Infection Control B.V Vlierberg 7 3755 BS Eemnes Tel: +31 (35) 53 80 800 Fax: +31 (35) 53 80 280 Email:
What it is, what it does and how to treat
1. Nosocomial Infections, a Worldwide Problem 1.1 What are Nosocomial Infections
Nosocomial means "hospital acquired." So, infections acquired during a hospital stay are called nosocomial infections. Formally, they are defined as infections arising after 48 hours of hospital admission. For earlier periods it is presumably assumed that the infection arose prior to admission, though this is not always going to be true. Patients with only a brief hospital stay may find they have a nosocomial infection after leaving hospital.
1.2 Nosocomial infections: contagious diseases from all kinds of micro organisms
These contagious diseases constitute major health threats, particularly in intensive-care units, surgical wards, transplant units, neonatal units, cancer wards, and burn wards. Nosocomial diseases include: 1) viruses such as influenza, parainfluenza, enteroviruses and respiratory syncytial virus (RSV), 2) bacteria such as Legionella, Clostridium difficile (See Annex B), Pseudomonas aeruginosa, antibiotic-resistant Enterobacter, antibiotic-resistant Staphylococcus (MRSA: see annex A) and Burkholderia cepacia, and 3) fungi such as species of Aspergillus and Candida.
1.3 Who Is Affected by Emerging Nosocomial Pathogens?
Nosocomial infections typically affect patients who are immuno-compromised because of age, underlying diseases, or medical or surgical treatments. Aging of our population and increasingly aggressive medical and therapeutic interventions, including implanted foreign bodies, organ transplantations, and xenotransplantations, have created a cohort of particularly vulnerable persons. As a result, the highest infection rates are in intensive care unit (ICU) patients. Nosocomial infection rates in adult and pediatric ICUs are approximately three times higher than elsewhere in hospitals
1.4 Deaths from Nosocomial infections
Deaths from Nosocomial infections: 80,000 deaths in the U.S.A. annually (Starfield, JAMA 284(4), 2000) In Europe, the number of such deaths is estimated to be about 90,000 per annum. If anything, the situation is getting worse: previously encountered essentially in a hospital environment, infections of this kind have now started to affect all places frequented by the public. Nosocomial infections are common with estimates at about 10% of American hospital patients, or more than 2 million cases annually in the USA. Cost estimates were as much as $4.5 billion in 1995 already. Loss of income and cleaning costs due to epidemic infections in hospitals in the Netherlands can be estimated at levels of Euro 300 per bed per day (PP).
1.5 Increased attention in Europe
European health care authorities increasingly are pinpointing nosocomial infections as an area of concern and attention both in hospital and after hospital discharge. Reported levels of methicillin-resistant Staphylococcus aureus infections are rising, according to recently published findings of the European Prevalence of Infections in Intensive Care (EPIC) study.
1.6 MRSA Problems in the UK (source BBC News)
The number of deaths in which the superbug MRSA has been cited as a cause has doubled in four years, official statistics show. The Office for National Statistics said in 2003 MRSA was mentioned on 955 death certificates - up from 487 in 1999. But the figures suggested some of the rise may be down to better reporting of the bug. Other statistics revealed the number of HIV diagnoses seems to have levelled off after a decade of increases. However, it was the MRSA figures which have proved most controversial. MRSA was involved in two out of 1,000 deaths in hospitals and three out of 1,000 deaths in NHS nursing homes, compared to an overall figure of one out of 1,000 deaths for the years 1999 to 2002. But laboratory reporting of MRSA cases only increased by 7% in the last year compared to a 19% rise in deaths.
1.7 Why Are Nosocomial Infections Emerging Now?
Three major forces are involved in nosocomial infections:
Antimicrobial use in hospitals and long-term care facilities.
The increased concern about gram-negative bacilli infections in the 1970s to 1980s led to increased use of cephalosporin antibiotics. As gram-negative bacilli became resistant to earlier generations of cephalosporin antibiotics, newer generations were developed. Widespread use of cephalosporin antibiotics is often cited as a cause of the emergence of enterococci as nosocomial pathogens. About the same time, MRSA, perhaps also in response to extensive use of cephalosporin antibiotics, became a major nosocomial threat. Widespread empiric use of vancomycin, as a response to concerns about MRSA and for treatment of vascular catheterassociated infection by resistant coagulase-negative staphylococci, is the major initial selective pressure for VRE. Use of antimicrobial drugs in long-term care facilities and transfer of patients between these facilities and hospitals have created a large reservoir of resistant strains in nursing homes.
