NOSOCOMIAL INFECTION

Nosocomial disease
a hospital acquired disease Up to 15% of hospitalized patients get a nosocomial infection. (WHO 2002 ; 8,7%) Most nosocomial infections are caused by opportunistic pathogens that are typically considered to be Normal Flora.

Centers for Disease Control Atlanta, defined :

Nosocomial Infection as a localized infection or one that is widely spread throughout the body that results from an adverse reaction to an infectious microorganism or toxin that was not present at the time of admission to the hospital

who
An infection acquired in hospital by a patient who was admitted for a reason other than that infection An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission

Nosocomial infections
Infections are considered nosocomial if they first appear 48 hours or more after hospital admission. The most common nosocomial infections are of the urinary tract, and various pneumonias.

Usually related to a procedure treatment used to treat the patient

or

Transmission of infection within a hospital requires three elements

a source of infecting microorganisms a susceptible host a means of transmission for the microorganism.

Factors contributing to nosocomial infections

host
People are as a reservoir or source of microorganisms, as the transmitter of microorganisms and as a receptor for microorganisms Infections coming from another person in the hospital (cross-infection), from an inanimate object recently contaminated by a human source (environmental infection) or may be caused by a patients own flora (endogenous infection).

sources
Human sources may be patients, personnel, visitors, persons with acute disease, persons in the incubation period of a disease, persons who are colonized by an infectious agent but have no apparent disease, or persons who are chronic carriers of an infectious agent. Environmental objects that have become contaminated, including equipment and medications.

Types of nosocomial infections

Why nosocomial infections are so common:

Hospitals house large numbers of people who are sick and whose immune systems are often in a weakened state. medical staff move from patient to patient, providing a way for pathogens to spread. many medical procedures bypass the body's natural protective barriers. routine use of anti-microbial agents in hospitals creates the emergence of resistant strains

etiology
The most common microbiological cause of nosocomial infection is bacteria. Gram-negative bacteria, E.coli, Proteus mirabilis and other members of the family Enterobacteriacaea are predominant. These bacteria are residents of the intestinal tract, spread via fecal contamination of people, instruments or other surfaces. Other Gram-negative : Pseudomonas and Acinetobacter

etiology

Gram-positive bacteria, especially Staphylococcus coagulase negative, frequently cause infections of wounds. This bacterium is part of the normal flora on the surface of the skin, and so can readily gain access to a wound or surgical incision

Bacteria
Commensal bacteria found in the normal flora of healthy humans, have a significant protective role by preventing colonization by pathogenic microorganisms. Some commensal bacteria may cause infection if the natural host is compromised. For ex, Staphylococcus epidermidis causes IV line infection, Escherichia coli (E. coli) are the most common cause of urinary infection.

Pathogenic bacteria have greater virulence, and cause infections regardless of host status. For example:
Anaerobic

Gram-positive rods (e.g. Clostridium) cause gangrene. Gram-positive bacteria: Staphylococcus aureus (bacteria that colonize the skin and nose of patients and hospital staff) cause a wide variety of lung, bone, heart and bloodstream infections and are frequently resistant to antibiotics

 Gram-negative

(e.g. E. coli, Proteus, Klebsiella, Enterobacter, Serratia marcescens) may also be highly antibiotic resistant. Pseudomonas spp. are often isolated in water and damp areas. They may colonize the digestive tract of hospitalized patients. other bacteria are a unique risk in hospitals. Legionella species may cause pneumonia through inhalation of aerosols containing contaminated water (air conditioning, showers, therapeutic aerosols).

bacteria: Enterobacteriaceae

Viruses
Including the 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 fecal-oral route) Other viruses such as cytomegalovirus (CMV), HIV, Ebola, influenza viruses, herpes simplex virus, and varicella-zoster virus, may also be transmitted.

Parasites and Fungi

Giardia lamblia are transmitted easily fungi and parasites are opportunistic organisms and cause infections during extended antibiotic treatment and severe immunosuppression (Candida albicans, Aspergillus spp., Cryptococcus neoformans, Cryptosporidium), cause of systemic infections among immunocompromised patients. Environmental contamination by airborne organisms such as Aspergillus spp. which originate in dust and soil, especially during hospital construction. Sarcoptes scabies (scabies) is an ectoparasite which has repeatedly caused outbreaks in health care facilities.

Predisposition to infection
People in hospitals are usually in a poor state of health, impairing their defence against bacteria Acute disease can greatly increase the risk of infection burns and trauma cause the loss of skin, an important barrier against infection.

Invasive devices, for instance intubation tubes, catheters, surgical drains and tracheostomy tubes bypass the bodys natural lines of defence against pathogens. immunosuppression and antacid treatment undermine the bodys defences, while antimicrobial therapy (removing competitive flora and only leaving resistant organisms) recurrent blood transfusions, parenteral nutrition have all been identified as risk factors.

Predisposition to infection

Transmission
Direct-contact between a susceptible host and an infected person, such as occurs when a person turns a patient, gives a patient a bath, or performs other patientcare activities that require direct personal contact. also can occur between two patients, with one serving as the source of the infectious microorganisms and the other as a susceptible host.

Transmission
Indirect-contact,

involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, or contaminated hands that are not washed and gloves that are not changed between patients

Major routes of transmission and prevention of spread of nosocomial pathogens.

Droplet transmission
is a form of contact transmission. Droplets are generated from the source person primarily during coughing, sneezing, and talking, and procedures such as suctioning and bronchoscopy. Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance through the air and deposited on the host's conjunctivae, nasal mucosa, or mouth.

Airborne Transmission
occurs by dissemination airborne droplet nuclei (small-particle residue 5 m or smaller) of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time, or by dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient Microorganisms transmitted by airborne transmission include M. tuberculosis, rubeola and varicella viruses.

Other Transmission
Common Vehicle Transmission applies to microorganisms transmitted by contaminated items such as food, water, medications, devices, and equipment. Vectorborne Transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin transmit microorganisms

Which Nosocomial Infections Are Emerging?

Acquired antimicrobial resistance VRE and MRSA are the major gram-positive pathogens of concern P. aeruginosa, Klebsiella, and Enterobacter have chromosomal or plasmid-mediated beta-lactamase enzymes are the major resistant gram-negative pathogens The contribution of antibiotic resistance to excessive death rates in hospitals is difficult to evaluate, antimicrobial resistance contributes to nosocomial deaths. viral and fungal resistance could become important because of the small number of therapeutic options