Focus

Say No to Nosocomial Infections

Lack of uniform guidelines for tackling nosocomial infections has hospitals revising their own strategies to combat the menace. Are the guidelines adequate? Nancy Singh finds out

Nosocomial infections would be no more than a fashionable topic for debate if they did not create a serious problem. The effect is less prejudicial to the quality of health as it is to the healthcare budget, which has run up enormous costs.

Goddet Bernard, Health review no. 620, 1997

Who says hospitals are safe havens for getting cured? The above observation sums up that all is not well as far as hospital hygiene is concerned and that there is a need to employ stringent and urgent measures to tackle it. Nosocomial infections or Hospital Acquired Infections (HAI) have been in the news with reports of patients losing sight after an eye surgery or of an epidemic outbreak after patients were admitted to hospitals. Such incidents did create a furore, a few eyebrows were raised and committees constituted, but the topic was soon forgotten. But what no one thought of was that nosocomial infections do have a significant impact on medical costs, hospital stay, and mortality among patients.

According to an estimate by the Centre for Disease Control (CDC), nosocomial infection is the fourth major cause of deaths in the US, with an infection rate of 10 per cent. Though no statistics are available, according to infection control experts, HAI could be between 10 and 30 per cent in India too.

Gloves should be worn before direct contact with blood	Steel cupboards dry easily and absorb less moisture than wood
Hand washing is passé. It’s the alcoholic rub that is the most preferrd one to be placed at every bed	An antiobioic policy is the need of the hour

Steps to Combat HAI

Hospital infection control demands representation from every part of the organisation. CDC suggests a four-pronged approach, which includes adequate training, administrative support by providing adequate infrastructure, continuous surveillance, and use of personal protective equipment.

The Hospital Infection Control Committee: In the absence of an official regulatory body like the CDC, Indian hospitals set up their own protocols. The prescripts are laid down by the committee, which functions under the chairmanship of the medical superintendent and includes microbiologists, surgeons, physicians, pharmacologists, nurses in-charge and the hospital administrators.

The committee forms and reviews its own guidelines to be followed in the different areas of the hospital.

Besides the committee, the other proactive step has been the formation of the Hospital Infection Society, an autonomous body working since 1992, which has an affiliation with 80 hospitals in Mumbai Forum.

"Many practitioners adhere to policies abroad, but undermine it in India" - Dr Ajita Mehta, Chairperson Mumbai Forum of Hospital Infection Society

Antibiotic Control Programmes: Having an antibiotic policy and antimicrobial management programme is the need of the hour as the antibiotic cover provided by newer antibiotics has led to the emergence of multi-drug resistant bacteria. Inappropriate use of antibiotics due to the lack of a uniform antibiotic policy and disregard for hospital infection control practices have resulted in acquired anti-microbial resistance. "Earlier, we administered powerful antibiotics, but this produced resistant bugs which are now being hit by more powerful antibiotics. This selected a super bug, which needs more powerful and toxic antibiotics. The use of these agents has opened the faucet of fungal infections," elaborates Dr Satish Amaranth, Head of Hospital Infection Control Committee and Advisor - Microbiology, Manipal Hospital, Bangalore.

Says Dr Manoj Jain, Medical Director at University of Tennessee's Quality Improvement Organisation, "Lack of prudence in prescribing the right antibiotic is a major concern not only in India, but in the US as well."

Over-the-counter use of antibiotics is another major concern. Says Dr Sunitha Desikan, Chairman Infection Control Committee, Columbia Asia Medical Centre, Bangalore, "Misconceptions about the correct dosage and timing of administering the antibiotic amongst the public and a few practitioners are of prime concern. Sometimes, after a single dose, patients may fail to seek medical opinion during a subsequent infection and take what they believe to be the right antibiotic." According to Dr Ajita Mehta, Chairperson of Mumbai Forum of Hospital Infection Society, many practitioners adhere to policies abroad, but undermine it in India.

The strategies for influencing antimicrobial prescribing patterns within healthcare facilities include education, formulary restriction, prior approval programmes, computer-assisted management programmes and active efforts to remove redundant antimicrobial combinations.

Education & Training: It would surprise you to know that training programmes of physicians do not teach ways to beat nosocomial infection. "Personal hygiene and other infection control activities are mainly addressed superficially," informs Dr Mehta. Hospitals also fail to educate ground-level staff about the repercussions of the nosocomial infections.

