Nosocomial infection

DEFINITION
• Nosocomial infection is
an infection that is not
present or incubating
when a patient is
admitted to a hospital
• Nosocomial infections are infections that are
a result of treatment in a hospital or a healthcare
service unit.
• Infections are considered nosocomial if they first
appear 48 hours or more after hospital
• Infections that occur after the patient is
discharged from the hospital can be considered
healthcare-associated if the organisms were
acquired during the hospital stay.
• Healthcare-associated infections are most
commonly caused by viral, bacterial, and
fungal pathogens.
• These pathogens should be investigated
in all febrile patients who are admitted for
a nonfebrile illness or those who develop
clinical deterioration unexplained by the
initial diagnosis.
 Your baby was born prematurely.

She was progressing in the neonatal intensive

care unit until she developed a bloodstream
infection related to her umbilical catheter.
Your father has open heart surgery.

The surgery goes well

but he later dies in a
nursing home of a
MRSA wound infection
that developed after
surgery.
 Your sister contracts Clostridium
difficile after giving birth.

She has lived with this unbearable

infection through 6 months of relapses.
 Your mother is being treated for cancer
• And now has to fight two diseases because
she got Hepatitis C from an unsafe
injection
 HAI Burden
What is Known: Acute Care Settings
• 1.7 million infections (5% of all admissions)
– Most (1.3 million) were outside of ICUs
• $28–33 billion in excess costs
• 99,000 associated deaths
• Most common type of infections:
– Bloodstream infections (BSI)
– Urinary tract infections
– Pneumonia
– Surgical site infections

Klevens, et al. Pub Health Rep 2007;122:160-6

 TYPES OF NCI BY SITE

1. Urinary tract infections (UTI)

2. Surgical wound infections
(SWI)
3. Lower respiratory infections
(LRI)
4. Blood stream infections (BSI)
Known nosocomial infections
• Ventilator associated pneumonia (VAP)
• Staphylococcus aureus
• Methicillin resistant Staphylococcus aureus (MRSA)
• Pseudomonas aeruginosa
• Acinetobacter baumannii
• Stenotrophomonas maltophilia
• Clostridium difficile
• Tuberculosis
• Urinary tract infection
• Hospital-acquired pneumonia (HAP)
• Gastroenteritis
• Vancomycin-resistant Enterococcus (VRE)
 TYPES BY ORIGIN
1.Endogenous:
Caused by the organisms that are
present as part of normal flora of
the patient
2. Exogenous:
caused by organisms acquiring by
exposure to hospital personnel,
medical devices or hospital
environment
• The germs can survive for a long time
on surfaces in the hospital
and
enter the body through:
- wounds
- catheters
- ventilators
• Most patients who have healthcare-
associated infections caused by bacterial
and fungal pathogens have a
predisposition to infection caused by
invasive supportive measures such as
endotracheal intubation and the placement
of intravascular lines and urinary
catheters.
 Invasive devices:
 - intubation tubes
 - catheters
 - surgical drains
 - tracheostomy tubes
all bypass the body’s natural lines of
defence against pathogens and provide an
easy route for infection.
 Risk factors
general risk:
-advanced age
-premature birth
-antimicrobial therapy (removing competitive
flora and only leaving resistant organisms)
- recurrent blood transfusions
specific risks - for instance, chronic obstructive
pulmonary disease can increase chances of
respiratory tract infection.
• Patient-related risk factors for invasion of
colonizing pathogen include:
• severity of illness
• underlying immunocompromised state
• and/or the length of in-patient stay
In 2006, the most common infection sites were:
• urinary tract infections (30,3 %)
• pneumopathy (14,7 %)
• infections of surgery site (14,2 %)
• infections of the skin and mucous membrane
(10,2 %)
• other respiratory infections (6,8%)
• bacterial infections / blood poisoning (6,4 %).
 Causes