Hospital personnel fail to follow basic infection control
Second, many hospital personnel fail to follow basic infection control, such as hand washing between patient contacts. In ICUs, asepsis is often overlooked in the rush of crisis care.
Patients in hospitals are increasingly immuno compromised.
The shift of surgical care to outpatient centers leaves the sickest patients in hospitals, which are becoming more like large ICUs. This shift has led to the greater prevalence of vascular access-associated bloodstream infections and ventilator-associated pneumonias.
Other precipitating factors also can be anticipated in hospitals. Transplantation is a double-edged sword because of the combined effects of immunosuppression of transplant patients and of infectious diseases that come with some transplanted organs. The blood supply will continue to be a source of emerging infectious diseases. Moreover, as hospitals age, infrastructure repairs and renovations will create risks of airborne fungal diseases caused by dust and spores released during demolition and construction. Infections due to other pathogens, such as Legionella, may also result from such disruptions.
1.8 Public awareness of the urgency to fight nosocomial infections
The healthcare industry could be facing a major crisis as the public gains more awareness, particularly with the prospect of highly publicized lawsuits. In general, healthcare facilities have responded to this threat by increased infection control procedures, concurrent with limiting publicity of the problem in the past. This changed radically due to the SARS outbreak some time ago, which initially was primarily spread through exposures in healthcare facilities. In response to the apparent increasing incidence of nosocomial infections, the CDC recently released a guideline with recommended infection control and JCAHO (Joint Commission for Accreditation of Healthcare facilities), the primary accrediting body for healthcare facilities, instituted Standard EC 3.2.1 in January of 2002, mandating infection control monitoring during any construction, reconstruction or renovation of healthcare facilities.
1.9 BBC Reference News
NHS superbug death rate doubles BBC News - February 24, 2005:
Q&A: MRSA 'superbugs' Thursday, 24 February, 2005
Lawyers consulted over MRSA baby Tuesday, 2 August 2005
Baby may not have died from MRSA Monday, 1 August 2005
1.10 Preventing nosocomial infections with current (conventional) methods, The Search & Destroy Programme
The control of nosocomial infections must entail good infection control practices. These include in general:
Improved maintenance of facility HVAC systems, containment facilities, and delivery systems such as medical gases.
Policies dedicated to improved infection control, candor, and patient protection, Improved disinfection practices,
Instigation of monitoring systems to detect potential infectious agents in air, water, surfaces, and personnel, and
Adequate and competent staffing of the facility incorporating higher qualifications for staff and on-going training program to improve staff participation in effective infection control.
More specifically methods of preventionthe chain of transmission ) include:
frequent hand washing especially between patients
careful handling, cleaning, and disinfection of fomites with Chloride
where possible use of single-use disposable items
avoidance where possible of medical procedures that can lead with high probability to
various institutional methods such as air filtration within the hospital
general awareness that prevention of requires constant personal surveillance
1.11 Why Infection Control by IC-4 H²O² ultra mist Technology 1.11.1 Healthcare industry not successful enough against nosocomial infections
Like said before, major contributors to this increase in nosocomial infections include the emergence of antibiotic-resistant bacteria, poor hygiene practices by healthcare providers, understaffed healthcare facilities, substandard practices and apathy. Although the healthcare industry has successfully avoided dealing with this escalating problem in the past, it is probably only a matter of time until plaintiff attorneys pursue this matter that continues to result in wrongful deaths and personal injury. The current Search & Destroy programs appear to not to be adequate and sufficient anymore.
1.11.2 Current disinfecting methods appear to become more costly every day
Despite the above mentioned measures, nosocomial infections become more common every day. In line with European wide Search and Destroy policies, contaminated area's have to be cleaned with traditional methods like cleaning with Chloride. Apart from the eye and lung irritating effects, room and area disinfecting effects are never complete and effective everywhere in the treated volume. Labor cost is extremely high and closing down departments causing significant income losses (sometimes > 300 Euro per day per bed).
Hospital acquired MRSA
What is MRSA?
