The presentation is solely meant for Academic purpose

Nil

MMWR 1999 / 48(29);621-629 Slide - Dr Paul Tambyah

Chuang YC et al. Secular trends of healthcare-associated infections at a teaching hospital in Taiwan, 1981-2007. J Hosp Infect 2010.

2004: Annual, intensive, project-based control programs introduced

‘nosocomial infections’ ◦ Greek nosos ‘disease’, komien ‘to care for’ ◦ Roman military hospital orderlies were called

nosocomi

‘hospital-acquired infections’ ◦ Introduced by James Simpson (England) in

1830s ◦ Called the problem ‘Hospitalism’

‘healthcare-associated infections’ (HAI) ◦ Increasing complexity of healthcare delivery

Louis Pasteur: 1822-1895, French chemist & microbiologist

Robert Koch: 1843-1910, German physician

Miasma theory: origin of

epidemic diseases due to

noxious form of ‘bad air’

HAIs due to poor

ventilation & NOT direct

contact

Post Bacteriological era

Germ theory: infections due

to microorganisms

HAIs recognized in obstetric,

surgical patients and later,

medical patients

• Surgeon at obstetric clinic in

Vienna in 1848

Divided into two clinics, alternating admissions every 24 hours:

◦ First Clinic: Doctors and medical students

◦ Second Clinic: Midwives

doctors taught anatomy in the

mornings, midwives came from home http://www.cdc.gov/handhygiene/materials.htm

Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.

http://www.cdc.gov/handhygiene/materials.htm

Suggested handwashing and use of antiseptic solution for hands and surgical instruments for physicians

Adapted Slide - Dr Paul Tambyah

Maternal Mortality due to Postpartum Infection

General Hospital, Vienna, Austria, 1841-1850

0

2

4

6

8

10

12

14

16

18

1841 1842 1843 1844 1845 1946 1847 1848 1849 1850

Ma

tern

al M

ort

alit

y (

%)

MDs Midwives

Semmelweis’ Hand

Hygiene Intervention

~ Hand antisepsis reduces the frequency of

patient infections ~

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

http://www.cdc.gov/handhygiene/materials.htm

Within 2 years of his idea, forced to quit medicine Died in asylum for the mentally unstable

Florence Nightingale (1820-1910, founder of modern nursing)

– promoted hospital reform Joseph Lister (1827-1912,

British surgeon) ◦ Introduced hand washing and

carbolic acid antisepsis ◦ Infections post limb amputations 47% 15%

You do not find what you are not looking for…

You need to know your baseline

You need to know before someone else does!

You want to improve outcomes for your patients

Slide - Dr Paul Tambyah

• Effectiveness has to be measured • We want to objectively assess the

impact of interventions • Measurement is not neutral • Questions asked are different:

– Patient: which is the best hospital? • What are my chances of getting bettter?

Worse?

– Doctor: how am I doing? – Administrator: What is the bottom

line?

Slide - Dr Paul Tambyah

To establish baseline rates of HAI

To identify outbreaks

To evaluate the effectiveness of IC prevention activities

To identify preventable infections in high-risk areas

To help limited resources be more effectively targeted to high priority areas

Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

Slide - Dr Paul Tambyah

National level, surveillance should be standardized with ◦ standardized case definitions & ◦ surveillance methods

Local level, surveillance should include ◦ assessment of the local situation ◦ selection of appropriate methods ◦ reporting

Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

Alert microorganism surveillance can be done if: ◦ there is a good microbiology laboratory ◦ support from the clinicians ◦ support from senior management

Simplest forms of surveillance: ◦ Mortality, a very crude measure of quality ◦ Readmission rates per surgical procedure or

per ICU admission ◦ Periodic point prevalence surveillance can be

used to monitor the effectiveness of IC measures

Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

US CDC’s National Health and Safety Network (NHSN) definition: ◦ Widely used as most widely disseminated and readily

available ◦ interpretation and application may not be easy

International Nosocomial Infection Control

Consortium (INICC) ◦ first multinational, collaborative HAI control program ◦ established to control HAIs in hospitals in limited

resource countries ◦ founded in Argentina in 1998 ◦ network of 173 ICUs in 25 countries

Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

“…a healthcare associated infection (HAI) is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility.” ◦ All factors satisfying CDC/NHSN site-specific infection criterion

1st present on or after 3rd day of hospitalization

◦ Purpose of definition: NHSN surveillance

CDC. Identifying Healthcare-associated Infections (HAI) in NHSN. Jan 2013

CDC/NHSN major and specific types of HAI ◦ Bone and joint infection ◦ Bloodstream infection ◦ CNS ◦ CVS infection ◦ Eye, ear, nose, throat or mouth infection ◦ GI system infection ◦ Lower respiratory infection, other than pneumonia ◦ Pneumonia ◦ Reproductive tract infection ◦ SSI ◦ Skin and soft tissue infection ◦ Systemic infection ◦ UTI ◦ Ventilator-associated event

CDC. CDC/NHSN Surveillance Definition of Healthcare-associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting. Jan 2013.

Goal of NHSN AUR module:

- “…to provide a mechanism for facilities to report and analyze antimicrobial use and/or resistance as part of local or regional efforts to reduce antimicrobial resistant infections through antimicrobial stewardship efforts or interruption of transmission of resistant pathogens at their facility”

CDC. Antimicrobial Use and Resistance Module. Jan 2013

HAIs can be caused by endogenous or exogenous sources: ◦ Endogenous – body sites eg. skin, nose, mouth, GIT

or vagina

◦ Exogenous – external to patient eg. patient care personnel, visitors, patient care equipment, medical devices or healthcare environment

CDC. Identifying Healthcare-associated Infections (HAI) in NHSN. Jan 2013

Rosenthal, Maki,Graves AJIC 2008;36:e1-12

Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

Features of the International Nosocomial Infection Control Consortium Hospitals and Intensive Care

Units*

Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

Ventilator-Associated Pneumonia in the International Nosocomial Infection Control

Consortium Intensive Care Units*

Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

Central Venous Catheter-Associated Bloodstream Infections in the International Nosocomial Infection Control Consortium Intensive Care Units*

Rosenthal, V. D. et. al. Ann Intern Med 2006;145:582-591

Comparison of Device Use and Rates of Device-Associated Infection in the Intensive Care Units of the International Nosocomial Infection Control

Consortium and of the U.S. National Nosocomial Infection Surveillance System*

173 ICUs in Latin America, Asia, Africa and Europe.

6 year study, data from 155,358 patients Device utilization in the developing countries’

ICUs remarkably similar to US Some HAIs markedly higher in the ICUs of the

INICC hospitals: ◦ CLABSIs: 7.6% vs 2.0 per 1000 central line days ◦ VAP: 13.6 vs 3.3 per 1000 ventilator days

Mayhall. Hospital Epidemiology and Infection Control. 4th Edn.

Hospitals were originally set up for the sick and dying among the poor

The wealthy had physicians go to their homes to provide care

Hospitals were widely and correctly perceived as dangerous places

Pittet et al http://www.hopisafe.ch Slide - Dr Paul Tambyah

7 year old boy with acute leukemia, finishing chemotherapy in remission

Was admitted after his last course of chemotherapy with fever

Had Clostridium difficile infection (Antibiotic associated colitis)

Also developed bloodstream and soft tissue infection

Slide - Dr Paul Tambyah

Blood cultures persistently positive

Debrided in ICU as he was too sick for surgery

Slide - Dr Paul Tambyah

Hsu LY et al, Emerg Infect Dis 2007;13:1944-7

Slide - Dr Paul Tambyah

Hsu LY et al, Emerg Infect Dis 2007;13:1944-7 Slide - Dr Paul Tambyah

Slide - Dr Paul Tambyah

Clin Infect Dis 2007:44:1107 Slide - Dr Paul Tambyah

Clin Infect Dis 2007:44:1107

Slide - Dr Paul Tambyah

Slide - Dr Paul Tambyah

NEJM, 2012

‘…no evidence that financial disincentives reduced infection rates.

As CMS continues to expand this policy to cover Medicaid through the Affordable Care Act, require public reporting of NHSN data through the Hospital Compare website, and impose greater financial penalties on hospitals that perform poorly on these measures, careful evaluation is needed to determine when these programs work, when they have unintended consequences and what might be done to improve patient outcomes.’

Lee GM et al. NEJM 2012