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Dr.T.V.Rao MD

HOSPITAL INFECTIONS

HEALTH CARE SOLUTIONS 

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MICROBIOLOGY - SCIENTIFIC ERAINFECTION

Anton van Leeuwenhoek (1632-1722) 

• Dutch linen draper

• Amateur scientist

• Grinding lenses, magnifying glasses, hobby

•

First to see bacteria “little beasties” • No link between bacteria and disease

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Ignaz Semmelweis(1818-1865)

• Obstetrician,practised in Vienna

•

Studied puerperal(childbed) fever

• Established that highmaternal mortalitywas due to failure of

doctors to washhands after post-mortems

• Reduced maternalmortality by 90%

•

Ignored and ridiculed bycolleagues

SCIENTIFIC ERA CONTINUED . . . ..

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SCIENTIFIC ERA CONTINUED. . . . .

Louis Pasteur (1822-1895)

• French professor of chemistry

•

Studied how yeasts (fungi) ferment wine andbeer

• Proved that heat destroys bacteria andfungi

• Proved that bacteria can cause infection -the “germ theory” of disease 

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SCIENTIFIC ERA CONTINUED

Robert Koch (1843-1910) 

• German general practitioner

• Grew bacteria in culture medium

• Showed which bacteria caused

particular diseases• Classified most bacteria by 1900

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HOSPITAL ACQUIRED INFECTION

• Infection which was neither present norincubating at the time of admission

•

Includes infection which only becomesapparent after discharge from hospitalbut which was acquired during

hospitalisation.• Also called nosocomial infection

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• Healthcare associated

infections (HCAIs) are

infections transmitted to

patients (and healthcare

workers) as a result of healthcare procedures, in

hospital and other 

healthcare settings.

Recent years have seenan increase in the

awareness of HCAIs, in

particular those caused

by antibiotic-resistant

„superbugs 

WHAT ARE HEALTH CARE ASSOCIATED

INFECTIONS

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•  A wide variety of micro-

organisms can cause

HCAIs, leading to an

extensive range of different diseases.

• Experts estimate that

9% of in-patients have

an HCAI at any one

time.

WHAT ARE HEALTH CARE

ASSOCIATED INFECTIONS ??? 

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HEALTH CARE ASSOCIATED INFECTIONS

AND MICROBES

• HCAIs are mostly caused by bacteria. Bacteria can

exist harmlessly in people, for example on the skin or in

the gut. However, some types of bacteria can cause

HCAIs when they enter the body, for example throughwounds and the use of surgical devices, or when the

body‟s natural balance is disturbed. HCAIs occur in the

lungs (23% of all HCAIs), urinary tract (23%), blood

(6%), skin (11%) and gut. Infections are usually treatedwith antibiotics. However, many bacteria have

developed resistance to antibiotics This can make

infections harder to treat.DR.T.V.RAO MD 9

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• Increasing antibiotic

use. The more

antibiotics are being

used, the more likelybacteria become

resistant to them.

 Antibiotics are

sometimes prescribedfor conditions that are

not treatable with

antibiotics, such as

colds and the „flu.

INCREASED USE OF ANTIBIOTICS

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ANTIBIOTIC RESISTANCE

• Not a new problem - Penicillin in 1944

• Hospital “superbugs” 

• Methicillin Resistant StaphylococcusAureus [MRSA]

• Vancomycin Intermediate Staphylococcus

Aureus [VISA]• Tuberculosis - antibiotic resistant form

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 • Patterns of antibiotic

use. Many people do

not finish their courses

of antibiotics becausethey start feeling better.

This means that

bacteria are not killed

off, so they multiply,become resistant and

transmit to others.

