Hospital Acquired Infection

1. HOSPITAL
ACQUIRED
INFECTIONS
Presentation by
Khushi Parmar

2. INTRODUCTION
Hospital Acquired Infections are also called as Healthcare Associated
Infections. These infections are not present at the time of admission into
the hospital but are acquired nasocomically after staying in hospital.
Hospital acquired infection is one of the common problem of Health
care management. Hospital Acquired Infection may cause serious health
problems such as increased patient morbidity, mortality, hospital stay
and health care cost
Thus, to minimize the risk of spread of infection and to provide high
quality health care for patients and staff in hospital effective infection
prevention and control is necessary.

3. HOSPITAL ACQUIRED
INFECTIONS
Improper infection control practices, immune system of
patient, older age, length of stay in hospital, mechanical
ventilatory support, recent operations, multiple
underlying comorbidities, frequent visits to healthcare
facilities, recent operations and stay in Intensive Care
Unit(ICU) are some of the reasons for causing Hospital
Acquired Infections.
To control such HAI certain Hospital Infection Control
policies should be practiced and monitored by the
Hospital Infection Control Team (HICT) and Hospital
Infection Control Committee (HICC).
Following are the Hospital Infection
Control policies:
1. Guidelines for prevention of control of
infection.
2. Antimicrobial policy.
3. Surveillance policy.
4. Disinfection policy.
5. Isolation policy.
6. Policy for investigation of an
outbreak of infection.

4. TYPES OF HEALTHCARE
ASSOCIATED
INFECTIONS
Ventilator associated events/
Ventilator associated pneumonia
Urinary Tract Infections
Surgical Site Infections(SSI)
Centrally associated Bloodstream Disorder
1
2
3
4

5. BUNDLE APPROACH
Bundle approach or care bundles in preventing infection or infection safety are simple sets of evidence based
practices. When these practices are implemented collectively, they improve the reliability of their delivery and
improve patient outcomes. Bundle approach helps in infection prevention, unnecessary prescription of
antibiotics etc.
General Principles:
1. Implementation of bundle approach/care bundle (i.e. set of evidence based measures) helps to improve
patient care and greater impact rather than that of isolated implementation of individual measures.
2. Each element of bundle should be implemented collectively with complete consistency to achieve desired
outcome.
3. Bundle approach should be adapted, followed, recorded, evaluated and ensured by all members of the health
care team.
4. A multidisciplinary approach combined with will-building, awareness programme, training, education,
measurement and feedback of performance are required to improve and maintain implementation of care
bundles in hospitals.
5. A bundle compliance percentage goal should be decided so that heaithcare team will work accordingly to
achieve the goal.

6. BUNDLE APPROACH FOR URINARY TRACT INFECTION
Urinary Tract Infections (UTI) are the common healthcare associated infections of about 40%
of total HAIs. Mostly urinary tract infection caused by urinary drainage devices such as
bladder catheters.
The chances of infection are increases with increase of catheterisation. at Hence, urinary
catheters should any aut used in serious medical indications such as problem with emptying
the bladder, measurement of urine production. They should be removed immediately if not
needed.
Napkins or absorbent pads should be used during urinary incontinance instead of catheters.
During urination urethral flora migrates towards the bladder and flushed out along with
urine but if catheter is inserted the flora passes into bladder and remain in the fluid layer
between the outside of catheter and urethral mucosa and thus there are chances of infection
Bacterial reflux from contaminated urine in the drainage bag may also cause urine infection.

7. BUNDLE APPROACH FOR UTI
Hands of personnel may contaminate urinary catheter and thus should be cleaned
before insertion of catheter and removal of catheter.
Urinary Tract Infections are usually caused by endogenous microorganisms i.e.
microorganisms are usually present inside the patient’s bowel. In community
acquired infections, E.coli and proteus spp. are common microorganisms which
are sensitive to antibiotics and thus can be treated easily.
However, in health care associated UTI, the infection is caused by resistant micro-
organisms (i.e. micro-organisms which is resistant to the antibiotics) e.g. Klebsiella
and pseudomonas. Infection may occur due to transfer from other person,
environmental sources, urinary catheters etc.

