Nosocomial Infection from Surgery in Hospitals - Research Paper Example

? Even after provision of care to patients there is annual rise in the rate of Nosocomial Infections. These infections result in substantialmorbidity, mortality and increase in cost and are common among nursing home patients. The susceptibility to infection is increased by invasive methods of treatment, deteriorating immune system, functional disability, chemotherapy or old age. Surgical site infections account for 15% of all the Hospital Acquired infections. Hospital based surveillance programs for control and prevention of SSI’s need to be developed. Pharmacologic treatment of infection depends upon the etiology, due to increase antimicrobial resistance antibiotics should be used logically. This is based on the route, duration and time of administration of the antibiotic after susceptibility test and clinical responses. NOSOCOMIAL OR HOSPITAL ACQUIRED INFECTIONS Care to patients is provided in wide range of facilities ranging from highly equipped clinics to advanced public universities. Despite progress and advancement in hospital care, infections continue to prevail in hospitalized patients and even in hospital staff. Decreased immunity among the patients, variety of invasive techniques creates a kind potential route for the infections to incubate and grow in the ideal atmosphere. Poor controls for the spread of infection can also be the key factor for the stretch of infections among crowded hospital populations. Nosocomial or Hospital acquired infections can be defined as: Nosocomial or hospital acquired infections are defined as the infections acquired by patients during their stay at the hospital, who are admitted for a reason other than that infection and the infection causing agent was not present or incubating at the time of admission. This also includes those infections occurring in staff members or patients who are recently discharged from the hospitals. (Pittet ,2011) EPIDIMILOGY Nosocomial infections occur in both developed and third world countries and it is the major cause of death among hospital patients. A survey conducted by WHO in 55 hospitals of 14 countries including Europe, Eastern Mediterranean, South East Asia and Western pacific. The result shows an average of 8.7% patients suffer from Hospital Acquired Infections every year. The burden of HAI is already substantial in developing countries where Nosocomial infections hit every 5 to 155 patients in regular wards and 50% patients in ICU (Vincent, Rello , Marshall, Silva, Anzueto, Martin,2009). The magnitude of the problem remains ignored or unknown because diagnosis is complex and suirvillience activities requires expertise and resources to guide interventions.(Allegranzi& pittet,2008) PATHOPHYSIOLOGY: Nosocomial infections can be acquired from both exogenous and endogenous sources. Endogenous sources are part of patient’s body or body sites, such as infections growing or incubating inside the body. Exogenous sources are those outside from the body. Examples include visitors, medical personnel, equipment and healthcare environment. HAI’s may be caused by patient’s own flora, the organisms harmlessly entangled with patients own body such as skin (S.Aureus) or intestine (E. coli). The infections targeting ICU patients or patients with weak immune system are those which are the victims of environment filled with the micro-organisms. These organisms usually cause lung infections. Infections may be transferred from one to another person such as Antibiotic resistant micro-organisms are likely to come from the person already infected or colonized from the organism, via the hands of health care worker or through the environment where the patient is being cared for. C.difficile is the causative agent for diarrhea and can be carried in the intestine of the patient or can be acquired from other patient already infected because C. Difficile produces spores which make it easier for their spread and also make it resistant to unfavorable conditions. The agents causing HAI are mostly viruses, bacteria’s, or fungal pathogens. These pathogens need to be investigated in all the effected patients who are admitted for the reason other than these infections. Most of these effected patients are the victims of bacterial and fungal infections caused by invasive measures such as endotracheal intubation or placement of intravascular lines, covering over 91% cases of blood stream infections. 95% pneumonia cases occur due to mechanical ventilation and 77% of UTI’s are caused by Urinary catheters. The three major sites that are blood stream, lower respiratory tract and urinary tract infections are one way or the other associated with invasive methods. The top pathogens are Cougulase negative Staphylococci (38%), Enterococcus(11%), Candida albicans account for 5.5% whereas S. Aureus accounts for 9%., all of these causing bloodstream infections. Pneumonia causing bacteria are P aeruginosa(22%), S. Aureus(17%) and Heamophillis influenza(10%). Urinary tract infections are mainly caused by Eschericia Coli(17%), P. Auregnosa(13%), C albaican (14%). The top 3 pathogens for surgical site infections are S aureus (20%), P aeruginosa (15%), and coagulase-negative staphylococci (14%). Retrovirus causes acute gastroenteritis in hospitalized patients younger than 3 years. Symptoms including diarrhea, fever, vomiting, cramps etc. Other viruses causing Nosocomial infections may include Norovirus and Adenoviruses. SPREAD OF ORGANISM OR MODE OF TRANSMISSION: When the patient is already