Nosocomial infections prevention

NOSOCOMIAL
INFECTIONS
&
ITS CONTROL
Mentored by:
Prof. Sumitra
Pattnaik.
Presented by:
Dr. Subraham

Nosocomial infection or
Healthcare-associated infections
(HAI)
"nosus" = disease
"komeion" = to take care of

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 & also occupational infections
DEFINITION (WHO):

THE FOLLOWING INFECTIONS ARE
NOT CONSIDERED HAI:
* Infections associated with complications or extensions
of infections already present on admission, unless a
change in pathogen or symptoms strongly suggests the
acquisition of a new infection
* Infections in infants that have been acquired
transplacentally (e.g., TORCH, or syphilis) and become
evident within 48 hours after birth

THE HISTORY OF HAI’S
Hippocrates made the relatively profound statement
“Primum non nocere”
that - If you wish to become a physician, always
follow the maxim, first do no harm.
It is obviously the case that modern medicine bears
little resemblance to that practiced two millennia ago,
but the maxim clearly still applies.

Nearer to the present day, Florence Nightingale
paraphrased Hippocrates’ words with the phrase “It may
seem a strange principle to enunciate as the very first
requirement in a hospital that it should do the sick no
harm”.
In the context of this dissertation her words were
particularly poignant as she was referring to the
THE HISTORY OF HAI’S (CONTD. …)

In Europe, Dr Ignaz Semmelweis, 1861 realized that it was
hospital staff who were largely responsible for the dreadful
death toll of puerperal fever in the maternity units that he
was responsible for.
His seminal observation was that puerperal fever claimed
the lives of 25% of the mothers who delivered in hospital
but only 5% of those who delivered at home. (Playfair,
1847).
By a complex series of exclusion experiments he was able
to discover that by getting the hospital staff to wash their
THE HISTORY OF HAI’S (CONTD. …)

HAI IN THE 20TH – 21ST CENTURY
The present era of healthcare- associated infections
(HAI) started with the CDC in the USA.
It started the National Nosocomial Infection Surveillance
System (NNIS) in 1950s and the SENIC project in 1974.
It was observed that one-third of healthcare- associated
infections were preventable through effective infection
control and prevention .

Many guidelines were produced by Healthcare Infection
Control Practices Advisory Committee (HICPAC).
In 2005, hospitals started contributing data to National
Healthcare Safety Network. There are many current
Quality Initiatives.
Agency for Healthcare Research and Quality (AHRQ)
promotes patient safety; improve quality of healthcare &
Evidence-based Practice Centres.
(CONTD. ..)

Since 2005, various member countries of the
world have signed the pledge of WHO’s First Global
Patient Safety Challenge.
Introducing low-cost measures, such as hand
hygiene, staff education and inclusion of basic
principles of infection control in medical and
paramedical curricula can reduce health care
(CONTD. ..)

EPIDEMIOLOGICAL
INTERACTION
HOST FACTORS
Suppressed immune system
due to Age, Poor nutritional
status, severity of underlying
disease, complicated diagnostic
& therapeutic procedure ,
therapeutic,
THE AGENT
Varieties of organisms
Institutional and human
Reservoirs & their
THE ENVIRNOMNET
Everything that surrounds the
patient in the hospital is his
environment.
Other patients
Hospital staff and visitors
Eatables
NCI

MAGNITUDE OF HAIS
Both developed and resource-poor countries are faced
with the burden of healthcare-associated infections. In
a World Health Organization (WHO) cooperative study
(55 hospitals in 14 countries), about 8.7% of
hospitalized patients had nosocomial infections.
Overall, 1.4 million people worldwide are suffering
from nosocomial infections, & in India alone, the
nosocomial infection rate is at over 25-30%.

