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Research Chronicle in Health Sciences 2017,3(2),15-21
ISSN 2395-552X
An official journal of Reschrone Medico Publisher

Research Article

An Audit of Hospital Acquired Infection in a Tertiary Care Centre

Dr. Vaishali C. Shelgaonkar & Dr. Annu Choudhary
Department of Anaesthesia, IGGMC, C.A. Road, Nagpur, Maharashtra, India- 440018

Abstract
Background: Hospital acquired infection is one of the common causes of increased morbidity and mortality. The
situation is more alarming in Indian set up. As compared to other places, the incidence rate is much higher in ICU due
to multiple reasons. So, this study was planned to know the incidence, risk factors and outcome of infection to plan
preventive measures accordingly. Methods: This hospital-based observational study was carried out from Jan 2016 to
Dec2016 in the 8-bedded surgical intensive care unit (SICU) of a tertiary care hospital. Results: A total of 554 patients
were admitted in the ICU. 490 of these were included in the study. 45 of these patients developed HAI with a
frequency of 9.18%. The incidence rate (IR) of central line related blood stream infections (CLBSI) was 15.32/1000,
Catheter-associated urinary tract infections (CAUTI) 9.62/1000 and ventilator-associated pneumonias (VAP) was
17.59/1000. Length of stay was found to be an independent risk factor. Conclusion: Routine surveillance is necessary
to know the severity of problem and plan preventive measures and hospital antibiotic policy accordingly.

Keywords-Hospital acquired infection, risk factors, Infection control

Introduction acquired infection may spread between health care

Infections are one of the most common
causes of mortality in the world, more in low and
lower-middle socioeconomic countries [1,2]. India is
seventh largest, second most populated nation of the
world and a land of diversity. So, there are several
parameters which decide the socioeconomic condition
of the nation where diversification exists on practically
every level [3].
Hospital acquired infection is a serious
prevailing issue in critical care unit. They are leading
causes of morbidity and mortality among indoor
patients [4]. This proportion is greater in immune
compromised, patients with underlying diseases,
elderly, undergoing invasive procedures, secondary
infections after exposure to broad-spectrum
antimicrobials [5]. Increased susceptibility can also be
due to risks of aseptic mistakes in patient
management during invasive procedures [6]. It
increases the length of stay, economic burden, causes
disability, reduces quality of life, creates emotional
stress and increased mortality [7-11]. Hospital
faculties through patient transfers and in between
patients also [12]. Further, the growing incidence of
multidrug resistance organisms is a chief concern.
Medico legal issues can also arise, as relatives can
blame hospital staff for the cause. So, it becomes
necessary to have timely and thorough survey to
prevent such complications.
Surveillance of healthcare associated
infections defines the extent and nature of problem,
which is the initial step toward controlling threat of
infection in vulnerable hospitalized patients [6]. It is a
key element which provides data about incidence, risk
factors, causes and set a background for appropriate
intervention methods [13]. These data will help to find
the preventable causes, educate the staff about
importance of asepsis and finally design protocols for
prevention of acquired infection.
This study was designed to determine the
incidence of infection, demographic and clinical risk
factors, bacteriological profile, drug sensitivity
patterns and outcome in a tertiary hospital of

