A PAPER FOR THE 45TH NATIONAL CONFERENCE/SCIENTIFIC WORKSHOP OF THE ENVIRONMENTAL HEALTH OFFICERS ASSOCIATION OF NIGERIA (EHOAN) HELD FROM 19TH-23RD NOVEMBER,2012, AT FUNFIELD PARKS & EVENTS CENTRE, OSHOGBO, OSUN STATE, NIGERIA.
1.0 Introduction:
Right from time the dispensation of
health care services has always been accompanied with one adverse effect or the
other occasionally. With the institutionalization of health care, a prominent
hazard whose consequence has the tendency of spreading within the health care
community emerged and this consequence is nosocomial infection. It is also
called hospital acquired infection (HAI) or healthcare associated infection but
here for consistency we will adopt the terminology, “nosocomial infection”.
Nosocomial infection can be defined
as adverse biological response to pathogenic micro organism’s presence or the
presence of its toxin in a patient undergoing treatment that was not manifested
or incubated before admission (Garner, Jarvis, Emori, Horan & Hughes, 1996,
P.AI; Inweregbu, Dave & Pillard, 2005; WHO, 2002). Operationally, infection
that commenced 48hours after admission, within 3 days after discharge or 30
days after operation is regarded as nosocomial infection (Inweregbu, Dave &
Pillard, 2005).
Nosocomial infection continues to present challenges to
healthcare and patients safety despite the advances in healthcare technology.
This is because as state-of-art technologies emerge for the delivery of
effective and efficient health care for the population, these technologies
involve invasive devices, the hospitals in most developing world is being
crowded, patients population is becoming older, increase in immune compromised
patients and improper use of antibiotics.
Organisms responsible for
nosocomial infections are bacteria, fungi, viruses and parasites (CDC, n.d.).
2.0 Public health and economic
burden
In the United States of America, about
1.7million people suffer from nosocomial diseases annually (CDC, 2010). Among
these patients; 52,328 are newborns, 417,946 are adults and children in
intensive care units, while 1,266,851 are children and adults from other units
(CDC, 2010). It is estimated that about 5% of hospitalized patients acquire
nosocomial infection in America,
while in the European countries, it is about 10% of hospitalized population and
recent studies put in between 10-15% (Yinnon et al., 2012; CDC 2010). Dilek, et
al (2012) observed that nosocomial infection rate in developing countries is
about three to five times higher than the rate in America. A patient with nosocomial
infection spends 21/2times longer in hospital
accumulating additional cost of £3,000 more hospital bill in Europe
(Inweregbu, et al., 2005). They also estimated that 5,000 deaths are due to
nosocomial infection annually causing up to one billion pounds to the National Health
Service. Study indicated that intensive care units have nosocomial infections
prevalence of about 20.6% (Inweregbu, et al., 2005), and blood stream infection
forms between 31.5% to 82.4% of intensive care unit nosocomial infection
morbidity and mortality (Chang et al., 2011).
3.0 Common sites of infection and
responsible organisms
Site
|
Organisms
|
Signs and Symptoms
|
Mode of Infection
|
Urinary tract infection (UTI)
|
- Escherichia coli
- Enterococci
- Pseudomonas aeruginosa
- Candida species
- Proteus mirabilis
- Providencia stuartii
|
Fever, frequent urination,
dysuria and supra public tenderness
|
Catheter
|
Lower respiratory infection or
pneumonia
|
- Klabsiella species
- Staplylococcus aureus
- Pseudomonas aeruginosa
- Enterobacter species
- Legionella species
- Aspergillus species
|
Cough, high blood temperature and purulent sputum
|
Inhalation of aerosol or droplet
discharges
|
Surgical site infection
|
- Staphylococcus aureus
- Enteroccoccus
- Yeast
- Gram-negative organisms
|
Can be as for
UTI, pneumonia and blood stream infections
|
Surgical wounds
|
Bloodstream infection
|
- Staphylococcus
- Euterococus
- Canadida species
- Klebsiella pneumoniae
- Entcrobacter species
- Canadida species
|
Fever, chills,
malaise, anxiety, nausea, vomiting and others
|
Inversive techniques
|
Gastro intestinal infection
|
- Clostridium difficile
- Rotavirus
- Salmonella species
|
Diarrhea
|
Ingestion
|
Eye infection
|
- Chlamydia trachomatis
- Staphylococcus species
- Neisseria gonorrhoeae
- Adenovirus typeB
|
-
Pains in the eye
-
Foreign body sensation
-
Bloody or other coloration of the eye
-
Fever
-
Redness of the eye
-
Excessive watering
|
Contact infection
|
Central Nervous System Infections
|
- Streptococcus
pneumonia
- Hemophilus
influenza
|
Headache, Nausea vomiting &
Light secession fever
|
Wounds, foreign bodies, head
trauma, neuroinvaside procedures
Airborne & droplet
|
Other emerging and re-emerging
organisms can also cause nosocomial disease. Examples are those resistant to
common antimicrobial agents like Methicilin Resistant Staphylococcus Aureus
(MRSA), Vancomycin Resistant Enterococcus (VRE), Penicillin Resistant Streptococcal
Pneumonia and Sever Acute Respiratory Syndrome (SARS) (Chotani, Roghmann &
Peri, 2007, P.535 – 6).
4.0 Mode of transmission
The mode of transmission of nosocomial
infection is related to sources of infection. Nosocomial infection can be
transmitted from two main sources: exogenous and endogenous sources: Exogenous
sources are factors within the healthcare environments including building,
plants, devices, instrument, patients and health workers. Endogenous sources
are normal flora organisms of a patient. Normal flora organisms could be part
of the patient flora before admission and is responsible for primary endogenous
infection, while those that become part of the flora during patients stay in
the hospital cause secondary infection (Chotani et al., 2007, P.517). Nosocomial
infection transmission can occur through airborne, droplets, direct or indirect
contact, ingestion or administration of contaminated water, food, medication,
intravenous fluids and blood products.
