Transcript PREVENTION & CONTROL OF NOSOCOMIAL INFECTIONS. PART-2 Dr. A K.AVASARALA MBBS, M.D. PROFESSOR & HEAD DEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGY PRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P. INDIA:

PREVENTION & CONTROL OF
NOSOCOMIAL INFECTIONS. PART-2
Dr. A K.AVASARALA MBBS, M.D.
PROFESSOR & HEAD
DEPT OF COMMUNITY MEDICINE
& EPIDEMIOLOGY
PRATHIMA INSTITUTE OF
MEDICAL SCIENCES,
KARIMNAGAR, A.P.
INDIA: +91505417
[email protected]
PREVENTION
PREVENTION OF UTI
1. AVOID CATHETER
2. IFCATHETERIZED, PREVENT
BACTERURUA(BU),
3. ONCE BU +, PREVENTION OF
BLOOD STREAM INFECTION (BSI)
AVOID CATHETER
• MINIMIZE THE DURATION,
IF CATHETR IS A MUST, EMPLOY
CLOSED DRAINAGE SYSTEM.
• GOOD HAND WASHING AFTER
CARING EACH PATIENT
PREVENTS CROSS INFECTION.
AVOID CATHETER
SAFEST & BEST IF POSSIBLE
GENERAL ALTERNATIVES: PATIENT TRAINING
TO VOID
• BIOFEED BACK, MEDICATIONS,
• SURGERY,
• USE OF SPECIAL CLOTHES & PADS
SPECIFIC APPRPOACHES:
INTERMITTANT CATHETERIZATION,
EXTERNAL COLLECTION DEVICES (CONDOM
CATHETER),
SUPRAPUBIC CATHETERIZATION,
URUNARY DIVERSIONS
PREOPERATIVE PREVENTION OF
SWI - 1
Environmental Factors
1. Ultraviolet Light
2. Laminar flow ventilation systems
3. Limit operation theater traffic
4. Pre-operative preparations
5. Avoid antibiotic use except for
surgical antibiotic prophylaxis
PREOPERATIVE PREVENTION
OF SWI - 2
6. Eliminate basal colonization with
S.aureus
7. Pre-operative antimicrobial shower
8. Treat distant site infections before
elective procedures
9. Hair removal Avoid shaving / hair
clipping is recommended as near to the
site of surgery as possible
10. Skin preparation Scrubbing for 5 to 7
minutes
PREOPERATIVE PREVENTION
OF SWI - 3
11. Resolve malnutrition and obesity
12. Discontinue cigarette smoking
13. Optimize diabetic control
14. Antibiotic prophylaxis
15. Choice, timing and duration are critical
16. OT team discipline
17. Vigilance for breaks in aseptic
techniques
INTRAOPERATIVE PREVENTION
18. GOOD SURGICAL TECHNIQUE
19. LESS DURATION OF SURGERY
20. APPROPRIATE USE OF SURGICAL
DRAINS
21. ASEPTIC DRESSINGS
22. FEEDBACK OF SURGEON SPECIFIC
INFECTION RATES TO OTHER
SURGEONS TO ADOPT THE SAME
TECHNIQUES AND TO REDUCE SWI
PREVENTION BY ANTIBIOTIC
PROPHYLAXIS IN SURGERY
• ESSENTIAL PREVENTIVE MEASURE TO
PREVENT SWI
• MAY BE EXPENSIVE FOR HOSPITAL BUT
• COST BENEFIT ANALYSIS OF
PROPHYLACTIC ANTIBIOTICS?
• WHAT IS THE COST OF WOUND
INFECTION? IN MONEY? IN SUFFERING?
• HOW EFFECTIVE IS PROPHYLAXIS
• HOW MUCH WE CAN SPEND TO PREVENT
A CASE OF SWI?
PREVENTION OF ANTIBIOTIC
ABUSE
• To avoid antibiotics abuse, CMC has
categorized its antibiotics
1. The first line of antibiotics can be
prescribed by anybody
2. second line by consultants and
3. third line to special cases like bone
marrow transplant, adds Kang
IDEAL REQUIREMENTS FOR
PREVENTION
1. More space per bed
2. Special air handling provisions for clean
air without recirculation
3. Hand wash area in the wards
4. Special anti-bacterial methods of flooring
5. Air curtains,
6. Isolation wads
7. Positive air zones and
8. Hand wash area outside each bed in the
ICU
PREVENTIVE EPIDEMIOLOGIC
STUDIES
• To indentify risk factors for endemic
infections so that preventive strategies
can be formulated and implemented.
