health care associated infections debjyoti mohapatra

Presented byDr Debjyoti MohapatraJunior residentDept of Community medicinePt B D Sharma,PGIMS.

Health care associated infections:

The silent pandemic

Contents

• Introduction• Historical perspective• WHO criteria for surveillance of HAIs• Burden and impact of HAIs• Epidemiology of HAIs• Infection control practices• Organization of infection control committee• Conclusion

IntroductionWhat is health care associated infections?

WHO defines it as

‘Health care-associated infections, or “nosocomial infections” are

infections, that affect patients in a hospital or other health-care

facility, and are not present or incubating at the time of admission.

They also include infections acquired by patients in the hospital or

facility but appearing after discharge, and occupational infections

among staff.’

An infection that occurs more than 48 hours after a person is admitted to

the hospital is usually considered to be a healthcare associated infection,

because the person most likely did not have the infection before being

admitted .

They can happen when you are being treated in hospital, at home, in a

GP clinic, a nursing home or any other healthcare facility

Historical perspective

Ignaz Semmelweis (1818-1865)


• Semmelweis worked as a obstretician in Vienna General hospital.


What protected those who delivered outside the clinic from these

destructive unknown endemic influences?• The First Clinic was the teaching service for medical students,

while the Second Clinic had been selected in 1841 for the

instruction of midwives only.

• The first clinic conducted postmortems and dissection and the

students involved in postmortem conduction were also

conducting deliveries.This was not the case in the second

hospital.


Jakob Kolletschka

"cadaverous particles"

Cadaverous particles from the dead body

Cause of childbed fever(puerperial sepsis)

Missing linkHands of health care provider

WHO simplified criteria for surveillance of Health care associated infections

Burden of Health care associated infections

• Limited data availaible due to lack of proper surveillance and reporting.

Out of 100 hospitalized patients,7 in developed countries*10 in developing countries*

Acquire at least one health care-associated infection.

*World Health Organization:Health care associated infection:fact sheet;2010:WHO


• At any time Prevalence of HAI

In developed countries vary between3.5 to 12%

In middle and low income countries it varies from 5.7 to 19.1%.

Urinary tract infection is the most common HAI in developed countries.

In low and middle income countries it is surgical site infection.

World Health Organization:Health care associated infection:fact sheet;2010:WHO


• In high-income countries, approximately 30% of patients in

intensive care units (ICU) are affected by at least one health

care-associated infection.

• In low- and middle-income countries the frequency of ICU-

acquired infection is at least 2-3 fold higher than in high-

income countries; device-associated infection densities are up

to 13 times higher than in the USA.

World Health Organization:Health care associated infection:fact sheet;2010:WHO

Impact of health care associated infections

• Prolonged hospital stay.• Long term disability.• Massive additional financial burden,both for

the patient and the health care system.• Extra burden on caretaker.• Unnecessary sufferings and deaths.

Epidemiology of health care associated infections

Microbiological agent:endogenous exogenous

Environmental factors:Hospital location,overcrowding, invasive diagnostic procedure, surgical devices,exposure to other infected patients or HCP.

Intrinsic host suceptibility:age,poor nutritional status,debilitated condition,decreased immunity

Overuse and irrational use of antibiotics

Modes of transmissionContact transmission is the most common and most preventable means of

transmission.

• Direct contact involves body surface to body surface contact with a physical

transfer of microorganisms.

• Indirect contact (cross-contamination) involves body surface contact with a

contaminated intermediate object.

Droplet transmission Droplets containing microorganisms from an infected person are

propelled through the air and land on the mouth, eyes, or nose of another person.

Transmitted upto a distance of less than 3 feet.

Droplets are generally more than 5 micron in size.

Example. Bordetella pertussis , influenza virus , adenovirus , rhinovirus ,mumps

Mycoplasma pneumoniae , SARS-associated coronavirus (SARS-CoV) , group A

streptococcus and Neisseria meningitidis ,

Modes of transmission

Airborne transmission. Airborne transmission occurs by dissemination of either

airborne droplet nuclei or small particles in the respirable size range(less than 5

micron) containing infectious agents that remain infective over time and distance.

Examples Mycobacterium tuberculosis , rubeola virus (measles) , and varicella-

zoster virus(chickenpox) ,anthrax.

Common vehicle transmission refers to contaminated items such as food, water,

medications, devices, and equipment.

