Download Infection control

Infection control
concept
Dr Hania Al-Jouzy
Head of neonatal department
Hoy Family Hospital
2008
Historical perspectives
DR Hania –AlJouzy
Historical perspectives

Nosocomial infection have been a
serious problem ever since sick
patients were first congregated in
hospitals.
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Florence Nigtingales 1854.
Ignas Semmelwies 1847.
DR Hania –AlJouzy
Does Handwashing Work?
Semmelweis - 1847
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Month
April
May
June
July
births
312
294
268
250
DR Hania –AlJouzy
mortality
57
36
6
3
%
18.3
12.2
2.4
1.2
Historical perspectives
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1940 widespread use of antibiotics
revolutionized the treatment of
infectious diseases.
1950 a pandemic of Staph. aureus struck
hospitals in USA.
1958 first national conference on the
control of staphylococcal disease.
1963 the first international conference
was held on institutionally acquired
infection.
DR Hania –AlJouzy
Historical perspectives
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1968 Americans set up the concept of infection
control nurse & set up training courses of
infection control nurses.
1970 first international committee on nosocomial
infection. [Strong recommendations to adopt certain
policies and strategies by all hospitals].
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1974 a nation wide study was conducted by CDC
to evaluate the effectiveness of policies adopted
in 1970.
1976, [legislation]
DR Hania –AlJouzy
Historical perspectives
The main lesson derived from the
past is that preventing, surveillance
& controlling nosocomial infection
requires:
 Organised management system.
 Dedicated personnel to influence the
behavior of medical & paramedical
workers.
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DR Hania –AlJouzy
Why a big problem ?
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The concentration of patients in one place
offers many potential routes for
transmission of harmful bacteria between
patients, and from the environment to
patients.
Nosocomial infections are a major
problem, estimated to affect 10-12% of
hospitalized patients.
They have significant effects on
mortality, mean length of patient stay and
antibiotic usage.
DR Hania –AlJouzy
Big problem ?

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Aprpoximately 10% of American
hospital patients (about 2 million
every year) acquire a clinically
significant nosocomial infection.
Fourth Decennial International Conference on Nosocomial and
Healthcare-Associated Infections.
MMWR, February 25, 2000 / 49(07);138
DR Hania –AlJouzy
Big problem ?
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The cost of hospital-acquired infections
has been estimated at $4.6 billion.
It contributed to more than 88,000
deaths , one death every 6 minutes.
The U.S. Institute of Medicine ranked
health care-associated infection in the
top ten causes of death
CDC national infection surveillance system
DR Hania –AlJouzy
Reasons the problem exists:
Nosocomial infections are the
result of three factors :

–
–
–
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high prevalence of pathogens
high prevalence of compromised hosts
efficient mechanisms of transmission
from patient to patient*
*this is also known as chains of
transmission .
DR Hania –AlJouzy
The six links in the chain
of infection
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causative agent.
reservoir host.
portal of exit.
mode of
transmission.
portal of entry.
susceptible host
DR Hania –AlJouzy
Transmission

