DR.T.V.RAO MD 1

Dr.T.V.Rao MD

HOSPITAL INFECTIONS HEALTH CARE SOLUTIONS

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MICROBIOLOGY - SCIENTIFIC ERA

INFECTION

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

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Ignaz Semmelweis (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

SCIENTIFIC ERA CONTINUED . . . . .

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SCIENTIFIC ERA CONTINUED . . . . .

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

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SCIENTIFIC ERA CONTINUED

Robert Koch (1843-1910)

• German general practitioner

• Grew bacteria in culture medium

• Showed which bacteria caused particular diseases

• Classified most bacteria by 1900

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HOSPITAL ACQUIRED INFECTION

• 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.

• Also called nosocomial infection

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• Healthcare associated infections (HCAIs) are infections transmitted to patients (and healthcare workers) as a result of healthcare procedures, in hospital and other healthcare settings. Recent years have seen an increase in the awareness of HCAIs, in particular those caused by antibiotic-resistant ‘superbugs

WHAT ARE HEALTH CARE ASSOCIATED INFECTIONS

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• A wide variety of micro-organisms can cause HCAIs, leading to an extensive range of different diseases.

• Experts estimate that 9% of in-patients have an HCAI at any one time.

WHAT ARE HEALTH CARE ASSOCIATED INFECTIONS ???

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HEALTH CARE ASSOCIATED INFECTIONS AND MICROBES

• HCAIs are mostly caused by bacteria. Bacteria can exist harmlessly in people, for example on the skin or in the gut. However, some types of bacteria can cause HCAIs when they enter the body, for example through wounds and the use of surgical devices, or when the body’s natural balance is disturbed. HCAIs occur in the lungs (23% of all HCAIs), urinary tract (23%), blood (6%), skin (11%) and gut. Infections are usually treated with antibiotics. However, many bacteria have developed resistance to antibiotics This can make infections harder to treat.

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• Increasing antibiotic use. The more antibiotics are being used, the more likely bacteria become resistant to them. Antibiotics are sometimes prescribed for conditions that are not treatable with antibiotics, such as colds and the ‘flu.

INCREASED USE OF ANTIBIOTICS

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ANTIBIOTIC RESISTANCE• Not a new problem - Penicillin in 1944

• Hospital “superbugs”

• Methicillin Resistant Staphylococcus Aureus [MRSA]

• Vancomycin Intermediate Staphylococcus Aureus [VISA]

• Tuberculosis - antibiotic resistant form

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• Patterns of antibiotic use. Many people do not finish their courses of antibiotics because they start feeling better. This means that bacteria are not killed off, so they multiply, become resistant and transmit to others.

IRREGULAR USE OF ANTIBIOTICS

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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

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HOSPITAL ACQUIRED INFECTION

• 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

• Also called Nosocomial infection

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MODES OF SPREADTwo 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)

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• Using leftover antibiotics to self-medicate against a fresh infection can exacerbate the problem, as specific bacterial infections require specific antibiotics

USE OF LEFTOVER ANTIBIOTICS

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• The indiscriminate use of antibiotics in livestock has further compounded the problem by increasing the likelihood of resistance factors emerging.

USE OF ANTIBIOTICS IN LIVESTOCK

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• Methicillin-resistant S. aureus (MRSA) is resistant to several antibiotics. Another form of S. aureus, vancomycin-resistant S. aureus (VRSA), is resistant to one of the most powerful, last line of defence antibiotics, vancomycin

CONCERNS WITH STAPHYLOCOCCUS

RESISTANT GRAM NEGATIVE ORGANISMS

RESISTANCE TO MULTIPLE ANTIBIOTICS

ORGANISMS:E .COLI

PROTEUS ENTEROBACTER ACINETOBACTER

PSEUDOMONAS AERUGINOSA

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• Escherichia coli (E. coli) has gradually become resistant to different types of antibiotics. In 2003, the overall resistance of E. coli to common amino penicillin antibiotics reached 47% across Europe

E.COLI AND EMERGING RESISTANCE

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• Pseudomonas aeruginosa (P. aeruginosa) and Extended Spectrum Beta Lactamase (ESBL) -producing bacteria are increasingly becoming resistant to antibiotics.

PSEUDOMONAS AERUGINOSA

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OBJECTIVES – REDUCING INFECTIONS

• Reducing infection rates• Establishing endemic baseline rates• Identifying outbreaks• Identifying risk factors• Persuading medical personnel• Evaluate control measures• Satisfying regulators• Document quality of care• Compare hospitals’ NCI rates

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SURVEILLANCE• Important means of monitoring HAI

Early detection of trends outbreaks

• . Laboratory Based Microbiology Laboratory lists +ve organisms ICN reviews ‘Alert organisms’ reported

• 2. Ward Based Ward staff monitor patientsICN reviews ICN visits wards

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• All hospitals?

• All departments?

• All specialties?

• Other health

institutions?

WHO WILL PRACTICE PREVENTIVE MEASURES

Surveillance of

surgical site infections

Centraladm.

Local adm.

ICP

It-dep.

Surgicalwards

Surgicalward. 2

PatientsLab

Service dep.

MinistryOf health

Directorat

PublicHealth

instituteI

…..

Stakeholders

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PERSONAL PROTECTIVE EQUIPMENT

• 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

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UNIVERSAL PRECAUTIONS• 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

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Why Don’t Staff Wash

their Hands

(Compliance estimated at less than 50%)

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HAND WASHING• 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

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WHY NOT?• Skin irritation• Inaccessible hand washing facilities• Wearing gloves• Too busy• Lack of appropriate staff• Being a physician

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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WHY NOT?

• Working in high-risk areas • Lack of hand hygiene promotion• Lack of role model• Lack of institutional priority• Lack of sanction of non-compliers

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SUCCESSFUL PROMOTION

• 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)

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• Reminders in the workplace

• Promote and facilitate skin care

• Avoid understaffing and excessive workload; Nursing shortages have caused

SUCCESSFUL PROMOTION

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AREAS MOST FREQUENTLY MISSED

HAHS © 1999

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HAND CARE• Nails• Rings• Hand creams• Cuts & abrasions• “Chapping”• Skin Problems

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• Hand hygiene is the simplest, most effective measure for preventing hospital-acquired infections.

HAND HYGIENE

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• 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)

SHARPS INJURIES

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WASTE DISPOSAL• 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 (May, 2000)

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SPILLAGE OF BODY FLUIDS• 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

H.A.I. IS INCREASING:· compromised patients· ward and inter-hospital transfers· antibiotic resistance (MRSA, resistant Gram negatives)· increasing workload

· staff pressures· lack of facilities· ? lack of concern

HAI is inevitable but some is preventable (irreducible minimum)· realistically reducible by 10-30%

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• Journal of Infection Prevention is the professional publication of the Infection Prevention Society. The aim of the journal is to advance the evidence base in infection prevention and control, and to provide a publishing platform for all health professionals interested in this field of practice. The journal is a bi-monthly peer-reviewed publication containing a wide range of articles: Original primary research studies, Qualitative and quantitative studies,.

JOURNAL OF INFECTION PREVENTION

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CONSEQUENCES OF HOSPITAL INFECTIONS ???

Hospital Pathogen Unhappypatients

Unhappydirector

Hospital Surveillance HappyPatients

Happydirector

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Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the

Developing World

Email

doctortvrao@gmail.com