HOSPITAL-ACQUIRED

INFECTIONS

NDIMWIBO ARTHUR
MICROBIOLOGY TUTOR
RUBAGA HOSPITAL TRAINING SCHOOLS

Nosocomial infections by Ndimwibo Arthur 1

LEARNING OBJECTIVES
Introduction to HAIs
Factors responsible for HAIs
Causative organisms
Modes of transmission
Different types of HAIs
Prevention of HAIs
Surveillance of HAIs
Bundle care approach

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 DEFINITION
( HOSPITAL ACQUIRED INFECTIONS= NOSOCOMIAL
INFECTIONS= HEALTHCARE ASSOCIATED INFECTIONS )

Nosocomial infections also referred to as healthcare-associated

infections (HAI), are infection(s) acquired during the process of
receiving health care that was not present during the time of
admission.
• They may occur in different areas of healthcare delivery, such as in hospitals, long-term care facilities, and
ambulatory settings, and may also appear after discharge. HAIs also include occupational infections that
may affect staff.

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• Infection occurs when pathogen(s) spread to a
susceptible patient host. In modern healthcare,
invasive procedures and surgery, indwelling medical
devices, and prosthetic devices are associated with
these infections. The etiology of HAI is based on the
source or type of infection and the responsible
pathogen, which may be bacterial, viral, or fungal.

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DEFINITION CONT.
It also includes
infections appearing after discharge and
occupational infections among healthcare workers.
It does not include
colonization or
inflammation resulting from tissue response to injury
or non‑infectious agents.
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FACTORS AFFECTING HAI

• Immune status
• Hospital environment
• Hospital organisms
• Diagnostic or therapeutic interventions
• Transfusion
• Poor hospital administration
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 SOURCES OF HAI

• Endogenous source- patient’s own flora

• Exogenous source
oEnvironmental sources
oHealth care workers
oOther patients
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MICROORGANISMS IMPLICATED IN HAI
PATHOGENS RESPONSIBLE FOR NOSOCOMIAL
INFECTIONS INCLUDE BACTERIA, VIRUSES, AND FUNGI.
• Bacteria
o Bacteria may originate from an exogenous or endogenous source as
part of the natural flora.
o Opportunistic bacterial infections occur when there is a breakdown
of the host immune system functions
o Common Gram-positive organisms include: Staphylococcus aureus,
Streptococcus species, and Enterococcus species (e.g. faecalis,
faecium). Of all HAI associated pathogens, Clostridioides difficile
accounts for the most commonly reported pathogen in hospitals 8
BACTERIA CONTINUED….
• Clostridioides difficile accounts for the most commonly reported pathogen in hospitals

• Common Gram-negative organisms include species of the

Enterobacteriaceae family, including Klebsiella
pneumoniae and Klebsiella oxytoca, Escherichia coli,
Proteus mirabilis, and Enterobacter species; Pseudomonas
aeruginosa, Acinetobacter baumanii, and Burkholderia
cepacian. Acinetobacter baumanii is associated with high
mortality within the intensive care setting owing to its
inherent multi-drug resistant properties.
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MICROORGANISMS IMPLICATED IN HAI

Fungi
• Fungal pathogens are usually associated with opportunistic infections
in immunocompromised patients and those with indwelling devices,
such as central lines or urinary catheters. Candida species, such as
Candida albicans, Candida parapsilosis, and Candida glabrata are the
most commonly encountered fungal organisms associated with HAI
• Aspergillus fumigatus may be acquired by airborne environmental
contamination in areas of healthcare construction. However, infected
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hospitalized patients may be a primary source

