Nosocomial infection

Indah K. Murni
Dept of Pediatrics
Dr Sardjito Hospital
2011
 Nosocomial infection

Hospital-acquired infection
Healthcare-associated infection
 Definition

It was not present or incubating at the time the

patient was admitted to hospital and is not present
less than 48 hours after admission
 Nosocomial infection sites
Nosocomial pneumonia
Bloodstream infection (BSI)
Nosocomial urinary tract infection (UTI)
Nosocomial gastroenteritis
Surgical site infection
Upper respiratory tract infection
 Pneumonia

Nosocomial pneumonia
Ventilator-associated pneumonia (VAP)
 Criterion 1
Patient has rales or dullness to percussion on
physical examination of the chest
AND at least one of the following:
a. new onset of purulent sputum or change in
character of sputum
b. organisms cultured from blood
c. isolation of an etiologic agent from a specimen
obtained by transtracheal aspirate, bronchial
brushing, or biopsy.
 Criterion 2
Patient has a chest radiographic examination that shows
new or progressive infiltrate, consolidation, cavitation, or
pleural effusion
AND at least one of the following:
a. new onset of purulent sputum or change in character of
sputum
b. organisms cultured from blood
c. isolation of an etiologic agent from a specimen obtained by
transtracheal aspirate, bronchial brushing, or biopsy
d. isolation of virus from or detection of viral antigen in
respiratory secretions
e. diagnostic single antibody titer (IgM) or fourfold increase in
paired sera (IgG) for pathogen
f. histopathologic evidence of pneumonia.
 Criterion 3
Patient 1 year of age has at least two of the following
signs or symptoms: apnea, tachypnea, bradycardia,
wheezing, rhonchi, or cough
AND at least one of the following:
a. increased production of respiratory secretions
b. new onset of purulent sputum or change in character of
sputum
c. organisms cultured from blood or diagnostic single antibody
titer (IgM) or fourfold increase in paired sera (IgG) for
pathogen
d. isolation of an etiologic agent from a specimen obtained by
transtracheal aspirate, bronchial brushing, or biopsy
e. isolation of virus or detection of viral antigen in respiratory
secretions
f. histopathologic evidence of pneumonia.
 Criterion 4
Patient 1 year of age has a chest radiologic
examination that shows new or progressive infiltrate,
cavitation, consolidation, or pleural effusion
AND at least one of the following:
a. increased production of respiratory secretions
b. new onset of purulent sputum or change in character of
sputum
c. organisms cultured from blood or diagnostic single
antibody titer (IgM) or fourfold increase in paired sera
(IgG) for pathogen
d. isolation of an etiologic agent from a specimen obtained
by transtracheal aspirate, bronchial brushing, or biopsy
e. isolation of virus from or detection of viral antigen in
respiratory secretions
f. histopathologic evidence of pneumonia
 Bloodstream infection (BSI)