• The top 3 pathogens for urinary tract

infections:
- Escherichia coli (19%)
- C albicans (14%)
- P aeruginosa (13%).
Gram-negative enteric organisms accounted
for about 50% of all urinary tract infections.
• The top 3 pathogens for pneumonia:
- P aeruginosa (22%)
- S.aureus (17%)
- Haemophilus influenzae (10%).
• The top 3 pathogens for surgical site infections:
• S aureus (20%)
• P aeruginosa (15%)
• coagulase-negative staphylococci (14%).
Surgical site infections (SSI) occur within 30
days after the operative procedure or within
1 year if an implant was placed
Criteria for the diagnosis of SSI
• purulent drainage at the site of incision
• clinical symptoms of infection (such as
pain, redness, swelling, etc),
• presence of an abscess
• isolation of organism from the site culture
• clinical diagnosis of SSI by the surgeon.
• The top 3 pathogens in bloodstream
infections:
- coagulase-negative staphylococci (38%)
- Enterococcus (11%)
- S aureus (9%)
Candida albicans accounted for about 5.5%
of bloodstream infections
• Rotavirus is the most common cause of
acute gastroenteritis in hospitalized
children, with greatest susceptibility in
children younger than 3 years
• Other viruses that can cause hospital-
associated gastroenteritis include
norovirus and adenoviruses.
• Clostridium difficile is the most important
bacterial cause of healthcare-associated
gastroenteritis.
• Associated clinical conditions include
asymptomatic carriage, diarrhea, and
pseudomembranous colitis.
• Diagnosis is suspected in a patient with diarrhea
and recent history of antibiotic use (especially
cephalosporins and clindamycin).
 Transmission

• Contact transmission
• Droplet transmission
• Airborne transmission
• Common vehicle transmission
• Vector borne transmission
 Contact transmission
• the most important and frequent mode of
transmission of nosocomial infections
• divided into two subgroups:
- direct-contact transmission
- indirect-contact transmission.
 Direct-contact transmission
• involves a direct body surface-to-body surface
contact and physical transfer of microorganisms
between a susceptible host and an infected or
colonized person, such as occurs when a
person turns a patient, gives a patient a bath, or
performs other patient-care activities that require
direct personal contact.
• Direct-contact transmission also can occur
between two patients, with one serving as the
source of the infectious microorganisms and the
other as a susceptible host.
 Indirect-contact transmission
• involves contact of a susceptible host with
a contaminated intermediate object,
usually inanimate, such as contaminated
instruments, needles, or dressings, or
contaminated gloves that are not changed
between patients
 Droplet transmission
• occurs when droplets are generated from
the source person mainly during coughing,
sneezing, and talking, and during the
performance of certain procedures such
as bronchoscopy.
• Transmission occurs when droplets
containing germs from the infected person
are propelled a short distance through the
air and deposited on the host's body.
 Airborne transmission
• occurs by dissemination of either airborne
droplet nuclei (small-particle residue {5 µm or
smaller in size} of evaporated droplets
containing microorganisms that remain
suspended in the air for long periods of time) or
dust particles containing the infectious agent.
• Microorganisms transmitted by airborne
transmission include Legionella, Mycobacterium
tuberculosis, rubeola and varicella viruses.
 Common vehicle transmission
• applies to microorganisms transmitted to
the host by contaminated items such as
food, water, medications, devices, and
equipment.
 Vector borne transmission

• occurs when vectors such as mosquitoes,

flies, rats, and other vermin transmit
microorganisms.
 Frequency

• Healthcare-associated infections are estimated

to occur in 5% of all hospitalizations in the
United States
• Both developed and resource-poor countries are
faced with the burden of healthcare-associated
infections.
• In a World Health Organization (WHO)
cooperative study (55 hospitals in 14 countries
from four WHO regions), about 8.7% of
hospitalized patients had nosocomial infections.
 Mortality/Morbidity

• Healthcare-associated infections result in

excess length of stay, mortality and
healthcare costs.
 Physical

• In addition to the presence of systemic signs and

symptoms of infection:
- fever
- tachycardia
- tachypnea
- skin rash
-general malaise
the source of healthcare-associated infections may
be suggested by the instrumentation used in
various procedures
• an endotracheal tube may be associated
with sinusitis, tracheitis, and pneumonia
• an intravascular catheter may be the
source of phlebitis or line infection
• a Foley catheter may be associated with
a urinary tract infection.
 Differentials

