Ida parwati djatnika setiabudi komite pirs rsup dr hasan sadikin bandung
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H EALTH CARE ASSOCIATED INFECTION S (HAIs) (NOSOCOMIAL INFECTION). Ida Parwati Djatnika Setiabudi Komite PIRS RSUP Dr. Hasan Sadikin Bandung. Dr.Hasan Sadikin General Hospital Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216.

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Ida parwati djatnika setiabudi komite pirs rsup dr hasan sadikin bandung


Ida Parwati


Komite PIRS

RSUP Dr. HasanSadikin Bandung

Dr.Hasan Sadikin General Hospital

Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216

Definition 1

Old concept:

  • Nosocomial Infection = Hospital acquired infection

    - An infection that occured during hospitalization (> 3 X 24 hours after admission) which are not present nor incubating upon hospital admission

    - Infection at the same location but the causative microorganism was different than at addmission OR the same microorganism but different location

Definition 2

  • Problems of old definition:

    1.Focus on infection occuring in the hospital


    What about in other health care system but

    not hospital?While many home-care are

    availlable now?

    2. Focus on patient’s infection

    What about healthcare worker?

Definition 3

New terminology:

nosocomial Infection =

Health-careassociated Infection

Health-care related Infection

Healthcare associated infection
Healthcare-associated infection


An infection occurring in a patient during the process of care in a hospital or other healthcare facilitywhich was not present or incubating at the time of admission.

This includes infections acquired in the hospital but appearing after discharge,

and also occupational infections among staff of the facility

In indonesia
In Indonesia

  • The term nosocomialinfection still being used

  • For nosocomialinfection occured in the hospital: Hospital Infection (”InfeksiRumahSakit”)

  • Control Program of HAIs called: “PencegahandanPengendalianInfeksiRumahSakit” (“PPIRS”)

Types of infe ct i ons 1

Types of Infections(1)

Four categories:

Surgical site infections(SSI)

Central line-associated bloodstream infections(CLABSI)

Ventilator-associated pneumonia(VAP)

Catheter-associated urinary tract infections(CAUTI)

Types of infe ct i ons 2

Types of Infections(2)


- Gastroenteritis

- Cellulitis

-Hepatitis B and C



Ida parwati djatnika setiabudi komite pirs rsup dr hasan sadikin bandung

The 10 most common pathogens

(accounting for 84% of any HAIs)

Coagulase-negative staphylococci (CONS) (15%),

Staphylococcus aureus (15%),

Enterococcus species (12%),

Candida species (11%),

Escherichia coli (10%),

Pseudomonas aeruginosa (8%),

Klebsiella pneumoniae (6%),

Enterobacter species (5%),

Acinetobacter baumannii (3%)

Klebsiella oxytoca (2%).

CDC, April 2013

Ida parwati djatnika setiabudi komite pirs rsup dr hasan sadikin bandung

Diseases and Organisms in Healthcare Settings


Burkholderia cepacia

Clostridium difficile

Clostridium sordellii

Enterobacteriaceae (carbapenem-resistance)






Mycobacterium abscessus


Pseudomonas aeruginosa

Staphylococcus aureus

Tuberculosis (TB)



CDC, April 2013

Why does hais important1

Why does HAIs important?

1.Increase morbidity & mortality

2.Prolong length of stay (LOS)

3.Increase cost

4.Related to ‘image’/ quality of the hospital

5.Important in medicolegaland “patient

safety” aspects.

Impact of hais
Impact of HAIs

They lead to

functional disability and emotional stress to the patient

disabling conditions that reduce the quality of life

They are one of the leading causes of death

Impact of hais cont d
Impact of HAIs (cont’d)

  • The increased economic costs are high:

    - Increased length of hospital stay

    - extra investigations

    - extra use of drugs

    - extra health care by doctors and nurses

Nosocomial infections cost
Nosocomial Infections Cost

  • The cost varies according to the type and severity of these infections

  • An estimated: 1 - 4 extra days for a UTI

    7 – 8 days for a surgical site infections

    7 – 21 days for a blood stream infection

    7 – 30 days for pneumonia

  • The CDC has recently reported that US$5 billion are added to US health costs every year as a result of NI

Impact of nosocomial infections cont d
Impact of Nosocomial Infections (cont’d)

  • Organisms causing N.I. can be transmitted to the community through discharged patients, staff and visitors

  • If organisms are multi-resistant they may cause significant disease in the community

Goals of infection control
Goals of infection control

  • To protect the patients from HAIs e.g UTI, SSI, IV line infection, pneumonia (HAP, VAP), Blood stream infection (sepsis)

  • To protect the patients from others infection which acquire through contact with other patients or healthcare worker whom colonized by contagious microorganisms.

