RUSSIAN NATIONAL RESEARCH MEDICAL UNIVERSITY (RNRMU) DEPARTMENT OF HYGIENE AND BASIC HUMAN BEING ECOLOGY INTERHOSPITAL INFECTIONS

Contents

Title Introduction Known Interhospital Infections Epidemiology Major Interhospital Infections and their Causes Bacteria that Cause Infections Main Routes of Transmission Routes of Contact Transmission Risk Factors Prevention Conclusion & Recommendation Reference

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Introduction
The World Health Organization offers several definitions of a interhospital infection/ hospital acquired infection: -An infection acquired in a hospital by a patient who was admitted for a reason other than that infection . -An infection 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. As a general timeline, infections occurring more than 48 hours after admission are usually considered interhospital. Interhospital infections are also divided into two classes, endemic or epidemic. Most are endemic, meaning that they are at the level of usual occurrence within the setting. Epidemic infections occur when there is an unusual increase in infection above baseline for a specific infection or organism.

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Known Interhospital Infections

Ventilator-associated pneumonia Staphylococcus aureus Methicillin resistant Staphylococcus aureus Candida albicans Pseudomonas aeruginosa Acinetobacter baumannii Stenotrophomonas maltophilia Clostridium difficile Tuberculosis Urinary tract infection Hospital-acquired pneumonia Gastroenteritis Vancomycin-resistant Enterococcus Legionnaires' disease

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Epidemiology
Interhospital infections are commonly transmitted when hospital officials become complacent and personnel do not practice correct hygiene regularly. Also, increased use of outpatient treatment in recent decades means that a greater percentage of people who are hospitalized today are likely to be seriously ill with more weakened immune systems than in the past. Moreover, some medical procedures bypass the body's natural protective barriers. Since medical staff move from patient to patient, the staff themselves serve as a means for spreading pathogens. Essentially, the staff act as vectors.

Breathing Machines

People who are in the hospital and using breathing machines such as ventilators may get interhospital infections such as pneumonia. The breathing machines can become contaminated with germs, especially when handled by medical staff who do not use the proper infection control procedures. People on breathing machines may also be unable to cough and expel germs from their lungs, which is another cause of interhospital infections.

Catheters

Catheters are a medical device used to remove urine from hospital patients who are unable to use a toilet. Catheters are a common cause of urinary tract infections that occur during a hospital stay. Urinary tract infections result when the catheter becomes contaminated by medical staff during insertion or is not properly maintained while in use.

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Improper Hygiene

Visitors and staff at hospitals can infect patients with diseases such as pneumonia and methicillin resistant staphylococcus aureus (MRSA) as a result of improper hygiene. Doctors and nurses who forget to wash their hands before conducting an exam of a patient can spread MRSA among hospitalized people. Visitors who have respiratory illnesses and sneeze into the air or their hands can spread their germs as well.

Injections

Hospital staff who do not properly give injections may cause interhospital infections in patients. Infections such as hepatitis B, C and HIV can be spread through sharing of syringes that touch contaminated blood. Patients may receive medications into their intravenous lines by staff who do not change syringes between patients, which is another way to spread infections.

Surgery

People in the hospital for surgical procedures may develop interhospital infections. If incisions tear or are not properly bandaged, they can become contaminated with bacteria from the skin. Surgical equipment can also be contaminated and introduce bacteria into the patient's body, resulting in infections.

Transplants

Although less common today than in the past, certain procedures such as transplants and transfusions can result in interhospital infections. Illnesses such as hepatitis B, hepatitis C, HIV and syphilis can be spread through bone and tissue grafts. Interhospital infections can also be spread through blood transfusions, organ and skin transplants.

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Major Interhospital Infections and their Causes

Urinary Infections: According to hospital statistics, urinary infections comprise 33% to 40% of interhospital infections. These are most commonly caused by the insertion of a catheter, and account for 17% of all infections in this catefory.

Surgical infections: account for 10% to 12% of Interhospital Infections. They usually occur within thirty days of surgery but can take as long as a year if a prosthesis or implant has been inserted. The death rate is 4% to 5%.

