Surveillance Of Health Care associated
infections
By
Dr. Alaa Gad
Infection Prevention & Control Specialist
Infection at Healthcare Facilities
DEFINITION
Health care associated or hospital-acquired
infection (HAI) (nosocomial infections) can be
defined as:
Infection acquired during hospitalization; not
present or incubating at the time of admission to
hospital (i.e. occurs at least 48 hours after
admission).
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Factors contributing to increased incidence of infection
transmission at healthcare facilities
•
•
•
•
Patients are generally less immune.
Patients may have infections.
Patients undergo invasive procedures.
Healthcare providers may transmit infections to
clients and to themselves.
• Other general factors
Overcrowding with limited physical space
Staff shortages.
Poor infrastructure.
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Modes of Nosocomial Infection Transmission
Endogenous source
Exogenous source
Normal flora
Any Organism
C/A
Altered resistance
Or
Introduction of
microbes into
normally sterile areas
e.g. intravenous
catheter.
Results
from
Introduction of microbes
into or on the patient
from an outside source
e.g. hands of staff
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Disease-Transmission Cycle
(The Chain of Infection )
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How to Prevent Nosocomial Infection
Killing the agent
• e.g., applying an skin antiseptic
agent before surgery
Blocking means of
transmission from
infected to
susceptible
• e.g., hand washing to remove
bacteria or viruses acquired
through touching an infected
patient
Immunize susceptible • e.g. HBV vaccination of HCWs
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Break The Chain
Inhibiting
or killing
the agent
Blocking
transmission
Immunize
susceptible
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Infectious Agent
• The infectious agent is the microorganism that can
cause infection or disease.
• Pathogens may be classified as conventional,
conditional, or opportunistic based on their ability to
cause disease in normal Vs immunocompromised
hosts. However, almost any microbe, in favorable
circumstances e.g. if introduced into a normally
sterile area, can cause infection.
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Conventional (acute)
pathogens
Cause disease in
Examples
Conditional pathogens
Opportunistic
pathogens
Healthy individuals
•Local trivial infection in
healthy.
•Persons with reduced
resistance to infection.
•When implanted
directly into tissue or in
a normally sterile area.
only in
patients with
profoundly diminished
resistance to infection
e.g. AIDS, cancer.
Bacteria:
•Staph. aureus,
•Strept. pyo,
•Salmonella,
•Shigella,
•C. diphtheriae,
•M. tuberculosis,
•B. pertussis
,
Viruses:
•Hepatitis A, B, C,
•Rubella virus,
•Rotavirus,
•HIV
•Strept. agalactiae,
•Enterococci.,
•C. tetani,
•E. coli,
•Klebsiella ,
•Serratia marcescens,
•Acinetobacter
baumanii,
•Pseudomonas
aeruginosa,
•Candida
•Listeria
monocytogenes,
•Toxoplasma,
•Aspergillus,
•Legionella.
•Atypical mycobacteria,
•Nocardia asteroides,
•Pneumocystis carinii,
•Cryptococcus
neoformans,
•Histoplasma,
•Cryptosporidium.
•Previous columns.
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Colonization Vs Infection
• It is the presence of microorganisms at a body
site(s) without presence of symptoms or clinical
manifestations of illness or infection.
• Colonization may be a form of carriage and is a
potential method of transmission.
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The transition from colonization to
infection
• Developing an infection after contact with
microorganisms depends upon the interaction
between the contaminating organisms and the
host.
• Not all individuals who are colonized will
develop infection. In fact, those who have
progressed from colonization to infection may
represent only the “tip of the iceberg” of
persons carrying a particular pathogen.
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Minimal infective dose of a microorganism
• It is the critical number of microorganisms present on or
in a tissue that when exceeded, it is very likely that the
tissue will become infected.
• It varies by the type of microorganism and by point of
entry or invasion.
• Many causative agents of Hospital-acquired infections
have a relatively high minimal infective dose e.g. For
Klebsiella, Serratia spp. and other Enterobacteriaceae it
is more than 100,000 microorganisms (105 cfu/ml).
• Some causative agents, however, require very few
particles to infect, such as hepatitis B virus (less than 10
viral particles).
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Surveillance of Hospital
– Acquired infections
Surveillance is the ongoing, systematic
collection, analysis, interpretation, and
dissemination of data regarding a healthrelated event for use in public health
action in order to reduce morbidity and
mortality and to improve health.