"Clean shoes and floors do help in controlling infection, but only to an extent. So, imparting the right kind of training to all people associated is necessary," says Dr FD Dastur, Director, Medical Education, PD Hinduja Hospital, Mumbai. The right kind of education can only be possible through a collective effort rather than leaving it on a few individuals, he feels.

According to the The New England Journal of Medicine (Volume 355:2725-2732), catheter-related blood stream based infections reduced by 66 per cent bringing the infection rate to 'zero' in three months by continued surveillance and intervention without any technological advancement.

"Practical training of every member of the hospital related to care is important and it needs to be incorporated early," suggests Dr Ramesh Babu, President, Infection Control Committee, Meenakshi Mission Hospital, Madurai.

Realising the potential of proper training, HIS conducts annual Infection Prevention Week which addresses all those involved in infection control. Apart from conferences and seminars, it also conducts poster workshops and contests to inculcate interest among the ground staff.

Smart Designing: Given the choice of improving technology or human behavior, technology comes up trumps! Antimicrobial resistance problems and the advent of xenotransplantation, which is transplantation of tissues of one species to another, emphasise the importance of newer microbiologic methods. The major hindrance here is the cost. "Manual methods may be cost-effective, but technology benefits in the long-run, be it in terms of time, performance or energy consumption are more efficacious," believes Rahul Patil, Sales Manager of Getinge Infection Control Equipment.

It is estimated that compliance with hand-washing rarely exceeds 40 percent due to shortage of sinks, which are often inconveniently placed, lack of time or simply forgetfulness or even disagreement with recommendations.

Sometimes, a solution for expensive issues can rather be simple. Some hospitals have replaced all wooden cupboards by steel ones in the ICU-DU room to keep everything dry viz. kidney tray, sputum mug, bedpan, etc as wood tends to rot. Internationally too, improving the design of invasive devices has met with success. This is particularly important, given the marked increase in frequency of vascular access-associated bloodstream infections, particularly in ICU patients.

Of particular importance is the development of non-invasive monitoring devices and minimally invasive surgical techniques that help avoid the high risk associated with bypassing normal host defense barriers like the skin and mucous membranes.

Common Culprits

The most common type of nosocomial infections are surgical wound infections, respiratory infections, genitourinary infections, as well as gastrointestinal infections. The major nosocomial pathogens in India are methicillin resistant staphylococcus aureus, enterobacteriaceae group like escheria coli, klebsiella pneumoniae, psuedomonas aeruginosa.

For investigation of outbreaks of multidrug-resistant pathogens, pulsed-field gel electrophoresis has become a routine epidemiological tool in the US. For diagnosis of syndromes caused by unusual pathogens, representational difference analysis and specialisation by use of the pathogen's phylogenetic r-RNA clock may become routine.

"The new healthcare technologies, right from medical equipment, disposable instruments and newer drugs, to the trends in the practice of medicine, like daycare surgeries have a major impact on lowering the HAI rates," feels Dr Shakti Gupta, Medical Supritendent, Dr Rajendra Prasad Center for Ophthalmic Sciences, AIIMS, New Delhi.

Surveillance: Approximately, one third of nosocomial infections are preventable. The Study on the Efficacy of Nosocomial Infection Control Project (SENIC) by the CDC found that hospitals reduced their nosocomial infection rates by approximately 32 per cent by emphasising on surveillance activities and vigorous control efforts.

To meet and exceed this level of prevention, there is a need to pursue several strategies simultaneously and continued surveillance helps in accomplishing this as it forms an appropriate reference laboratory system.

Agrees Dr Prithwiraj Chakrabarti, Consultant & Head, Dept of Clinical Microbiology, Advanced Medicare Research Institute, Kolkata, "A nationwide multi-centric hospital infection database is necessary to understand the gravity of the situation."

A separate bedpan for each patient in the ICU is a must	Separate colours for different kinds of waste aid in segregation
Sharp instruments need to be placed in sharps containers and not re-capped	Wearing a mask is necessary to prevent splashing of body substances

The four Ps

Even as the experts are aware of the latest techniques and methods to beat HAI, management seems to be reluctant to invest. "That is because the guidelines do not have a commercial or immediate benefit," opines Dr Mehta.

All infection control measures will need to pass the test of the four Ps. Are the recommendations plausible? Are they affordable? Are they acceptable, i.e. will the administration agree? And, will the hospital personnel follow them?

Experts are hopeful that the emergence of medical tourism and the rise in clinical trials will act as a stimulus to the hospitals to upgrade themselves to international standards by practicing the best methods to deal with HAI.

nancy.singh@expressindia.com