Examples include food(salmonella),blood(hepatitis b,hepatitis

c),water(V.cholerae)

Infection control practicesInfection control practices can be grouped in two categories

(1)standard precautions;

(2)additional (transmission-based) precautions

Standard precautions

These include the following:• hand washing and antisepsis (hand hygiene);• use of personal protective equipment when handling blood, body

substances, excretions and secretions;• appropriate handling of patient care equipment and soiled linen;• prevention of needlestick/sharp injuries;• environmental cleaning and spills-management; and• appropriate handling of waste.

Hand hygiene

Five moments of hand hygiene

Hand hygiene

• Alcohol based solution for handrub Major constituents:Ethanol or isopropanol or n-propanol or a

combination of above.

May also contain small amounts of • hexachlorophene,• quartenary ammonium compounds,• povoidine iodine,

• chlorhexidine.

Before hand washing:• Remove jewellery (rings, bracelets) and

watches• ensure that the nails are clipped short (do not

wear artificial nails),• roll the sleeves up to the elbow

Personal protective equipments

• Provides a physical barrier between micro-organisms and the wearer

Personal protective equipment includes:• gloves• protective eye wear (goggles)• mask• apron• gown• boots/shoe covers and• cap/hair cover

Personal protective equipmentsPrinciples of use: Personal protective equipment should be chosen according to the risk

of exposure. Avoid any contact between contaminated (used) personal protective

equipment and surfaces, clothing or people outside the patient care area.

Discard the used personal protective equipment in appropriate disposal bags, and dispose of as per the policy of the hospital.

Do not share personal protective equipment. Change personal protective equipment completely and thoroughly wash hands each time you leave a patient to attend to another patient

or another duty.

Disinfection and sterilization

Critical items : Must be sterilized

Critical items confer a high risk for infection if they are contaminated with any

microorganism.

This category includes surgical instruments, cardiac catheters, implants, and ultrasound

probes used in sterile body cavities.

Semicritical Items: Must be disinfected with atleast high level

disinfectant(sterilization if possible)

Semicritical items contact mucous membranes or nonintact skin.

This category includes respiratory therapy and anesthesia equipment, some

endoscopes, laryngoscope blades esophageal manometry probes,

cystoscopes 25, anorectal manometry catheters,. These medical devices should be free

from all microorganisms; however, small numbers of bacterial spores are permissible

Classifications of disinfectants High level disinfectants:Should be virucidal, bactericidal, tuberculocidal, fungicidal

and sporicidal.Must act rapidly

eg-Glutaraldehyde,per-acetic acid, ortho phthalaldehyde,formaldehyde(7.5%).

Intermediate level disinfectants:Inactivates vegetative bacteria, most fungi,

mycobacteria, and most viruses (particularly the enveloped viruses) but not bacterial

spores.

ex-ethyl alcohol,isopropyl alcohol,phenolic germicidal.iodophor

Low level disinfectants:Inactivates most vegetative bacteria, some fungi, and some

viruses but cannot be relied on to inactivate resistant microorganisms (e.g.,

mycobacteria or bacterial spores).ex-quarternary ammonium compounds.

Different types of sterilization.

(1) Steam under pressure (moist heat),

(2) Dry heat,

(3) Ethylene oxide,

(4)Plasma sterilization

(5) Gamma Irradiation

Responsibility of laundry services

• Housekeeping and laundry personnel should wear gloves and

other personal protective equipment as indicated when collecting,

handling, transporting, sorting and washing soiled linen.

• When collecting and transporting soiled linen, it should be

handled as little as possible and with minimum contact to avoid

accidental injury and spreading of microorganisms.

• All cloth items (e.g., surgical drapes, gowns, wrappers) used during

a procedure should be considered as infectious.

•Carry soiled linen in covered containers or plastic bags to prevent

spills and splashes, and confine the soiled linen to designated areas

(interim storage area) until transported to the laundry.

•Carefully sort all linen in the laundry area before washing.

•Machine Washing with hot water 70-80 degree or soak in bleaching

powder solution.

Laundry services in PGIMS

Safe injection practices

Safe injection practices

General safety practices• hand hygiene

• gloves where appropriate

• other single-use personal protective equipment

• skin preparation and disinfection.

Perform hand hygiene BEFORE:• starting an injection session (i.e. preparing injection material

and giving injections); • coming into direct contact with patients for health-care related

procedures; • putting on gloves (first make sure hands are dry).

