Hospital Aquired Infections and infection control in a healthcare setup


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  • : patient to healthcare worker, healthcare worker to patient, and patient to patient
  • Prolongs hospital stay.-An estimated 1 to 4 extra days for a urinary tract infection, 7 – 8 days for a surgical site infection, 7 – 21 days for a blood stream infection, and 7 – 30 days for pneumonia.Extra expenses -The CDC has recently reported that US$5 billion are added to US health costs every year as a result of NI
  • The microbial agent -Developing of clinical disease depends on organisms virulence, infective dose and resistance . Heavy reliance on use of antibiotics leading to resistant strainseg. GPC, GNB, Anaerobic bacteria, Viruses- blood borne , resp, parasites- Giardia, scabiesPatient susceptibilityAge: infants and old age have decreased resistance to infection. Immune status: Patients with chronic diseases as malignancy, leukaemia, diabetes mellitus, renal failure or AIDS have increased susceptibility to infection. Immunosuppressive drugs or irradiationComplicated diagnostic procedures like venepunctures,aspirations,catheterisationetc, Lengthy Surgical proceduresEnvironmental factors-. The infection can be acquired from : other patients, hospital staff and visitors, food, dust and other contaminated inanimate articlesand materials, which subsequently contact susceptible body sites of patients. Inadequate Knowledge of functionaries with regard to hospital infections and aseptic practices. Crowded conditions within hospital, frequent transfers of patients between units, Shortage of nursing personnel, Lack of planning of facilities
  • Remove source of infection -by treating infection in patients, carriers and staffBlock Route of transfer by - High standard of aseptic techniques,Isolation of infected and susceptible patient ,Barrier nursing ,Proper mechanical ventilation ,Special attention to house keeping, cleaning, waste disposal, C.S.S.D and laundry hygiene Increase in resistance of host-by careful handling of tissues, surgery, removal of sloughs and foreign body, control of diabetes, immunization
  • Ancillary facilities - Good and efficient CSSD,Mechanised laundry,Prompt and coordinated system of waste disposal ,Minimum manual handling of food during procurement, preparation and distribution ,Isolationfacilities and reverse isolation facilities in the wards,Procedure manuals for the workers,Regular health check-up of the workers working in sensitive areas,Check on visitors
  • These guidelines were developed for hospitalized inpatients, and the principles can be applied in outpatient settings. Standard - Apply forBlood,All body fluids,Non-intact skin,Mucous membranesTransmission-Based Precautions-Contact Precautions- Apply forGastrointestinal, respiratory, skin, or wound infections, Skin infections that are highly contagious Airborne Precautions- Apply toMeasles,Varicella (including disseminated zoster) ,Tuberculosis Droplet Precautions-Apply toHaemophilusinfluenzae type b,Neisseria meningitidis,Diphtheria (pharyngeal),Mycoplasma pneumonia,Pertussis,Pneumonic plague,Streptococcal,, pharyngitis, pneumonia, or scarlet fever,Serious viral infections spread by droplet transmission, including:,Adenovirus ,Influenza,Mumps,Parvovirus B19,Rubella
  • The concept of Universal Health Precautions emphasizes that all our patients should be treated as though they have potential blood born infections, and can infect the caring health care workers.They were initially designed to minimize risk to staff from unknown carriers of bloodborne pathogens, such as hepatitis B, hepatitis C, or HIV. protecting staff, protect patients , required by federal law and the OSHA Bloodborne Pathogens Standards.Human materials/Tissues considered Highly Infectious: Blood,Semen,Vaginal secretions,C S F,Synovial fluids,Amniotic fluid,All other body fluidsNot Infectious unless contaminated with Blood or Body fluids: Feces,Nasal secretions,Sputum,Sweat,Tears,Urine / Vomitus,Saliva unless blood stained
  • Link to video – 7 steps of hand washing, 5 moments of hand hygieneAlcohol based gels/ rubs have been shown to be more convenient and effective than handwashing,Reduce time,Convenient to carry,Less dryness of hands,More effectiveAgents Used for Disinfection of Hands-,Alcohol ,Iodophores ,ChlorhexidineGluconate ,Phenol Derivatives
  • Use of a pair of disposable gloves can protect if chances of contact with Blood or Body fluid is anticipated/inevitable.Use of Mask, Cap, Eye Wear,Will certainly protect us from splashes of Blood or Body fluids.Wearing foot wear covering entire sole protects the entry of Microbes from the contaminated floors with Blood and Body fluids.
