HOSPITAL

INFECTIONS
illustrated
Dr.T.V.Rao MD
What are Hospital acquired
infections
 An infection acquired in hospital by a
patient who was admitted for a
reason other than that infection . An
infection occurring in a patient in
a hospital or other health care
facility in whom the infection
was not present or incubating at
the time of admission. This
includes infections acquired in the
hospital but appearing after
discharge, and also occupational
 Nosocomial Infections
 Nosocomial comes from the Greek
word nosokomeion 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
infections).

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 Nosocomial Infections on
Public Health
 Nosocomial
infections are
widespread. They
are important
contributors to
morbidity and
mortality. They will
become even more
important as a
public health
problem with
increasing economic
and human impact
Crowding a Major Factor
 Increasing
numbers and
crowding of
people. More
frequent impaired
immunity (age,
illness,
treatments).
New
microorganisms.
 Increasing bacterial
resistance to
antibiotics
 When the Nosocomial
infections manifest

 Majorityof such infections

become evident during their
stay in the Hospital or some
times only after their
discharge from the patient.
 How and When Hospital
acquired infections occur.
 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.
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 Commonly occurring
Microorganisms in
Hospital Infections
 Microorganisms and
Nosocomial Infections
 The patient is exposed
to a variety of
microorganisms
during hospitalization.
Contact between the
patient and a
microorganisms does
not by itself
necessarily result in
the development of
clinical disease —
other factors influence
the nature and
frequency of
 Urinary tract Infections
 Escherichia coli
 Klebsiella,
Serratia,Proteus spp
 Pseudomonas
aeruginosa
 Enterococcus spp
 Candida albicans
Respiratory Infections
 Haemophilus
influenzae
 Streptococcus
pneumonia
 Staphylococcus
aureus
 Enterobacteriaceae
 Respiratory viruses
 Fungi, Candida spp
 Aspergillus's spp
 Skin sepsis and Wounds
 Staph aureus
 Streptococcus
pyogenes
 E.coli
 Proteus spp
 Anaerobic bacteria
 Enterococcus spp
 Coagulase negative
Staphylococcus
Gastro Intestinal
Infections
 Salmonella
serotypes
 Clostridium
difficile
 Norwalk like
viruses
 Drug Resistance –
Nosocomial Infection
 The likelihood of
exposure leading to
infection depends
partly on the
characteristics of the
microorganisms,
including resistance
to antimicrobial
agents, intrinsic
virulence, and amount
(inoculum) of infective
material.
 Pathophysiology

 Within hours of admission, colonies of

hospital strains of bacteria develop in
the patient's skin, respiratory tract,
and genitourinary tract. Risks factors
for the invasion of colonizing
pathogens can be categorized into 3
areas: iatrogenic, organizational, and
patient-related
 Iatrogenic risk
 Iatrogenic risk factors
include pathogens on
the hands of medical
personnel, invasive
procedures (eg,
incubation and
extended ventilation,
indwelling vascular
lines, urine
catheterization), and
antibiotic use and
prophylaxis.
 Organizational
 Organizational risk
factors include
contaminated air-
conditioning
systems,
contaminated water
systems, and
staffing and
physical layout of
the facility (eg,
nurse-to-patient
ratio, open beds
 Patient associated
 Patient risk factors
include the severity
of illness,
underlying
immunocompromise
d state, and length
of stay.
 Prolonged stay in
the hospital is a
Major
contributing
factor
 Routes of Transmission of
Infection
 A susceptible host
and appropriate
inoculum of
infecting
microorganism with
an appropriate
route of
transmission
contributed in
majority of cases

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 Air – borne route
 From respiratory tract
via talking, coughing,
sneezing
 From the skin by
natural shedding of
the skin scales during
would dressing or bed
making.
 From aerosols from
equipment,
respiratory apparatus,
air-conditioning
plants.