About 25-36% of these infections are preventable
through the adherence to strict guidelines by health care
workers when caring for patients.
Prolonged stay not only increases direct costs to patients
or payers but also indirect costs due to lost work.
The increased use of drugs, the need for isolation & the
use of additional laboratory & diagnostic studies also
MAGNITUDE OF HAIS
(CONT.…)

A 6-year surveillance study from 2002-2007 involving
intensive care units (ICUs) in Latin America, Asia, Africa,
and Europe, revealed
higher rates of central-line associated blood stream
infections (BSI),
ventilator associated pneumonias (VAP),
and catheter-associated urinary tract infections
MAGNITUDE OF HAIS
(CONT.…)

The estimated rate in USA was 4.5% in 2002
CDC prevalence of 7.1% in European countries.
MOHFW – India is unable to report the burden. In addition
the limited number of studies in these settings has been
published in the scientific literature
Consolidated data on device associated infection from
India has been published as a part of the INICC study
(Annals of Internal Medicine 2006). All the hospitals were
private, corporate hospitals, and fails to reflect the actual
scenario.
MAGNITUDE OF HAIS
(CONT.…)

THE INANIMATE ENVIRONMENT CAN
FACILITATE TRANSMISSION

Viruses
Bacteria
Fungi
Parasites
ALL MICROORGANISMS CAN CAUSE
NOSOCOMIAL INFECTIONS

Gram +ve
Staphylococcus aureus
Staphylococcus epidermidis
Gram -ve
Enterobacteriaceae
Pseudomonas aeruginosa
Acinetobacter baumanni
Mycobacterium tuberculosis
BACTERIA

Pseudomonas
aeruginosa
Enterococcus
Coag-neg staphylococcl
E-coli
Staphylococcus aureus
Other
COMMON BACTERIAL AGENTS
(9%)
(10%)
(11%)
(12%)
(13%)
(45%)

Viruses
•Blood borne
infections : HBV,
HCV, HIV
•Others: rubella,
varicella, SARS
Fungi
•Candida
•Aspergill
us

Urinary tract infections (UTI)
Surgical wound infections (SWI)
Lower respiratory infections
Traumatic wounds and burns infections
Primary bacteremia
Gastrointestinal tract
Central nervous system
TYPES OF INFECTIONS

MAJOR TYPES OF NOSOCOMIAL
INFECTIONS
0
5
10
15
20
25
30
35
Overall ICU
UTI
Pneumonia
SWI
Bloodstream
Other

MODE OF TRANSMISSION
Contact/hand borne (most
common)
Aerial route or air borne
Oral route
Parenteral route
Vector borne

Direct (physical contact)
 Hands & clothing
 Droplet contact followed by
autoinoculation
 Clinical equipment
Indirect via contaminated articles
 Bedpans,
 bowls, jugs,
 Instruments like needles,
 dressings,
 contaminated gloves, etc.
1. CONTACT (MOST COMMON)

2. Airborne Transmission
 Droplet respiratory secretions on surfaces
 Inhalation of infectious particles
e.g. (TB, Varicella)
3. Oral route
4. Parenteral route
5. Vector borne: through mosquitoes,

COMMON
INFECTIONS
Following are the most common
nosocomial infections:
* Urinary tract infection
* Catheter associated infection
* Pneumonia
* Blood stream infections

PROBLEMS OF NOSOCOMIAL
INFECTIONS
Nosocomial infections will
become more important as
public health problems as it
causes,
* Nosocomial suffering
* Prolonged hospital stay
* Increase the cost of care

SURGICAL SITE INFECTIONS
* They are frequent
* The definition is mainly clinical
(purulent discharge around wounds
or the insertion site of drain, or
spreading cellulites from wounds)
* The infections can be exogenously
or endogenously

NOSOCOMIAL
PNEUMONIA
The most important are patients on ventilators in
ICU.
Recent and progressive radiological opacities of the
pulmonary parenchyma, purulent sputum and
recent onsite fever.
Most commonly caused by acino bacter.

