Healthcare aquired infections

Healthcare acquired infections also known as nosocomial infections are defined as an infection obtained by a patient 48 hours or later after admission into a healthcare service. Any infections thought to be obtained prior to 48 hours are considered to be obtained within the community (Gould et al, 2000). This standard of the 48 hour inoculation period is however arbitrary as it has remained the standard for many years despite the variable rate of incubation in different bacteria (Ami et al, 2003). It also includes infections acquired by patients after discharge and occupational infections among staff. It is a major issue in health care services as it increases mortality rate, In 2007 alone, 9,000 deaths were recorded as a result of MRSA and Clostridium difficile (NICE, 2012). The cost incurred by the NHS as a result of HAIs is approximately 1 billion each year (NICE, 2012).

Acinetobacter species, Anaerobic Gram negative bacillus, Candida albicans, Clostridium difficile (C.difficile), Coagulase negative staphylococci, Comamonas acidovorans, Enterobacter species, Enterococcus species, Escherichia coli (E.coli), Extended Spectrum beta-lactamase producing Gram-negative organisms, Glycopeptide resistant enterococci, Group A Streptococcus (Streptococcus pyogenes), Group B Streptococcus, Group G Streptococcus, Glycopeptide resistant enterococci, Klebsiella species, Methicillin Resistant Staphylococcus aureus (MRSA), Methicillin Sensitive Staphylococcus aureus (MSSA), Norovirus, Pantoea agglomerans, Proteus species, Pseudomonas aeruginosa, Respiratory Tract Infections, Serratia species, Stenotrophomonas maltophilia, Streptococcus pneumoniae (Pneumococcus), Streptococcus species (alpha- haemolytic), Surgical Site Infections and Urinary Tract Infections, these are all varieties of infections associated with HAI’s (Gould et al, 2000. NICE, 2012. Taylor et al, 2001. NHS, 2009. Haslam, 2006. Hywel Dda Health Board, 2014). The chart below shows which type of infection is most predominantly acquired in a healthcare setting.

(Hwyel Dda Health Board, 2014)

Pathogens enter the patient’s body via portals of entry such as respiratory tract, gastrointestinal tract, urogenital tract or breaks in the surface of the skin, from small abrasions to surgical wounds. Due to the increase of invasive procedures used in today’s medicine, such as IV lines catheters etc., pathogens can gain direct entry into the bloodstream and tissue (Gould et al, 2000). Once they have entered the body and intended target site it thrives by obtaining all its nutrients from the host and multiply rapidly and colonise (NHS, 2009).
If the host is susceptible to disease then these pathogens will cause illness. Patients in hospitals or other health care environment tend to be more vulnerable to infection due to their already weak immune system less able to fight infection (Hywel DDa Health Board, 2014). The virulence of pathogens is dependent on several factors, such as the size of the inoculating dose, the ability to invade the hosts tissue, Enzyme and toxin production in defence against the host’s immune system (Gould et al, 2000).
The wide spread over use of antibiotics is also a major issue as it can lead to micro-organisms becoming resistant to treatment of antibiotics. Antibiotics need to be avoided where possible; if an antibiotic is needed then a suitable one at the lowest dose should be prescribed. It is also alarming the amount of antibiotic found in human food, due to the treatment of animals, e.g. antibiotics administered to cows in their feed in the treatment of mastitis (Taylor et al, 2001). Due to the amount of contact we have with antibiotics, pathogens can mutate by either preventing the antibiotic from reaching its target by a change in its cell wall making it resilient against the antibiotic, by a change in its antigen camouflaging itself and imitating another cell, it can also avoid antibiotics by hiding in the body’s cells. Another mutation has been known to aggressively destroy antibiotics by the release of toxins which increase the virulence of the pathogen (Gould et al, 2000).

Transmission of these infections can arise from endogenous infection, where the pathogens originate from the same individual, organisms are transferred from a reservoir to new sites where they colonise and cause infection. Exogenous, where pathogens are spread person to person via touch. Poor hand hygiene can attribute to the spread of infection, contact with contaminated body fluids, inhalation of air bourn microbes, cross contamination of foods, Insects can transmit pathogens to food or via bites, and fomites can carry pathogens (NHS, 2009) the reservoir of pathogens can survive on surfaces for months and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed (Kramer et al, 2006).