colonized by the infection, either by surgery or by any other means, it acts as a host for the organism to develop or incubate it. Host or reservoir is the place where organisms live and reproduce and when they get the perfect opportunity, leave the reservoir through the route of exit from the body such as urine, mucous, blood, vomit or wound discharge. Then they come in contact with the victim either directly or indirectly such as contact with a contaminated site or body surface where body droplets have landed, touched by the person or spread by unwashed hands. Infected particles are also released when the infected person sneezes or coughs, which can be inhaled by any other person. Swallowing of contaminated particles present on hands, in food or water already colonized. Blood exposures, parasite bites are the other reasons for the spread of infections. Inhaling, ingesting or breakthrough protective skin barriers or mucous membranes cause the start of colonization of organism in the body of the victim. Colonization is the condition when someone is exposed to organism such as S. aureus or C. difficile then the person becomes colonized. The person can remain uninfected for a time period and organisms take up residence harmlessly or it can grow and cause infection. Sometimes it is better to use medical treatments before the surgery to cause colonization clearance. GENERAL PRECAUTIONS AGAINST NOSOCOMIAL INFECTIONS Wash the hands with any antibacterial soap or alcohol hand gel. Disposable gloves, aprons etc should be used to prevent clothing etc. Maintain cleanliness and hygiene inside hospitals or nursing home and to make sure careful use of antibiotics, to minimize the risk of resistant strains. SURGICAL SITE INFECTIONS: Surgical site infections account for 15% of all HAIs, but 50% to 80% of the SSI’s become apparent after the discharge from the hospitals so there is difficulty in estimating there exact frequency but these infections increase the cost of hospitalization for the patients, particularly if they involve vital organs such as infections occurring after cardiac surgery or any other vital organ which will increase the morbidity/ mortality rate and length of stay of the patients at hospital.(Mirza 2011). They usually appear within 30 days of the surgery or with in 1 year if an implant is placed. Diagnosis criteria for SSI is drainage from the site of surgery, infectious symptoms’ such as redness, swelling, pain, presence of abscesses etc. These infections are classified from incisional/organ space infections or other organ/the spaces manipulate between surgical procedures. Incisional is further divided into superficial (skin or subcutaneous tissue) or deep (Soft tissue or fascia). Surgical wound classification include clean wound that is uninfected, non-inflammatory wound that was closed at the time of surgery, clean-contaminated wounds in which respiratory, gastro-intestinal or urinary tract is included but without unusual contamination. Contaminated wounds are accidental open wound or dirty wound are the old wounds with dead tissue, with existing clinical infection. The pathogens usually isolated from SSI’s are S. Aureus from the skin of patient usually in clean wound case in other cases of wounds polymicrobial aerobic or anaerobic flora is the usual cause. PREVENTION FROM SURGICAL SITE INFECTIONS: SURGICAL EXPERTISE Major factor in these infections is the skill of the surgeon that causes the contamination of the wound. For example if silk suture is used to close the wound or if wounds remain open for a longer period of time then it may increase the risk of surgical site infection. For some reasons beyond experience or adherence to proper guidelines of surgical procedure surgeons play a major role in spreading the infection.(Surgical Site Infections in Colon Surgery, 2011) PROPHYLACTIC USE OF ANTIBIOTIC Other precaution may include the use of an antibiotic prior to the operation. Time or route of administration of antibiotic is based on well planned clinical studies. For example rate of wound infections after appendectomy is five times higher than any other infection.post operative infections occur due to lack of preoperative antibiotic against most likely candidate for infection. A single dose of parentraly administered antibiotic, given just before abdominal exploration for penetrating abdominal trauma, is associated with low postoperative infection rate in patients with no observed gastrointestinal leakage. Patients having congestive heart diseases or prosthetic heart valves may not respond well in reducing the risk of endocarditic to prophylactic antibiotics. PREVENTIVE MEASURES GIVEN BY CDC: According to Centre of diseases control 1999, few guidelines were provided to the hospitals to implement in their surgical units for infection prevention. These guidelines were even for limited resources settings and can be implemented except very few such as application of positive pressure in intraoperative operating room ventilation, may not be financially possible. Other guidelines such as reduce the trafficking inside the operation theater, wearing sterilized surgical clothes, use of sterilized instrumentation, cover a clean incision closed beyond 48 hours, to ask the patient to avoid showering or bathing after the surgery without dressing. Other factors may include prolonged hospitalization of patients before surgery exposes the patient to hospital flora, so correcting the underlying problem and completing presurgical evaluation before admission to the hospital. Preoperative