Perform hand hygiene AFTER: • an injection session;• any direct contact with patients; • removing gloves.

Indication of gloves use in injection practices

Skin preparation and disinfection

Occupational risk and management Basic occupational health care:• Testing for HBV,HCV and HIV.• Immunization against HBV.

Prevention of needle stick injury: Elimination of hazard

eliminating all unnecessary injections

removing sharps and needles when possible (e.g. by substituting jet injectors for needles )

Engineering controls

sharps disposal containers,hub cutters.

when possible, use of sharps protection devices for all procedures (devices with needles that retract, sheathe or blunt immediately after use).

Administrative controls :

allocation of resources demonstrating a commitment to health-worker safety;

a needle-stick injury prevention committee;

an exposure control plan

consistent training on the use of safe devices Work practice controls :

no needle recapping;

placing sharps containers at eye level and within arms’ reach;

sealing and discarding sharps containers when they are three quarters full;

establishing means for the safe handling and disposal of sharps devices before beginning a procedure

Health care facility cleaning

Spills management

Biomedical waste management

Steps in the management of hospital waste include:· generation,· segregation/separation,· collection,· transportation· storage,· treatment,· final disposal

Pit for disposal of sharp waste, PGIMS

Additional (transmission-based)precautions

Airborne precautions:• Implement standard precautions• Place patient in a single room that has a monitored negative airflow pressure, and is

often referred to as a “negative pressure room”.• Use of N95 mask.• Limit the movement and transport of the patient from the room for essential

purposes only. If transport is necessary, minimize dispersalof droplet nuclei by masking the patient with a surgical mask.

Droplet precautions• Implement standard precautions• Place patient in a single room.• Wear a surgical mask when working within 1-2 meters of the patient• Place a standard surgical splash proof mask on the patient if transport is necessary• Negative pressure room not essential

Patient placement• Ideally a single room should be used for isolation.

• Minimum distance between beds-1-2feet.(in case single room not

possible)

Cohorting

• For infection control purposes, if single rooms are not available, or

if thereis a shortage of single rooms, patients infected or colonized

by the same organism can be kept together.

Anterooms• Single rooms used for isolation purposes may include an anteroom

to supportthe use of personal protective equipment.

The rise and rise of Super bugs:End of antibiotic era?

MRSA

Vancomycin resistant enterococcus

XDR-TB Carbapenem resistant enterobactericiae

C.difficile

Multidrug resitant A.baumani

This serious threat is no longer a prediction for the future, it is happening right now in every region of the world

and has the potential to affect anyone, of any age, in any country

Organizational structure of a infection control programme in a health facility

Infection control committees Infection control team

Infection control committeeMembers• Heads of clinical departments• Head of microbiology• Head of nursing service• Members of ic team• Incharge of pharmacy• Incharge of support service and facilities• Financial and administrative head of hospital• The medical superitendent should ideally head the committee.

Functions

• develop an infection control programme to ensure the well being of both

patients and staff

• develop annual work plan to assess and promote good healthcare,appropriate

isolation; sterilization; and other practices, staff training,and epidemiological

surveillance

• provide sufficient resources to support the infection control programme

• review risks associated with new technologies before their introduction

• review and provide input into investigation of outbreaks and epidemics• to assess and promote improved practice at all levels of the health facility.• To develop an effective and safe antibiotic policy.

Infection control team• Should consist of a doctor and a nurse for each 150 bed.

• Should be full time employees totally dedicated to infection control

activities

Functions

• To overlook the day to day implementation of infection control programme.

• To have a strict surveillance of any HAIs.

• To ensure availaibilty of supplies and equipments needed for infection

control.

• To overlook into training of staffs

• To report outbreaks

HAI surveillanceTwo types

• Active surveillance-trained personnel,mainly full time

dedicated members of Infection control team assess each

patient for occurrence of any HAI.

• Passive surveillance-Persons who do not have a primary

surveillance role, such as ward nurses,doctors during

routine patient evaluation or respiratory therapists, identify

and report HAI

Conclusion

• Health care associated infections are catastrophic events that can have devastating effects

• The silver lining is the fact that it can be controlled by simple means.

• It is essential for each and every HCP to understand that patients’ come to them with high expectations to get relieve from his/her sufferings and agonies.

• The worst we can do to him/her is to

Start an exchange offer of diseases.

health care associated infections debjyoti mohapatra

Health & Medicine