EPIDEMIOLOGY OF NOSOCOMIAL

INFECTIONS (NCIs) PART-1

Dr. A.K.AVASARALA MBBS, M.D.

PROFESSOR & HEAD
DEPT OF COMMUNITY MEDICINE &
EPIDEMIOLOGY
PRATHIMA INSTITUTE OF MEDICAL
SCIENCES, KARIMNAGAR, A.P..
INDIA: +91505417
avasarala@yahoo.com
 DEFINITION
Nosocomial infection is
an infection that is not
present or incubating
when a patient is
admitted to a hospital
 LEARNING OBJECTIVES
LEARNER SHOULD LEARN

PUBLIC HEALTH IMPACT OF

HOSPITAL ACQUIRED INFECTIONS.
EPIDEMIOLOGY, PREVENTION,
SURVEILLANCE AND CONTROL
STRATEGIES
INDIAN SITUATION OF THE PROBLEM
 PERFORMANCE OBJECTIVES
LEARNER SHOULD BE ABLE TO
1. Estimate the extent and nature of nosocomial
infections in his hospital
2. Identify the changes in the incidence of
nosocomial infections and the pathogens that
cause them.
3. Provide his hospital with comparative data on
nosocomial infection rates.
4. Develop efficient and effective data collection,
management and analysis methods for his
hospital.
5. Conduct collaborative research studies on
nosocomial infections in his hospital.
 TYPES BY ORIGIN
1.Endogenous:
Caused by the organisms that are
present as part of normal flora of
the patient
2. Exogenous:
caused by organisms acquiring by
exposure to hospital personnel,
medical devices or hospital
environment
 TYPES OF NCI BY SITE

1. Urinary tract infections (UTI)

2. Surgical wound infections
(SWI)
3. Lower respiratory infections
(LRI)
4. Blood stream infections (BSI)
 EPIDEMIOLOGICAL INTERACTION
Intrinsic host susceptibility
Age, Poor nutritional status,
Co morbidity, severity of
underlying disease

Environmental factors
hospital location,
diagn procedures,
Agent factors
immunosuppressive,
varieties of
chemotherapy, antibiotics,
organisms
med & surgical devices,
Institutional and human exposure to infected patients
or health workers,
Reservoirs & their
asymptomatic carriers
virulence
 DISEASE BURDEN
5-10% in developed countries
10-30% IN DEVELOPING COUNTRIES
Rates vary between countries, within
the country, within the districts and
sometimes even within the hospital
itself, due to
1) complex mix of the patients
2) aggressive treatment
3) local practices
INDIAN SCENARIO
 HOSPITAL INFECTION
SOCIETY (HIS), INDIA
Ten to 30 per cent of patients
admitted to hospitals and
nursing homes in India, acquire
nosocomial infection as against
an impressive five per cent in
the West, according to member
of HIS, Rita Dutta Mumbai.
 HINDUJA, HOSPITAL
Dr F D Dastur, Director, Medical
education, P D Hinduja, Hospital:

nosocomial control programme is at

a nascent stage in Indian hospitals,
with some yet to establish a central
sterilization and supply department
(CSSD) and appoint an infection
control nurse
ASIAN HEART INSTITUTE (AHI)

Dr Vijay D Silva, director, critical care,

Asian Heart Institute (AHI):

Suggestions to strengthen the

infection control programme is turned
down by the management of most
hospitals as spending on infection
control does not generate revenue.
 INCIDENCE
Average Incidence - 5% to 10%, but
maybe up to 28% in ICU
Urinary Tract Infection - usually
catheter related -28%
Surgical Site Infection or wound
infection -19%
Pneumonia -17%
Blood Stream infection - 7% to 16%
 INCIDENCE
1. Depends upon
2. Average level of patient risk
depends upon intrinsic host
factors and extrinsic
environment factors
3. Sensitivity &specificity of
surveillance programmes
 AGE RANKS OF NCIs
Ranks in Ranks in Ranks in
infants children adults