MICROORGANISMS IMPLICATED IN HAI
CONTINUED….
Viruses
• Infections due to viral pathogens are the least reported, making
up 1-5% of all HAIs pathogens. Healthcare-acquired hepatitis B
and C and human immunodeficiency virus (HIV) has been
implicated in unsafe needle practices. Globally 5.4% of all HIV
infections are healthcare-associated and frequently occur in
developing countries.
• Other reported viral pathogens include rhinovirus,
cytomegalovirus, herpes simplex virus, rotavirus, and influenza.
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 MODES OF TRANSMISSION OF HOSPITAL-ACQUIRED PATHOGENS

Route Description
Contact transmission e.g. Staphylococcus aureus, Clostridioides difficile, rotavirus etc
Direct contact Skin to skin contact
Indirect contact Contaminated inanimate objects such as-
 Dressings, or gloves, instruments (e.g. stethoscope)
 Parenteral transmission through- Infusions, splashes, saline flush,
syringes, vials etc

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MODES OF TRANSMISSION OF HOSPITAL-ACQUIRED PATHOGENS.

Route Description
Inhalational mode
Droplet Droplets of >5 µm size can travel for shorter distance (<3 feet).
transmission  Generated while coughing, sneezing, and talking
 Propelled for a short distance through the air and deposited on the
host's body.
 E.g -Neisseria meningitis, Bordetella pertussis, influenza virus, etc.
Airborne Airborne droplet nuclei (≤ 5 µm size) or dust particles
transmission Remain suspended in the air for long time and can travel longer distance.
 This is more efficient mode than droplet transmission.
 E.g. Legionella, Mycobacterium tuberculosis, Chickenpox virus
measles and varicella viruses.

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 MODES OF TRANSMISSION OF HOSPITAL-ACQUIRED PATHOGENS

Route Description
Vector • Via vectors such as mosquitoes, flies, etc. carrying the
microorganisms
• Rare mode

Common vehicle such as food, water, medications, devices, and equipment.

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 MAJOR TYPES OF HAIS

• Catheter-associated urinary tract infection (CAUTI)

• Central line-associated blood stream infection (CLABSI)
• Ventilator-associated pneumonia (VAP)
• Surgical site infection (SSI).

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 CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI)

This is a urinary tract infection that occurs in the setting of an indwelling urinary
catheter, which may be inserted for numerous medical indications.

Risk factors

• Advanced age

• Female gender

• Severe underlying disease

• Placement of a urinary catheter for > 2 days.

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 CAUTI (CONT..)

Organisms

• Gram negative rods -majority of hospital acquired UTIs

• E.coli is the MC organism implicated.

• Gram-positive bacteria –may also cause UTI

• S.aureus, enterococci - occasionally cause CAUTI.

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 CENTRAL LINE ASSOCIATED BLOOD STREAM
INFECTION
(CLABSI)
• This occurs in the setting of a central venous line when bacteria on the skin proliferate
along the external portion of an intravenous line toward the intravascular part or it maye
caused by Contamination of the intravenous line during insertion or manipulation.

• Organisms

o S.aureus – Most common

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 CLABSI (CONT..)
Risk factors

• Patient related:

o Age (<1 year and >60 years)

o Malnutrition

o Low immunity

o Severe underlying disease

o Loss of skin integrity (burn or bed sore)

o Prolonged stay in ICUs

• Device related: presence of central line : multi-lumen, non-tunnelled

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• HCW related: poor IC practices such as HH.

 VENTILATOR ASSOCIATED PNEUMONIA

Risk factors for VAP

• Device related: endotracheal intubation

• Patient related:

• Prolonged ICU stay

• Aspiration of oropharyngeal flora due to various reasons such as semiconscious state, supine position
etc

• HCW related: poor IC practices such as HH

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 VAP (CONT..)

Organisms:
• Gram-negative rods such as Acinetobacter species and Pseudomonas
• Other gram-negative
• Gram positive bacteria

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 SURGICAL SITE INFECTIONS (SSI)

Definition:
• Develop at the surgical site within 30 days of surgery

• Within 90 days if prosthetic material is implanted at surgery, breast, cardiac, CABG,

craniotomy, spinal fusion, open reduction of fracture, pacemaker, herniorrhaphy,
ventricular shunt and peripheral vascular bypass surgeries respectively

• Under reported because 50% of SSIs develop after the patient is discharged.