Laboratory-confirmed bloodstream infection

Clinical sepsis
 Criterion 1
Patient has a recognized pathogen cultured
from one or more blood cultures
AND
organism cultured from blood is not related to
an infection at another site.
 Criterion 2
Patient has at least one of the following signs or
symptoms: fever (>38 C), chills, or hypotension
AND at least one of the following:
a. common skin contaminant (e.g., diphtheroids, Bacillus
sp., Propionibacterium sp., coagulase-negative
staphylococci, or micrococci) is cultured from two or
more blood cultures drawn on separate occasions
b. common skin contaminant (e.g., diphtheroids, Bacillus
sp., Propionibacterium sp., coagulase-negative
staphylococci, or micrococci) is cultured from at least one
blood culture from a patient with an intravascular line,
and the physician institutes appropriate antimicrobial
therapy
c. positive antigen test on blood (e.g., H. influenzae, S.
pneumoniae, N. meningitidis, or group B Streptococcus)
and signs and symptoms and positive laboratory results
are not related to an infection at another site.
 Criterion 3
Patient 1 year of age has at least one of the following signs
or symptoms: fever (>38 C), hypothermia (<37 C), apnea,
or bradycardia
AND at least one of the following:
a. common skin contaminant (e.g., diphtheroids, Bacillus sp.,
Propionibacterium sp., coagulase-negative staphylococci, or
micrococci) is cultured from two or more blood cultures drawn
on separate occasions
b. common skin contaminant (e.g., diphtheroids, Bacillus sp.,
Propionibacterium sp., coagulase-negative staphylococci, or
micrococci) is cultured from at least one blood culture from a
patient with an intravascular line, and physician institutes
appropriate antimicrobial therapy
c. positive antigen test on blood (e.g., H. influenzae, S.
pneumoniae, N. meningitidis, or group B Streptococcus) and
signs and symptoms and positive laboratory results are not
related to an infection at another site.
 Clinical Sepsis
Criterion 1
Patient has at least one of the following
clinical signs or symptoms with no other
recognized cause: fever (>38 C), hypotension
(systolic pressure <90 mm), or oliguria (<20
cm 3 /hr)
AND blood culture not done or no organisms
or antigen detected in blood
AND no apparent infection at another site
AND physician institutes treatment for sepsis.
 Criterion 2
Patient 1 year of age has at least one of the
following clinical signs or symptoms with no
other recognized cause: fever (>38 C),
hypothermia (<37 C), apnea, or bradycardia
AND blood culture not done or no organisms
or antigen detected in blood
AND no apparent infection at another site
AND physician institutes treatment for sepsis.
Upper respiratory tract infections
 Criterion 1
Patient has at least two of the following signs or
symptoms with no other recognized cause: fever (>38
C), erythema or pharynx, sore throat, cough,
hoarseness, of purulent exudate in throat
AND at least one of the following:
a. organisms cultured from the specific site
b. organisms cultured from blood
c. positive antigen test on blood or respiratory secretions
d. diagnostic single antibody titer (IgM) or fourfold increase
in paired sera (IgG) for pathogen
e. physician's diagnosis of an upper respiratory infection.
 Criterion 2
Patient has an abscess seen on direct
examination, during a surgical operation, or
during a histopathologic examination.
 Criterion 3
Patient 1 year of age has at least two of the following
signs or symptoms with no other recognized cause:
fever (>38C), hypothermia (<37 C), apnea,
bradycardia, nasal discharge, or purulent exudate in
throat
AND at least one of the following:
a. organisms cultured from the specificsite
b. organisms cultured from blood
c. positive antigen test on blood or respiratory secretions
d. diagnostic single antibody titer (IgM) or fourfold increase
in paired sera (IgG) for pathogen
e. physician's diagnosis of an upper respiratory infection.
Gastroenteritis
 Criterion 1
Patient has an acute onset of diarrhea (liquid
stools for more than 12 hours) with or without
vomiting or fever (>38 C) and no likely
noninfectious cause (e.g., diagnostic tests,
therapeutic regimen, acute exacerbation of a
chronic condition, or psychologic stress).
 Criterion 2
Patient has at least two of the following signs or
symptoms with no other recognized cause: nausea,
vomiting, abdominal pain, or headache
AND at least one of the following:
a. an enteric pathogen is cultured from stool or rectal swab
b. an enteric pathogen is detected by routine or electron
microscopy
c. an enteric pathogen is detected by antigen or antibody
assay on blood or feces
d. evidence of an enteric pathogen is detected by
cytopathic changes in tissue culture (toxin assay)
e. diagnostic single antibody titer (IgM) or fourfold increase
in paired sera (IgG) for pathogen.
 Surgical site infection
Infection occurs within 30 days after the operative
procedure
AND involves only skin and subcutaneous tissue of the
incision
AND patient has at least 1 of the following:
a. purulent drainage from the superficial incision
b. organisms isolated from an aseptically obtained culture of
fluid or tissue from the superficial incision
c. at least 1 of the following signs or symptoms of infection: pain
or tenderness, localized swelling, redness, or heat, and
superficial incision is deliberately opened by surgeon and is
culture positive or not cultured. A culture-negative finding
does not meet this criterion.
d. diagnosis of superficial incisional SSI by the surgeon or
attending physician.
 Phlebitis
there is one of signs and symptoms consisting
of erythema with or without pain, oedema,
streak formation, palpable venous cord, or
purulent discharge around the intravenous
catheter
Simplified criteria for surveillance of
nosocomial infections (WHO, 2002)
 A new fever or new clinical or laboratory signs of
infection after admission
new onset of diarrhoea, fever, cough, cellulitic
inflammation around an intravenous drip site, cloudy
urine, increase in CRP, I/T ratio (>0.2), or a 30% increase
in total white cell count, new changes on chest x-ray
AND a bacteria is isolated from an otherwise sterile
site (a bacteriologically-proven nosocomial
infection)
OR the clinical AND laboratory signs are highly
suggestive of a new infection, even if the
bacteriological investigations are negative (a likely
nosocomial infection).
 Frequency of infection
Incidence varies
Intensive care units (ICUs) > general wards.
Developed countries:
1% to 9.8% in the general pediatric units
up to 23.6% in the Pediatric ICUs.
BSI (28%), pneumonia (21%) and UTI (15%)
Developing countries
5.9% and 13.9% in the pediatric wards
Relatively few numbers of studies have been
conducted to estimate the burden of this infection
 Impact of Nosocomial Infection
Increase mortality rate (18.7 75.1%)

Increase length of stay (3.9 12 days)

Increase health cost ($ 593 to $ 40,000 per

case)

(Biwersi et al, 2009; Taconelli et al, 2009; Madani et al, 2009)

 Risk of nosocomial infection
Intrinsic factors
Patients disease severity
endogenous flora
young age
genetic syndrome
immunocompromised condition
Malnutrition

