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Nosocomial infection

 
Dental Dictionary: nosocomial infection
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n

Any infection that first occurs during a patient’s stay at a health-care facility, regardless of whether it is detected during the stay or after.

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Encyclopedia of Public Health: Nosocomial Infections
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A nosocomial, or hospital-acquired, infection is a new infection that develops in a patient during hospitalization. It is usually defined as an infection that is identified at least forty-eight to seventy-two hours following admission, so infections incubating, but not clinically apparent, at admission are excluded. With recent changes in health care delivery, the concept of "nosocomial infections" has sometimes been expanded to include other "health care–associated infections," including infections acquired in institutions other than acute-care facilities (e.g. nursing homes); infections acquired during hospitalization but not identified until after discharge; and infections acquired through outpatient care such as day surgery, dialysis, or home parenteral therapy.

Early studies reported at least 5 percent of patients became infected during hospitalization. With the increased use of invasive procedures, at least 8 percent of patients now acquire nosocomial infections.

The most frequent types of infection are urinary-tract infection, surgical-wound infection, pneumonia, and bloodstream infection (see Table 1). These infections follow interventions necessary for patient care, but which impair normal defenses. At least 80 percent of nosocomial urinary infections are attributable to the use of an indwelling urethral catheter. Surgical-wound infection follows interference with the skin barrier, and is associated with the intensity of bacterial contamination of the wound at surgery. Nosocomial pneumonia occurs most frequently in intensive-care-unit patients with endotracheal intubation on mechanical ventilation—the endotracheal tube bypasses normal defenses of the upper airway. Finally, primary nosocomial bloodstream infection occurs virtually only with the use of indwelling central vascular catheters, and correlates directly with the duration of catheterization.

Table 1

Frequency of most common nosocomial infections
Infection SiteIncidence
All patientsDevice-related
SOURCE: Mayhall, ed.
Urinary tract infection2.34/100 admissions5.3-10.5/1,000 catheter days
Surgical site infection4.6-8.2/1,000 discharges2.1-7.1% of wounds
Pneumonia0.5-1.0/100 admissions9-47% ventilated patients 1-3%/ventilator day
Central vascular line—1.4% of central catheters 1.7/1,000 catheter days

The clinical status of the patient is important in the development of infection. Many hospitalized patients, such as leukemia patients or transplant patients, have profoundly impaired immunity due to both their disease and therapy. These patients are highly susceptible to infection, frequently with organisms that do not cause infection in normal persons. Patients with neurologic problems may have swallowing difficulties due to aspiration of bacteria from the mouth or stomach, which can lead to pneumonia. Patients who have received antimicrobials may develop nosocomial infectious diarrhea caused by Clostridium difficile.

The hospital environment may also contribute to infections. Repeated outbreaks of Legionnaire's disease caused by organisms in a hospital's potable water or in air conditioning cooling towers have occurred. Increases in Aspergillus spores in the air during hospital construction cause fungal pneumonia in some immunocompromised patients, with a mortality rate of over 50 percent. Bacterial contamination of sterile intravenous fluids or equipment has repeatedly caused outbreaks of nosocomial infections. Finally, patients may acquire tuberculosis or chicken pox from other patients.

Nature and Dimension of Public Health Problem

The high frequency of nosocomial infections places a substantial burden on individual patients and on the health care system. There is increased morbidity, including delayed wound healing, delayed rehabilitation, increased exposure to antimicrobial therapy and its potential adverse effects, and prolonged hospitalization. The average prolongation of stay is 3.8 days for urinary infection, 7.4 days for surgical-site infection, 5.9 days for pneumonia, and 7 to 24 days for primary bloodstream infection. Some infections, such as infection occurring in a hip or knee replacement, result in prolonged or even permanent disability and require repeated rehospitalization and reoperation. Nosocomial infections also cause mortality. The case-fatality rate for patients with ventilator-associated pneumonia is 42 percent, with an attributable mortality of 15 to 30 percent. For nosocomial bloodstream infection, the case fatality rate is 14 percent, with an estimated attributable mortality of 19 percent.

