Nosocomial Infection as a Clinical Problem

Introduction

Nosocomial infections refers to the infections that occur or are contracted by patients within the first 48 hours of their admission in the hospitals, 30 days after an operation, or 3 days after discharge from the hospital. Research shows that 10 percent of patients who are admitted in health facilities contract this infection. One third of these hospital acquired infections are preventable. It is also arued that hand washing is the major preventive easure to curd thes infection. There is aalso a need to note that grloves cannot be used as a substite of hand washing. Besides, in adequate antibiotic therepy leads emergence and poor outcome of sthe hospital-acquired infections. Nosocomial infections is believed to resuld in at least 5,000 deaths annually this increasing fthe cost of The National Health Srevice to a billion pounds. On average, it is also estimated that those patients who contact these infections stay 2.5 days longer in the health facilities leading to an additional cost of £3000 compared to those patients who are infected. Generally, in a hospital setting, the Intensive Care Unit (ICU) is believed to have ethe highest prevalence of nosocomial infections. The purspose of this study therefore focuses on the causes of the nosocomial infection, their control, and there prevention ina a hospital setting.

Causes of nosocomial infections

The commones cause of nosocomial infection is the gram-positive bacteria whereas Staphylococcus aureus is the predominant pathogen. In the ICU, there is increased rate of antibiotic resistance bacteria which are lined to the hospital-acquired infections. The resistance of the bacteria to the antibiotics are as a result of acquiring a new genetic material. Thais is caused by poor selection and prescription of the infections. The genic material that is resitsnac to the drugs are transfered  to other strains. It is also belved that 60 percent of the nosocomial infections in ICU are caused by Methicillin-resistant S. aureus (MRSA). A the antibiotics that are used in the treatment of these bacteria is vancomycin despited vancomycin-resistant enterococci and in some cases of vancomycin-resistant S. aureus have been reported. For this reason, yhere is need for proper use of antibiotics whereas some health facilities discourage the use of vancomycin as the first treatment of Clostridium difficile diarrhoea. 

Infection control

According to The Study of the Efficacy of Nocosomial Infection Control (SENIC), a third of hospital acquired infections might be prevented proper use of the mitigation measure. These comprise prevention strategies, surveillance methods, and treatment programs. In the united kingdom, Every Trust has its on measiure to comtrol nosocomial infections which include an infection control doctor who is majorly a consultant in microbiology, an infection control managr and nurse. Their responsibility is to ensure that all aspects of prevention and control of the nosocomial infections within the hospital are achieved at all costs within the health facility and report to the Trust Chief Executive. They are responsible for the organization of staff training, provide giuidance and advice as part of the training, develop incftion contol measures and policies locally, and conduct audit and surveillance. Effective infection control programs extensively depend on knowledge of the local epidemiology of pathogens and the development of a system that recognizes and monitors the emerging antibiotic-resistant bacteria. 

Surveillance

This is the continuous, systematic collection, analysis and interpretation of health related information. This is vital for the timeliness in the  dissemination of information and implementation, planning, and evaluation of public health and also the. the Nosocomial Infection National Surveillance Service in the united kingdom was founded in 1996 and under the management of the Health Protection Agency (HPA). The aim of the surveillance service is to collect a database for nationwide comparisons of nosocomial infections and to improvecare of patiets through reducing the rates of nosocomial infection and helpinf clinical practice. For instance, in 2002, A total of 102 hospitals participated ina survey. Currently, there exists two protocals: (i) the surveillance of sites of the surgical infections; and (ii) the surveillance of nosocomial bacteraemia. More protocols for lower respiratory tract (second most common cause of hospital-acquired infections) and the urinary tract have not yet been developed. The results in the 2002  survaillance noted the fact that only one-third of bacteraemias were not linked with intravascular components and central i.v. catheters was found to the major cause of nosocomial bacteraemia. 3.5 patients in every 1000 patiemnts were diagnosed with Bacteraemias in hospital admissions whereas in the ICU, it is  9.1 patients per 1000 admissions. 

Factors that predispose to nosocomial infections. 

the common pathogens that are linked with hospital-acquired infections and their preferred areas of manifestaion include, multi-drug-resistant Acintobacter spp, vancomycin-resistant enteroccocus (VRE), methicillin-sensitive S. aureus (MSSA), and MRSA. Locally, since 2000, it is a must to monitor certain pathogens (MRSA and C. difficile). in 1994 called HELICS (Hospitals in Europe Link for Infection Control through Surveillance), a surveillance program was initiated across the European nations with an aim of gathering anfortion and creating a database for hospital-acquired infections from public health facilities across Europe. 

Prevention

In a study conducted by EPIC (The European Prevalence of infection in Intensive Care), several factors exposing patients to hospital-acquired infections were found. 40% of nosocomial infections  are attributed to poor hand hygiene. Surveys found that proper hand hygiene is capable of curbing nosocomial infections. the use of alcohol gels and Accessible hand washing stations improves hand washing compliance. Alcohol gel is virucidal, fungicidal and bactericidal and dries quickly. Numerous studies insicate that nurses wash their hands frequently than doctors and tips of fingers, web spaces, backs of hands, and thumb are commonly missed areas.as a consequence hand washing guidelines was developed. health providers wear Protective garments are necessary to prevent them from exposure to body fluids like blood, oropharyngeal fluids, sweat, or urine. Gloves and aprons should be worn when handing body fluids. for sputum smear positive patients, High efficiency particulate air (HEPA) filter masks are required with tuberculosis, particularly for cough-inducing procedures. Contamination of hands can occur, therefore, hands washing is receommeded after removing gloves.