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 Contact spread
 In direct contact
spread from person to
person
 By indirect contact
spread via
contaminated hands
or equipment.
 Clothing of staff,
 Urinary catheters,
contaminated with
hands of the operator
may introduce
organisms, or patients
own flora from urethra
may contribute to
infection.
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 Food borne spread
 From hospital
kitchen, or in
special diets, infant
feeds, kitchen, or
commercial supplies
 Mechanical vectors
flies, cockroaches or
insects, or rodents
act as carriers of
infection.
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 Blood borne spread
 The accidental
transmission of
infections as HIV,
HBV,and HCV by
needle stick injuries
is documented
 Syphilis and malaria
a concern in high
prevalence areas
 Self Infections and Cross
infections
 Lower bowel surgery,
 Self infection may
occur due to flora from
nose, Staphylococcus
may be introduced into
wounds.
 Cross infection
between patients
occur due to spread
of Staphylococcus or
coli forms
Other contributing factors
 Surgeons punctured
surgical gloves, or
moistened gown,
imperfectly
sterilized surgical
instruments, or by
airborne theatre
dust. Faulty wound
dressings may
cause infections.
Patients own flora too
infective
 Selfinfection
from patient’s
own flora from
Bowel can be
major
contributor of
infections in
bowel surgery.
 Other Source of Hospital
Infections
 Hospital environment,
includes defective
constructions,
 People

their behaviour has

great impact.
.
Objects, food, water,
Air in the hospital too
contribute to infections.
 Cross Infection
 Many different
bacteria, viruses, fungi
and parasites may
cause Nosocomial
infections. Infections
may be caused by
micro organism
acquired from another
person in the hospital
(cross-infection) or
may be caused by the
patient’s own flora
(endogenous
infection).
 Used/Contaminated Syringes a
great threat in Developing world
 Some organisms
may be acquired
from an inanimate
object or
substances recently
contaminated from
another human
source (environmental
infection).

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Primary Etiological agents
causing Hospital Infections
 Nosocomial
infections are
primarily caused
by opportunists ,
particularly by

Staphylococcus
aureus

Enterococcus
spp.
 Changing trends in infection
etiology
 With advances in more elaborate surgery
and intensive care, with combined use of
broad spectrum antibiotics and
immunosuppresevive drugs, Gram
Negative bacteria increased in
importance
 Pseudomonas aeruginosa gained
importance in causing infection in
compromised patients.
 They exhibit natural resistance to antibiotics
and antiseptics
 Emerging Infectious
Agents
 A group of Microbes
that played no role
in the past have
emerged.
 1 Coagulase
negative
Staphylococci

2 Acinetobacter
baumanii
 Microbes from
Environment
 The dissemination
from environment
such as cooling
towers and hot
water system is
proving a threat
with Legionella
pneumophila
causing infections of
respiratory systems
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Virus too play a Important
role
 Awareness on risk
of Blood born
viruses including
Hepatitis B, C
and HIV essential

CMV virus in
association with
organ and cellular
transmission
 Iatrogenic Spread a
Concern
 The possible risk of
iatrogenic spread of
Prions causing
Cruetzfeldt-Jacob
disease is a concern

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 Common sites associated
with etiological agents
 Urinary tract
 Surgical wounds
 Respiratory tract
 Skin (especially burns)
 Blood (bacteraemia)
 Gastrointestinal tract
 Central nervous system

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 Collection of Data in Cross
Infections
 Always collect information and
document information on
1 Patient details
2 Site and extent of infection
3 Date of admission – operative
procedure
first recognition of infection
4 Specimen and laboratory isolates and
typing results
5 Ward and staff details.
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 Prevention and Control
 The basic responsibility of any good
hospital remain with establishment of
good infection control policies, which
can always be achieved with
1 An infection control committee
2 An Infection team