Article History: Article received: Feb 15, 2017; Article revised: March 03, 2017; Article published: March 30, 2017
Corresponding Author: Dr. Annu Choudhary, Senior Resident, Department of Anaesthesia, IGGMC, C.A. Road, Nagpur, Maharashtra, India.
Pin 440018. Email address: anucdry@gmail.com
Shelgaonkar & Choudhary /Research Chronicle in Health Sciences 2017, 3(2), 15-21
Maharashtra. The primary focus was over the current
status of hospital acquired infection and to determine
the preventive measures.
Methodology
After approval from the Institutional Ethics
Committee, we conducted this prospective
observational study in the 8 bedded surgical ICU of a
tertiary care medical college hospital between January
1 and December 31, 2016. Out of the total of 554
patients admitted to the ICU during the one year study
period, 490 patients staying for more than 48 hours in
the ICU were included in the study, less than 48 hours
stay were excluded.
All patients who were above 14 years of age,
admitted in the surgical ICU with different complains
or presentations and developed clinical evidence of
infection that did not originate from patient’s
admitting diagnosis, were included in the study. These
critical patients were referred for observation,
monitoring and critical management from different
departments, e.g. general surgery,
gynaecology/obstetric, orthopaedics, ENT including
emergency department (acute trauma). Data was
collected for all patients admitted in ICU in the
proforma. Patients who were re-admitted 72 h after
discharge from the ICU were regarded as new
admissions. Patients with infection at the time of
admission were included in the non-infected group for
the purpose of analysis. However, such patients were
included in the group with ICU-acquired infection
when they developed a new infection at a different
anatomical site during the ICU stay.
A detailed history of patients was taken along
with thorough clinical examination was performed at
the time of admission. Patients were examined on
daily basis to assess the treatment response and to
detect the evidence of development of any new
infection. Vital parameters, input/output and
temperature were recorded daily. All the routine
investigations such as complete blood count, blood
sugar level, kidney function test, liver function test,
arterial blood gas analysis, urine analysis and chest
radiograph were also done.
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Nosocomial infections were diagnosed
according to the standard definition of the (United
States centers for disease control and prevention
(CDC).Infections studied in present study were central
line-related blood stream infection (CLBSI), catheter-
associated urinary tract infection (CAUTI), ventilator-
associated pneumonias (VAP) and surgical-site
infection (SSI).
Patients who developed any of the signs or
symptoms of acquired infection were immediately
evaluated and sample from probable etiology was sent
to the microbiology department of the institute. Other
relevant investigations were also performed according
to the clinical presentation of patients and also after
taking opinion from consultants of relevant
departments, if required.
Microbiological Analysis
Patients were always sampled for microbial
culture before starting a new antimicrobial drug.
For classification of the different causative
pathogens associated with nosocomial infections, all
the microorganisms isolated on culture from each of
the patients with confirmed infection according to the
CDC definitions were recorded and their relative
frequency of isolation were determined as percentage.
Bacterial isolates were identified by Gram-stain,
cultures on routine media (e.g. Blood agar, MacConkey
agar) and where necessary, selective media and
specific biochemical tests following standard
protocols. Fungal isolates were identified by cultures
on Sabouraud dextrose agar, and Sabouraud dextrose
chloramphenicol agar media followed by Gram-stain,
lactophenol cotton blue mount and germ tube testing
following standard protocols. The interpretation was
based on the recommendations of Clinical Laboratory
Standards Institute (CLSI).
For the determination of risk factors
associated with ICU acquired infection, the following
putative risk factors were recorded-age, gender, site
from where the patient was transferred to the ICU,
16
underlying disease, co-morbidity, mechanical
ventilation, surgical procedure, prior antimicrobial
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therapy, antacid and stress ulcer prophylaxis therapy,
Shelgaonkar & Choudhary /Research Chronicle in Health Sciences 2017, 3(2), 15-21

