HAI(Nosocomial Infection)

Definition-
“Develop after 48 hours of hospital admission or within 30 days of treatment , which were not
present or incubating at the time of admission.”

characteristic
 after 48 hrs
 upto 3 days of discharge
 upto 30 days of operation
 in neonates after passage from birth anal
CHAIN of Infection:
Causative agent
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Susceptible host
Causes
 host ->microbes->environment
 therapeutic procedures
 transfusion
 poor hospital administration
hai rate
hai=i/d ( i=total no of hospital infection, d =total no of discharge including death)

rate=(i/d)x100
Sources of Infection (Reservoirs)
Infections in hospitals can originate from:
 Endogenous Sources (Patient's Own Body)
o Patient's own normal flora (e.g., gut bacteria, skin flora).
o Becomes infectious when immunity is low or during surgery/invasive procedures.
o eg; ssi
 Exogenous Sources (Outside the Patient) (cross infection)
o Healthcare personnel – unwashed hands, contaminated clothing.
o Other patients – cross-infection from roommates or shared facilities.
o Visitors – carrying infections unknowingly.
o Hospital environment – contaminated surfaces, air, water.
o Medical equipment – non-sterile instruments, catheters, ventilators.
o Food and water – poorly handled or contaminated.

Modes of Spread (Transmission)

Infection can spread via several routes in hospitals:
 Contact Transmission
o Direct: Touching infected wounds, fluids, or patient.
o Indirect: Via contaminated instruments, surfaces, gloves.
 Droplet Transmission
 o Large respiratory droplets from cough/sneeze.
o Travels up to 1 meter (e.g., influenza, COVID-19).
 Airborne Transmission
o Very small droplets (aerosols) remain suspended in air.
o Can spread over long distances (e.g., TB, measles).
 Common Vehicle Transmission
o Through contaminated food, water, IV fluids, medications.
 Vector-Borne Transmission
o Less common in hospitals.
o Carried by insects like flies or mosquitoes (e.g., in poor sanitation).
 Hospital water supply
 hospital food
 infusion fluids (endotoxic shock)

Microorganism implicated in hai

ESKAPE
o Enterococcus faecium
o Staphylococcus aureus ( MRSA)
o Klebsiella pneumoniae (including Carbapenem-resistant Enterobacteriaceae or CRE)
o Acinetobacter baumannii
o Pseudomonas aeruginosa
o Enterobacter species

o bacteria- e.coli,mycobacterium tuberculosis

o virus-sars cov2
o fungi –fungal spore

Common Types of HAIs

 Catheter-Associated Urinary Tract Infection (CAUTI)
 Central Line-Associated Bloodstream Infection (CLABSI)
 Ventilator-Associated Pneumonia (VAP)
 Surgical Site Infection (SSI)
 Gastrointestinal infections (e.g., Clostridium difficile)

Cauti
 most common 33 percent
 person with an indwelling catheter. Indwelling catheters provide a direct portal for microbes into the bladder,
and bacteria can rapidly ascend and colonize on the catheter surface

 Risk Factors for CAUTI

o duration of catherization
o gender –female (shorter urethra)
o dm
o old age
o poor personal hygiene
o failure in adherence to aseptic technique
 o Breaks in sterile technique
 PATHOGENESIS OF CAUTI
 catheter bypasses normal host defenses, allowing bacteria to enter the
bladder
 2 route
o EXTRALUMINAL SPREAD:
colonize the catheter’s external surface soon after insertion (often
due to imperfect asepsis) and then migrate up into the bladder

o INTRALUMINAL SPREAD:
enter the bladder when the closed system is opened (e.g. for
drainage bag emptying) or via reflux of contaminated urine from the
bag
 form biofilms on catheter surfaces –protect from antibiotics and host immunity
 predisposes to high-density bacteriuria and eventual infection if the catheter remains.
 Biofilm formation on catheter surfaces protects bacteria and leads to persistent
bacteriuria