Nosocomial infections are costly. The direct costs of hospital-acquired infections in the United States is estimated to be $4.5 billion per year. In England, the cost for one health unit is estimated to be 3.6 million pounds per year. Prolongation of stay necessitated by nosocomial infection limits access of other patients to hospital resources, and contributes to overcrowding on wards and in emergency departments.

Nosocomial infections also contribute to the emergence and dissemination of antimicrobial-resistant organisms. Antimicrobial use for treatment or prevention of infections facilitates the emergence of resistant organisms. Patients with infection with antimicrobial-resistant organisms are then a source of infection for other hospitalized patients. Some bacteria, such as methicillin-resistant Staphylococcus aureus, may subsequently spread to the community.

Control and Prevention

Prevention of nosocomial infections requires a systematic, multidisciplinary approach. This is usually achieved under the leadership of an institutional infection-control program. The principle activities of such a program include surveillance, outbreak management, policy development, expert advice, and education. An optimal program may decrease the incidence of nosocomial infections by 30 to 50 percent.

Surveillance of nosocomial infections, by itself, may decrease the incidence. When each surgeon is provided with their own wound-infection rates and with other surgeons' rates for comparison, the institutional surgical-wound infection rate decreases. Outbreak control includes early identification of potential outbreaks, as well as evaluation and intervention if an outbreak is identified. Continuing education of hospital staff about the importance of, and their role in, preventing nosocomial infections is necessary. The infection-control program also provides expert consultation to other hospital programs such as occupational health, clinical microbiology, and pharmacy.

Institutional policies and practices must be developed and adhered to. In particular, optimal handwashing and glove use must be facilitated and reinforced, as transmission of organisms between patients occurs primarily on the hands of staff members. Isolation guidelines to identify and segregate patients who have an increased risk of transmitting infection to other patients or staff are also essential. Other important policies include: for urinary infection, the use and care of the indwelling catheter; and for surgical wound infection, optimal surgical technique including preoperative preparation and prophylactic antimicrobials. Many national or local standards and regulations will also prevent nosocomial infection, and institutions must be in compliance. These regulations cover hospital construction, municipal water supply, laundry management, food handling, waste disposal, sterilization and other reprocessing procedures, as well as standards for pharmacy and microbiology laboratory practice.

An effective infection-control program requires dedicated staff with appropriate training and sufficient resources. The number of personnel is determined by the size and complexity of the facility. Infection-control practitioners, usually from a nursing background, are responsible for program activity. In larger hospitals, program leadership is provided by a physician with training in epidemiology and infection control. Smaller facilities may obtain such expertise by contractual arrangement with outside experts. Oversight of the infection-control program is usually provided by a multidisciplinary infection-control committee. The program director, however, should report directly to senior hospital management to ensure optimal program effectiveness.

(SEE ALSO: Antisepsis and Sterilization; Barrier Nursing; Contagion; Hospital Administration)

Bibliography

Centers for Disease Control and Prevention (1999). "Guidelines for Prevention of Surgical Site Infection." Infection Control and Hospital Epidemiology 20:247–278.

Health Canada Laboratory Centre for Disease Control (1998). "Handwashing, Cleaning, Disinfection, and Sterilization in Health Care." Canadian Communicable Disease Report 24S8(Supp.).

—— (1999). "Routine Practices and Additional Precautions for Preventing Transmission of Infection in Health Care." Canadian Communicable Disease Report 25S4(Supp.).

Mayhall, C. G., ed. (1999). Hospital Epidemiology and Infection Control, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

Scheckler, W. E.; Brumhall, D.; Buck, A. S.; Farr, B. M.; Friedman, C.; Garibaldi, R. A.; Gross, P. A.; Harris, J. A.; Hierholzer, W. J., Jr.; Martone, W. J.; McDonald, L. L.; Solomon, S. L. (1998). "Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report." Infection Control and Hospital Epidemiology 19:114–124.