sedative analgesic therapy, vasopressor therapy, development of nosocomial infection. Other risk
parenteral nutrition, enteral nutrition, blood factors considered did not have significant association.
transfusion, hypoalbuminemia, diabetes mellitus,
chronic renal failure, chronic alcoholism, malnutrition Table 1: Age wise distribution of patients
Age (years) PNAI PAI
and immune-compromise, smoking habits, alcohol or
Number %
drug abuse, presence of ischemic heart disease, 14-45 217 30 13.82
chronic obstructive pulmonary disease, diabetes 46-60 143 12 8.39
mellitus, underlying malignancy, elective or emergency >60 85 3 3.52
PNAI- Number of patients not acquired infection; PAI- Number of
operations during the preceding 14 days, infection on patients acquired infection
admission, and previous antimicrobial therapy. Also,
the presence of invasive lines, central venous Table 2: Clinical characteristics of patients
SN VARIABLE PNAI (n=445) PAI (n=45) P - Value
catheterization, arterial catheterization, peripheral
Length of Stay
venous catheterization, urinary catheterization, 1. 3.36 7.88 <0.05
(Mean days)
endotracheal intubation, tracheostomy, nasogastric Duration of
Mechanical
tube insertion was studied. 2. 2.08 5.86 <0.05
Ventilation
After recording all data, analysis was done at (Mean days)
the end of each month. These data were combined 3. SICU Mortality 182 27 0.0000
and a complete data for year 2016 was prepared. For PNAI- Number of patients not acquired infection; PAI- Number of
patients acquired infection
statistical analysis, quantitative variables were
expressed in terms of mean and standard deviations. Table 3: Patient Characteristics
Qualitative data were expressed as proportions. To SN VARIABLE PNAI PAI P-
test the significance between two proportions chi (n=445) (n=45) Value
1. Pre Admission Infection 135 3 0.002
square test and fisher’s test were used. To test the 2. Category of Admission
significance between two mean t test was used. All Elective 134 6 0.017
results were two tailed and p value <0.05 was Emergency 311 39
3. Comorbidities
considered significant. Open epi software was used to
Malignancy 36 2 0.4966
calculate p-value. DM 49 5 0.7551
IHD 45 4 1.000
Observations and Results COPD 27 0 0.0891
Out of total 554 patients admitted in surgical 4. Source of Admission
ICU, 490 were considered for study. These critical Direct 89 8 0.7729
Wards 366 37
patients were referred from various surgical 5. Addiction
departments and included both elective and Smoking 80 5 0.3982
emergency. There were 356 males and 134 females in Alcohol 62 7 0.5166
study group. Maximum patients were between 14-45 Both 37 1 0.1947
PNAI- Number of patients not acquired infection; PAI- Number of
years age group, followed by patients in 45-60 years patients acquired infection
and then by >60 years age group. The distribution of
patients according to age group is demonstrated in Among the various invasive devices used, the
table 1. order of association with acquiring infection was
The various risk factors were considered in tracheostomy tube > central venous catheter >
present study and tabulated sequentially in table 2 endotracheal tube > intercostal drainage tube >
17

and 3. It was found that duration of ICU stay and urinary catheter > suction drain > nasogastric tube =
mechanical ventilation, pre admission infection and arterial line. Exact values and percentage is shown in
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emergency admissions were strongly associated with

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table 4. But this does not consider the duration of pnemoniae, staphylococcus aureus then E.coli, non
time, invasive device was present in situ. fermenter and polymicrobial were causative organism.
CAUTI contributed 11% of total infection and rate was
Table 4: Relation of Invasive devices and procedures 9.62/1000 intervention days. Organism associated
with SICU Infection were candida albicans, klebsiella pnemoniae,
SN Invasive device & procedure PNAI PAI % enterococci, acinatobacter and staphylococcus. All
1. Urinary Catheter 355 11 3.09
these data are shown in table 5, 6 and 7.
2. Central Venous Catheter 161 8 4.96
3. Arterial Line 15 0 0
4. Endotracheal Tube 226 11 4.86
Table 5: Rate of common ICU infections
5. Tracheostomy Tube 61 10 16.39 SN Type of Total Infection / 1000
Infection Number (%) Intervention Days
6. Suction Drain 222 4 1.80
1. VAP 21 17.59
7. Intercostal drainage Tube 46 2 4.34 2. CAUTI 11 9.62
8. Nasogastric Tube 355 0 0
PNAI- Number of patients not acquired infection; PAI- Number of
3. CLBSI 8 15.32
patients acquired infection 4. SSI 9

