S.P Siva Shankari @ Rekha Nosocomial Infection “Infections Are Most Often Transmitted From Patient To Patient On The Hands Of Healthcare Workers…” - Dr.William Jarvis S.P Siva Shankari @ Rekha M.Sc Nanoscience Lady Doak College Iva Puspitasari,MD

Introduction: "Nosocomial" comes from two Greek words - "nosus" meaning "disease" + "komeion" meaning "to take care of" -disease contracted by a patient while under medical care. Infection may manifest during the patient’s stay, after get discharged, Visitors to the hospital also. Also called as “Hospital Acquired Infection” (HAI).

Arti infeksi nosokomial Pasien yang dirawat di Rumah Sakit dan mendapatkan infeksi di Rumah Sakit yang sebelumnya pasien tidak dalam fase prodromal/inkubasi penyakit tersebut

Factors Predispose HAI : Hospital Pathogen Poor Condition Of Hospital Crowding Of Patient’s Instruments Extremes Of Age Immunity Contaminations

Source Of Nosocomial Infection : Endogenous Cause Self Infection Or Auto Infection Exogenous Cause Cross Infection Or Environmental Infection

Routes of transmission:   Airborne Transmission Common vehicle Transmission Contact Transmission Droplet Transmission Vector borne Transmission

Air borne transmission : Tiny droplet nuclei (< 5 microns) that remain Suspended in the air. Dusts From Bedding & Floor. Exudates Dispersed From Wound.

Common vehicle transmission: Transmitted indirectly by material contaminated with the infectious microbes. Example: contaminated food , blood products, water or contaminated instruments & other items.

CONTACT TRANSMISSION: Most important and frequent mode of transmission of nosocomial infections. It is divided into two subgroups : Direct-contact transmission Indirect-contact transmission

Droplet transmission : Droplets generated by : Coughing Sneezing Respiratory tract procedures such as bronchoscopy Secretions  

Vector transmission : Transmitted through insect & other invertebrate animals. Examples : mosquitoes can transmit “malaria” and “yellow fever”. Fleas can transmit “plague”.

Nosocomial infection factors : High prevalence of pathogen . High prevalence of compromised hosts . Efficient mechanisms of transmission from one to another. This is also known as chain of transmission : o The movement of pathogen from individual to individual via various routes.

Pathological agents important in nosocomial infection: Staphylococcus aureus Escherichia coli Pseudomonas aeuroginosa

Viruses : There is a possibility of nosocomial transmission of, Hepatitis B & C viruses (transfusion , dialysis, injection, endoscopy) Respiratory Synctyial Virus (RSV) Rotavirus

Cytomegalovirus Herpes virus Influenza

Parasites & Fungi:   Many of them are lethal organisms and cause infection during extended antibiotics treatment and severe immunosuppression. Candida albicans, Aspergillus species Cryptosporidium, Toxoplasma pneumoniae.

SITES OF INFECTION : Distribution according to the French national prevalence survey(1996), Following are the most common nosocomial infections: Urinary tract Surgical Site Respiratory tract Bacteraemia

Surgical site infection: They are also frequent : the incidence varies from 0.5 to15% depending on the type of operation & underlying patient status. The definition is mainly clinical : discharges around the wound, or spreading pus from the wound. By Stitches, Umbilical Cuts, Surgery spots. Organisms: S.aureus, P.aeruginosa.

Risk factor SSI: Advanced age Obesity Infection at a remote site (spread through blood stream) Malnutrition Diabetes Extended preoperative hospital stay Greater than 12 hours between preoperative shaving of site and surgery Extended time of surgery Inappropriate timing of prophylactic antibiotics

Nosocomial pneumonia : The most important are patients on ventilators in intensive care units, where the rate of pneumonia is 3% per day . It accounts for 15% and have high mortality (13-55%). Mostly caused by respiratory devices, instruments. Organisms : S. aureus , Streptococcus pneumoniae , Influenzae.