Blood Infections (Bacteremia): Primary blood infections are the most common, and account for 44% of Bacteremia. The insertion of a catheter the most common cause. Secondary blood infections are infections that are caused by another Interhospital Infection, such as urinary or surgical infections. The mortality rate can reach 25%.

Lung Infections: constitute 12% of Interhospital Infections and are a serious risk, especially among patients who require breathing assistance. The average death rate is 7% but can reach 31% among patients using an artificial breathing apparatus, and 62% of bone marrow transplant patients.

Digestive Infections: typically affect infants. Diarrhea caused by C. difficile (clostridium difficile) has become increasingly frequent over the years. Whereas digestive infections accounted for only 1% to 2% of NIs (Interhospital Infections) thirty years ago, the percentage rose to 26% in the USA between the years 2000 and 2001. Between 2003 and 2005, digestive infections struck 14,000 patients in Quebec, of whom 2,000 died. In 2004, digestive infections killed 44,000 patients in Great Britain.
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Other Infections: include soft tissue infections such as bed sores, viral gastro

enteritis (especially among infants), influenza, conjunctivitis, and assorted respiratory and sinus related infections.

Bacteria that Cause Infections

Among the categories of bacteria most known to infect patients are the category MRSA (resistant strain of S. aureus), member of Gram-positive bacteria and Acinetobacter (A. baumannii), which is Gram-negative. While antibiotic drugs to treat diseases caused by Gram-positive MRSA are available, few effective drugs are available for Acinetobacter. Acinetobacter bacteria are evolving and becoming immune to existing antibiotics, so in many cases, polymyxin-type antibacterials need to be used. "In many respects its far worse than MRSA,".

Another growing disease, especially prevalent in New York City hospitals, is the drug-resistant, Gram-negative Klebsiella pneumoniae. An estimated more than 20% of the Klebsiella infections in Brooklyn hospitals "are now resistant to virtually all modern antibiotics, and those supergerms are now spreading worldwide. The bacteria, classified as Gram-negative because of their reaction to the Gram stain test, can cause severe pneumonia and infections of the urinary tract, bloodstream, and other parts of the body. Their cell structures make them more difficult to attack with antibiotics than Gram-positive organisms like MRSA. In some cases, antibiotic resistance is spreading to Gram-negative bacteria that can infect people outside the hospital. "For Gram-positives we need better drugs; for Gram-negatives we need any drugs," said Dr. Brad Spellberg, an infectious-disease specialist at Harbor-UCLA Medical Center, and the author of Rising Plague, a book about drug-resistant pathogens.

One-third of interhospital infections are considered preventable. The CDC estimates 2 million people in the United States are infected annually by hospital-acquired infections, resulting in 20,000 deaths. The most common interhospital infections are of the urinary tract, surgical site and various pneumonias.
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Main routes of transmission

Route

Description

Contact transmission

The most important and frequent mode of transmission of interhospital infections is by direct contact.

Droplet transmission

Transmission occurs when droplets containing microbes from the infected person are propelled a short distance through the air and deposited on the host's body; droplets are generated from the source person mainly by coughing, sneezing, and talking, and during the performance of certain procedures, such as bronchoscopy.

Airborne transmission

Dissemination can be either airborne droplet nuclei (small-particle residue {5 m or smaller in size} of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors; therefore, special air-handling and ventilation are required to prevent airborne transmission. Microorganisms transmitted by airborne transmission include Legionella, Mycobacterium tuberculosis and the rubeola andvaricella viruses.

Common vehicle transmission

This applies to microorganisms transmitted to the host by contaminated items, such as food, water, medications, devices, and equipment.

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Vector borne transmission

This occurs when vectors such as mosquitoes, flies, rats, and other vermin transmit microorganisms.

Contact transmission is divided into two subgroups: direct-contact transmission and indirect-contact transmission.

