Hospital Acquired Infections

Hospital Acquired Infections (Nosocomial Infections)

Nosocomial infections are infections in a hospitalized patient that were not present or incubating on
admission and are strictly hospital acquired infections.

5-10% of patients admitted to acute care hospitals acquire infections. of nosocomial infections
occur in ICUs.
The severity may range from mild to serious (including death)
Some of these may be acquired in the hospital but may present after discharge from the
hospital
Some occur in outbreaks or clusters (about 10%) but majority are endemic
Can result from diagnostic or therapeutic procedures such as catheters in bladder or blood
vessel, surgery etc. These correlate with length of stay.

Pathogenesis

3 main ingredients are required:

a. Susceptible host
b. Virulent organism
c. Portal/ mode of entry

The host defenses may be depressed by underlying disease or treatment, malnutrition, age etc. In some
cases, anatomic barriers are breached by IVs, foleys, vents etc. There is also exposure to virulent
organism many of which are resistant to multiple antibiotics.

Sources of microbes

patient's own flora

cross infection from medical personnel
cross infection from patient to patient
hospital environment- inanimate objects
- air
- dust
- IV fluids & catheters
- washbowls
- bedpans
- endoscopes
- ventilators & respiratory equipment
- water, disinfectants etc

Sources of pathogens may include:

Reactivation of latent infection such as TB or herpes. This is less common.

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Endogenous pathogens such as normal commensals of skin, GI, GU, Resp Tract. These are
common
Exogenous pathogens, which may come from inanimate env (Aspergillus from hospital
construction) or animate env. These are common.

Mechanism of Transmission

Contact: direct (person-person), indirect (transmission through an intermediate object--

contaminated instruments
Cross transmission
Airborne: organisms that have a true airborne phase as pattern of dissemination (TB, Varicella)
Common-vehicle: common animate vehicle as agent of transmission [ingested food or water
(oral route), blood products and IV fluids (parenteral route)]
Droplet: brief passage through the air when the source and patient are in close proximity
Arthropod: not reported in US (but certainly in Pakistan :P)

Common Microbes

Bacteria: Gram Positive (S. aureaus, S. epidermidis, Strep. Pneumoniae); Gram Negative Bacteria
(In recent decades gram negative bacilli are most imp hospital pathogens), Enterobacteria
Fungi: Aspergillus, Candida, Mucor
Viruses: HIV, HBV, HCV, Viral Diarrhea etc
Protozoa: Toxoplasmosis, Entamoeba, Plasmodia, Pneumocystis carinii

Sites of Nosocomial Infections

UTIs
a. Most common site (41% of NI), 80% related to urinary catheters. Patients develop
bacterurias and subsequently gram negative bacteremias. Most common sources are
endogenous (catheter, patients own enteric flora such as E.coli, retrograde movement
through urethra), although some exogenous are reported (cross contamination of drainage
systems).
b. Most common etiology of catheter related UTI is E.coli (32%) or proteus (14%) infection
c. Treatment is done for UTIs for 7-10 days
d. Most imp is prevention via:
- Avoid catheter and discontinue ASAP
- Aseptic insertion
- Maintain closed drainage system
- Ensure dependent drainage
- Minimize manipulation of system
- Silver coated catheters
Nosocomial Pneumoniae

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a. Lower resp tract infection that develops during hospitalization and does not become
manifest in first 48-72 hrs of admission. It comprises 13-18% of NIs and is the leading cause
of death from NIs.
b. If early onset, caused by antibiotic sensitive organism such as S. pneumoniae, H. influenzae,
S. aureus
c. If late onset, caused by antibiotic resistant nosocomial organisms such as MRSA, Ps.
aeruginosa, Acinetobacter spp, Enterobacter spp [REMEMBER MRSA]
d. Predisposing factors are Endotracheal Intubation (most imp), ICU, Antibiotics, Surgery,
Chronic Lung Disease, Advanced Age, Immunosuppression
e. In ventilator-associated pneumonia (VAP), most common organism is P. aeruginosa followed
by MRSA
f. Prevention is done by pulmonary toilet, frequent suctioning, bronchoscopy to remove
mucus plugging, deep breathing and incentive spirometry
Wound and Surgical Site Infections
a. Most common pathogen is S. aureaus followed by enterococci
Nosocmial GIT infections (such as diarrhea due to E. Coli, Salmonella)
Bacteremia and Septicemia
a. Most common cause of NI of bloodstreams is CVC (central venous catheter). This is one of
the most commonly used catheters in medicine placed through a central vein such as IJV,
Subclavian or femoral
b. Gram negative bacteria are common pathogens here as well

Diagnosis of NI

Direct Smear Exam

Culture and Sensitivity Testing
Sampling
Typing

Prevention of NIs

For all patients:

Wear gloves when touching blood, all body fluids, nonintact skin and mucus membranes
Wash hands after glove removal and between patients immediately
Wear masks, eye protection, face shields
Wear gowns esp during activities involving splashes or sprays
For sharps, avoid recapping needles, removing needles from syringes by hand, and place used
sharps in puncture resistant containers
For airborne precautions, use private, negatively pressurized room with door closed and wear
orange duckbill mask prior to entering
Use droplet and contact precautions

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Hand Hygiene is the single most effective intervention to reduce the cross transmission of
nosocomial infections
Hand washing must have some characteristics. It should be bacteriologically effective, done
before wearing gloves or using forceps, done after contact with infected patient or infective
material. Disinfectant soap should be used and before surgery more prolonged and thorough
scrub should be used.
Use alcohol based hand sanitizers
Sterilization and disinfection measures should be carried out

What is MRSA?

- Methicillin resistant S. Aureus

- Appeared in 1980s
- carriers not necessarily ill
- reduce transmission by detecting and treating all infected and colonised patients
- infection control procedures
- esp handwashing and patient contact isolation
- drug of choice is vancomycin
- recent reports of a vancomycin resistant strains of S.aureus
- Certain to be an increasingly difficult management problem

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