  • All the linen contaminated with Blood or Body fluids should be soaked in 1: 100 bleach solution for 30 minutes.Advised Autoclaving, as the most ideal procedure for decontaminating Linen
  • Active surveillance (Prevalence and incidence studies)Targeted surveillance (site, unit, priority-oriented)Appropriately trained investigatorsStandardized methodologyRisk- adjusted rates for comparisons
  • The exposed site or wound should be washed thoroughly with soap and water.Mucous membranes should be flushed with water.Do not squeeze to increase bleedingDo not produce more injury to the siteDo not panic,Reassure and Counsel about risk,About screening,About PEP
  • Virex – didecyl dimethyl ammonium chlorideFor routine disinfection of surfaces where BMW is handled, use a 1:10 solution of freshly diluted bleach or 1% hypochlorite (ethanol evaporates too quickly!)
  • New Rules 2011 already formulated but still to be notified--8 categories: liquid and incineration ash removed Yellow: Animal, anatomical waste and soiled wasteRed: Microbiology waste, sharps and solid plastic wasteBlue: Chemical waste
  • Hospital Aquired Infections and infection control in a healthcare setup

    2. 2. Goals of Infection Control Training • Ensure that health professionals understand how pathogens can be transmitted in the work environment (patient to healthcare worker, healthcare worker to patient and patient to patient ) • Apply current scientifically accepted infection control principles • Minimize opportunity for transmission of pathogens to patients and healthcare workers
    3. 3. Points to be discussed …………  History of Hygiene  Overview : Hospital Aquired infections (HAI)  Other definitions  Public Health Importance, Consequences  Sources, Routes of Transmission & Factors influencing HAI  Sites and Criteria for HAI  Control of HAI  Take Home Message
    4. 4. History of Hygiene Greek Era : Aristotle recommended Boiling water to armies. Advised the Alexander Semmelweis: Practiced & emphasizes the importance of washing hands with chlorinated water in Obstetrics to reduce maternal mortality
    5. 5. Historical Aspects Changed the History 1867 –Dr. Joseph Lister first identifies airborne bacteria and uses Carbolic acid spray in surgical areas 1880 – Johnson and Johnson introduce antiseptic surgical dressings. Reduction of Hospital associated infections Mortality reduced Morbidity reduced
    6. 6. What are Hospital Acquired Infections ? (Nosocomial Infections, Health Care Associated Infections) Any infection that is not present or incubating at the time the patient is admitted to the hospital This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility
    7. 7. Other definitions Community Acquired Infection An infection Present or Incubating at the time of admission to a health care facility without any association to previous hospitalization at the same facility Colonization The presence of microorganism in or on a host, with growth and multiplication but without tissue invasion or damage Contamination The presence of microorganism on inanimate objects (Clothing, surgical instruments, water, food, milk ) or in substances
    8. 8. Public Health Importance Major public health problem Incidence- 2% to 12% in the developed countries The overall incidence in various hospitals in India varies between 10-20% (inadequately reported/ under reported) The incidence depends on type of hospital, type of patients and the type of surgeries performed.