There are three different
ways to transmit diseases:
Contact Transmission (Direct and Indirect
Contact with an Infected Person)
Direct contact includes touching, sexual
contact, blood, and body fluids
Indirect contact includes clothing,
dressings, equipment used in care and
treatment
Droplet & Airborne Transmission
DR Hania –AlJouzy
Breaking the Chain of
Infection. How?
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Healthcare workers are
expected to follow various
policies and procedures
aimed at breaking the
links in the chain of
infection.
Specific strategies are
employed.
Evidence based medicine
DR Hania –AlJouzy
Transmission
Contaminated hands
(dirty hands) are
the most common
means of spreading
infections or
diseases.
DR Hania –AlJouzy
Breaking the Chain of
Infection.
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Hand hygiene is
considered a top
infectioncontrol measure.
But poor
compliance
continues.
DR Hania –AlJouzy
Breaking the Chain of
Infection.
One of the most
important methods
for breaking the
chain of infection is
asepsis & using
aseptic practices to
prevent the
transmission of
pathogens.
DR Hania –AlJouzy
So How can you prevent the
spread of infection?
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The Centers for Disease Control and Prevention
(CDC) suggests the following measures to
reduces the spread of infectious diseases.
Wash your hands properly .
Routinely clean and disinfect surfaces.
Sterilisation of materials used in hospitals.
Handle and prepare food safely.
Get immunized.
Use antibiotics appropriately.
DR Hania –AlJouzy
The 4 questions ?
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Which Nosocomial Infections Are
Emerging?
Who Is Affected by Emerging
Nosocomial Pathogens?
Why Are Nosocomial Infections
Emerging Now?
How Can We Prevent and Control
Emerging Nosocomial Infections?
DR Hania –AlJouzy
Which nosocomial infection
are emerging?
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Historically,
staphylococci,
pseudomonads, and
Escherichia coli have been
the nosocomial infection
troika.
a cyclical parade of
pathogens in hospitals.
DR Hania –AlJouzy
Which nosocomial infection
are emerging?
Changing etiology over time
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[1940 to 1950] S. aureus caused major
nosocomial problems and was the
hospital pathogen of major concern.
[1960- 1970s] gram-negative bacilli,
particularly Pseudomonas aeruginosa
and Enterobacteriaceae, became
synonymous with nosocomial infection.
[1980-1990s] methicillin-resistant S.
aureus (MRSA) and vancomycinresistant enterococci (VRE) emerged.
DR Hania –AlJouzy
Which nosocomial infection
are emerging?
In 1990 to 1996,
 The three most common gram-positive
pathogens—S. aureus, coagulase-negative
staphylococci, and enterococci—accounted
for 34% of nosocomial infections.
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CNS is becoming the most frequent cause
of BSI in NICU (31% in 1992 to 45% in
1999).
The four most common gram-negative
pathogens—Escherichia coli, P. aeruginosa,
Enterobacter spp., and Klebsiella
pneumoniae—accounted for 20%to 32%.
DR Hania –AlJouzy
Which nosocomial infection
are emerging?
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In the late 1983 the extended-spectrum βlactamase (ESBL) bacteria was first described.
ESBL-producing enterobacteria have been
frequently implicated in outbreaks in pediatric
intensive care units (PICUs) and neonatal
intensive care units (NICUs.
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􀁺2000-1 – First UK isolates (Klebsiella)ESBL.
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􀁺2003 onwards – widespread across UK & ather
places in the world.
DR Hania –AlJouzy
Acquired antimicrobial resistance is
the major anticipated problem in
hospitals
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The contribution of antibiotic
resistance to excessive death rates
in hospitals is difficult to evaluate,
but evidence is mounting that
antimicrobial resistance contributes
to nosocomial deaths.
DR Hania –AlJouzy
Acquired antimicrobial resistance is
the major anticipated problem in
hospitals
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Once resistant strains of
bacteria are present in a
population, exposure to
antimicrobial drugs favors
their survival.
Reducing antimicrobial
selection pressure is one
key to preventing
antimicrobial resistance
and preserving the utility
of available drugs for as
long as possible.
DR Hania –AlJouzy
Centers for Disease Control and Prevention
National Center for Infectious Diseases
Division of Healthcare Quality Promotion
Campaign to Prevent
Antimicrobial
Resistance
Clinicians hold
the solution!
DR Hania –AlJouzy
Who Is Affected by
Emerging Nosocomial
Pathogens?
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The highest infection rates are in intensive care unit
(ICU) patients.
Up to 45% of hospital-acquired infections occur in ICU
patients, although these patients occupy only 8% of
hospital beds.
Nosocomial infection rates in adult and pediatric ICUs are
approximately three times higher than elsewhere in
hospitals.
Health care associated infection are 5 times higher in the
neonatal population
[adams-chapman and stoll 2002]
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DR Hania –AlJouzy
NICU infants
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Overall neonatal ICU (NICU) patient
infection rates are reported to range
from 6 to 25%.
Infants with birth weights < 1500 g have
significantly higher rates of infection.
The highest risk of infection is seen in
patients weighing < 1000 g with more than
two invasive interventions.
DR Hania –AlJouzy
NICU infants why?
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All aspects of immune function are
impaired in NICU infants, including –
-the phagocytic,
- humoral,
- and reticuloendothelial systems,
-as well as the skin barrier, which is
immature.
Risk factors include
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broad-spectrum antibiotic use, intravenous fat
emulsions, and use of central lines.
DR Hania –AlJouzy
Why Are Nosocomial
Infections Emerging Now?
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1.
2.
3.
4.
5.
Three major forces are involved in nosocomial
