Nosocomial Infections

Dr. Nessren Farouk

Lecturer of public health and community medicine
Infections are the most common complication
affecting hospital patients and in many cases are
preventable.

 Nosocomial infections (NCIs)

 hospital-acquired infections (HAIs)
 health care associated infections:
are infections that a patient acquires while being
treated in a hospital for some other condition.

"nosus" = disease
"komeion" = to take care of
 Definition
NCI is an infection acquired in hospital by a
patient who was admitted for a reason other
than that infection.
It is occurring in a patient in a hospital or other
health care facility in whom the infection 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.
(WHO)
 Public health importance
NCIs are widespread. They are important
contributors to morbidity and mortality.
They will become even more important as a
public health problem with increasing economic
and human impact because of:
Increasing number & crowding of people,
More frequent impaired immunity/immuno-
compromized (age, illness, treatments, &
malnutrition),
New microorganisms,
 Cont…….
Increasing bacterial resistance to antibiotics (routine
use of anti-microbial agents in hospitals creates selection
pressure for the emergence of resistant strains.
Ward and inter-hospital transfers: medical staff
move from patient to patient, providing a way for pathogens to
spread.
Increasing workload
staff pressures (nurse-to-patient ratio)
lack of facilities (as washing)
 lack of concern
HAI is inevitable but some is preventable
realistically reducible by 10-30%
 NCIs burden
• 5-10% in developed countries
• 10-30% in developing countries
• Rates vary between countries, within the
country, within the districts and sometimes
even within the hospital itself
 Incidence
Depends upon
1. Average level of patient risk which
depends upon intrinsic host factors and
extrinsic factors
2. Sensitivity & specificity of surveillance
programs
Consequences/impact of nosocomial infections:

• HAIs’ impact on the patient can range from:

1) longer hospital stays to 2) more serious
conditions that may require surgery or result in
negative long-term health effects. 3) In severe
cases, HAIs may cause death (in order - LRI, BSI,
UTI).
• HAIs’ impact on health care system, as
1) increase treatment costs and result in
2) longer wait times for a hospital bed for other
patients.
 Economics of NCIs
• Extra cost of NCI consequences,
• Bed (length of hospitalization),
• Intensive care unit stay,
• Extra hematological, biochemical,
microbiological and radiological tests,
• Antibiotics & other drugs,
• Extra surgical procedures,
• Working hours
 Risk factors for nosocomial infections:
• Endo-tracheal intubation
• Bladder catheter
• Intravenous catheter
• Immuno-suppression
• Hyper-alimentation
• Operative procedures
 NCIs
Types by origin (sources):

Exogenous Endogenous

Environment
Another Patients own flora
- instruments
- air patient/staff (auto-infection)
- vectors & (cross-infection)
vehicles
Sources may be found within or outside the
hospital.
1-Sources Within the hospital:
• The patient: infects others in different ways.
• Working Personnel: when anyone is a case (mild or unapparent)
or a carrier. Personnel may play also a third-person (source-not
reservoir) role through carrying infection on contaminated
hands, clothing or footwear.
• Unsanitary hospital environment.
2-Sources Outside hospital:
• Visitors: when anyone is a case (mild or unapparent) or carrier.
They also may play non-reservoir role through the food they
carry to cases.
• Vehicles/vectors of unsanitary surrounding environment.
Modes of transmission:

A. By Contact:
1-Direct – patient to patient and health care
personnel to patient
2-Indirect - contaminated inanimate objects
in environment (Endoscopes etc)
3-Droplet infections by large aerosols
B. Through common vehicle like food, blood & blood
products, diagnostic reagents, medications
C. Airborne
D. Vector-borne – by flies, mosquito
Types of NCIs by common sites:
1. Urinary tract infections (UTI), usually catheter
related
2. Surgical site or wound infections (SWI)
3. Lower respiratory infections (LRI), pneumonia
4. Blood stream infections (BSI)
 EPIDEMIOLOGICAL INTERACTION
Intrinsic host susceptibility
Age, Poor nutritional status,
Co-morbidity, severity of
underlying disease

Environmental factors
hospital location,
diagnosis procedures,
Agent factors immuno suppressives,
varieties of chemotherapy, antibiotics,
organisms: med & surgical devices,
Institutional and human, exposure to infected
their virulence patients or health workers,
asymptomatic carriers
 Causative agents
Bacterial:
• Staphylococcus aureus: cause lung, bone,
heart and blood stream infection
• Staphylococcus epidermidis
• Enterobacteria
• Pseudomonas
 Causative agents
Viruses
• HIV, Hepatitis C&B virus
• Cytomegalovirus, influenza virus, Herpes virus,
Enteroviruses
• Viral diarrhea, Checkenpox can be spread in hospitals
Fungi
• Candida albicans, aspergillus
Protozoa
• Entamoeba histolitica, Toxoplasma
 Examples of Nosocomial Agents
By Type of Infection

TYPE OF INFECTION MICROORGANISM

Urinary Catheter Escherichia coli
Klebsiella spp.
Pseudomonas aeruginosa
Serratia marcescens
Streptococcus faecalis

Pneumonia Enterobacter spp.

