Ida Parwati Djatnika Setiabudi Komite PIRS RSUP Dr. Hasan Sadikin Bandung HEALTH CARE ASSOCIATED INFECTIONS (HAIs) (NOSOCOMIAL INFECTION) Dr.Hasan Sadikin.

Ida Parwati Djatnika Setiabudi Komite PIRS RSUP Dr. Hasan Sadikin Bandung HEALTH CARE ASSOCIATED INFECTIONS (HAIs) (NOSOCOMIAL INFECTION) Dr.Hasan Sadikin General Hospital Jalan Pasteur No. 38 Bandung West Java Indonesia Phone /57 Fax Definition (1) Old concept: Nosocomial Infection = Hospital acquired infection - An infection that occured during hospitalization (> 3 X 24 hours after admission) which are not present nor incubating upon hospital admission - Infection at the same location but the causative microorganism was different than at addmission OR the same microorganism but different location Old concept: Nosocomial Infection = Hospital acquired infection - An infection that occured during hospitalization (> 3 X 24 hours after admission) which are not present nor incubating upon hospital admission - Infection at the same location but the causative microorganism was different than at addmission OR the same microorganism but different location Definition (2) Problems of old definition: 1. Focus on infection occuring in the hospital only. What about in other health care system but not hospital? While many home-care are availlable now? 2. Focus on patients infection What about healthcare worker? Definition (3) New terminology: nosocomial Infection = Health-care associated Infection Health-care related Infection Healthcare-associated infection Definition: An infection occurring in a patient during the process of care in a hospital or other healthcare facility which was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility In Indonesia The term nosocomial infection still being used For nosocomial infection occured in the hospital: Hospital Infection (Infeksi Rumah Sakit) Control Program of HAIs called: Pencegahan dan Pengendalian Infeksi Rumah Sakit (PPIRS) Types of Infections (1) Four categories: 1)Surgical site infections (SSI) 2)Central line-associated bloodstream infections (CLABSI) 3)Ventilator-associated pneumonia (VAP) 4)Catheter-associated urinary tract infections (CAUTI) Types of Infections (2) Others: Others: - Gastroenteritis - Gastroenteritis - Cellulitis - Cellulitis - Hepatitis B and C - Hepatitis B and C - HIV / AIDS - HIV / AIDS - SARS - SARS The most common causative pathogens UTISSIResp.BloodSkin E. coli Klebsiella Pseudomonas Enterococcus S. aureus E. coli Proteus Pseudomonas Klebsiella Pseudomonas S. aureus E. coli S. aureus Klebsiella Pseudomonas S. aureus Pseudomonas Proteus Coagulase-negative staphylococci (CONS) (15%), Staphylococcus aureus (15%), Enterococcus species (12%), Candida species (11%), Escherichia coli (10%), Pseudomonas aeruginosa (8%), Klebsiella pneumoniae (6%), Enterobacter species (5%), Acinetobacter baumannii (3%) Klebsiella oxytoca (2%). The 10 most common pathogens (accounting for 84% of any HAIs) CDC, April 2013 Acinetobacter Burkholderia cepacia Clostridium difficile Clostridium sordellii Enterobacteriaceae (carbapenem-resistance) Hepatitis HIV Influenza Klebsiella CDC, April 2013 MRSA Mycobacterium abscessus Norovirus Pseudomonas aeruginosa Staphylococcus aureus Tuberculosis (TB) VISA and VRSA VRE Diseases and Organisms in Healthcare Settings Why does HAIs important? Why does HAIs important? Why does HAIs important? 1.Increase morbidity & mortality 2.Prolong length of stay (LOS) 3.Increase cost 4.Related to image/ quality of the hospital 5.Important in medicolegal and patient safety aspects. safety aspects. Impact of HAIs They lead to functional disability and emotional stress to the patient disabling conditions that reduce the quality of life They are one of the leading causes of death Impact of HAIs (contd) The increased economic costs are high: - Increased length of hospital stay - extra investigations - extra use of drugs - extra health care by doctors and nurses Nosocomial Infections Cost The cost varies according to the type and severity of these infections An estimated: extra days for a UTI 7 8 days for a surgical site infections 7 21 days for a blood stream infection 7 30 days for pneumonia The CDC has recently reported that US$5 billion are added to US health costs every year as a result of NI ) Impact of Nosocomial Infections (contd) Organisms causing N.I. can be transmitted to the community through discharged patients, staff and visitors If organisms are multi-resistant they may cause significant disease in the community Goals of infection control To protect the patients from HAIs e.g UTI, SSI, IV line infection, pneumonia (HAP, VAP), Blood stream infection (sepsis) To protect the patients from others infection which acquire through contact with other patients or healthcare worker whom colonized by contagious microorganisms. To protect healthcare workers, Visitor, in hospital environtment from infections SIX COMPONENTS OF THE CHAIN OF INFECTION Schaffer SD et al: Infection Prevention and Safe Practice, Mosby, 1996 Risk Factors (1) Age: neonatus >> Age: neonatus >> Interuption of anatomical barrier : Interuption of anatomical barrier : - Urine catether - Urine catether - Operation procedure - Operation procedure - Respiration intubation - Respiration intubation - Vein/artery canule - Vein/artery canule - Burn wound