Epidemiology of HCAI

Dr. Dhanalakshmi S
Assistant Professor, Clinical Microbiology
Health Care Associated Infections
(HCAI) Definition
• Infection which was neither present nor incubating at the
time of admission

• Acquired 48 hours after admission in the hospital

• Includes infection which only becomes apparent after

discharge from hospital but which was acquired during
hospitalisation
Importance of Health care associated infections
(HCAI)

• The economic costs are considerable

• The increased length of stay for infected patients is the

greatest contributor to cost

• The increased use of drugs, the need for isolation, and

the use of additional laboratory and other diagnostic
studies also contribute to costs.

• Transmission of multi drug resistant (MDR) organisms

• Mortality and morbidity

Health care associated infections
Factors promoting HAI

 Decreased immunity among patients

 The increasing variety of medical procedures and

invasive techniques creating potential routes of
infection

 The transmission of drug-resistant bacteria among

crowded hospital populations

 Poor infection control practices

 Staphylococcus aureus
Enterococci
Clostridrium difficle
M.tuberculosis
Bacteria
E.coli
Klebsiella
Enterobacter
Pseudomonas
Acinetobacter
Microorganisms

Fungi Candida species

Influenza virus
Viruses
Chicken pox
Sources of Infection

• Endogenous or self-infection –
organisms which are harmless in one site can be
pathogenic when transferred to another site

• Exogenous or cross-infection –
organisms transmitted from another source e.g.,
nurse, doctor, other patient, environment
 Portal of exit
• The Pathogen escapes
from the reservoir where it
has been growing
• Blood
• Urine
• Faeces
• Breaks in skin
• Wound
• Body secretions
• drains
Mycobacteria bearing droplets 1-5 µm

Number of Organisms Liberated:

Talking 0 – 200
Coughing 0 – 3500
Sneezing 4500 – 1 000 000
Portal of Entry
Routes
• Skin- wound care – post op
• Respiratory- Ventilator / inhalation
• Blood stream- IV catheter care
• Urinary tract- Catheter care
Compromised patients
Frequency of common HCAI
Surveillance of HCAI
Surveillance

• Systematic collection, analysis and interpretation of

data on specific events/infections and disease,
followed by dissemination of that information to
those who can improve the outcomes
Aim & Objectives
• Establish endemic/baseline rate of infections
• Compare HCAI rate within/between health care
facilities
• Convince the clinical team to adopt best practices
• Reduce HCAI by introducing evidence based cost-
effective interventions
• Identify and control outbreaks
In CMC…
Methodology

• Active targeted surveillance for

• Ventilator associated pneumonia (VAP)

• Central line associated blood stream infection (CLABSI)

• Catheter associated urinary tract infection (CAUTI)

• Surgical site infection (SSI)

Areas under surveillance
• Medical ICU & HDU

• Surgical ICU & HDU

• Paediatric ICU & HDU

• Thoracic surgery ICU & SICU

• Neuro ICU/ HDU & neuro trauma ICU

• AICU

• Level 3 Nursery

• BMTU and a haematology ward

Surveillance definitions
Definitions of 3 device associated infections & Surgical site infection.
• Am J Infect Control 2008;309-32 & CDC device associated events March2009
VAP – CMC
Patient must meet following 5 criteria;

1.Patient mechanically ventilated > 2 days

2.Abnormal chest X-ray: 2 or more serial radiographs with at

least one of the following;

• New or progressive and persistent infiltrate/

consolidation/ cavitation

• Pneumatocoels in infants < 1 year old

3. Systemic features;

• Fever (>100.4°F) or hypothermia (< 97.7°F) with no other

recognised cause

• Leuopenia (total WBC < 4000/cmm) or leucocytosis (total

WBC > 12000/cmm)

4. Respiratory findings;

• Purulent ET aspirate or increased respiratory secretions or

increased suctioning requirements

• Worsening gas exchange (PaO2/FiO2 > 240), increased O2

requirements or increased ventilator demand
5. If only one of the two findings mentioned in “4” are present
then diagnosis needs to be supported by positive culture
(ETA/BAL/blood/pleural fluid)

In immuno compromised patient

• Any one of the findings mentioned in “3 & 4” with a positive culture

and an abnormal chest X-ray to diagnose pneumonia is sufficient

Patient without underlying pulmonary or cardiac disease

• One definitive chest radiograph is acceptable

Since 2013…
• CDC introduced a new
surveillance paradigm –
Ventilator associated events
(VAE)

• objective, streamlined, and

potentially automatable criteria
that identify a broad range of
conditions and complications
VAC: After 2days of stability
i. Increase in daily minimum FiO2≥ 0.2 over the daily
minimum FiO2 or
ii. Increase in daily minimum PEEP ≥ 3 cm water, and
sustained for 2 calendar days

iVAC
Within 2days before or after VAC:
i. Body temperature (>38 C or <36 C) or leucocyte count
(≥12,000 cells/μL or ≤4,000 cells/μL) and
ii. A new antimicrobial agent was started, which was
continued for ≥4 days

PVAP
Within two days before or after VAC: any one of the following
i. Positive cultures of respiratory specimens or
ii. Purulent respiratory secretion plus organism identified from
respiratory specimen or
iii. Any one of the following positive test -Organism identified
from pleural fluid or positive pathology demonstrating
pneumonia or positive diagnostic test for legionella or viral
respiratory pathogen
CLABSI - CMC
Patient must meet following 4 criteria:
1.Patient has indwelling vascular catheter > 2 days

2.Fever (>100.4°F) or hypothermia (< 97.7°F)

3.Positive blood culture either

i. One or more positive blood culture with a recognised
pathogen (OR)
ii. A common skin contaminant is cultured from two or more
blood culture on separate occasions No other source
evident
4. No other source evident
CAUTI - CMC
Patient must meet following 5 criteria:

1.Patient had an indwelling urinary catheter > 2 days

2.Fever > 100.4°F
3.Positive urine culture >100,000 cfu/ml
4.Patient has at least one of the following features;
a. Cloudy urine
b. Malodorous urine
c. Pyuria (urine analysis >10 WBC/HPF)
5.No other cause evident
Computerised
surveillance for device
associated infections
Report
• Incidence rate

• Prevalence rate

• Trends

• Feedbacks

• Discussion with ICU liaison

Calculation
• Incidence rate = No of HAI/device days x1000

• Prevalence rate = No of HAI/No of patients admitted x 100

Benchmark

Singh et al. 2014, J Nat Accred Board Hosp healthcare Providers

SSI - CMC
Patient must meet following 2 criteria
1.Patient had a surgery within past 30 days for all surgeries and 90 days for
surgeries with prosthetic devices and
2.Any one of the following;
• Purulent discharge from the incision and positive culture from an
aseptically obtained culture of fluid or tissue from superficial
incision
• Abscess at surgical site involving the deeper layers and a positive
pus culture (swab from deep pus)
• Surgeon’s diagnosis of SSI
Surgical site infection

• Active, prospective surveillance for 7 surgeries

30 days follow up 90 days follow up

1. Elective LSCS 1. Coronary artery bypass grafting

2. Laparoscopic (CABG)
cholecystectomy 2. Herniorraphy with mesh
3. Abdominal hysterectomy 3. Total hip replacement
4. Total knee replacement
Method of follow up

1. From the OR up to discharge from the hospital

2. On the day of suture removal / first follow up in OPD (Treatment room /

ward)

3. Telephonic calls by Infection control nurses, 2 or 3 times depending on the

duration of follow-up

4. Reports presented in the Safety steering committee quarterly and

submitted to NABH
Thank you