Extrinsic factors
invasive devices: mechanical ventilators, central venous
catheters, and urinary catheter
parenteral nutrition
inappropriate antibiotic use
crowding situation
 Microorganisms
of nosocomial infection
 Bacteria
Commensal bacteria found in normal flora
of healthy humans.
protective role.
May cause infection if the natural host is
compromised.
cutaneous coagulase-negative staphylococci
intravascular line infection
intestinal Escherichia coli urinary infection.
 Pathogenic bacteria: have greater virulence, cause infections
(sporadic or epidemic) regardless of host status.
Anaerobic Gram-positive rods (e.g. Clostridium) gangrene.
Staphylococcus aureus (skin and nose) lung, bone, heart and
bloodstream infections and are frequently resistant to
antibiotics
Enterobacteriacae (e.g. E. coli, Proteus, Klebsiella,
Enterobacter, Serratia marcescens), may colonize sites when the
host defences are compromised (catheter insertion, bladder
catheter, cannula insertion) serious infections (surgical site,
lung, bacteraemia, peritoneum infection). They may also be
highly resistant.
Pseudomonas spp. (water , damp areas, colonize the digestive
tract of hospitalized patients).
Legionella species pneumonia (sporadic or endemic)
through inhalation of aerosols containing contaminated water
(air conditioning, showers, therapeutic aerosols).
 Viruses
hepatitis B and C viruses (transfusions,
dialysis, injections, endoscopy)
respiratory syncytial virus (RSV)
rotavirus, and enteroviruses (transmitted by
hand-to-mouth contact and via the faecal-oral
route)
cytomegalovirus, HIV, Ebola, influenza
viruses, herpes simplex virus, and varicella-
zoster virus, may also be transmitted.
 Parasites and fungi
Giardia lamblia are transmitted easily among
adults or children.
Candida albicans, Aspergillus spp., Cryptococcus
neoformans, Cryptosporidium
opportunistic organisms infections during
extended antibiotic treatment and severe
immunosuppression
Environmental contamination by airborne
organisms such as Aspergillus spp. which
originate in dust and soil
Sarcoptes scabies (scabies)
Reservoirs and transmission
of nosocomial infection
The permanent or transient flora of the patient
(endogenous infection).
Bacteria present in the normal flora cause
infection because of:
transmission to sites outside the natural habitat
(urinary tract),
damage to tissue (wound)
inappropriate antibiotic therapy that allows
overgrowth (C. difficile, yeast spp.).
Gram-negative bacteria in the digestive tract
frequently cause surgical site infections after
abdominal surgery or urinary tract infection in
catheterized patients.
 Flora from another patient or member of staff
(exogenous cross-infection).
Bacteria are transmitted between patients:
(a) through direct contact between patients (hands, saliva
droplets or other body fluids),
(b) in the air (droplets or dust contaminated by a patients
bacteria),
(c) via staff contaminated through patient care (hands,
clothes, nose and throat) who become transient or
permanent carriers, subsequently transmitting bacteria
to other patients by direct contact during care,
(d) via objects contaminated by the patient (including
equipment), the staffs hands, visitors or other
environmental sources (e.g. water, other fluids, food)
 Flora from the health care environment
(endemic or epidemic exogenous environmental infections)
Several types of microorganisms survive well in the hospital
environment:
in water, damp areas, and occasionally in sterile products or
disinfectants (Pseudomonas, Acinetobacter, Mycobacterium)
in items such as linen, equipment and supplies used in care;
appropriate housekeeping normally limits the risk of bacteria
surviving as most microorganisms require humid or hot conditions
and nutrients to survive
in food
in fine dust and droplet nuclei generated by coughing or speaking
(bacteria smaller than 10 m in diameter remain in the air for
several hours and can be inhaled in the same way as fine dust).
 People are at the centre of the
phenomenon:
as main reservoir and source of
microorganisms
as main transmitter, notably during treatment
as receptor for microorganisms, thus
becoming a new reservoir.
Prevention of Nosocomial Infection
Key factor of a good quality of healthcare
40% of NIs can be prevented

Two preventable causal factors:

Transmission of infection by health workers
Inappropriate antibiotic use

(Wenzel, 1987; Damani, 2007)

 There are two mechanisms of developing antibiotic-
resistant nosocomial infection, which through:
cross transmission
antibiotic exposure.

Cross transmission occurs via person-to-person

transmission which hands of the health workers as a
vehicle.
Colonization of the antimicrobial-resistant pathogen
usually happens before developing nosocomial
infection.
The colonization can occur in the hands and other
inanimate objects around patients
a reservoir for transmission to other patients.
 Hand Hygiene
Direct contact
The hands : vehicle of transmission

Proper hand hygiene removes microorganisms

Hand hygiene: the simplest and most effective measure
for preventing nosocomial infections
Increase the rate of hand hygiene compliance
(14% to 81.2%)
Reduce the rate of nosocomial infection
(47.5 to 27.9 per 1000 patient-days)

(Gould et al, 2008; Roshental et al, 2005; Allegranzi and Pittet, 2009)
 Rational antibiotic use

Irrational antibiotic use alterations in flora balance

Irrational antibiotic use increase AB resistant NI

Rational antibiotic use decrease mortality in NI

(91 38%)

(Center for Disease Control and Prevention (CDC) statistics, de Mallo et al, 2009)
 Practice & Problems
in Developing Countries
Surveillance of NI: unreliable, inconsistent,
and not well implemented

Compliance of HH: low

Studies on how to improve compliance: low

Irrational AB use: high

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Thank you