Infection control concept

1. Infection control concept Dr Hania Al-Jouzy Head of neonatal department Hoy Family Hospital 2008

2. Historical perspectives

3. Historical perspectives • Nosocomial infection have been a serious problem ever since sick patients were first congregated in hospitals. • Florence Nigtingales 1854. • Ignas Semmelwies 1847.

4. Does Handwashing Work?Semmelweis - 1847 • Month births mortality % • April3125718.3 • May2943612.2 • June26862.4 • July25031.2

5. Historical perspectives • 1940 widespread use of antibiotics revolutionized the treatment of infectious diseases. • 1950 a pandemic of Staph. aureus struck hospitals in USA. • 1958 first national conference on the control of staphylococcal disease. • 1963 the first international conference was held on institutionally acquired infection.

6. Historical perspectives • 1968 Americans set up the concept of infection control nurse & set up training courses of infection control nurses. • 1970 first international committee on nosocomial infection. [Strong recommendations to adopt certain policies and strategies by all hospitals]. • 1974 a nation wide study was conducted by CDC to evaluate the effectiveness of policies adopted in 1970. • 1976, [legislation]

7. Historical perspectives • The main lesson derived from the past is that preventing, surveillance & controlling nosocomial infection requires: • Organised management system. • Dedicated personnel to influence the behavior of medical & paramedical workers.

8. Why a big problem ? • The concentration of patients in one place offers many potential routes for transmission of harmful bacteria between patients, and from the environment to patients. • Nosocomial infections are a major problem, estimated to affect 10-12% of hospitalized patients. • They have significant effects on mortality, mean length of patient stay and antibiotic usage.

9. Big problem ? • Aprpoximately 10% of American hospital patients (about 2 million every year) acquire a clinically significant nosocomial infection. • Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections.MMWR, February 25, 2000 / 49(07);138

10. Big problem ? • The cost of hospital-acquired infections has been estimated at $4.6 billion. • It contributed to more than 88,000 deaths , one death every 6 minutes. • The U.S. Institute of Medicine ranked health care-associated infection in the top ten causes of death • CDC national infection surveillance system

11. Reasons the problem exists: • Nosocomial infections are the result of three factors : • high prevalence of pathogens • high prevalence of compromised hosts • efficient mechanisms of transmission from patient to patient* • *this is also known as chains of transmission .

12. The six links in the chain of infection • causative agent. • reservoir host. • portal of exit. • mode of transmission. • portal of entry. • susceptible host

13. Transmission • There are three different ways to transmit diseases: Contact Transmission (Direct and Indirect Contact with an Infected Person) Direct contact includes touching, sexual contact, blood, and body fluids Indirect contact includes clothing, dressings, equipment used in care and treatment Droplet & Airborne Transmission

14. Breaking the Chain of Infection. How? • Healthcare workers are expected to follow various policies and procedures aimed at breaking the links in the chain of infection. • Specific strategies are employed. • Evidence based medicine

15. Transmission Contaminated hands (dirty hands) are the most common means of spreading infections or diseases.

16. Breaking the Chain of Infection. • Hand hygiene is considered a top infection-control measure. • But poor compliance continues.

17. Breaking the Chain of Infection. One of the most important methods for breaking the chain of infection is asepsis & using aseptic practices to prevent the transmission of pathogens.

18. So How can you prevent the spread of infection? •  The Centers for Disease Control and Prevention (CDC) suggests the following measures to reduces the spread of infectious diseases. • Wash your hands properly . • Routinely clean and disinfect surfaces. • Sterilisation of materials used in hospitals. • Handle and prepare food safely. • Get immunized. • Use antibiotics appropriately.

19. The 4 questions ? • Which Nosocomial Infections Are Emerging? • Who Is Affected by Emerging Nosocomial Pathogens? • Why Are Nosocomial Infections Emerging Now? • How Can We Prevent and Control Emerging Nosocomial Infections?

