Surveillance of HAI - Coming of Age

1. The presentation is solely meant for
Academic purpose

3.  Nil

4. MMWR 1999 / 48(29);621-629
Slide - Dr Paul Tambyah

5. 2004:
Annual, intensive,
project-based
control programs
introduced
Chuang YC et al. Secular trends of healthcare-associated infections at a teaching hospital in Taiwan,
1981-2007. J Hosp Infect 2010.

6.  ‘nosocomial infections’
◦ Greek nosos ‘disease’, komien ‘to care for’
◦ Roman military hospital orderlies were called
nosocomi
 ‘hospital-acquired infections’
◦ Introduced by James Simpson (England) in
1830s
◦ Called the problem ‘Hospitalism’
 ‘healthcare-associated infections’ (HAI)
◦ Increasing complexity of healthcare delivery

7. Louis Pasteur: 1822-
1895, French chemist &
microbiologist
Robert Koch: 1843-1910,
German physician

8. Bacteriological era
Post
Miasma theory: origin of Germ theory: infections due
epidemic diseases due to
to microorganisms
noxious form of ‘bad air’
HAIs due to poor HAIs recognized in obstetric,
ventilation & NOT direct
surgical patients and later,
contact
medical patients

9. • Surgeon at obstetric clinic in
Vienna in 1848
 Divided into two clinics,
alternating admissions every
24 hours:
◦ First Clinic: Doctors and
medical students
◦ Second Clinic: Midwives
 doctors taught anatomy in the
mornings, midwives came
from home
http://www.cdc.gov/handhygiene/materials.htm

10. Suggested handwashing
and use of antiseptic
solution for hands and
surgical instruments for
physicians
Hand hygiene basin at the Lying-In
Women’s Hospital in Vienna, 1847.
http://www.cdc.gov/handhygiene/materials.htm
Adapted Slide - Dr Paul Tambyah

11. Maternal Mortality due to Postpartum Infection
General Hospital, Vienna, Austria, 1841-1850
18
16 Semmelweis’ Hand Within 2 years of
Maternal Mortality (%)
14 Hygiene Intervention
12
his idea, forced
10
to quit medicine
8
6
4 Died in asylum
2
0
for the mentally
1841 1842 1843 1844 1845 1946 1847 1848 1849 1850
unstable
MDs Midwives
~ Hand antisepsis reduces the frequency of
patient infections ~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
http://www.cdc.gov/handhygiene/materials.htm

12.  Florence Nightingale (1820-
1910, founder of modern
nursing)
– promoted hospital reform
 Joseph Lister (1827-1912,
British surgeon)
◦ Introduced hand washing and
carbolic acid antisepsis
◦ Infections post limb amputations
47%  15%

13.  You do not find what
you are not looking
for…
 You need to know your
baseline
 You need to know
before someone else
does!
 You want to improve
outcomes for your
patients
Slide - Dr Paul Tambyah

14. • Effectiveness has to be measured
• We want to objectively assess the
impact of interventions
• Measurement is not neutral
• Questions asked are different:
– Patient: which is the best hospital?
• What are my chances of getting bettter?
Worse?
– Doctor: how am I doing?
– Administrator: What is the bottom
line?
Slide - Dr Paul Tambyah

15.  To establish baseline rates of HAI
 To identify outbreaks
 To evaluate the effectiveness of IC prevention
activities
 To identify preventable infections in high-risk
areas
 To help limited resources be more effectively
targeted to high priority areas
Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

16. Slide - Dr Paul Tambyah

17.  National level, surveillance should be
standardized with
◦ standardized case definitions &
◦ surveillance methods
 Local level, surveillance should include
◦ assessment of the local situation
◦ selection of appropriate methods
◦ reporting
Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

18.  Alert microorganism surveillance can be
done if:
◦ there is a good microbiology laboratory
◦ support from the clinicians
◦ support from senior management
 Simplest forms of surveillance:
◦ Mortality, a very crude measure of quality
◦ Readmission rates per surgical procedure or
per ICU admission
◦ Periodic point prevalence surveillance can be
used to monitor the effectiveness of IC
measures
Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

19.  US CDC’s National Health and Safety Network
(NHSN) definition:
◦ Widely used as most widely disseminated and readily
available
◦ interpretation and application may not be easy
 International Nosocomial Infection Control
Consortium (INICC)
◦ first multinational, collaborative HAI control program
◦ established to control HAIs in hospitals in limited
resource countries
◦ founded in Argentina in 1998
◦ network of 173 ICUs in 25 countries
Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

