When hospitals cause infections

Why do ill people who visit a hospital for the treatment of an infection sometimes return with an entirely different, more dangerous infection? Why do perfectly healthy relatives of patients in hospital become casualties to infection themselves? The reason behind this is a group of diseases called hospital-acquired infections.

The World Health Organisation defines this as an infection acquired in 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 healthcare 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.

These infections can be contracted from contaminated medical equipment, unclean hospital rooms, and other patients and healthcare staff themselves, and can be fatal. A study conducted across 20 Indian cities over 10 years involving 236,700 ICU patients and 970,713 hospital bed-days revealed infection rates of 5.1 central intravenous line-associated bloodstream infections/1,000 central line-days, 9.4 cases of ventilator-associated pneumonia/1,000 mechanical ventilator-days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter-days. These infections are more difficult to treat than those contracted outside the hospital, but fortunately, they can be prevented.

Dr Sweta Shah, Consultant – Microbiology & Infection Prevention at Mumbai’s Kokilaben Dhirubhai Ambani Hospital gives us an insider’s perspective on how this can be achieved, and what machines, chemicals and techniques are used at her hospital:

Standards for Hospital Infection Control

Our hospital follows guidelines from the Center for Disease Control (USA), Infectious Diseases Society of America, the Association for Professionals in Infection Control, and Hospital Infection Society (India). These guidelines provide a framework for each hospital’s infection control program, but the details vary from center to center, depending upon the type of patient, type and infrastructure of the medical unit.

For example, patients in the Intensive Care Unit are more critical and more prone to acquiring hospital-associated infections than patients in a ward, and hence extra efforts and care are needed for prevention of infection among such highrisk patients. In labour rooms, infection control efforts are generally directed towards prevention of infection among new-borns.

However, the basic framework of the infection prevention methodology in every area remains the same, which will include hand hygiene, care of all the intravenous lines and/or devices used for the assistance of patient and environmental disinfection, apart from the appropriate use of preventive, broad-spectrum antibiotics.

Rates of hospital acquired illnesses

The rates of hospital-acquired illnesses are declining, since awareness about them and their prevention has increased. This allows us to do more critical, high-end work like bone marrow transplants, which require a level of sterility that was previously unachievable — to prevent posttransplant infections. However, the path isn’t straight, and unseen challenges are a common occurrence. The rates of hospitalassociated infections are still higher in India as compared to various international standards. The rate in India varies among types of hospital set-ups.

Although the rates of hospitalassociated infection may be reducing, the infections caused by antibiotic-resistant bacteria are increasing. These infections are often difficult to treat.

How infection control techniques can vary based on the size of the hospital

Infection control techniques should remain exactly the same between hospitals, irrespective of the size of the hospital or the number of the patients. Often, it is a subjective phenomenon and dependent upon the management of the hospital. It often differs depending upon the type of the hospital e.g. the practices among neonatal intensive care units are generally far better than adult ICUs. By and large, implementation of infection control practices in the private sector is often better than in public hospitals.

Patients with cancer have lower immunity. Patients on chemotherapy often get new infections or their old infections get reactivated, since chemotherapy can reduce white blood cells, which are responsible for battling infections. Thus, such patients need to be handled with the most sterile techniques. For example, drug preparation for such cases is done in biosafety cabinets and only sterile gloves are used to handle their vascular lines.

[box type=”shadow” ] Hospital managements have come to realise that hospital-associated infections can increase the length of stay of a patient, causing more burden on the hospital, which can also lead to increased resistance to antimicrobial drugs, and can prove catastrophic to the ‘image’ of the hospital.[/box]

Patients with traumatic injuries come to hospital with wounds contaminated by microorganisms from the external environment. The chances of bacteria and fungi from soil causing infections of the wound are very high. Accidents are one of the important causative agents of gas gangrene. Thus, source control for patient and environmental cleaning here is more important.

Management attitude towards infection control

Hospital managements have come to realise that hospitalassociated infections can increase the length of stay of a patient, causing more burden on the hospital, which can also lead to increased resistance to antimicrobial drugs, and can prove catastrophic to the ‘image’ of the hospital. Accreditation agencies are also emphasising on infection control as an important component of patient safety. Hence, the importance of infection control is increasing in the management’s eyes, and from it percolates down from there.

Staff dedicated to hospital infection control

In my hospital, we have three dedicated nurses for infection control. We are three doctors who are involved with infection control along with our lab work or clinical work. We have also trained all our nursing incharges of wards and ICUs for infection control. This is useful as implementation of policies is smoother and more inclusive. Our management, nursing head and Quality head also work with us in close association to remove all the barriers.

Heads of department like Central Sterile Services Department, OT, Housekeeping Services and pharmacy are part of the infection control committee, which allows us to have a holistic and comprehensive program.

Processes for infection control

The laundry list is long and should be tailor-made for every hospital. A few salient points include:

• Hand hygiene program for all staff in clinical, para-clinical or non-clinical setting, patients themselves, and their relatives
• Cleaning and Disinfection of all the surfaces by correct disinfectant in correct dilution with correct equipment at correct intervals.
• Maintenance of air and water quality.
• Sterilisation of equipment
• Care of all invasive procedures while performing or when support lines/device are in situ.
• Appropriate Biomedical Waste Disposal
• Appropriate isolation of infectious patient or staff
• Appropriate health program for staff
• Antimicrobial stewardship
• Training for all
• Surveillance and Audit to monitor implementation

Latest techniques and machines used for infection control and monitoring

The infection control program has so far been people-driven, and is now moving towards automation. A few examples include:

• Automated hand antiseptic dispensers
• Automated disinfectant dilutor and automated fogging machine
• ATP counters are used for surveillance
• Chemicals are now becoming more environmental-friendly
• Macerators allow you to use disposable papier-mâché bedpans and urinals
• HEPA filters keep the air sterile in operative rooms and in transplant units
• Media and communication has made training easier and replicable.

Future trends in hospital infection control
These will include:

• Disinfection of surfaces and AC duct is becoming automated. Automated Foggers, UV light, robotic arm are making their way in, making hard labour less human-dependent and may provide more regulated and reproducible systems.
• Coated surfaces like door knobs, curtains, bed sheets and clothes promise to decrease transmission of bacteria via contact.
• Even catheters and dressing materials are being coated with silver or platinum to reduce bacterial burden or biofilm production.
• Chemical disinfectants are being replaced by negatively charged radicals like O- and OH- which do not allow bacteria to become resistant to disinfectants.
• Increasing support from imaging (radiology) services and laboratory services are crucial in diagnosing and treating patient sooner for better clinical outcomes.
• Use of Artificial Intelligence in predicting chances of patients acquiring infections while in hospital will allow concentrating the efforts on patients who are at higher risk.