Hospital – acquired Infection
Definition :
It is infection acquired while staying in hospital . It meets the following criteria :-
Not found on admission .
Temporally associated with admission or a procedure at a health care facility .
It was not incubating at admission and may be related to a previous procedure or admission to same or other health care – facility e.g HIV acquired from previous blood transfusion .
Routes of infection : -
Self infection (auto genous infection) .
Cross – infection .
Environmental infection
-Dust.
-Bed linen
-Air .
-Moist solutions may be contaminated Pseudomonas
Klebsiella
Factors which promote hospital acquired infection : -
Impaired general host defencas of the patient .
Impaired local host defences of the patient .e.g injury of skin barrier .
Presence of hospital pathogen which are endemic epidermidis . Increasing problem is associated with MRSA strepto . pneumonia is the next common gram positive assoiated with lower respiratory tract infection .
Types of hospital infection : -
The three most frequent types : -
Urinary tract infection .
Wound infection .
Lower respiratory tract infection .
Other types of less common infections : -
Bed sores and varicose ulcer infection
Alimentary tract infection .
All severe bacterial infections lead to septicaemia .
Organisms causing Hospital acquired infection : -
In many hospital but also each hospital has specific endemic or epidemic strains of particular types of organism in certain areas .
In hospitals with large specific units e.g oncology , special care baby units opportunists organisms as well as the common pathogens are likely to cause problem
Pathogens causing hospital acquired infections include
Conventional pathogen e.g strepto-pyogenes .
Conditional pathogen e.g Bacteroides .
Opportunists pathogen e.gPneumocystis carinii .
The most common organisms are staph. aureus and staph.epidermidis
-Gram Negative bacilli such as : -
E.coli is the most prequent single bacterial species associated with hospital acquired infection .
klebsiella , proteus species and Pseudomonas are also common cause .
- Fungal and viral infection are only ocassionaly acquired in hospital .
- Protozoa are rare .
Laboratory diagnosis Of Hospital – acquired Infections :
Samples collected from the patient includes Blood culture , sputum, tracheostomy wound swabs and other samples. Perform cultured before antibiotics therapies and judged accurately if the isolate is just contamination or already a true pathogen .
Samples from the environment includes all equipments in the ICU and from antiseptic solutions according to the place of environmental assay.
Typing of the isolated organisms from both patients, environment and personnel by the following typing methods :
Bio typing
Sero typing
Phage typing
Bacteriocine typing
DNA finger printing
1- Hospital – acquired urinary tract infections
The most common type of hospital infection (about 25%)
The source auto- genous from patient's own faecal flora or from the environment (urinals , wash bowl) .
Colonization of the patient's large intestine by hospital resistant strains of Gram – negative bacilli occurs when the patient stays in hospital more than few days or when patient take antibiotics .
E.coli is the most common pathogen especially resistant strains to sulfonamides and ampicillin other pathogens such as klebsiella aerogenes, Enterococcus spp. (Vancomycin resistant) and Pseudomonas are common .
Ocassionally candida and serratia marscenes may cause such infection .
Patients with impaired immune system may become infected wit T.B and Nocardia asteroids , salmonella spp. Or Papoviruses .
Mixed infections are common with catheterization
Effects of UII : -
Asymptomatic infection .
Symptomatic infection
Prologed hospital stay .
Pyelonephritis , haemorrhage after operation
Septicaemic shock .
Catheterization hazards : -
Patients with catheter have the following dangers:
10-30% develop UTI by the fifth day .
100% develop UTI by 2-3 weeks .
Prevention of catheter – associated urinary infection : -
Good aseptic technique to the surrounding
area with chlorhxidine solution and cream .
Never touch the tip of the catheter .
Wash hands with chlor hexidine solution .
Chlorhexidine installation into the bladder .
Early removal of the catheter .
Change it within few days or when dirty .
-Take care not to soil the hands of the staff .
