Hospital Infections

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Hospital Infections

• The Burden, Prevention and Control
• Prof. Abdulkarim Al-Aska
• Infectious Diseases Unit,
• King Khalid University Hospital

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Definition

• Hospital acquired Nosocomial
• Occurring after admission
• Neither presenting or incubating at the time of
  admission
• Occasionally the illness may develop weeks or
  months after discharge.

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History

• Earliest Europeans hospitals were established in
  middle ages
• No resemblance to modern hospitals in either
  structure or function
• There were lack of space and shifts were ordered
  for patients and occasionally more than one
  patients in beds.

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• Consequences
• Increased physical contact promoting infection
  spread
• The squalid situations led to the hospitals
  called pest houses

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• 19TH century reports
• Surgery almost always followed by infection
• 60 of limb amputations resulted in fatal
  infection

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Observation

• In 1846 there was differential mortality of
  childbed fever between 2 obstetrics wards 1 2
  at University of Geneva.
• 11.4 vs 2.7.
• Investigation was then launched by Ignaz Phillip
  Semmelweis who was the director of Obstetrics
  services

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• Then Pathologist doing post mortem died of
  similar illness having nicked his hand with
  scalpel.
• Conclusion from infectious materials.

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• Hospital staff and students were subsequently
  ordered to wash their hands with calcium
  hypochlorite after examining each patients.
• Mortality rate dropped from 11.4 to 1.3 in ward
  1 decline of 89.

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• Hand washing also ordered for ward 2, rate
  declined by 52.
• This clearly demonstrated the spread and
  prevention of hospital infection
• Ignaz Phillip Semmelweis was later regarded as
  the Father of Hospital Epidemiology.

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• The discovery of penicillins in the 30s and 40s
  led to lower infection rate.
• Subsequently MRSA became problem.
• The 1990s saw the emergence of Vancomycin
  resistant Enterococci

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• Advancement in medicine also posed new challenges
  like catheter related blood stream infection and
  ventilator associated pneumonia.

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• Last two decades, increase number of susceptible
  patients as a result of survival to immune
  modifying disease or effect of therapy.
• Resulting in patients expose to life threatening
  diseases due to change in natural or acquired
  immunities.

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Importance of Hosp Infection

• Estimates in the 70s, 6-8 per 100 patients
  admitted.
• Additional suffering and mortality for patients
• Nosocomial infection also increased length of
  hospital stay and extra costs to authorities.

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Prolongation of Hospital Stay due to Nosocomial
Infections in the USA
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Annual Costs and Benefits of Infection Control
Program in a Hypothetical 250-bed Hospital
Each 1000 invested in infection control will
return 3000 in net direct cost savings
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Hospital-acquired Infectionwhy worry?

• 10-15 of patients will get infected during a
  stay in hospital
• Costs gt1 billion per year in UK
• A single large outbreak can cost 10-100K

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• Effects of nosocomial infection
• Increased mortality morbidity
• Prolonged hospital stay
• Increased drugs bill
• Increased staffing costs
• Demoralising for staff patients
• Decreased public confidence in hospitals
  doctors

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Why is hospital-acquired infection different from
community-acquired infection?

• Many vulnerable patients in close proximity to
  each other for prolonged periods of time
• Many patients have impaired immunity
• After anti-cancer chemotherapy
• After transplants
• Extremes of age

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• Many patients have impaired normal physiological
  defences
• Breaches in skin
• Implanted foreign bodies (biofilms)
• Impaired physiology (Peristalsis, mucociliary
  escalator)

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Antibiotic-Resistant Infections

• Associated with extended illness
• Longer hospital stay
• Higher risk for death
• Increased costs to health system
• Microbes with mutation for resistance has a
  selective advantage to
• Survive, proliferate and spread.

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• Controlling antibiotic prescriptions within
  hospitals had helped in reduction of resistant
  organism emergence.
• Contact precautions with gowns and gloves had
  prevented the spread of MRSA and VRE.