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•Data disseminated by a public health surveillance system can be used
for:
• Guide immediate action for cases of public health importance;
• Measure the burden of a disease (or other health-related event),
• Monitor trends in the burden of a disease (or other healthrelated event), including the detection of epidemics (outbreaks)
and pandemics;
• Guide the planning, implementation, and evaluation of programs
to prevent and control disease, injury, or adverse exposure;
• Prioritize the allocation of health resources;
• Provide a basis for epidemiological research.
• Surveillance of Hospital-acquired infections is a key function of the
Infection Prevention & Control team.
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Steps of surveillance
• Assess the population served by the facility so that
interventions can be directed at those
complications of greatest importance given
available resources.
• Select the outcome (surgical site infection) or
process (prophylactic antibiotics )for surveillance.
• Define all data elements and assure criteria
definitions are valid, accurate, and reproducible.
• Collect the surveillance data.
• Calculate and analyze surveillance rates.
• Report and distribute surveillance information.
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Aim of Surveillance
•serve as an early warning system for impending
public health emergencies.
•Document the impact of an intervention, or
track progress towards specified goals.
•Monitor and clarify the epidemiology of health
problems, to allow priorities to be set.
surveillance
Major Types of health –care
associated infection
UTI
SYS
SSI
SST
BSI
CAUTI
VAP
REPR
PNEU
CLABSI
LRI
BJ
Device associated
Infections
GI
CNS
EENT
CVS
Urinary Tract Infection
Surgical Site Infection
Blood Stream Infection
Pneumonia
Bone and Joint Infection
Central Nervous system
Cardiovascular System infections
Eye , Ear , Nose and Throat
Gastrointestinal System Infection
Lower Respiratory Tract infection
Reproductive Tract Infection
Skin and Soft Tissue infection
Systemic Infection
NHSN / CDC facts
•
•
•
•
•
14 Million operative procedures done annually
SSI is the second most common HAI
SSI Proportion is 17%
SSI overall rate is almost 2%
SSI associated with more than 8000 deaths
annually
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What is operative procedure
• Procedure performed to a patient (inpatient
/Outpatient) takes place during an
operation(single trip to OR)where a surgeon
makes at least one incision through the skin or
mucus membrane , including laparoscopic
approach and close the incision before the
patient leaves the OR
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SSI surveillance
• Feedback of appropriate data to surgeons has
been shown to be an important component
of strategies to reduce SSI risk (CATS Implementation
after mesurment).
• Successful surveillance program needs
Epidemiologically sound infection definitions
and effective surveillance methods
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Surgical Site Infection
Organ
space
DIP
SIP
SSI
DIS
SIS
Superficial incision surgical site
infection
•Infection occurs within 30 days after the operative procedure
•Involves only skin and subcutaneous tissue of the incision
•Purulent drainage
•Organism isolated (aseptically obtained culture of fluid or tissue
from the superficial incision )
• Pain , Tenderness , Localized swelling , Redness or Heat
•Physician diagnosis (evidence : documenting ,Antibiotic , TLC
changes ! )
Deep incision surgical site
infection
•Infection occurs within 30 days after the operative procedure if
no implant is left in place (1 year)
•Involves deep soft tissues fascial and muscle layers of the
incision
•Purulent drainage
•Organism isolated (aseptically obtained culture of fluid or tissue
from the deep incision)
• fever , localized pain, tenderness
•Abscess or other evidence of infection involving the deep
incision is found by direct examination ,reoperation ,
histopathology or radiologic examination
•Physician diagnosis (evidence : documenting ,Antibiotic ,TLC
changes ! )
Organ / Space surgical site
infection
•Involves any part of the body excluding the skin incision , Fascia
, muscle layers.
Osteomyleitis
Breast Abscess or mastitis
Myocarditis or periarditis
Disc Space
Ear ,Mastoid
Endometritis
Endocarditis
Eye other than
conjunctivitis
GI tract
Intraabdominal
Intracranial ,brain abscess
or dura
Respiratory tract (Not PPP)
Mediastinitis
Meningitis or ventricullitis
Oral cavity
Male or female
reproductive tract
Urinary tract infection
Spinal abscess without
meningitis
Sinusitis
Upper respiratory tract
Arteial or venous infection
Vaginal cuff
Joint or bursa
Organ / Space surgical site
infection
Appendectomy with subsequent subdiaphragmatic abscess will be reported
as organ /space SSI at the intraabdominal specific site
Organ / Space surgical site
infection
•Infection occurs within 30 days after the operative procedure if
no implant is left in place (1 year)
•Involves any part of the body excluding the skin incision ,fascia
or muscle layers that is opened or manipulated during the
operative procedure.