4) Policies for control of hospital acquired urinary tract infections :
This depends upon the extent to which these policies are effectively carried from day to day .
Isolate patients with multiple antibiotic resistant strains .
Sponge with antiseptic solution should be put between catheter and urethra especially in females.
Repeated self catheterization with use of antiseptic solution is preferred in paraplegic patient .
2-Surgical wound Infection
1) The type of the wound is the most single factor associated with the development of wound infection . The major types of surgical wounds can be classified as follows : -
-Clean operation wounds in area not involve regions of gastrointestinal tract, respiratory tract or genitourinary tract. It is associated with very low rates of infection 2-5%.
- Contaminated operation Surgery that involves a site with known normal flora (apart from skin) e.g operation on colon , gall bladder , mouth or vagina .
- Infected operation wounds , the operation site may be infected at time of surgery e.g incision of an abscess .
2) Surgical team:
- Skill of surgeon
- Good aseptic techniques
- Carriage of staph. aureus .
3) Age and general condition of the patient .
Persistence of local structural abnormal .
Ward factors post operatively
Complication of wound Infections : -
Delayed wound healing
Failure of graft .
Infections of bones , joints , peritoneal cavity .
Septiceamia
Types of hospital acquired wound infections include : -
Ward infection
Theatre infection
(How to differentiate ?)
Prevention of theatre infection : -
Protective of theatre clothing .
Gloves for the hands after chlorhexidine antiseptic solution
Movements of staff should be reduced to a minimum .
Very clean theatre with good managing of the air direction around the operative table .
Disifect the skin of the patient and many use preoperative baths with hexachlorophene or chlorhexidine detergents .
Prevention of wards infections : -
Isolation rooms for wards should be available for patients infected with MRSA or with severe wound infections especially in high risk surgery e.g cardio thoracic orthopaedic , neuro surgical units and ICU .
Adequate non touch technique for dressing of the wound .
Suitable bad spacing between patients (2.5m)todecrease air or dust spread .
The patient should be admitted for the shortest time before the operation to decrease the chances of colonization or infection with hospital strains .
Restrict the use of prophylactic antibiotics .
Exclude patients with skin disease from the word .
Exclude members of staff with boils , abscess or other infected skin lesions .
If an out breaks occur , how to control ?
Be sure that it is cause by the same epidemic strain with similar antibiotic resistance pattern and phage type .
Isolate the patient .
The medical staff shown to be carrier should temporarily cease the work and use chlorhexidine on the affected area with all hygiene measure .
Close the ward in severe cases .
Use vancomycin for therapy .
3-Acute Lower Respiratory tract Infection
Third most common infection in hospital acquired infection
Patients predisposed are usually paediatric patients or elderly patients with predisposing chest conditions .
Causative pathogens include , strepto . pneumoniae , staph. aureus , influenza A or B , respiratory syncytial virus and legionella species.
Infections in ICU
It is very common to find high rates of infections in intensive care units.
Samples collected from the patient includes Blood culture , sputum, tracheostomy wound swabs and other samples. Perform cultured before antibiotics therapies and judged accurately if the isolate is just contamination or already a true pathogen .
Samples from the environment includes all equipments in the ICU and from antiseptic solutions .
Preventive measures are the same as before and the measures for the equipments include : -
Adequate cleaning of the equipment in between patients
Heating water in the ventilator to 50oC every day .
Use of autoclavable ventilator or decontaminate it with ethylene or formaldehyde gas .
Anaesthetic bags , suction apparatus , face masks may be efficiently cleaned with washing machine or by low temperature disinfectant .
Infective hazards of intravenous fluid
Between 0.2 – 8% of patients receiving intravenous fluid develop septicaemia and may develop endotoxic shock if gram – negative bacilli multiply at the additive solution added to the fluid .
Causative organisms : -
Gram negative bacilli contaminating fluid solutions .
