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Today we’ll talk about Nosocomial Infections and Healthcare

Epidemiology, chapter 12 from the text book
Let’s begin with some definitions:
Healthcare Epidemiology is the study of the occurrence, of
determinants and distribution of health and disease within healthcare
facilities, and includes any activities designed to improve patient care
outcomes.
The primary focus of healthcare epidemiology is on infection control and
the prevention of healthcare- associated infections
So generally speaking, people can acquire two types of infections:
1- There are diseases or infections that people acquire outside the
healthcare settings and these are called community-acquired infections
and these aren’t the focused of these talk.
2- You have infections that you can acquire during your stay at the
health facilities such as a hospital or a clinic and these are called
healthcare-associated infections and another common name for them is
Nosocomial Infections.
Nosocomial Infections are very serious problem, for example, in the
United States -which obviously has high standards with health care- even
in that country, out of 40 million people who end up being hospitalized,
2 million people end up acquiring an infection during the hospital stay
and many of these people end up with serious diseases and might
actually died from these type of infections.
So there are certain strains of bacteria more commonly associated with
nosocomial infections and I want you to memorize these names. So we
have bacteria that are Gram-positive and Gram-negative that cause these
types of infections and
- we’ll begin with the Gram-positive ones We have Staphylococcus
aureus, coagulase-negative staphylococci, and Enterococcus spp.

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- For the Gram-negative, we have Escherichia coli, Pseudomonas

aeruginosa, Enterobacter spp., and Klebsiella spp.
So these bacteria can come from variety of sources, sometimes they can
be taken or they cause infections because their part of the normal flora of
the patient himself, so if you have a surgical wound, that surgical wound
can be contaminated from the patient’s skin. Sometimes these bacteria
can be derived from health care workers and from surfaces in the lab.
And a major problem of these infections is that most of the bacteria that
cause the infections are drug-resistant bacteria, so that they only cause
infections in immune compromised people but also they are very hard to
treat with the regular or usual types of anti-microbial agents.
The diseases caused by these bacteria in a descending order of
frequency, most commonly we have:
1- Urinary tract infections
2- Surgical site infections
3- Lower respiratory infections (primarily pneumonia)
4- Finally, we have Bloodstream infections or Septicemia (least
common)
Also we have other causes of disease in the hospital sitting; an example
is Clostridium difficile- associated disease which usually appears if you
take course of antimicrobial agents for many periods of time.
Patients at risk of developing human or health care associated
infections:
Basically any person who undergoes invasive procedures, invasive
surgical procedures or catheterization or people with Immune
suppressions, these people are more like to develop or acquire hospital
-acquired infections, for example:
1- Elderly patients
2- Women in labor and delivery
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3- Premature infants and newborns

4- Surgical and burn patients
5- Diabetic and cancer patients
6- Patients receiving treatment with steroids, anticancer drugs, ant
lymphocyte serum, and radiation
7- Immunosuppressed patients in general
8- Patients who are paralyzed or are undergoing renal dialysis or
catheterization
So we have lots of factors to acquiring the health care associated
infections but the three most common factors are:
1- We have increasing numbers of drug-resistant pathogens that are
emerging in the community
2- Failure of healthcare professionals to follow infection control
guidelines, for example: they might not be washing their hands properly
or they might not be washing their hands frequently between patients, so
you can’t handle a patient with a severe infection then go and handle
another person without washing your hands.
And finally more people are surviving these days with immune-
suppressed status; so people now with cancer can survive for a long time,
so these people can acquire more easily the nosocomial infections.
Then we have additional factors that play a role and these basically are
common sense:
- Overcrowding of hospitals and shortages of healthcare staff.
- The indiscriminate use of antimicrobial agents and the false sense of
security about antimicrobial agents; so people now keep saying if you
go to any small clinic at any town and you tell them you have strept
throat they will give you amoxicylin ,without testing the bacteria so now
they are giving antimicrobial agents without doing the proper steps and

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this is generating lots of bacteria that are resistant to the regular

antimicrobial agents.
- Lengthy and more complicated types of surgery; the more invasive and
the more prolonged the procedure is, the more chance that you might
acquire an infection from that procedure.
- Increased use of less-highly trained healthcare workers.
- Increased use of anti-inflammatory and immunosuppressant agents.
- Overuse and improper use of indwelling devices.
*How can we prevent nosocomial infections?
Each hospital or each clinic needs to have certain established guidelines
and rules to prevent infections, we call these Infection control
guidelines, and one of the major steps or things that you need to apply
during an infection control plan is hand washing. Hand washing alone
can prevent a lot of the nosocomial infections, so by hand washing you
reduce the risk of transmitting the disease from one patient to another or
even transmitting the disease or the pathogen from one anatomical site of
the patient to another site of the patient.
Finally we have another means of control and again these most of them
are more common sense so using proper disinfection and sterilization
techniques,, air filtration for people for example transmitting air born
infections,, the use of ultraviolet lights to sterilize large surfaces( floors,
sealing) , isolation of especially infectious patients; so people with
Swine flu for example you need to quarnty these people in a certain
private rooms,, wearing gloves, masks, and gowns whenever appropriate.
*Infection control:
Definition of infection control: it is the numerous measures taken to
prevent infections from occurring in healthcare settings.
One of the major techniques that are required for infection control is
something called Asepsis, which means without infection. So aseptic

