1. Hospital Infections The Burden, Prevention and Control Prof. Abdulkarim Al-Aska Infectious Diseases Unit, King Khalid University Hospital

2. Definition Hospital acquired– Nosocomial Occurring after admission Neither presenting or incubating at the time of admission Occasionally the illness may develop weeks or months after discharge.

3. History Earliest Europeans hospitals were established in middle ages No resemblance to modern hospitals in either structure or function There were lack of space and shifts were ordered for patients and occasionally more than one patients in beds.

4. Consequences: Increased physical contact promoting infection spread The squalid situations led to the hospitals called ‘’pest houses’’

5. 19 TH century reports Surgery almost always followed by infection 60% of limb amputations resulted in fatal infection

6. Observation In 1846 there was differential mortality of childbed fever between 2 obstetrics wards 1 & 2 at University of Geneva. 11.4% vs 2.7%. Investigation was then launched by Ignaz Phillip Semmelweis who was the director of Obstetrics services

7. Then Pathologist doing post mortem died of similar illness having nicked his hand with scalpel. Conclusion from infectious materials.

8. Hospital staff and students were subsequently ordered to wash their hands with calcium hypochlorite after examining each patients. Mortality rate dropped from 11.4% to 1.3% in ward 1— decline of 89%.

9. Hand washing also ordered for ward 2, rate declined by 52%. This clearly demonstrated the spread and prevention of hospital infection Ignaz Phillip Semmelweis was later regarded as the Father of Hospital Epidemiology.

10. The discovery of penicillins in the 30s and 40s led to lower infection rate. Subsequently MRSA became problem. The 1990s saw the emergence of Vancomycin resistant Enterococci

11. Advancement in medicine also posed new challenges like catheter related blood stream infection and ventilator associated pneumonia.

12. Last two decades, increase number of susceptible patients as a result of survival to immune modifying disease or effect of therapy. Resulting in patients expose to life threatening diseases due to change in natural or acquired immunities.

13. Importance of Hosp Infection Estimates in the 70s, 6-8 per 100 patients admitted. Additional suffering and mortality for patients Nosocomial infection also increased length of hospital stay and extra costs to authorities.

14. Prolongation of Hospital Stay due to Nosocomial Infections in the USA

15. Annual Costs and Benefits of Infection Control Program in a Hypothetical 250-bed Hospital Each $1000 invested in infection control will return $3000 in net direct cost savings

16. Hospital-acquired Infection why worry? 10-15% of patients will get infected during a stay in hospital Costs >£1 billion per year in UK A single large outbreak can cost 10-100K

17. Effects of nosocomial infection – Increased mortality & morbidity – Prolonged hospital stay – Increased drugs bill – Increased staffing costs – Demoralising for staff & patients – Decreased public confidence in hospitals & doctors

18. Why is hospital-acquired infection different from community-acquired infection? Many vulnerable patients in close proximity to each other for prolonged periods of time Many patients have impaired immunity – After anti-cancer chemotherapy – After transplants – Extremes of age

19. Many patients have impaired normal physiological defences – Breaches in skin – Implanted foreign bodies (biofilms) – Impaired physiology (Peristalsis, mucociliary escalator)

20. Antibiotic-Resistant Infections Associated with extended illness Longer hospital stay Higher risk for death Increased costs to health system Microbes with mutation for resistance has a selective advantage to: Survive, proliferate and spread.

21. Controlling antibiotic prescriptions within hospitals had helped in reduction of resistant organism emergence. Contact precautions with gowns and gloves had prevented the spread of MRSA and VRE.

22. Transmission facilitated by hospital staff who rarely: Wash their hands Disinfect or dispose their clothing Disinfect their equipment

23. Hand washing

24. Method Wet hands with clean (not hot) water Apply soap Rub hands together for about 20 seconds Rinse with clean water Dry with disposable towel or air dry Use towel to turn off faucet

25. Alcohol-based Hand Rubs Effective if hands not visibly soiled More costly than soap & water Method Apply appropriate (3ml) amount to palms Rub hands together, covering all surfaces until dry

26. How consistent are we in washing hands between attending patients?

27. Recent studies Forty per cent (40%) wash their hands after contact with a patient before the next. Nurses comply more than doctors Worst compliance regrettably in ICUs.

29. UTI Thirty per cent of all nosocomial infections Rate of 1% with single in-out catheterisation Risk of 3 to 6% per catheter-day for prolonged usage. Higher for females than males Post 10-14 days, half of pateints have bacteriuria.

30. NNIS Data (CDC). E coli Coagulase -ve Staph Enterococcus spp Other fungi P aeruginosa Citrobacter spp Candida spp S aureus K pneumoniae Enterobacter spp Proteus mirabilis

31. Preventive measures have confirmed the advantage of closed drainage system. Also the use of silver alloy urinary catheter

32. Pneumonia Mainly from aspirated gastric contents. Also from microbes-laden secretions of upper respiratory tract. Septic emboli from infected CVP or A-V fistula Rarely, inhalation of pathogens from the air for example M tuberculosis and Aspergillus fumigatus

33. S aureus P aeruginosa Enterobacter spp K pneumoniae E coli

34. Most patients are ventilated in ICU. Rates from 6 to 30%. Risk of 1 to 3% per day. Higher inocula with patients on either H 2 blocker or antacid therapy. Less with sucralfate.

35. Preventive measures: Keeping patients at an angle of 45 degrees. Use of device for subglottic suction to reduce the pooling of secretions. Led to less clinical aspirations and lower pneumonia rates.