Bacterial orviral contamination of blood and blood products including HIV , HTLVI , hepatitis viruses , Epestein Barr virus , CMV , Treponema pallidam and malarial parasites .
Prevention of infections with Fluid Infusion.
Perfect antiseptic technique to the skin over the area used with shaving of the excess hair and palpate the vein before use of antiseptic solurtion (chlorohexidine or iodine)
Place the needle in the place and needs to be anchored securely as excessive movement predisposes to site infection
Topical Betadine antiseptic solution and if needed antifungal cream may be added .
Inspect the site of the drip , if infected with draw the complete set immediately and insert it at different site .
Change the complete set every 24-48h
Restrict the use of antibiotic therapy
Diagnosis of infections associated with intravenous infusion therapy : -
With draw blood samples for blood culture .
Send the bottle , cannula and there catheter to the microbiological lab.
Inspect the bottle for presence of defects , and with draw fluid for microscopic examination , culture at 35oC , 4oC and at room temperature .
Culture the catheter tip or cannula on broth or by rolling moistend cannula on surface of blood agar plate – organisms isolated include staph. epidermidis , staph. aureus , candida albicans , klebsiella species , serratia , pseudomonas aeruginosa .
Begins blind therapy with cloxacillin plus gentamicin .
Policies for prevention of infection to or / and from Health works
1) Tuberculosis : -
Staff are Mantoux tested and have chest X ray at start of hospital employment .
Mantoux negative BCG immunization and be sure to convert mantoux negative to positive .
Mantoux positive Deals with patients with open T.B or samples known to have T.B. bacilli .
Isolate patient with open T.B in single room until 2-3 weeks after antituberculous therapy .
Each sputum sample should be handled as if it had T.B and never be opened in the ward .
In the lab See precautions of handling sputum samples .
2) Viral Hepatitis :
Exclude staff with HBsAg positive from renal dialysis units or from carrying exposure – prone procedures
Precautions should be taken in the lab. To prevent infections to workers .
All staff with regular contact with blood should have anti HBS with titre > (10 lu/L)
Precautions to prevent viral hepatitis : -
Isolate the patients (stool / urine / needle isolation)
Take blood samples with gloves
Transport to the lab in sealed plastic bags.
Samples are put in upright position in non leaking screw caps containers
Samples and requests should be labeled ashepatitis risk .
Take care of samples from suspected patients .
Accidental prick to staff should be reported to senior staff , take hyper immune globulin with 24-48 hours and vaccinate if HBS antibodies is negative .
Wearing of two gloves , waterproof apron and goggles together with many other precautions are necessary when surgery is carried out on patients with hepatitis B. (universal precautions) .
Staff members positive for HBsAg or e antigen should not work in dialysis unit , oncology , surgery or transplant unit .
3)AIDS :
Blood and blood products should be screened for HIV 1/2.
Universal precautions against blood – borne viruses should be taken when blood or blood staining splashing are anticipated as risk .
Post exposure drug prophylaxis is recommended for staff sustaining a sharp injury from a patient or HIV .
Policies for Control of Hospital –acquired Infections
Each hospital has many procedures and policies which attempt to reduce the chances of hospital infection occurring , but the extent to which these policies are effectively carried out on a day to a day basis varies greatly between different hospitals or different areas in the hospital .
Procedures for control Include : -
Sterilization and disinfection of contaminated items .
Disposal of infected rubbish or linen .
Aseptic techniques in the operating theatre
Procedures carried in wards such as changing of wound dressings , urinary catheterization and setting up of an intravenousdrip .
Protective isolation of infected patients or protective isolation of highly susceptible patients .
Use of antibiotics therapy according to a greed policy .
Education of hospital staff in hospital hygiene .
Good staff health facilities .
Adequate use of the clinical microbiology for the precise bacteriological diagnosis .
Control infection committee which helps to design hospital policies and discusses any difficulties encountered during the implementation of these policies .