infections in general .
The first is antimicrobial abuse in hospitals.
Second, many hospital personnel fail to follow
basic infection control, such as hand washing
between patient contacts.
In ICUs, asepsis is often overlooked in the rush
of crisis care.
Third, patients in hospitals are increasingly
immunocompromised.
the greater prevalence of vascular access
associated bloodstream infections and
ventilator-associated pneumonias.
DR Hania –AlJouzy
Why Are Nosocomial
Infections Emerging more in
NICU ?
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1.
2.
3.
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5.
6.
Health care associated infection [HCAI]
rates increase in NICU is partly explained
by the :
Improved survival rates in neonates.
Increase in invasive monitoring.
Duration of exposure to invasive
devices [CVC,MV]
Exposure to broad spectrum
antibiotics
TPN
Increased length of stay.
DR Hania –AlJouzy
Nosocomial infection point
prevelance in NICU
Study done between
1999-2000 in 31
hospitals USA.
11.4% of NICU acquired
nosocomial infection
117 micro-organisms
identified
DR Hania –AlJouzy
Microorganism
Percentage
CNS
31.6%
Entercocci
10.3%
E.Coli
8.5%
Pseudomonas
6.8%
Klebsiella
pneumonia
6.0%
Candida albicans
6.0%
Enterobacter
cloace
6.0%
Others
24.8%
How Can We Prevent and Control
Emerging Nosocomial Infections?
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Infection control can be
very cost-effective.
Approximately one third
of nosocomial infections
are preventable.
To meet and exceed
this level of prevention,
we need to pursue
several strategies
simultaneously.
DR Hania –AlJouzy
How Can We Prevent and Control
Emerging Nosocomial Infections?
1985, the Centers for Disease Control and Prevention's
(CDC's) Study on the Efficacy of Nosocomial Infection
Control reported that hospitals with four key infection
control component reduced nosocomial infection
1.
2.
3.
4.
rates by approximately one third .
An effective hospital epidemiologist [local
microbiology laboratory]
One infection control practitioner
Active surveillance mechanisms,
Ongoing control efforts [optimal infection
prevention programs.]
DR Hania –AlJouzy
•Infectious diseases specialists are one important resource
for providing input, but many other professionals also
contribute to optimal care for patients with infections.
multidisciplinary collaboration is key!
DR Hania –AlJouzy
How Can We Prevent and Control
Emerging Nosocomial Infections?
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Improve national surveillance of nosocomial
infections so that we have more representative
data.
Develop a system for surveillance.
Assess the sensitivity and specificity of our
surveillance & ensure that surveillance used are
valid.
Nosocomial infection rate is used as a core
indicator of quality of care.
Aggressive antibiotic control programs.
Changing human behaviour .[the biggest challenge
might be addressing individuals’ resistance to
change. Most people change only if they want to
change]
More use of non invasive monitoring devices.
DR Hania –AlJouzy
Surveillance ?
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Problematic?
-definitions [maternal vs hospital acquired]
-colonization vs infection.
- contamination –infection{CNS}
Clear objectives, definitions of infection.
Reliable data collection methods.
Use appropriate denominator.
Stratification [ birth weight]
Are all ICU’s comparable.
DR Hania –AlJouzy
Infection
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Presence of micro-organism in or on a
host, with growth and multiplication in the
tissues resulting in local cellular injury
associated with clinical manifestation or
immunologic response.
Taber's Cyclopedic Medical Dictionary
defines infection as: " the presence and
growth of a microorganism that produces
tissue death."
DR Hania –AlJouzy
Nosocomial infection
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The term nosocomial comes from the
Greek word that means care that is given
to a patient.
Nosocomial infection usually occurs during
hospitalization motivated by another
pathology or condition by which this
infection was not present, and incubation
occurred during hospitalization.
This duration should be more than 48
hours after admission.
DR Hania –AlJouzy
Colonisation
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Implies the presence of a micro-organism
in or on a host, with growth &
multiplication of the micro-organism but
without invading the surrounding tissues
and causing damage.
This is usually a defensive mechanism
that begins at birth and continues as
contact is made with people and the
environment.
DR Hania –AlJouzy
Contamination
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Transitory
presence of microorganism on body
surface
[ such as hands]
without tissue
invasion or
physiologic
reaction.
DR Hania –AlJouzy
Carrier
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Is an individual colonised with a specific
micro-organism and from whom the
organism can be recovered [cultured] but
who shows no overt expression of the
presence of the micro-organism at the
time of it is isolated.
A carrier may have a history of previous
disease due to the organism.
The carrier state may be transient or
intermittent or chronic.
DR Hania –AlJouzy
Septecemia
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Septecemia: [hemia:blood]
Systemic disease or clinical
signs of generalised
inflammation associated with
the presence and persistence
of pathogenic micro-organism
and or their products in the
blood.
Blood poisoning.
DR Hania –AlJouzy
Bacteremia
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Bacteremia: The presence of
bacteria in the blood.
Refer to bloodstream invasion that
may be associated with fever but no
other signs or symptoms of
circulatory compromise or end-organ
malperfusion or dysfunction.
DR Hania –AlJouzy
Conclusion
•Preventing infections
•Effective diagnosis and treatment
•Optimizing antimicrobial use [use
antibiotics wisely ]
•Finally, preventing transmission of
resistant organisms from one
person to another is critical to
successful prevention efforts.
DR Hania –AlJouzy
Conclusion
All infection control measures will need to
continue to pass the test of the "four Ps":
1.
2.
3.