Healthcare setting Infection control is maintained by training healthcare workers and ensuring that they comply with Infection control policies and procedures. Education of patients, carers and healthcare workers in good personal hygiene, thorough hand washing before and after any contact with patients is a simple, low cost and effective at preventing the spread of infections. Correct hand washing technique is demonstrated in the diagram located on page 4 (NHS, 2009). According to Haslam (2006), if all healthcare workers follow correct hand washing procedures it should decrease the instance of infection by a third.

(NHS, 2009)
Alcohol hand rubs are encouraged to be utilised by all within the healthcare environment, by staff patients and visitors. It can kill up to 99.9% of bacteria; however this also includes good bacteria which can upset the balance of the body’s natural flora (NHS, 2009).
Personal protective equipment (PPE) should be utilised including gloves and aprons when in contact with patients. However some pathogens can penetrate PPE, so it is vital to wash hands even if PPE is utilised. Asepsis is very important in the sterilisation of invasive devises. All waste needs to be dealt with accordingly, sharps need to be safely used and disposed of in a sharps box and emptied regularly in accordance with BSI regulations, clinical waste also needs to be disposed of correctly and promptly, in yellow bags, blue bags need to be utilised for waste that needs to be autoclaved. Appropriate waste disposal is an essential duty of care and is covered by legislation. Incorrect and neglectful waste disposal can lead to fines or prosecution (Gould et al, 2000). Clothing may be laundered separately and in red bags to prevent cross contamination. Patients who are known to have an infectious disease may be quarantined or “barrier nursed” to safeguard other patients from contracting the infection. The screening and heat-treating of blood products is essential to prevent the transmission of pathogens from the donor to the patient (Gould et al, 2000).

The Hywel Dda Health board (2014), reports that the top ten blood stream infections in Carmarthenshire hospitals, between the period 01/01/2008 to 31/12/2008 in ranking order are E.coli (56 cases for the period), MSSA (18), Streptococcus pneumonia (14), Enterococcus species (12), Klebsiella species (12), Coagulase negative staphylococcus (8), Proteus species (8), MRSA (6), Enderobacter species (5), Pseudomonas aeruginosa (4).
Compared to the report for the same period in 2012 which states that , E.coli (84 cases for the period has an increase of 28 cases), MSSA (23, +5), Enterococcus species (18, +6), Klebsiella species (17, +5), Streptococcus pneumonia (13, +1), Coagulase negative staphylococcus (10, +2), Proteus species (8, no change), Coliform (8), Pseudomonas aeruginosa (7, +3), Enderobacter species (5, no change). These reports show that although increasing efforts have been made to safeguard patients from HAI’s, there is more work needed to decrease and eradicate the occurrence of HAI’s Hywel Dda Health Board, 2014. This could be contributed to by the shortages of trained nurses within hospitals. Staff are under increased pressures to carry out their role and do not have sufficient amounts of time to change personal protective equipment and wash their hand between each and every patient throughout their shift (Gould, D. 2004).

Escherichia coli also known as E.coli appears to be the most predominant HAI in local hospitals and healthcare settings in Carmarthenshire. The factors that attribute to this is the rate at which E. coli divide, approximately once every twenty minutes (Gould et al, 2000), the vast quantity of E. coli strains. The most common are the urinary tract infections which if infection spreads into the blood stream it can lead to bacteraemia. A few serotypes of E. coli carry an antigen that protects them from the host’s immune system of the white blood cells neutrophils that destroy bacteria via phagocytosis (Gould et al, 2000). Approximately a third of e.coli is now resistant to the antibiotic penicillin.

(How stuff works, 2001).

In conclusion prevention and control of healthcare acquired infections (HAI's) The UK is working hard to lower the amount of HAI's. They are a priority issue and for prevention and control of infection to work effectively, critical activities such as good hand hygiene, utilisation of personal protective equipment has to be embedded into everyday practice. Integrity of hospitals throughout the UK is maintained by minimising potential risk and exposure. Hand hygiene and PPE is a major method of decontamination used routinely to reduce risk of HAI's. Reducing and preventing HAI's is essential for all of those connected to the healthcare environment ensuring everyone is at a minimal risk of exposure. All staff must transparently demonstrate good infection control and it is vitally important that in today's society continuingly using procedures to break the chain of infection.

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