• These strategies include measures to
reduce the risk for infection associated
with invasive techniques for intravascular
pressure monitoring and
hyperalimentation.
PREVENTION OF LRI
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GENERAL MEASURES:
HAND WASHING,
BARRIER ISOLATION,
ROUTINE DECONTAMINATION OF EQUIPMENT,
SPECIFIC MEASURES:
AVOID H2 BLOCKERS AS THEY REDUCE THE
PROTECTIVE EFFECT OF GASTRICACID
• USING TOPICAL ANTIBIOTICS,
• IMMUNOSYSTEM MODULATION INFLUENZA VACCINE
RISK REDUCTION OF PNEUMONIAS
• Hand washing during patient care and after glove
removal
• Change gloves after coming into contact with
respiratory secretions, in between patients
• Change tubing, masks and suction catheters
between patients
• Anti-stress ulcer prophylaxis with sucralfate
• Early enteral feeding
• Elevate head end of patient to a 30 to 45 degree
angle
• Prevention of atelectasis
• No routine antimicrobial prophylaxis
RISK ALGORITHM
CAN BE PREPARED
• TO PREDICT RISK OF WOUND
GETTING INFECTED.
BASING ON
1) PATIENT FACTORS
2) TYPE OF PROCEDURE
SURVEILLANCE
SURVEILLANCE DEFINITION
A dynamic process of gathering,
managing, analyzing and
reporting data on events that
occur in a specific population
OBJECTIVES OF THE
SURVEILLANCE
1. Reducing the infection rate within
a hospital.
2. Establishing baseline rates.
3. Identifying outbreaks.
4. Comparing infection rates among
hospitals.
FIVE COMPONENTS OF SURVEILLANCE
1. CASE DEFINITION: DEFINE THE HEALTH
PROBLEM TO BE SURVEYED AS
PRECISELY AS POSSIBLE
2. DATA COLLECTION: SYSTEMATIC AND
VALID
3. DATA PRESENTATION IN A USEFUL
MANNER
4. DATA ANALYSIS AND INTERPRETATION
5. FEED BACK TO BRING ABOUT THE
CHANGE IN CAUSATIVE FACTORS
SURVEILLANCE INDIACTORS
1. Overall rate = No. Of NCIs / TOTAL NO. OF
ADMITTED OR DISCHARGED PATIENTS
2.
3.
4.
5.
6.
7.
INFECTION RATES BY INFECTED SITES
INFECTION RATES BY PATHOGEN
INFECTION RATES BY SERVICE SPECIALITY
INFECTION RATES PER PATIENT CARE AREA
SURGEON-SPECIFIC WOUND INFECTION RATES
PROCEDURE -SPECIFIC WOUND INFECTION
RATES
FEEDBACK
“Surveillance is not
complete until the results
are disseminated to those
who use it to prevent and
control”
SENIC STUDY INFERENCE
• SURVEILLANCE WAS
THE MAIN COMPONENT
ESSENTIAL FOR REDUCING
SWI, PNEUMONIA, UTI &
BACTEREMIA.