1) SKIN 1) SKIN 1) UTI

2) LRI 2) LRI
3) BSI 2) LRI 3) SWI
4) UTI 3) BSI 4) BSI
5) SWI 4) UTI
 PEDIATRIC INFECTIONS
Epidemiology is Unique
Rates of infection by site and
pathogen differ from those reported
in adults
Pathogen distribution is also
different S. aureus in children and
E. Coli in adults
Pediatric viral URI&LRI far exceeds
that caused by bacterial ones.
 CONSEQUENCES OF
NOSOCOMIAL INFECTIONS
1. Prolongation of hospital stay:
Varies by site, greatest with
pneumonias and wound infections
2. Additional morbidity
3. Mortality increases - in order - LRI, BSI,
UTI
4. Long-term physical &neurological
consequences
5. Direct patient costs increased-
Escalation of the cost of care
 ECONOMICS OF NCIS
Extra cost of NCI consequences
Bed,
Intensive care unit stay,
Hematological, biochemical,
microbiological and radiological tests,
Antibiotics & other drugs,
Extra surgical procedures
Working hours
COMMON BACTERIAL
AGENTS
(9%)

(10%)

(11%)

(12%)

(13%)

(45%)
KASTURBA MEDICAL COLLEGE, MANGALORE
Drug resistance was more common with MRSA
nosocomial strains.
All MRSA strains were resistant to penicillin and
sensitive (73.8 percent), ciprofloxacin (78.6 percent)
gentamicin (84.7 percent) and trimethoprim-
sulphamethoxazole (95.7 percent).
Bhat KG; Bhat MV
Department of Microbiology, Kasturba Medical
College, Light House Hill Road, Mangalore - 575001,
India
Prevalence of nosocomial infections due to methicillin
resistant staphylococcus aureus in Mangalore, India
Biomedicine. 1997; 17(1): 17-20
 CHRISTIAN MEDICAL COLLEGE,
VELLORE

Says Dr J Kang, professor of

microbiology at CMC:
While MRSA is the troublemaker in
most cases, at Vellore nosocomial
infection due to MRSA is only five per
cent because of genotyping.
 FUNGI
Due to increased antibiotic use &host
susceptibility
Candida species most common, causing BSI
(38% mortality)
Changing bacterial & fungal spectrum in the
hospital reflects the increased use, particularly
of the newer antibiotics
Development of resistance (MRSA, VRE, MDRTB)
Overcrowding & understaffing of nursing units
increased the rates of infections
(MRSA colonization)
 VIRUSES

CMV, HERPES SIMPLEX

V-Z VIRUSES
HEPATITIS VIRUSES- A, B ,C
HIV
INFLUENZA, PARA INFLUENZA,
R.S.VIRUS, ROTAVIRUS
 EPIDEMIOLOGY OF VIRAL
INFECTIONS
Mostly affects Resp &
Gastrointestinal tracts (90%)
whereas bacterial infections attack
these systems to about 15% only.
Pediatric viral URI & LRI far
exceeds that caused by bacterial
ones.
 PLACE DISTRIBUTION
ICU RISK
PROLONGED ICU STAY
MECHANICAL VENTILATION
TRAUMA
URINARY CATHETER,VASCULAR
CATHETER
STRESS ULCER PROPHYLAXIS
 RISK FACTORS
Malnutrition
Sex (females with UTI)
Extremes of age
Infections at remote site
Use of antibiotics, H2 blockers, sedatives
Diabetes, Renal Failure and causes of
immunosuppression
Altered mental status
Surgery
ICU setting, endotracheal intubation with
mechanical ventilation
 MODES OF TRANSMISSION
BY CONTACT
1) Direct - between Patients and between
patient care personnel
2) Indirect - contaminated inanimate objects
in environment (Endoscopes etc)
3) Droplet infections by large aerosols
B) THRO COMMON VEHICE like Food, Blood &
blood products, Diagnostic reagents,
Medications
C) AIRBORNE e.g. legionellosis, aspergillosis
D) VECTORBORNE by flies
 UTI

Contribute to one third of NCI s

80% due to catheter
5-10% due to urinary tract
manipulation
Prolongs hospital stay by 1-2 days
 BACTERIURIA (BU)

PERIURETHRAL COLONIZATION
WITH POTENTIAL PATHOGENS
INCREASES BU BY THREE FOLD

LATE CATHETERIZATION
INCREASES BU
 RISK FACTORS FOR BU
DURATION OF CATHETRIZATION

MICROBIAL COLONIZATION

NO PRIOR ANTIBIOTIC USE

FEMALE GENDER

DIABETES MELITUS

ABNORMAL SERUM CREATININE

FAILURE TO USE URINOMETER (DRIP CHAMBER)