 Catheter use leads to high bacteriuria (≥10^5 CFU/mL in ~1–2 days) by inhibiting normal
flushing
clinical manifestation
 Fever and chills without another source (most common alert)
 Suprapubic or lower abdominal pain/tenderness.
 Dysuria, urgency, frequency (if catheter not continuously draining)
 pyelonephritis
 Altered mental status, confusion, or malaise in the elderly
 Cloudy, bloody, or malodorous urine
Laboratory Diagnosis
urine culture:>103 cfu –symptomatic pt
>105 cfu –asymptomatic pt
care bundle for the prevention of cauti
Insertion:
 Insert only if clinically indicated
 Use aseptic technique
 Perform hand hygiene
 Apply sterile gloves, drapes, and lubricant
 Use smallest appropriate catheter size
 Secure catheter to prevent trauma
Maintenance:
 Daily assess need for catheter
 Closed, sterile system must be maintained
 Keep bag below bladder at all times
  Ensure unobstructed urine flow
 Perform daily hygiene (perineal care)
 Clean port before access
 Remove catheter promptly when not needed

clabsi
blood stream infection caused by indwelling central line
Risk factors
 Prolonged duration of catheter use.
 Insertion in emergency or non-sterile conditions.
 Femoral vein access (higher infection risk).
 Immunosuppression (e.g., chemotherapy, steroids).
 ICU stay or severe underlying illness.
 Inadequate catheter maintenance (poor hand hygiene, dressing care).
 parenteral nutrition or frequent line access.

. Pathogenesis
CLABSI develops when pathogens enter the bloodstream via a central line.
Entry can occur through:
 Extraluminal route: Microbes on the skin migrate along the catheter tract at the
insertion site.
 Intraluminal route: Contamination during hub manipulation (e.g., injections, flushing).
 Hematogenous route from a distant infected site.
 Microorganisms adhere to the catheter surface and form biofilms, which protect them
from antibiotics and immune clearance.

3. Laboratory Diagnosis
Blood cultures:
 Two sets (one from the central line, one peripherally).
 Positive culture from the central line ≥2 hours earlier than peripheral line suggests
CLABSI.
Quantitative cultures: Higher colony counts from the catheter tip or catheter-drawn sample.
Catheter tip culture: If catheter is removed, ≥15 CFU by roll-plate method is significant.
Other supportive labs: CBC (elevated WBC), CRP, procalcitonin.

Signs and Symptoms

 Fever, chills, or rigors (especially during catheter use).
 Hypotension
 Redness, swelling, or pus at insertion site.
 Sepsis or septic shock in severe cases.
 altered mental status
CARE BUNDLE
Insertion:
 Hand hygiene
  Maximal barrier precautions
 Chlorhexidine skin prep
 Best site selection (avoid femoral,sub clavaian preferred)
 Trained inserters only
 Proper documentation
Maintenance:
 Hand hygiene before access
 Daily necessity review – remove ASAP
 Disinfect hubs/ports before access
 Dressing changes with aseptic technique
 Monitor insertion site daily
 Change IV sets per protocol

VAP
 “Pneumonia that occurs after 48-72 hours after endotracheal intubation and
mechanical ventilation”
Risk factors:
 Endotracheal intubation/ventilation
 Prolonged ventilation: ICU stay >5–10 days greatly raises VAP risk
 Re-intubation/Tracheotomy: Additional airway manipulation increases infection risk
 Sedation/coma: Loss of cough/gag reflex allows aspiration.
 Position: Supine or flat position promotes aspiration; keep HOB elevated
 Prior antibiotics: Antibiotic exposure (especially IV) selects MDR pathogens
 Critical illness: Shock, ARDS, organ failure increase susceptibility
 age

