People visit hospitals when they are sick. What if the hospitals itself make them sick? A large number of people who visit hospitals come back with something more serious. Hospital Acquired Infections, commonly known as HAI’s or nosocomial infections are infections that patients contract while receiving health care. It is developed from a hospital or other health care facility. It first appears 48 hours or more after hospital admission, or within 30 days after having received health care. HAI’s are more common in India compared to western countries.

HAIs are likely to be the most common complication of hospital care. According to the World Health Organisation, at any given time over 1.4 million people across the globe suffer from a nosocomial or hospital-acquired infection (HAI). HAIs account for 2 million cases and about 80,000 deaths a year.

HAI in India

As we said, HAI prevalence in India is higher compared to western countries. This occurs at an alarming rate of one infection per four hospital visits compared to one in ten for a European country and one in twenty for the United States. Overcrowded hospitals with poor infrastructure, lack of basic hygiene, low healthcare professionals to patient ratio, inappropriate usage of invasive devices and antibiotics, and lack of regulation enforcement contribute to nosocomial infections-associated deaths in India.

A study published in 2015 by the INICC led by Dr Rosenthal, researched the rate of device-associated infection rates in 40 hospitals from 20 Indian cities over 10 years from 2004. The study collected data from 236,700 intensive care unit (ICU) patients for 970,713 bed-days and found that rates of HAIs and antimicrobial resistance were higher in India than the rates reported by the Centers for Disease Control and Prevention, the leading national public health institute in the United States.

The rate of vancomycin-resistant enterococcus (VRE), a dangerous hospital infection in Indian ICU’s is five times the rate in the rest of the world. Rates of methicillin-resistant Staphylococcus aureus are also high, with one study finding over 80 per cent of S. aureus samples testing positive for resistance to methicillin and closely related antibiotics.

The study found an incidence rate of 7.92 central line-associated bloodstream infections per 1,000 central line-days, 10.6 catheter-associated urinary tract infections per 1,000 urinary catheter-days and a ventilator-associated pneumonia rate of 10.4 per 1,000 mechanical ventilator-days in adult ICUs. The study reports that these high rates could reflect ]the typical ICU situation in hospitals in India.

Most common organisms

Organisms causing hospital infections in India are similar to those around the world, with S. aureus and P. aeruginosa among the most common disease-causing pathogens. A prospective study of 71 burn patients at Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh found that up to 59 patients (83 per cent) had hospital-acquired infections: 35 per cent of pathogens isolated from wounds and blood were S. aureus, 24 per cent were P. aeruginosa, and 16 per cent were haemolytic streptococci. Another six-month study conducted in 2001 of the intensive care units (ICUs) at All India Institute of Medical Sciences (AIIMS) in New Delhi, found that 140 of 1,253 patients (11 per cent) had 152 hospital-acquired infections, where P. aeruginosa made up 21 per cent of isolates, 23 per cent were S. aureus, 16 per cent Klebsiella spp., 15 per cent Acinetobacter baumannii and 8 per cent Escherichia coli. Further, a study of 493 patients in a tertiary teaching hospital in Goa also found that 103 people (21 per cent) developed 169 infections.

Prevention methods

The high rates of HCAIs in a facility are an indicator of poor quality of healthcare services. A large percentage of HAIs are preventable through effective infection prevention and control measures. Considering morbidity, mortality increased the length of stay and the cost, efforts should be made to make the hospitals as safe as possible by preventing such infections.

Nosocomial infection can be prevented by minimizing the spread of causative agents, arranging isolation for the patient suffering from infectious disease and maintaining proper sanitary conditions in hospitals and medical care units.

1. Proper Hand Hygiene: One of the most important routes of disease transmission is our hand. According to WHO, while visiting a hospital, one should follow the standard practices of hygiene. One should wash the hands

• Before touching a patient
• Before an aseptic procedure
• After body fluid exposure risk
• After touching a patient
• After touching the patient’s surroundings.

