Hospital Associated Infections and

epidemiological markers

Dr. Ritu Amatya

 Introduction

• Advances in Medical therapeutics and intervention

procedures have revolutionized medical sciences

• Increase in the use of expensive heat labile instruments

• Increase in the number of immunocompromised host

 Introduction (cont)

• Increase in the infections associated with health care -

HAI

• Some are endemic and source endogenous

• Some are outbreaks and sources exogenous ( target

of control program)

• Problems more in the overburdened hospitals of

developing countries
 Hospital Associated Infections
(Nosocomial infections)

• Clinically recognizable microbiologic

disease developing in a patient after 48
hours of admission to the hospital

• or as a consequence of his attending

hospital for treatment

• or the hospital staff as a consequence of

their work
 Routes of Transmission

• Contact Direct or indirect

• Droplet(>5microns)

• Airborne(<5microns)

• Additional Equipments, solutions,

blood, water
Health care personnel as a source
Nosocomial Infections Organisms*

▪ Respiratory tract infections Gram negative-

▪ Urinary tract infections ▪ Enterobacteriaceae
▪ Surgical site infections ▪ Psuedomonas aeruginosa
▪ Blood stream infections ▪ Acinetobacter sp.

Gram positive-
▪ Staphylococcus aureus
▪ CoNS
▪ Enterococcus fecalis/fecium

*multidrug resisitant
 Organisation of HIC Programme –
Administrative Aspects
• Organization-Infection control team, Infection control
committee

• Formulation of policies on infection control

• Implementation of policies

• Surveillance and feedback of results

• Staff immunization and occupational health

• Education and training of staff
 Infection Control Process

• Surveillance
• Designing the building
• Safe procedures
cleaning, sterilization and disinfect ion
standard procedures and OT practices
isolation
• Use of antibiotics
• Health of staff
• Education
Infection control is a quality standard of patient care

&

needs a proper infection control program

 Surveillance of HAI

• Important activity of the ICT

• The routine collection of data on hospital acquired

infections

• Analysis of this data

• Feedback of the results to infection control committee,

clinicians and nursing staff
 Objectives of Surveillance

• Monitor and identify the spread of infection

• Observe practices related to infection control and

their efficacy

• Detect unusual changes in the level of infection

and rapid implementation of control measures.

• Monitor antibiotic use and resistance

 Types of Surveillance

• Active surveillance– prospective, clinical and laboratory

criteria, more accurate infection rates

• Passive surveillance –retrospective- depends on

laboratory records only

• Should be cost effective , limited to specific areas

• ICT must be trained to detect “ Alert” conditions

 Case Definitions for classifying HAI

CDC criteria of including a case as HAI

e.g.
• Ventilator associated pneumonia (VAP)
• Urinary tract infections
• Laboratory confirmed blood stream infection (LC-BSI)
• Catheter related blood stream infections (CR-BSI)
• Surgical Site Infections
 Surveillance of staff

• Staff for nasal carriers of MRSA, carriers of Salmonella

typhi or HIV

• Limited role, only in suspected outbreak

• HIV testing must follow the guidelines recommended

 Environmental surveillance

• Category 1- Compulsory

Monitoring sterilization and disinfection

Parenteral or other fluids prepared in-house

Critical care areas

Random checks for disinfected equipments

 Environmental surveillance (cont.)

● Category 2- Optional

Operating room

New born nurseries

Dialysis units
 Environmental surveillance (cont.)

● Category 3- Not recommended

Routine surveys of patients of hospital personnel

Routine surveys of commercial sterile products
Post fumigation swabbing

● Category 4- Epidemiologically determined testing.

 Microbiology Laboratory in Surveillance

• Laboratory record of culture and antibiotic sensitivity

results

• Testing biological indicators of autoclaves

• “in-use” test of chemical disinfectants-The working

solution of the disinfectants being used in the hospital
are sampled at different times during their use
 Rapid in-use tests for 2% gluteraldehyde

The efficacy of gluteraldehyde after activation over a

period of use can be tested at site using the
“sterilog strips (3M)”

Testing bacteriological quality of water

Surveillance is not an end but an instrument for

measuring effectiveness of infection control

program

and enabling action to be taken

Biomedical waste segregation
 Introduction

• Hospital waste: All waste ,either biological or non

biological generated from hospital

• Covers the process of collection to disposal of waste

• Risk to individual and environment from improper

disposal or handling of hospital waste

• Waste generated: 1-2kgs/bed/day, only about 5%

infectious
BIOHAZARD
 Hospital waste

Non- Hazardous
Hazardous

Infectious,pathological Other
Municipal S Hazardous
dumps P
E •Non-sharp •Radioactive
C •Sharp
I •Glass wares
A •Plastic •Chemicals
L disposable •Cytotoxic
•Liquid •Incineration ash
tt
 Categories of BM Waste

