HAIS, NOSOCOMIAL INFECTIONS,PREVENTION AND SURVEILLANCE

1. Hospital-Acquired Infections
Dr. Neelam Gupta
M.D. MICROBIOLOGY

2. • Also called as “NOSOCOMIAL
INFECTIONS.”
• ‘Nosus’ means disease.
• ‘Kameion’ means to take care of

3. DEFINITION
Hospital-acquired infections (HAls) can be defined as
the infections acquired in the hospital by a patient:
• Who was admitted for a reason other than that
infection.
• In whom the infection was not present or incubating at
the time of admission
• Symptoms should appear at least after 48 hours after
Admission.
This also includes infections acquired in the hospital but
appearing after discharge, and also occupational
infections among staff of the hospital care facility.

4. • It is estimated that 5-10% of patients admitted to
acute care hospitals develop HAIs.
• Treatment of these HAIs adds a huge economic
burden to the patient and hospital.

5. Factors Affecting HAIs
• Immune status
• Hospital environment:
• Hospital organisms:
• Diagnostic or therapeutic interventions such as
insertion of intravenous or urinary catheters, or
endotrachealTube
• Transfusion: Blood, blood products and
intravenous Fluids
• Poor hospital administration: Strong administrative
support is essential to control the HAIs

6. HOST FACTORS
THEAGENT
EPIDEMIO- LOGICAL
INTERACT- ION
ENVIRONMENT

7. SOURCES OF INFECTION
ENDOGENOUS
2 SOURCES :
EXOGENOUS

8. Endogenous
They involve patient's own microbial flora which
may invade the patient's body during some surgical or
instrumental manipulations.

9. Exogenous Source
• Exogenous sources are from hospital environment, staff,
or patients.
• Environmental sources include inanimate objects, air,
water and food in the hospital. Inanimate objects in the
hospital are medical equipment (endoscopes, catheters,
etc.), bed pans, surfaces contaminated by patients’
excretions, blood and body fluids
• Healthcare workers may be potential carriers, harboring
many organisms; which may be multidrug resistant, e.g.
nasal carriers of Methicillin-resistant Staphylococcus
aureus (MRSA)
• Other patients of the hospital may also be the source of
infection.

10. Microorganisms Implicated in HAIs
• The ESKAPE pathogens:
• Enterococcus faecium (DAIs).
• Staphylococcus aureus
• Klebsiella pneumoniae
• Acinetobacter baumannii
• Pseudomonas aeruginosa
• Enterobacter species.
• Other infections that can spread in hospitals include:
• Escherichia coli
• Nosocomially-acquired Mycobacterium tuberculosis
• Legionella pneumophila
• Candida albicans
• Clostridium difficile diarrhea.
• Blood-borne infections transmitted through contaminated needle prick
injury or mucocutaneous exposure of blood includes HIV; hepatitis B
and hep C viral infections.

11. MODES OF
TRANSMISSION
ROUTES OF
SPREAD
CONTACT AIR BORNE EXOGENOUS

12. CONTACT
TRANSMISSION
(MOST COMMON MODE OFTRANSMISSION)
CONTACT
DIRECT
HANDS,
AUTOINOCULATION,
EQUIPMENT.
INDIRECT
BEDPANS,DRESSINGS,
CONTAMINATED
GLOVES

13. AIR BORNE
TRANSMISSION
• DROPLET NUCLEI IN
THE ATMOSPHERE
• RESPIRATORY
SECRECTIONS ON
SURFACE (FOMITES)

14. EXOGENOUS INFECTIONS
SITES
IN HOSPITAL-INFECTIONS

17. Urinary Tract Infection
Catheter associated (CAUTI) and non-catheter
associated;
Risk factors that predispose patients to acquire a
nosocomial UTI include:
i) advanced age, ii) female gender, iii) severe underlying
disease, iv) placement of a urinary catheter for >2 days
Organisms: Gram-negative rods cause the majority of
hospital-acquired UTis and E. coli is the most common
organism implicated. Gram-positive bacteria such as
S. aureus, enterococci can occasionally cause CAUTI.

