Health Care-Associated Infections in King Faisal Hospital Christine Mukashema

Learning Objectives To be aware about the HCAI problem Describe principles of control measures

What is Health Care-Associated Infections? Also referred to as “nosocomial” or “hospital” infection “An infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge, and also occupational infections among health-care workers of the facility”

Why this presentation HCAI places a serious disease burden and significant economic impact on patients and health-care systems No health-care facility, no country, no health-care system in the world can claim to have solved the problem

Estimated rates of HCAI worldwide over 1.4 million people suffering HCAI In developed world: 5–10% of patients acquire one or more infections In developing countries: risk of HCAI is 2–20 times higher than in developed countries exceed 25% of patients affected by HCAI In intensive care units 30% of patients 44% of attributable mortality

Most frequent KCAI in KFH 2011 Klebsiella  17.6% Pseudomonas 7.6% Acinetobacter 5.5% Staphylococcus Aureus 8.2% E.Coli 37.7% Infection rate 9.4% 2012 Klebsiella 19.5% Acinetobacter: 10.5% Pseudomonas: 7.6% Staphylococcus Aureus 7.4% E.Coli: 34.7% 34.7% Infection rate 11%

Most frequent in KFH The Respiratory tract: Urinary tract: procedures and equipment associated with intubation, ventilator support and tracheotomy management of TB…  Urinary tract: procedures and equipment associated with urinary drainage systems indwelling catheters catheters and their care Intravascular devices: procedures and equipment associated with peripheral venous lines, CVCs…. Surgical wounds: procedures and equipment associated with their care  

Some HAI in ICU(2011- May2012) SPECIMEN KLEBSIELLA PSEUDOMONAS ACIENTOBACTER BLOOD 3 1 2 CSF 4 FLUID 6 22 PUS 9 7 SPUTUM URINE 8 5 Total 31 18 34

Some HAI in Surgical (2011- May 2012) SPECIMEN KLEBSIELLA PSEUDOMONAS ACIENTOBACTER BLOOD 5 CSF 1 FLUID 4 6 18 PUS 9 14 SPUTUM 3 URINE 15 8 TISSUE 2 Total 35 34 52

Organisms isolated during 8 months by ward Ward Names January February March April May June July August Total Percentage Surgical 19 15 18 30 12 26 22 17 159 33% ICU 13 10 6 9 1 5 14 68 14% Medical 16 11 7 23 106 22% Paediatric 3 77 16% NICU 2 2% Urusaro Maternity 4 21 4.3% HDU 8 25 5% Haemodialysis 69 60 49 65 48 59 76 70 485

Where we can found those Microbes? Bed rails Bedside tables Ventilators Infusion pumps Mattresses Pillows Air humidifiers Patient monitors X-ray view boxes Curtain rails Curtains Equipment carts Sinks Ventilator circuits Floor mops HCWs

Possible causes of HCAI in KFH Poor Hand Hygiene Knowledge of the policies, guidelines/standards No in ward training No orientation in the department High turnover of staff Lack of staff Negligence/ignorance Stock outs / recycling/ lack of instruments Staff motivation Cleaning of instruments/ soaking of instruments Dilution of chemicals used for cleaning- bed area and the instruments No guideline on screening patients transferred from other institutions Personal hygiene – staff uniform and cleaning Labeling and changing of invasive Isolation Precautions (sometimes not possible) Use of PPE Frequent stock outs of IPC items

Antibiotic sensitivity Bad usage of antibiotic causes drug resistance Not given in Appropriate time Appropriate dose Appropriate course Appropriate antibiotics

Most frequent infection sites & their risk factors URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% 13% LOWER RESPIRATORY TRACT INFECTIONS Mechanical ventilation Aspiration Nasogastric tube Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency LACK OF HAND HYGIENE Most common sites of HCAI and the risk factors SURGICAL SITE INFECTIONS Inappropriate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision BLOOD INFECTIONS Vascular catheter Neonatal age Critical care Severe underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision Central nervous system depressants 17% 14%

Hand transmission Hands are the most common vehicle to transmit health care-associated pathogens 5 sequential steps to transmit of health care-associated pathogens from one patient to another via health-care workers’ hands

5 stages of hand transmission One Two Three Four Five Germs present on patient skin and immediate environment surfaces Germ transfer onto health-care worker’s hands Germs survive on hands for several minutes Suboptimal or omitted hand cleansing results in hands remaining contaminated Contaminated hands transmit germs via direct contact with patient or patient’s immediate environment

The impact of HCAI HCAI can cause: more serious illness prolongation of stay in a health-care facility long-term disability excess deaths high additional financial burden high personal costs on patients and their families

Study on the Efficacy of Nosocomial Infection Control (SENIC) >30% of HCAI are preventable Relative change in NI in a 5 year period (1970–1975) 10 20 30 -40 -30 -20 -10 % Without infection control 14% 9% 19% 26% 18% LRTI SSI UTI BSI Total With infection control -31% -35% -27% -32% Haley RW et al. Am J Epidemiol 1985

Prevention of HCAI At least 50% of HCAI could be prevented Validated and standardized prevention strategies have been shown to reduce HCAI Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries

Possible solutions A proper orientation in all departments Regular training of staff in IPC Monthly IPC audit, hand washing audit Avail all necessary items from the management Motivation of staff A proper reporting of infections Administration to facilitate repair and/or establishment of hand washing facilities in all areas To put in place some measures if policies/ guidelines are not followed

Possible solutions 9. Implementation of IPC policies and guidelines in all department 10. To procure all necessary items and equipments needed 11. To recruit enough nurses 12. To follow policy on the use of antibiotics in the hospital 13. Environmental decontamination 14. The HoU, NUMs should follow closely their staff (close supervision)

Why should you clean your hands? Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene Therefore hand hygiene concerns you! You must perform hand hygiene to: protect the patient against harmful germs carried on your hands or present on his/her own skin protect yourself and the health-care environment from harmful germs

The “My 5 Moments for Hand Hygiene” approach