Pathogenesis
 Microaspiration
Contaminated secretions leak around the ETT cuff into the lungs
 Biofilm:
Pathogens form a protective biofilm on/in the ETT, evading clearance
 Lower airway invasion:
Bacteria colonize bronchi/alveoli, causing lung infection.
 disruption of normal ciliary clearance
Microorganism
early onset
 staphylococcus aureus
 haemophilus influenza
 streptococcus pneumonia
late onset
 eskap
lab diagnosis
 Endotracheal aspirate or BAL for Gram stain and culture
 Chest X-ray
 Blood cultures
 Lung biopsy
 CPIS Score: (Clinical Pulmonary Infection Score)

sign and symptoms

 Fever and Leukocytosis:
 Purulent secretions: Thick, yellow/green tracheal secretions on suction
 Respiratory worsening
 Tachycardia
 hypotension (sepsis)
 hypoxemia

CARE BUNDLE
insertion
 Aseptic intubation
 Subglottic suction ETT
 Cuff pressure 20–25 cm H₂O to prevent leakage of secretion
 Elevate HOB(head of bed) ≥30°
 Confirm tube placement
 Avoid unnecessary reintubation
Maintenance
 HOB 30–45°
 Daily sedation hold + SBT
Chlorhexidine oral care
 Subglottic suctioning
 Don’t routinely change circuits
 Wean early if possible
Hand hygiene + PPE

SSI
“Infection that develop at the surgical site within 30 days of surgery or up to 90 days if an
implant is in place”
 CLASSIFICTION
Superficial Incisional SSI:
skin and subcutaneous tissue of the incision( within 30 days post-op.)
  Deep Incisional SSI:
Infection involves deeper soft tissues (fascia and/or muscle layers) of the incision
 Organ specific SSI

RISK factor
 advanced age,
 malnutrition
 obesity
 diabetes (especially poorly controlled)
 smoking
 immunosuppression (steroids, HIV, chemotherapy)
 prolonged operation time
 lack of infection control
 Pathogenesis
 Surgical incision breaches the protective skin barrier.
 Introduction of microorganisms from:
Patient’s skin flora (Staphylococcus aureus, etc.)
Contaminated surgical instruments or environment
Surgeon's or staff's hands or attire
 Microorganisms colonize the incision site or deeper tissues.
 Local immune response is activated.
 Impaired host defense due to:
Poor perfusion
Hypoxia
Diabetes, malnutrition, or immunosuppression
 Bacterial proliferation at the site causes:
Inflammation (redness, warmth, swelling)
Purulent discharge (in some cases)
 Tissue damage and delayed wound healing occur
gastroenteritis
Inflammation of the stomach and intestines, leading to diarrhea, vomiting, or both

RISK FACTOR
 Poor hygiene/sanitation
 Contaminated food/water
 Daycare, nursing homes, travel
 Immunocompromised patients
 Antibiotic use (C. difficile)
 Age extremes (infants, elderly)

Pathogenesis
 Viral: Infects intestinal lining → fluid loss (e.g. Rotavirus
 Bacterial: Toxins/invasion → inflammation (e.g. E. coli, Salmonella)
 Parasitic: Chronic diarrhea/malabsorption (e.g. Giardia)


Signs & Symptoms

 Sudden diarrhea (watery or bloody)
 Vomiting, nausea
 Fever
 abdominal cramps
 Dehydration: dry mouth, sunken eyes, low urine, lethargy
Lab Diagnosis
 Stool exam: for WBCs, culture, ova/parasites, C. difficile toxin
 Electrolytes: check Na⁺, K⁺, HCO₃⁻ (dehydration)
 BUN/Creatinine: assess renal function
 CBC: if fever or suspected sepsis
 Viral antigen/PCR: rotavirus/norovirus (if indicated)

Care Bundle (IV Insertion & Maintenance)

