Nosocomial infection and its surveillance

Nosocomial infection and its surveillance

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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  A patient withpneumonia visited a health care centre for treatment and was admitted to the hospital. After 10 days of admission, this patient developed UTI. In this case, all of the following could be the most probable source of infection except: a) Patient visitors b) Hospital staffs c) Hospital devices used in the process of treatment d) His home place Shyam Kumar Mishra
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  Nosocomial infection Shyam KumarMishra Assistant Professor, Institute of Medicine Shyam Kumar Mishra
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  Etymology - In Greek,nosocomialis = hospital Nosokomos (nosos = disease, komeo = to take care of) • Related to hospital, so it is also termed as ‘Hospital Acquired Infection (HAI)’ • Now, new term ‘’Health-care associated infection’’ Shyam Kumar Mishra
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  Nosocomial infection Any clinicallyrecognizable microbiologic disease that affects the patients as a consequences of his being admitted to the hospital or attending for treatment or acquired from hospital staff as a consequence of their works whether or not the symptoms of disease appear while the affected person is in the hospital (WHO). A localized or systemic condition that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and that was not present or incubating at the time of admission to the hospital. (Center for Disease Control) Shyam Kumar Mishra
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  • Those infectionswhich are a result of treatment in a hospital or hospital like setting but secondary to the patients' original condition. Infections are considered nosocomial if they first appear 48 hours or more after hospital admission or within 30 days after discharge. • For most bacterial nosocomial infections usually become evident after 48 hours (i.e., the typical incubation period) or more after admission. However, because the incubation period varies with the type of pathogen and to some extent with the patient's underlying condition, each infection must be assessed individually for evidence that links it to the hospitalization.Shyam Kumar Mishra
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  History Dr. Ignaz Semmelweis ShyamKumar Mishra
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  Florence Nightingale • At1863 established the importance principle of nursing, hospital design and hygiene. • Quoted remark in her book Notes on Hospitals. Shyam Kumar Mishra
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  Joseph Lister Father ofantiseptic surgery Shyam Kumar Mishra
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  Even today,HAI hasbeen the problem both in developed and developing world. Its' explanation could be any one or more of the following: • Hospitals receive large numbers of sick people and whose immune systems are often in a weakened state. • Medical staff move from patient to patient without washing their hands in-between, providing a way for pathogens to spread. • Many medical procedures bypass the body’s natural protective barriers. • Unnecessary use of antimicrobial agents in hospitals creates selection pressure for the emergence of resistant strains • Other factors like hospitals age, infrastructure repairs and renovations will create risks of airborne diseases caused by dust and spores released during demolition and construction. Shyam Kumar Mishra
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  Hospital persons Hospital person Surgical Procedures Air Food Medication Devices, Drains, Catheters Water Fomites Insects Patients’ normal flora Visitors Otherpatients Shyam Kumar Mishra
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  Chain of infection ShyamKumar Mishra
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  Nosocomial infectionNosocomial infectionShyamKumar Mishra
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  Shyam Kumar Mishra
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  SOURCES OF HOSPITAL INFECTIONS A.Exogenous - Other patients or personsor persons (cross-infection)(cross-infection) - Health care workers - Hospital environment . -. - Inanimate objectsInanimate objects (fomites) vehicle(fomites) vehicle Inanimate environment of the hospital that acts as an important source comprises (a) Contaminated air, water, food (b) Contaminated equipments and instruments (c) Soiled linen (d) Hospital waste (Biomedical waste) B. EndogenousB. Endogenous source is the normalsource is the normal flora or colonizers offlora or colonizers of skin and other epithelialskin and other epithelial surfaces transient orsurfaces transient or residentsresidents Shyam Kumar Mishra