Are the recommendations Plausible biologically
(e.g., is it likely to work)?
Are they Practical (e.g., are they affordable)?
Are they Politically acceptable (e.g., will the
administration agree)?
And, will Personnel follow them (e.g., can they
and will they)?
Nosocomial Infection Update
Robert A. Weinstein
Cook County Hospital & Rush Medical College, Chicago, Illinois, USA
DR Hania –AlJouzy
Hand washing
DR Hania –AlJouzy
DR Hania –AlJouzy
DR Hania –AlJouzy
DR Hania –AlJouzy
Lets work together to fight nosocomial infection.
Thank you for your patience
DR Hania –AlJouzy
Continuous Education on Infection control
to all persons coming in contact with sick
patients .
DR Hania –AlJouzy
Antisepsis

Method of infection
control includes using
soap and water to
wash the hands and
body as well as the
use of antiseptics
such as alcohol, iodine
and betadine to clean
the skin for medical
procedures, as these
inhibit the growth of
pathogenic
microorganisms.
DR Hania –AlJouzy
Antiseptics

Antiseptics are considered as
medications capable of eliminating
and killing the microorganisms or
inhibiting their growth and
development in or on living tissues
{e.g. health care personnel hand
washes and surgical scrub}.
DR Hania –AlJouzy
Disinfection
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is the process of using chemical
agents or boiling water to destroy or
kill pathogenic microbes.
Disinfectants are often harsh
and may irritate or damage the skin
so they are mainly used on surfaces ,
equipment and instruments.
DR Hania –AlJouzy
Disinfection
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Common disinfectants
include Clorox bleach
solutions.
In the health care
environment a variety
of commercial
disinfectants are
used.
DR Hania –AlJouzy
Sterilization
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is the only level of asepsis that kills all
microbes both pathogenic and
nonpathogenic.
It is the method used by all health care
facilities and includes the use of gas,
chemicals, steam under pressure and
radiation.
Sterilization is mainly used on medical
instruments and equipment, surgical
dressings, gowns etc.
DR Hania –AlJouzy
Breaking the Chain of
Infection.

There are three
levels of aseptic
control.
Antisepsis.
Disinfection.
Sterilization.
DR Hania –AlJouzy
Three Crucial Components of
an Infection Control Program
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Epidemiological — survey to
determine the type of
infection occurring.
Policies and procedures — are
established based on the type
of infection identified in the
survey.
Specially trained personnel —
collect the surveillance data
and coordinate the type of
interventions to set in place.
DR Hania –AlJouzy