 For IV Catheters (Peripheral/Short-term):
Insertion:
 Hand hygiene + sterile gloves
 Use chlorhexidine skin prep
 Insert using aseptic technique
 Use smallest gauge possible
 Label date/time/gauge at site
Maintenance:
 Inspect site every shift (redness, pain, swelling)
 Clean port with alcohol before access
 Use flush (0.9% saline) after use
 Change dressing if damp/loose
 Remove if not needed or infected
surveillance of hai
Definition:
“HAI (Healthcare-Associated Infection) Surveillance is the ongoing, systematic collection,
analysis, and interpretation of health data related to infections acquired in healthcare
settings”
Purpose: -
 Detect infection trends and outbreaks early
 Evaluate infection control measures
 Improve patient safety and quality of care
 Guide staff education and resource allocation
Types of Surveillance: -
 Active: Done by trained staff via chart review or lab data
 Passive: Routine reporting by healthcare workers
 Prospective: Data collected during hospital stay
 Retrospective: Data analyzed after discharge
 Targeted: Focus on high-risk areas (ICU, NICU, surgeries)
Common HAI Indicators: -
 SSI
 CAUTI
 CLABSI
 VAP
HAI Rate Calculation: HAI Rate = (Number of Infections / Device days or procedures) × 1000

Steps in Conducting HAI Surveillance:

1. Define infection criteria (CDC/NHSN)
2. Collect data from wards/labs
3. Analyze infection rates
4. Identify outbreaks
5. Provide feedback to units
6. Implement corrective actions
7.Monthly surveillance report
Data source
- Patient charts
- Lab/microbiology reports

- Staff incident reports

- Surgical/ICU logs

Hospital Infection Control Committee (HICC)

Definition: Multidisciplinary team that develops, implements, and monitors infection
prevention policies.
Goals: -
  Prevent and control HAIs
 Develop evidence-based protocols (e.g., hand hygiene, PPE, bundles)
 Audit and monitor infection trends
Key Members and Functions: -
 Chairperson: Approves policies and guides decisions
 Infection Control Officer (ICO): Leads program and surveillance
 Infection Control Nurse (ICN): Collects data, monitors, trains staff,nodal
officer for occupational exposure
 Microbiologist: Tracks pathogens and resistance trends
 Clinicians: Diagnose infections, ensure clinical compliance
 Nursing Superintendent: Supervises nursing practices and training
 Pharmacist: Supports antimicrobial stewardship
 Housekeeping In-Charge: Ensures proper cleaning and disinfection
 Biomedical Engineer: Maintains sterilization equipment (optional)
 Hospital Administrator: Ensures resources and enforces policy
Nurse's Role in Infection Control
 Follow hand hygiene and PPE protocols
 Report and document suspected HAIs
 Support in data collection and surveillance
 Educate patients and families
 Implement care bundles (e.g., CAUTI, CLABSI, VAP, SSI)
 Adhere to aseptic technique during all procedures
Main Functions of HICC
Function Description
1. Policy Development Frame protocols for hand hygiene, PPE use, isolation, disinfection, etc.

2. Surveillance Oversight Monitor HAIs (CAUTI, CLABSI, SSI, VAP), analyze trends

3. Outbreak Investigation Identify, manage, and control infection outbreaks

4. Training & Education Regular training for staff on infection prevention and control

Conduct regular audits of hospital units for hygiene and protocol

5. Audits and Compliance Checks
adherence

6. Antimicrobial Stewardship Ensure rational use of antibiotics to prevent resistance

7. Waste Management Monitoring Ensure biomedical waste is handled per guidelines

8. Feedback and Reporting Submit infection reports to hospital admin and national health authorities

📋 Action Plan of HICC (Step-by-Step)

 Form a multidisciplinary team (Chairperson, ICO, ICN, Microbiologist, Nursing Head,
etc.)
 Identify high-risk areas (ICU, OT, dialysis units, etc.)
 Establish surveillance system (collect data weekly/monthly)
 Set infection control goals (e.g., reduce CAUTI rate by 25% in 6 months)
 Conduct staff training (hand hygiene, standard precautions, bundles)
 Perform periodic audits (compliance with bundles, PPE usage, handwashing)
 Analyze infection trends and review microbiological reports
 Report findings to admin, suggest changes if needed
 Take corrective actions for non-compliance or outbreaks
 Evaluate impact and revise policies annually or as needed