Urinary Tract Infections : It constitutes 40% of Nosocomial infections. Typically by catheterization, Instruments. Manifests as Cystisis, Urethritis. Organisms : E.coli, Proteus, Klebsilla

Risk factor uti: Advanced age Female gender Severe underlying diasese Placement of indwelling urine catheter

Nosocomial Bacteraemia: These infection represent a small proportion of nosocomial infection (approximately 5-6%). The incidence is increasing , particularly for certain organisms such as Staphylococcus & Candida Species Infection may occur at the skin entry site of the intravascular device , or in the subcutaneous path of the catheter ,organisms colonizing the catheter within the vessel may produce bacteraemia without visible external infection.

Risk factor BSI: Age 1 year of age or younger or 60 years of age and older Malnutrition Immunosuppressive chemotherapy Loss of skin integrity (burns, decubitus) Severe underlying illness Indwelling device (catheter) Intensive care unit stay Prolonged hospital stay

Problems of nosocomial infection :   Nosocomial infection will become more important as public health problem, as it causes: Additional suffering Prolong hospital stay Increase the cost of care significantly Nosocomial infection are important contributors to morbidity & mortality

Results : May cause death Increase emotional stress of the patient Morbidity ,mortality ratio Excess costs on stay Can be transmitted to discharged patients or visitors High antibiotic resistance

Diagnosis : phenotypic Biotyping Phage typing Serotyping Plasmid profile Antibiogram

Diagnosis: genotypic Plasmid analysis Restriction endonuclease analysis of chromosomal DNA

Control Mask, Eye Protection:  To prevent splashes, sprays of secretions & excretion transmitting infection. Sterilization : Sterilization of all reusable equipment such as ventilators , humidifiers & any devices that come in contact with the respiratory tract. Linen : Solid, reusable items are placed in biohazard bags to prevent leakage. 

Gloves: On contact with blood, body fluids, wounds. Change of gloves after using it for 1 patient Removal always in reversal manner so as not to touch surface. Hand washing: Is the single most important measure to reduce the risk of transmitting microorganisms from one person to another or from one site to another on the same patient. 

Cleaning of all isolation rooms alter the patients after is discharged control Segregation of infected patients in private rooms or chorting of patients if private rooms is not available Cleaning of all isolation rooms alter the patients after is discharged Placement of cards on the patien’s door specifiying the type of isolation and instruction for visitor and nursing staff

Category of isolation Strict isolation (chicken pox, pneumoniae plaque, lassa fever) Respiration isolation (measle, haemophilus influenza, Neisseria meningitidis) Enteric precaution (amoebic dysentri, Salmonella, Shigella) Contact isolation for patient infected MDRO AFB isolation for patient with M.tuberculosis Drainage and secretion precaution for person with conjunctivitis and burn Blood and body fluid precaution for individual with AIDS

Tell your doctor everything: All symptoms. Other prescription medications. Previous diseases. Don’t assume it’s not important just because your doctor did not ask.   Aprons : Wearing an aprons during patient care reduces the risk of infection . The apron should be disposable.

Conclusion : There is no official, national approach and no real managerial support from health authorities for control of nosocomial infections All diposable items should be properly diposed in puncture proof bags without touching. Miss use of antibiotics has produced antibiotic resistant organisms and these increase clinical complications of patients, lengthening their hospital stay and adding to treatment costs. Only thing is proper asepsis ,sterilization ,proper washing of hand.

REFERENCES Gerard J. Tortora, Berdell R. Funke, Christine L. case, “Microbiology – An introduction”, 9th edition, pearson and Benjamin Cummings Inc., 2006. BS Nagoba, Asha Pichare , “Medical Microbiology” , 1st edition, Reed Elsevier private Limited, New Delhi,2007. Eugene W Nester, Denise G. Anderson, C. Evans Roberts Jr, Nancy N Pearsall, Martha T. Nester, “Microbiology- A Human Perspective”, 3rd Edition, Mc Graw Hill, North America. http://en.wikipedia.org/wiki/hospital_acquired_infection

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