    9. 9. Consequences of Hospital Infections Prolongs hospital stay. An estimated 1 to 4 extra days for a urinary tract infection, 7 – 8 days for a surgical site infection, 7 – 21 days for a blood stream infection, and 7 – 30 days for pneumonia. Extra expenses US$5 billion are added to US health costs every year as a result of NI The patient suffers bodily mentally and economically. Increase in mortality rate Law suits Technical competence of experienced doctors turned into disaster Quality of care suffers and it leads to bad public image Infected patients are twice as likely to die, twice as likely to spend time in ICU and five times more likely to be readmitted after discharge
    10. 10. Source of HAI  Endogenous : normal flora of the patient- About 50% of N.I.  Exogenous : 1. Other patients and environment 2. Hospital personnel (surgical team/staff) 3. Inanimate objects-Tools, instruments, and materials used 4. Seeding from distant focus of infection (prosthetic device, implants)  Good infrastructures do not mean a safe environment
    11. 11. Routes of Transmission Transmission Contact Transmission Direct Indirect Droplet Transmission Airborne Transmission Common Vehicle Transmission(uncommon) Vector-borne Transmission (uncommon)
    12. 12. Factors Influencing H.A.I. The microbial agent Patient susceptibility Environmental factors
    13. 13.  Urinary tract infection: most common type of N I (30- 40% of reported cases), associated with an indwelling urinary catheter or instrumentation.  Lower respiratory and surgical wound infections are the next ( each about 15%).  Less frequent include bacteraemia (5%), intravenous site infection, gastrointestinal tract and skin infections. Nosocomial Infection Sites
    14. 14. Criteria of Nosocomial Infections Surgical site infection Any purulent discharge, abscess or spreading cellulitis at the surgical site during the month after operation Urinary infection Positive urine culture (1 or 2 species) with at least 100000 bacteria/ml, with or without clinical symptoms Respiratory infection Respiratory symptoms with at least 2 signs: cough; purulent sputum; new infiltrate on chest, appearing during hospitalization Vascular catheter infection Inflammation, lymphangitis or purulent discharge at the insertion site Septicaemia Fever or rigours and at least one positive blood culture
    15. 15. The chain of infection. Source of infection Method of spreading Person at risk Point of entry Breaking this chain by removing any part of it will control or stop the spread of infection
    16. 16. Control of Hospital Infections Infection control is an essential component of care and one which has too often been undervalued Prevention of HAI require a multifaceted approach Three main principles : Remove source of infection Block route of transfer Increase in resistance of host To prevent infection, one must break the chain of infection.
    17. 17. Thus the Control may be through: General measures Special Control measures Infection Control Organisation in Hospitals Surveillance and control programmes Prevention of infections like HIV, Hepatitis B,C in Health Care setting and Health care workers Proper management of waste in hospital
    18. 18. General Measures Personal hygiene Standard Precautions Environmental sanitation Efficient house keeping services Provision of ancillary facilities (Good and efficient CSSD, Mechanised laundry, waste disposal , Minimum handling of food , Isolation and reverse isolation facilities, Procedure manuals, Regular health check-up of the workers, Check on visitors)
    19. 19. Personal hygiene The most important person in this organisation is YOU. You get it right and both you and the organisation will meet all the legal requirements. You get it wrong and someone could become ill: That someone could be YOU.
    20. 20. Isolation Precautions (CDC Recommendations) Four types of precautions, evidence-based recommendations based on the mode of transmission of the organism known or suspected to be present. 1.Standard Precautions Transmission Based Precautions: 2.Contact Precautions 3. Airborne Precautions 4. Droplet Precautions
    21. 21. Standard - Apply for Blood, All body fluids, Non-intact skin, Mucous membranes Transmission-Based Precautions- Contact Precautions- Apply for Gastrointestinal, respiratory, skin, or wound infections, Skin infections that are highly contagious Airborne Precautions- Apply to Tuberculosis ,Measles, Varicella (including disseminated zoster) , Droplet Precautions- Apply to Haemophilus influenzae type b, Neisseria meningitidis, Diphtheria (pharyngeal), Mycoplasma pneumonia, Pertussis, Pneumonic plague, Streptococcal,, pharyngitis, pneumonia, or scarlet fever, Serious viral infections eg. Adenovirus , Influenza, Mumps, Parvovirus B19, Rubella These guidelines were developed for hospitalized inpatients, and the principles can be applied in outpatient settings
    22. 22. Standard Precautions Standard Precautions are to be used with all patients, regardless of diagnosis. formerly known as Universal Precautions #1: Handwashing #2: Gloves #3: Mask, Eye Protection, Face Shield #4: Gown # 5: Patient-care Equipment #6: Environmental Control #7: Linen #8: Sharps #9: Ventilation Devices #10: Patient Placement All our patients should be treated as though they have potential blood born infections
    23. 23. #1: Handwashing Hand hygiene is still the single most important procedure for preventing the spread of infection! (Wash hands with plain soap or waterless antiseptic agent, alcohol-based product)
    24. 24. Words of Wisdom on Hand Washing Soap, water and Common sense are still the Best Antiseptics William Osler
    25. 25. 2,3,4- Personnel safety devices The use of protective gears should be made mandatory for all the personnel if chances of contact with Blood or Body fluid is anticipated/inevitable
    26. 26. # 5: Patient-care Equipment Clean or reprocess reusable equipment before using it for the care of another patient. Ensure that single- use items are discarded properly. # 6: Environmental Control Routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces. #7: Linen Handle, transport, and process used linen soiled with blood or body fluids
    27. 27. #8: Sharps All used needles and sharps should be deposited in puncture resistant containers. Bending, Reshaping, should be prohibited. Do not recap the needles . All used Disposable syringes and needles should be discarded into Bleach solution at the work station before final disposal.