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• Transmission facilitated by hospital staff who
  rarely
• Wash their hands
• Disinfect or dispose their clothing
• Disinfect their equipment

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Hand washing
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• Method
• Wet hands with clean (not hot) water
• Apply soap
• Rub hands together for about 20 seconds
• Rinse with clean water
• Dry with disposable towel or air dry
• Use towel to turn off faucet

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Alcohol-based Hand Rubs

• Effective if hands not visibly soiled
• More costly than soap water
• Method
• Apply appropriate (3ml) amount to palms
• Rub hands together, covering all surfaces until
  dry

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• How consistent are we in washing hands between
  attending patients?

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• Recent studies
• Forty per cent (40) wash their hands after
  contact with a patient before the next.
• Nurses comply more than doctors
• Worst compliance regrettably in ICUs.

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UTI

• Thirty per cent of all nosocomial infections
• Rate of 1 with single in-out catheterisation
• Risk of 3 to 6 per catheter-day for prolonged
  usage.
• Higher for females than males
• Post 10-14 days, half of pateints have
  bacteriuria.

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NNIS Data (CDC).

• E coli Coagulase -ve Staph
• Enterococcus spp Other fungi
• P aeruginosa Citrobacter spp
• Candida spp S aureus
• K pneumoniae
• Enterobacter spp
• Proteus mirabilis

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• Preventive measures have confirmed the advantage
  of closed drainage system.
• Also the use of silver alloy urinary catheter

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Pneumonia

• Mainly from aspirated gastric contents.
• Also from microbes-laden secretions of upper
  respiratory tract.
• Septic emboli from infected CVP or A-V fistula
• Rarely, inhalation of pathogens from the air for
  example M tuberculosis and Aspergillus fumigatus

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• S aureus
• P aeruginosa
• Enterobacter spp
• K pneumoniae
• E coli

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• Most patients are ventilated in ICU.
• Rates from 6 to 30.
• Risk of 1 to 3 per day.
• Higher inocula with patients on either H2
  blocker or antacid therapy.
• Less with sucralfate.

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• Preventive measures
• Keeping patients at an angle of 45 degrees.
• Use of device for subglottic suction to reduce
  the pooling of secretions.
• Led to less clinical aspirations and lower
  pneumonia rates.

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Surgical Site Infections

• Still occur despite aseptic techniques
• Clearly the obese and diabetic patients require
  adequate preparations.
• Use of dry shaving a day before surgery is better
  than clippers hours before.
• Emergent surgery on inherently contaminated
  organs like the colon.

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• S aureus
• Coagulase ve Staph
• Enterococci
• E coli
• Enterobacter
• Klebsiella
• Candida

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Blood Stream Infections

• Primary 80 mainly from infected vascular
  catheter.
• Secondary 20 local infection in another organ.
• Catheter-related BI begins with colonization of
  the catheter with microbes.
• Femoral more prone than IJ and SC

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• Cultured tips of catheter in cardiac surgery are
  infected within 1-2 hours of insertion.
• Earlier on tackled by the bodys immune system.
• Subsequently microbes moved through the catheter
  tract to enter the blood stream.

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• By 10 days there is an increasing frequency of
  intra-luminal contamination.
• Multiple randomised trials had shown that
  antiseptic preparation with chlorhexidine is far
  superior in risk reduction of colonisation as
  compared with alcohol or povidone-iodine
  preparations.

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• Chlorhexidine-silver sulphadiazine treated
  catheter has been shown to reduce colonization
  and blood stream infection by about half.
• Cotton gauze covered by tape were associated with
  lower risk of colonization versus transparent
  dressings.

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• Antibiotic-coated catheter reduced colonization
  by 55 as compared with standard catheters.
• Comparative study had shown that the capacity of
  minocycline/rifampicin coated catheter were
  superior in resisting infection versus
  chlorhexidine-silver sulfadiazine catheter.

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Organization for Infection Control

• Surveillance
• Outbreak investigations
• Education
• Hospital employee health
• Antimicrobial utilization
• Policy development
• Quality assessment

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Infection Control Programs

• Size and intensity of program predicts infection
  rates.
• Most effective associated with 32 reduction
  compared with hospital without program.
• One hospital with effective program in 1985
  reported saving costs of 2million for the year.
  