• Acinetobacter
• Adenoviruses
• Burn Wound Infections
• Candidiasis
• Clostridium Difficile Colitis
• Colitis
• Croup
• Endocarditis, Bacterial
• Endocarditis, Fungal
• Enterobacter Infections
• Enterococcal Infections
• Enteroviral Infections
• Escherichia Coli Infections
• H1N1 Influenza (Swine Flu)
• Hepatitis A
• Hepatitis B
• Hepatitis C
• HIV Disease
• Influenza
• Legionella Infection
• Measles
• Nursing Home Acquired Pneumonia
• Parainfluenza Virus Infections
• Pseudomonas Infection
• Respiratory Syncytial Virus Infection
• Rhinovirus Infection
• Sepsis, Bacterial
• Stenotrophomonas Maltophilia
• Streptococcus Group A Infections
• Thrush
• Toxic Shock Syndrome
• Tuberculosis
• Urinary Tract Infection
• Varicella-Zoster Virus
 Medical Care

• Symptomatic treatment of shock,

hypoventilation, and other complications
should be provided, along with
administration of empiric broad-spectrum
antimicrobial therapy
 Bloodstream infections

• Line removal should be considered if:

• the line is no longer needed
• the infection is caused by S aureus, Candida species, or
mycobacteria
• the patient is critically ill;
• the patient fails to clear bacteremia in 48-72 hours;
• symptoms of bloodstream infection persist beyond 48-
72 hours;
• noninfectious valvular heart disease, endocarditis,
metastatic infection, or septic thrombophlebitis is
present.
• Antibiotics with coverage against gram-positive
and gram-negative organisms, including
Pseudomonas, should be empirically started and
then tailored according to susceptibility pattern
of isolated organisms.
• Antifungal therapy (eg, fluconazole,
caspofungin, voriconazole, amphotericin B) in
some cases are added to empiric antibiotic
coverage
• Antiviral therapy (eg, ganciclovir, acyclovir) can
be used in the treatment of suspected
disseminated viral infections
• Duration of therapy depends on several factors,
including isolated pathogen, retention of
catheter, or presence of complications
(endocarditis, sepsis).
• For most bacterial organisms, the duration of
therapy is 10-14 days after blood cultures
become negative.
 Pneumonia

• Initial empiric antibiotic therapy should be broad and

later on streamlined based on results of examination and
cultures of sputum, endotracheal suction material and
bronchial lavage wash.
• The choice of empiric antibiotic coverage should take
into consideration the risk for multidrug-resistant
(MDR) pathogens.
• Risk factors for MDR include antimicrobial therapy over
the past 90 days, current hospitalization of 5 days or
more, high frequency of antibiotic resistance in the
community, or hospital and immunosuppression.
• No clear consensus has been reached as to the
duration of antimicrobial therapy for
ventilator-associated pneumonia (VAP).
• Many experts treat for 14-21 days.
• However, shorter course of antibiotic therapy
(about 1 wk) may be adequate therapy for some
cases.
• Antiviral medications against influenza have
been used to treat symptomatic patients and
patients with immunodeficiency or chronic lung
diseases to limit morbidity and mortality.
 Urinary tract infection

• Indwelling catheters should be

removed if possible, to avoid persistence
and recurrence of infection.
• In some cases, removal of catheter may
result in spontaneous resolution of
bacteriuria or asymptomatic cystitis.
• Empiric antibiotic and antifungal therapy
should be considered to avoid major
complications, including pyelonephritis, renal
damage, and bloodstream infections.
• Duration of therapy is controversial.
• Most experts recommend at least 10-14 days of
therapy for children with sepsis, pyelonephritis,
or urinary tract abnormalities.
 Surgical-site infection