NOSOCOMIAL BACTERAEMIA
The incidence is increasing particularly
for certain organisms such as multi
resistance coagulase negative
staphylococcus and candida.
Infections may occurs at the skin entry
site of the IV device or in the sub
cutaneous path of catheter.

URINARY TRACT
INFECTIONS
It is the most common cause
of nosocomial infections
80% of the infections are
associated with indwelling
catheters.

PREVENTION AND
CONTROL
Prevention and control of nosocomial
infections can be done by the
following ways:
ISOLATION
Designed to prevent transmission of
microorganisms by common routes in
hospitals.
Because agent and host factors are
more difficult to control, interruption
of transfer of microorganisms is

Sterilization
Sterilization of all reusable
equipment's such as
ventilator,
humidifier and
any device that come in
contact with the respiratory
tract.

The hands are the most
important
vehicle of transmission of
Nosocomial Infections

Why
Don’t Staff
Wash their
Hands
? ? ?
? ?

WHY NOT?
Skin irritation
Inaccessible hand washing
facilities
Wearing gloves
Too busy
Lack of appropriate staff
Being a physician
(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital
Epidemiology. Vol. 21 No. 6 Page 381)

HAND HYGIENE TECHNIQUES
1. Alcohol hand rub
2. Routine hand wash 10-15 seconds
3. Aseptic procedures 1 minute
4. Surgical wash 3-5 minutes

Repeatproceduresuntilhandsareclean
ROUTINE HAND WASH

AREAS MOST FREQUENTLY MISSED
HAHS © 1999

HAND CARE
Nails
Rings
Hand creams
Cuts & abrasions
“Chapping”
Skin Problems

Hand hygiene is the simplest,
most effective measure for
preventing hospital-acquired
infections.

HOSPITAL INFECTION
PREVENTION
STRATEGIES

STANDARD PRECAUTIONS
Guidelines recommended by the CDC and
Prevention for reducing the risk of
transmission of blood-borne and other
pathogens in hospitals.

OCCUPATIONAL HEALTH
PROGRAM
All health care workers should be assessed by an
occupational heath team prior to commencing work.
This assessment should include:
Immunisations- hep B vaccine.
screening HCW’s who perform exposure prone
procedures for blood borne viruses.

PATIENT PLACEMENT
HCW’s should include the potential for
transmission of infectious agents in patient
placement decisions
Where possible, place patients who contaminate
the environment or cannot maintain appropriate
hygiene in isolation rooms with en suite toilet
facilities etc.

USE OR PERSONAL PROTECTIVE
EQUIPMENT
Face protection mask
gloves
Aprons/ gowns
Eye wear
shoes

BARRIER NURSING
The aim is to erect a barrier to the passage of
infectious pathogenic organisms between the
contagious patient & other patients & staff in the
hospital, and hence to the outside world.
The nurses, attending consultants as also any
visitors must wear gowns, masks, and sometimes
rubber gloves and they observe strict rules that

PREVENTION OF ENVIRONMENT TO
PATIENT TRANSMISSION-
ENVIRONMENT DECONTAMINATION
Cleaning of hospital environment. This may be achieved
by classifying areas into one of four hospital zones-
Zone A: no patient contact. Normal domestic cleaning (e.g.
administration, library).
Zone B: care of patients who are not infected, and not
highly susceptible. Cleaning with detergent solutions.

Zone C: infected patients (isolation wards). Clean with a
detergent/disinfectant solution, with separate cleaning
equipment for each room.
Zone D: highly-susceptible patients (protective isolation)
or protected areas such as operating suites, delivery
rooms, intensive care units, premature baby units,
casualty departments and haemodialysis units.

