Nosocomial
infections: How to handle? An Indian Perspective
Nosocomial infections sometimes called Health Care Associated Infection
(HAIs) are one of the biggest problems for health departments constituting a significant healthcare burden. They are attributed to millions of deaths every
year. However, HAIs are only a small fraction of Health Care Associated Deaths
(HADs). Among the HADs, Adverse Drug Reactions (ADRs) are attributed to many
more times of deaths than HAIs. Besides, accidents like fire, gas leakage and
facility failure in hospitals also cause a substantial number of deaths in
outpatients and hospitalized patients. Only in the USA, ADRs reported by the
Food and Drug Administration's Adverse Event Reporting System (FAERS) were over
1.25 million serious adverse events and nearly 175,000 deaths. In India, >720,000 adverse events occur per annum causing
400,000 people to die each year from adverse drug reactions (ADRs) with
6.7% incidence of serious ADRs and 0.32% fatal ADRs (FADRs) and it varies among
different states and hospitals significantly. The average direct
cost of treating an ADR per patient has been estimated at about ₹690.
An analysis revealed that the global number of hospital-associated drug-resistant infections (HARIs) is about 246 million per year, with the highest burden in China, Pakistan, and India. In India, 10–20% of patients admitted to the hospital acquire an HAI. The rate of HAIs can vary from 4.4–83.09% across different hospitals. In India, about a decade ago, 20 lakh patients suffered due to nosocomial or healthcare-associated infections (HAIs) and 80,000 die each year. The incidence rate for HAIs in India varies from 11–83% depending on the type of infection, hospitals and health care system. Based on limited data from India including 89 intensive care (ICU) and 26 tertiary care it was estimated that bloodstream infections (BSI) ranged between 5·3–7·3 per 1000 patient days, central line-associated bloodstream infections (CLABSI) rates ranged between 8·3–12·1 per 1000 central line days. The pooled urinary tract infections (UTI) and catheter-associated urinary tract infection (CAUTI) rates in these ICUs ranged between 1·7–2·8 per 1000 patient days and 8·3–12·1 per 1000 catheter days, respectively. Deaths in the surgical intensive care unit (ICU) (25%), medical ICU (20%), burns ward (20%) and paediatric ward (12.17%) were identified to have a significant association with HAI.
The most common factors responsible
for HAIs in India include:
·
Poor infrastructure
·
Overcrowded hospitals
·
Lack of hygiene
·
Low healthcare professional-to-patient ratio
·
Inappropriate use of antibiotics and
invasive devices
·
Lack of regulation enforcement
·
Lack of continuing education policy,
and poor response of clinicians to
continuing education for updating the knowledge. This policy
should emphasize identifying
the aetiology of nosocomial infections, describing the procedure for the appropriate
evaluation of nosocomial infections, explaining the treatment options available
for nosocomial infections, and developing interprofessional team strategies for
improving care coordination and communication to reduce nosocomial infections
and improve outcomes.
·
Excessive interventions by
pharmaceutical representative offering biased knowledge, commissions for
prescribing their products and much more.
·
Poor quality control of medicines
and vaccines
Types
of HAIs:
Though there may be innumerable types of HAIs classified in
many different ways most common types include bloodstream infections,
pneumonia, urinary tract infections, and surgical site infections. The Centre for Disease Control (CDC) broadly
classify HAI as follows:
1.
Central
line-associated bloodstream infections (CLABSI)
2.
Catheter-associated
urinary tract infections (CAUTI)
3.
Surgical
site infections (SSI)
4.
Ventilator-associated
pneumonia (VAP)
5.
Non-ventilator-associated
hospital-acquired pneumonia (NV-HAP)
6.
Antibiotic
treatment-induced gastrointestinal infections (Clostridioides difficile)
7.
Other
primary bloodstream infections—not associated with central catheter use.
8.
Urinary
tract infections—not associated with catheter use.
9.
Skin
and soft-tissue infections, cardiovascular infections, bone and joint
infections, central nervous systems infections, and reproductive tract
infections associated with surgical implants.
According
to causative agents HAIs are classified as:
Bacterial:
Common Gram-positive
organisms include coagulase-negative Staphylococci, Staphylococcus
aureus, Streptococcus species, and Enterococcus faecalis,
Enterococcus faecium, C. difficile (responsible for 15% HAIs
in the US hospitals). Common Gram-negative organisms include Klebsiella
pneumoniae, Klebsiella oxytoca, Escherichia coli, Proteus mirabilis,
Enterobacter species, Pseudomonas aeruginosa, Acinetobacter baumanii,
Alcaligenes species, Burkholderia cepacia, and multidrug-resistant
(MDR) bacteria (about 20% of all reported pathogens show MDR. Among the most notorious
MDR pathogens methicillin-resistant Staphylococcus aureus (MRSA),
Vancomycin-intermediate Staphylococcus aureus (VISA), Vancomycin-resistant Staphylococcus
aureus (VRSA), extended-spectrum beta-lactamase (ESBL) producer Enterobacteriaceae,
vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacteriaceae and Acinetobacter species,
and multi-drug-resistant Pseudomonas aeruginosa are the most
important.
Viral:
Infections due to viral pathogens are the least reported ones among HAIs and make
up 1-5% of all HAIs, important ones are healthcare-acquired hepatitis B
and C and human deficiency virus (HIV). Other HAI viral causes include Coronavirus,
Rhinovirus, Cytomegalovirus, Herpes Simplex Virus, Rotavirus, and Influenzavirus.