and trauma - Burn wound and trauma Risk factors (2) Implantation of: Implantation of: - indwelling catheter - indwelling catheter - surgical suture material - surgical suture material - cerebrospinal fluid shunts - cerebrospinal fluid shunts - valvular / vascular prostheses - valvular / vascular prostheses Changes in normal microflora : Changes in normal microflora : antibiotics usage antibiotics usage Routes of Transmission of Infection A susceptible host and appropriate inoculum of infecting microorganism with an appropriate route of transmission contributed in majority of case Airborne (resp tract, aerosols from equipment etc) Contact spread (person to person) Food borne spread Blood borne spread Self infections (endogenous) and cross infections Transmission (1) Contact transmission: - Direct: body contact physically causative microorganism transfer physical examination, patients bathing - Indirect: most of the time !!! contact through objects (tools) instrumentation, needle, bandage unwashed hand Contact transmission: - Direct: body contact physically causative microorganism transfer physical examination, patients bathing - Indirect: most of the time !!! contact through objects (tools) instrumentation, needle, bandage unwashed hand Transmission (2) Droplet transmission : - droplet particles > 5 m - coughing, sneezing, talking - short transmission distance, and only short time in the air - deposit at conjungtival mucous, nose, mouth - e.g.: Diphteria, Pertussis, Hib, Mycoplasma Influenza Virus, mumps, rubella Transmission (3) Airborne transmission : - small particles < 5 m - long standing in the air - long transmission distance - easy inhaled - e.g : Mycobacterium tuberculosis varicella virus, morbilli, fungi spore. Pathophysiology Within hours of admission, colonies of hospital strains of bacteria develop in the patient's skin, respiratory tract, and genitourinary tract. Risks factors for the invasion of colonizing pathogens can be categorized into 3 areas: iatrogenic, organizational, and patient-related Iatrogenic risk Iatrogenic risk factors: include pathogens on the hands of medical personnel, invasive procedures (intubation and extended ventilation, indwelling vascular lines, urine catheterization), and antibiotic use and prophylaxis. Organizational Organizational risk factors include: contaminated air- conditioning systems, contaminated water systems, and staffing and physical layout of the facility (eg, nurse- to-patient ratio, open beds close together). Patient associated Patient risk factors include the severity of illness, underlying immunocompromised state, and length of stay. Prolonged stay in the hospital is a Major contributing factor Blood stream infections Most important pathogen: coagulase negative Staphylococcus (CONS): 39.3% 10 15% of patients with HAI have a BSI Needle sticks may offer a path of entry for the microbes Pneumonia Most important pathogens Staphylococcus aureus: 16.8% Pseudomonas aeruginosa : 16.1% 10 15% of patients with a HAI get pneumonia 20 50% mortality rate Intubation and mechanical ventilation increase the risk of pneumonia by S. aureus Pneumonia usually caused by aspiration of bacteria clusters found in resp. Tract/GI tract Urinary tract infection Most important pathogens Escherichia coli 18.2% Candida albicans 15.3% Up to 40% of patients with HAIs get a UTI E. coli is a natural inhabitant of the GI tract it is commonly found near the anterior urethra Candida albicans is a natural inhabitant of the GI and genital tract Normal urination clears the urethra of harmful microbes while catheterization may allow microbes to colonize and infect the urinary tract Surgical site infection Most important pathogens Enterococci spp. 14.5% Coagulase negative Staphylococcus (CoNS) 13.5% Up to 54% of patients with HAI who have also had surgery get a SSI: 500,000 infections/year Enterococci spp. are a natural inhabitant of the GI tract Urinary catheterizations and antimicrobial use during hospital stays increases risk of infection 3 Major players in HAIs 1. Antimicrobial use in hospitals and long-term care facilities: has produced resistant strains that are often found colonizing health care workers. These strains can be transferred to patients by normal human contact Medical devices such as catheters and sutures offer a portal of entry for the microbes 2. Failure of hospital personnel to follow basic infection control: Handwashing, PPE etc. 3. Hospital patients are increasingly immunocompromised Prevention and Control The basic responsibility of any good hospital remain with establishment of good infection control policies, which can always be achieved with 1. An infection control committee 2. An Infection team The Functions of the Committee: To do surveillance and infection monitoring of hygiene practices. Educate the Medical and Paramedical staff on policies relating to prevention of infection, and safe procedures Infection Control Nurse Is the key member of the team Maintain the close working relations between Microbiology Laboratory, different clinical services and supportive services like laundry, pharmacy and engineering Collect information and document on HAIs Universal Precautions! Correlation between Handsrub usage and MRSA MDRO in the Hospital, Al Ichsan Bandung 21 August 2013 botol Thank you