HEALTH CARE ASSOCIATED INFECTIONS
(HAIs)
(NOSOCOMIAL INFECTION)
Ida Parwati
Djatnika Setiabudi
Komite PIRS
RSUP Dr. Hasan Sadikin
Bandung
Dr.Hasan Sadikin General Hospital
Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216
Definition(1)
Old concept:
• Nosocomial Infection = Hospital acquired infection
- An infection that occured during hospitalization (>
3 X 24 hours after admission) which are not
present nor incubating upon hospital admission
- Infection at the same location but the causative
microorganism was different than at addmission
OR the same microorganism but different location
Definition(2)
• Problems of old definition:
1. Focus on infection occuring in the hospital
only.
What about in other health care system but
not hospital? While many home-care are
availlable now?
2. Focus on patient’s infection
What about healthcare worker?
Definition (3)
New terminology:
nosocomial Infection =
Health-care associated Infection
Health-care related Infection
Healthcare-associated infection
• Definition:
An infection occurring in a patient during the
process of care in a hospital or other
healthcare facility which was not present or
incubating at the time of admission.
This includes infections acquired in the hospital
but appearing after discharge,
and also occupational infections among staff
of the facility
In Indonesia
• The term nosocomial infection still being used
• For nosocomial infection occured in the hospital:
Hospital Infection (”Infeksi Rumah Sakit”)
• Control Program of HAIs called: “Pencegahan
dan Pengendalian Infeksi Rumah Sakit”
(“PPIRS”)
Types of Infections (1)
Four categories:
1) Surgical site infections (SSI)
2) Central line-associated bloodstream
infections (CLABSI)
3) Ventilator-associated pneumonia (VAP)
4) Catheter-associated urinary tract infections
(CAUTI)
Types of Infections (2)
Others:
- Gastroenteritis
- Cellulitis
- Hepatitis B and C
- HIV / AIDS
- SARS
The most common causative pathogens
UTI
SSI
Resp.
E. coli
Klebsiella
Pseudomonas
Enterococcus
S. aureus
E. coli
Proteus
Pseudomonas
Klebsiella
Pseudomonas
S. aureus
E. coli
Blood
Skin
E. coli
S. aureus
S. aureus
Pseudomonas
Klebsiella
Proteus
Pseudomonas
The 10 most common pathogens
(accounting for 84% of any HAIs)
Coagulase-negative staphylococci (CONS) (15%),
Staphylococcus aureus (15%),
Enterococcus species (12%),
Candida species (11%),
Escherichia coli (10%),
Pseudomonas aeruginosa (8%),
Klebsiella pneumoniae (6%),
Enterobacter species (5%),
Acinetobacter baumannii (3%)
Klebsiella oxytoca (2%).
CDC, April 2013
Diseases and Organisms in Healthcare
Settings
Acinetobacter
Burkholderia cepacia
Clostridium difficile
Clostridium sordellii
Enterobacteriaceae
(carbapenem-resistance)
Hepatitis
HIV
Influenza
Klebsiella
MRSA
Mycobacterium abscessus
Norovirus
Pseudomonas aeruginosa
Staphylococcus aureus
Tuberculosis (TB)
VISA and VRSA
VRE
CDC, April 2013
Why does HAIs important?
Why does HAIs important?
1.Increase morbidity & mortality
2.Prolong length of stay (LOS)
3.Increase cost
4.Related to ‘image’/ quality of the hospital
5.Important in medicolegal and “patient
safety” aspects.
Impact of HAIs
They lead to
functional disability and emotional stress to the patient
disabling conditions that reduce the quality of life
They are one of the leading causes of death
Impact of HAIs (cont’d)
• The increased economic costs are high:
- Increased length of hospital stay
- extra investigations
- extra use of drugs
- extra health care by doctors and nurses
Nosocomial Infections Cost
 The cost varies according to the type and severity of
these infections
 An estimated: 1 - 4 extra days for a UTI
7 – 8 days for a surgical site infections
7 – 21 days for a blood stream infection
7 – 30 days for pneumonia
 The CDC has recently reported that US$5 billion are
added to US health costs every year as a result of NI
Impact of Nosocomial Infections (cont’d)
 Organisms causing N.I. can be transmitted to the
community through discharged patients, staff and
visitors
 If organisms are multi-resistant they may cause
significant disease in the community
Goals of infection control
• To protect the patients from HAIs e.g UTI, SSI,
IV line infection, pneumonia (HAP, VAP), Blood
stream infection (sepsis)
• To protect the patients from others infection
which acquire through contact with other
patients or healthcare worker whom colonized
by contagious microorganisms.
• To protect healthcare workers, Visitor, in hospital
environtment from infections
SIX
COMPONENTS
OF THE CHAIN
OF INFECTION
Schaffer SD et al: Infection
Prevention and Safe Practice,
Mosby, 1996
Risk Factors (1)
• Age: neonatus >>
• Interuption of anatomical barrier :
- Urine catether
- Operation procedure
- Respiration intubation
- Vein/artery canule
- Burn wound and trauma
Risk factors(2)
• Implantation of:
- “indwelling catheter”
- “surgical suture material”
- “cerebrospinal fluid shunts”
- “valvular / vascular prostheses”
• Changes in normal microflora :
antibiotics usage
Routes of Transmission of Infection
A susceptible host and appropriate inoculum of
infecting microorganism with an appropriate
route of transmission contributed in majority
of case