IRREGULAR USE OF ANTIBIOTICS 

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THE NATURE OF INFECTION

• Micro-organisms - bacteria, fungi,viruses, protozoa and worms

• Most are harmless [non-pathogenic]

• Pathogenic organisms can cause

infection• Infection exists when pathogenic

organisms enter the body, reproduce

and cause diseaseDR.T.V.RAO MD 13

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HOSPITAL ACQUIREDINFECTION

• Infection which was neither presentnor incubating at the time of

admission• Includes infection which only becomes

apparent after discharge from

hospital but which was acquired duringhospitalisation

•

Also called Nosocomial infectionDR.T.V.RAO MD 14

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MODES OF SPREADTwo sources of infection:• Endogenous or self-infection - organisms

which are harmless in one site can be

pathogenic when transferred to anothersite e.g., E. coli

• Exogenous or cross-infection - organismstransmitted from another source e.g.,nurse, doctor, other patient,environment (Peto, 1998)

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• Using leftover 

antibiotics to self-

medicate againsta fresh infection

can exacerbate

the problem, asspecific bacterial

infections require

specific antibiotics

USE OF LEFTOVER ANTIBIOTICS

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 • The indiscriminate

use of antibiotics in

livestock has further 

compounded theproblem by

increasing the

likelihood of resistance factors

emerging.

USE OF ANTIBIOTICS IN LIVESTOCK

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• Methicillin-resistant S.

aureus (MRSA) is

resistant to several

antibiotics. Another form of S. aureus,

vancomycin-resistant S.

aureus (VRSA), is

resistant to one of themost powerful, last line

of defence antibiotics,

vancomycin

CONCERNS WITH STAPHYLOCOCCUS

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RESISTANT GRAM NEGATIVE ORGANISMS

RESISTANCE TO MULTIPLE ANTIBIOTICS

ORGANISMS: E .COLI 

PROTEUS

ENTEROBACTER 

 ACINETOBACTER 

PSEUDOMONAS AERUGINOSA

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 • Escherichia coli (E. coli )

has gradually become

resistant to different

types of antibiotics. In2003, the overall

resistance of E. coli to

common amino

penicillin antibioticsreached 47% across

Europe

E.COLI AND EMERGING RESISTANCE

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• Pseudomonas

aeruginosa (P.

aeruginosa) and

Extended SpectrumBeta Lactamase

(ESBL) -producing

bacteria are

increasingly becomingresistant to antibiotics.

PSEUDOMONAS AERUGINOSA

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OBJECTIVES – REDUCING

INFECTIONS• Reducing infection rates

• Establishing endemic baseline rates

• Identifying outbreaks

• Identifying risk factors

• Persuading medical personnel

• Evaluate control measures

• Satisfying regulators

• Document quality of care

• Compare hospitals‟ NCI rates 

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SURVEILLANCE

DR.T.V.RAO MD 23

• Important means of monitoring HAIEarly detection of trends outbreaks

• . Laboratory BasedMicrobiology Laboratory lists +ve organismsICN reviews ‘Alert organisms’ reported 

• 2. Ward Based

Ward staff monitor patientsICN reviews ICN visits wards

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•  All hospitals?

• All departments?

•  All specialties?

• Other health

institutions?

WHO WILL PRACTICE PREVENTIVE

MEASURES

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Surveillance

of 

surgical site

infections

Central

adm.

Local

adm.

ICP

It-

dep.

Surgical

wards

Surgical

ward. 2

PatientsLab

Service

dep.

Ministry

Of health

Directorat

Public

Health

instituteI

….. 

Stakeholders

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PERSONAL PROTECTIVEEQUIPMENT 

•

PPE when contamination or splashing withblood or body fluids is anticipated

• Disposable gloves

• Plastic aprons• Face masks

•

Safety glasses, goggles, visors• Head protection

• Foot protection

• Fluid re ellent ownsDR.T.V.RAO MD 26

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UNIVERSAL PRECAUTIONS• Hand washing

• Personal protective equipment [PPE]• Preventing/managing sharps injuries

• Aseptic technique

•

Isolation• Staff health

• Linen handling and disposal

• Waste disposal

• Spillages of body fluids

• Environmental cleaning

• Risk management/assessment

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WhyDon‟t Staff Wash

their Hands

(Compliance estimated at less than 50%)