    28. 28. DISPOSAL OF USED NEEDLES AND SYRINGESOF SHARPSDestroy needle Cut syringe tip Decontaminate in twin bucket having 1% bleach SHARPS including catheter guide wires
    29. 29. Dealing with Needle stick Injuries Consider all Needle stick injuries as a serious health hazard in the era of AIDS All events of Needle stick injuries to be reported to the supervisory staff. Wash the injured areas with soap and water. Encourage bleeding if any. Prophylaxis for prevention of HIV/HBV is top priority.
    30. 30. Risk of Transmission – Blood borne viruses Human immunodeficiency virus (HIV) Percutaneous exposure 0.33% Mucocutaneous 0.09% Hepatitis B virus (HBV) Percutaneous exposure sAg 1 – 6% eAg 22 – 31% Hepatitis C virus (HCV) Percutaneous exposure 1.9%
    31. 31. #9: Ventilation Devices Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to- mouth resuscitation methods. #10: Patient Placement Place a patient who contaminates the environment in a private room.
    32. 32. Special Measures Proper planning of OTs and monitoring of its functioning Monitoring Functioning of Nurseries and ICUs Isolation facilities, daily washing, asepsis Infection Oriented training to hospital staff to assess the standards of asepsis, personal hygiene and cleanliness
    33. 33. ORGANIZATION Hospital administrator/head should establish ICC (provides resources for ICP) ICT IC Officer IC Nurse Microbiologist
    34. 34. Hospital Surveillance and Control Programme Weekly Report OPD Reports Bacteriological Reports Discharge Reports Personal Clinics Ward Visits Autopsies Training Programme Regular Reports Infection Committee Investigations CONTROL
    35. 35. Handling , Operating on HIV/High risk groups It is a concern - all should be cared equally. Law may not change for equality but motivated health workers should bring in change of attitude. Adherence of Universal Health precautions bring in safety to all HCW. Follow the precautions even in Non HIV patients as some of our patients are in window period and more dangerous than truly positive with Sero testing. We handle so many patients in emergency situation with out any details.
    36. 36. Post Exposure Management Managing the site Counseling Vaccine and prophylaxis
    37. 37. Post Exposure Management HBV In susceptible HCWs who have never been immunized, the HBV vaccine series and one dose of HBIG at 0.06 ml/kg should be immediately administered. Exposures to nonresponders and hyporesponders to the HBV vaccine require HBIG at the time of exposure Routine follow up should include anti-HBs, anti-HBc, HBsAg, and liver functions tests with repeat at 1 and 6 months. The HCW should be instructed to be aware of the signs and symptoms of acute hepatitis
    38. 38. Importance of Vaccination in Hepatitis B Infection. We have > 400 Million carriers with Hepatitis B infections. Every HCW is at risk of infection. Vaccination is safe - great hope for prevention All HCW’s must take at least three doses of Vaccine, At 0 – 1 – 6 months High risk HCW’s should undergo estimation of anti HB s ( antibodies ) to know whether they were well protected. Never forget to take Hepatitis B Vaccine if You are a HCW
    39. 39. Post Exposure Management of HIV HIV PEP Evaluation Exposure Status of Source HIV+ and Asymptomatic HIV+ and Clinically symptomatic HIV status unknown Mild Consider 2-drug PEP Start 2- drug PEP Usually no PEP or consider 2-drug PEP Moderate Start 2-drug PEP Start 3- drug PEP Usually no PEP or consider 2-drug PEP Severe Start 3-drug PEP Start 3- drug PEP Usually no PEP or consider 2-drug PEP
    40. 40. Handling of Spills & Surface Disinfection • Notify people in the area • Don appropriate PPE • Place absorbent material on spill • Apply appropriate disinfectant 1% hypochlorite– min contact time (30 min) • Pick up material; dispose • Reapply disinfectant and wipe • For large/high hazard spills use 5 % hypochlorite