PATIENT CARE EQUIPMENT &
DECONTAMINATION OF MEDICAL
DEVICES:
All patient equipments must be thoroughly cleaned prior
to use on another patient/resident. They can be
disinfected or sterilised as per hospital guidelines.
Disinfection procedures must
 meet criteria for killing of organisms
 have a detergent effect
 act independently of the number of micro-organisms

MANAGEMENT OF HEALTH CARE RISK
WASTE
Ensure safe waste management.
Treat waste contaminated with blood, body fluids,
secretions and excretions as clinical waste, in accordance
with local regulations.
Human tissues and laboratory waste that is directly
associated with specimen processing should also be
treated as clinical waste.

MANAGEMENT OF NEEDLE STICK
INJURIES (NSI) AND BLOOD AND
BODY FLUID EXPOSURE:
Use care when:
Handling needles, scalpels, and other sharp
instruments or devices.
Cleaning used instruments.
Disposing of used needles and other sharp
instruments.

SAFE INJECTION PRACTICES
All injections should be prepared in a clean area.
This area must not be used for disposing of used
needles and syringes, handling blood samples, or any
material contaminated with blood or body fluids
An aseptic technique must be used when drawing up
injections
Needles, syringes and cannula are sterile, single use

Use single dose vials wherever possible
Do not use single dose vials for multiple patients
Wear a surgical mask when placing a catheter or
injecting material into the spinal canal or subdural
space
SAFE INJECTION PRACTICES
(CONT..)

MANAGEMENT FOR PREVENTION OF HIV
AFTER NEEDLE STICKS
(POST EXPOSURE PROPHYLAXIS)
It is most effective if started 1- 2 hours after exposure
Can be given up to 72 hours after exposure
Should NEVER be given without medical follow-up and
filing an incident report because of the serious side
effects, and the need to try to prevent similar injuries
Must be taken for 28 days.
Pregnant staff can take PEP drugs.
Staff member on PEP should avoid sex or practice safe

RESPIRATORY HYGIENE AND
COUGH ETIQUETTE
Persons with respiratory symptoms should use source
control measures:
Cover their nose and mouth when coughing/sneezing
with tissue or mask, dispose of used tissues and masks,
and perform hand hygiene after contact with respiratory
secretions.
Health-care facilities should:
Place acute febrile respiratory symptomatic patients at

Post visual alerts at the entrance to health-care
facilities instructing persons with respiratory
symptoms to practise respiratory hygiene/cough
etiquette.
Consider making hand hygiene resources, tissues
and masks available in common areas and areas used
for the evaluation of patients with respiratory illnesses.
RESPIRATORY HYGIENE AND COUGH
ETIQUETTE
(CONT.…)

LAUNDRY CARE
Laundry should be handled and transported in a
manner that prevents transmission of micro-
organisms to other patients, or the environment
Staff handling soiled linen should wear gloves and a
disposable plastic apron.
Segregation and transportation of used laundry
should be in accordance with the biomedical waste

ENVIRONMENT
Health services — including public and private hospital
services — must meet quality standards (ISO 9000 and
ISO 14000 series).
An infection control team member should participate on
the planning team for any new hospital construction or
renovation of existing facilities.
The role of infection control in this process is to review
and approve construction plans to ensure they meet

WHY SURVEILLANCE?
NCI cause of morbidity and mortality
One third may be preventable
Surveillance = key factor
an infection control measure
overview of the burden and distribution of
NCI
allocate preventive resources

OBJECTIVES
Reducing infection rates
Establishing endemic
baseline rates
Identifying outbreaks
Identifying risk factors
Persuading medical
personnel
Evaluate control measures
Satisfying regulators
Document quality of care
Compare hospitals’ NCI
rates.

THE SURVEILLANCE LOOP
Event
Action
Data
Information
Health care
system
Surveillance
centre
Reporting
Feedback,
recommendations
Analysis,
interpretation

CONSIDERATIONS WHEN
CREATING A SURVEILLANCE
SYSTEM
Goal of the surveillance
system (why)
Engage the stakeholders
(who)
Available resources
Surveillance method
(what, how, when)
definition
what to collect
how to collect (operation of

WHO
All hospitals?
All departments?
All specialties?
Other health institutions?