5.0 Risk factors for Nosocomial
infection
Host factor,
environmental, microbiological and extrinsic factors can constitute risk
factors for nosocomial infection (WHO, 2002). Extreme young or old age, nature
of illness, poor nutrition, underlying conditions like obesity, abnormal
functioning or inadequate ventilators, dusty conditions, wet surfaces and walls
can posse danger of nosocomial infection. Water systems can be colonized by
legionella organisms, pseudomonas species, Acinobacters and others, while
inanimate objects like formite can encourage the spread of VRE or MRSA. Other
risk factors are duration of stay in the hospital and use of total parenteral
nutrition (Saloojee & Steenhoff, 2001)
Three main microbiological risk
factors of nosocomial diseases are the organism’s virulence, ability to survive
in the healthcare environment and ability to resist antimicrobial agents,
extrinsic factors are medical procedures and chemotherapeutic agents (WHO,
2002).
6.0 Prevention and Control of
Nosocomial infection
In every given
healthcare setting the existence of an integrated arrangement that would
involve infection control department in conjunction with other units like the
microbiological laboratory, staff health services, pharmacy and Data/computer
units is vital to surveillance and prevention of nosocomial infection. An
infection control committee should be formed, where the infection control
officer would either chair or be the secretary to the committee. The committee
organizes surveillance activities, collect data on exposures, antibiotic use,
pathogenic isolates and molecular finger printing, antimicrobial resistant
organisms and so on. The committee should draw a check list on hygiene practices
among the health workers, organize training and monitor the implementation in
the wards. Infectious disease control rounds that adopted check list and
monthly report on nosocomial disease situation in a hospital unit is associated
with a significant decline in nosocomial infection in that unit (Linnon et al.,
2012). This is also consistent with the observation that education of health
worker on good hygiene and aseptic techniques proved successful but
unfortunately is not sustainable (Saloojee & Steenhoff, 2001). In a related
study device associated nosocomial infection was reduced on the application
surveillance procedures in a hospital (Dilek et al., 2011).
This is mainly
where the Environmental Health Personnel should make an impact as the infection
control officer/personnel. The committee should designate environmental health
officers to survey the hospital plants, environment and instruments for
efficient functioning and hygiene purposes and report to it. Where necessary
the infection control officer should make adequate arrangement to secure the
abatement of nuisance detected and ensure regular flushing and cleansing of
water systems.
Other important components of nosocomial
infection control activities include hand washing, isolation, microbal agent
control and immunization.
Hand washing by
the healthcare personnel is one of the most effective means of preventing
nosocomial infection in the healthcare facilities. The hands of health workers
are always inhabited by normal flora organisms (e.g. Staphylococci species and
micrococci) which can also extend to the deeper layers of the skin and
transient organisms (like Klebsiella – Enterobacter and Acinetobacter). Normal
flora organisms can be dangerous to immuno compromised patients or patients
with inserted prolonged foreign object. Thorough hand wash with warm water and
detergent substantially reduces microbal colonization of health workers hand.
Facilities for hand washing should be located at proximate points as possible.
Unfortunately health workers neglect this important procedure, and studies
indicated the physicians are the most negligent professional group in this regard
and compliance is about 40% of the time in most health institutions (Chotani et
al., 2007, P.541). The reason for poor practice of hand wash is the fact that
many health workers suffer from a complex Saloojee & Steenhoff described as
“Omo-syndrome” – that is a feeling of being super neat and sterile (Saloojee
& Steenhoff, 2001).
Isolation is meant to break the
chain of transmission of pathogens from source to susceptible person. Health
workers, patients or visitors could be source of infection. There are two types
of isolation: standard and transmission based isolation. Under standard isolation
everybody fluid or skin abrasion is considered infectious. Use of protective
devices like masks, glove, cleaning equipment and linen, environmental control
and cohorting patients are advised.
Transmission based isolation is
implementation of standard precautions plus measures specific to the
transmission mode. For airborne infection; private room isolation and negative
pressure room and for droplet infection; private room isolation or cohorting of
patients should be practiced, while private isolation or cohorting patients
will be used for contact infection (Chotani et al., 2007, P.453).
Immunization of health worker is
essential in some instances in the case of infection that is vaccine
preventable. Some organisms can cause infection both at community level and at
hospital level. Diphtheria, Hepatis A & B, influenza, measles and
chickenpox immunization should be given to the health workers depending on the risk
they face in their occupational setting.
Another important measure for the
control of nosocomial infection is antibiotic control in health institutions.
Antibiotic is the second most used class of drugs in hospital setting and study
has shown that 40% of the times, antibiotics were not properly used. Improper use
of these drugs leads to the emergence of anti-microbial bacteria and drug
reaction. So it is important that an antibiotic policy that will control the
use of the drug evolves in a hospital.
7.0 Conclusion:
Nosocomial infection cases are
increasing throughout the world and the situation is more pronounced among
developing countries. The rate of nosocomial infections in a hospital varies
according to the unit, with intensive care units having the highest rate than
other units in a hospital, present invasive medical devices, hospital
environment, poor personal hygiene of health workers, age and immune level of
patients are factors that predisposes people to nosocomial infection.
Continuous integrated infection control activities, surveillance, immunization
of health workers, isolation and antibiotic use control policies are vital
measures towards the control of nosocomial infection in a health facility.