• Surgical-site infections (SSIs) should be

managed with a combination of surgical
care and antibiotic therapy.
• Antibiotic coverage should be modified
once culture results are available.
• Severe infections such as streptococcal
gangrene and extensive tissue necrosis
need aggressive surgical intervention
 Other healthcare-associated infections

• Rotavirus gastroenteritis is a self-limited

disease and only needs supportive care.
Medical management should focus on
preventing dehydration
• Treatment is not necessary for asymptomatic carriers of
Clostridium difficile.
• For those who have mild symptoms, discontinuance of
antibiotics alone may result in resolution of symptoms.
• For those who have more severe diarrhea, oral
metronidazole is the preferred treatment.
• Oral vancomycin is reserved for treatment failure with
metronidazole.
• Clinical improvement is usually seen within 2 days of
initiating therapy, and duration of treatment is usually 10
days
 Prevention

• Hospitals have sanitation protocols regarding

uniforms, equipment sterilization, washing, and
other preventative measures.
• Thorough hand washing
use of gloves
use of alcohol rubs by all medical personnel
before and after each patient contact is one of
the most effective ways to combat nosocomial
infections.
• More careful use of antimicrobial agents,
such as antibiotics, is also considered vital
• patients are often prescribed antibiotics and
other antimicrobial drugs to help treat
illness; this may increase the selection pressure
for the emergence of resistant strains.
• Moreover, multidrug-resistant infections can
leave the hospital and become part of the
community flora if we do not take steps to
stop this transmission.
 Isolation

• Isolation precautions are designed to

prevent transmission of microorganisms
by common routes in hospitals.
• Because agent and host factors are more
difficult to control, interruption of transfer of
microorganisms is directed primarily at
transmission.
 Surface sanitation

• Modern sanitizing methods such as:

NAV-CO2 have been effective against
gastroenteritis, MRSA, and influenza
Hydrogen peroxide is effective against
endospore-forming bacteria, such as
Clostridium difficile, where alcohol has
been shown to be ineffective
• A Bio-Intervention process is effective for hard
surface disinfection, providing a 6-log kill
(99.9999%)for many organisms including MRSA,
VRE, Psudomonas aeruginosa, Staphylococcus
aureus, Rhinovirus, Salmonella enterica, H1N1,
HIV-1 and Hepatitis A.
• The unique kill mechanism is new to the market
and will be an effective method against mutation
and resistance of organizations.
 Mitigation

• The most effective technique of controlling nosocomial

infection is to strategically implement QA/QC(quality
assurance/quality control) measures to the health care
sectors and evidence-based management can be a
feasible approach.
• For those VAP/HAP diseases (ventilator-associated
pneumonia, hospital-acquired pneumonia), controlling
and monitoring hospital indoor air quality needs to be on
agenda in management
• for nosocomial rotavirus infection, a hand hygiene
protocol has to be enforced
• Other areas that the management needs
to be covered include ambulance transport
 Occupational exposures

Occupational exposures to bloodborne and other

pathogens and consequent infection can occur not
only as the result of accidents, but also during the
performance of routine work activities.
Therefore, it makes good sense to plan your work
with regard to the basic principles of biosafety.
 Hepatitis C Virus (HCV)
• Flavivirus; non-A non-B virus
• Acquired through blood contact – blood
transfusions, needle sharing by drug abusers
• Infections with varying characteristics -75-85%
will remain infected indefinitely; possible to have
severe symptoms without permanent liver
damage; more common to have chronic liver
disease, without overt symptoms
• Cancer may also result from chronic HCV
infection.
• Treatment with interferon and ribavirin to lessen
liver damage; no cure
• No vaccine
Natural History of HCV Infection
 Profilaxie şi combatere
• Măsurile profilactice se aplică similar hepatitei B.
• Screeningul donatorilor implică dozarea ALAT,
depistare anticorpilor anti-VHC
• Profilaxia hepatitei acute cu IgG nu a dat rezultate.
• Administrarea interferonului în infecţia acută reduce
riscul cronicizării, fiind indicat pacienţilor la care
ARN-VHC este decelabil peste 1-2 luni de la debutul
bolii.
• Administrarea de interferon în hepatita cronică C induce
remisie pentru o perioadă de aproximativ 3 ani doar la
20-30% dintre pacienţi.
 Hepatitis B Virus (HBV)