8. BUNDLE STRATEGIES FOR PREVENTION OF
UTI

9. DIAGNOSIS OF UTI
In non-catheterised patients infection is caused by single micro-
organism. While in catheterised patients infection is caused by multiple
types of micro-organisms.
The urine sample is collected carefully and bacterial colony forming
units (CFU)/ml in a patient are calculated.
Urine must be processed fastly because urine sample may contain
contaminants which may multiply at room temperature and give false
results for bacterial colony forming units.
If there is delay in processing, specimen should be stored in ice box or 1%
w/v or 1 gm boric acid/10 ml of urine should be added for preventing
multiplication of bacteria.
Fever, supra-public tenderness, frequency of urination and dysuria are
some of the symptoms of urinary tract infection.

10. PREVENTION OF UTI
• Care bundle approach:
Care bundle approach includes package of evidence based interventions when implemented together in all
patients resulted in treating urinary tract infection. Care bundle treatment plans for catheter associated
urinary tract infection have been developed by the US Institute for Healthcare Improvement and the UK
Department of health.
2. Staff training:
Proper training should be given to health care professionals regarding correct procedure for insertion and
maintenance of urinary catheters.
3. Catheter size:
There are different sizes of catheters. Small diameter catheters should be used because they allow free flow
of urine. While large diameter catheters may produce pressure on urethral mucosa which may cause trauma
and ischemic necrosis. Larger diameter catheters are required in urological patients and should be after
consulting the specialist.
4. Antimicrobial coated catheter:
Latex coated silver alloy are the antimicrobial coat catheter. They are used to prevent UTI. They should be
used only for 1 week as the is no significance of decreasing infection.

11. PREVENTION OF UTI
5. Catheter Insertion: Catheter insertion should be performed using all Sterile techniques and disinfected
equipments. To reduce discomfort to patient and trauma sterile lubricant or anesthetic gel should be used.
6. Metal Cleansing: Soap and water should be used for cleaning of metal and making it free from micro-
organisms. Use of antimicrobial ointment or disinfectant may produce harmful effects.
7. Drainage bags: The catheter drainage bag should be fixed below the level of the bladder to promote
proper drainage. The drainage bag and drainage tap must not touch floor if stand is used. During movement
of patient the clamp should be placed to drainage tube to prevent back flow of urine.
8. Emptying the drainage bag: Regular emptying of drainage bag should be done If drainage bag have tap at
the bottom of bag, emptying should be done through tap, once 3/4th bag is filled with urine. If drainage tap
is not there, the bag should be replaced by using aseptic techniques. Care must be taken to prevent cross-
infection Clean disposable gloves should be used for emptying the drainage bag. Hands mus be washed and
disinfected by using alcohol based hand sanitizer before and after emptying of drainage bag. Separate
container should be used for each patient. The urine container must be washed and disinfected with the
help of heat after each use It should be washed in washer-disinfectant unit, dried and stored in clean and dry
place in inverted position.

12. PREVENTION OF UTI
09. Bladder irrigation: Bladder irrigation/washout with the user of antiseptic or
antimicrobial should be strictly avoided as it may damage bladder mucosa and
promote growth of resistant bacteria instead of preventing UTI. Resistant bacteria are
difficult to treat.
10. Specimen collection: Urine sample for bacteriological examination should be
collected by using aseptic technique. From sampling port 70% isopropyl alcohol
impregnated swab should be used for disinfection. Sample should be transferred
into sterile container using sterile needle. Sample should not be collected from
drainage bag.
11. Use of antimicrobial agents: Routine administration of antibiotic/antimicrobial
agents should be avoided as it may develop resistant microorganisms. A single dose
of prophylactic antibiotic at the time of catheter change in patient having clinical
infection or at higher risk of developing UTI is acceptable.

13. BUNDLE APPROACH FOR PREVENTION
OF SURGICAL SITE INFECTIONS
Surgical site infections are one of the most important Hospital acquired
infections. About 25% of HAIs are covered by surgical site infections. 40-60% SSI
are preventable. SSI may prolong the hospital stay for about 6-30 days and thus
increases health care cost.
Factors causing surgical site infection are as follows:
(a) Patient risk factors.
(b) Operative risk factors.
(c) Environmental risk factors.

14. FACTORS CAUSING SURGICAL SITE INFECTION

15. BUNDLE APPROACH FOR PREVENTION OF SURGICAL SITE INFECTIONS
(a) Patient risk factors: Factors causing surgical site infection
(i) Nutritional status: Malnutrition increases risk of surgical site infection.
(ii) Diabetes: Increase Blood glucose level (> 200 mg/dl) before operation
may cause SSI.
(iii) Smoking: Consumption of Nicotine delay's wound healing and thus
smoking should be avoided to avoid SSI.
(iv) Obesity: There are more chances of SSI in persons having Body Mass
Index > 40. (v) Co-existing remote infection: Presence of active skin or
respiratory tract infection increases risk of SSI during all types of surgeries.
(v) Colonisation with micro-organisms: Presence of S. aureus in nasal
cavity may cause SSI.
(vii) Length of preoperative stay.