  • To protect healthcare workers, Visitor, in hospital environtment from infections

Ida parwati djatnika setiabudi komite pirs rsup dr hasan sadikin bandung


Schaffer SD et al: Infection Prevention and Safe Practice, Mosby, 1996

Risk fa c tor s 1

Risk Factors(1)

Age: neonatus >>

Interuption of anatomical barrier:

- Urine catether

- Operationprocedure

- Respiration intubation

- Vein/artery canule

- Burn wound and trauma

Risk f a c tor s 2

Risk factors(2)

Implantation of:

- “indwelling catheter”

- “surgical suture material”

- “cerebrospinal fluid shunts”

- “valvular / vascular prostheses”

Changes in normal microflora :

antibiotics usage

Routes of transmission of infection
Routes of Transmission of Infection

A susceptible host and appropriate inoculum of infecting microorganism with an appropriate route of transmission contributed in majority of case

  • Airborne (resp tract, aerosols from equipment etc)

  • Contact spread (person to person)

  • Food borne spread

  • Blood borne spread

  • Self infections (endogenous) and cross infections

Transmission 1

  • Contact transmission:

    - Direct:

    body contact

    physically causative microorganism transfer

     physical examination, patients bathing

    - Indirect: most of the time !!!

    contact through objects (tools)

    instrumentation, needle, bandage

     unwashed hand

Transmission 2

  • Droplet transmission :

    - droplet particles > 5 μm

    - coughing, sneezing, talking

    - short transmission distance, and only short time in the air

    - “deposit” at conjungtival mucous, nose, mouth

    - e.g.: Diphteria, Pertussis, Hib, Mycoplasma

    Influenza Virus , mumps, rubella

Transmission 3

  • Airborne transmission :

    - small particles < 5 μm

    - long standing in the air

    - long transmission distance

    - easy inhaled

    - e.g : Mycobacterium tuberculosis

    varicella virus, morbilli,

    fungi spore.


Within hours of admission, colonies of hospital strains of bacteria develop in the patient's skin, respiratory tract, and genitourinary tract.

Risks factors for the invasion of colonizing pathogens can be categorized into 3 areas: iatrogenic, organizational, and patient-related

Iatrogenic risk
Iatrogenic risk

  • Iatrogenic risk factors: include pathogens on the hands of medical personnel, invasive procedures (intubation and extended ventilation, indwelling vascular lines, urine catheterization), and antibiotic use and prophylaxis.


  • Organizational risk factors include:contaminated air-conditioning systems, contaminated water systems, and staffing and physical layout of the facility (eg, nurse-to-patient ratio, open beds close together).

Patient associated
Patient associated

  • Patient risk factors include the severity of illness, underlying immunocompromised state, and length of stay.

  • Prolonged stay in the hospital is a Major contributing factor

Blood stream infections
Blood stream infections

  • Most important pathogen:

    coagulase negative Staphylococcus (CONS): 39.3%

  • 10 – 15% of patients with HAI have a BSI

  • Needle sticks may offer a path of entry for the microbes


  • Most important pathogens

    • Staphylococcus aureus: 16.8%

    • Pseudomonas aeruginosa: 16.1%

  • 10 – 15% of patients with a HAI get pneumonia

  • 20 – 50% mortality rate

    • Intubation and mechanical ventilation increase the risk of pneumonia by S. aureus

    • Pneumonia usually caused by aspiration of bacteria clusters found in resp. Tract/GI tract

Urinary tract infection
Urinary tract infection

  • Most important pathogens

    • Escherichia coli – 18.2%

    • Candida albicans – 15.3%

  • Up to 40% of patients with HAIs get a UTI

  • E. coli is a natural inhabitant of the GI tract

    it is commonly found near the anterior urethra

  • Candida albicans is a natural inhabitant of the GI and genital tract

  • Normal urination clears the urethra of harmful microbes while catheterization may allow microbes to colonize and infect the urinary tract

Surgical site infection
Surgical site infection

  • Most important pathogens

    • Enterococci spp. – 14.5%

    • Coagulase negative Staphylococcus (CoNS)– 13.5%

  • Up to 54% of patients with HAI who have also had surgery get a SSI: 500,000 infections/year

  • Enterococci spp. are a natural inhabitant of the GI tract

  • Urinary catheterizations and antimicrobial use during hospital stays increases risk of infection

3 major players in hais
3 Major players in HAIs

1. Antimicrobial use in hospitals and long-term care facilities: has produced resistant strains that are often found colonizing health care workers. These strains can be transferred to patients by normal human contact

  • Medical devices such as catheters and sutures offer a portal of entry for the microbes

    2. Failure of hospital personnel to follow basic infection control: Handwashing, PPE etc.

    3. Hospital patients are increasingly immunocompromised

Prevention and control
Prevention and Control

  • The basic responsibility of any good hospital remain with establishment of good infection control policies, which can always be achieved with

  • 1. An infection control committee

  • 2. An Infection team

  • The Functions of the Committee:

  • To do surveillance and infection monitoring of hygiene practices.

  • Educate the Medical and Paramedical staff on policies relating to prevention of infection, and safe procedures

Infection control nurse
Infection Control Nurse

  • Is the key member of the team

  • Maintain the close working relations between Microbiology Laboratory, different clinical services and supportive services like laundry, pharmacy and engineering

  • Collect information and document on HAIs

Correlation between handsrub usage and mrsa
Correlation between Handsrub usageand MRSA


MDRO in the Hospital, Al Ichsan Bandung 21 August 2013