INFECTION SURVEILLANCE
1. SURVEILLANCE OF PATIENT CARE
PRACTICES
2. REGULAR, FREQUENT VISIT
TO PATIENT CARE AREAS
3. REVIEWING PATIENT CARE PLANS& LAB
CHARTS
4. WATCHING LIST OF PATIENTS TAKING
ANTIBIOTICS
5. WATCHING PATIENTS IN ISOLATION
PROCEDURES
SURVEILANCE LIMITS
• ROUTINE MICROBIOLOGICAL
SURVEILLANCE OF INANIMATE
HOSPITAL ENVIRONMENT –
IS NOT RECOMMENDED
HOSPITAL WIDE SURVEILLANCE
(HWS)
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Hospital wide
Periodic
Targeted
Defining the threshold limit
Post discharge
DATA SOURCES (HWS)
COLLECTION
1. Daily reports of microbiology labs
2. Medical records of febrile patients
3. Medical records of patients taking
antibiotics
4. Medical records of isolated patients
5. Daily interview with nurses & patients
6. Periodic review of autopsy reports
7. Periodic review of medical records of
staff
PERIODIC SURVEILLANCE
1. Hospital wide surveillance (HWS)
during specified periods and
2. Targeted Surveillance during
alternate periods or
3. Rotating from one unit to the other
TARGETED SURVEILLANCE
SELECTED GEOGRAPHIC AREA
(E.G. ICU)
– SELECTED SERVICE (E.G. CARDIO
THORACIC SURGERY)
– SPECIFIC POPULATIONS OF PATIENTS
OR INFECTIONS:
• AT HIGH RISK OF ACQUIRING INFECTION
( E.G. TRANSPLANTATION)
• UNDERGOING SPECIFIC INTERVENTIONS
(E.G. DIALYSIS)
• AT SPECIFIC SITE (E.G. BLOOD STREAM)
CONTROL PROGRAM
INFECTION CONTROL
PROGRAM
• INFECTION CONTROL TEAM
INFECTION CONTROL TEAM
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HOSPITAL EPIDEMIOLOGIST
INFECTION CONTROL PRACTITIONER/S
MICROBILOGIST
HOSPITAL PHYSICIAN/SURGEON
ICU STAFF NURSE
HOSPITAL EPIDEMIOLOGIST
USUALLY A COMMUNITY PHYSICIAN
DUTIES
-PROVIDES LIASON WITH OTHER MEMBERS OF
MEDICAL STAFF & ADVISES ABOUT THE
CLINICAL IMPLICATIONS OF PATIENT CARE
PRACTICES, INFECTION PROBLEMS AND
PREVENTION & CONTROL MESURES.
-PROVIDES ADVICE ABOUT SURVEILLANCE
METHODS, ANALYSIS OF SURVEILLANCE DATA,
METHODS OF CONDUCTING EPIDEMIOLOGICAL
STUDIES
-DEVELOPMENT OF CONTROL MEASURES
-SUPERVISES THE INFECTION CONTROL
PRACTITIONERS AND NURSES
-DEVELOPING POLICIES AND PROCEDURES OF
COMMITTEE
DUTIES OF HOSPITAL
EPIDEMIOLOGIST-1
• SURVEILLANCE OF NCIS
• OBSERVES THE PATTERNS OF TRANSMISSION
OF NCI
• OUTBREAK INVESTIGATION
• ISOLATION PRECAUTIONS
• EVALUATION OF EXPOSURES
• EMPLOYEE’S HEALTH
• DISINFECTION & STERILIZATION
• HOSPITAL ENGINEERING & ENVIRONMENT
• REVIEWING POLICIES & PROCEDURES FOR
PATIENT CARE
INFECTION CONTROL
PRACTITIONERS
• CAN BE A LAB TECHNICIAN, A NURSE, SANITARY
INSPECTOR,
• DUTIES
• TO PROVIDE DAY TO DAY CO-ORDINATION OF
SURVEILLANCE AND CONTROL PROGRAMMES
• TO COLLECT AND ANALYZE SURVEILLANCE
DATA
• ASSISTING IN DEVELOPMENT OF INFECTION
CONTROL POLICIES
• PROVIDING EDUCATION AND CONSULTATION TO
HOSPITAL PESONNEL
CONTROL POLICIES
DEVELOP AND IMPLEMENT POLICIES FOR
1. ISOLATION WITH POTENTIALLY
COMMUNICABLE DISEASES,
2. USE OF ANTIBIOTICS,
3. CONTROL OF HOSPITAL ENVIRONMENT
SENIC PROJECT (CDC)
YEAR 1970 IN 338 HOSPITALS
• STRATIFIED BY SIZE, MEDICAL SCHOOL
AFFILIATION, TYPE OF INFECTION
CONTROL TEAM
• OBJECTIVE TO KNOW RATES OF UTI, LRI,
BSI, SWI IN ADULTS
• RESULTS:
1) HOSPITALS WITH ICC (INFECTION
CONTROL COMMITTEE) HAVE FEWER NCIs
COMPARED TO THOSE WITHOUT ICC
FUNCTIONS OF INFECTION
CONTROL PROGRAM (SENIC)
1. SURVEILLANCE OF NCIs
2. DEVELOP WRITTEN POLICIES FOR
ISOLATION OF PATIENTS
3. DEVELOPMENT OF WRITTEN POLICIES
TO REDUCE RISK FROM PATIENT CARE
PRACTICES
4. ELIMINATION OF ALL WASTEFUL &
UNNECESSARY PRACTICES
5. EDUCATION OF HOSPITAL STAFF ON
INFECTION CONTROL
FUNCTIONS OF INFECTION