Escherichia coli
Klebsiella pneumonia
Legionella penumophilia
Pseudomonas aeruginosa
Staphylococcus aureus

Surgical Site Enterococcus species

Escherichia coli
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus faecalis

Intravenous Catheter Candida spp.

Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus faecalis
 Factors influencing the developing of
nosocomial infections
• The microbial agent
• Patient susceptibility: patient factors
including extreme age, immune status,
malnutrition, chronic diseases such as
malignant tumors, AIDS etc.
• Environmental factor: eg. crowded conditions
within hospital
• Bacterial resistance
 Many Personnel Don’t Realize When
They Have Germs on Their Hands
Healthcare workers can get 100s to 1000s of bacteria
on their hands by doing simple tasks like:
– Pulling patients up in bed
– Taking a blood pressure or pulse
– Touching a patient’s hand
– Rolling patients over in bed
– Touching the patient’s gown or bed sheets
– Touching equipment like bedside rails, overbed
tables, IV pumps
 Prevention of NCIs
The cornerstone of prevention and
control of nosocomial infections is
asepsis –a concept that includes
cleaning, disinfection, surveillance,
epidemiologic methods, and patient
isolation.
 Standard precautions for prevention and
control of infections in health care settings:
-Hand hygiene
-Asepsis (to reduce patient/client exposure to
microorganisms)
-Personal protective equipment (to provide a
barrier to contact with blood, body fluids, non-intact skin
or mucous membranes)
-Routine environmental cleaning
-Cough etiquette
-Sharps & waste management
-Immunization
Knowing the chain of infection helps identify
effective points to prevent disease
transmission.
Methods of prevention of NCIs (and breaking
the chain of transmission) include:

1-Sanitation of environment:
• Clean hospital environment (including
incineration of particular forms of hospital
refuse and disinfection of air in operating
theaters, premature centers and some
laboratories by ultraviolet radiation).
• Sanitary surrounding area, which should be
clean and free of any breeding places for
insects.
 Cont.

2-Patient isolation
• Isolation precautions are designed to prevent
transmission of microorganisms in hospitals. Because
agent and host factors are more difficult to control,
interruption of transfer of microorganisms is directed
primarily at transmission.
• Placing a patient on isolation precautions, however,
often presents certain disadvantages to the hospital,
patients, personnel, and visitors. Isolation precautions
may require specialized equipment and environmental
modifications that add to the cost of hospitalization.
 Cont.
3-Medical care providers (personnel): should be:
• Free of infection (by pre-employment and periodic examination).
• Educated & supervised for proper health behavior and clean
habits. Hand washing frequently is called the single most
important measure to reduce the risks of transmitting micro
organisms from one person to another or from one site to
another on the same patient.
• careful handling, cleaning, and disinfection of fomites. Where
possible use of single-use disposable items patient isolation
• Suspected infectious cases should be segregated until proving
free of infection.
• Doctors, nurses and other health staff who come in close contact
with patients should be vaccinated against common hospital
infections as hepatitis b, meningitis, typhoid, H. influenza …….
 Cont.
4-Sterilization and antisepsis: must be strictly followed
throughout all processes, procedures and activities which may be
associated with the risk of infection. (asepsis is the basic
preventive measure of hospital infection).
5-Chemoprophylaxis: is valuable under certain conditions of
unsatisfactory fulfillment of asepsis, and unavoidable infection. 
6-Administrative regulations: to fulfill precise organization
of work, including asepsis, supervision of personnel, and control
of hospital visits (special hours and limited numbers). Those who
suffer e.g. from cold should not be allowed in the ward).
6-Early case-finding: by early screening and diagnosis of
hospitalized cases who have acquired infection, to be properly
managed.
Hand hygiene is the simplest,
most effective measure for
preventing hospital-acquired
infections.
Areas Most Frequently Missed

HAHS © 1999
 Successful Promotion
of hand hygiene
 Education
 Routine observation & feedback
 Engineering controls
– Location of hand basins: easy & convenient
– Alcohol-based hand rubs available
 Sterilization & disinfection

Sterilization: Destruction of all forms of life

(organisms, spores, parasites, insects and others)
which may be found in the environment and
contaminated objects.
Disinfection: Destruction of pathogenic organisms
outside the body of reservoirs of infection (man or
animal) i.e. destruction of the pathogens in the
environment and contaminated objects.
Antisepsis: Inhibition of the growth of organisms.
In a hospital:
Disinfection: it is the process of killing
pathogenic organisms coming out of the
patients’ body.
All articles, utensils……etc used by or were in
close contact with an infectious case should be
disinfected as soon as possible to eliminate its
danger.
Disinfection is done by:
Concurrent disinfection: it is carried out
immediately, during the course of the disease, for
discharges, stool, urine, sputum, handkerchiefs,
clothes, utensils, objects in nursing ………………etc
Terminal disinfection: it is done after recovery of
the case (cure) and release from isolation, or when
transferring the case from the hospital or in case of
death.
All beddings, clothes, utensils, the floor, the walls
are disinfected.
THANK YOU