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Hospital Infection and Control

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microbiology scientific era infection
Anton van Leeuwenhoek (1632-1722)

Dutch linen draper

Amateur scientist

Grinding lenses, magnifying glasses, hobby

First to see bacteria “little beasties”

No link between bacteria and disease

Microbiology - scientific erainfection

Dr.T.V.Rao MD

scientific era continued
Scientific era continued . . . . .

Ignaz Semmelweis (1818-1865)

  • Obstetrician, practised in Vienna
  • Studied puerperal (childbed) fever
  • Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems
  • Reduced maternal mortality by 90%
  • Ignored and ridiculed by colleagues

Dr.T.V.Rao MD

scientific era continued4
Louis Pasteur (1822-1895)

French professor of chemistry

Studied how yeasts (fungi) ferment wine and beer

Proved that heat destroys bacteria and fungi

Proved that bacteria can cause infection - the “germ theory” of disease

Scientific era continued . . . . .

Dr.T.V.Rao MD

scientific era continued5
Robert Koch (1843-1910)

German general practitioner

Grew bacteria in culture medium

Showed which bacteria caused particular diseases

Classified most bacteria by 1900

Scientific era continued

Dr.T.V.Rao MD

hospital acquired infection
Infection which was neither present nor incubating at the time of admission

Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation.

Also called nosocomial infection

Hospital acquired infection

Dr.T.V.Rao MD

what are health care associated infections
What are health care associated infections
  • Healthcare associated infections (HCAIs) are infections transmitted to patients (and healthcare workers) as a result of healthcare procedures, in hospital and other healthcare settings. Recent years have seen an increase in the awareness of HCAIs, in particular those caused by antibiotic-resistant ‘superbugs

Dr.T.V.Rao MD

what are health care associated infections8
What are Health care associated infections ???
  • A wide variety of micro-organisms can cause HCAIs, leading to an extensive range of different diseases.
  • Experts estimate that 9% of in-patients have an HCAI at any one time.

Dr.T.V.Rao MD

health care associated infections and microbes
Health care associated infections and microbes
  • HCAIs are mostly caused by bacteria. Bacteria can exist harmlessly in people, for example on the skin or in the gut. However, some types of bacteria can cause HCAIs when they enter the body, for example through wounds and the use of surgical devices, or when the body’s natural balance is disturbed. HCAIs occur in the lungs (23% of all HCAIs), urinary tract (23%), blood (6%), skin (11%) and gut. Infections are usually treated with antibiotics. However, many bacteria have developed resistance to antibiotics This can make infections harder to treat.

Dr.T.V.Rao MD

increased use of antibiotics
Increased use of antibiotics
  • Increasing antibiotic use. The more antibiotics are being used, the more likely bacteria become resistant to them. Antibiotics are sometimes prescribed for conditions that are not treatable with antibiotics, such as colds and the ‘flu.

Dr.T.V.Rao MD

antibiotic resistance
Not a new problem - Penicillin in 1944

Hospital “superbugs”

Methicillin Resistant Staphylococcus Aureus [MRSA]

Vancomycin Intermediate Staphylococcus Aureus [VISA]

Tuberculosis - antibiotic resistant form

Antibiotic resistance

Dr.T.V.Rao MD

irregular use of antibiotics
Irregular use of antibiotics
  • Patterns of antibiotic use. Many people do not finish their courses of antibiotics because they start feeling better. This means that bacteria are not killed off, so they multiply, become resistant and transmit to others.

Dr.T.V.Rao MD

the nature of infection
Micro-organisms - bacteria, fungi, viruses, protozoa and worms

Most are harmless [non-pathogenic]

Pathogenic organisms can cause infection

Infection exists when pathogenic organisms enter the body, reproduce and cause disease

The nature of infection

Dr.T.V.Rao MD

hospital acquired infection14
Infection which was neither present nor incubating at the time of admission

Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation

Also called Nosocomialinfection

Hospital acquired infection

Dr.T.V.Rao MD

modes of spread
Two sources of infection:

Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli

Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998)

Modes of spread

Dr.T.V.Rao MD

use of leftover antibiotics
Use of leftover antibiotics
  • Using leftover antibiotics to self-medicate against a fresh infection can exacerbate the problem, as specific bacterial infections require specific antibiotics

Dr.T.V.Rao MD

use of antibiotics in livestock
Use of antibiotics in livestock
  • The indiscriminate use of antibiotics in livestock has further compounded the problem by increasing the likelihood of resistance factors emerging.

Dr.T.V.Rao MD

concerns with staphylococcus
Concerns with staphylococcus
  • Methicillin-resistant S. aureus (MRSA) is resistant to several antibiotics. Another form of S. aureus, vancomycin-resistant S. aureus (VRSA), is resistant to one of the most powerful, last line of defence antibiotics, vancomycin

Dr.T.V.Rao MD

slide19

RESISTANT GRAM NEGATIVE ORGANISMSResistance to multiple antibiotics Organisms: E .coli Proteus Enterobacter Acinetobacter Pseudomonas aeruginosa

e coli and emerging resistance
E.Coli and emerging resistance
  • Escherichia coli (E. coli) has gradually become resistant to different types of antibiotics. In 2003, the overall resistance of E. coli to common amino penicillin antibiotics reached 47% across Europe

Dr.T.V.Rao MD

pseudomonas aeruginosa
Pseudomonas aeruginosa
  • Pseudomonas aeruginosa (P. aeruginosa) and Extended Spectrum Beta Lactamase (ESBL) -producing bacteria are increasingly becoming resistant to antibiotics.