 CATHETER & UTI
Presence of catheter leads to
increased incidence of Bacteriuria
Short term catheter use (urinary
output measurement, surgery )
increase BU by 15%
Long term catheter use (retention,
obstruction, incontinence) increases
BU by 90%
CATHETER USE COMPLICATIONS

MORE SEEN IN MEN (BACTEREMIA DUE

TO UTI 15%)
SHORT TERM USE - EVERS,
SYMPTOMATIC UTI, BACTEREMIA
LONG TERM CATHETER USE - ABOVE +
CATHETER OBSTRUCTION, URINARY
STONES, PERIURINARY INFECTIONS,
RENAL FAILURE, BLADDER CANCER
SURGICAL WOUND INFECTIONS
(SWI)

Incidence varies from 1.5 to 13 per

100 operations.
1. It can be classified as
2. Superficial incisional SWI
3. Deep incisional SWI and
4. Organ/Space SWI.
 EPIDEMIOLOGY OF SWI

HOST FACTORS
OLD AGE
OBESITY
CURRENT INFECTION AT ANOTHER
SITE
PROLONGED POST OPERATIVE
HOSPITALIZATION
SOURCES OF INFECTION

1. DIRECT INOCULATION FROM

PATIENTS FLORA
2. CONTAMINATED HOST TISSUES
3. HANDS OF SURGEONS
4. AIRBORNE TRANSMISSION
5. POST- OPERATIVE DRAINS/CATHETERS
 LOWER RESPIRATORY INFECTIONS
(LRI)
MOSTLY SEEN IN ICU
RISK FACTORS
1. TRACHEOSTOMY,
2. ENDOTRACHEAL INTUBATION, VENTILATOR,
3. CONTAMINATED AEROSOLS, BAD EQIPPMENT,
4. CONDENSATE IN VENTILATOR TUBING,
5. ANTIBIOTICS,
6. SURGERY,
7. OLD AGE ,
8. COPD,
9. IMMUNO SUPPRESSION
 LOGISTIC REGRESSION OF
CONTRIBUTING FACTORS
TIME FROM ADMISSION TO PNEUMONIA
+++++++
PROLONGED HOSPITAL STAY +++++
NASOGASTRIC INTUBATION +++
AGE ++
PRIOR USE OF MECHANICAL
VENTILATORS++
POST TRACHEOSTOMY STATUS++
IMMUNOSSUPPRESSION OR
LEUKOPENIA++
NEOPLASTIC DISEASE +
 COHORT STUDY

ON PNEUMONIA PATIENTS WITH

VENTILATORS
ATTRIBUTABLE RISK 27%
DEATH RISK 2%
LRI IS DIRECTLY RELATED TO THE
LENGTH OF STAY
 RISK FACTORS FOR
DIARRHEAS

1. BY CLOSTRIDIUM DIFFICILE
2. OLD AGE
3. SEVERE UNDERLYING DISEASE
4. HOSPITALISATION FOR >1 WEEK
5. LONG STAY IN ICU
6. PRIOR ANTIBIOTICS
BLOOD STREAM INFECTIONS
(BSI)
PRIMARY = ISOLATION OF BACTERIAL
BLOOD PATHOGEN IN THE ABSENCE OF
INFECTION AT ANOTHER SITE

SECONDARY = WHEN BACTERIA ARE

ISOLATED FROM THE BLOOD DURING
AN INFECTION WITH THE SAME
ORGANISM AT ANOTHER SITE i.e. UTI,
SWI OR LRI
 BACTEREMIA (BSI)
BSI ARE INCREASING PRIMARILY DUE TO
INCREASE IN INFECTIONS WITH GM+VE
BACTERIA & FUNGI

MOST COMMON IN NEONATES IN HIGH

RISK NURSERIES

MORTALITY RATE FOR NOSOCOMIAL

BACTEREMIA IS HIGHER THAN FOR
COMMUNITY ACQUIRED BACTEREMIA
 SOURCES OF BSI
IV CATHETERS, INTRINSIC IV FLUID
CONTAMINATION
MULTIDOSE PARENTERAL MEDICATION
VIALS
VASCULAR CATHETER RELATED
INFECTIONS, CONTAMINATED ANTISEPTICS,
CONTAMINATED HANDS OF HEALTH CARE
WORKERS
AUTOINFECTION FOLLOWING
HEMATOGENOUS SEEDLING - RISK
INCREASES WITH LONGER DURATION >72
HOURS