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techniques are techniques that prevent infection from happening and we

have two types of asepsis: we have something called Medical asepsis
also known as clean technique and we have something called surgical
asepsis or sterile technique.
Medical asepsis are basically precautionary measures necessary to
prevent direct transfer of pathogens from one person to another or
indirect transfer of pathogens through the air or on the instruments,
bedding equipment, and other inanimate objects.
So with medical asepsis you are trying to reduce the risk of transmission
of pathogens by reducing the number of bacteria and reducing the ways
that these bacteria can spread to people. And more likely or mostly with
medical asepsis you are preventing the transfer of pathogenic bacteria.
This is in contrast to surgical asepsis or sterile technique in which you
try to observe or to create sterile environment. So you are preventing the
transfer of all types of bacteria regardless of whether they are pathogenic
or nonpathogenic.
So obviously surgical asepsis is required for surgery rooms, when you
are doing catheterization or when you are taking samples of blood or
trying to take a sample of fluid through lumber puncture, so during all
these techniques you have to create a sterile environment either by
rubbing the skin with alcohol or by using types of disinfectants or light
to sterilize the whole environment.
Infection control involves two types of precautions:
First we have what is called standard precautions; these are universal
precautions that need to be applied regardless of the patient you are
dealing with or regardless of the department, so these are global rules
that you need to follow, for example wearing of gloves , masks, eye
protection, and gowns, safe injection practices… all these you have
always to do them regardless of the person you are dealing with whether
or not he has aids or whether or not he has for example the common cold
and usually each facility should have a sticker that shows you the various
types or standard precautions that are established in that facility, for
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example for all people you need to do the proper hand washing and this
sticker ( refer to slide 15 ) will tell you how to do the proper hand
washing, when to wear gloves, when to wear masks and eye protection,
when to wear gowns, patient-care equipment for example it is not wise to
use one blood pressure machine for a whole Work so you can’t keep
using it for patient after patient after patient and the best thing to do is to
Medicate one blood pressure machine to each room so only that patient
will use that machine and so on.
Environmental control: you need to observe certain ways how to clean
beds, tables and so on.
Occupational health and blood borne pathogens; there are certain
guidelines how to eliminate and discard sharps such as needles, how to
dispose contaminated material and finally there are guidelines for how
and when to place people in private rooms .
So here are example of ways or we can use prevent infection so you
might to wear a sterile gown, mask, and gloves.
Gloves in general have a special way to take or remove from your hand
so let’s say you have used it with a patient and now obviously
contaminated with skin normal flora or bacteria taken from a surgical
site with infection or blood so you don’t want to contaminate your hand
with these bacteria so the way to take them out is using your right hand
to grape the edge of the other glove and take out and then from the inside
of the glove you try to grape it and then you take it out without touching
your hand.
Transmission-Based Precautions
So they are used are used for patients who are known or suspected to be
infected or colonized with highly transmissible or epidemiologically
important pathogens, for example someone with Evola or Swine flu you
obviously want to guarantee on these people and make that you don’t
transmit the diseases to other people , so these precautions are divided to
three categories :