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 Infection control
committee
 Should meet
regularly to
formulate and
update policies for
the whole hospital
on all matter which
have bearing on
infection control
and to mange
outbreaks of
Nosocomial
infection
 Infection Control Team
 Which will function
under the guidance
of Infection control
Doctor.
 A Medically
qualified
Microbiologist,
who will take
responsibility of
day to day for the
policies formulated
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 The Functions of the
Committee
 To do surveillance and infection
monitoring of hygiene practices.
 Educate the Medical and Paramedical
staff on policies relating to prevention
of infection, and safe procedures

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 Infection Control Nurse
 Is the key member of
the team
 Maintain the close
working relations
between Microbiology
Laboratory, different
clinical services and
supportive services
like laundry,
pharmacy and
engineering

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All are campaigners of Safe
practices
 It is the minimal
responsibility of
the members to
campaign on
issues related to
safe practices
including Hand
washing

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 Decontamination and
Sterilization
 Fundamental
importance lies with
supply of sterile
instruments, dressings
and fluids.
 A availability of single
use syringes, needles,
catheters and drainage
bags to be assured and
planned for the regular
supplies .
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Aseptic techniques
 A no touch technique
when dealing with
sterile equipment
coupled with strict
personal hygiene.
 A strict rules laid when
dealing the patients in
the operation theatre
and other procedures
such as wound dressing
and insertion of IV and
urinary catheters.
 Cleaning and Disinfection
 Basic cleaning, waste
disposal, and laundry
carry priority.
 The use of chemical
disinfectants for wall
floors, and furniture is
warranted in special
circumstances, such as
spillages, of body fluids
from patients with
blood born viral
infections
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Care of Mop Heads and
other items
 All the Mop heads and
cloths used in crucial
areas should be heat
disinfected and stored
in dry places after use.
 Bed pans washers and
disinfectants and
dishwashers should be
monitored to ensure
reliable performance

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 Skin disinfection and
Antiseptics
 Hand washing is a
most important
procedure which
should be practiced by
health care worker,
gram – ve bacteria
on the hands of the
staff is an important
factor in the spread of
hospital infection

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Hand washing
 Thorough hand
washing after any
procedure involving
nursing care or close
contact with the patient
is essential.
 Alchool based hand
antiseptics gaining
importance where
washing with water and
soap are not
practicable.
 Wearing a Glove
 Gloves may be worn for
any dirty contact
procedure such as
emptying a urinary
cans, or bed pans,
however it should not
be forgotten gloved
hand may also become
colonized by transient
hospital flora.

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 Disinfection policies
 All the hospitals should create
disinfection policies which suit
circumstances and economic resources.
 The procedures and products should have a
limited range of options, and chemicals to
be used only in desired circumstances.
 The policies should take into consideration
surgical instruments, heat disinfection,
Laundry, crockery and cleaning of floors and
furniture
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 Importance of Staff
 Staff should have
well understood
responsibilities.
 Effective
implementation of
policy requires ,
motivated staff, with
training,
 Regular updating as
new methods become
available
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Prophylactic antibiotics
 Wide spread and haphazard
use of antibiotics hasten
emergence of antibiotic
resistant bacteria.
 Rational antibiotic
prophylaxis plays an
important role in infection
control
 Antibiotic policy limits
the use of broad
spectrum agents, and is
important in both
prophylaxis and
treatment.
 Protective Clothing
 Different activities
within the hospital
require different
degrees of protection
to staff and patients.
 In operation theatre the
wearing of sterile
gowns, gloves, head
gear and face mask
minimizes the shedding
of microorganisms.
Barrier Nursing
 Barrier nursing is
highly essential
when soiling of
clothing is
anticipated, and
dealing with
communicable
diseases, eg in
EBOLA and
MARBURG
infections.
 Other Measures
 Gloves, face mask,
and goggles are
indicated in specific
procedures.
 The use of the above
should confirm to
international
standards and the
staff should be
trained in their
proper use and
disposal
Isolation in Infectious
Diseases
 Practiced as a source
isolation and to
protect the
susceptible or
immunocompromised.
 It needs a highly
disciplined approach
by all staff to ensure
that none of the
barriers to
transmission are
breached.

