Principles and practices in hospital infection control
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The document discusses hospital infection control principles and practices, including definitions of healthcare-associated infections (HCAI), the organization of infection control committees, and key strategies such as surveillance and standard precautions. It highlights the importance of infection prevention in various settings, particularly in ICUs and operating theaters, as well as the economic burden and risks associated with HCAIs. Additionally, the document emphasizes the necessity of antimicrobial stewardship and the implementation of care bundles to mitigate the incidence of nosocomial infections.
Principles and practices in hospital infection control
- 1. PRINCIPLES AND PRACTICES IN HOSPITAL INFECTION CONTROL Maj (Dr) Shilpi Gupta Gd Spl (Microbiology)
- 2. 1. Introduction 2. Definitions and types of Healthcare associated infections (HCAI) 3. Organisation of Hospital Infection Control Committee (HICC) 4. Various parameters under Hospital Infection Control (HIC) (a) Surveillance (b) Standard precautions (c) Infection control in ICU and OT (d) Antimicrobial Stewardship Program 5. Conclusion
- 3. She was progressing in the neonatal intensive care unit until she developed a bloodstream infection related to her umbilical catheter. A baby was born prematurely.
- 4. The surgery goes well but he later dies in a nursing home of a MRSA wound infection that developed after surgery. An adult has open heart surgery.
- 5. She has lived with this unbearable infection through 6 months of relapses. A lady contracts Clostridium difficile after giving birth.
- 6. A lady is being treated for cancer • And now has to fight two diseases because she got Hepatitis C from an unsafe injection
- 8. Florence Nightingale, Notes on Hospitals, 1863 It may seem a strange principle to enunciate as the very first requirement of a hospital is that it do the sick no harm
- 9. INTRODUCTION • In 1972 – Centers for Disease Control and Prevention (CDC) initiated the hospital infection branch. • Infection control – prevention and management of infection – application of research based knowledge to practices.
- 10. IMPORTANCE HCAI Developed countries Developing countries Hospitalized patients 3.5%-12% 5.7%-19.1% ICU settings Upto 51% Upto 88.9% http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
- 11. Occurrence of HCAI Added burden to the hospital Increase length of stay Increase cost Increase morbidity & mortality
- 12. HEALTH ECONOMICS RELATED TO HCAI PARAMETER NON - INFECTED HCAI INFECTED Mean mortality 2.5 % 8.75 % Mean LOS ICU 2.27 days 8 days Mean LOS Hospital 10.3 days 33.5 days Costs (Bed charges, pharmacy, bedside procedures, consumables, investigations, consultation) $ 2268 $ 7186
- 13. DEFINITION • Earlier Nosocomial infection • Healthcare associated infection (HCAI) • Infection neither present nor incubating at the time of admission and becomes apparent after 48 hrs of hospital admission
- 14. TYPES OF HOSPITAL ACQURIED INFECTION HCAI Surgical site infection Urinary tract infection Respiratory infection (VAP/HAP) Blood stream infections (CLABSI)
- 15. CAUSATIVE MICROORGANISMS • Two-third of total infections are 6 ESKAPE organisms
- 16. CAUSATIVE MICROORGANISMS contd... • Other Bacterial organism • Burkholderia cepacia • Stenotrophomonas maltophilia • Clostridium difficile • Candida spp. • Virus • HBV, HCV, HIV • Respiratory viruses
- 17. RISK FACTORS • Hands of HCWs • Invasive procedures Iatrogenic • Contaminated air conditioning system • Contaminated water • Contaminated instruments Organisational • Severity of illness • Immuno-compromised state • Length of stay Patient related
- 18. ORGANISATION OF HICC Chairperson: MS/ Dean Member Secretary: Senior Microbiologist Members: HODs/ MOI/c Dept and wards,Addl MS, Nursing suptd Support services: OI/C CSSD, BMW, Med Store Infection Control Team (ICT)
- 19. INFECTION CONTROL TEAM (ICT) Comprises of • Infection Control Officer (ICO) - Microbiologist • Infection Control Nurse (ICN)
- 20. Schematic Representation of Working of ICT HODs / In-charge of clinical dept./wards Daily ward rounds Obsn on IC procedures & practices Training program Surveillance of HCAI ICN ICO Chairperson Coordinate lab findings with cases Formulate A/B policy Data compilation Secretary
- 22. SURVEILLANCE • Recording and counting of infections arising in the hospital • Important means of monitoring HCAI • Determined in term of rates
- 23. OBJECTIVE OF SURVEILLANCE • Establish endemic baseline rate. • To establish priorities for infection control activities. • To identify trends manifested over a finite period. • Evaluating and monitoring infection control measures.