Shlaes, D. M.; Gerding, D. N.; John, J. F.; Craig, W. A.; Bornstein, D. L.; Duncan, R. A.; Eckman, M. R.; Farrer, W. E.; Greene, W. H.; Lorian, V.; Levy, S.; McGowan, J. E.; Paul, S. M.; Ruskin, J.; Tenover, F. C.; and Watanakunakorn, C. (1997). "Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals." Infection Control and Hospital Epidemiology 18:275–291.

— LINDSAY E. NICOLLE


Wikipedia: Nosocomial infection
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Nosocomial infections are infections which are a result of treatment in a hospital or a healthcare service unit, but secondary to the patient's original condition. Infections are considered nosocomial if they first appear 48 hours or more after hospital admission or within 30 days after discharge. Nosocomial comes from the Greek word nosokomeion (νοσοκομείον) meaning hospital (nosos = disease, komeo = to take care of). This type of infection is also known as a hospital-acquired infection (or more generically healthcare-associated infection).

Nosocomial infections are transmitted due to the fact that hospitals house large numbers of people who are sick and whose immune systems are often in a weakened state. Increased use of outpatient treatment means that people who are hospitalized are more ill and have more weakened immune systems than may have been true in the past. Moreover, some medical procedures bypass the body's natural protective barriers. Since medical staff move from patient to patient, the staff themselves serve as a means for spreading pathogen.

Hospitals have sanitation protocol regarding uniforms, equipment sterilization, washing, and other preventative measures. Thorough hand washing and/or use of alcohol rubs by all medical personnel before and after each patient contact is one of the most effective ways to combat nosocomial infections[1]. More careful use of anti-microbial agents, such as antibiotics, is also considered vital.[2]

Despite sanitation protocol, patients cannot be entirely isolated from infectious agents. Furthermore, patients are often prescribed antibiotics and other anti-microbial drugs to help treat illness; this may increase the selection pressure for the emergence of resistant strains.

Epidemiology

In the United States, it has been estimated that as many as one hospital patient in ten acquires a nosocomial infection, or 2 million patients a year. Estimates of the annual cost range from $4.5 billion to $11 billion and up. Nosocomial infections contributed to 88,000 deaths in the U.S. in 1995. One third of nosocomial infections are considered preventable. Ms. magazine reports that as many as 92 percent of deaths from hospital infections could be prevented.[3] The most common nosocomial infections are of the urinary tract, surgical site and various pneumonias [4]

In France, prevalence in a sample of hospital patients was 6.7% in 1990, and the rate of nosocomial infections was 7.4% (patients may have several infections).[5] At national level, prevalence among patients in health care facilities was 6.7% in 1996[6], 5.9% in 2001[7] and 5.0% in 2006.[8]. The rates for nosocomial infections were 7.6% in 1996, 6.4% in 2001 and 5.4% in 2006.

In 2006, the most common infection sites were urinary tract infections (30,3 %), pneumopathy (14,7 %), infections of surgery site (14,2 %). infections of the skin and mucous membrane (10,2 %), other respiratory infections (6,8%) and bacterial infections / blood poisoning (6,4 %).[9]

The rates among adult patients in intensive care were 13,5% in 2004, 14,6% in 2005, 14,1% in 2006 and 14.4% in 2007.[10]

It has been estimated that nosocomial infections make patients stay in the hospital 4-5 additional days. Around 2004-2005, about 9,000 people died each year with a nosocomial infection, of which about 4,200 would have survived without this infection.[11]

In Italy, in the 2000s, about 6.7 % of hospitalized patients were infected, i.e. between 450,000 and 700,000 patients, which caused between 4,500 and 7,000 deaths.[12] A survey in Lombardy gave a rate of 4.9% of patients in 2000.[13]

In Switzerland, extrapolations assume about 70,000 hospitalised patients are affected by nosocomial infections (between 2 and 14% of hospitalized patients).[14] A national survey gave a rate of 7.2% of patients in 2004.[15]

The rate of nosocomial infections was estimated at 8.5% of patients in Finland in 2005[16], and 8.2% in England in 2006.[17]

The methods used differ from country to country (definitions used, type of nosocomial infections covered, health units surveyed, inclusion or exclusion of imported infections, etc.), so that international comparisons of nosocomial infection rates should be made with the utmost care.