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Infection Control in hospital

• Interrupt transmission
• Human-to-human
• Hand washing
• Ward routine (e.g. wet mopping)
• Aseptic technique
• Sterilisation disinfection
• Isolation procedures
• Environment
• Food hygiene, pest control, theatre design

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Precautions

• Standard
• Specific ----Airborne
• ----Droplets
• ----Contact

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Standard Precautions

• Perform hand hygiene
• Wear gloves
• Wear gowns
• Wear a mask and goggles and glasses

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Standard Precautions

• Hand hygiene
• Respiratory hygiene and cough etiquette
• Personal protective equipment (PPE)
• Based on risk assessment to avoid contact with
  blood, body fluids, excretions, secretions
• Safe injection practices
• Environmental control
• Patient placement

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• Specific Isolation Categories

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Airborne precautions

• Use a negative-pressure room
• Keep doors closed
• Wear grade N95 or better mask
• If patient transport is necessary, then patient
  to wear surgical mask
• TB, Measles, Chickenpox

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Droplet precautions

• Keep doors closed
• Wear a surgical mask if entering the room
• Discard mask after leaving the room
• If patient transport is necessary, patient to
  wear surgical mask
• Meningitis, Mumps, Pertussis, Rubella

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Contact precautions

• Wear a gown and gloves to enter the room
• Use a dedicated stethoscope and thermometer
• Remove gown and gloves before leaving the room
• Acute infectious diarrhea, Abscess/draining wound

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• Occupational Exposures

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Occupational Risk for Hepatitis

• Hepatitis B is much more frequent occupational
  infection and a cause of deaths among HCWs.
• Standard precautions and vaccination had reduced
  infection.
• Ten per cent of HCWs do not respond to
  vaccination.
• No vaccine yet for Hepatitis C

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• Occupational exposures
• General steps in management
• Wash and clean wounds
• Flush mucous membranes immediately

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• Unvaccinated Exposed HCW
• Injury from HBsAg ve source, give HBIG 0.06mL
  per Kg and initiate HB vaccine
• Injury from HBsAg -ve source, initiate HB
  vaccine
• Injury from unknown status of HBsAg initiate HB
  vaccine and determine HBsAg of source.

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• Vaccinated HCW/unknown Ab status
• Injury from HBsAg ve source, do anti- HBS on
  exposed person
• --If titergt10milli-IU/ml no treatment.
• --If titerlt10milli-IU/ml, give HBIG 0.06mL per Kg
  1 dose of HB vaccine

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• Injury from HBsAg -ve source, no treatment is
  necessary.
• Injury from unknown status of HBsAg do anti-HBS
  on exposed person
• --If titer gt10milli-IU/ml no treatment.
• --If titer lt10milli-IU/ml, give 1 dose of HB
  vaccine plus HBIG if source high risk

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Hepatitis C exposure

• Determine anti-HCV from both exposed person and
  source.
• If source known ve and exposed ve follow up HCV
  testing advised.
• Baseline and serial LFTs
• HCV RNA after 2 weeks of exposure.

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• No recommended prophylaxis immune globulin not
  effective.
• Monitor for early infection as therapy may reduce
  risk of progression to chronic hepatitis.

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• Risk factors from case control study.
• Needle from artery and veins.
• Deep injury.
• Male HCW.
• Source 6 million copies/mL.

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Occupational Risk for HIV Infection

• Approximately 1 in 300-400 needle sticks injuries
  will transmit HIV.
• Chances increased with large-bore hollow needle
• Wash wounds and flush mucous membranes.

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• Baseline HIV test, CBC, renal and hepatic tests
• Viral load of source.
• HIV testing should be repeated as follows
• 3-4 weeks and 3 6 months
• PEP should be started within hours

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• Regimens
• Treat for 4 weeks
• Monitor drug side-effects fortnightly
• Basic regime
• Zidovudine Lamivudine or Stavudine Lamivudine
• Expanded regime
• Above Lopinavir Ritonavir

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Occupational Risk for T B

• Infection occurs in setting lacking isolation
  techniques
• These are
• Absence of negative-pressure ventilation rooms
• Lack of administrative control measures

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• Further recommendations
• Annual and semi-annual PPD testing
• Training and retraining of staff

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• An extract from the work book of Dr Fester, aged
  24, newly qualified house officer...
• 50 lines as punishment for poor hand hygiene

• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients
• I promise to wash my hands between patients...

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• Thank you