Dr.T.V.Rao MD

objectives reducing infections
Reducing infection rates

Establishing endemic baseline rates

Identifying outbreaks

Identifying risk factors

Persuading medical personnel

Evaluate control measures

Satisfying regulators

Document quality of care

Compare hospitals’ NCI rates

Objectives – reducing infections

Dr.T.V.Rao MD

surveillance
SURVEILLANCE
  • Important means of monitoring HAI Early detection of trends outbreaks
  • . Laboratory Based Microbiology Laboratory lists +ve organisms ICN reviews ‘Alert organisms’ reported
  • 2. Ward Based Ward staff monitor patientsICN reviews ICN visits wards

Dr.T.V.Rao MD

who will practice preventive measures
Who will practice preventive measures
  • All hospitals?
  • All departments?
  • All specialties?
  • Other health institutions?

Dr.T.V.Rao MD

slide25

Stakeholders

Dr.T.V.Rao MD

personal protective equipment
PPE when contamination or splashing with blood or body fluids is anticipated

Disposable gloves

Plastic aprons

Face masks

Safety glasses, goggles, visors

Head protection

Foot protection

Fluid repellent gowns

Personal protective equipment

Dr.T.V.Rao MD

universal precautions
Hand washing

Personal protective equipment [PPE]

Preventing/managing sharps injuries

Aseptic technique

Isolation

Staff health

Linen handling and disposal

Waste disposal

Spillages of body fluids

Environmental cleaning

Risk management/assessment

Universal precautions

Dr.T.V.Rao MD

slide28
Why

Don’tStaff Wash their Hands

(Compliance estimated at less than 50%)

Dr.T.V.Rao MD

hand washing
Single most effective action to prevent HAI - resident/transient bacteria

Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken

No recommended frequency - should be determined by intended/completed actions

Research indicates:

poor techniques - not all surfaces cleaned

frequency diminishes with workload/distance

poor compliance with guidelines/training

Hand washing

Dr.T.V.Rao MD

why not
Skin irritation

Inaccessible hand washing facilities

Wearing gloves

Too busy

Lack of appropriate staff

Being a physician

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

Why Not?

Dr.T.V.Rao MD

why not31
Working in high-risk areas

Lack of hand hygiene promotion

Lack of role model

Lack of institutional priority

Lack of sanction of non-compliers

Why Not?

Dr.T.V.Rao MD

successful promotion
Education

Routine observation & feedback

Engineering controls

Location of hand basins

Possible, easy & convenient

Alcohol-based hand rubs available

Patient education

(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

Successful Promotion 

Dr.T.V.Rao MD

successful promotion33
Successful Promotion 
  • Reminders in the workplace
  • Promote and facilitate skin care
  • Avoid understaffing and excessive workload; Nursing shortages have caused

Dr.T.V.Rao MD

areas most frequently missed
Areas Most Frequently Missed

HAHS © 1999

Dr.T.V.Rao MD

hand care
Nails

Rings

Hand creams

Cuts & abrasions

“Chapping”

Skin Problems

Hand Care

Dr.T.V.Rao MD

hand hygiene
Hand hygiene
  • Hand hygiene is the simplest, most effective measure for preventing hospital-acquired infections.

Dr.T.V.Rao MD

sharps injuries
Sharps injuries
  • Prevention
    • correct disposal in appropriate container
    • avoid re-sheathing needle
    • avoid removing needle
    • discard syringes as single unit
    • avoid over-filling sharps container
  • Management
    • follow local policy for sharps injury (May, 2000)

Dr.T.V.Rao MD

waste disposal
Clinical waste - HIGH risk

potentially/actually contaminated waste including body fluids and human tissue

yellow plastic sack, tied prior to incineration

Household waste - LOW risk

paper towels, packaging, dead flowers, other waste which is not dangerously contaminated

black plastic sack, tied prior to incineration

Follow local policy (May, 2000)

Waste disposal

Dr.T.V.Rao MD

spillage of body fluids
PPE - disposable gloves, apron

Soak up with paper towels, kitchen roll

Cover area with hypochlorite solution e.g., Milton, for several minutes

Clean area with warm water and detergent, then dry

Treat waste as clinical waste - yellow plastic sack

Follow local policy

Spillage of body fluids

Dr.T.V.Rao MD

slide40
H.A.I. IS INCREASING:

compromised patients

ward and inter-hospital transfers

antibiotic resistance (MRSA, resistant Gram negatives)

increasing workload

staff pressures

lack of facilities

? lack of concernHAI is inevitable but some is preventable (irreducible minimum)

realistically reducible by 10-30%

journal of infection prevention
Journal of Infection Prevention
  • Journal of Infection Preventionis the professional publication of the Infection Prevention Society. The aim of the journal is to advance the evidence base in infection prevention and control, and to provide a publishing platform for all health professionals interested in this field of practice. The journal is a bi-monthly peer-reviewed publication containing a wide range of articles: Original primary research studies, Qualitative and quantitative studies,.

Dr.T.V.Rao MD

consequences of hospital infections
Consequences of hospital infections ???

Pathogen

Unhappy

patients

Unhappy

director

Hospital

Surveillance

Happy

Patients

Happy

director

Hospital

Dr.T.V.Rao MD

slide43

Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World

Email

doctortvrao@gmail.com

Dr.T.V.Rao MD