Hospital Acquired Infections

1. Hospital acquired infectionsour role in prevention, and personal safety Dr.T.V.Rao MD Dr.T.V.Rao MD

2. Microbiology - scientific era 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 Dr.T.V.Rao MD

3. Scientific era continues . . . . . Ignaz Semmelweiss (1818-1865) • Obstetrician, practised in Vienna • Studied puerperal (childbed) fever • Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems • Reduced maternal mortality by 90% • Ignored and ridiculed by colleagues Dr.T.V.Rao MD

4. Scientific era continues . . . . . Louis Pasteur (1822-1895) • French professor of chemistry • Studied how yeasts (fungi) ferment wine and beer • Proved that heat destroys bacteria and fungi • Proved that bacteria can cause infection - the “germ theory” of disease Dr.T.V.Rao MD

5. Scientific era continues . . . . . Joseph Lister (1827-1912) • Scottish surgeon • Recognised importance of Pasteur’s work • Concerned about infection of compound fractures and post-operative wounds • Developed carbolic acid spray to disinfect instruments, patient’s skin, surgeon’s skin • Largely ignored by medical colleagues Dr.T.V.Rao MD

6. Scientific era continues Robert Koch (1843-1910) • German general practitioner • Grew bacteria in culture medium • Showed which bacteria caused particular diseases • Classified most bacteria by 1900 Dr.T.V.Rao MD

7. Defining a Nosocomial infection • A nosocomial infection (nos-oh-koh-mi-al), also known as a hospital-acquired infection or HAI, is an infection whose development is favored by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff. Such infections include fungal and bacterial infections and are aggravated by the reduced resistance of individual patient Dr.T.V.Rao MD

8. Infection which was neither present nor incubating at the time of admission Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation (Rcn, 1995) Also called nosocomial infection When you say Hospital acquired infection Dr.T.V.Rao MD

9. When the Hospital acquired infections increase • Nosocomial infections are commonly transmitted when hospital officials become complacent and personnel do not practice correct hygiene regularly. Also, increased use of outpatient treatment means that people who are hospitalized are more ill and have more weakened immune systems than may have been true in the past. Moreover, some medical procedures bypass the body's natural protective barriers. Since medical staff move from patient to patient, the staff themselves serve as a means for spreading pathogens. Essentially, the staff act as vectors. Dr.T.V.Rao MD

10. Sources of Hospital acquired infections • 1.Patients own flora - Endogenous (50%) Autoinfection ( Greatest source of potential danger)2.Environment - Exogenous(15%) (Air-5%; Instruments-10%) 3.Another Patient/Staff - Cross Infection (35%) Dr.T.V.Rao MD

11. H.A.I. are INCREASING: in 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% Dr.T.V.Rao MD

12. 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 disease Dr.T.V.Rao MD

13. Staphylococci - wound, respiratory and gastro-intestinal infections Escherichia coli - wound and urinary tract infections Salmonella - food poisoning Streptococci - wound, throat and urinary tract infections Proteus - wound and urinary tract infections (Peto, 1998) HAI - common bacteria Dr.T.V.Rao MD

14. HAI - common viruses • Hepatitis A - infectious hepatitis • Hepatitis B - serum hepatitis • Human immunodeficiency virus [HIV] - acquired immunodeficiency syndrome [AIDS] (Peto, 1998) Dr.T.V.Rao MD

15. Two sources of infection: Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998) Modes of spread Dr.T.V.Rao MD

16. Spread - entry and exit routes • Natural orifices - mouth, nose, ear, eye, urethra, vagina, rectum • Artificial orifices - such as tracheostomy, ileostomy, colostomy • Mucous membranes - which line most natural and artificial orifices • Skin breaks - either as a result of accidental damage or deliberate inoculation/incision. Dr.T.V.Rao MD

17. Source/reservoir of micro-organisms infected person [host] or other source Method of transmission hands, instruments, clothing, coughing, sneezing, dust etc. Point of entry orifices, mucous membranes, skin Susceptible host low resistance to infection. Chain of infection Dr.T.V.Rao MD

18. Cdc estimates major infections are caused common microbes • According to the CDC, the most common pathogens that cause nosocomial infections are Staphylococcus aureus, Pseudomonas aeruginosa, and E. coli. Some of the common nosocomial infections are urinary tract infections, respiratory pneumonia, surgical site wound infections, bacteremia, gastrointestinal and skin infections. Dr.T.V.Rao MD