Routes of contact transmission

Route Description

This involves a direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person, such as when a person turns a patient, gives a Direct-contact patient a bath, or performs other patient-care activities that require direct transmission personal contact. Direct-contact transmission also can occur between two patients, with one serving as the source of the infectious microorganisms and the other as a susceptible host.

This involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, or dressings, or contaminated gloves that are not Indirect-contact changed between patients. In addition, the improper use of saline flush transmission syringes, vials, and bags has been implicated in disease transmission in the US, even when healthcare workers had access to gloves, disposable needles, intravenous devices, and flushes.

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Risk factors
Factors predisposing a patient to infection can broadly be divided into three areas: People in hospitals are usually already in a 'poor state of health', impairing their defense against bacteria advanced age or premature birth along with immunodeficiency (due to drugs, illness, or irradiation) present a general risk, while other diseases can present specific risks - for instance, chronic obstructive pulmonary disease can increase chances of respiratory tract infection.

Invasive devices, for instance intubation tubes, catheters, surgical drains, and tracheostomy tubes, all bypass the bodys natural lines of defence against pathogens and provide an easy route for infection. Patients already colonised on admission are instantly put at greater risk when they undergo invasive procedures.

Patients' treatments can leave them vulnerable to infection immunosuppression and antacid treatment undermine the bodys defences, while antimicrobial therapy (removing competitive floraand only leaving resistant organisms) and recurrent blood transfusions have also been identified as risk factors.

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Prevention
Hospitals have sanitation protocols regarding uniforms, equipment sterilization, washing, and other preventive measures. Thorough hand washing and/or use of alcohol rubs by all medical personnel before and after each patient contact is one of the most effective ways to combat interhospital infections. More careful use of antimicrobial agents, such as antibiotics, is also considered vital.[22] Despite sanitation protocol, patients cannot be entirely isolated from infectious agents. Furthermore, patients are often prescribed antibiotics and other antimicrobial drugs to help treat illness; this may increase the selection pressure for the emergence of resistant strains.

Sterilization
Sterilization goes further than just sanitizing. It kills all microorganisms on equipment and surfaces through exposure to chemicals, ionizing radiation, dry heat, or steam under pressure.

Isolation
Isolation precautions are designed to prevent transmission of microorganisms by common routes in hospitals. Because agent and host factors are more difficult to
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control, interruption of transfer of microorganisms is directed primarily at transmission.

Handwashing and gloving

Handwashing frequently is called the single most important measure to reduce the risks of transmitting skin microorganisms from one person to another or from one site to another on the same patient. Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of infection control and isolation precautions. The spread of interhospital infections, among immunocompromised patients is connected with health care workers' hand contamination in almost 40% of cases, and is a challenging problem in the modern hospitals. The best way for workers to overcome this problem is conducting correct hand-hygiene procedures; this is why the WHO launched in 2005 the GLOBAL Patient Safety Challenge. Two categories of micro-organisms can be present on health care workers' hands: transient flora and resident flora. The first is represented by the micro-organisms taken by workers from the environment, and the bacteria in it are capable of surviving on the human skin and sometimes to grow. The second group is represented by the permanent micro-organisms living on the skin surface (on the stratum corneum or immediately under it). They are capable of surviving on the human skin and to grow freely on it. They have low pathogenicity and infection rate, and they create a kind of protection from the colonization from other more pathogenic bacteria. The skin of workers is colonized by 3.9 x 104 4.6 x 106 cfu/cm2. The microbes comprising the resident flora are: Staphylococcus epidermidis, S. hominis, and Microccocus, Propionibacterium, Corynebacterium, Dermobacterium, and Pitosporum spp., while in the transitional could be found S. aureus, and Klebsiella pneumoniae, and Acinetobacter, Enterobacter and Candida spp. The goal of hand hygiene is to eliminate the transient flora with a careful and proper performance of hand washing, using different kinds of soap, (normal and antiseptic), and alcohol-based gels. The main problems found in the practice of hand hygiene is connected with the lack of available sinks and timeconsuming performance of hand washing. An easy way to resolve this problem could be the use of alcohol-based hand rubs, because of faster application compared to correct hand washing.
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Although handwashing may seem like a simple process, it is often performed incorrectly. Healthcare settings must continuously remind practitioners and visitors on the proper procedure to comply with responsible handwashing. Simple programs such as Henry the Hand, and the use of handwashing signals can assist healthcare facilities in the prevention of interhospital infections. All visitors must follow the same procedures as hospital staff to adequately control the spread of infections. Visitors and healthcare personnel are equally to blame in transmitting infections. Moreover, multidrug-resistant infections can leave the hospital and become part of the community flora if steps are not taken to stop this transmission. In addition to handwashing, gloves play an important role in reducing the risks of transmission of microorganisms. Gloves are worn for three important reasons in hospitals. First, they are worn to provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. In the USA, the Occupational Safety and Health Administration has mandated wearing gloves to reduce the risk of bloodborne pathogen infections. Second, gloves are worn to reduce the likelihood microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient's mucous membranes and non intact skin. Third, they are worn to reduce the likelihood the hands of personnel contaminated with micro-organisms from a patient or a fomite can be transmitted to another patient. In this situation, gloves must be changed between patient contacts, and hands should be washed after gloves are removed. Wearing gloves does not replace the need for handwashing, because gloves may have small, inapparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between patient contacts is an infection control hazard.

