial
infection (NI) ” can be 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 or incubating at
the time of admission.

3. For a HAI, the infection must occur:
- After 48 hours of hospital admission
- Up to 3 days after discharge
- Up to 30 days after an operation
- Admission in hospital for reasons other than that particular infection
- Ideally, it should be less than 1-2%
Characteristics of HAI

5. HAI Rate
Hospital Acquired Infection = i / d
Hospital Acquired Infection Rate = (i / d)×100
Where,
i = Total Number of Hospital Infections
d = Total Number of Discharges (Including Deaths)

6. Frequency of HAI
A prevalence survey conducted by WHO in 55 hospitals of 14 countries
representing 4 WHO Regions (Europe, Eastern Mediterranean, South-
East Asia and Western Pacific) showed an average of 8.7% of hospital
patients had nosocomial infections.
The highest frequencies of nosocomial infections were reported from
hospitals in the Eastern Mediterranean and South-East Asia Regions
(11.8 and 10.0% respectively).
A study in a tertiary hospital in Dhaka found a prevalence rate of
8.33% for HAI (Amin ZA et al, 2015) in ICU, Post Operative Units and
selective surgical units.

7. Impact of nosocomial infections
- Hospital-acquired infections add to functional disability and
emotional stress to the patient.
- The increased length of stay (For surgical wound infections average
8.2 days) is the greatest contributor to cost.
- The increased use of drugs, the need for isolation, and the use of
additional laboratory and other diagnostic studies also contribute to
costs.
- Organisms causing nosocomial infections can be transmitted to the
community through discharged patients, medical staffs, and visitors.
- In severe cases (eg, Septicemia), it may lead to death.

10. COST of HAI in USA

13. Types of HAI (By Methods of Transmission)

14. Routes of Transmission
The main routes are:
- Airborne infection:
Infection usually occurs by the respiratory route, with the agent
present in aerosols (infectious particles <5 μm in diameter).
- Droplet infection:
Large droplets carry the infectious agent (>5 μm in diameter).
- Infection by direct or indirect contact:
infection occurs through direct contact between the source of
infection and the recipient or indirectly through contaminated
objects.

16. Risk Factors of HAI

17. 1. The microbial agent
- Contact between the patient and a microorganism.
- Characteristics of the microorganisms, including resistance to
antimicrobial agents, intrinsic virulence, and amount (inoculum) of
infective material.
- Infections may be caused by a microorganism acquired from
another person in the hospital (cross-infection) or may be caused by
the patient’s own flora (endogenous infection).
- Most infections acquired in hospital are common in the general
population, in whom they cause no or milder disease than among
hospital patients (Staphylococcus aureus, coagulase-negative
staphylococci, enterococci, Enterobacteriaceae).

21. 2. Patient susceptibility
- Age, immune status, underlying disease, and diagnostic &
therapeutic interventions.
- The extremes of age: Infancy and old age, are associated with a
decreased resistance to infection.
- Patients with chronic disease such as severe anaemia, malignant
tumors, leukemia, diabetes mellitus, renal failure, or AIDS have an
increased susceptibility.
- Immunosuppressive drugs or irradiation may lower resistance.
- Injuries to skin bypass natural defense mechanisms.
- Malnutrition.
- Diagnostic and therapeutic procedures, (eg, catheterization,
intubation/ventilation and suction and surgical procedures, etc).

22. 3. Environmental factors
- Health care settings are an environment where both infected
persons and persons at increased risk of infections congregate.
- Crowded conditions within the hospital, frequent transfers of
patients from one unit to another, and concentration of patients
highly susceptible to infection in one area (e.g. newborn infants, burn
patients, intensive care).
- Contaminated objects, devices, and materials which are
subsequently transferred to susceptible patients.
- Lack of house-keeping and Waste Management services.
- Inappropriate building design and ventilation.

24. 4. Bacterial resistance
- The indiscriminate use of antimicrobials for therapy or prophylaxis.
- Many strains of pneumococci, staphylococci, enterococci, and
tuberculosis are currently resistant to most or all antimicrobials.
- Multi-resistant Klebsiella and Pseudomonas aeruginosa are
prevalent in many hospitals.
Antibiotic Resistant Organisms in HAI:
- MRSA: Methicillin Resistant S. aureus
- VRE: Vancomycin Resistant Enterococci
- ESBL: Extended Spectrum Beta-Lactamase Producing E coli/
Klebsiella

25. Prevalence of infection as per site

28. Cancer Ward.
Operation Theatre.
Delivery Rooms.
Orthopaedics Dept

29. Sources of Infection

31. Environmental Factors for HAI
Hospital environment that significantly contributes to HAI are:
- Building features,
- Ventilation,
- Water,
- Food and wastes.
- Housekeeping
- Medical Devices

32. Buildings feature:
- Traffic flow to minimize exposure of high-risk patients and facilitate
patient transport
- Adequate spatial separation of patients
- Adequate number and type of isolation rooms
- Appropriate access to hand-washing facilities
- Materials (e.g. carpets, floors) that can be adequately cleaned
- Appropriate potable water systems to limit Legionella spp.
- Inlets and outlets

33. Ventilation
Fresh filtered air, appropriately circulated, will dilute and remove
airborne bacterial contamination. It also eliminates smells.
Ultra-clean air
For minimizing airborne particles, air must be circulated into the
room with a velocity of at least 0.25 m/sec through a high-efficiency
particulate air (HEPA) filter, which excludes particulate matter of
defined size. If particles 0.3 microns in diameter and larger are
removed, the air entering the room will be essentially clean and free
of bacterial contaminants.