The organism Staphylococcus aureus is found on many individuals skin and seems to cause no major problems. However if it gets inside the body, for instance under the skin or into the lungs, it can cause important infections such as boils or pneumonia. Individuals who carry this organism are usually totally healthy, have no problems whatever and are considered simply to be carriers of the organism. The term MRSA or methicillin resistant Staphylococcus aureus is used to describe those examples of this organism that are resistant to commonly used antibiotics. Methicillin was an antibiotic used many years ago to treat patients with Staphylococcus aureus infections. It is now no longer used except as a means of identifying this particular type of antibiotic resistance. Individuals can become carriers of MRSA in the same way that they can become a carrier of ordinary Staphylococcus aureus which is by physical contact with the organism. If the organism is on the skin then it can be passed around by physical contact. If the organism is in the nose or is associated with the lungs rather than the skin then it may be passed around by droplet spread from the mouth and nose. We can find out if and where Staphylococcus aureus is located on a patient by taking various samples, sending them to the laboratory and growing the organism. Tests done on any Staphylococcus aureus grown from such specimens can then decide how sensitive the organisms is to antibiotics and if it is a methicillin resistant (MRSA) organism. These test usually take 2-3 days.
Why bother with MRSA?
MRSA organisms are often associated with patients in hospitals but can also be found on patients not in a hospital. Usually it is not necessary to do anything about MRSA organisms. However if MRSA organisms are passed on to someone who is already ill, then a more serious infection may occur in that individual. When patients with MRSA are discovered in a hospital, the hospital will usually try to prevent it from passing around to other patients. This is known as infection control.
How do we prevent the spread of MRSA?
Measures to prevent the spread of organisms from one person to another are called isolation or infection control. The type of infection control or isolation required for any patient depends on the organism, where the organisms is found on an individual and the patient. The most important type of isolation required for MRSA is what is called Contact Isolation. This type of isolation requires everyone in contact with the patient to be very careful about hand washing after touching either the patient or anything in contact with the patient. If the organism is in the nose or lungs it may also be necessary to have the patient in a room to prevent spread to others by droplet spread. Because dust and surfaces can become contaminated with the organism, cleaning of surfaces are also important. This usually occurs after the patient leaves the hospital. If a number of patients are infected with the same organism it is possible to nurse them in the same area. On occasions for the sake of other patients it may be necessary to move carriers of MRSA to an isolation unit such as ours which specializes in isolating all types of infections to protect other persons. The medical care of such patients will continue in an isolation unit which are well used to caring for all types of medical and surgical problems associated with infections.
What do visitors need to do?
Provided relatives and friends of patients with MRSA are healthy there is no restriction on visiting and it carries no risk. Visitors are not required to wear special clothing BUT we would ask you to help us prevent this organism spreading around our hospital by keeping the patients' door closed at all times and always washing your hands whenever you leave the room.
What about MRSA at home?
In patients who are otherwise well the organisms often disappear once the patient leaves the hospital. Sometimes they do not however, and this may mean that when a patient has to go back into hospital the isolation precautions need to be used again. Provided everyone at home is healthy special precautions are not required at home.
What can be done about MRSA?
In certain situations it may be a good idea to try to get rid of the organism from a patient and this can be done with various creams and shampoos or on occasions combinations of antibiotics taken by mouth or by injection depending on the health of the patient.
Hospital-acquired Clostridium difficile
What is Clostridium difficile
Clostridium difficile is a bacterium normally found in the intestines of humans, other mammals and fish, mammalian feces, and soils. This Gram positive anaerobic bacterium is a member of the bacteria family that produces exotoxins that can cause tetanus and botulism, as well as other diseases.
What is the risk of CD
Sometimes under diagnosed, as unspecified intestinal infections, C. difficile causes approximately 3 million cases of diarrhea and colitis in the United States each year. It is considered to be one of the main causes of hospital-acquired diarrhea. Patients at greatest risk include those that have undergone antimicrobial or antibiotic treatments, such as those with inflammatory bowel disease. These patients on antibiotic therapy can develop infectious diarrhea from a sudden overgrowth of C. difficile, commonly known as Clostridium difficile Associated Diarrhea and Colitis (CDAD). Symptoms can include cramps, fever, fatigue, loss of appetite, nausea, and abdominal pain. Most cases of C. difficile are mild and go away without treatment, but patients, especially the young and elderly, are at risk for dehydration. In rare cases, patients can develop a more serious disease, pseudomembranous colitis (PMC), which can cause severe damage to the large intestines.
Characteristics and what can be done against it?
C. difficile is a spore forming bacillus that can exist in the environment up to 70 days. Common routes of transmission include contaminated patient-to-patient contact, and health care provider contact with contaminated feces (infected humans) or environmental surfaces (contaminated inanimate objects) to patient contact. Additional contamination sites can include toilets, telephones, electronic rectal thermometers, and bathtubs. To prevent infection, health care providers are recommended to use gloves, hand washing, environmental disinfection, isolation techniques (private rooms) and other aseptic procedures.
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