Surface sanitation
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Sanitizing surfaces is an often overlooked, yet crucial, component of breaking the cycle of infection in health care environments. Modern sanitizing methods such as NAV-CO2 have been effective against gastroenteritis, MRSA, and influenza agents. Use of hydrogen peroxide vapor has been clinically proven to reduce infection rates and risk of acquisition. Hydrogen peroxide is effective against endospore-forming bacteria, such as Clostridium difficile, where alcohol has been shown to be ineffective.

Antimicrobial surfaces
Micro-organisms are known to survive on inanimate touch surfaces for extended periods of time. This can be especially troublesome in hospital environments where patients withimmunodeficiencies are at enhanced risk for contracting interhospital infections. Touch surfaces commonly found in hospital rooms, such as bed rails, call buttons, touch plates, chairs, door handles, light switches, grab rails, intravenous poles, dispensers (alcohol gel, paper towel, soap), dressing trolleys, and counter and table tops are known to be contaminated with Staphylococcus, MRSA (one of the most virulent strains of antibiotic-resistant bacteria) andvancomycinresistant Enterococcus (VRE). Objects in closest proximity to patients have the highest levels of MRSA and VRE. This is why touch surfaces in hospital rooms can serve as sources, or reservoirs, for the spread of bacteria from the hands of healthcare workers and visitors to patients. Copper alloy surfaces have intrinsic properties to destroy a wide range of microorganisms. In the interest of protecting public health, especially in heathcare environments with their susceptible patient populations, an abundance of peerreviewed antimicrobial efficacy studies have been and continue to be conducted around the world regarding coppers efficacy to destroy E. coli O157:H7,methicillinresistant Staphylococcus aureus (MRSA), Staphylococcus, Clostridium difficile, influenza A virus, adenovirus, and fungi. Much of this antimicrobial efficacy work has been or is currently being conducted at the University of Southampton and Northumbria University (United Kingdom), University of Stellenbosch (South Africa), Panjab University (India), University of Chile (Chile), Kitasato University (Japan), the Instituto do Mar and University of Coimbra (Portugal), and the University of
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Nebraska and Arizona State University (USA). A summary of the antimicrobial copper touch surfaces clinical trials to date is available. In 2007, U.S. Department of Defenses Telemedicine and Advanced Technologies Research Center began to study the antimicrobial properties of copper alloys in a multisite clinical hospital trial conducted at the Memorial Sloan-Kettering Cancer Center (New York City), the Medical University of South Carolina, and the Ralph H. Johnson VA Medical Center (South Carolina). Commonly touched items, such as bed rails, over-the-bed tray tables, chair arms, nurse's call buttons, IV poles, etc. were retrofitted with antimicrobial copper alloys in certain patient rooms (i.e., the coppered rooms) in the intensive care units (ICUs). Early results disclosed in 2011 indicated the coppered rooms demonstrated a 97% reduction in surface pathogens versus the control rooms. This reduction is the same level achieved by terminal cleaning regimens conducted after patients vacated their rooms. Furthermore, of critical importance to health care professionals, the preliminary results indicated the patients in the coppered ICUs had a 40.4% lower risk of contracting a hospital-acquired infection versus patients in the control ICUs. The US Department of Defense investigation contract, which is ongoing, will also evaluate the effectiveness of copper alloy touch surfaces to prevent the transfer of microbes to patients and the transfer of microbes from patients to touch surfaces, as well as the potential efficacy of copper alloy-based components to improve indoor air quality. In the US, the Environmental Protection Agency (EPA) regulates the registration of antimicrobial products. After extensive antimicrobial testing according to the agencys stringent test protocols, 355 copper alloys, including many brasses, were found to kill more than 99.9% of MRSA, E. coli O157:H7, Pseudomonas aeruginosa, S. aureus, Enterobacter aerogenes, and VRE within two hours of contact. Normal tarnishing was found to not impair antimicrobial effectiveness. On February 29, 2008, the EPA granted its first registrations of five different groups of copper alloys as antimicrobial materials with public health benefits. The registrations granted antimicrobial copper as "a supplement to and not a substitute for standard infection control practices." Subsequent registration approvals of additional copper alloys have been granted. The results of the EPA-supervised antimicrobial studies, demonstrating copper's strong antimicrobial efficacies across a wide range of alloys, have been published. These copper alloys are the only solid surface materials to be granted antimicrobial public health claims status by EPA.