CONTROL PROGRAM - (SENIC)
6. ONGOING REVIEW OF ALL ASEPTIC,
ISOLATION & SANITATION
TECHNIQUES
7. MONITORING OF ANTIBIOTIC
UTILIZATION
8. MONITORING OF ANTIBIOTIC
RESISTANT ORGANISMS
RELATED TASKS (SENIC)
1. OUTBREAK INVESTIGATION
2. COOOPERATION WITH
OCCUPATIONAL HEALTH
3. COOPERATION WITH QUALITY
IMPROVEMENT PROGRAM
SENIC RECOMMENDATIONS
• ACTIVE INFECTION SURVILLANCE SYSTEM WITH
REPORTING OF RESULTS TO STAFF MEMBERS
• PRESENCE OF VIGOROUS CONTROL MEASURES
DESIGNATED TO ELIMINATE RECOGNIZED
HAZARDS
• ATLEAST ONE FULL TIME INFECTION CONTROL
PRACTITIONER FOR EVERY 250 BEDS
• A PHYSICIAN ON THE STAFF KNOWLEDGEBLE
ABOUT NCI
(SENIC PROJECT)
CONTROL MEASURES
• RELATED TO
SPECIFIC PATIENT CARE
PRACTICES
• GUIDELINES TO MINIMIZE THE
RISK OF INSTRUMENTATION TO
BE DEVELOPED
•
COST-EFFECTIVE CONTROL
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Reducing incidence
Reduce morbidity
Shorten hospital stay
Reduce cost of treating infections
Reduce cost of preventive measures
Stop infective control measures
HOSPITAL INFECTIONS SYSTEM, INDIA
• Says Dr Ajita Mehta, President, HIS, India
• While simple chores like regular washing of
hands and proper sterilization of instruments
prevent nosocomial infection, the awareness
of medicos about these is far from
encouraging.
• “While nosocomial infection is high in the
operation theatre, it’s the surgeons who do
not pay attention to the basic guidelines.
• Awareness of other medicos is also low.”
• She, however, added that the awareness level
is improving following the scare created by
TB and AIDS.
ROLE OF MICROBIOLOGISTS
• As many skin barriers are
transgressed in the form of IV lines,
urinary tract catheters central lines
used in specialised ICU exist infection
control is the only way in which a
check can be kept on infection and in
all this micriobiologist has an
important role to play.
WASTE MANAGEMENT PRACTICES
Dr Vijay D Silva, Director, Critical care, Asian
Heart Institute (AHI) says
• It’s the improper waste management practices
which has resulted in the high infection rate in
India,
• “Washing hands before touching the patients is
crucial in checking nosocomial infection.
• To minimize transmission of microorganisms from
equipment and environment, adequate method of
cleaning, disinfecting and sterilization should be
made,”
EPIDEMIOLOGICAL INVESTIGATION
• It is necessary to carry out Epidemiological
investigation in the management of acute
outbreaks of nosocomial infection.
• Most outbreaks require only local
assistance with technically trained
personals of that area.
• Onsite Epidemiological assistance will help
in early identification of the cause and
source of the infection and the appropriate
measures to control and prevent it.
ICU STUDIES
• Recently epidemiologic studies have
been focussed more on intensive care
units, where the nosocomial infection
with resistant strains of pathogens in
causing havoc among the old,
debilitated patients as well as patients
with chronic illnesses.
• It has increased the morbidity and
mortality among those patients admitted
to the ICU's.
REFERENCES
1. Maxcy - Rosenau- Last, Public health &
Preventive medicine, Robert B. Wallace, Bradley
N .Doebbeling, 14th edition
2. Epidemiology of Nosocomial infections , James
M. Hughes & William R. Jarvis Manual of clinical
Microbiology, fourth edition,1985
3. Surveillance methods of nosocomial infections
by Masud Yunesian,M.D., Epidemiologist, super
course lecture at
www.pitt.edu/~super1/lecture/lec2041/index.htm
4. WHO Country Profile & Practical manual -2
edition on Nosocomial infections