Antibiotic use

Proper use of antibiotics is vital. 30% of ventilator associated pneumonias are not treated adequately. There is increasing evidence to support that the use of early and appropriate antibiotics improves mortality and morbidity. To Appropriately use antibiotic, one requires a good understanding of  mode of action and previous history of antibiotic, local pathogen prevalence and local bacterial resistance profile. Admistration of antibiotics should be for the appropriate duration and at the right dose. The local consultant microbiologist and antibiotic formulary are valuable resources. 

common antibiotics’ Mode of action

Daily intensive care units ward monitoring with the microbiologist can result in rational use of antibiotics aimed to be of benefit to individual patients. Antibiotic-resistant bacteria require treatment with expensive and toxic antibiotics, increase the risk of death, and prolong hospitalization. Empirical use of antibiotic is often necessary as laboratory results are often not available for 48 h after the samples are sent to the laboratory for culture. Appropriate specimens include, wound swabs, urine, bronchoalveolar lavage, sputum,pus and blood. in a third of cases, Blood cultures are only positive for pathogens. Once the antibiotic profile is available, there is commencement of a narrow-spectrum antibiotic can. Indicators of response to treatment are C-reactive protein (CRP) levels, temperature, and leucocyte count. In response to septic shock,  macrophages secrete Procalcitonin and is an a more specific and early marker of bacterial infection than CRP. The interpreteation od these parameters must be conducted in the clinical setting. Improvements in the ventilatory and inotrope requirements can provide indirect and additional evidence for treatment response. 

The aim of any antibiotic guideline or policy should aim to reduce the selective pressure for resistant microorganisms and limit the use of antibiotics. Policies designed to ensure rational antibiotic use in ICU are an important element in quality of care, infection control and cost containment. De-escalation therapy, selective digestive decontamination (SDD), antibiotic rotation (cycling) therapy and restrictive guidelines can address these concerns. Optimizing any antimicrobial therapy includes both shortening the duration of antimicrobial use and appropriate use of combination therapy to reduce the emergence of resistance. Research into these antibiotic management programs is limited and results are controversial. 

De-escalation

This is the early initiation of antibiotic therapy’s broad-spectrum in patients with suspected sepsis without the availability of microbiology results. The increase in antibiotic resistant pathogens such as MRSA has led some investigators to suggest broader antibiotic coverage by adding a glycopeptide to carbapenem as the initial empirical therapy. This aggressive empirical regimen is continued for 24–48 hours by which time laboratory tests have confirmed the causative organisms and sensitivities. This permits de-escalation of antibiotic therapy. 

This regimen should be reserved for selected patients on ICU who are seriously ill, with an extended antibiotic history and evidence of colonization by multi-resistant organisms. Unnecessary continuation of this regime will increase the risk of colonization with resistant bacteria. 

Rotational antibiotic therapy

References

Kanič, Z., Mičetić-Turk, D., & Kanič, V. (January 01, 2014). The effect of probiotic combination (Lactobacillus acidophylus, Enterococcus faecium and Bifidobacterium infantum) on nosocomial infections of very low birth weight preterm infants. Program & Abstract Book.

Rozman, U., Fijan, S., Fesel, M., Matić, M., Bočkaj, M., & Šostar-Turk, S. (January 01, 2015). Detecting common nosocomial pathogens on hospital textiles. Proceedings 2015, 1425-1428.

McGrath, E. J., & Asmar, B. I. (January 01, 2011). Nosocomial Infections and Multidrug-Resistant Bacterial Organisms in the Pediatric Intensive Care Unit. The Indian Journal of Pediatrics, 78, 2, 176-184.

Al-Tonbary, Y. A., Soliman, O. E., Sarhan, M. M., Hegazi, M. A., El-Ashry, R. A., El-Sharkawy, A. A., Salama, O. S., … Yahya, R. (January 01, 2011). Nosocomial infections and fever of unknown origin in pediatric hematology/oncology unit: a retrospective annual study. World Journal of Pediatrics : Wjp, 7, 1, 60-4.

Kampf, G., & Ostermeyer, C. (January 01, 2011). “Persistent activity” of chlorhexidine or alcohol-based hand rubs-what is really necessary to prevent nosocomial infections?. American Journal of Infection Control, 39, 3, 255-6.

Femling, J. K., West, S. D., Hauswald, E. K., Gresham, H. D., & Hall, P. R. (January 01, 2013). Nosocomial infections after severe trauma are associated with lower apolipoproteins B and AII. The Journal of Trauma and Acute Care Surgery, 74, 4, 1067-73.

Curtis, L. T. (January 01, 2013). Bundling or multiple interventions needed to control nosocomial infections. Burns : Journal of the International Society for Burn Injuries, 39, 3, 538-9.

Yilmaz, G. (2016). Cost analysis and evaluation of nosocomial infections in intensive care units. Turkish Journal Of Medical Sciences, 46(5), 1385-1392. doi:10.3906/sag-1504-106