- 24. TYPES OF SURVEILLANCE Passive Lab based Alert organisms - Multidrug resistant organism (MDRO) - MDR GNB, MRSA, VRE Ward based Alert conditions - Chicken pox - Post surgical sepsis Active High risk area – Operation Theatres – ICU, NICU, PICU - Burns, Dialysis units, Labour room - CSSD -
- 26. HISTORY OF INFECTION CONTROL PRECAUTION • UNIVERSAL PRECAUTIONS • HIV & other blood borne infections 1985 • BODY SUBSTANCE ISOLATION • Blood & body fluids 1987 • STANDARD PRECAUTION • TRANSMISSION BASED PRECAUTION (hospitalized) 1996 • ISOLATION PRECAUTIONS • SARS-CoV-1, H1N1 2007
- 27. 1.HAND HYGIENE 3. ISOLATION PRECAUTIONs 2.PPE 4. STERILIZATION AND DISINFECTION 5. ENVIRONMENTAL INFECTION PREVENTION AND CONTROL KEY ELEMENTS OF STANDARD PRECAUTION
- 28. Improved Patient Outcomes Associated With Proper Hand Hygiene Ignaz Philipp Semmelweis (1818-1865) Chlorinated lime hand antisepsis
- 29. Impact of Hand Hygiene on Hospital Infections YEAR AUTHOR SETTING DURATION IMPACT ON INFECTION RATE 1977 Casewell et al Adult ICU 2 years Klebsiella spp. decreased 1989 Konly JM Hospital 6 years HCAI decreased (33% to 12%) 1994 Webster NICU 9 mon MRSA eliminated 2003 McDonald Orthopaedic 10 mon HCAI decreased (36%) SSI rates (8.2% to 5.3%) 2007 Archibald et al Neurosurgery 2 years SSI rates decreased (54%) 2007 Pessoa S et al Neonatal unit 27 mon Decrease in HCAI in VLBW neonates (15.5 to 8.8/ 1000 patient-days) 2008 Ngyun et al Urology 6 mon HCAI rates (13.1 – 2.1%) 2011 Chen Y Hosp wide 4 years MRSA and MDR Acinetobacter decreased 2017 Ahmad Hosp wide 6 mon HCAI decreased
- 30. HAND HYGIENE • When to observe? • How to observe?
- 31. HAND HYGIENE When to observe ? • The “My 5 Moments for Hand Hygiene”approach
- 32. HAND HYGIENE How to observe ? • Hand wash • Availability of soap, scrubs • Hand rubs (alcohol based) - Availability of gels, solutions Note: Hands should always be washed whenever soiled
- 33. Areas Most Frequently Missed HAHS © 1999
- 35. PERSONAL PROTECTIVE EQUIPMENT (PPE)
- 36. TRANSMISSION BASED PRECAUTIONS Types Mode of transmission Examples Contact HCW, environment &/or eqpt MRSA, MDR GNB, C. difficile Gloves Gowns Airborne Air currents Tuberculosis, measles, Chicken pox N 95 mask Droplet Droplets Mumps, influenza, N. meningitidis Mask PPE
- 37. ISOLATION ROOM Ref: Shweta K, Gupta SK, Chandrashekhar R, Kant S. Planning and Designing an Isolation Facility in Hospitals: Need of the Hour. Int J Res Foundation Hosp Healthc Adm 2015;3(1):48-56. Positive Pressure Room Negative Pressure Room
- 38. FUNCTIONAL CLASSIFICATION ISOLATION ROOMS Features S Standard N Negative P Positive Basic facilities (separate area, dedicated eqpt) Present Present Present Key ventilation criteria No air pressure difference Air pressure in room lesser than in adjacent area Air pressure in room is greater than in adjacent corridor Transmission based precautions Contact or droplet Airborne Prevention of infection immunosuppressed Examples • MRSA • MDR GNB • Gastroenteritis • COVID 19 • Chicken pox • Tuberculosis • Aspergillosis in bone- marrow transplant recipients
- 39. STERILIZATION & DISINFECTION • Sterilization is defined as a process where all microbes are removed from a defined object, inclusive of bacterial spores • Disinfection is a process where most microbes are removed from defined object or surface, except spores • Antisepsis is a process of removal of germs from the living tissue or skin.