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HAND WASHING•

Single most effective action to prevent HAI -resident/transient bacteria

• Correct method - ensuring all surfaces are cleaned -more important than agent used or length of time

taken• No recommended frequency - should be determined

by intended/completed actions

• Research indicates:

• poor techniques - not all surfaces cleaned• frequency diminishes with workload/distance

• poor compliance with guidelines/training

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WHY NOT?• Skin irritation

• Inaccessible hand washing facilities

•

Wearing gloves• Too busy

• Lack of appropriate staff 

• Being a physician 

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection

Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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WHY NOT?

• Working in high-risk areas

•

Lack of hand hygiene promotion• Lack of role model

•Lack of institutional priority

• Lack of sanction of non-compliers

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SUCCESSFUL PROMOTION  

• Education

• Routine observation & feedback

• Engineering controls

• Location of hand basins

• Possible, easy & convenient

•  Alcohol-based hand rubs available• Patient education

(Improving Compliance with Hand Hygiene in Hospitals . Didier Pittet. Infection Control and HospitalEpidemiology. Vol. 21 No. 6 Page 381) 

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• Reminders in the

workplace

•

Promote andfacilitate skin care

•  Avoid understaffing

and excessiveworkload; Nursing

shortages have

caused

SUCCESSFUL PROMOTION 

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 AREAS MOST FREQUENTLY MISSED

HAHS © 1999DR.T.V.RAO MD 34

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HAND CARE• Nails

• Rings

• Hand creams

• Cuts & abrasions

• “Chapping” 

• Skin ProblemsDR.T.V.RAO MD 35

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 • Hand hygiene is

the simplest, most

effective measurefor preventing

hospital-acquired

infections.

HAND HYGIENE

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• Prevention• correct disposal in

appropriate container

• avoid re-sheathing needle

• avoid removing needle

• discard syringes as singleunit

• avoid over-filling sharpscontainer

•

Management• follow local policy forsharps injury (May, 2000)

SHARPS INJURIES

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WASTE DISPOSAL• Clinical waste - HIGH risk

• potentially/actually contaminated waste includingbody fluids and human tissue

•  yellow plastic sack, tied prior to incineration

• Household waste - LOW risk

• paper towels, packaging, dead flowers, otherwaste which is not dangerously contaminated

• black plastic sack, tied prior to incineration

• Follow local policy (May, 2000)

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SPILLAGE OF BODY FLUIDS•

PPE - disposable gloves, apron• Soak up with paper towels, kitchen roll

• Cover area with hypochlorite solution e.g.,

Milton, for several minutes

• Clean area with warm water anddetergent, then dry

• Treat waste as clinical waste - yellow plastic sack 

•

Follow local policyDR.T.V.RAO MD 39

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H.A.I. IS INCREASING: compromised patients

ward and inter-hospital transfers

antibiotic resistance (MRSA, resistant Gram negatives)

increasing workload 

staff pressures

lack of facilities

? lack of concernHAI is inevitable but some is preventable (irreducible minimum)

realistically reducible by 10-30%

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  • Journal of Infection Prevention 

is the professional publication of 

the Infection Prevention Society.

The aim of the journal is to

advance the evidence base in

infection prevention and control,and to provide a publishing

platform for all health

professionals interested in this

field of practice. The journal is a

bi-monthly peer-reviewedpublication containing a wide

range of articles: Original primary

research studies, Qualitative and

quantitative studies,.

JOURNAL OF INFECTION PREVENTION

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CONSEQUENCES OF HOSPITAL

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CONSEQUENCES OF HOSPITAL

INFECTIONS ???

Hospital Pathogen Unhappy

patients

Unhappy

director 

Hospital Surveillance Happy

PatientsHappy

director DR.T.V.RAO MD 42

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Programme created by Dr.T.V.Rao MD for 

Medical and Paramedical Professionals in theDeveloping World

Email

doctortvrao@gmail.com