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  Factors influencing thenosocomial infections A. The microbial factors - Characteristics of microorganisms - Amount of inoculum - Virulence - Bacterial resistance B. Host factors : Patient susceptibility, immune status, Underlying disease, the extreme of life (old age, infancy). Patients with chronic disease (Leukemia, DM, TB, Renal disease) C. Environmental factors Crowded conditions, contaminate objects, water ,food D. Diagnostic and therapeutic intervention E. Intensive care units – Medical, surgical, neonatal, burn units Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  IMPORTANT EXTRINSIC RISKFACTORS FOR MAJOR NOSOCOMIAL INFECTIONS INFECTIONS RISK FACTORS Urinary tract Indwelling catheter Duration of catheterization Pneumonia Endotracheal tube Mechanical ventilation Thoracoabdominal surgery Nasogastric tube Surgical wound Pre operative stay Preoperative shaving Duration of surgery Degree of wound contamination Presence of foreign body Primary bacteremia Intravascular cannula Duration of cannulation Shyam Kumar Mishra
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  Risk factors forHA-UTI • Duration of catheterization • Long hospital stay • Diabetes • Malnutrition • Female sex • Improper catheter care Shyam Kumar Mishra
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  ● Previous antibioticexposure, particularly to third generation cephalosporins ● Reintubation or prolonged intubation ● Mechanical ventilation ● Age >70 years ● Chronic lung disease ● Decreased consciousness ● Chest surgery ● Presence of an nasogastric tube Risk factors for HAP Shyam Kumar Mishra
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  • Diabetes • Over60 years of age • Long duration of the surgical procedure • Pre-existing infection at the site of the wound • Systemic corticosteroids or treatment with other immunosuppressive drugs • Malnutrition • Preoperative nasal carriage or colonization at other sites with S. aureus • Presence of a remote focus of infection • Duration of preoperative hospitalization • Preoperative preparation, shaving of hair from the site Risk factors for SSI Shyam Kumar Mishra
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  Mortality rate dueto Nosocomial infection (Argentina, 2003) Types of infection (%) Urinary Tract Infection 5.0 Catheter-related Blood stream infection 25.0 Ventilator-associated Pneumonia 35.0 Rosenthal VD, Guzman S, Orellano PW. Am J Infect Control 2003;31:291-5.Shyam Kumar Mishra
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  Length of hospitalstay due to nosocomial infection TYPES OF INFECTION EXTRA DAYS EXTRA COST (US $) Pneumonia 5.9 5683 Blood stream 7.4 3517 Surgical site 7.3 3152 Urinary tract 1.0 680 All 4.0 2100 Emori TG, Gaynes RP. Clin Microbiol Rev 1993;6:429-442. Shyam Kumar Mishra
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  Agents OF HAIAgentsOF HAI Virtually all microorganisms can cause nosocomial infectionsVirtually all microorganisms can cause nosocomial infections Bacteria is the most common cause of nosocomial infection • BacteriaBacteria • VirusesViruses • FungiFungi • ParasitesParasites Gram-positive bacteriaGram-positive bacteria Staphylococcus aureusStaphylococcus aureus Staphylococcus epidermidisStaphylococcus epidermidis Enterococcus faecalisEnterococcus faecalis Gram-negativeGram-negative EnterobacteriaceaeEnterobacteriaceae Pseudomonas aeruginosaPseudomonas aeruginosa Acinetobacter baumanniAcinetobacter baumanni Mycobacterium tuberculosisMycobacterium tuberculosis VirusVirus HBV, HCV, HIVHBV, HCV, HIV Others: CMV, rubella, varicella,Others: CMV, rubella, varicella, SARS, Rota virusSARS, Rota virus FungiFungi CandidaCandida AspergillusAspergillus Shyam Kumar Mishra
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  Antimicrobial resistance 1945 –Penicillin 1948 – Penicillin-resistant S.aureus 1959 – Methicillin 1960s - Beta lactamase enzyme, Temoniera (TEM) 1961 – Methicillin-resistant S. aureus 1983 - ESBL in Germany 1988 - Amp C Beta lactamase in Canada-Vancover 1990s – MBL 1996 - VISA in Japan reduced susceptibility to Vancomycin in S. aureus 2002 – Vancomycin-resistant S.aureus Shyam Kumar Mishra
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  Surveillance Shyam Kumar Mishra