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The EPA registrations state laboratory testing has shown, when cleaned regularly: Antimicrobial copper alloy surfaces (ACAs) continuously reduce bacterial contamination, achieving 99.9% reduction within two hours of exposure. ACAs kill greater than 99.9% of Gram-negative and Gram-positive bacteria within two hours of exposure. ACAs deliver continuous and ongoing antibacterial action, remaining effective in killing greater than 99% of bacteria within two hours, and continue even after repeated contamination. ACAs help inhibit the buildup and growth of bacteria within two hours of exposure between routine cleaning and sanitizing steps. Testing demonstrates effective antibacterial activity against S. aureus, E. aerogenes, MRSA, E. coli O157:H7, and Pseudomonas aeruginosa.

The registrations state, antimicrobial copper alloys may be used in hospitals, other healthcare facilities, and various public, commercial and residential buildings.

Aprons
Wearing an apron during patient care reduces the risk of infection.The apron should either be disposable or be used only when caring for a specific patient.

Mitigation
The most effective technique for controlling interhospital infection is to strategically implement QA/QC measures to the health care sectors, and evidence-based management can be a feasible approach. For those with ventilator-associated or hospital-acquired pneumonia, controlling and monitoring hospital indoor air quality
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needs to be on agenda in management, whereas for interhospital rotavirus infection, a hand hygiene protocol has to be enforced. Other areas needing management include ambulance transport.

Conclusion
Interhospital infections occur worldwide, both in the developed and developing world. They are a significant burden to patients and public health. They are a major cause of death and increased morbidity in hospitalized patients. They may cause increased functional disability and emotional stress and may lead to conditions that reduce quality of life. Not only do they affect the general health of patients, but they are also a huge burden financially. The greatest contributors to these costs are the increased stays that patients with interhospital infections require. The increased length of stay varies from 3 days for gynecological procedures to 19.8 days for orthopedic procedures. Other costs include additional drugs, the need for isolation, and the use of additional studies. There are also indirect costs due to loss of work. Intensive care is a risk factor for the emergence of antibiotic resistant bacteria. Effective infection control programs are essential to controlling and preventing interhospital infections. Recommendation: Effective infection control programs and methods are essential to controlling and preventing interhospital infections. These methods and programs include a core of the infection control committee, infection control practitioner, and individual employee actions. It is also important that we seek to continually improve existing infection control policies.

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Reference

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