18. Central Line Associated Blood Stream Infection
Central line associated blood stream infection ( CLABSI) is the
fourth common cause of HAIs.
Organisms: Coagulase negative staphylococci, and
S. aureus are increasingly reported to cause CLABSI
recently, followed by gram-negative rods and Candida
Risk factors that predispose to acquire a CLABSI
include:
• Patient related: • Age ( < 1 year and >60 years.)
Malnutrition • Low immunity • Severe underlying disease •
Loss of skin integrity (burn or bed sore) • Prolonged stay in
ICUs.
• Device related: Presence of central line • HCW related: Poor
infection control practices such as hand hygiene.

19. Ventilator-associated Pneumonia
Ventilator-associated pneumonia (VAP) are the second
common cause of HAIs next to UTI.
Risk factors include:
• Device related: Endotracheal intubation
• Patient related: (i) prolonged ICU stay leading to increased
risk of colonization of hospital MDROs, (iii) aspiration of
oropharyngeal flora due to various reasons such as
semiconscious state, supine position, etc
. • HCW related: Poor infection control practices such as poor
hand hygiene.
Organisms: Gram-negative rods such as Acinetobacter species
and Pseudomonas species account for majority ofVAP.

20. Surgical Site Infection (SSI)
• Surgical site infection is defined as infection that develops at
the surgical site within 30 days of surgery ( within 90 days
for breast, cardiac and joint surgeries).
• Though SSI is a major threat in the hospitals, it is often
under reported because 50% of SSis develop after the
discharge
• Organisms: Surgical site wounds are classified as clean,
clean -contaminated, contaminated or dirty.
• For clean wound: The skin flora of the surgery team or the
environmental organisms are the major pathogens; most
common being S. aureus.

22. PREVENTING NOSOCOMIAL
INFECTIONS
The preventive measures for HAIs can be broadly
categorized into (i) standard precautions and (ii)
transmission-based or specific precautions.

24. HAND WASHING

26. CONTROL OF DROPLET
INFECTION
 Use of face-mask
 Proper bed-spacing
 Prevention of overcrowding
 Ensure adequate ventilation

27. COLOR WASTE TREATMENT
YELLOW Human & animal anatomical
waste/Microbiology waste and soiled
cotton/dressings/linen/bedding etc.
INCINERATION/ DEEP
BURIAL
RED Tubing/catheters/i.v. sets etc. AUTOCLAVE/MICRO
WAVE/CHEMICAL
TREATMENT
BLUE/ Waste sharps AUTOCLAVE/MICRO
WHITE (needles,syringes,scalpels,blades etc.) WAVE/CHEMICAL
TREATMENT/
DESTRUCTION
BLACK Discarded medicines/
cytotoxic drugs/incineration
ash/chemical waste
DISPOSAL IN LAND
FIELDS
PROPER DISPOSAL OF HOSPITAL WASTE

28. DISINFECTION
• Disinfection prevents transmission of
organisms between patients.
• LEVELS OF DISINFECTION:
o HIGH LEVEL - destroys all the microorganisms except heavy
contamination by bacterial spores.
o INTERMEDIATE LEVEL – inactivates M.tuberculosis,
vegetative
bacteria, most viruses & fungi.
o LOW LEVEL – kills most bacteria, some viruses & some
fungi.

29. HOSPITAL INFECTION CONTROL COMMITTEE
• The hospital infection control program is organized and run
by the Medical Superintendent (MS), for which he /she
constitutes the Hospital Infection Control Committee (HICC).
• The HICC provides a forum for multidisciplinary input and
cooperation, and information sharing, required for hospital
infection control and prevention.
• The HICC is advisory to the MS and makes its
recommendations to the MS.

