Ida Parwati Djatnika Setiabudi Komite PIRS RSUP Dr. Hasan Sadikin Bandung

Ida ParwatiDjatnika Setiabudi

Komite PIRSRSUP Dr. Hasan Sadikin

Bandung

HEALTH CARE ASSOCIATED INFECTIONS(HAIs)

(NOSOCOMIAL INFECTION)

Dr.Hasan Sadikin General HospitalJalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216

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

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 patient’s 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: - Gastroenteritis

- Cellulitis - Hepatitis B and C

- HIV / AIDS - SARS

The most common causative pathogens

UTI SSI Resp. Blood SkinE. coliKlebsiellaPseudomonasEnterococcus

S. aureusE. coliProteusPseudomonas

KlebsiellaPseudomonasS. aureus E. coli

E. coliS. aureus KlebsiellaPseudomonas

S. aureus PseudomonasProteus

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 difficileClostridium sordellii Enterobacteriaceae (carbapenem-resistance)Hepatitis HIVInfluenzaKlebsiella

CDC, April 2013

MRSAMycobacterium abscessusNorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)VISA and VRSAVRE

Diseases and Organisms in Healthcare Settings

Why does HAIs important?

Why does HAIs important?

1.Increase morbidity & mortality2.Prolong length of stay (LOS)3.Increase cost4.Related to ‘image’/ quality of the hospital5.Important in medicolegal and “patient safety” aspects.

Impact of HAIs

They lead to functional disability and emotional stress to the patientdisabling conditions that reduce the quality of life

They are one of the leading causes of death

Impact of HAIs (cont’d)

• 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: 1 - 4 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 (cont’d)

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 >>• Interuption of anatomical barrier : - Urine catether - Operation procedure - Respiration intubation - Vein/artery canule - Burn wound and trauma

Risk factors(2)

• Implantation of: - “indwelling catheter” - “surgical suture material” - “cerebrospinal fluid shunts” - “valvular / vascular prostheses”• Changes in normal microflora : 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

Transmission (2)

• Droplet transmission : - droplet particles > 5 μm - 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 μm - 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