Transmission

Microorganisms are transmitted in hospitals by several routes, and the same microorganism may be transmitted by more than one route. There are five main routes of transmission—contact, droplet, airborne, common vehicle, and vectorborne.

  • Contact transmission, the most important and frequent mode of transmission of nosocomial infections, is divided into two subgroups: direct-contact transmission and indirect-contact transmission.
    • Direct-contact transmission involves a direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person, such as occurs when a person turns a patient, gives a patient a bath, or performs other patient-care activities that require direct personal contact. Direct-contact transmission also can occur between two patients, with one serving as the source of the infectious microorganisms and the other as a susceptible host.
    • Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, or dressings, or contaminated gloves that are not changed between patients. Additionally, the improper use of saline flush syringes, vials, and bags have been implicated in disease transmission in the US, even when healthcare workers had access to gloves, disposable needles, intravenous devices, and flushes.[18]
  • Droplet transmission occurs when droplets are generated from the source person mainly during coughing, sneezing, and talking, and during the performance of certain procedures such as bronchoscopy. Transmission occurs when droplets containing germs from the infected person are propelled a short distance through the air and deposited on the host's body.
  • Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle residue {5 µm or smaller in size} of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors; therefore, special air handling and ventilation are required to prevent airborne transmission. Microorganisms transmitted by airborne transmission include Legionella, Mycobacterium tuberculosis and the rubeola and varicella viruses.
  • Common vehicle transmission applies to microorganisms transmitted to the host by contaminated items such as food, water, medications, devices, and equipment.
  • Vector borne transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin transmit microorganisms.

Predisposition to infection

Factors predisposing a patient to infection can broadly be divided into three areas:

  • People in hospitals are usually already in a poor state of health, impairing their defense against bacteria – advanced age or premature birth along with immunodeficiency (due to drugs, illness, or irradiation) present a general risk, while other diseases can present specific risks - for instance chronic obstructive pulmonary disease can increase chances of respiratory tract infection.
  • Invasive devices, for instance intubation tubes, catheters, surgical drains and tracheostomy tubes all bypass the body’s natural lines of defence against pathogens and provide an easy route for infection. Patients already colonised on admission are instantly put at greater risk when they undergo an invasive procedure.
  • A patient’s treatment itself can leave them vulnerable to infection – immunosuppression and antacid treatment undermine the body’s defences, while antimicrobial therapy (removing competitive flora and only leaving resistant organisms) and recurrent blood transfusions have also been identified as risk factors.

Prevention

Isolation

Isolation precautions are designed to prevent transmission of microorganisms by common routes in hospitals. Because agent and host factors are more difficult to control, interruption of transfer of microorganisms is directed primarily at transmission.

Handwashing and gloving

Handwashing frequently is called the single most important measure to reduce the risks of transmitting skin microorganisms from one person to another or from one site to another on the same patient. Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of infection control and isolation precautions.

Although handwashing may seem like a simple process, it is often performed incorrectly. Healthcare settings must continually remind practitioners and visitors on the proper procedure in washing their hands to comply with responsible handwashing. Simple programs such as Henry the Hand, and the use of handwashing signals can assist healthcare facilities in the prevention of nosocomial infections.

All visitors must follow the same procedures as hospital staff to adequately control the spread of infections. Visitors and healthcare personnel are equally to blame in transmitting infections. Moreover, multi-drug resistant infections can leave the hospital and become part of the community flora if we don't take steps to stop this transmission.