Airborne (resp tract, aerosols from equipment etc)
Contact spread (person to person)
Food borne spread
Blood borne spread
Self infections (endogenous) and cross infections
Transmission
(1)
• Contact transmission:
- Direct:
body contact
physically causative microorganism transfer
 physical examination, patients bathing
- Indirect: most of the time !!!
contact through objects (tools)
 instrumentation, needle, bandage
 unwashed hand
Transmission
(2)
• Droplet transmission :
- droplet particles > 5 μm
- coughing, sneezing, talking
- short transmission distance, and only short
time in the air
- “deposit” at conjungtival mucous, nose, mouth
- e.g.: Diphteria, Pertussis, Hib, Mycoplasma
Influenza Virus , mumps, rubella
Transmission
(3)
• Airborne transmission :
- small particles < 5 μm
- long standing in the air
- long transmission distance
- easy inhaled
- e.g : Mycobacterium tuberculosis
varicella virus, morbilli,
fungi spore.
Pathophysiology
Within hours of admission, colonies of hospital
strains of bacteria develop in the patient's skin,
respiratory tract, and genitourinary tract.
Risks factors for the invasion of colonizing
pathogens can be categorized into 3 areas:
iatrogenic, organizational, and patient-related
Iatrogenic risk

Iatrogenic risk factors:
include pathogens on
the hands of medical
personnel, invasive
procedures (intubation
and extended ventilation,
indwelling vascular lines,
urine catheterization),
and antibiotic use and
prophylaxis.
Organizational

Organizational risk
factors include:
contaminated airconditioning systems,
contaminated water
systems, and staffing
and physical layout of
the facility (eg, nurseto-patient ratio, open
beds close together).
Patient associated
Patient risk factors
include the severity of
illness, underlying
immunocompromised
state, and length of stay.
 Prolonged stay in the
hospital is a Major
contributing factor

Blood stream infections
• Most important pathogen:
coagulase negative Staphylococcus (CONS): 39.3%
• 10 – 15% of patients with HAI have a BSI
• Needle sticks may offer a path of entry for the
microbes
Pneumonia
 Most important pathogens
 Staphylococcus aureus: 16.8%
 Pseudomonas aeruginosa : 16.1%
 10 – 15% of patients with a HAI get pneumonia
 20 – 50% mortality rate
 Intubation and mechanical ventilation increase
the risk of pneumonia by S. aureus
 Pneumonia usually caused by aspiration of
bacteria clusters found in resp. Tract/GI tract
Urinary tract infection
 Most important pathogens
 Escherichia coli – 18.2%
 Candida albicans – 15.3%
 Up to 40% of patients with HAIs get a UTI
 E. coli is a natural inhabitant of the GI tract
it is commonly found near the anterior urethra
 Candida albicans is a natural inhabitant of the GI and
genital tract
 Normal urination clears the urethra of harmful
microbes while catheterization may allow microbes
to colonize and infect the urinary tract
Surgical site infection
 Most important pathogens
 Enterococci spp. – 14.5%
 Coagulase negative Staphylococcus (CoNS)– 13.5%
 Up to 54% of patients with HAI who have also had
surgery get a SSI: 500,000 infections/year
• Enterococci spp. are a natural inhabitant of the GI
tract
• Urinary catheterizations and antimicrobial use during
hospital stays increases risk of infection
3 Major players in HAIs
1. Antimicrobial use in hospitals and long-term care
facilities: has produced resistant strains that are often found
colonizing health care workers. These strains can be transferred
to patients by normal human contact
– Medical devices such as catheters and sutures offer a portal
of entry for the microbes
2. Failure of hospital personnel to follow basic infection
control: Handwashing, PPE etc.
3. Hospital patients are increasingly
immunocompromised
Prevention and Control
The basic responsibility of any good hospital remain
with establishment of good infection control policies,
which can always be achieved with
1. An infection control committee
⦁
2. An Infection team

The Functions of the Committee:
 To do surveillance and infection monitoring of hygiene
practices.
 Educate the Medical and Paramedical staff on policies
relating to prevention of infection, and safe procedures

Infection Control Nurse



Is the key member of the team
Maintain the close working
relations between Microbiology
Laboratory, different clinical
services and supportive services like
laundry, pharmacy and engineering
Collect information and document
on HAIs
Universal Precautions!
Correlation between Handsrub usage and MRSA
botol
MDRO in the Hospital, Al Ichsan
Bandung 21 August 2013
Thank you