Category Waste
1 Human Anatomical
2 Animal
3 Microbiology & Biotechnology
4 Sharps
5 Discarded Medicines & Cytotoxic Drugs

6 Soiled (Contaminated with Blood & Body Fluids)

7 Solid (Disposable Items other than Sharps)

8 Liquid
9 Incineration
10 Chemical
 Colour Coding for BMW

• Maximum 5 colours– Red, Blue, Yellow, Black & White

• Minimum 4 colours – Blue, Yellow, Black & White
• Ideally same all over the state / region
 Colour Coded Segregation of BMW
(As Per Bio-Medical Waste (Management & Handling Rules) 1998)

Waste Categories
• 1,2, 3, & 6
Type of Container
• Plastic bags (Non chlorinated) and bins
Waste Items
• Items contaminated with blood and body
fluids e.g. Cotton dressings, soiled plaster
cast etc.
Yellow • Human tissues, organs e.g. amputated limbs
etc.
• Laboratory wastes e.g. stock / culture
solutions, live attenuated vaccines etc.
• Waste from animal houses / experimental
laboratories.
Treatment Options
• Incineration / Deep burial
 Colour Coded Segregation of BMW
(As Per Bio-Medical Waste (Management & Handling Rules) 1998)

Waste Categories
• 4, 7 & 6 (for red only)
Type of Container
• Plastic bags and bins
Waste Items
Blue • Solid waste generated from disposable
items e.g. catheters, IV sets, BT sets,
Red tubings, blood bags etc.(except sharps)

• Glassware from laboratories used for

transfer of cultures, stock solutions,
vaccines sera etc (which cannot be
incinerated)
Treatment Options
• Autoclaving or micro waving shredding
 Colour Coded Segregation of BMW
(As Per Bio-Medical Waste (Management & Handling Rules) 1998)

Waste Categories
• 5, 9 & 10 (solids)
Type of Container
• Plastic bags and bins
Waste Items
• Discarded medicines/drugs– outdated,
contaminated,
• Ash from incinerators
Black • Chemical wastes – expired insecticides,
chemicals used in laundry etc.
• All non-hazardous – “general” waste from
kitchen, offices, cafeteria, computer facility
etc
Treatment Options
• Municipal authority  Secure landfills
 Colour Coded Segregation of BMW
(As Per Bio-Medical Waste (Management & Handling Rules) 1998)

Waste Category
• 4

Type of Container
• Puncture proof plastic / metal containers

Waste Items
White/ • Waste sharps (any item which can cause
Transparent cuts) e.g. needles, syringes, scalpels,
blades, veinflow etc

Treatment Options
• Needle destroyer (direct)1% bleach soln.
• Contact period 30 mins
• Change soln. daily
• From soln. to blue bag
 Conclusion
• Proper segregation is the ‘core’ of all
functions

• Collection & transportation forms the

vital link between generation &
treatment of waste

• The human element is more important

well trained, motivated staff and change
in the attitude is the key
Prevention of Hospital-Associated
Infections
Measures to control spread of infections from different sources in a hospital
• Universal / Standard precautions
• Transmission-based precautions
• Hospital associated respiratory infections
• Surgical site infections
• Urinary tract infections
• Intravascular catheter related infections
Barrier precautions
 Hospital associated respiratory infections

• Nosocomial pneumonia is one of the most serious hospital

associated infections
• Defined as lower respiratory tract infection that
appears during or after hospitalization of the
patient who was not incubating the infection on
admission to hospital
• The diagnostic criteria are:
– Fever, cough, development of purulent sputum
– Radiological changes showing progressive
infiltration,
– Sputum Gram stain showing > 25 WBCs per LPF
 Surgical site infections

• Infection in the surgical site that occurs within

30 days of the surgical procedure or within one
year if there is an implant or foreign body such
as prosthetic heart valve or joint prosthesis
• Factors which influence the frequency of surgical
site infections include:
– Surgical technique
– Extent of endogenous contamination of the
wound at surgery (clean, clean-contaminated)
– Duration of operation
– Underlying patient status
– Operating room environment
– The number of organisms shed from the skin
of the operating room team and from the skin
of the patient
 Urinary tract infections

• Definition: An infection of the urinary tract that was

not incubating at the time of admission
• Usually caused by faecal organisms that lead to
ascending infection of the urinary tract
• The great majority of these infections are associated
with an indwelling urethral catheter
• The diagnostic criteria are:
– Fever, suprapubic tenderness, frequency & dysuria
– Presence of bacteria in urine in significant numbers
Hospital-associated UTI Prevention
Selection of catheter size
The smallest size which fits
should be used to avoid
trauma
Insertion technique of
catheter Aseptic “no touch”
technique, use sterile gloves,
hygienic hands and perineal
disinfection prior to insertion
Hospital associated UTI Prevention
Drainage system
Closed system of drainage
prevents infections, hygienic
hand disinfection prior to
manipulation of drainage
Training of health care system
workers
Education & training helps to
avoid infections
Traumatic insertion of Recommended technique
catheter should be followed
 Intravascular catheter related infections