In addition to handwashing, gloves play an important role in reducing the risks of transmission of microorganisms. Gloves are worn for three important reasons in hospitals. First, gloves are worn to provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin; the wearing of gloves in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by the OSHA Bloodborne Pathogens final rule. Second, gloves are worn to reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient's mucous membranes and nonintact skin. Third, gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or a fomite can transmit these microorganisms to another patient. In this situation, gloves must be changed between patient contacts and hands should be washed after gloves are removed.

Wearing gloves does not replace the need for handwashing, because gloves may have small, non-apparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between patient contacts is an infection control hazard.

Surface sanitation

Sanitizing surfaces is an often overlooked yet critical component of breaking the cycle of infection in health care environments. Modern sanitizing methods such as NAV-CO2 have been effective against gastroenteritis, MRSA, and influenza. Use of hydrogen peroxide vapor has been clinically proven to reduce infection rates and risk of acquisition. Hydrogen peroxide is effective against endospore forming bacteria, such as Clostridium difficile, where alcohol has been shown to be ineffective.[19]

Aprons

Wearing an apron during patient care reduces the risk of infection.[citation needed] The apron should either be disposable or be used only when caring for a specific patient.

Mitigation

The most effective technique of controlling nosocomial infection is to strategically implement QA / QC measures to the health care sectors and evidence-based management can be a feasible approach. For those VAP/HAP diseases (ventilator-associated pneumonia, hospital-acquired pneumonia), controlling and monitoring hospital indoor air quality needs to be on agenda in management [20] whereas for nosocomial rotavirus infection, a hand hygiene protocol has to be enforced.[21][22][23]