Definition :
It is infection acquired while staying in hospital . It meets the following criteria :-
Not found on admission .
Temporally associated with admission or a procedure at a health care facility .
It was not incubating at admission and may be related to a previous procedure or admission to same or other health care – facility e.g HIV acquired from previous blood transfusion .
Routes of infection : -
Self infection (auto genous infection) .
Cross – infection .
Environmental infection
-Dust.
-Bed linen
-Air .
-Moist solutions may be contaminated Pseudomonas
Klebsiella
Factors which promote hospital acquired infection : -
Impaired general host defencas of the patient .
Impaired local host defences of the patient .e.g injury of skin barrier .
Presence of hospital pathogen which are endemic epidermidis . Increasing problem is associated with MRSA strepto . pneumonia is the next common gram positive assoiated with lower respiratory tract infection .
Types of hospital infection : -
The three most frequent types : -
Urinary tract infection .
Wound infection .
Lower respiratory tract infection .
Other types of less common infections : -
Bed sores and varicose ulcer infection
Alimentary tract infection .
All severe bacterial infections lead to septicaemia .
Organisms causing Hospital acquired infection : -
In many hospital but also each hospital has specific endemic or epidemic strains of particular types of organism in certain areas .
In hospitals with large specific units e.g oncology , special care baby units opportunists organisms as well as the common pathogens are likely to cause problem
Pathogens causing hospital acquired infections include
Conventional pathogen e.g strepto-pyogenes .
Conditional pathogen e.g Bacteroides .
Opportunists pathogen e.gPneumocystis carinii .
The most common organisms are staph. aureus and staph.epidermidis
-Gram Negative bacilli such as : -
E.coli is the most prequent single bacterial species associated with hospital acquired infection .
klebsiella , proteus species and Pseudomonas are also common cause .
- Fungal and viral infection are only ocassionaly acquired in hospital .
- Protozoa are rare .
Laboratory diagnosis Of Hospital – acquired Infections :
Samples collected from the patient includes Blood culture , sputum, tracheostomy wound swabs and other samples. Perform cultured before antibiotics therapies and judged accurately if the isolate is just contamination or already a true pathogen .
Samples from the environment includes all equipments in the ICU and from antiseptic solutions according to the place of environmental assay.
Typing of the isolated organisms from both patients, environment and personnel by the following typing methods :
Bio typing
Sero typing
Phage typing
Bacteriocine typing
DNA finger printing
1- Hospital – acquired urinary tract infections
The most common type of hospital infection (about 25%)
The source auto- genous from patient's own faecal flora or from the environment (urinals , wash bowl) .
Colonization of the patient's large intestine by hospital resistant strains of Gram – negative bacilli occurs when the patient stays in hospital more than few days or when patient take antibiotics .
E.coli is the most common pathogen especially resistant strains to sulfonamides and ampicillin other pathogens such as klebsiella aerogenes, Enterococcus spp. (Vancomycin resistant) and Pseudomonas are common .
Ocassionally candida and serratia marscenes may cause such infection .
Patients with impaired immune system may become infected wit T.B and Nocardia asteroids , salmonella spp. Or Papoviruses .
Mixed infections are common with catheterization
Effects of UII : -
Asymptomatic infection .
Symptomatic infection
Prologed hospital stay .
Pyelonephritis , haemorrhage after operation
Septicaemic shock .
Catheterization hazards : -
Patients with catheter have the following dangers:
10-30% develop UTI by the fifth day .
100% develop UTI by 2-3 weeks .
Prevention of catheter – associated urinary infection : -
Good aseptic technique to the surrounding
area with chlorhxidine solution and cream .
Never touch the tip of the catheter .
Wash hands with chlor hexidine solution .
Chlorhexidine installation into the bladder .
Early removal of the catheter .
Change it within few days or when dirty .
-Take care not to soil the hands of the staff .