•Purulent drainage from the drain
•Organism isolated (aseptically obtained culture of fluid or tissue
from the organ /space)
•Abscess or other evidence of infection involving organ /space is
found by direct examination ,reoperation , histopathology or
radiologic examination
•Physician diagnosis (evidence : documenting ,Antibiotic ,TLC
changes ! )
Data Analysis
Numerator
All SSI patients recorded during the selected time
period .
Denominator
All patients having procedure during the same time
period .
SSI rate per 100 %
Data Stratification
Total SSI rate % reflecting total infected procedures regardless
the likelihood of getting infection
Individual differs from each other of their susceptibility of
getting infection
We have to do Stratification for all / Selected operative
procedure
Data will be presented by Standardized Infection Ratio
RISK INDEXD
We calculate patient risk index category using the four elements
1.
2.
3.
4.
ASA score
Wound class
Operation duration
Laparoscopy
ASA
Rated by Anesthesiologist prior to operation
ASA Physical Status 1 - A normal healthy patient
ASA Physical Status 2 - A patient with mild systemic disease
ASA Physical Status 3 - A patient with severe systemic disease
ASA Physical Status 4 - A patient with severe systemic disease
that is a constant threat to life
ASA Physical Status 5 - A moribund patient who is not expected
to survive with / without the operation
Wound class
An assessment of likelihood and degree of contamination of
surgical wound at the time of the operation
Clean
An uninfected operative wound in which no inflammation is
encountered and the respiratory ,alimentary ,genital or
uninfected urinary tract are not entered
Clean –Contaminated
Operative wound in which the respiratory ,Alimentary ,genital or
urinary tract are entered under controlled conditions and
without unusual contamination (no evidence of infection)
Contaminated
Open ,fresh ,accidental wound in addition operations with major
break in the sterile technique
Dirty / Infected
Traumatic wound with retained devitalized tissue and those
involving existing clinical infection or perforated viscera
NHSN/CDC data
Cut point (75th
percentile )
Hospital Joining
the data
collection
Standardized Infection Ratio
Standardized Infection Ratio, SIR, is a summary
measure used to compare the HAI experience
among one or more groups off patients to that
of a standard population’
Accounts for differences in risk of HAI among
the group
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Calculation of SIR
•
•
•
•
SIR = Observed (O) HAIs
Expected (E) HAIs
Ratio of Observed to Expected infection
Risk-adjusted summary measure
Used to compare overall HAI rates of any two
patient cohorts, groups, or hospitals
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Aim of the project
1. Measuring the Current situation in the participating
hospital
2. Enhancing the quality of patient care by encouraging
hospitals to use data obtained from surveillance to
compare their rates of SSI over time and against a
benchmark rate, and to use this information to review
and guide clinical practice.
3. Establishing a National /regional Benchmark.
Surveillance methodology
Active surveillance by trained personnel
use a variety of methods to identify
cases of infection.
Participating Hospitals
Targeted Procedure
Methods of surveillance to
identify surgical site infections
Follow-up of patients during the inpatient stay:
Review medical and nursing records, temperature and treatment charts
to identify signs and symptoms that may indicate an SSI.
Methods of surveillance to
identify surgical site infections
Follow-up of patients during the inpatient stay:
Review microbiology reports to find any positive surgical site cultures
from patients in the study population and check with the ward why
the cultures were taken and if there are clinical signs of infection.
Methods of surveillance to
identify surgical site infections
Detecting SSI in patients readmitted to hospital / OR
•
establish systems to alert if a patient included in the
surveillance is readmitted.
If a patient is admitted with an SSI resulting from an operation performed in
another hospital the IPCD
should liaise with surveillance staff at the hospital in which the procedure took
place so that they can
report the infection .
SSI Surveillance
Readmission
OR/Hospital for
the target
procedure in
the surveillance
time period
Flagging System
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Methods of surveillance to
identify surgical site infections
SSI detected by healthcare professional during systematic post
discharge follow up
All patients included in the surveillance attend OPD after their
operation and this provides an opportunity to review their
wound for SSI. Clinicians should clearly indicate symptoms on a
standard report form
Methods of surveillance to
identify surgical site infections
• SSI reported by patient PostDischarge
Phone contact from the HCWs ,Educating patient about
warning signs of infection to contact the hospital
SSI surveillance
High Risk High Volume
Data Sources
Classification according to risk Index
Post discharge
Continuo
monitoring
Benchmarking
Readmission
OPD
Home Contact
Feedback
Improvement Plan
analysis
Surveillance
period
Analysis &
Interventions
Calculation of SSI rate within each
risk index category and compare
with the NHSN Benchmark
1 year
1 month
THANK YOU FOR ALL YOU
DO TO PROTECT PATIENTS
FROM HARM!
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