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 Cubicle Isolation
 In which patient nursed
alone in a room
separated by door and
corridor from other
patients confers a
substantial measures of
protection.
 Desirable to supply
clean, filtered air is
supplied to room with
facilities for own toilet
and washing facilities
Critical Situations
 In some critical
situations such as
bone marrow
transplant units,
where air borne
contamination with
environmental fungal
spores is a problem
the efficiency of an air
filtration may be
increased and laminar
airflow maintained as
barrier around the
patient
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 Trexler isolator

 Stringent isolation
such as a plastic
tent or Trexler
isolator, is required
only for patients
with highly
contagious
infections.
Hospital building and Design
 Routine maintenance
of the Hospital
building is important,
ensuring that surfaces
wherever possible are
smooth, impervious
and easy to clean.
 All constructions
around the existsting
Hospitals generate
fungal spores and
bacterial spores with
have impact on
specialized units
serving
 Legionnaires’ disease
prevention
 The risk of
Legionnaires’ disease is
reduced by regular
flushing all outlets and
installing water
supplies that circulate
below 200c for the cold
and above 600c for the
hot circuit

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Equipment
 All the equipment in
contact with patients
need decontamination
and sterilization
 Heat is a preferred
method.
 However heat
sensitive to the
sterilized with
chemical and other
newer emerging
methods
 Personnel care of Health Care
Workers
 All health care workers
should screened for
possible communicable
diseases before
employment, and
offered immunization
against Hepatitis B
Viral infection.
 An education on
Universal Health
Precautions is highly
essential
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 Needle Stick Injuries
 Who sustain needle
stick injuries from
potentially
contaminated
sources should
have access to
advise and post
exposure
prophylaxis with
antiviral agents or
immunization.
Monitoring of the
Environment ?
 Routine
Microbiological
monitoring of the
environment is of
little benefit,
 But monitoring of
the Air conditioning
plants, and
machinery used for
disinfection and
sterilization is
essential

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 Screening of Staff or
Patients
 Microbiological
screening of staff and
patients not
undertaken routinely
but it may be needed
for specific purpose to
detect carriers or MRSA
and Hepatitis viruses in
those performing some
types of surgery or
where transmission to
patients has occurred.
 Surveillance and Role of
Microbiology Laboratories
 Thedetection and identification of
hospital infection incidents or
outbreaks rely on the laboratory data
that alert the infection control team to
unusual cluster of infection, called as
‘alert organism’ system.

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 Surveillance
 Identification of MRSA
& ESBL and timely
information to
clinicians will help the
ongoing events in the
Hospital warrant to
track the events on
source of outbreaks
and action to control
the similar situations
in future

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Practical Teaching to
Staff
 Regular visits to
wards are also
important to record
data on infected
patients from whom
no specimens have
been received and to
respond to problems
as they occur.
 Such visits will bring in
grater human
interaction with
paramedical staff and
deliver the practical
teaching.
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 Efficacy of Infection
control
 The Following measures will certainly
control the infections
1 Sterilization

2 Hand washing
i 3 Closed drainage systems for
urinary catheters.
”
4 Intravenous catheter care
5 Peri operative antibiotic
prophylaxis for contaminated wounds, and
care of equipment used in respiratory
therapy.
飈
 Measures proved to be
ineffective
 Chemical
disinfection of
floors, walls, and
sinks
 Routine
environmental
monitoring is
losing its
concerns.
”
What is most Important
 Effective
surveillance and
action by the
infection control
team have shown to
reduce infection
rates.
 One important role
of the team is to
monitor compliance
and practices
known to be
 Saving the Costs in
prevention if Infections
 With raising
economic costs in
running safe
hospitals eliminate
the many rituals or
less effective
practices that they
may even increase
the incidence or
cost of cross
infection.
Created for benefit of
Health care workers in
the Devloping World
Doctorrao’s ‘e’ learning series

Dr.T.V.Rao MD
Email
doctortvrao@gmail.com