Dr Victor D Rosenthal, Founder and Chairman of The International Nosocomial Infection Control Consortium (INICC) speaks to Prathiba Raju on increasing risk and adverse effect of hospital acquired infection and AMR among patients in India
What is nosocomial infection control and what are the measures to control it?
Nosocomial infections are also referred to as Hospital-acquired Infection (HAI). Measures to control the infections comprise of identifying patients at risk of getting infected, evaluating hand hygiene practices, monitoring and surveillance of medical instruments such as vascular catheters, respiratory tubes, and other hospital gear. Additionally, behavioural change is an important component for controlling the spread of HAIs along with proper training to healthcare workers when dealing with patients.
The hospital settings are at a highest risk of acquiring these infections especially the intensive care units and operating theatres. Hence, it is of umpteen importance that control measures are practiced to stop the infection spread. The breeding ground for such infections can also be nursing homes, rehabilitation centres, the healthcare staff, susceptible patients, contaminated equipment and devices, bed linens, air droplets along with contaminated food and water.
How Device Associated- Hospital Acquired Infections (DA-HAIs) are among the principal threat to patient safety and is the main causes of patient morbidity and mortality? What is the status in India?
Patients in the ICU can get infected with diseases like pneumonia, bloodstream infection and urinary tract infection (UTI) due to contamination. Some of the most life-threatening bacteria that infects the ICUs are Acinetobacter, Pseudomonas, and Klebsiella.
Over the years, there has been an increase in HAIs among patients in India. The infections are caused due to the lack of compliance with infection control guidelines, such as hand hygiene, use of outdated technology, misuse or excessive use of antibiotics and more. These infections are further leading to morbidity, mortality and increased financial burden among patients. Implementation of proper guidelines and preventing the infection with bacterial resistance rather than treating it with antibiotics will help reduce the disease burden.
What are the chances of bloodstream infection, ventilator-associated pneumonia, catheter-associated urinary tract infection, non ventilator-associated pneumonia? How can these be avoided?
In 20 cities of India during 10 years, we collected data from 236,700 ICU patients for 970,713 bed-days. Pooled device-associated healthcare-associated infection rates for adult and paediatric ICUs were 5.1 central line-associated bloodstream infections (CLABSIs)/1,000 central line-days, 9.4 cases of ventilator-associated pneumonia (VAPs)/1,000 mechanical ventilator-days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter-days In neonatal ICUs (NICUs) pooled rates were 36.2 CLABSIs/1,000 central line-days and 1.9 VAPs/1,000 mechanical ventilator-days. Non ventilator associated pneumonia represent less than 10 per cent of all healthcare acquired pneumonia, and they usually are caused after aspiration.
Extra length of stay in adult and paediatric ICUs was 9.5 for CLABSI, 9.1 for VAP, and 10.0 for catheter-associated urinary tract infections. Extra length of stay in NICUs was 14.7 for CLABSI and 38.7 for VAP Crude extra mortality was 16.3 per cent for CLABSI, 22.7 per cent for VAP, and 6.6 per cent for catheter-associated urinary tract infections in adult and pediatric ICUs, and 1.2 per cent for CLABSI and 8.3 per cent for VAP in NICUs. They can be avoided by applying bundles of infection control measures.
As an example to prevent Blood Stream Infections (BSI) following are key measures: Maximal barrier, avoid femoral vein, skin antisepsis with chlorhexidine, sterile dressing impregnated with chlorhexidine, needle free connectors, single use flushing protocol, collapsible IV fluid bags, keep line when is necessary, don’t replace lines with fixed intervals, and replace administration set every 96 hours.
How HAI are aggravating the AMR among Indian patients? Why should India take HAI seriously? Also, share the outcomes of the study you had conducted?
Antimicrobial Resistance (AMR) is associated with healthcare-associated infections (HAI), both the issues are becoming a major threat to the country as cases have increased enormously. There is a connection between HAI and AMR as the approach taken at times is to prevent hospital acquired infections with antibiotics which leads to many people consuming large proportion of antibiotics which leads to resistance towards those drugs. AMR has also become one of the leading causes of deaths in the country.
Additionally, Central-venous-catheter-Related Blood Stream Infections (CRBSIs) are a common cause of hospital-acquired infection associated with morbidity, mortality, and huge costs. The adverse impact of CRBSIs has been observed in both, patients with central and peripheral vascular catheters. The use of peripheral vascular catheters is ten times more in hospitals than central vascular catheters. Hence, total number of BSI in patients with peripheral vascular catheters is five times more than the patients with central vascular catheters. It is shown that in the case of sepsis, around 60 per cent of patients die in the intensive care unit (ICU).
The study published in 2015 by INICC evaluated the rates of device associated infections across 40 Indian hospitals compared to several other countries. The studies were conducted on patients in intensive care units (ICUs). The findings specified that 7.92 central line-associated bloodstream infections occurred per 1,000 central line-days, 10.6 catheter-associated urinary tract infections per 1,000 urinary catheter-days and a ventilator-associated pneumonia rate of 10.4 per 1,000 mechanical ventilator-days.
In India, doctors, nurses to patient ratio is less. Having one nurse for 3 ICU beds, insufficient hospital funds, isn’t full infection control programme a challenge? What are the immediate steps required to overcome this?
The ideal scenario at ICU is to have a nurse to patient ratio of 1:1. Other than that the necessary components of an infection control program are an adapted bundle, education, surveillance of HAI rates, benchmark with standards, measurement of extra length of stay, extra mortality and extra cost due HAIs, monitoring of compliance with hand hygiene and bundles to prevent HAIs, and performance feedback to health care workers. Always consider cost effectiveness when a new product shall be incorporated to the bundle of care. At hospitals participating in INICC program, the above-described strategy reduces HAI rates more than 50 per cent during the first four months of intervention.
How does INICC, the non-profit international research center, help to prevent HAI in developed and developing countries, particularly India?
The International Nosocomial Infection Control Consortium (INICC) is an international, non-profit, multicentric healthcare associated infection (HAI) cohort surveillance network. The INICC comprises of affiliated infection control professionals from 1,000 hospitals in 67 countries and is the only source of aggregate standardised international data on HAI epidemiology.
Recently, we partnered with Becton Dickinson (BD-India) to organise Heal-o-nomics’. The program is conceptualized to apprehend the challenges of preventing HAIs with the aim to achieve better health outcomes at optimised cost. We received a great response from some of the healthcare institutes based in Delhi and Bangalore. We hope such initiatives will help in reducing the disease spread caused by hospital-acquired infections and help in better treatment and care.