hair removal should be avoided if it is not necessary. Prepping of the incision site with antiseptic solution prior to surgery helps to reduce migration of organism to the wound .use of good surgical techniques such as handling the soft tissue gently, use of absorbable suture, use of closed suction drains to prevent accumulation of tissue fluid and prompt discharge of patient after the surgery. MRSA INFECTIONS MRSA or antibiotics resistant infections are not different from the infections caused by non- antibiotic resistant organisms, the only difference is that the organism is resistant to antibiotics that are given for treatment and due to which the treatment becomes difficult. ESBL or extended spectrum beta lactamase producing bacteria is the other example of antibiotic resistant organism. Widespread use of antibiotics makes the organisms resistant to the antibiotic.( by killing the sensitive range of bacteria leaving behind the resistant ones) MRSA infections are causing severe morbidity and mortality rate in clinical settings with death rates ranging from 20% to 50%. MRSA is a primary soyrce for all the Nosocomial infections. In 1992, European multi center research found that 57% of ICU- acquired infections are caused by Methicilline Resistant Staphylococcus Aureus cases. Among U.S patients the range is from 40% to 50%. Spreading from person to person, they pose a great problem for nursing homes, Isolated mostly from urinary catheters and gastronomy tubes. Many nursing homes act as reservoirs for MRSA so when patients are transferred to hospitals they act as reservoirs carriers. Alarming rate of increase of community acquired MRSA infection have been identified which can pose a public health threat in near future because these infections are occurring in patients with no pre disposing factors. Moreover, critically ill patients or those with longer duration of stay at hospital are highly susceptible to MRSA. Other factors of high risk for MRSA include recent exposure to broad spectrum antibiotic therapy, presence of surgical wounds, ulcers, invasive devices IV catheters, physical proximity of the patient infected with MRSA. MRSA is carried in mucosal regions or in epithelial regions without causing infection in colonized patients and without any signs of it either. Any surgical intervention or exudation might cause this harmless colonization to convert into infection. Also health care personnel might carry these organisms from infected person to highly susceptible patients unknowingly. General consensus proves that health care professionals are the major cause of spread of patient to patient MRSA transmission because hands of nurses or physicians become frequently colonized due to examinations of patients. Due to inadequate hand washing transmission rate is high.( General Information on Healthcare associated infections ,2010) Reasons for inadequate compliance are generally lack of time, high patient care load, urgency of care, irritation to soaps. Precautions include gloves, gowns, hand hygiene for each patient contact, general awareness regarding likelihood of MRSA transmission during contacts with infected patients. CONCLUSION The most frequent infections occur after surgeries, urinary tract infections, and respiratory tract infections. The highest prevalence occurs in intensive care unit, orthopedic wards and acute surgical wards where the use of any invasive method is common. Old age increases susceptibility, chemotherapy and immune system impairments might also be the reason of high prevalence among hospital patients. Despite many improvements in the surgical site practices such as sterilization of instruments, better prevention techniques, increase concern of surgeons, surgical site infection remains the major cause of Nosocomial infection. Moreover in third world countries even caesarian or appendectomy are associated with high risk factors, due to limited resources so precaution is the best medicine as compared to the treatment after the infection but it requires compromise and commitment in the health care system. Health care associated infections need increase interest and concern of the authorities of the medical field. BIBLIOGRAPHY Mirza A.,( 2011),Medscape References, Hospital Acquired Infections Available at: http://emedicine.medscape.com/article/967022-overview Didier Pittet. ( July 2011), Health-care-associated infection in Africa: a systematic review, Available at http://www.who.int/bulletin/volumes/89/10/11-088179/en/ Archibald LK, Jarvis WR,(2007). Incidence and nature of endemic and epidemic healthcare-associated infections. In: Jarvis W, ed. Hospital infections. Philadelphia: Lippincott Williams & Wilkins Allegranzi B, Pittet D. (July 2011) Preventing infections acquired during health-care delivery. Lancet 2008:Retreived from http://www.who.int/bulletin/online_first/11-088179.pdf . Top of Form Vincent, J.-L., Rello, J., Marshall, J., Silva, E., Anzueto, A., Martin, C. D., Moreno, R., ... Reinhart, K. (December 02, 2009). International study of the prevalence and outcomes of infection in intensive care units. Jama - Journal of the American Medical Association, 302, 21, 2323-2329. Bottom of Form Health Protection Agency. (updated 2010). General Information on Healthcare associated infections (HCAI). available at http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HCAI/GeneralInformationOnHCAI/ Archives of Surgery.(2011) .Surgical Site Infections in Colon Surgery Available at http://archsurg.ama-assn.org/cgi/content/abstract/archsurg.2011.176 Read More