The microorganism known as Hepatitis B Virus (HBV) causes an

inflammation of the liver.
This can result in
illnesses such as chronic hepatitis, cirrhosis of the liver, and
liver cancer
Hepatitis B Virus is a serious health
concern for any employee whose work responsibilities bring
them in contact with blood or body fluids.
• Pentru personalul medical protejat prin
vaccinare antihepatită B nu se adoptă
atitudini imunoprofilactice particulare (faţă
de VHB), dacă titrul de anticorpi este
cunoscut şi este de peste 10 mUI /ml.
Personalul medical protejat prin vaccinare,
dar cu status imun necunoscut, va fi
protejat prin revaccinare antihepatită B şi/
sau HBIG.
• Personalul medical neprotejat prin vaccin, expus
percutan (ex. înţepătură cu ac) sau permucos la
sânge provenit de la persoane infectate cu VHB,
devine protejat prin administrare de HBIG (0,06
ml/Kg sau 5 ml pentru adult) administrate în
primele 24 h şi prin vaccinare antihepatită B
cu 4 doze la 0, 1, 2 şi 12 luni (prima vaccinare
este concomitentă cu HBIG, dar în alt situs
anatomic).
 Human Immunodeficiency Virus (HIV)

This life-threatening virus

compromises the body's immune system. Early symptoms
may be similar to those of the flu. During later stages of the
disease, the body is incapable of warding off other infections
which frequently prove fatal.
Conduita în caz de accident după
expunere la HIV
• Dezinfecţia plăgii (alcool iodat, alcool etilic 70%,
betadine) - 5-10 minute
• Declararea accidentului imediat după expunere şi
înregistrarea datelor identificare ale pacientului sursă
(dacă e posibilă identificarea)
• Efectuarea serologiei după accident, ulterior se
repetă la 6 săptămâni, la 3 şi 6 luni.
• Evitarea donărilor de sânge şi a actelor sexuale
neprotejate timp de 6 luni de zile (riscul este maxim în
primele 6-12 săptămâni)
• Chimioprofilaxia recomandată asociază 3 antiretrovirale,
4 săptămâni, începută prompt - preferabil în 1 -2 ore
postexpunere, max până la 36 de ore.
(zidovudină+lamivudina+indinavir)
(stavudina+lamivudina+abacavir)
 Penetration into the Bloodstream

Contact alone does not mean infection will result.

Pathogens must enter the bloodstream to cause infection.
In the workplace, an employee may be
exposed to HBV or HIV when infected blood or body fluid is
allowed to enter the body by means of penetration.

This can occur through:

• a needle stick
• a cut or break in the skin
• contact with mucous membranes such as those of the
eye, nose, and mouth
 Accidental Exposures

If your skin is cut or punctured while

handling potentially infectious materials:

• encourage the wound to bleed

• flush with water
• apply antiseptic

Then notify your supervisor, and immediately seek

medical attention.
 Bloodborne Pathogens
DACC has developed a Bloodborne Pathogens Exposure Control Plan
(available in the DACC Safety and Procedures Plan)
that outlines how to report an exposure incident, where to
go to receive an immediate medical evaluation, and what services are
available for follow-up care.
 Preventive Measures

Wash your hands to remove infectious

organisms before they can enter the body.
Wear gloves as a barrier when handling blood
and other body fluids.
Wear face protection when work tasks
include the potential for spraying
or splattering of body substances.
Receive an HBV vaccination to decrease your
susceptibility to the disease.
Presently, no vaccine for HIV is available.
 Immunization

Finally, decrease your susceptibility to infection by being

immunized.