16. BUNDLE APPROACH FOR PREVENTION OF SURGICAL SITE INFECTIONS
(b) Operative risk factors:
(i) Colonisation of the operative site/antiseptic bath: Antiseptic bath before operation
decreases the microbial colony count and thus reduces risk of SSI
(ii) Colonisation of the operative site/skin antiseptics: Antiseptic solution should be applied
on skin before operation to reduce the microbial colony. Alcohol chlorhexidine are used as
antiseptics.
(iii) Colonisation of surgical team/surgical scrub: Antiseptics like isopropyl alcohol,
chlorhexdine, iodine/iodophors, triclosan, parachloro-meta-xylenol etc. are used to remove
the microbial colony on the hands of surgical team.
(iv) Pre-operation shaving: Shaving or removal of hairs at surgical site should not be done in
advance as it may cause SSI. Shaving should be done just before the operation. Depilatories
should be used for removing the hairs.
(v) Infected or colonised surgical personnel: Personal having skin diseases like psoriasis,
active infections such as staphylococci etc. should be excluded from surgical activities.

17. BUNDLE APPROACH FOR PREVENTION OF SURGICAL SITE INFECTIONS
(b) Operative risk factors:
(vi) Duration of operation: Time required for operation is directly proportional to risk of SSI.
Hence, operation should be performed in minimum duration of time.
(vii) Contamination of the operative site/Antimicrobial prophylaxis: Maximum 3 doses of
antimicrobial prophylaxis are sufficient for bactericidal concentration of drug in tissue at
the time of incision.
(viii) Foreign material in the surgical site (Sutures and drains): Monofilament sutures causes
loss irritation. Foreign material may increase chances of inflammation Drains should be
removed or passed through separate incision away from the
operative wound.
(ix) Hypothermia: Vasoconstriction is caused due to hypothermia which may lead to
decreased delivery of oxygen to wound space and thus impairement of leukocyte function.
(x) Systal techniques: Contaminated syringes and equipments may increase risk of SSL
Appointment of experienced surgeons and monitoring of surgical techniques should be
done to avoid SSI.

18. BUNDLE APPROACH FOR PREVENTION OF SURGICAL SITE INFECTIONS
(c) Environment risk factors:
(i) Operating Room ventilation: Entry of personnel in operating room should be
restricted as there is directly proportional relation between number of people and
the movement with microbial count. Ultra clean filtered or should be supplied in
operating room at pressure of atleast 20 air changes per hour.
(ii) Inadequate sterilization of instruments: All the equipment should be sterilized
by using validated procedures. Inadequate sterilization may increase risk of SSL.
(ii) Contamination from the surgical team/surgical clothes and gloves: Caps, masks,
aprons, shoe cover, gloves should be used to minimize the exposure of surgical
team to patient's wound.

19. PRE-OPERATIVE RECOMMENDATIONS
FOR PREVENTION OF SSI
1. Identify and treat all other active infections before operation.
2. Maintain proper blood glucose level.
3. Avoid preoperative stay.
4. Do not remove hairs at operation site in advance unless necessary. Remove
them just before operation using non-invasive method.
5. Clean the skin by using antiseptic.
6. Using appropriate antiseptic, perform pre-operative scrub.
7. Those persons having signs and symptoms of infection should be excluded
from surgical team.
8. Administer prophylactic antibiotic if required.
9. Use trained surgeons in complex surgeries

20. INTRA-OPERATIVE RECOMMENDATIONS
FOR PREVENTION OF SSI
1. Use surgical checklist.
2. Finish the operation in short period of time.
3. Use sterile instruments.
4. Wear surgical gloves, mask, aprons, caps, foot-wares to avoid spread of infection.
5. Maintain proper ventilation in operation room.
6. Keep operation room doors closed to avoid entry of foreign particles. Open them
only for passage of equipment, personnel and patient.
7. Restrict entrance in operation theatre.
8. Use proper aseptic techniques during operation.
9. Keep body temperature of patient below 37°C.
10. Keep normal glucose level during operation.
11. Surgical team should avoid use of artificial nails.