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  • Surveillance canbe defined as the systematic, active on- going observation of the occurrence and distribution of a disease within a population and of the events that increase or decrease the risk of the disease occurrence. If the incidence, distribution and associations of a disease are known, then resources can be targeted, predisposing factors can be reduced or eliminated, and the incidence of the disease reduced. Shyam Kumar Mishra
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  Why surveillance??? • Toreduce the incidence of HAI and thus to reduce the associated morbidity, mortality, and costs. – To assess magnitude of problem – To monitor implementation of health programs – To understand local epidemiology of the problem – To assess changes in trend of disease or its distribution – To identify specific groups at risk – To enable predictions about pattern of occurrence of diseases – To assess the impact of the programme intervention for control of diseases Shyam Kumar Mishra
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  SURVEILLANCE METHOD ACTIVE PASSIVE ShyamKumar Mishra
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  Formal surveillance (each patientto be assessed, often repeatedly, by trained staff) (very expensive) Therefore, surveillance is often done routinely by analysing laboratory reports, or by informal ward visits, or by a combination of the two. However, laboratory reports are not always indicative of true infection. Negative reports (or no report) do not always mean infection is absent. Nevertheless, active surveillance (case finding by the Infection Control Nurse increased detection from approximately 25% of defined infections to more than 85% in some studies.Shyam Kumar Mishra
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  Incidence and prevalenceof HAI • The prevalence of HAI is the number of cases of active HAI in a defined patient population either during a specified period of time (the period prevalence) or at a specified point in time (point prevalence). • The incidence of HAI is the number of new cases of disease that occur in the defined patient population during a specified time period. Shyam Kumar Mishra
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  Targeted surveillance • Site-orientedsurveillance • Unit-oriented surveillance • Priority-oriented surveillance – Alert-condition surveillance – Alert-organism surveillance Shyam Kumar Mishra
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  Patient-based surveillance a) CountHAI, assess risk factors, and monitor patient care procedures and practices for adherence to infection control principles b) Requires ward rounds and discussion with caregivers Laboratory-based surveillance a) Detection is based solely on the findings of laboratory studies of clinical specimens Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  Prospective surveillance a) Monitorpatients during their hospitalization b) For SSIs, also monitor during the post-discharge period Retrospective surveillance a) Identify infections via chart reviews after patient discharge Shyam Kumar Mishra
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  Risk-adjusted rates a) Ratesare controlled for variations in the distribution of major risk factors associated with an event’s occurrence b) Such rates allow inter- and intra-facility rate comparisons Crude rates a) Rates assume equal distribution of risk factors for all events b) Such rates cannot be used for inter-facility comparisons Shyam Kumar Mishra
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  Data to collect 1.Demographic – name, date of birth, gender, hospital identification number, admission date 2. Infection – onset date, site of infection, patient care location of HAI onset 3. Risk factors – devices, procedures, other factors associated with HAI 4. Laboratory – pathogens, antibiogram, serology, pathology 5. Radiology/imaging – X-ray, CT scan, MRI, etc. Shyam Kumar Mishra
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  Sources of data 1.Admission/discharge/transfer records, microbiology laboratory records 2. Visits to patient wards for observation and discussion with caregivers 3. Patient charts (paper or computerized) for case confirmation a) Laboratory and radiology/imaging results b) Nursing and physician’s notes and consults c) Admission diagnosis d) History and physical examination findings e) Records of diagnostic and surgical interventions f) Temperature chart g) Information on administration of antibiotics Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  • Most infectiousdisease physicians, infection preventionists and epidemiologists agree that HAIs are under-reported. Why? Shyam Kumar Mishra
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  Post-discharge surveillance oftenposes considerable logistic problems and may add further expense to surveillance activities. Shyam Kumar Mishra