19. Other etiological agents in nosocomial infections • Nosocomial infections are not just limited to bacteria; certain fungi such as Candida albicans and aspergillus, as well as, viruses such as Respiratory Syncytial Virus and influenza have also been implicated in a number of hospital acquired infections. Dr.T.V.Rao MD

20. Not a new problem - Penicillin in 1944 Hospital “superbugs” Methicillin Resistant Staphylococcus Aureus [MRSA] Vancomycin Intermediate Staphylococcus Aureus [VISA] Tuberculosis - antibiotic resistant forms on rise Antibiotic resistance Dr.T.V.Rao MD

21. Discovered in 1981 Found on skin and in the nose of 1 in 3 healthy people - symptomless carriers Widespread in hospitals and community Resistant to most antibiotics When fatal - often due to septicaemia MRSA Dr.T.V.Rao MD

22. MRSA • Discovered in 1981 • Found on skin and in the nose of 1 in 3 healthy people - symptomless carriers • Widespread in hospitals and community • Resistant to most antibiotics • When fatal - often due to septicaemia Dr.T.V.Rao MD

23. IMPLICATIONS OF BIOFILM INFECTIONS • Total resistance to host defenses Highly resistant to antimicrobials Involve antimicrobial resistant organisms • High rate of exchange of resistant plasmids • Rapid development of antimicrobial resistance Dr.T.V.Rao MD

24. Hospital acquired infection continues .. • Incidence of 10% • Effective hand washing is the most effective preventative measure • Dirty wards and re-use of disposable equipment also blamed Dr.T.V.Rao MD

25. Improving hospitals and reducing infections a priority Dr.T.V.Rao MD

26. Devised in US in the 1980’s in response to growing threat from HIV and hepatitis B Not confined to HIV and hepatitis B Treat ALL patients as a potential bio-hazard Adopt universal routine safe infection control practices to protect patients, self and colleagues from infection Universal infection control precautions Dr.T.V.Rao MD

27. 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 Universal precautions Dr.T.V.Rao MD

28. Healthcare workers can get 100s to 1000s of bacteria on their hands by doing simple tasks like: pulling patients up in bed taking a blood pressure or pulse touching a patient’s hand rolling patients over in bed touching the patient’s gown or bed sheets touching equipment like bedside rails, overbed tables, IV pumps Many Personnel Don’t Realize When They Have microbes on Their Hands Casewell MW et al. Br Med J 1977;2:1315 Ojajarvi J J Hyg 1980;85:193 Dr.T.V.Rao MD

29. 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 Hand washing Dr.T.V.Rao MD

30. Working in high-risk areas Lack of hand hygiene promotion Lack of role model Lack of institutional priority Lack of sanction of non-compliers Why we are not washing hands ??? Dr.T.V.Rao MD

31. Optimal “hand hygiene” requirements • Running water: large washbasins which require little maintenance, with ant splash devices and hands-free controls products: soap or antiseptic depending on the procedurefacilities for drying without contamination (disposable towels if possible). • For hand disinfection: specific hand disinfectants: alcoholic rubs with antiseptic and emollient gels which can be applied to physically clean hands Dr.T.V.Rao MD

32. 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 Hospital Epidemiology. Vol. 21 No. 6 Page 381) Successful Promotion  Dr.T.V.Rao MD

33. SKIN ANTISEPSIS: A 2 STEP PROCESS • Disinfect clean skin with an appropriate antiseptic before insertion and at the time of dressing changes. • A 2% chlorhexidine ispreferred. Dr.T.V.Rao MD

34. PPE when contamination or splashing with blood or body fluids is anticipated Disposable gloves Plastic aprons Face masks Safety glasses, goggles, visors Head protection Foot protection Fluid repellent gowns Personal protective equipment Dr.T.V.Rao MD

35. Sharps injuries • Prevention • correct disposal in appropriate container • avoid re-sheathing needle • avoid removing needle • discard syringes as single unit • avoid over-filling sharps container • Management • follow local policy for sharps injury (May, 2000) Dr.T.V.Rao MD