20. Which nosocomial infection are emerging? • Historically, staphylococci, pseudomonads, and Escherichia coli have been the nosocomial infection troika. • a cyclical parade of pathogens in hospitals.

21. Which nosocomial infection are emerging? Changing etiology over time • [1940 to 1950] S. aureus caused major nosocomial problems and was the hospital pathogen of major concern. • [1960- 1970s] gram-negative bacilli, particularly Pseudomonas aeruginosa and Enterobacteriaceae, became synonymous with nosocomial infection. • [1980-1990s] methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE) emerged.

22. Which nosocomial infection are emerging? In 1990 to 1996, • The three most common gram-positive pathogens—S. aureus, coagulase-negative staphylococci, and enterococci—accounted for 34% of nosocomial infections. • CNS is becoming the most frequent cause of BSI in NICU (31% in 1992 to 45% in 1999). • The four most common gram-negative pathogens—Escherichia coli, P. aeruginosa, Enterobacter spp., and Klebsiellapneumoniae—accounted for 20%to 32%.

23. Which nosocomial infection are emerging? • In the late 1983 the extended-spectrum β-lactamase (ESBL) bacteria was first described. • ESBL-producing enterobacteria have been frequently implicated in outbreaks in pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs. • 􀁺2000-1 – First UK isolates (Klebsiella)ESBL. • 􀁺2003 onwards – widespread across UK & ather places in the world.

24. Acquired antimicrobial resistance is the major anticipated problem in hospitals • The contribution of antibiotic resistance to excessive death rates in hospitals is difficult to evaluate, but evidence is mounting that antimicrobial resistance contributes to nosocomial deaths.

25. Acquired antimicrobial resistance is the major anticipated problem in hospitals • Once resistant strains of bacteria are present in a population, exposure to antimicrobial drugs favors their survival. • Reducing antimicrobial selection pressure is one key to preventing antimicrobial resistance and preserving the utility of available drugs for as long as possible.

26. Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare Quality Promotion Campaign to Prevent Antimicrobial Resistance Clinicians hold the solution!

27. Who Is Affected by Emerging Nosocomial Pathogens? • The highest infection rates are in intensive care unit (ICU) patients. • Up to 45% of hospital-acquired infections occur in ICU patients, although these patients occupy only 8% of hospital beds. • Nosocomial infection rates in adult and pediatric ICUs are approximately three times higher than elsewhere in hospitals. • Health care associated infection are 5 times higher in the neonatal population [adams-chapman and stoll 2002]

28. NICU infants • Overall neonatal ICU (NICU) patient infection rates are reported to range from 6 to 25%. • Infants with birth weights < 1500 g have significantly higher rates of infection. • The highest risk of infection is seen in patients weighing < 1000 g with more than two invasive interventions.

29. NICU infants why? • All aspects of immune function are impaired in NICU infants, including – -the phagocytic, - humoral, - and reticuloendothelial systems, -as well as the skin barrier, which is immature. Risk factors include • broad-spectrum antibiotic use, intravenous fat emulsions, and use of central lines.

30. Why Are Nosocomial Infections Emerging Now? • Three major forces are involved in nosocomial infections in general . • The first is antimicrobial abuse in hospitals. • Second, many hospital personnel fail to follow basic infection control, such as hand washing between patient contacts. • In ICUs, asepsis is often overlooked in the rush of crisis care. • Third, patients in hospitals are increasingly immunocompromised. • the greater prevalence of vascular access associated bloodstream infections and ventilator-associated pneumonias.

31. Why Are Nosocomial Infections Emerging more in NICU ? • Health care associated infection [HCAI] rates increase in NICU is partly explained by the : • Improved survival rates in neonates. • Increase in invasive monitoring. • Duration of exposure to invasive devices [CVC,MV] • Exposure to broad spectrum antibiotics • TPN • Increased length of stay.

