HOSPITAL AQUIRED INFECTIONS &

INFECTION CONTROL IN A HEALTH CARE SETUP

Dr. SUMI NANDWANI

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

Points to be discussed …………

History of HygieneOverview : Hospital Aquired infections (HAI)Other definitionsPublic Health Importance, ConsequencesSources, Routes of Transmission & Factors influencing HAISites and Criteria for HAIControl of HAITake Home Message

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

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

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

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 ContaminationThe presence of microorganism on inanimate objects (Clothing, surgical instruments, water, food, milk ) or in substances

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.

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

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

Routes of TransmissionTransmission Contact Transmission

Direct Indirect

Droplet Transmission Airborne Transmission Common Vehicle Transmission(uncommon) Vector-borne Transmission (uncommon)

Factors Influencing H.A.I.

The microbial agent

Patient susceptibility

Environmental factors

ª Urinary tract infection: most common type of N I (30-40% of reported cases), associated with an indwelling urinary catheter or instrumentation.

ª Lower respiratory and surgical wound infections are the next ( each about 15%).

ª Less frequent include bacteraemia (5%), intravenous site infection, gastrointestinal tract and

skin infections.

Nosocomial Infection Sites

Criteria of Nosocomial InfectionsSurgical site infection Any purulent discharge, abscess or

spreading cellulitis at the surgicalsite during the month after operation

Urinary infection Positive urine culture (1 or 2species) with at least 100000bacteria/ml, with or without clinicalsymptoms

Respiratory infection Respiratory symptoms with at least2 signs: cough; purulent sputum;new infiltrate on chest, appearingduring hospitalization

Vascular catheterinfection

Inflammation, lymphangitis orpurulent discharge at the insertionsite

Septicaemia Fever or rigours and at least onepositive blood culture

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

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.

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

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)

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.

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 PrecautionsTransmission Based Precautions: 2.Contact Precautions3. Airborne Precautions4. Droplet Precautions

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

Standard PrecautionsStandard 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 PlacementAll our patients should be treated as though they have potential blood born infections

#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)

Words of Wisdom on HandWashing

Soap, water and Common sense are still

the Best Antiseptics

William Osler

2,3,4- Personnel safety devicesThe use of protective gears should be made mandatory

for all the personnel if chances of contact with Blood or Body fluid is anticipated/inevitable

# 5: Patient-care EquipmentClean or reprocess reusable equipment

before using it for the care of another patient.

Ensure that single- use items are discarded properly.

# 6: Environmental ControlRoutine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces. #7: LinenHandle, transport, and process used linen soiled with blood or body fluids

#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.

DISPOSAL OF USED NEEDLES AND SYRINGESOF SHARPSDestroy

needle

Cut syringe tip

Decontaminate in twin bucket having 1% bleach

SHARPS including catheter guide wires

Dealing with Needle stickInjuries 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.

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%

#9: Ventilation DevicesUse mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods.

#10: Patient PlacementPlace a patient who contaminates the environment in a private room.

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

ORGANIZATION

Hospital administrator/head

should establish

ICC (provides resources for ICP)

ICT

IC OfficerIC Nurse Microbiologist

Hospital Surveillance and Control Programme

Weekly Report

OPD Reports

Bacteriological Reports

Discharge Reports

Personal Clinics

Ward Visits Autopsies

Training Programm

e

Regular Reports

Infection Committee

Investigations

CONTROL

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.

Post Exposure Management

Managing the siteCounselingVaccine and prophylaxis

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

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

Post Exposure Management of HIVHIV PEP Evaluation

Exposure  Status of Source 

HIV+ andAsymptomatic

HIV+ andClinically 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

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

CATEGORIES OF BIO-MEDICAL WASTECategory

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

Category

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

Prevention of Urinary tract InfectionCDC: 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

Prevention of Surgical site infections Pre-operative

Intra-operative

Post-operative

Preoperative preventive measures

Preparation of the patient

Hand/ forearm antisepsis for surgical team

Antimicrobial prophylaxis

Intra-operative preventive measures

Ventilation Cleaning & disinfection of surfaces Sterilization of surgical instruments Surgical attire & drapes Asepsis & surgical technique Normothermia and glucose control

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

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

Prevention of Blood Stream InfectionsCDC: 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

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.

Infection Controlis

Responsibility Of

Everyone

Take Home Message

ALL Hospitals should implement Infection

Control Program

References Principles, And Practices of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe. www.cdc.gov/cdc.htm www.cdc.gov/ncidod/dhqp/gl_isolation.html. www.his.org.uk www.ific.narod.ru 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 suminandwani@gmail.com