Fungal:
Candida albicans, C. parapsilosis, C. glabrata and C. auris are serious problems associated with high morbidity and
mortality due to difficulty with diagnoses and high rates of treatment failure.
Besides, Aspergillus fumigatus and other Aspergillus species strains are
important causes of ventilator-associated pneumonia and created havoc during the COVID-19 pandemic as black fungus and white fungus infections.
Parasitic: Some of the important parasitic nosocomial infections include blood transfusion malaria, water-borne cryptosporidiosis, Strongyloides
stercoralis transmission by solid organ transplantation, nosocomial myiasis,
blood transfusion babesiosis, person-to-person transmitted scabies etc.
Others:
Many of the vaccine strains and substandard vaccines have
been reported to cause serious life-threatening infections like Polioviris, FMD
virus, Rabies, KFD etc.
According
to the systems affected: The most common types of nosocomial infections
are urinary tract infections, lower respiratory tract infections, and
infections of surgical wounds. They most often occur in intensive care units and in acute
surgical and orthopaedic wards.
Prevention of HAIs: The
HAIs can be prevented if not completely to a large extent by adopting:
·
Good hand hygiene and personal
hygiene by clinicians and hospital staff. Sanitizing hands before and
after touching a patient, scrub washing after using toilets, and coming in contact
with body fluids and wastes. In a study in Bareilly, >20% of fingertip swabs
of surgeons were positive for NDM bacteria and bacteria like Acientobacter
baumannii.
- Sanitizing hospital surfaces
- Using hydrogen peroxide vapor
- Using ultraviolet cleaning devices
- Limiting the number of healthcare assistants
- Placing patients at different risk levels of infection separately
- Shortening the treatment time of patients
- Avoiding unnecessary injuries like avoiding
shaving at the surgical sites, using hair clippers, and using alternatives
for suturing with needles.
·
Using vaccines, antibiotics,
and screening and testing guidelines properly
·
Improving scientific diagnosis
of infectious diseases
·
Implementing an infection
control program and appointing responsible infection control officers in
hospitals to ensure an infection-free environment in hospital facilities
·
Be vigilant about antimicrobial
resistance and practising antimicrobial stewardship recommendations
·
Adopting a bundled health care
policy
·
Managing hazardous hospital
wastes, disposals and effluent properly.
·
Construction of hospital
facilities having automatic sensor-based touchless doors, water taps, stairs
etc.
·
Regular disinfection of hospital
fixtures
·
Using suitable masks in
hospitals by hospital staff and patients (patient caretakers too).
·
Continuous monitoring and surveillance
of HAIs and HADs. Including India, most of the low-income countries (LICs) in
the world have very poor HAI and HAD surveillance systems. In comparison to the developed
world, the risk of acquiring HAI is up to 20 times higher in LMICs.
In the USA, every year 17.5 lakh cases of HAIs and ~90000 deaths due to
HAIs per annum indicates the rigour in surveillance, otherwise with more than 4
times of population, low income and poorer health facilities how can we claim a lesser
number of HAI deaths in India than the USA. The Indian government initiative, namely
Kayakalp, is aimed at improving and promoting cleanliness, hygiene, waste
management, and infection control practices in public healthcare facilities.
·
Ensuring medicine and vaccine
quality control in India. Indian markets are flooded with unapproved and substandard
antibiotics, vaccines and other health products. In a study >50% of
Ultrasound gels are reported contaminated with bacteria like Burkholderia
caenocepacia, B. cepacia and others capable of causing multiple drug-resistant
(MDR) fatal infections.
Further reading:
Balasubramanian R
et al. (2023). Global incidence in hospital-associated infections
resistant to antibiotics: An analysis of point prevalence surveys from 99
countries. PLOS Medicine 20(6): e1004178.
Murhekar MV
et al. (2022). Health-care-associated infection surveillance in India. The
Lancet Global Health, Volume 10, Issue 9, e1222 - e1223.
Nair
V et al. (2017). Point prevalence & risk factor assessment for
hospital-acquired infections in a tertiary care hospital in Pune, India. The Indian Journal of Medical Research, 145(6), 824.
Mathur P. (2023). Need for National-level Surveillance of HAIs in India. Journal of
Clinical Infectious Diseases Society 1(2):137-139.
World Health
Organization. (2011). Report on the Burden of Endemic Health Care-Associated
Infection Worldwide. Geneva: World Health Organization.
Lohiya R and Deotale V. (2023).
Surveillance of health-care-associated infections in an intensive care unit at
a tertiary care hospital in Central India. GMS Hyg Infect Control. 29:18.
Thakkar J et al. (2023).
The Pattern and Impact of Hospital-Acquired Infections and Its Outlook in
India. Cureus. 2023 Nov 9;15(11: e48583
Goyal
M, Chaudhry D. (2019). Impact of educational and training programs on knowledge
of healthcare students regarding nosocomial infections, standard precautions
and hand hygiene: a study at tertiary care hospital. Indian J Crit Care Med. 23:227–231.
Sikora A, Zahra F. (2024).
Nosocomial Infections. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559312/.
Du Q et al. (2021). Nosocomial
infection of COVID‑19: A new challenge for healthcare professionals (Review).
Int J Mol Med 47: 31, 2021.