There are 3 principal goals for hospital infection
control & prevention programs:
1. Protect the patients
2. Protect the health care workers, visitors, and others
in the healthcare environment.
3. Accomplish the previous two goals in a cost
effective and cost efficient manner, whenever
GOALS FOR INFECTION CONTROL AND
HOSPITAL EPIDEMIOLOGY

The purpose of standard precautions is to break
the chain of infection focusing particularly but not
exclusively on the mode of transmission, portal of
entry and susceptible host sections of the chain.

 observance of aseptic technique
 frequent hand washing especially between patients
 careful handling, cleaning, and disinfection of
fomites
 where possible use of single-use disposable items
 patient isolation
 avoidance where possible of medical procedures
PREVENTION & CONTROL OF
NOSOCOMIAL INFECTIONS

Various institutional methods such as air filtration
within the hospital.
Appropriate isolation precautions to protect patients,
visitors and HCWs.
Surveillance for common infections, monitoring of high
risk patients, and hospital area to identify outbreaks,
PREVENTION & CONTROL OF
NOSOCOMIAL INFECTIONS (CONT.)

UTTERMOST CARE SHOULD BE TAKEN
IN FOLLOWING SERVICES:
House keeping
Dietary services
Linen and laundry
Central sterile supply department
Nursing care
Waste disposal
Antibiotic policy
Hygiene and sanitation

THE 5 PILLARS OF INFECTION
CONTROL
Isolation&barrier
precautions
Decontaminationof
equipment
Prudentuseof
antibiotics
Handwashing
Decontaminationof
environment

INFECTION CONTROL
COMMITTEE (ICC):
The hospital ICC is charged with the responsibility for
the planning, evaluation of evidenced-based practice
and implementation, prioritization and resource
allocation of all matters relating to infection control.

INFECTION CONTROL TEAM
Infection Control Nurse
(ICN)Infection Control Doctor (ICD)

INFECTION CONTROL TEAM
Should consist of individuals who are specialists in
infection control or contributing to it in any way.
public health specialists,
microbiologists,
epidemiologists,
nursing administration &
infection control physicians.

ROLE OF INFECTION
CONTROL TEAMS
surveillance and research,
developing and assessing policies and practical
supervision, evaluation of material and products,
control of sterilization and disinfection,
Implementation of training programmes.
support and participate in research and assessment
programmes at the national and international levels

INFECTION CONTROL
RESPONSIBILITY
Role of hospital
management-
Leadership
Establishing HICC
Identify appropriate
resources & apply them for
prevention of HAIs
Education and training of
Role of the physician
complying with the practices
approved by the ICC.
notifying cases of HAI.
obtaining appropriate
microbiological specimens
when an infection is present or
suspected

Role of microbiologist
developing guidelines for appropriate collection,
transport, and handling of specimens
 ensuring laboratory practices meet appropriate
standards
performing antimicrobial susceptibility testing
following internationally recognized methods.
monitoring sterilization, disinfection and the

Role of the pharmacist
dispensing anti-infectious drugs and maintaining records
 obtaining and storing and dispensing vaccines or sera,
 providing the Antimicrobial Use Committee and Infection
Control Committee with summary reports and trends of
antimicrobial use
 having available the information on disinfectants, antiseptics
and other anti-infectious agents

Role of nursing staff-
maintaining hygiene, consistent with
hospital policies and good nursing practice
on the ward
 monitoring aseptic techniques.
 reporting infection in patients
 limiting patient exposure to infections
from visitors, hospital staff, other patients,
 maintaining a safe and adequate supply of
ward patient care supplies.
Role of CSSD-
clean,
decontaminate,
test,
prepare for use, sterilize,
and
store aseptically all sterile
hospital equipment.
BMW management.

