NOSOCOMIAL INFECTIONS
Nosocomial infections, defined as infections acquired during or as a result of hospitalization are major cause of morbidity and mortality in hospitalized children. Generally, All new infections, manifesting after 48 hours of hospitalization are considered as nosocomial, unless proved otherwise.
Incidence of nosocomial infections in general hospital wards is estimated to be ~ 3-5%, but may be as high as gt;40-50% in post-operative wards, intensive care units, high-risk patients, and after prolonged hospitalization.
Epidemiology of nosocomial infections varies from hospital to hospital and even within the hospital from ward to wards.
Sources: Hospital flora is full of pathogenic and seemingly innocuous organisms that keeps on changing time to time. Nosocomial infections may originate from:
• Inanimate objects, e.g. (a) hospital floorings, walls, furnitures, fixtures, linens, etc. (b) water supply and sanitation closets, (c) resuscitation or other equipment, e.g. catheters, nebulizers, ventilators, etc., or (d) shared use sources, e.g. suction apparatus, oxygen bottles/ tubings, dressings, antiseptic solutions, etc. or
• Animate objects, e.g. (a) asymptomatic/symptomatic hospital persons, visitors and other patients and (b) patient's own flora, i.e. auto-inoculation during aspiration and IV lines.
Mode of infection: Nosocomial infections may be acquired via multiple routes, e.g.
• Direct contact with unsterilized equipments or infected hands of hospital personnel,
• Inhalation of suspended organisms, i.e. droplet infections,
• Ingestion of contaminated hospital-food and medicines,
• Vector-borne spread from flies and mosquitoes,
• Auto-inoculation from own flora, e.g. aspiration or IV lines.
High-risk factors: Although all patients in a hospital ward are exposed to nearly similar risk for colonization with hospital pathogens, some are more susceptible to develop nosocomial infections than others (Table 10.60).
Apart from these host-related factors, infection control practices, antibiotic policy and waste-management policies of the hospital are important determinants of nosocomial infections.Clinico-microbial profile: Nosocomial infections may be caused by any normal or opportunistic organisms (OIs)
TABLE 10.60: High-risk host factors for Nosocomial infections
• Newborns and young infants
• Immunocompromized states
• Critically sick, debilitated or unconscious child
• Surgical, oncological or burn cases
• Invasive devices, e.g. vascular catheters
• Prolonged antibiotic therapy
• Prolonged hospitalization
present in the hospital environment, depending on the source. Common nosocomial infections in children are as follows:
• Respiratory tract infections account for 25-30% of nosocomial infections, more common in cases with airway interventions (oxygen, nebulizers, ventilators, intubation/tracheostomy) or high-riskof aspiration (debilitated or unconscious children). Most of them are caused by Staph. aureus and Pseudomonas.
• Urinary tract infections are common in general wards (40-45%), specially prevalent in cases with indwelling urinary catheters, genitourinary surgery and urinary retention/incontinence, these infections are usually caused by gram negative bacilli, e.g. Klebsiella; coagulase negative staphylococci (CONS); and enterococci, etc.
• Surgical wounds and burn infections (5-7%) are common in cases with poor wound drainage or infected dressings. These infections are usually caused by Staph. aureus, Pseudomonas and CONS; though enterococcal and anaerobic infections are common in feces-contaminated wounds.
• Vascular-catheter related infections (~3-5%) are more likely with central vascular lines, prolonged peripheral IV therapy and total parenteral nutrition. Risk of bacteremia/septicemia in these cases is directly related to duration of cannulation. Microbial agents in catheter-related infections are usually derived from normal skin flora, e.g.
CONS, anaerobes and Staph. aureus, although candidemia is also common after prolonged cannulations.• Gastrointestinal infections, e.g. enterocolitis (~8-10%) are common in patients with prolonged antibiotic therapy (Candida, C. defficile) or hospital-diet (Salmonella).
• Skin infections of nosocomial etiology are common at IV or monitor-probe sites. Most of them are staphylococcal in origin (Staph. aureus or CONS), though candidal infections may develop at macerated skin sites, e.g. back-sores.