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1. Contact Precautions
2. Droplet Precautions: basically are utilized so when we have someone
coughing (for particles > 5 µm in diameter)
3. Airborne Precautions: are for people who sneeze and create very
small particle witch diameter is less than 5 µm.
The particle that are more than 5 µm cannot spread or staminate for large
distances usually 1 meter, whereas the other particles witch smaller in
size ( less 5 meters ) can spread for large distance ;so these two types
have different ways of precautions .
Contact precautions again these are common sense so whenever
possible you have to place the patient in private room, if you don’t have
a private room for every patient you have to group patients with similar
disease in one sterile room, whenever you have to deal with patient you
obviously have to wear gloves and discard these gloves from patient to
patient, wash your hands before and after dealing with these patients.
Wear gown if necessary, limit transport patient from location to location,
and finally try to keep one medical instrument for each patient if
possible, so by doing these things we can prevent direct transmittion
from surface to surface or from body surface to body surface and you
can also prevent the indirect transmition pathogen through contaminated
object to another patient.
Almost there is a lot of bacteria and microorganism can transmitted
directly through contact and this is just a small list of such pathogens and
I don’t want you to memorize these but you can read them for your own
interest ( ya3ni btetsallo feehom b aw8at l fara3’ :P ) .
Droplet precaution :Are for particle that larger than 5 µm witch cannot
spread for large distance and usually for 1 meter and then there are not a
problem .
So a health care professionals needs to wear a mass around these patients
and if you transporting the patient outside his/her room try or you should
basically put a mass around the patient himself because if he coughs
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outside the room there is a little chance to transmit the pathogen to other
people . And again there’s some examples of such pathogens and skip
them.
And finally airborne precaution :So these are for particles which have
size less than 5 µm so if you sneeze you can generate these particles and
these can be carried in air conditioning unit, in rooms, in large hallways
for large distances, so you have to use special type of masks for these
called an N95 respirator and for the patient himself if you transporting
him outside a typical surgical mask can be enough.
And again we have some examples of some pathogens that you need to
observe these types precautions (skip the slide) and if you look to these
pathogens you will notice that some of them need contact precaution,
some airborne precaution, and some it need all of the precautions, so it’s
not exclusive; we can have contact and airborne precaution for one
bacteria and virus.
SARS is caused by a virus it’s called corona viruses and most corona
viruses caused upper tract infection and there are no other corona
viruses cause lower tract infection except for SARS and I think the
mortality rate for the SARS = 10% so it’s fatal .
Here is an example for the N95 respirator. We have something called
Airborne Infection Isolation Room or ( AIIR) , so let’s say someone has
SARS , SWINE flu and you want to protect people from being affected
with these pathogens so what you do is replace this person in a small
private room and the goal of this room is to prevent the pathogens from
going outside the room , and basically this room is equipped with vent
and this vent respect has a very tight filter attached to it , this filter
called a keeper filter or highly efficiency particular filter so this filter can
isolate all type of bacteria , so basically first station in this room you set
the air outside the room and all the air will pass through the filter so all
the air leaving the room will be sterile and basically when you draw the
air out you leave negative pressure inside the room so the negative
pressure will lead to the air in the hallway to enter the room , so basically
when we do this no air will exit the room and so you keep the people
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outside the room protected from this pathogens, and the air exit from the
room will be sterile because it pass through the filter . So we will do this
for people infected with highly infection pathogens again such as SARS,
SWINE flu and so on.
The opposite scenario happens with something called the protective
environment, so some people are severe immune-compromised and
susceptible to many pathogens even components of the normal flora,
example of that people with leukemia, transplant or immuno-suppressed
patients, patients receiving radiation treatment, leukopenic patients,
premature infants. So these people are susceptible to most bacteria and
most viruses and can be easily infected , so one way to protect them is to
place them in a private room but now you using event to put air inside
the room so all air entering the room is sterile and this will create a
positive pressure inside the room so air will exit the room and will not
enter the room from the hallway , so this patient will never experience
any pathogen from outside , all the air he/she exposed to will be sterile
air .
Handling Fomites
So when you working with healthcare professions you will generate a lot
of inanimate wastes , for examples gowns, cotton , wooden sterile ,
surgical instruments, needle, and gloves , all of these can be
contaminated with pathogens , so you have to handle these fomites with
special guidelines , so for example it’s preferable to use something that’s
disposable than it’s reusable, Disinfect or sterilize equipment soon after
use, Use individual equipment for each patient, Use disposable
thermometers or thermometer covers for each patient .
Needles and sharp materials have special guidelines for the disposal, so
if you have broken glass you have to place the broken glass in a special
container, if you have needle you have to place them in especial puncture
proof container, and usually each hospital should have guidelines how to
handle the sharps and other material.

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Infection Control Committees and Infection Control Professionals

So each hospital and each institution should have a group of people
dedicated to monitor and establishing Infection Control guidelines and
this is called the infection control committee or (ICC) ; so ideally you
should have members in this committee that represent most department
of the hospital and health care facility , so you have person to represent
including medical and surgical services, pathology, nursing, hospital
administration, risk management, pharmacy, housekeeping, food
services, and central supply , but in addition to these the chairperson or
the president of this committee need to have high knowledgeable about
infectious diseases so you need to have an epidemiologist or infectious
disease specialist, an infection control nurse, or a microbiologist as a
chairperson to that committee .
Role of the Clinical Microbiology Laboratory (CML) in Hospital
Epidemiology and Infection control
So obviously the microbiological labs is always testing sample from
patient and try to see what type of organism are present so let’s assume
that the lab is processing sample from a burn wound and he start to
observe many infection caused by Seminomas Arigona bacteria, finding
these high frequency of infection triggers a life that could be potentially
coming from a local source and not necessary come from the
environment so the lab needs to tell the infection control committee that
they were observing higher than normal infections of this type of
organism so the infection control committee will implement certain
guidelines to investigate if there’s actually contamination with this
bacteria or not ;then they will start to doing random or methodological
screening for particular ward, they start to taking sample from pinch top ,
from nursing hands , doctors hands , to know where is the bacteria came
from.
All healthcare workers must fully comprehend the problem of HAIs,
must be completely knowledgeable about infection control practices, and
must personally do everything in their power to prevent HAIs from
occurring. This the course are very sever and can either increase stay of
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the patient in the hospital or killing the patient , and HAIs can be avoided
through proper education and disciplined compliance with infection
control practices.

Sorry for any mistake, we did our best.

Done By Haneen al-kawamleh , Wala’a khdour .
Special hi goes to Eman tawalbeh and Difaf khwaileh 

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