Role of the food service
defining the criteria for the
purchase of foodstuffs,
equipment use, and cleaning
procedures
ensuring that the equipment
used and all working and
storage areas are kept clean
 issuing written policies and
instructions for handwashing,
clothing, staff responsibilities
and daily disinfection duties
Role of laundry service
ensuring appropriate flow of
linen, separation of “clean”
and “dirty” areas
recommending washing
conditions (e.g. temperature,
duration)
ensuring safety of laundry
staff through prevention of
exposure to sharps or

HOSPITAL INFECTIONS SOCIETY(HIS)
The HIS-India (HISI) is an association of medical professionals
with a special interest in the prevention & control of hospital
infection. It is registered with Registrar of Societies at Delhi.
Founded in 1991, the society presently has 450 members.
Vision- Every Indian hospital has a functioning infection
control programme.
Mission statement- HISI provides the essential tools, education
materials & communication that unite HISI members and foster

OBJECTIVES:
Advance medical knowledge and disseminate information
on the subject of Hospital Infections and their prevention
Provide individuals and institutions with information and
assistance to form hospital Infection control programmes
and similar activities.
Gather and disseminate information about Hospital
Infections and their prevention in both technical and
practical aspects.
Hold training courses and educational symposia, seminars
on all aspects of Hospital Infections.
Form liaison with similar associations at national and

CURRENT CHALLENGES
AND RECOMMENDATIONS
FOR THE FUTURE

Indian ICUs show high HAI rates; possible reasons for
this include the absence of a legal framework for
infection control programs or their implementation,
restricted funds, low nurse-to-patient ratios,
overcrowded wards and insufficient supplies.
Only a small part of the Indian healthcare industry is
advanced enough to incorporate effective solutions to
prevent HAIs in their setup, the general population
CURENT CHALLENGES

CURRENT CHALLENGES (CONT…)
The Government can be most effective in controlling
HAI by implementing mandatory surveillance of HAI for
the entire country, updating guidelines for the
accreditation of hospitals, and requiring a mandatory
presence of infection control teams in hospitals.
All hospitals should have software and forms to
collate data, which can be analysed by a set of

There should be separate team of doctors and nurses
to diagnose all of the cases of HAI.
Every health care facility should have an antimicrobial
use programme.
The goal should be to ensure effective and
economical prescribing to minimize the selection of
resistant microorganisms.
CURRENT CHALLENGES (CONT…)

This committee should involve in prescribing policies,
reviews and approves practice guidelines, audits
antibiotic use, oversees education, and interacts with
pharmaceutical representatives.
As far as the availability of equipment is concerned,
India has most of it. But, the need is to properly utilize
available resources.
CURRENT CHALLENGES (CONT.…)

CONCLUSION
We must change the culture of clinical care in India.
This will come by mandatory reporting of HAI and it
is the consumer who must push for it.
Clinicians, health system leaders, payers, purchasers,
and above all, patients need to demand care that is
proven to be effective as a condition of delivering,
paying for, or receiving it.
A time has come, when we need to move together,

REFERENCES
Centre for disease control and prevention. Hospital associated infections.
http://www.cdc.gov/HAI/prevent/prevention.html
International nosocomial infection control consortium. www.inicc.org
Prevention of hospital-acquired infections: A practical guide. 2nd edition.
WHO/CDS/CSR/EPH/2002.12
Hospital infection society of India.
High prevalence of multidrug-resistant MRSA in a tertiary care hospital of northern India.
Hare Krishna Tiwari, Darshan Sapkota, Malaya Ranjan Sen.November 2008, 2008:1 57 – 61.
http://www.apiindia.org/pdf/medicine_update_2012/infectious_disease_14.pdf
Am J Infect Control. 2010 Mar;38(2):95-104.e2. doi: 10.1016/j.ajic.2009.12.004.
International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-
2008, issued June 2009.
Chemotherapy. 1988;34(6):553-61.
Study on the efficacy of nosocomial infection control (SENIC Project): results and

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