Recommended Vaccines:

• HBV for potential exposure to

blood or body fluids
• Measles, Rubella, Diphtheria,
Poliomyelitis, and Tetanus for
anyone who has not been
vaccinated in childhood
• Tetanus and Rabies for work with animals
• Other vaccines for foreign travel and research with
pathogens
The HBV vaccine is offered free of charge
to all employees who may be occupationally
exposed to blood or other body fluids. The
vaccine is effective in more than 90% of
healthy people who receive the series of
injections. It is administered intramuscularly
in three doses within a six-month period. The most common side effect
of vaccination is soreness at the injection site.

If you decide against vaccination, you will

be required to sign a declination form.
However, you will remain eligible for
vaccination if you desire it at a later time.
 Bloodborne Pathogens
Preventing infection from bloodborne pathogens involves?

A. Vaccination against HIV.

B. Preventing blood or body

fluids from contacting your
skin or mucous membranes.

C. Washing your hands before beginning work.

D. Wearing gloves as a barrier against

needle sticks.

The answer is…

 Bloodborne Pathogens
B. Preventing blood or body fluids from
contacting your skin or mucous
membranes.
 Mycobacterium (tuberculosis)

Another group of pathogens known as

Mycobacterium cause the chronic lung
disease tuberculosis (TB). Although
human beings are the main reservoirs,
other primates, cattle, and swine can also
be reservoirs. TB is transmitted
primarily through the air. A person with
an active case of TB discharges the microorganisms by coughing or
sneezing.

Inhalation: Exposure occurs when others breathe the contaminated air.

Once inhaled, the pathogen may lodge in lung tissue and produce
lesions.
 Preventive Measures

If necessary, and risk factors for TB are

present, wear respiratory protection.
Screen yourself for exposure to TB by
receiving a TB skin test.
 Salmonella

The next disease, salmonellas, is caused by a group of bacteria called

salmonella. The most common manifestation of this disease is acute
gastroenteritis or intestinal inflammation. Both animals and humans are
reservoirs for the salmonella organism. Diseased animals and humans
discharge large numbers of salmonella in their feces.
 Ingestion

Infection results from ingesting (i.e., through the mouth) salmonella

organisms. Employees may be exposed to these organisms when
handling soiled diapers and linens, working with animals, or cleaning and
maintaining restrooms.
As a first line defense against ingesting
microorganisms, don't put anything in
your mouth while at work.

Wear gloves when your hands will likely come in

contact with contaminated materials.
 Bloodborne Pathogens

Wipe counters with a disinfectant after

performing tasks with materials that
may be contaminated.

And, thoroughly wash your hands after

handling potentially contaminated items.
Even microscopic amounts of fecal matter
may contain millions of salmonella
organisms.
 Bloodborne Pathogens
Preventing ingestion of salmonella
organisms involves?

A. Not washing your hands if they look clean.

B. Wearing gloves, washing hands, and disinfecting work

surfaces.

C. Not eating right after work.

D. Putting only your own pencils and pens in your mouth.

The answer is…

 Bloodborne Pathogens
B. Wearing gloves, washing hands, and
disinfecting work surfaces.
Bloodborne Pathogens
An important practice aimed at preventing
transmission of pathogens is routine use of
chemical disinfectants for wiping work surfaces.
Wipe your work area with an appropriate
disinfectant before starting work, between projects,
immediately after a spill, and at the end of the work
shift.

Use a disinfectant to wipe equipment that cannot

be autoclaved or soaked. This is especially
important if the equipment is sent elsewhere to be
recalibrated or repaired.

If parts of the equipment cannot be disinfected, the

equipment must be packaged and labeled to
ensure that others will handle it with caution.
 Bloodborne Pathogens
Never discard needles, syringes, blades, or other
sharp objects directly into waste bags because of
the high puncture risk. Instead, place them in an
approved, puncture-resistant, leak-proof sharps
container that is labeled or color coded red by the
supplier.

Use the approved sharps container for all sharp

items, even those free of pathogens. Never reach
inside, and be sure to replace containers when
about three-fourths full. Overfilling containers is
hazardous.

Contaminated laundry and linens should be placed

in designated bags provided by DACC for safe
collection and decontamination.