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 SURGICAL SITE INFECTIONS (CONT..)

Organisms

Surgical site wounds are classified as clean, clean-contaminated, contaminated or dirty.

• For clean wound- The skin flora (S.aureus.)

• For other types- endogenous flora.

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 SURGICAL SITE INFECTIONS (CONT)

• Risk factors for nosocomial wound infection include:

o Advanced age, obesity, malnutrition, diabetes
o Infection at a remote site that spread through blood stream
o Preoperative shaving of the site
o Inappropriate timing of prophylactic antimicrobial agent.

• Note: The antimicrobial prophylaxis is usually given to the patient to prevent the seeding of organisms on the
surgical site. It is given 1 hour prior to the incision, usually along with the induction of anesthesia.

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 PREVENTION OF HAI

• The preventive measures for HAIs can be broadly categorized into

o Standard precautions
o Transmission-based or specific precautions.

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STANDARD PRECAUTIONS

• Set of work practices used to minimize transmission of HAIs.

• Measures to be used when providing care to/handling –

o All individuals

o All specimens (blood or body fluids)

o All needles and sharps

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 COMPONENTS OF STANDARD PRECAUTIONS

• Hand hygiene
• Personal protective equipment
• Biomedical waste including sharp handling
• Spillage cleaning
• Disinfection
• Respiratory hygiene and cough etiquette

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 HAND HYGIENE

• Hands are the main source of transmission of infections during

healthcare.

• Hand hygiene is therefore the most important measure to

avoid the transmission of harmful microbes and prevent
healthcare-associated infections.

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 TYPES OF HAND HYGIENE METHODS- HAND RUB

• Alcohol based (70–80% ethyl alcohol) and chlorhexidine (2–4%) based hand rubs are
available.
• Duration - 20–30 seconds.
• Advantage: After a period of contact, it gets evaporated of its own hence drying of hands is
not required separately
• Indications:
o Indicated during routine rounds in the wards or ICUs
o In all the moments or situations requiring hand hygiene, except when the hands are
visibly dirty or soiled, when it will be ineffective.
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 TYPES OF HAND HYGIENE METHODS- HAND WASH

• Antimicrobial soaps (liquid, gel or bars) are available.

• If facilities are not available, then even ordinary soap and water can also be used.
• Duration - 40–60 seconds.
• Indications:
o When the hands are visibly soiled with blood, excreta, pus, etc.
o Before and after eating
o After going to toilet
o Before and after shift of the duty.
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 FIVE MOMENTS FOR HAND
HYGIENE

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STEPS OF HAND RUBBING AND HAND WASHING
(WHO)

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 PERSONAL PROTECTIVE EQUIPMENT (PPE)

• Used to protect the skin and mucous membranes of HCWs

from exposure to blood and/or body fluids

• From the HCW’s hands to the patient during sterile and

invasive procedures.

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PERSONAL PROTECTIVE EQUIPMENT (PPE)
Gloves (non-sterile) Used when there is a risk of infection to HCWs (e.g. while touching
blood, body fluids, secretions, excretions of patients, items/equipment
or environment).

Gloves (sterile) Used when there is a risk of infection to HCWs as well as to the patients
(during surgeries /invasive procedures).

Plastic apron Used during surgeries

Gown Used during surgeries and when soiling is likely to be expected.

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PERSONAL PROTECTIVE EQUIPMENT (PPE)
Surgical mask Used during surgeries and while handling patients on droplet
precautions

N95 mask Used while handling patients on airborne precaution (tuberculosis).

Cap, face shield, goggles Used when spillage of blood is suspected, e.g. during major cardiac
surgeries etc.

Surgical shoes Used mainly in ICUs and operation theatres to protect HCWs and
environment from transmission of organisms.

