NOSOCOMIAL

INFECTION
Retno Budiarti, dr. MKes
Microbiology laboratory
Hang Tuah Medical Faculty

Nosocomial disease
a hospital acquired disease
Up to 15% of hospitalized patients get a nosocomial
infection. (WHO 2002 ; 8,7%)
Most nosocomial infections are caused by opportunistic
pathogens that are typically considered to be Normal Flora.

Centers for Disease Control

Atlanta, defined :
Nosocomial Infection as a localized infection or one that is
widely spread throughout the body that results from an
adverse reaction to an infectious microorganism or toxin that
was not present at the time of admission to the hospital

who
An infection acquired in hospital by a patient who was
admitted for a reason other than that infection
An infection occurring in a patient in a hospital or other health
care facility in whom the infection was not present or
incubating at the time of admission

Nosocomial infections
Infections are considered nosocomial if they first appear 48
hours or more after hospital admission.
The most common nosocomial infections are of the
urinary tract, and various pneumonias.
Usually related to a procedure or treatment used to treat the
patient

Transmission of infection within a

hospital requires three elements
a source of infecting microorganisms
a susceptible host
a means of transmission for the microorganism.

Factors contributing to nosocomial

infections

host
People are as a reservoir or source of
microorganisms, as the transmitter of
microorganisms and as a receptor for
microorganisms
Infections coming from another person in the
hospital (cross-infection), from an inanimate
object recently contaminated by a human
source (environmental infection) or may be
caused by a patients own flora (endogenous
infection).

sources
Human sources may be patients,
personnel, visitors, persons with acute
disease, persons in the incubation period
of a disease, persons who are colonized by
an infectious agent but have no apparent
disease, or persons who are chronic
carriers of an infectious agent.

Types of nosocomial infections

Why nosocomial infections are so

common:
Hospitals house large numbers of people who
are sick and whose immune systems are often
in a weakened state.
medical staff move from patient to patient,
providing a way for pathogens to spread.
many medical procedures bypass the body's
natural protective barriers.
routine use of anti-microbial agents in hospitals
creates the emergence of resistant strains

etiology
The most common microbiological cause of nosocomial
infection is bacteria.
Gram-negative bacteria, E.coli, Proteus mirabilis and other
members of the family Enterobacteriacaea are predominant.
These bacteria are residents of the intestinal tract, spread via
fecal contamination of people, instruments or other
surfaces. Other Gram-negative : Pseudomonas and
Acinetobacter

Bacteria
Commensal bacteria found in the normal flora
of healthy humans, have a significant
protective role by preventing colonization by
pathogenic microorganisms.
Some commensal bacteria may cause
infection if the natural host is compromised.
For ex, Staphylococcus epidermidis causes IV
line infection, Escherichia coli (E. coli) are the
most common cause of urinary infection.

Pathogenic bacteria have greater virulence, and

cause infections regardless of host status. For
example:
Anaerobic Gram-positive rods (e.g. Clostridium) cause gangrene.
Gram-positive bacteria: Staphylococcus aureus (bacteria that
colonize the skin and nose of patients and hospital staff) cause a
wide variety of lung, bone, heart and bloodstream infections and are
frequently resistant to antibiotics
Gram-negative bacteria: Enterobacteriaceae (e.g. E. coli, Proteus,
Klebsiella, Enterobacter, Serratia marcescens) may also be highly
antibiotic resistant.
Pseudomonas spp. are often isolated in water and damp areas. They
may colonize the digestive tract of hospitalized patients.
other bacteria are a unique risk in hospitals. Legionella species may
cause pneumonia through inhalation of aerosols containing
contaminated water (air conditioning, showers, therapeutic aerosols).

Viruses
Including the hepatitis B and C viruses (
transfusions, dialysis, injections, endoscopy)
respiratory syncytial virus (RSV), rotavirus, and
enteroviruses (transmitted by hand-to-mouth
contact and via the fecal-oral route)
Other viruses such as cytomegalovirus (CMV),
HIV, Ebola, influenza viruses,
herpes simplex virus, and varicella-zoster virus
, may also be transmitted.

Parasites and Fungi

fungi and parasites are opportunistic
organisms and cause infections during
extended antibiotic treatment and severe
immunosuppression (Candida albicans,
Aspergillus spp., Cryptococcus neoformans,
Cryptosporidium), cause of systemic infections
among immunocompromised patients.
Environmental contamination by airborne
organisms such as Aspergillus spp. which
originate in dust and soil, especially during
hospital construction.

Predisposition to infection
People in hospitals are usually in a poor state of health,
impairing their defence against bacteria
Acute disease can greatly increase the risk of infection
burns and trauma cause the loss of skin, an important barrier
against infection.

Predisposition to infection
Invasive devices, for instance intubation tubes, catheters,
surgical drains and tracheostomy tubes bypass the bodys
natural lines of defence against pathogens.
immunosuppression and antacid treatment undermine the
bodys defences, while antimicrobial therapy (removing
competitive flora and only leaving resistant organisms)
recurrent blood transfusions, parenteral nutrition have all
been identified as risk factors.

Transmission
Direct-contact between a susceptible host and an infected
person, such as occurs when a person turns a patient, gives
a patient a bath, or performs other patient-care activities that
require direct personal contact.
Indirect-contact, involves contact of a susceptible host with a
contaminated intermediate object, usually inanimate, such as
contaminated instruments, needles, or contaminated hands
that are not washed and gloves that are not changed
between patients

Major routes of transmission and

prevention of spread of nosocomial
pathogens.

Droplet transmission
is a form of contact transmission. Droplets are
generated from the source person primarily
during coughing, sneezing, and talking, and
procedures such as suctioning and
bronchoscopy.
Transmission occurs when droplets containing
microorganisms generated from the infected
person are propelled a short distance through
the air and deposited on the host's
conjunctivae, nasal mucosa, or mouth.

Airborne Transmission
occurs by dissemination airborne droplet nuclei
(small-particle residue 5 m or smaller) of
evaporated droplets containing microorganisms
that remain suspended in the air for long periods
of time, or by dust particles containing the
infectious agent.
Microorganisms carried in this manner can be
dispersed widely by air currents and may become
inhaled by a susceptible host within the same
room or over a longer distance from the source
patient
Microorganisms transmitted by airborne
transmission include M. tuberculosis, rubeola and
varicella viruses.

Other Transmission
Common Vehicle Transmission applies to microorganisms
transmitted by contaminated items such as food, water,
medications, devices, and equipment.
Vectorborne Transmission occurs when vectors such as
mosquitoes, flies, rats, and other vermin transmit
microorganisms

Which Nosocomial Infections Are

Emerging?
Acquired antimicrobial resistance
VRE and MRSA are the major gram-positive pathogens of
concern
P. aeruginosa, Klebsiella, and Enterobacter have
chromosomal or plasmid-mediated beta-lactamase enzymes
are the major resistant gram-negative pathogens
The contribution of antibiotic resistance to excessive death
rates in hospitals is difficult to evaluate, antimicrobial
resistance contributes to nosocomial deaths.
viral and fungal resistance could become important because
of the small number of therapeutic options

THANK
YOU