Improper hand wash doesn’t lead to complete eradication of germs and can be a reason for the infection. The rate of infection agent spread through hands can be reduced by following hand hygiene practice involved 11 steps of handwashing by WHO.

2. Avoid Surgical Site Infection: Surgical site infection (SSI) is an infection that occurs within 30 days up to 1 year of the surgical process. SSI is one of the significant causes of mortality, hence must be prevented and taken care. The risk factor involved in surgical site infection is the age, health, a habit like and immunity.

Increase in age results in the higher possibility of acquiring Nosocomial infection. This means, higher the age, higher the possibility of HAI. Along with that health is also a risk factor for contracting HAI. The obese patient who undergo surgery, especially laparoscopy are more prone to infection. The oxygenation of subcutaneous tissue reduced may lead to wound infection. Habits are also risk factors! For example, a smoker is more prone to respiratory infections by bacterial Streptococcus pneumonia, Neisseria meningitides, Haemophilus influenza, and Legionella pneumophila. Smoking is also associated with the risk of non-wound infections, bacteremia, and urinary tract infections. You may think of how immunity can be a risk factor of HAI. But it is. The patients who undergo organ transplantation treated with immunosuppressive drugs to avoid the rejection may lead the patient to be more prone to the infection.

To avoid such infections, it mandatory to care for the patients before and after the operation.

3. Isolation Unit for Patients suffering from Communicable Diseases: Isolation refers to the separation of the patient to control the infection or communicable disease. Patients are isolated depending on the mode of transmission of the disease. Below given are some isolation techniques

• Private room with minimum ventilation of six air changes per hour. Cross circulations of air are prohibited and only allowed if there are high air filters installed.
• An anteroom for the storage of gowns, gloves, and masks. They act as a barrier between the isolated rooms and hall. It possibly avoids the airborne spread of infectious agents from the rooms and corridors whenever the door is opened.
• Hospital personnel hygiene: It includes wearing of masks, gowns, gloves, caps, and These once used should not be reused. Masks should cover the nose and mouth. High efficient disposable masks that prevent the inhalation of the infectious agent and trap infectious agent outside preferable.

4. Sterilization of Medical Equipment: A medical device or surgical which comes in contact with the patient during treatment or operation carries a risk of disease transmission due to failure of sterilization or disinfection. The hospital staff must be educated to avoid nosocomial infection, and special attention should be given to teaching them about infection control and prevention.

General practices including hand wash before and after patient care, avoiding touching an inanimate object, wearing of gloves and mask while cleaning contaminated goods and learning about sterilization of equipment used in patient care helps.

5.  Microbiological Validation and Cleaning of Hospitals Environment: Microbial air contamination is monitored by colony-forming unit per cubic meter (CFU/m3) count. This can be done either by passive or active sampling methods. Passive air sampling includes measuring of Index of Microbial Air (IMA) Contamination, which is defined as the count of microbial fall out on a Petri plate of 9 cm diameter placed in area according to 1/1/1/ scheme (1 h / 1m above the floor, about 1 m away from walls or any major obstacle) and incubate at 36 ± 1 °C for 248 h. Air monitoring surveillance is essential in the hospitals and area high in bio-risk 27, 28. Active air sampling referred to the use of an air sampler, which collects known air volume that is blown on a nutrient medium. Different type of air samplers are available in the market viz., impingers, impactors (slit type), impactors (sieve type), filtration sampler, centrifugal sampler, electrostatic precipitation sampler, thermal precipitation samplers, etc. Each of these gives different result in the same place for the same duration of time.

It’s important to know that HAI’s are as dangerous as any other diseases. One of the successful strategies for addressing HAIs is to implement strong safety standards. Proper guidelines and newer techniques must be brought into practice for better supervision and disease management. Strict monitoring and surveillance is a must for reducing the chances of contracting HAI’s for both the medical staff and the patients.

Source: 1. The Hindu

2. http://ijpsr.com/bft-article/nosocomial-infection-source-and-prevention/

3. Biospectrum India

4. Health issues India

5. https://www.jppcm.org/sites/default/files/JPharPracComMed-4-2-43.pdf