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Health Care Associated

Infection (HAI)

Indonesia
December 17, 2012

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Healthcare Associated infection
(HAI)

 Definition
– Infection not present or incubating at
the time of the access to healthcare
facilities (outpatient clinic, outpatient
procedures, rehabilitation, chronic care
facility, hospital)

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 Magnitude of Healthcare -
Associated Infection
 World-wide: 1,400,000/day.
 ICU infection rate: 25%.
 USA: 2,000,000/yr---90,000 deaths ( 274/day).
 Great Britain: 5,000 deaths/year.
 Mexico: Third most common cause of deaths.
 Brazil: 50& of newborns infected, 12-52% die.
 Sub-Saharan Africa: SSI is common cause of death.

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 Worldwide: 4,500 children die of HAI.
 Economic Impact

 One surgical site infection may cost up to $15-$30,000

to treat.
 One blood stream infection cost up to $50,000 to treat.
 $40 – $75 billion dollars are spent to treat HAIs.

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 Healthcare-Associated Infections
 The Big Five
Central line associated blood stream infection
(CLABSI)
Ventilator associated pneumonia (VAP)

Surgical site infection (SSI)

Catheter-associated UTI (CAUTI)

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Clostridium difficile associated disease (CDAD)
 Blood Stream Infections

 14 % of all HAI

– Primary
– Secondary
– Catheter (device)-associated

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 Big Five of the HAI

 Central Line Associated Blood Stream Infection

(CLAB)
 Surgical Site Infection (SSI)
 Ventilator Associated Pneumonia (VAP)
 Catheter Associated U.T.I. (CAUTI)
 C. difficile associated disease (CDAD)

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Impact of Central Line Associated Blood
Stream Infection (CLABSI)

USA
 36,000,000 Inpatients
 164,000,000 Patient days
 18,000,000 ICU admissions
 9,700,000 Catheter days
 48,600 CLABSI (5/1,000 line days)

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 17,000 deaths ( mortality: 34.97%)
 CLABSI Trend

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 CLABSI Trend

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 STOP CLABSI !

 One intensive care unit had “O” central line sepsis for 12
months and another for 9 months between 2008 and
2009.

 HOW?: CLABSI Bundle in action! (Insertion policy, check

list, ultrasound, daily multidisciplinary rounds,
education, training, etc.)

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 STOP CLABSI!

 Central Line Bundle

– Insertion Policy
– Check List
– Log
– Dressing change
– Remove as soon as the line is no longer needed
– Education and Training

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 STOP CLABSI! : Ten Points

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 Surgical Site Infection (SSI)

 22 % of all HAIs

1. Superficial
2. Deep
3. Organ Space

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 Pathogens

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 Surgical Site Infection (SSI)

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 Surgical Site Infection (SSI)

• How to prevent?
1.MDRO screening and decolonization.
2. SCIP (Surgical Care Improvement Project).

◦ Time out
◦ Skin prep (antiseptic, NO SHAVING)
◦ Antibiotic prophylaxis
◦ Normothermia

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◦ VTE prophylaxis
 Pneumonia

 15% of all HAI

1. Ventilator Associated Pneumonia (VAP)

2. Aspiration Pneumonia/pneumonitis
3. Hematogenous

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Ventilator-Associated Pneumonia

 No ventilator associated pneumonia possible?

 How?: VAP Bundle
–Oral care
–Sedation vacation,
–Body position,
–PPI

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–DVT prophylaxis
 C. Difficile associated disease

 Antibiotic Stewardship

– Austere antibiotic formulary.

– Restriction of selected antibiotics.
– Drug Utilization Review (DUR).
– Routine use of probiotic.
– Automatic discontinuation of antibiotic.

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 Catheter Associated UTI
(CAUTI)

 The most common and most neglected

one.
 32 % of all HAI.

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 Catheter associated UTI
(CA-UTI)

 CA-UTI Bundle to prevent the most common

HAI.
Guidelines for
» insertion
» care
» removal

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 Another Major Battle

Mutidrug Resistant Organisms

(MDROs)

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Methicillin resistant
Staphylocuccus aureus (MRSA)
S. aureus is a bacterium that can be found
on the skin in 25–30% of the population; it
is the most common cause of wound
infections. MRSA is the most important
hospital-acquired infection, causing, for
example, problems related to surgery and
prosthesis infections. MRSA is mainly
spread in hospital settings but can also be

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found in the community. WHO
 MRSA Prevelance

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 USA
MRSA prevalence

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 MRSA Colonization

MRSA Colonization

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Control and Prevention of MRSA

Education, Training, and Implementation of

• Hand Hygiene
• “Surveillance” and isolation of patients
• “Selective” decolonization of nasal and
skin carrier (Mupirocin, antibacterial soap)

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 Hand Hygiene

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 Hand Hygiene!
Hand Culture
Before washing ---and After

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 MRSA infection:
Impact of Nasal screen, isolation and
decolonization

 Universal Surveillance and decolonization for Methicillin-Resistant

Staphylococcus aureus reduced MRSA-associated disease by 36%. .
Ari Robicsek et al, Ann Intern Med. 18 March 2008;148(6):409-418

 The number of surgical-site S. aureus infections acquired in the

hospital can be reduced [7.7% 3.4%] by rapid screening and
decolonizing of nasal carriers of S. aureus on admission. Lonneke
G.M. Bode et al, N Engl J Med 2010;362:9-17.

 MRSA SSI infections declined by 52% between 2006 and 2008

[Chun]

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MRSA infection:
Impact of Nasal screen, isolation but no
decolonization

 A universal, rapid MRSA admission screening strategy

did not reduce nosocomial MRSA infection in a
surgical department (Stephan Harbarth et al. JAMA.
2008;299(10):1149-1157)

 MRSA infection in ICU was reduced by 62% and non-

ICU infections by 45%. Veterans Affairs Initiative to
Prevent Methicillin Resistant Staphylococcus aureus
Infections. Rajiv Jain et al, N Engl J Med 2011; 364:

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1419-30.*
* Next slide
Active MRSA screening, isolation, hand
hygiene, and a culture change

-62%

-45%

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VA
The impact of Improved Hand Hygiene
on MRSA and HAI
HH Implemented

CDC

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MRSA Nasal Surveillance by
PCR
Same-day MRSA screen

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Control of Multidrug-Resistant
Organisms (MDROs)

Antibiotic stewardship

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 Q and A

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