- 40. SPAULDING CLASSIFICATION CLASSIFICA TION DEFINITION EXAMPLES PROCESSING Critical Enters sterile tissue including the vascular system • Surgical instruments • Biopsy instruments Sterilization Semicritical Contacts non-intact skin or mucous membranes but do not penetrate them • Anaesthesia equipment • Endoscopes High level disinfection (sterilization preferred if heat tolerable) Noncritical Touches only intact skin and not mucous membranes • ECG leads • BP cuffs • Bedpans • Stethoscope Low level disinfection
- 41. METHODS OF STERILIZATION HEAT STERILIZATION CHEMICAL STERILIZATION RADIATION STERILIZATION Steam (autoclave) Ethylene oxide Non ionizing radiation - UV irradiation Hot air oven Glutaraldehyde based formulations Hydrogen peroxide Peracetic acid Ionizing radiation - X-ray - Gamma
- 42. CLASSIFICATION OF DISINFECTANTS HIGH LEVEL INTERMEDIATE LEVEL LOW LEVEL Ethylene oxide Ethyl or Isopropyl alcohol (70%) Quaternary ammonium compounds (chlorhexidine) 2% Glutaraldehyde Hydrogen peroxide 1% Sodium hypochlorite Phenolic solutions
- 43. POINTS TO NOTE Cleaning before sterilization Concentration Duration or contact time
- 44. Monitoring of autoclave TYPE FREQUENCY QUALITY INDICATOR Mechanical With each cycle Temperature Pressure Time Chemical With each load Chemical indicator tape Biological Weekly Spores of Bacillus stearothermophilus
- 45. Monitoring Chemical indicator tape Biological indicator Test strips
- 46. ENVIRONMENTAL INFECTION PREVENTION AND CONTROL
- 47. GENERAL PRINCIPLES FOR CLEANING AND DISINFECTING ENVIRONMENTAL SURFACES Division of area • High touch • Low touch Frequency • More in high risk areas Cleaning procedures • Wet mopping recommended • Proceed from cleaner to dirtier area Use of disinfectant • Type • Appropriate dilution Source: Manual Guide for Environmental Cleaning and Disinfection, Ministry Of Health Infection Control Directorate 2016
- 48. INFECTION CONTROL IN ICU • Objective: To reduce occurrence of Device associated hospital acquired infections (DA-HAI) • Infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. • Central line associated blood stream infections (CLABSI) • Ventilator associated pneumonia (VAP) • Catheter associated urinary tract infections (CAUTI)
- 49. INDIAN STUDIES Study period Place of study HAI incidence VAP CAUTI CLABSI Reference 2004-2005 New Delhi 34.1% 31.4 11.2 3.4 Habibi et al 2006-2007 Puducherry NA 30.6 NA NA Joseph et al 2010-2011 Chandigarh 29.1% 6.0 9.08 13.8 Datta P et al 2009-2010 Pune 17.6% 32 9 16 Singh et al 2010-2011 Vellore NA 40.1 NA NA Mathai et al 2011-2013 Puducherry 50.2% 72.5 12.4 3.9 Bammi et al 2015-2016 New Delhi NA 16.7 7.3 10.3 Bineeta et al
- 50. WARNING Nosocomial Infections in ICU are Waiting
- 51. CARE BUNDLES • A care bundle is a collection of preventive interventions that are evidence based such that the application of all the interventions is consistent for all the patients at all times to prevent DA-HAI.