21. POST-OPERATIVE RECOMMENDATIONS FOR
PREVENTION OF SSI
Post-operative recommendations for prevention of SSI:
1 Do not touch the wound unless necessary.
2. Review daily necessity of use of drains. If not required stop it.

22. BUNDLE APPROACH FOR PREVENTION OF VENTILATOR
ASSOCIATED EVENTS (VAE)
Ventilator Associated Events (VAE) involves three new indicators as follows:
1. Ventilator Associated Conditions (VAC): This is first step of VAE. Here
complications occurring in mechanically ventilated patients are identified.
2. Infection Related Ventilator Associated Complications(IVAC): This is the
second step of VAE. Here, subgroups of VAE which are related to infection, e.g
abnormal white blood cell count, modified temperature, initiation of new anti-
microbial treatment for atleast four days are identified.
3. Ventricular Associated Pneumonia(VAP): when there are positive results of
purulent respiratory secretions, microbiological tests performed on respiratory
tract specimens IVAC can become VAP.

23. PREVENTION OF VAE AND VAP
Prevention of VAE and VAP:
1. Follow hand hygiene guidelines.
2. Health care providers should wear cap, mask, aprons etc. while doing
bronchoscopy, tracheostomy or any other respiratory tract related operation
and change masks, gloves, aprons etc. while providing the care to another
patient.
3. Avoid unnecessary use of respiratory devices such as nasogastric tubes
endotracheal tubes, tracheostomy etc.
4. Instead of using nasotracheal intubation perform orotracheal intubation
unless contraindicated.
5. Non-invasive ventilation procedure should be followed.
6. Avoid unplanned extubation.
7. Unplanned reintubation should also be avoided.

24. PREVENTION OF VAE AND VAP
8. Cuffed endotracheal tube with in-line or subglotic suctioning should be used.
9. Avoid using histamine receptor blocking agents.
10. Avoid using proton pump inhibitors.
11. Oral hygiene is important to avoid VAE. Hence, oral cavity should be cleaned
regularly by using antiseptic solution.
12. Condensate from ventilatory circuit should be removed and circuit should be
kept closed.
13. Frequent replacement of ventilatory circuit should be avoided. It should be
changed only if malfunctioning is observed.
14. Respiratory therapy equipments should be maintained, cleaned and
disinfectant.
properly and should be stored according to required storage conditions.
15. Proper education and training should be given to health care providers who
tale care of patients undergoing ventilation about VAP.

25. PREVENTION OF CENTRAL LINE ASSOCIATED BLOOD STREAM
INFECTION (CLABSI)
Central Line Associated Blood Stream Infections (CLABSI), is defined as “A
Laboratory confirmed blood stream infection not related to an infection at another
site taht develops within 48 hours of a central line placement”.
CLABSI can be caused by various pathogens, including gram-negative bacteria,
gram-positive bacteria, Candida spp, and anaerobes. These microorganisms can
colonize the central line and subsequently enter the bloodstream, leading to
systemic infections.
Improper insertion practices, improper dressing care, practices, failure to remove a
device which is no longer required for treatment insufficient nurse to patient ratio
are some of the reasons for developing Central Line Associated Blood Stream
Infection.

26. BUNDLE APPROACH FOR PREVENTION OF
CLABSI
Bundle Approach for Prevention of CLABSI:
1. Follow appropriate hand hygiene practices.
2. Use chlorhexidine for skin preparation.
3. Use full-barrier precautions during central venous catheter insertion.
4. Avoid using the femoral vein for catheters in adult patients.
5. Remove unnecessary catheters.
6. Use 70% isopropyl alcohol for skin preparation.
7. Subclavian site should be used for catheter insertion.
8. Proper training and education should be provided to health care workers.
9. Hospital infection control policy for intra-vascular device related infection should be
adopted.
10. Injection ports should be disinfected before use.
11. Stopcocks should be capped when not required.

27. BUNDLE APPROACH FOR PREVENTION OF CLABSI
12. Polyvinyl chloride or polyethylene catheters should be avoided and
Teflon or polyurethane catheters should be preferred.
13. Transparent dressing should be changed after every 7 days.
14. Sterile gauze dressing should be changed after every 2 days.
15. Antimicrobial coated catheters should be used if duration of
catheter use is more than 5 days to avoid catheter associated blood
stream infection.
16. Tubes used for blood products, lipid emulsions and propofol
injections should be replaced regularly.
17. Tunnelled central venous catheters should be used for long term (> 7
days) of catheterization.

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