    41. 41. CATEGORIES OF BIO-MEDICAL WASTE Cate gory Waste type Colour coding Treatment & Disposal 1. Human anatomical Yellow Incineration / deep burial 2. Animal waste Yellow Incineration / deep burial 3 Microbiology & Biotechnology Waste Yellow/ Red Autoclaving/microwaving/ Incineration 4 Waste Sharps White / blue / Translucent puncture proof containers Disinfection by chemical treatment/autoclaving/ Microwaving & mutilation/shredding 5 Discarded medicines and Cytotoxic drugs Black Destruction/ neutralization & disposal in secured landfills
    42. 42. Categor y Waste type Colour coding Treatment & Disposal 6 Soiled waste Yellow/red Incineration / autoclaving/ microwaving 7 Solid ( plastic) Blue/ White/ Red Disinfection by chemical treatment/autoclaving/ Microwaving & mutilation/shredding 8 Liquid waste ------- Disinfection by chemical treatment and discharge into drains 9 Incineration Ash Black Disposal in municipal landfill 10 Chemical Black Chemical treatment and discharge into drains for liquids and secured landfill for solids
    43. 43. Prevention of Urinary tract Infection CDC: Guideline for prevention of catheter-associated urinary tract infections 2009 Avoid catheterization Use intermittent catheterization Decrease duration of catheterization Insert catheters aseptically Maintain a close sterile drainage system Use condom catheter in cooperative patients Maintain gravity drainage Apply topical meatal antimicrobials in women Separate infected and non-infected patients
    44. 44. Prevention of Surgical site infections  Pre-operative  Intra-operative  Post-operative
    45. 45. Preoperative preventive measures Preparation of the patient Hand/ forearm antisepsis for surgical team Antimicrobial prophylaxis
    46. 46. Intra-operative preventive measures Ventilation Cleaning & disinfection of surfaces Sterilization of surgical instruments Surgical attire & drapes Asepsis & surgical technique Normothermia and glucose control
    47. 47. Post-operative incision care Protect with a sterile dressing for 24-48 hrs Wash hands before & after dressing changes & any contact with the surgical site Use aseptic technique when an incision dressing must be changed
    48. 48. Prevention of ventilator associated pneumonia • Standard Precautions (Hand hygiene, Gloving) • Aseptic technique for performing or changing tracheostomy tube • Sterile fluid to remove secretion • Sterile single use catheter if open system suction • Elevation of the head end of bed 30°-45° • Care of oral cavity • Sedation vacation • Spontaneous breathing trial • Oral access to trachea and stomach • EVAC tube for drainage of subglottic secretion
    49. 49. Prevention of Blood Stream Infections CDC: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal catheter site selection, with Subclavian vein as the preferred site for non-tunneled catheters in adults Daily review of line necessity with prompt removal of unnecessary lines Line secure and dressing clean and intact
    50. 50. Staff health promotion and education: 1. HCW are at risk of acquiring infection, they can also transmit infection to patients and other employee. 2. Employee health history must be reviewed, immunizations recommendations to be considered. 3. Release from work if sick, occupation injury must be notified. 4. Continuous education to improve practice, better performance of new techniques.
    51. 51. Infection Control is Responsibility Of
    52. 52. Everyone
    53. 53. Take Home Message ALL Hospitals should implement Infection Control Program
    54. 54. ReferencesPrinciples, And Practices of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe. WHO : Prevention of Hospital aquired infections. A practical guide. 2nd ed. 2002. Computational Fluid Dynamics Applications in Hospital Ventilation Design. The Australian Hospital Engineer 2003; 26(1):35-40. Nosocomial Infections, Burke JP. N Engl J Med. 2003;348:651-656. The direct medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009, R. Douglas Scott II, CDC. CDC: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 CDC: Guideline for prevention of catheter-associated urinary tract infections 2009 CDC: Guideline for prevention of Surgical Site Infections, 1999 Dr. SUMI NANDWANI Associate Professor, Microbiology, E.S.I.C-P.G.I.M.S.R and Hospital, Basaidarapur, New Delhi E Mail