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The presentation is solely meant for Academic purpose
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MMWR 1999 / 48(29);621-629 Slide - Dr Paul Tambyah
Chuang YC et al. Secular trends of healthcare-associated infections at a teaching hospital in Taiwan, 1981-2007. J Hosp Infect 2010.
2004: Annual, intensive, project-based control programs introduced
‘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
Louis Pasteur: 1822-1895, French chemist & microbiologist
Robert Koch: 1843-1910, German physician
Miasma theory: origin of
epidemic diseases due to
noxious form of ‘bad air’
HAIs due to poor
ventilation & NOT direct
contact
Post Bacteriological era
Germ theory: infections due
to microorganisms
HAIs recognized in obstetric,
surgical patients and later,
medical patients
• 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
Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.
http://www.cdc.gov/handhygiene/materials.htm
Suggested handwashing and use of antiseptic solution for hands and surgical instruments for physicians
Adapted Slide - Dr Paul Tambyah
Maternal Mortality due to Postpartum Infection
General Hospital, Vienna, Austria, 1841-1850
0
2
4
6
8
10
12
14
16
18
1841 1842 1843 1844 1845 1946 1847 1848 1849 1850
Ma
tern
al M
ort
alit
y (
%)
MDs Midwives
Semmelweis’ Hand
Hygiene Intervention
~ Hand antisepsis reduces the frequency of
patient infections ~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
http://www.cdc.gov/handhygiene/materials.htm
Within 2 years of his idea, forced to quit medicine Died in asylum for the mentally unstable
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%
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
• 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
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.
Slide - Dr Paul Tambyah
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.
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.
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.
“…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
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.
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
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
Rosenthal, Maki,Graves AJIC 2008;36:e1-12
Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591
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
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
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
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*
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.
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
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
Blood cultures persistently positive
Debrided in ICU as he was too sick for surgery
Slide - Dr Paul Tambyah
Hsu LY et al, Emerg Infect Dis 2007;13:1944-7
Slide - Dr Paul Tambyah
Hsu LY et al, Emerg Infect Dis 2007;13:1944-7 Slide - Dr Paul Tambyah
Slide - Dr Paul Tambyah
Clin Infect Dis 2007:44:1107 Slide - Dr Paul Tambyah
Clin Infect Dis 2007:44:1107
Slide - Dr Paul Tambyah
Slide - Dr Paul Tambyah
NEJM, 2012
‘…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