• Immunocompromised hosts are specially susceptible for candidal and anaerobic infections, as well as serious bacterial infections due to Staph. aureus and Pseudomonas.
• Transfusion-related infections develop immediately after receipt of blood/products, e.g. sepsis, malaria; or after many months/years, e.g. HIV, HBV, etc.
Prevention of NIs is one of the most important aspects in management of intensive care. Each hospital should have—(a) written hospital infection control policy, (b) efficient surveillance system to identify changing microbial profile, antibiotic-sensitivity patterns and new nosocomial outbreaks, and (c) periodically review of antibiotic policy, consistent with changing hospital flora. Important components of hospital-infection control measures include:
• Maintenance of environmental hygiene
- General cleanliness, e.g. regular vacuum cleaning or wet-floor mopping with antiseptics.
- Adequate sunlight and wind-movements. Airconditioner filters should be cleaned regularly.
- Restricted use of curtains and decorative items.
- Periodic fumigations, specially if an outbreak is suspected.
- Proper bio-medial waste disposal.
• Prevention of cross-infection
- Strict handwashing (discussed below).
- Minimum handling of patients.
- Isolation of highly septic/infectious cases.
- Barrier nursing for immunocompromised host.
- No overcrowding (restricted visitors).
- Use of mask, gloves, etc., whenever indicated.
• Prevention of device-related infections
- Use of disposable instruments/devices.
- Proper sterilization of equipments.
- Frequent change of invasive catheters.
- Regular cleaning of suction and oxygen bottles.
• Rational use of antibiotics
• Regular surveillance for:
- Hospital flora (cultures from various sites).
- Microbial profile to decide antibiotic policy.
- Early detection and control of NIs outbreaks.
• Health education of hospital staff
• Minimum hospitalization, as far as possible.
Handwashing is the most effective control measure against nosocomial infections. Important steps (Fig. 10.25) for proper handwash include:
a. Remove the watch and jewellery,
b. Wash with soap and running water, with special attention to inter-digital areas,
c. Minimum duration of wash - 3 minutes before the first handling and 30 seconds in-between the patients,
d. Dry under automatic hand drier or with disposable sterile napkins.
Use of antiseptic solutions, e.g. alcohol, cetrimide, chlorhexidine or iodine solutions, etc. for handwash is no way superior to simple soap and running water wash, though may be practiced in special circumstances.
Outbreak control measures in a suspected outbreak of NI include:
Fig. 10.25: Correct handwashing technique.
• Confirming the outbreak by review of records.
• Identification of index case and contacts.
• Barrier or cohort nursing for suspected cases.
• Search for the source of infection* and remedial measures.
• General measures, e.g. fumigation and post-fumigation swab-cultures from various sites.
• Continuous surveillance to further cases.
*Search for the source involves environmental cultures, cultures from probable inanimate sources, e.g. suction bottles; as well as nasopharyngeal cultures from health-care personal.
Biomedical Waste Disposal
Biomedical waste is defined as 'any waste, generated during the diagnosis, treatment, or immunization of human beings and animals as well as during related research activities'.
Nearly 75-90% of this waste is comparable to any domestic waste, without any additional health-risk.
However, remaining 10-25%, containing biological tissues and secretions, drugs, sharp devices, etc.
| TABLE 10.61: Essentials of bio-medical waste disposal | |||
| Color code | Type of waste | Container | Method of disposal |
| Yellow | Biological waste* | Plastic bag | Incineration or deep burial |
| Red | Reusable, non-sharp waste | P. bag/sterile container | Autoclaving, chemical, microwave |
| Blue | Sharp waste | Puncture-proof container | Shredding gt; disinfection gt; recycling |
| Black | Drugs and chemicals | Plastic bag | Land-burial |
*Blood, tissues and laboratory samples
Is potentially harmful and needs to be disposed carefully. Important steps in biomedical waste disposal (as per GOI rules, 1998) include:
• Segregation of the waste at ward-level, in suitable color-coded containers (Table 10.61).
• Transport to disposal sites by proper means, e.g. covered trucks without spillage.
• Proper method of disposal, e.g. incineration, dumping, burning, etc.
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