30. Functions of HICC
• The HICC supervises the implementation of the hospital
infection control program. The various functions of the
committee include:
• HAI surveillance: Maintains surveillance of
hospitalacquired infections. The four key parameters used
for HAI surveillance are as follows
• 1. CA-UTI ( Catheter-associated urinary tract infection).
• 2. CLABSI (Central line -ass ociated bloo dstream infection).
• 3. VAP (Ventilator-associated pneumonia).
• 4. SSI (Surgical site infection).

31. • Develops a system for identifying, reporting, analyzing
investigating and controlling hospital-acquired infections.
• Antimicrobial stewardship program (AMSP): Develops
antibiotic policies, monitors the antibiotic usage, advises the
MS on matters related to the proper use of antibiotics, and
also recommends remedial measures when antibiotic
resistant strains are detected.
• Policies: Reviews and updates the hospital infection control
policies and guidelines from time to time. Education:
Conducts teaching sessions for healthcare workers regarding
matters related to HAIs.

32. • Staff health: Monitors employee health activities regarding
matters related to HAIs such as needle stick injury
prevention, hepatitis B vaccination, etc.
• Outbreak m anagement: Develops strategies to identify
infectious outbreaks, their source and implements
preventive and corrective measures
• Reviews risks associated with new technologies, and
monitor infectious risks of new devices and products, prior
to their approval for use
• HICC Meetings: meet regularly not less than once a month
and as often as required.
Other departm ents: Central Sterile Supplies department
(CSSD) , Biomedical Safety Committee • Blood Transfusion
Committee.

33. HOSPITAL-ACQUIRED INFECTION SURVEILLANCE
• healthcare-associated infections (HAIs) surveillance is a
system that monitors the HAIs in a hospital. Main objectives
of HAI surveillance include:
• Provides endemic or baseline HAI rate and information on
type of HAIs in the hospital.
• Helps in comparing HAI rates within and between hospitals.
• Identifies the problem area; based on which root cause
analysis can be conducted to find out the breakdowns in
infection control measures and then the appropriate
corrective measures are implemented.
• Provides timely feedback to the clinicians; thus, reinforces
them to adopt best practices.

34. Targeted Surveillance
Where to conduct: intensive care units (ICUs) What type of
HAIs to be monitored: only the major type of HAI to be
monitored such as:
• Catheter-associated urinary tract infection (CAUTI)
• Central line-associated blood stream infection ( CLABSI)
• Ventilator-associated event (VAE)
• Surgical site infection (SSI).
Who will conduct: The infection control nurses (ICNs) under
the supervision of the officer in-charge of HICC conduct HAI
surveillance

35. Method of Conducting HAI Surveillance
• The HAI surveillance cycle consists of data
collection – data analysis – data interpretation –
data dissemination.

36. PREVENTION OF MAJOR TYPES OF HAIs
Prevention of Device-associated Infections (DAls): CAUTI, CLABSI
and YAP. Presence of device itself is a major risk factor for
developing such infection. This is because of various reasons:
(i) risk of introduction of patients own flora,
(ii) risk of introduction of HCW's hand flora due to improper
handling during insertion or daily maintenance of the device;
(iii) ability of the invading organism to produce biofilm over the
device;
(iv) persistence of organisms as majority of them are MDROs
(multi-drug resistant organisms)
Strict aseptic techniques must be followed while insertion and
daily maintenance of the devices.
 The preventive measures for each of the DAis are grouped as
bundle care approach

37. Bundle Care Approach
Most hospitals follow bundle care approach for the
prevention of DAIs.
 Bundle care comprises of 3 to 5 evidence-based elements
with strong clinician agreement; each of the component
must be followed during the insertion or maintenance of
the device.
Compliance to the bundle care is calculated as all or-none
way, i.e. failure of compliance to any of the component
leads to non-compliance to the whole bundle.

38. •THANK YOU