34. Operating theatres
- The operating room is usually under positive pressure relative to
the surrounding corridors, to minimize inflow of air into the room.
- Modern operating rooms which meet current air standards are
virtually free of particles larger than 0.5 μm (including bacteria) when
no people are in the room.
- operating rooms are ventilated with 20 to 25 changes per hour of
high-efficiency filtered air

35. Food
The most common errors related to food which contribute to
outbreaks include:
— Preparing food more than a half day in advance of needs
— Storage at room temperature
— Inadequate cooling
— Inadequate reheating
— Use of contaminated processed food (cooked meats and poultry,
pies and take-away meals) prepared in premises other than those in
which the food was consumed
— Undercooking
— Cross-contamination from raw to cooked food
— Contamination from food handlers.

36. Water
The physical, chemical and bacteriological characteristics of water
used in health care institutions must meet local regulations.
Waste
Health care waste is a potential reservoir of pathogenic
microorganisms, and requires appropriate handling. Appropriate
colour-coding for waste segregation, transportation, handling and
disposal should be ensured.

37. Housekeeping:
Proper supervision.
Regular cleaning.
Proper Linen and Laundry Services.
Adoption of 5S (5s-CQI-TQM) system of hospital- quality
improvement.
Medical Equipment:
Proper CSSD Services.
Avoid unnecessary instrumentation.
Aseptic condition (Including sterilization)
Policy on use of medical devices (Including duration of use).

38. Standards to be maintained at hospitals

39. Rodac Plates (RODAC = Replicate Organism Detection And Counting) can be used for microbiological
control of all surfaces.

40. Antimicrobial resistance
Currently many microorganisms have become resistant to different
antimicrobial agents, and in some cases to nearly all agents. Some
strains of methicillin-resistant Staphylococcus aureus (MRSA) have a
particular affinity for nosocomial transmission. MRSA strains are
often resistant to several antibiotics in addition to the penicillinase-
resistant penicillins and cephalosporins, and occasionally are
sensitive only to vancomycin and teicoplanin.

42. Infection control programs
- National or regional programs
The responsible health authority should develop a national (or
regional) program to support hospitals in reducing the risk of
nosocomial infections.
- Hospital programs
Risk prevention for patients and staff is a concern of everyone in the
facility, and must be supported at the level of senior administration.
- Infection Control Committee

43. Composition of Infection Control Committee
- Hospital director as chairman
- Chief of Infection control team (Microbiology staff)
- Heads of all the major clinical departments
- Chief Nurse.
- Chief Pharmacist.
- Head of the maintenance and cleaning department.
- Head of CSSD.

44. Functions of Hospital Infection Control Committee
- Formulates infection control guidelines and procedures
- Monitors implementation of infection control practices.
- Conducts a hospital wide surveillance and identifies prevalent
microorganisms and nosocomial infections and makes appropriate
action.
- Facilitates/recommends risk reduction strategies to prevent
hospital acquired infections among patients, families and health
care providers
- Recommends appropriate advices on issues and problems related
to infection control practices.

45. - Plans/facilitates for the educational training of all hospital
employees on infection control practices.
- Conducts risk assessment activities for patients who are likely to
develop hospital acquired infections.
- Collates/analyzes statistical data on hospital infection and makes
prompt action and recommendations.
- Reviews the use of antibiotics as they relate to patient care.
- Conducts regular meeting or as the need arises.

46. Role of Infection Control Committee
• Education and Training
• Development and dissemination of infection control policy
• Monitoring and audit of hygiene practices
• Clinical Audit

47. Nosocomial Infection surveillance
Public health surveillance is the continuous, systematic collection,
analysis and interpretation of health-related data needed for the
planning, implementation, and evaluation of public health practice.
The development of a surveillance process to monitor HAI rate is an
essential first step to identify local problems and priorities, and
evaluate the effectiveness of infection control activity.

49. Prevention of Nosocomial Infection
1. Risk stratification
Vulnerability to nosocomial infection is determined by both patient
factors, such as degree of immuno-compromise, and interventions
performed. Thus categorize patients and plan infection control
interventions.
2. Reducing person-to-person transmission
Hand decontamination: Compliance with hand-washing is
frequently suboptimal, due to:
- Lack of appropriate accessible equipment.
- Insufficient knowledge of staff about risks and procedures.
- Too long a duration recommended for washing.
- Lack of washing facilities.
- Leniency of the management.

50. Personal hygiene: All staff must maintain good personal hygiene.
Nails must be clean and kept short.
Clothing:
- Clothes covered by a white coat.
- In special areas such as burn or ICU, uniform trousers and a short-
sleeved gown
- The working-cloths must be made of a material easy to wash and
decontaminate.
- Use of shoes and caps.
Masks
Gloves

51. Safe injection practices
- Eliminate unnecessary injections.
- Use sterile needle and syringe.
- Use disposable needle and syringes (If possible).
- Prevent contamination of medications.
- Follow safe sharps disposal practices.
3. Preventing transmission from the environment
- Adequate methods for cleaning, disinfecting and sterilizing.
- Ninety per cent of microorganisms are present within “visible dirt”,
and the purpose of routine cleaning is to eliminate this dirt.
- Safe disposal of Hospital Waste.

52. 4. Establishing Infection Control Committee
5. Establishment of Infection Control Program.
6. Provision of safe blood.
7. Proper hospital building and design.
8. HAI Surveillance.
9. Commitment of administrators and clinicians.
10. Financing infection control programs.
11. Raising awareness among the staffs, patients and attendants.
12. Special care to bed-ridden and unconscious patients for bed-
sore and septicemia.
13. Justify use of medical devices and duration of use.

53. 13. Control of Antimicrobial Resistance:

55. 5 Pillars of Infection Control

61. Conclusion