36. Surgical Site Infections Still occur despite aseptic techniques Clearly the obese and diabetic patients require adequate preparations. Use of dry shaving a day before surgery is better than clippers hours before. Emergent surgery on inherently contaminated organs like the colon.

37. S aureus Coagulase –ve Staph Enterococci E coli Enterobacter Klebsiella Candida

38. Blood Stream Infections Primary 80%: mainly from infected vascular catheter. Secondary 20%: local infection in another organ. Catheter-related BI begins with colonization of the catheter with microbes. Femoral more prone than IJ and SC

39. Cultured tips of catheter in cardiac surgery are infected within 1-2 hours of insertion. Earlier on tackled by the body’s immune system. Subsequently microbes moved through the catheter tract to enter the blood stream.

40. By 10 days there is an increasing frequency of intra-luminal contamination. Multiple randomised trials had shown that antiseptic preparation with chlorhexidine is far superior in risk reduction of colonisation as compared with alcohol or povidone-iodine preparations.

41. Chlorhexidine-silver sulphadiazine treated catheter has been shown to reduce colonization and blood stream infection by about half. Cotton gauze covered by tape were associated with lower risk of colonization versus transparent dressings.

42. Antibiotic-coated catheter reduced colonization by 55% as compared with standard catheters. Comparative study had shown that the capacity of minocycline/rifampicin coated catheter were superior in resisting infection versus chlorhexidine-silver sulfadiazine catheter.

43. Organization for Infection Control Surveillance Outbreak investigations Education Hospital employee health Antimicrobial utilization Policy development Quality assessment

44. Infection Control Programs Size and intensity of program predicts infection rates. Most effective associated with 32% reduction compared with hospital without program. One hospital with effective program in 1985 reported saving costs of $2million for the year.

45. Infection Control in hospital Interrupt transmission – Human-to-human Hand washing Ward routine (e.g. wet mopping) Aseptic technique Sterilisation & disinfection Isolation procedures – Environment Food hygiene, pest control, theatre design

46. Precautions Standard Specific ----Airborne ----Droplets ----Contact

47. Standard Precautions Perform hand hygiene Wear gloves Wear gowns Wear a mask and goggles and glasses

48. Standard Precautions Hand hygiene Respiratory hygiene and cough etiquette Personal protective equipment (PPE) Based on risk assessment to avoid contact with blood, body fluids, excretions, secretions Safe injection practices Environmental control Patient placement

49. Specific Isolation Categories

50. Airborne precautions Use a negative- pressure room Keep doors closed Wear grade N95 or better mask If patient transport is necessary, then patient to wear surgical mask TB, Measles, Chickenpox

52. Droplet precautions Keep doors closed Wear a surgical mask if entering the room Discard mask after leaving the room If patient transport is necessary, patient to wear surgical mask Meningitis, Mumps, Pertussis, Rubella

53. Contact precautions Wear a gown and gloves to enter the room Use a dedicated stethoscope and thermometer Remove gown and gloves before leaving the room Acute infectious diarrhea, Abscess/draining wound

54. Occupational Exposures

55. Occupational Risk for Hepatitis Hepatitis B is much more frequent occupational infection and a cause of deaths among HCWs. Standard precautions and vaccination had reduced infection. Ten per cent of HCWs do not respond to vaccination. No vaccine yet for Hepatitis C

56. Occupational exposures General steps in management Wash and clean wounds Flush mucous membranes immediately

57. Unvaccinated Exposed HCW Injury from HBsAg +ve source, give HBIG 0.06mL per Kg and initiate HB vaccine Injury from HBsAg -ve source, initiate HB vaccine Injury from unknown status of HBsAg initiate HB vaccine and determine HBsAg of source.

58. Vaccinated HCW/unknown Ab status Injury from HBsAg +ve source, do anti- HBS on exposed person:: --If titer>10milli-IU/ml no treatment. --If titer<10milli-IU/ml, give HBIG 0.06mL per Kg + 1 dose of HB vaccine

59. Injury from HBsAg -ve source, no treatment is necessary. Injury from unknown status of HBsAg do anti- HBS on exposed person:: --If titer >10milli-IU/ml no treatment. --If titer <10milli-IU/ml, give 1 dose of HB vaccine plus HBIG if source high risk

60. Hepatitis C exposure Determine anti-HCV from both exposed person and source. If source known +ve and exposed –ve follow up HCV testing advised. Baseline and serial LFTs HCV RNA after 2 weeks of exposure.

61. No recommended prophylaxis; immune globulin not effective. Monitor for early infection as therapy may reduce risk of progression to chronic hepatitis.

62. Risk factors from case control study. Needle from artery and veins. Deep injury. Male HCW. Source ≥ 6 million copies/mL.

63. Occupational Risk for HIV Infection Approximately 1 in 300-400 needle sticks injuries will transmit HIV. Chances increased with large-bore hollow needle Wash wounds and flush mucous membranes.

64. Baseline HIV test, CBC, renal and hepatic tests Viral load of source. HIV testing should be repeated as follows: 3-4 weeks and 3 & 6 months PEP should be started within hours

65. Regimens Treat for 4 weeks Monitor drug side-effects fortnightly Basic regime Zidovudine + Lamivudine or Stavudine + Lamivudine Expanded regime Above + Lopinavir + Ritonavir

66. Occupational Risk for T B Infection occurs in setting lacking isolation techniques These are: Absence of negative-pressure ventilation rooms Lack of administrative control measures

67. Further recommendations Annual and semi-annual PPD testing Training and retraining of staff

68. An extract from the work book of Dr Fester, aged 24, newly qualified house officer... 50 lines as punishment for poor hand hygiene I promise to wash my hands between patients I promise to wash my hands between patients...

69. Thank you