• Exit site infections: Infections with erythema,

tenderness, induration or purulence within 2 cm of
the skin at the exit site of the catheter. Commonly
caused by- Staphylococcus aureus, CoNS
• Bloodstream infections: may follow colonization of
peripheral or central venous line catheters. Growth
of > 15 (semi-quantitative) or > 103 (quantitative)
CFU from the catheter segment
• Contaminated infusions can lead to bacteraemia or
systemic infection and are mainly caused by gram
negative rods
Infection risks with IV Prevention
catheters
Catheter system To be avoided unless indicated
Prolonged catheterization to be
Duration avoided
Strict aseptic technique to be used
Skin preparation Catheter should be removed

Infection or colonization of catheter

 EXPOSURE

Defined as
per-cutaneous injury ( needle-stick or cut with a sharp
object) or
contact of mucous membrane or non-intact skin

( skin that is chapped, abraded, or afflicted with dermatitis)

with blood, tissue, or other body fluids that are
potentially infectious .

CDC-MMWR Sept 30, 2005 / Vol. 54 / No. RR-09

– Updated US PHS Guidelines for Management of Occup Exposure to HBV,HCV and HIV
and Recommendations for PEP
Estimated Risk of Infection Following a Needle-stick from an Infected Source-
Patient

35%
30% **Simonsen et al WHO bulletin 77,1999
30%

25%

20%

15%

10%

5% 3%
0.30%
0%
Hepatitis B Virus Hepatitis C Virus HIV
PEP for HBV Exposure
 Hepatitis B - Risk of Disease
depends on the HBeAg status

Clinical Hepatitis Seroconversion

Both +ve
Only Both +ve O nly HbsAg +ve
HbsAg +ve
22-31%
1-6%
37-62% 23-37%
HBV Remains active in dried blood at Room Temperature for at
least 1 Week
Can be a major cause of transmission
CDC-MMWR Sept 30, 2005 / Vol. 54 / No. RR-09
– Updated US PHS Guidelines for Management of Occup Exposure to HBV,HCV and HIV and
Recommendations for PEP
 PEP for HBV Exposure
HCP Vaccinated HCP Not Vaccinated

Antibody >10 mIU/ml Antibody <10 mIU/ml Vaccination (within 7

days) + HBIg (0.06
ml/Kg)
No PEP

Source HBsAg -ve Unknown Source Source HBsAg +ve

HCP:Booster dose or HCP:Booster dose or

Complete series Complete series + HBIg
 PEP for HCV Exposure
Determine status of source

No active prophylaxis
Immunoglobulins, immunomodulators antivirals not
recommended

Baseline antiHCV and after 6 months

Baseline ALT and monthly for 4 months
HCV RNA when ALT raised
PEP FOR OCCUPATIONAL EXPOSURE TO HIV
IN HCP
 RISK OF HIV
Type of Exposure
0.3
0.3
Risk /100 exposures

0.25

0.2

0.15
0.09
0.1

0.05
0
0

Intact skin Mucous Membrane

Percutaneous Exposure
1. Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med
1997;102(suppl 5B):9–15.
2. Ippolito G, Puro V, De Carli G, Italian Study Group on Occupational Risk of HIV Infection. The risk of occupational human
immunodeficiency virus in health care workers. Arch Int Med 1993;153:1451–8.
 IMMEDIATE TREATMENT OF EXPOSURE SITE

• Wash wound & skin site with soap and water

• Mucous membrane to be flushed with water
• Application of caustic agents or injection of
antiseptics into wound not recommended
 Follow-up HIV Testing of Exposed Person

•If source HIV positive, test at 6 weeks, 3

months, 6 months
– EIA standard test
– direct virus assays not recommended
• Extending follow-up to 12 months
– recommended for HCP who become infected
with HCV following exposure to co-infected
source
– optional in other situations
 Conclusion

• Occupational exposure management is complex

• Prevention is best
• Update oneself on all aspects of PEP
• Ensure reporting setup
• Ensure access to PEP medications and expert advice
 Epidemiological markers

• Biotyping
• Antibiogram
• Plasmid profile
• Bacteriophage typing
• Molecular typing
 (Nightingale, 1863)

“ It may seem a strange principle to enunciate as

the very first requirement in a Hospital that it
should do the sick no harm……..the actual
mortality in hospitals especially in those of large
crowded cities, is very much higher than any
calculation founded on the mortality of the same
class of diseases among patients treated out of
hospital……”