20.  “…a healthcare associated infection (HAI) is a
localized or systemic condition resulting from
an adverse reaction to the presence of an
infectious agent(s) or its toxin(s) that was not
present on admission to the acute care
facility.”
◦ All factors satisfying CDC/NHSN
 site-specific infection criterion
 1st present on or after 3rd day of hospitalization
◦ Purpose of definition: NHSN surveillance
CDC. Identifying Healthcare-associated Infections (HAI) in NHSN. Jan 2013

21.  CDC/NHSN major and specific types of HAI
◦ Bone and joint infection
◦ Bloodstream infection
◦ CNS
◦ CVS infection
◦ Eye, ear, nose, throat or mouth infection
◦ GI system infection
◦ Lower respiratory infection, other than pneumonia
◦ Pneumonia
◦ Reproductive tract infection
◦ SSI
◦ Skin and soft tissue infection
◦ Systemic infection
◦ UTI
◦ Ventilator-associated event
CDC. CDC/NHSN Surveillance Definition of Healthcare-associated Infection and Criteria for Specific Types of Infections
in the Acute Care Setting. Jan 2013.

22. Goal of NHSN AUR module:
- “…to provide a mechanism for facilities to report
and analyze antimicrobial use and/or resistance as
part of local or regional efforts to reduce
antimicrobial resistant infections through
antimicrobial stewardship efforts or interruption of
transmission of resistant pathogens at their facility”
CDC. Antimicrobial Use and Resistance Module. Jan 2013

23.  HAIs can be caused by endogenous or
exogenous sources:
◦ Endogenous – body sites eg. skin, nose, mouth, GIT
or vagina
◦ Exogenous – external to patient eg. patient care
personnel, visitors, patient care equipment, medical
devices or healthcare environment
CDC. Identifying Healthcare-associated Infections (HAI) in NHSN. Jan 2013

24. Rosenthal, Maki,Graves
AJIC 2008;36:e1-12

25. Features of the International Nosocomial Infection
Control Consortium Hospitals and Intensive Care
Units*
Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

26. Ventilator-Associated Pneumonia in the
International Nosocomial Infection Control
Consortium Intensive Care Units*
Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

27. Central Venous Catheter-Associated Bloodstream Infections in the International
Nosocomial Infection Control Consortium Intensive Care Units*
Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

28. Comparison of Device Use and Rates of Device-Associated Infection in the
Intensive Care Units of the International Nosocomial Infection Control
Consortium and of the U.S. National Nosocomial Infection Surveillance System*
Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

29.  173 ICUs in Latin America, Asia, Africa and
Europe.
 6 year study, data from 155,358 patients
 Device utilization in the developing countries’
ICUs remarkably similar to US
 Some HAIs markedly higher in the ICUs of the
INICC hospitals:
◦ CLABSIs: 7.6% vs 2.0 per 1000 central line days
◦ VAP: 13.6 vs 3.3 per 1000 ventilator days
Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

30.  Hospitals were
originally set up for
the sick and dying
among the poor
 The wealthy had
physicians go to
their homes to
provide care
 Hospitals were
widely and correctly
perceived as
dangerous places
Pittet et al http://www.hopisafe.ch
Slide - Dr Paul Tambyah

31.  7 year old boy with
acute leukemia,
finishing chemotherapy
in remission
 Was admitted after his
last course of
chemotherapy with
fever
 Had Clostridium
difficile infection
(Antibiotic associated
colitis)
 Also developed
bloodstream and soft
tissue infection
Slide - Dr Paul Tambyah

32.  Blood cultures
persistently positive
 Debrided in ICU as he
was too sick for
surgery
Slide - Dr Paul Tambyah

33. Hsu LY et al,
Emerg Infect Dis
2007;13:1944-7
Slide - Dr Paul Tambyah

34. Hsu LY et al, Emerg Infect Dis 2007;13:1944-7 Slide - Dr Paul Tambyah

35. Slide - Dr Paul Tambyah

36. Clin Infect Dis 2007:44:1107
Slide - Dr Paul Tambyah

37. Clin Infect Dis 2007:44:1107
Slide - Dr Paul Tambyah

38. Slide - Dr Paul Tambyah

39. NEJM, 2012

40.  ‘…no evidence that financial disincentives
reduced infection rates.
 As CMS continues to expand this policy to
cover Medicaid through the Affordable Care
Act, require public reporting of NHSN data
through the Hospital Compare website, and
impose greater financial penalties on
hospitals that perform poorly on these
measures, careful evaluation is needed to
determine when these programs work, when
they have unintended consequences and what
might be done to improve patient outcomes.’
Lee GM et al. NEJM 2012