Known diseases

See also

References

  1. ^ McBryde ES, Bradley LC, Whitby M, McElwain DL (October 2004). "An investigation of contact transmission of methicillin-resistant Staphylococcus aureus". J. Hosp. Infect. 58 (2): 104–8. doi:10.1016/j.jhin.2004.06.010. PMID 15474180. 
  2. ^ Lautenbach E (2001). "Chapter 14. Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance—Clostridium difficile and Vancomycin-resistant Enterococcus (VRE)". in Markowitz AJ. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Agency for Healthcare Research and Quality. http://www.ahrq.gov/clinic/ptsafety/chap14.htm. 
  3. ^ Ricks, Delthia (Spring 2007). "Germ Warfare". Ms. Magazine: 43–5. http://www.msmagazine.com/spring2007/germwarfare.asp. 
  4. ^ Klevens RM, Edwards JR, Richards CL, et al. (2007). "Estimating health care-associated infections and deaths in U.S. hospitals, 2002". Public Health Rep 122 (2): 160–6. PMID 17357358. 
  5. ^ Quenon JL, Gottot S, Duneton P, Lariven S, Carlet J, Régnier B, Brücker G. Enquête nationale de prévalence des infections nosocomiales en France : Hôpital Propre (octobre 1990). BEH n° 39/1993.
  6. ^ Comité technique des infections nosocomiales (CTIN), Cellule infections nosocomiales, CClin Est, CClin Ouest, CClin Paris-Nord, CClin Sud-Est, CClin Sud-Ouest, avec la participation de 830 établissements de santé. Enquête nationale de prévalence des infections nosocomiales,1996, BEH n° 36/1997, 2 sept. 1997, 4 pp.. Résumé.
  7. ^ Lepoutre A, Branger B, Garreau N, Boulétreau A, Ayzac L, Carbonne A, Maugat S, Gayet S, Hommel C, Parneix P, Tran B pour le Réseau d’alerte, d’investigation et de surveillance des infections nosocomiales (Raisin). Deuxième enquête nationale de prévalence des infections nosocomiales, France, 2001, Surveillance nationale des maladies infectieuses, 2001-2003. Institut de veille sanitaire, sept. 2005, 11 pp. Résumé.
  8. ^ Institut de veille sanitaire Enquête nationale de prévalence des infections nosocomiales, France, juin 2006, Volume 1 – Méthodes, résultats, perspectives, mars 2009, ii + 81 pp. Volume 2 – Annexes, mars 2009, ii + 91 pp. Synthèse des résultats, Mars 2009, 11 pp.
  9. ^ Ibid, Vol. 1, Tableau 31, p. 24.
  10. ^ Réseau REA-Raisin « Surveillance des infections nosocomiales en réanimation adulte. France, résultats 2007 », Institut de veille sanitaire, Sept. 2009, ii + 60 pp.
  11. ^ Vasselle, Alain « Rapport sur la politique de lutte contre les infections nosocomiales », Office parlementaire d'évaluation des politiques de santé, juin 2006, 290 pp. (III.5. Quelle est l’estimation de la mortalité attribuable aux IN ?).
  12. ^ L'Italie scandalisée par "l'hôpital de l'horreur", Éric Jozsef, Libération, January 17, 2007 (French)
  13. ^ Liziolia A, Privitera G, Alliata E, Antonietta Banfi EM, Boselli L, Panceri ML, Perna MC, Porretta AD, Santini MG, Carreri V. Prevalence of nosocomial infections in Italy: result from the Lombardy survey in 2000. J Hosp Infect 2003;54:141-8.
  14. ^ Facts sheet - Swiss Hand Hygiene Campaign. (.doc)
  15. ^ Sax H, Pittet D pour le comité de rédaction de Swiss-NOSO et le réseau Swiss-NOSO Surveillance. Résultats de l’enquête nationale de prévalence des infections nosocomiales de 2004 (snip04). Swiss-NOSO 2005;12(1):1-4.
  16. ^ Lyytikainen O, Kanerva M, Agthe N, Mottonen T and the Finish Prevalence Survey Study Group. National Prevalence Survey on Nosocomial Infections in Finnish Acute Care Hospitals, 2005. 10th Epiet Scientific Seminar. Mahon, Menorca, Spain, 13-15 October 2005 [Poster].
  17. ^ Press release for The Third Prevalence Survey of Healthcare-associated Infections in Acute Hospitals. Hospital Infection Society, Londres, 27/10/06.
  18. ^ Jain SK, Persaud D, Perl TM, et al. (July 2005). "Nosocomial malaria and saline flush". Emerging Infect. Dis. 11 (7): 1097–9. PMID 16022788. http://www.cdc.gov/ncidod/EID/vol11no07/05-0092.htm. 
  19. ^ Otter JA, French GL (January 2009). "Survival of nosocomial bacteria and spores on surfaces and inactivation by hydrogen peroxide vapor". J. Clin. Microbiol. 47 (1): 205–7. doi:10.1128/JCM.02004-08. PMID 18971364. 
  20. ^ Leung M, Chan AH (March 2006). "Control and management of hospital indoor air quality". Med. Sci. Monit. 12 (3): SR17–23. PMID 16501436. http://www.medscimonit.com/fulltxt.php?ICID=447117. 
  21. ^ Chan PC, Huang LM, Lin HC, et al. (April 2007). "Control of an outbreak of pandrug-resistant Acinetobacter baumannii colonization and infection in a neonatal intensive care unit". Infect Control Hosp Epidemiol 28 (4): 423–9. doi:10.1086/513120. PMID 17385148. 
  22. ^ Traub-Dargatz JL, Weese JS, Rousseau JD, Dunowska M, Morley PS, Dargatz DA (July 2006). "Pilot study to evaluate 3 hygiene protocols on the reduction of bacterial load on the hands of veterinary staff performing routine equine physical examinations". Can. Vet. J. 47 (7): 671–6. PMID 16898109. 
  23. ^ Katz JD (September 2004). "Hand washing and hand disinfection: more than your mother taught you". Anesthesiol Clin North America 22 (3): 457–71, vi. doi:10.1016/j.atc.2004.04.002. PMID 15325713. 
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Dental Dictionary. Mosby's Dental Dictionary. Copyright © 2004 by Elsevier, Inc. All rights reserved.  Read more
Encyclopedia of Public Health. Encyclopedia of Public Health. Copyright © 2002 by The Gale Group, Inc. All rights reserved.  Read more
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