The infection percentage in present study was Table 6: Association of Microbiological Isolate and
9.18%. The incidence of ventilator associated Outcome
pneumonia was highest among the acquired infection. Microorganism Duration Outcome
It contributed 21% of total and VAP rate was of Stay Recovered Expired
No. % No. %
17.59/1000 intervention days. Endotracheal tube and
Pseudomonas 29 0 0 4 100
tracheostomy tube acquired infection and positive Aeroginosa
bronchoalveolar lavage were considered. Klebisella 97 5 71.42 7 28.58
Pneumoniae
Acinatobacter was the most common organism found,
Non fermenter 17 2 66.6 1 33.3
followed by klebsiella pnemoniae, pseudomonas Acinatobacter 151 6 50 6 50
auroginosa and E. coli. For CLBSI, percentage out of Candida Albicans 57 1 20 4 80
total infection was 11 and rate was 15.32/1000 Staphylococcus 27 2 40 3 60
Aureus
intervention days as number of days of central line Polymicrobial 6 0 0 1 100
catheter was 522. Acinatobacter followed by klebsiella Enterococci 15 1 25 3 75
E. Coli 13 1 100 0 0

Table 7: Pathogenic Organisms isolated from various specimen

Organism ET TT Pleural Blood Urine BAL Pus Drain
sample sample Fluid Fluid
Pseudomonas 1 2 1
Aeroginosa
Klebisella 4 2 1 2 2 1 1
Pneumoniae
Non fermenter 1
Acinatobacter 3 4 1 3 1 1 1
Candida 5
Albicans
Staphylococcus 2 1 2
Aureus
Polymicrobial 1
Enterococci 2
18

E. Coli 1 1 1 1
There was no significant difference in mortality rate morbidity was surely increased as evident by length of
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between infected and non infected patients. But, stay. This is demonstrated in table 8.

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Table 8: Overall SICU outcome rate is inspite of using HME filter and disposable
Outcome Infected Uninfected Total circuits strictly. For the prevention of VAP, patients are
No. % No. % No. % kept in the semirecumbent position to drain of
Alive 17 58.62 258 57.97 274 55.91
Expired 29 41.32 182 40.89 211 43.06 condensate is performed from ventilator circuits after
Loss to follow up 0 00 5 1.12 5 1.02 a particular time period (after 4-6 h or earlier if need),
Total 45 100 445 100 490 100 regular aseptic subglottic suctioning, adequate
pressure is maintained in endotracheal tube cuff with
Discussion
the help of cuff pressure monitor, and strict adherence
Routine surveillance is prerequisite for
to all the elements of ventilator bundle protocol.
preventing hospital acquired infection. Studies have
Duration of mechanical ventilation is found to
shown that it can reduce the incidence by as much as
be the greatest risk factor along with patient’s intrinsic
30% [14]. In a nation like India with huge population,
condition. Tracheostomized patients had higher
lower socioeconomic standards, less resources, and
infection rate than intubated patients because of long
lower staff to patient ratio, it becomes difficult to
term mechanical ventilation and primary causes of
prevent such complications. But still compliance with
their admission. Acinatobacter (8 cases), klebsiella
simple hygiene care and preventive measures, is
pneumonia (6 cases), pseudomonas (3 cases) and E.coli
possible.
(2 cases) were found in sample which was similar to
ICU beds contribute less than 10% of total
results of a similar study conducted in same state by
beds in any hospital. But they a significant proportion
Singh et al [5]. The frequency of VAP reported in
in hospital acquired infection. There can be multiple
different studies were 6.04/1000 [19], 26.6/1000 [20],
reasons like patients have more co-morbidities, have
32/1000 [5], 40.1/1000 [21] intervention days. The
undergone major procedures, more invasive lines are
higher rate in our study can be due to fewer doctors to
required, immunosuppresion etc. Crude infection rates
patient ratio, as all airway handling is done only by
might not be representative of the overall problem
residents in our set up, but it was less than a few other
since they do not take into account the patients'
studies due to strict asepsis guidelines.
intrinsic risk of infection or extrinsic risks associated
The occurrence of CLBSI depends upon the
with exposure to medical interventions [15,16]. Wide
site, type of catheter, frequency of catheter
variation in rates of ICU acquired infections in various
manipulation, and patient’s primary illness [19]. In our
countries and hospitals of same country point to
set up we included subclavian, internal juglar and
disparities in cases, severity of illnesses, infection
femoral vein canulations. CABSI may occur as a result
control policies, compliance to hand hygiene, staff to
of the entry of pathogenic microorganisms to the
patient ratio and ICU designs and health care
bloodstream via four different routes: local insertion
expenditure of a nation the patient population and the
site colonization, catheter hub contamination,
precise definition and surveillance techniques used to
haematogenous seeding and infusion of contaminated
identify a nosocomial infection [15,17].
fluids [22].
In present study the total infection rate was
The infection rate in present study was
9.18%.VAP contributing the highest (VAP > CRBSI >
15.32/10000 intervention days which was slightly
CAUTI > SSI). Rate of ventilator associated pneumonia
lower than findings of Singh et al (16/1000
was 17.59/1000 intervention days and 21% of total
intervention days) [5], data et al (16.86/1000
acquired infection.VAP was suspected, if patient
intervention days) [19] due to vigilant and efficient
developed any added sound in chest or required
nursing staff. Also, the procedures are done either in
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increased ventilator support with radiographic findings