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  • Surveillance withoutaction should be abandoned. • Perform follow-up surveillance to monitor for improvement following changes (“close the loop”). SurveillanceSurveillance ReviewReview DisseminationDissemination ActionAction Shyam Kumar Mishra
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  Two components ofsampling 1. From persons engaged within the hospital – Doctor – Nurses – Ward attendant etc. 2. Environmental samples: – water – air sample – I.V. catheters – I.V.fluids – Sutures used in the hospital Other suspected objects – floors – walls – surfaces – sanitary, basins, sinks etc. Shyam Kumar Mishra
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  EPIDEMIOLOGICAL MARKERS FORNOSOCOMIAL INFECTION • Biotyping • Antibiogram • Serotyping • Bacteriophage typing • Bacteriocin typing • Dienes phenomenon • Bettelheim reaction (colony incompatibility) Shyam Kumar Mishra
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  Shyam Kumar Mishra
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  • Plasmid analysis •RFLP • PCR-RFLP • DNA/DNA hybridization • DNA/RNA hybridization • Pulse field gel electrophoresis • Randomly amplified polymorphic DNA (RAPD) • LCR • Ribotyping • Spoligotyping • MLST • Cloning • Sequencing Shyam Kumar Mishra
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  Prevention of Nosocomial infections There is a Nosocomial infection control committee (NICC) which includes: Matron Physician Surgeon Administrator Microbiologist Medical laboratory technologist Pharmacist House-keeping staff Shyam Kumar Mishra
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   Periodical trainingof staffs regarding nosocomial infection control  Immunizations for the staffs; PEPs  Microbial monitoring of hospital: Periodical exposure of culture plates/ swabbing (wards, ICUs, Operation theatre)  Carrier detection: Microbial culture of Nasal Swab, Hand Swab, Masks & gowns of Surgeons, Physicians, Nurses and other Staffs involved in Patient CareShyam Kumar Mishra
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   Much attentionneeds to be paid to Multidrug resistant (MDR) isolates.  Status of MDR bacterial isolates should be disseminated through scientific conferences, newsletters, journals and personal communication.  Hospital infection control guidelines should be prepared to investigate and control nosocomial infections. Shyam Kumar Mishra
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  Use of color-codedcontainers for segregation of laboratory and hospital wastes Proper disposal of hospital waste products Hospital building must meet ISO standard (Ventilation, Water, Waste) Shyam Kumar Mishra
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  Role of Microbiologist •Developing guidelines for appropriate collection, transport and handling of specimens. • Ensuring that the laboratory practice meet appropriate standards. • Ensuring safe laboratory practice to prevent infections in staff • Perform AST of clinical isolates • Monitor sterilization, disinfection procedures / environment where necessary • Timely communicate results to Infection Prevention Committee • Epidemiological typing of hospital microorganisms • Follow Antibiotic stewardship Shyam Kumar Mishra
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  • Antimicrobial stewardshiprefers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Shyam Kumar Mishra
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  Infection Prevention (IP) “Infectionprevention largely depends on placing the barriers between a susceptible host and microorganisms” Shyam Kumar Mishra
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  HAND WASHING “Hand washingis the most practical procedure for preventing cross- contamination (person to person). Hand washing may be the single most important procedure for preventing infection.” Global handwashing Day (15th October) Shyam Kumar Mishra
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  1. Wash yourhands when they are dirty and BEFORE eating 2. DO NOT cough into your hand 3. DO NOT sneeze into your hands 4. Above all, DO NOT put your fingers into your eyes, nose or mouth Shyam Kumar Mishra
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  HAND WASHING TECHNIQUE Source:World Health Organization. Regional Office for Western Pacific. Shyam Kumar Mishra
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  SIR WILLIAM OSLER- “Soap,Water and common sense are the best disinfectants in the hospital.” Shyam Kumar Mishra
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