- 52. VAP BUNDLE • Hand hygiene • Elevation of head end of bed (30˚– 45˚) • Oral care with 2% chlorhexidine 4-6 hourly • Avoid use stress ulcer prophylaxis who are not at risk • Daily assessment of readiness to wean and use of weaning protocols • Review necessity of ventilator daily
- 53. CAUTI BUNDLE • Hand hygiene • Urinary Flow • Meatal Care • Catheter change interval – unless infected • Irrigation with antimicrobials – not advised • Review necessity of catheter daily
- 54. CLABSI BUNDLE • Hand hygiene • Avoid femoral vein for central venous access • Insertion with maximal sterile barrier (MSB) precautions • Skin antisepsis with 2% chlorhexidine • Review necessity of CVC daily
- 56. INFECTION CONTROL IN OT • Objective: To reduce surgical site infections (SSI)
- 57. RISK FACTORS FOR SSI Pre-operative • Pre-op bathing • Surgical antimicrobial prophylaxis (SAP) • Hair removal • Site preparation • Surgical hand hygiene Intra-operative • Perioperative oxygen • Maintaining normothermia • Blood glucose control • Appropriate & adequate use of PPE • HVAC system Post-operative • Surgical wound dressing • Blood glucose control Source: Global guidelines for the prevention of surgical site infection, WHO, 2018
- 58. PARAMETERS OF HEATING VENTILATION AIR CONDITIONING (HVAC)SYSTEM HVAC system Temper- ature Humidity Pressure Air flow Air quality
- 59. RECOMMENDATIONS FOR HVAC SYSTEM FOR OT Parameter Requirement Remarks Temperature 21 °C +/- 3 °C For Ortho for Joints replacement as 18° C +/- 2° C) Humidity 20 to 60% Ideal RH is considered to be 55% Pressure 2.5 Pascal Positive pressure maintained between OT and adjoining areas at all times Air changes per hour (ACH) 4 - 20 ACH Minimum 4 fresh air changes out of total minimum 20 air changes. Air velocity 25-35 FPM (feet per minute) Airflow needs to be unidirectional and downwards on the OT table. Air Quality HEPA (High-efficiency particulate arrestance) filters Filtration area should extend one feet on each side of the OT table Source: REVISED GUIDELINES FOR AIR CONDITIONING IN OPERATION THEATRES. NABH-Air Conditioning 2018
- 60. AIR FLOW AND FILTERS
- 61. VALIDATION OF HVAC SYSTEM Temperature and Humidity check Air Change Rate Calculation Validation of HEPA Filters by appropriate tests like DOP (Dispersed Oil Particulate) Pressure Differential levels of the OT with adjoining areas Air velocity at outlet of terminal filtration unit
- 64. ANTIMICROBIAL PRESCRIBING FACT: THE 30% RULE 30% Hospitalized patient receive A/B Antibiotics prescribed inappropriately in community Surgical prophylaxis is inappropriate Antimicrobial cost can be saved by AMSP
- 65. WHAT IS ANTIMICROBIAL STEWARDSHIP? • DEFINITION: Coordinated interventions designed to measure and improve the appropriate use of antimicrobial agents by promoting optimal antimicrobial drug regimen. Drug selection Dosing Route of administration and Duration of therapy Source: Antimicrobial Stewardship program Guideline (2018), Indian Council of Medical Research (ICMR)
- 66. AMSP TEAM Ideal Stewardship team ID Physician Pharmac -ists Clinical Microbio- logist HICC Source: Antimicrobial Stewardship program Guideline (2018), Indian Council of Medical Research (ICMR)
- 67. COMPONENTS OF AMSP AMSP Antibiotic policy Prescription Audit Formulary restriction/ Preauthori- zation Streamlining / de- escalation Infection control Education Source: Antimicrobial Stewardship program Guideline (2018), ICMR
- 68. ANTIBIOTIC POLICY • Antibiotic policy is to be prepared by the antimicrobial stewardship team. • Objectives: • To achieve best clinical outcomes • Limiting the selective pressure • Reduce excessive costs • The policy is reviewed and updated annually
- 69. NATIONAL GUIDELINES FOR ANTIBIOTIC POLICY • Treatment Guidelines for Antimicrobial Use in Common Syndromes. Indian Council of Medical Research (ICMR) Department of Health Research New Delhi, India 2019. • NCDC(MOHFW) has launched National Treatment Guidelines for Antimicrobial Use in Infectious Diseases (Version 1.0 (2016). • Antibiotic policy, Dept of Medicine with multidisciplinary collaboration, AIIMS New Delhi.
- 70. Key Prevention Strategies Prevent infection Diagnose and treat infection effectively Use antimicrobials wisely Prevent transmission
- 71. CONCLUSION • HIC is a multidisciplinary team approach • Standard Precautions – Minimum preventive measure followed at all times, for all patients and in all situation • Bundle care in critical settings is the need of hour • Using antibiotics rationally with an implementable antibiotic policy
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