4) Policies for control of hospital acquired urinary tract infections :
This depends upon the extent to which these policies are effectively carried from day to day .
Isolate patients with multiple antibiotic resistant strains .
Sponge with antiseptic solution should be put between catheter and urethra especially in females.
Repeated self catheterization with use of antiseptic solution is preferred in paraplegic patient .
2-Surgical wound Infection
1) The type of the wound is the most single factor associated with the development of wound infection . The major types of surgical wounds can be classified as follows : -
-Clean operation wounds in area not involve regions of gastrointestinal tract, respiratory tract or genitourinary tract. It is associated with very low rates of infection 2-5%.
- Contaminated operation Surgery that involves a site with known normal flora (apart from skin) e.g operation on colon , gall bladder , mouth or vagina .
- Infected operation wounds , the operation site may be infected at time of surgery e.g incision of an abscess .
2) Surgical team:
- Skill of surgeon
- Good aseptic techniques
- Carriage of staph. aureus .
3) Age and general condition of the patient .
Persistence of local structural abnormal .
Ward factors post operatively
Complication of wound Infections : -
Delayed wound healing
Failure of graft .
Infections of bones , joints , peritoneal cavity .
Septiceamia
Types of hospital acquired wound infections include : -
Ward infection
Theatre infection
(How to differentiate ?)
Prevention of theatre infection : -
Protective of theatre clothing .
Gloves for the hands after chlorhexidine antiseptic solution
Movements of staff should be reduced to a minimum .
Very clean theatre with good managing of the air direction around the operative table .
Disifect the skin of the patient and many use preoperative baths with hexachlorophene or chlorhexidine detergents .
Prevention of wards infections : -
Isolation rooms for wards should be available for patients infected with MRSA or with severe wound infections especially in high risk surgery e.g cardio thoracic orthopaedic , neuro surgical units and ICU .
Adequate non touch technique for dressing of the wound .
Suitable bad spacing between patients (2.5m)todecrease air or dust spread .
The patient should be admitted for the shortest time before the operation to decrease the chances of colonization or infection with hospital strains .
Restrict the use of prophylactic antibiotics .
Exclude patients with skin disease from the word .
Exclude members of staff with boils , abscess or other infected skin lesions .
If an out breaks occur , how to control ?
Be sure that it is cause by the same epidemic strain with similar antibiotic resistance pattern and phage type .
Isolate the patient .
The medical staff shown to be carrier should temporarily cease the work and use chlorhexidine on the affected area with all hygiene measure .
Close the ward in severe cases .
Use vancomycin for therapy .
3-Acute Lower Respiratory tract Infection
Third most common infection in hospital acquired infection
Patients predisposed are usually paediatric patients or elderly patients with predisposing chest conditions .
Causative pathogens include , strepto . pneumoniae , staph. aureus , influenza A or B , respiratory syncytial virus and legionella species.
Infections in ICU
It is very common to find high rates of infections in intensive care units.
Samples collected from the patient includes Blood culture , sputum, tracheostomy wound swabs and other samples. Perform cultured before antibiotics therapies and judged accurately if the isolate is just contamination or already a true pathogen .
Samples from the environment includes all equipments in the ICU and from antiseptic solutions .
Preventive measures are the same as before and the measures for the equipments include : -
Adequate cleaning of the equipment in between patients
Heating water in the ventilator to 50oC every day .
Use of autoclavable ventilator or decontaminate it with ethylene or formaldehyde gas .
Anaesthetic bags , suction apparatus , face masks may be efficiently cleaned with washing machine or by low temperature disinfectant .
Infective hazards of intravenous fluid
Between 0.2 – 8% of patients receiving intravenous fluid develop septicaemia and may develop endotoxic shock if gram – negative bacilli multiply at the additive solution added to the fluid .
Causative organisms : -
Gram negative bacilli contaminating fluid solutions .