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PERSONAL PROTECTIVE EQUIPMENT (PPE)

Personal protective equipment (PPE):

A. Gloves;
B. Plastic apron;
C. Gown;
D. Surgical mask;
E. N95 mask;
F. Cap;
G. Face shield;
H. Goggles;
I. Surgical shoes

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 SELECTION OF APPROPRIATE PPE

• Level of risk associated with contamination of skin, mucous

membranes, and clothing by blood and body fluids during a
specific patient care activity or intervention
• Route of transmission of suspected organisms— contact, droplet
and inhalation

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 DONNING AND DOFFING

Donning (wearing) Doffing (removing)

Gown Gloves

Mask or respirator Goggles or face shield

Goggles or face shield Gown

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Gloves Mask or respirator

 SPILL MANAGEMENT FOR BLOOD AND BODY FLUIDS

• Spill management of blood and body fluids: Bring the spill kit to the site of spillage, wear appropriate PPE
(gloves and gown); put no entry sign board near the spill area.
• If spillage is small (<10 mL):
o Wipe up spill immediately with absorbent material and discard into appropriate bin
o Wipe the area with 10% sodium hypochlorite and allow to dry
o Remove PPE and perform hand hygiene
• If spillage is large (>10 mL):
o Place disposable paper towels over spill to absorb the spillage
o Pour 10% sodium hypochlorite on top of absorbent paper towels and leave for 15 minutes.
o Remove the absorbent papers; put fresh disposable paper towels to clean the area and then39 discard
Nosocomial infections by Ndimwibo Arthur

these into appropriate waste bin.

 RESPIRATORY HYGIENE AND COUGH ETIQUETTE

• Should be followed by anyone with signs and symptoms of a respiratory infection,

regardless of the cause.
o Cover the nose/mouth with single-use tissue paper when coughing, sneezing, wiping
and blowing noses
o If no tissues are available, cough or sneeze into the inner elbow rather than the hand
o Follow hand hygiene after contact with respiratory secretions and contaminated
objects/materials
o Keep contaminated hands away from the mucous membranes of the eyes and nose
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 RESPIRATORY HYGIENE AND COUGH ETIQUETTE

• In high-risk areas of airborne transmission such as pulmonary

medicine OPD:
o Give mask to the patients with cough and make separate
queue away from the general queue
o Sputum collection should be done in an open space or in a
well- ventilated room
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 TRANSMISSION-BASED PRECAUTIONS
(SPECIFIC PRECAUTIONS)

1.Contact Precautions

2. Droplet Precautions

3. Airborne Precautions

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 SPECIFIC PRECAUTIONS

Type Indication Isolation Gloves Gown Mask Eye Handling of Visitors

protection equipment
Contact MDROs, C.difficile Essential Essential Essential Surgical mask- As required** Single use or Same
Diarrheal pathogens Required if reprocess precautions
Highly contagious skin infectious agent before reuse on as for staff
infections is also next patient
transmitted by
droplet

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 SPECIFIC PRECAUTIONS

Type Indication Isolation Gloves Gown Mask Eye Handling of Visitors

protection equipment
Droplet Respiratory syncytial Essential As If soiling Surgical mask is As required** Same as Restrict
virus, Mycoplasma required* likely essential contact visitor
Parainfluenza numbers
Pertussis and
Plague, precautions
Meningococcus same as for
staff

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 SPECIFIC PRECAUTIONS

Type Indication Isolation Gloves Gown Mask Eye Handling of Visitors

protection equipment
Airborne Pulmonary TB, Essential As If soiling N95 respirator As required** Same as Restrict
Chicken pox (negative required* likely essential contact visitor
Measles pressure) numbers
SARS and
precautions
same as for
staff

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 HOSPITAL-ACQUIRED INFECTION SURVEILLANCE

HAIs for which surveillance is conducted:

• Catheter-associated urinary tract infection (CAUTI)
• Central line-associated blood stream infection (CLABSI)
• Ventilator-associated event (VAE)
• Surgical site infection (SSI).