36. Sepsis - harmful infection by bacteria Asepsis - prevention of sepsis Minimise risk of introducing pathogenic micro-organisms into susceptible sites Prevent transfer of potential pathogens from contaminated site to other sites, patients or staff Follow local policy of your hospital Aseptic technique Dr.T.V.Rao MD

37. Single room or group Source or protective Source - isolation of infected patient mainly to prevent airborne transmission via respiratory droplets respiratory MRSA, pulmonary tuberculosis Protective - isolation of immune-suppressed patient (May, 2000) Significant psychological effects (Davies et al, 1999) Isolation Dr.T.V.Rao MD

38. Risk of acquiring and transmitting infection Acquiring infection immunisation cover lesions with waterproof dressings restrict non-immune/pregnant staff Transmitting infection advice when suffering infection Report accidents/untoward incidents Follow local policy (May, 2000) Staff health Dr.T.V.Rao MD

39. Bed making and linen changing techniques Gloves and apron - handling contaminated linen Appropriate laundry bags Avoid contamination of clean linen Hazards of on-site ward-based laundering NHS Executive guidelines (1995) Follow local policy of your hospital Linen handling and disposal Dr.T.V.Rao MD

40. Clinical waste - HIGH risk potentially/actually contaminated waste including body fluids and human tissue yellow plastic sack, tied prior to incineration Household waste - LOW risk paper towels, packaging, dead flowers, other waste which is not dangerously contaminated black plastic sack, tied prior to incineration Follow local policy of your Hospitals Waste disposal Dr.T.V.Rao MD

41. 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 and detergent, then dry Treat waste as clinical waste - yellow plastic sack Follow local policy (May, 2000) Spillage of body fluids Dr.T.V.Rao MD

42. Recent concern regarding poor hygiene in hospital environments (NHSE, 1999) Some pathogens survive for long periods in dust, debris and dirt Poor hygiene standards - hazardous to patients and staff (May, 2000) Report poor hygiene to Domestic Services (UKCC, 1992) “Hospitals should do the sick no harm” (Nightingale, 1854) Environmental cleaning Dr.T.V.Rao MD

43. No risk of contact/splashing with blood/body fluids - PPE not required Low or moderate risk of contact/splashing - wear gloves and plastic apron High risk of contact/splashing - wear gloves, plastic apron, gown, eye/face protection (Rcn, 1995) Cerebrospinal fluid, peritoneal fluid, pleural fluid, synovial fluid, amniotic fluid, semen, vaginal secretions, and Any other fluid containing visible blood e.g., urine, faeces (Rcn, 1995) Risk assessment Dr.T.V.Rao MD

44. In spite many developments in medicine and asepsis hand washing still the best solution Hand hygiene is the simplest, most effective measure for preventing hospital-acquired infections. Dr.T.V.Rao MD

45. Dr.T.V.Rao MD

46. Ways to overcome the nosocomial infections • Besides, hospitals need to have infection control committees to conduct outcome and process surveillance for nosocomial infections. This committee should meet regularly and publish the results of their surveillance. At the same time, healthcare institutions should adopt new and better technology, like closed system IV fluids, in order to reduce the rates of infections. Further, training the paramedical staff on various aspects of HAIs and measures of infection prevention will help tremendously in reducing the morbidity & mortality resulting from nosocomial infections. Dr.T.V.Rao MD

47. Ignaz Semmelweis in 1847 demonstrated that washing hands saves lives Old bacteria are causing new problems New viral and prion diseases are causing new problems Reluctance to wash hands still the single most important cause of HAI (ICNA, 1998) Growing concern about poor hospital hygiene Basic hygiene is key to control infections Dr.T.V.Rao MD

48. Let us support our hospitals with clean hands Dr.T.V.Rao MD

49. go through the manual published by WHO • Prevention of hospital-acquired infections A practical guide 2nd edition WorldHealth Organization Department of Communicable Disease, Surveillance and Response Dr.T.V.Rao MD

50. http://www.icna.co.uk/ http://www.nursing-standard.co.uk/ http://www.medscape.com/ http://www.anes.uab.edu/medhist.htm http://www.shef.ac.uk/~nhcon/ http://medweb.bham.ac.uk/nursing/ http://www.healthcentre.org.uk/hc/library/default.htm On line information Internet sites Dr.T.V.Rao MD