Bacterial orviral contamination of blood and blood products including HIV , HTLVI , hepatitis viruses , Epestein Barr virus , CMV , Treponema pallidam and malarial parasites .
Prevention of infections with Fluid Infusion.
Perfect antiseptic technique to the skin over the area used with shaving of the excess hair and palpate the vein before use of antiseptic solurtion (chlorohexidine or iodine)
Place the needle in the place and needs to be anchored securely as excessive movement predisposes to site infection
Topical Betadine antiseptic solution and if needed antifungal cream may be added .
Inspect the site of the drip , if infected with draw the complete set immediately and insert it at different site .
Change the complete set every 24-48h
Restrict the use of antibiotic therapy
Diagnosis of infections associated with intravenous infusion therapy : -
With draw blood samples for blood culture .
Send the bottle , cannula and there catheter to the microbiological lab.
Inspect the bottle for presence of defects , and with draw fluid for microscopic examination , culture at 35oC , 4oC and at room temperature .
Culture the catheter tip or cannula on broth or by rolling moistend cannula on surface of blood agar plate – organisms isolated include staph. epidermidis , staph. aureus , candida albicans , klebsiella species , serratia , pseudomonas aeruginosa .
Begins blind therapy with cloxacillin plus gentamicin .
Policies for prevention of infection to or / and from Health works
1) Tuberculosis : -
Staff are Mantoux tested and have chest X ray at start of hospital employment .
Mantoux negative BCG immunization and be sure to convert mantoux negative to positive .
Mantoux positive Deals with patients with open T.B or samples known to have T.B. bacilli .
Isolate patient with open T.B in single room until 2-3 weeks after antituberculous therapy .
Each sputum sample should be handled as if it had T.B and never be opened in the ward .
In the lab See precautions of handling sputum samples .
2) Viral Hepatitis :
Exclude staff with HBsAg positive from renal dialysis units or from carrying exposure – prone procedures
Precautions should be taken in the lab. To prevent infections to workers .
All staff with regular contact with blood should have anti HBS with titre > (10 lu/L)
Precautions to prevent viral hepatitis : -
Isolate the patients (stool / urine / needle isolation)
Take blood samples with gloves
Transport to the lab in sealed plastic bags.
Samples are put in upright position in non leaking screw caps containers
Samples and requests should be labeled ashepatitis risk .
Take care of samples from suspected patients .
Accidental prick to staff should be reported to senior staff , take hyper immune globulin with 24-48 hours and vaccinate if HBS antibodies is negative .
Wearing of two gloves , waterproof apron and goggles together with many other precautions are necessary when surgery is carried out on patients with hepatitis B. (universal precautions) .
Staff members positive for HBsAg or e antigen should not work in dialysis unit , oncology , surgery or transplant unit .
3)AIDS :
Blood and blood products should be screened for HIV 1/2.
Universal precautions against blood – borne viruses should be taken when blood or blood staining splashing are anticipated as risk .
Post exposure drug prophylaxis is recommended for staff sustaining a sharp injury from a patient or HIV .
Policies for Control of Hospital –acquired Infections
Each hospital has many procedures and policies which attempt to reduce the chances of hospital infection occurring , but the extent to which these policies are effectively carried out on a day to a day basis varies greatly between different hospitals or different areas in the hospital .
Procedures for control Include : -
Sterilization and disinfection of contaminated items .
Disposal of infected rubbish or linen .
Aseptic techniques in the operating theatre
Procedures carried in wards such as changing of wound dressings , urinary catheterization and setting up of an intravenousdrip .
Protective isolation of infected patients or protective isolation of highly susceptible patients .
Use of antibiotics therapy according to a greed policy .
Education of hospital staff in hospital hygiene .
Good staff health facilities .
Adequate use of the clinical microbiology for the precise bacteriological diagnosis .
Control infection committee which helps to design hospital policies and discusses any difficulties encountered during the implementation of these policies .
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