32. Nosocomial infection point prevelance in NICU Study done between 1999-2000 in 31 hospitals USA. 11.4% of NICU acquired nosocomial infection 117 micro-organisms identified

33. How Can We Prevent and Control Emerging Nosocomial Infections? • Infection control can be very cost-effective. • Approximately one third of nosocomial infections are preventable. • To meet and exceed this level of prevention, we need to pursue several strategies simultaneously.

34. How Can We Prevent and Control Emerging Nosocomial Infections? 1985, the Centers for Disease Control and Prevention's (CDC's) Study on the Efficacy of Nosocomial Infection Control reported that hospitals with four key infection control componentreduced nosocomial infection rates by approximately one third . • An effective hospital epidemiologist [local microbiology laboratory] • One infection control practitioner • Active surveillance mechanisms, • Ongoing control efforts [optimal infection prevention programs.]

35. •Infectious diseases specialists are one important resource for providing input, but many other professionals also contribute to optimal care for patients with infections. multidisciplinary collaboration is key!

36. How Can We Prevent and Control Emerging Nosocomial Infections? • Improve national surveillance of nosocomial infections so that we have more representative data. • Develop a system for surveillance. • Assess the sensitivity and specificity of our surveillance & ensure that surveillance used are valid. • Nosocomial infection rate is used as a core indicator of quality of care. • Aggressive antibiotic control programs. • Changing human behaviour .[the biggest challenge might be addressing individuals’ resistance to change. Most people change only if they want to change] • More use of non invasive monitoring devices.

37. Surveillance ? • Problematic? -definitions [maternal vs hospital acquired] -colonization vs infection. - contamination –infection{CNS} • Clear objectives, definitions of infection. • Reliable data collection methods. • Use appropriate denominator. • Stratification [ birth weight] • Are all ICU’s comparable.

38. Infection • Presence of micro-organism in or on a host, with growth and multiplication in the tissues resulting in local cellular injury associated with clinical manifestation or immunologic response. • Taber's Cyclopedic Medical Dictionary defines infection as: " the presence and growth of a microorganism that produces tissue death."

39. Nosocomial infection • The term nosocomial comes from the Greek word that means care that is given to a patient. • Nosocomial infection usually occurs during hospitalization motivated by another pathology or condition by which this infection was not present, and incubation occurred during hospitalization. • This duration should be more than 48 hours after admission.

40. Colonisation • Implies the presence of a micro-organism in or on a host, with growth & multiplication of the micro-organism but without invading the surrounding tissues and causing damage. • This is usually a defensive mechanism that begins at birth and continues as contact is made with people and the environment.

41. Contamination • Transitory presence of micro-organism on body surface [ such as hands] without tissue invasion or physiologic reaction.

42. Carrier • Is an individual colonised with a specific micro-organism and from whom the organism can be recovered [cultured] but who shows no overt expression of the presence of the micro-organism at the time of it is isolated. • A carrier may have a history of previous disease due to the organism. • The carrier state may be transient or intermittent or chronic.

43. Septecemia • Septecemia: [hemia:blood] Systemic disease or clinical signs of generalised inflammation associated with the presence and persistence of pathogenic micro-organism and or their products in the blood. • Blood poisoning.

44. Bacteremia • Bacteremia: The presence of bacteria in the blood. • Refer to bloodstream invasion that may be associated with fever but no other signs or symptoms of circulatory compromise or end-organ malperfusion or dysfunction.

45. Conclusion •Preventing infections •Effective diagnosis and treatment •Optimizing antimicrobial use [use antibiotics wisely ] •Finally, preventing transmission of resistant organisms from one person to another is critical to successful prevention efforts.

46. Conclusion All infection control measures will need to continue to pass the test of the "four Ps": • Are the recommendations Plausible biologically (e.g., is it likely to work)? • Are they Practical (e.g., are they affordable)? • Are they Politically acceptable (e.g., will the administration agree)? • And, will Personnel follow them (e.g., can they and will they)? Nosocomial Infection Update Robert A. Weinstein Cook County Hospital & Rush Medical College, Chicago, Illinois, USA

47. Hand washing