• Infection Control Nurses under the supervision of the officer in-charge conduct HAI
surveillance.

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 METHOD OF CONDUCTING HAI SURVEILLANCE

Data collection

Data analysis

Data interpretation

Data dissemination
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 PREVENTION OF DEVICE-ASSOCIATED
INFECTIONS (DAIS)
• Bundle care approach
o Bundle care comprises of 3 to 5 evidence-based elements with strong clinician
agreement.
o Each of the component must be followed during the insertion or maintenance of the
device
o Compliance to the bundle care is calculated as all or-none way, i.e. failure of compliance
to any of the component leads to non-compliance to the whole bundle

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 BUNDLE CARE FOR URINARY CATHETER
Insertion bundle Maintenance bundle
1. Inserted only when appropriate 1. Daily catheter care
indication is present
2. Sterile items 2. Properly secured
3. Non-touch technique 3. Drainage bag must be above the floor and
below the bladder level.
4. Closed drainage system 4. Closed drainage system
5. Appropriate size catheter 5. Hand hygiene and change of gloves
6. Secured after placement between patients; separate jug for each bag,
alcohol swabs for outlet – while emptying
urine
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6. Daily assessment of readiness of removal
49
 BUNDLE CARE FOR CENTRAL LINE
Insertion bundle Maintenance bundle
1.Hand hygiene 1.Daily aseptic CL care during handling
2. Sterile PPE  Hand hygiene
 Alcohol hub decontamination
3. Site of insertion- 2.Daily documentation of local sign of infection
Subclavian preferred, avoid femoral
4. Chlorhexidine skin preparation 3.Change of dressing with 2% Chlorhexidine

5. Skin must be completely dry after use of 4.Daily assessment of readiness of removal
antiseptics
6.Use semi permeable dressing
7.Hand wash after procedure
8.Document data and time of insertion
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 Maintenance bundle for ventilator care

Maintenance bundle

• Adherence to hand hygiene

• Elevation of the head of the bed to 30-450
• Daily oral care with chlorhexidine 2% solution
• Need of PUD (peptic ulcer disease) prophylaxis to be assessed daily; if needed
only sucralfate should be used.

• DVT (deep vein thrombosis) prophylaxis should be provided if needed.

• Daily assessment of readiness to removal of MV
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 PREVENTION OF SSI
Preoperative measures

1. Preoperative bathing

2. For MRSA nasal carriers: Decolonization with mupirocin ointment

3.Hair removal: strongly discouraged, If needed should be removed only with a

clipper.
4. Pre-operative oral antibiotics combined with mechanical bowel preparation
(MBP) - elective colorectal surgery.

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 PREVENTION
OF SSI
Intra-operative measures
1.Surgical antimicrobial prophylaxis (SAP) must be provided for all except clean surgeries.
 Administered within 60-120 minutes before incision
 Choice- depends upon local antibiotic policy. Cefazolin or cefuroxime are the usual agent of choice.
 Frequency- SAP is usually given as single dose. Repeat dose may be required only for: duration >4 hr,
cardiac surgeries, drugs with lower half-lives, extensive blood loss during surgery

2. Surgical hand disinfection

3. Surgical site preparation should be performed with alcohol-based antiseptic solutions based on CHG.
4. Perioperative maintenance of oxygenation, temperature, blood glucose level, circulating volume and
nutritional support during surgery and immediate 4-6hr postoperative period.

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 PREVENTION OF SSI

Post -operative measures

1. Daily wound dressing

2. OT disinfection - with a high level disinfectant, in between cases and after the last case
(terminal disinfection).
3. Periodic monitoring the air quality of OT for various parameters such as no. of air
exchanges, temperature, humidity, pressure and microbial contamination.
4. SAP prolongation is not recommended.

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