H OSPITAL -A CQUIRED I NFECTIONS / N OSOCOMIAL I NFECTIONS while in a hospital or health care not present or incubating on admission) An infection contracted by a patient or staff member while in a hospital or health care facility (and not present or incubating on admission)

 Hospital acquired infections are a common problem  Hundreds of millions of patients are affected by health care-associated infections worldwide each year, leading to significant mortality and financial losses for health systems. Of every in developing countries will acquire at least one health care-associated infection  Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection  1 in 10!

E PIDEMIOLOGY OF N OSOCOMIAL I NFECTIONS  Most common sites for nosocomial infections  Surgical incisions  Urinary tract (i.e., catheter- related)  Lower respiratory tract  Bloodstream (i.e., catheter-related)

Surgical incisions

Urinary tract (i.e., catheter-related)

Lower respiratory tract Ventilator associated pneumonia

The CVC- is one of the most commonly used catheters in medicine The CVC is typically placed through a central vein such as the IJ, Subclavian or femoral Bloodstream (i.e., catheter-related) These serve as direct line for microbial bloodstream invasion

 Bloodstream (i.e., catheter-related) stream (i.e., catheter-related)

C OMMON MICROORGANISMS  Gram-positive cocci ( Staphylococcus aureas [MRSA], enterococci [vancomycin-resistant]),  Gram-negative bacilli ( Escherichia coli, P. aeruginosa, Enterobacter spp., and Klebsiella pneumoniae

N OSOCOMIAL TRANSMISSION OF COMMUNITY ACQUIRED, MULTIDRUG - RESISTANT ORGANISMS  M. tuberculosis  Salmonella spp.  Shigella spp.  V. cholerae

R OOT C AUSES OF N OSOCOMIAL I NFECTIONS  Lack of training in basic Infection Control  Lack of an IC infrastructure poor IC practices  Lack of an IC infrastructure and poor IC practices (procedures)  Inadequate facilities and techniques for hand hygiene  Lack of isolation precautions and procedures

 Use of advanced and complex treatments without adequate training and supporting infrastructure, including—  Invasive devices and procedures  Complex surgical procedures  Interventional obstetric practices  Intravenous catheters, fluids, and medications  Urinary catheters  Mechanical ventilators  Inadequate sterilization and disinfection  Inadequate sterilization and disinfection practices and inadequate cleaning of hospital

C ORE S TRATEGIES TO R EDUCE N OSOCOMIAL I NFECTIONS —H AND H YGIENE To ensure appropriate hand washing techniques—  Provide sinks, clean water, and soap at convenient locations  Where sinks, clean water, and hand washing supplies are unavailable, use alcohol-based products which are inexpensive, produced locally, convenient, and effective for hand hygiene.  Monitor compliance  Use gloves when necessary

I SOLATION AND S TANDARD P RECAUTIONS  Whenever possible, avoid crowding wards.  Implement specific policies and procedures for patients with communicable diseases:  Private rooms and wards for patients with specific diseases  Visitation policies  Hand washing and use of gloves  Gowns, when appropriate  Masks, eye protection, gowns  Precautions with sharp instruments and needles

E NSURING A C LEAN E NVIRONMENT  Establish policies and procedures to prevent food and water contamination  Establish a regular schedule of hospital cleaning with appropriate disinfectants in, for example, wards, operating theaters, and laundry  Dispose of medical waste safely  Needles and syringes should be incinerated  Other infected waste can be incinerated or autoclaved for landfill disposal  Bag and isolate soiled linen from normal hospital traffic

C LEANING, D ISINFECTION, AND S TERILIZATION OF I NSTRUMENTS AND S UPPLIES  Written policies and procedures are needed thoroughly cleaned  All objects to be disinfected or sterilized should first be thoroughly cleaned stream sterilization  Use stream sterilization whenever possible  Quality control in reprocessing  Quality control in reprocessing is essential  Monitor and record sterilization parameters (i.e., time, temperature, pressure)  Biological indicators should be used to ensure sterilization  Chemical indicators are necessary for chemical sterilization  Sterilized items must be stored in enclosed clean areas  Items or devices that are manufactured for single use should not be reprocessed (e.g., disposable syringes and needles)

S TANDARD P RECAUTIONS Masks, eye protection, face shield: Wear during activities likely to generate splashes or sprays Gowns Protect skin and soiling of clothing Wear during activities likely to generate splashes or sprays Sharps Avoid recapping of needles Avoid removing needles from syringes by hand Place used sharps in puncture –resistant containers

A IRBORNE P RECAUTIONS Designed to prevent airborne transmission of droplet nuclei or dust particles containing infectious agents For patient with documented or suspected: Measles Tuberculosis (primary or lanryngeal) Varicella ( airborne + contact ) Zoster (disseminated or immunocompromised patient; ( airborne and contact ) SARS ( Contact+airborne )

D ROPLET P RECAUTIONS Designed to prevent droplet (larger particle) transmission of infectious agents when the patient talks, coughs, or sneezes For documented or suspected: Adenovirus ( droplet+contact ) Group A step pharyngitis, pneumonia, scarler fever (in infants, young children) H. Influenza meningitis, epiglottitis Infleunza, Mumps, Rubella Meningococcal infections

S UMMARY  IC procedures  IC procedures are vital to preventing nosocomial infections and for controlling hospital costs.  Simple, inexpensive strategies can prevent many infections.  Hand washing and use of appropriate antiseptics and disinfectants  Monitoring IV and injection preparation and administration  Policy for Antibiotics  Guidelines for treatment and surgical prophylaxis  Selection of appropriate antimicrobials for the formulary  Antimicrobial use reviews

 Infection Control Committees or programs, when functioning effectively, will   Reduce the spread of infectious diseases  Decrease morbidity and mortality due to nosocomial infections  Maintain employee health and morale  Decrease the incidence of AMR  Decrease health care costs

Hand Hygiene is the single most effective intervention to reduce the cross transmission of nosocomial infections

R ECENT E XAMPLE OF HAI Outbreak of multiresistant Klebsiella pneumoniae in PBU of DGH Nuwara Eliya

W HY ? H OW ?? Poor hand hygiene? Contaminated infusates? Lack of general cleanliness?

R EGULAR V ISITS TO PBU

I S OUR HAND - RUB GIVES EXPECTED RESULTS ?

C HECK THE IN - HOUSE HAND - RUB ! Formulation I To produce final concentrations of ethanol 80% v/v, glycerol 1.45% v/v, hydrogen peroxide (H 2 O 2 ) 0.125% v/v. Pour into a 1000 ml graduated flask: ethanol 96% v/v, ml H 2 O 2 3%, 41.7 ml glycerol 98%,14.5 ml

Formulation II To produce final concentrations of isopropyl alcohol 75% v/v, glycerol 1.45% v/v, hydrogen peroxide 0.125% v/v : Pour into a 1000 ml graduated flask: isopropyl alcohol (with a purity of 99.8%), ml H 2 O 2 3%, 41.7 ml glycerol 98%, 14.5 ml

T O STOP OR CONTROL HAI Hand hygiene – Properly done “hand hygiene”