operation theatre or surgical ICU under strict aseptic
and confirmed by culture/sensitivity of the
condition followed by wrapping the lines with sterile
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endotracheal/tracheostomy/BAL sample. This higher

gauze, which was changed every day. But it was quite

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higher than findings of dasgupta et al (2.46/1000
intervention days) [20], may be because it was a
shorter duration study of 6 months only. Also, central
venous access were needed for extended periods of
time in our SICU and the catheter was manipulated
multiple times per day for the administration of fluids,
drugs, blood products and sampling purpose by staff
and residents. Further, some catheters were inserted
in emergency situations, when optimal aseptic
technique might not be feasible. Pathogenic organisms
noted were acinatobacter, klebsiella pneumonia,
staphylococcus aureus followed by E.coli and non
fermenters.
The incidence rate of CAUTI is 9.62/1000
intervention days in our study. This was similar to
findings of Singh et al (9/1000 intervention days) [5],
data et al (9.08/1000 intervention days) [19], and
Yadav et al 98.73/1000 intervention days) [23].
Candida species is the most frequently isolated
uropathogen in present study consistent with the
findings of the previous study [22]. This may be
attributed to the fact that, Candida species, a normal
genital flora becomes pathogenic under various
factors like prolonged catheterization, surgery, broad
spectrum antibiotics etc [24]. This lower incidence is
due to our nursing staff that takes care of foley’s
catheter. It is cleaned daily and urobag is emptied
timely as required. Foley’s catheter and urobag were
changed every seventh day.
Surgical site infection may arise in ICU
patients who are immunocompromised, older age,
diabetic, prehospital stay, the quality of surgical
technique, presence of foreign bodies including drains,
and the experience of the surgical team. The incidence
rate was 9% of total infection. Acinatobacter, klebsiella
pneumonia, pseudomonas aeroginosa and E.colito
prevent any acquired infection; daily dressing is done
surgery resident and wound care by nursing staff.
Conclusion
In a developing nation like India with huge
population and limited health resources, hospital
acquired infection imposes a great burden. It increases
the morbidity and mortality by several ways. In our
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study we found that ventilator associated pneumonia
is commonest acquired infection with acinatobacteras
main culprit. The routine surveillance will emphasis on
the severity of problem and help in planning
preventive measures. We recommend to increase the
nursing manpower, education and awareness among
health care workers and to have tailor made hospital
antibiotic policy as well as adherence to standard
guidelines for prevention of hospital acquired
infection.
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