Prevention of healthcare associated infections

Sunil EsampalliMRCPCH, UK

Overview

Hospital acquired infections study Professional dressing Recommendations

Healthcare associated Infections

Nosocomial infections Hospital acquired infections

8.7% ( 14 countries, 55 hospitals- 1987)1

Health-care associated infection in Africa: a systemic review by WHO- 20112

- Prevalence 14.8% (2.5-14.8%)- Average European prevalence -7.1%- In Uganda- ?

Ugandan data

Lacor hospital, Gulu, Uganda – In 2011: prevalence of 28% (47% in surgical and 21% in paediatrics)

Mulago hospital – MRSA from surgical wounds, 28.7% of all samples grew staphylococcal aureus and 31.5% of them were MRSA5.

In Kisiizi (unpublished data)- 60% of surgical wounds grew staph aureus. No access to MRSA testing (oxacillin agar screen).

Why should we be worried ?

Increases length of stay Increases morbidity Increases mortality 1.7 million HAI, 90000 deaths – in US 20023

Financial burden Increased mortality in children staying >5 days

“first do no harm” or, Latin phrase, “primum non nocere- 1860

Common HAI’s

Surgical wound sites Surgical drains Central venous catheters IV Cannula sites Urinary catheters

Common organisms

Staphylococcus epidermidis Staphylococcus aureus – often MRSA Enterobacter species Pseudomonas

Often these are resistant to commonly used antibiotics

Common means of transmission

Medical equipment

Do we need to clean our medical equipment? Stethoscopes Pulse oximeter probes Cannula ports when accessing Dangling drip ends

???????

Medical equipment cleanliness

10 different commonly used equipment in paediatric ward Swabs were taken and cultured

Equipment Organism 1 Organism 2

Stethoscope 1 Staph epidermidis

Stethoscope 2 Staph epidermidis

Stethoscope 3 Neiserria catarrhalis

MUAC tape Staph epidermidis coliform

Pulseox probe 1 Pseudomonas sps Bacteroides sps

Pulseox probe 2 Staph epidermidis

Pulseox probe 3 Staph epidermidis

Knee hammer Staph aureus

BP cuff Staph epidermidis

Thermometer Staph aureus

Is locally made alcohol based hand rub effective ?

Re-swabbed after cleaning with alcohol rub

Is alcohol based rub effective?

Equipment Organism 1 Organism 2 Alcohol rub

Stethoscope 1 Staph epidermidis No growth

Stethoscope 2 Staph epidermidis No growth

Stethoscope 3 Neiserria catarrhalis No growth

MUAC tape Staph epidermidis coliform No growth

Pulseox probe 1 Pseudomonas sps Bacteroides sps No growth

Pulseox probe 2 Staph epidermidis No growth

Pulseox probe 3 Staph epidermidis No growth

Knee hammer Staph aureus No growth

BP cuff Staph epidermidis No growth

Thermometer Staph aureus No growth

100 % effective

KISIIZI ALCOHOL HAND RUB FORMULAR FOR 20LITRES (WHO Formula I)

Method of Preparation

Ingredients Quantities

1. Alcohol 95.5 % (absolute) 80% 16000mL

1. Glycerol 98%w/w 0.725% 145mL

1. Hydrogen Peroxide 6%v/v (0.125%) 417mL

1. Distilled Water (fresh) to 20000mL

•Ensure cleaning of the 20 Liter ‘jerrycan’- Final container, and all the measuring cylinders and beakers has been done properly before production begins•Measure 145mL of Glycerol and pour into the final container •Measure 417 ml of 6% Hydrogen peroxide using the same cylinder you used to measure the glycerol so that it help rinse out all the glycerol since it is slightly viscous and pour into the final container.•Measure 16000mL of absolute Alcohol and power into the Final container•Top up to 20000mL with freshly distilled water•Label and allow to sit for 72 hours before use.

ABH cost- WHO survey4 2011

Clean Care is Safer Care- 2005 Thirty-nine sites from 29 countries (79% LIC and MIC)

included in the final data analysis Commercially produced ABH – 2.5 to 8.5USD / 100mls

dispenser Locally produced ABH- 1.6 to 2.2 USD / 100mls including

dispenser and salaries

White coat

Professional dress (Am J Med 2005)

Study done in 2005 in US. 76.3% favoured professional attire- white coat Scrubs 10.2% Business dress 8.8% Casual dress 4.7%

African study

The potential for nosocomial infection transmission by white coats used by physicians in Nigeria: implications for improved patient-safety initiatives.

Uneke CJ1, Ijeoma PA.

Swabs taken from cuffs and pockets 91.3% of coats had bacterial contamination Staphylococcus aureus, Gram negative bacteria and

dipheroids

Practice in the UK

White coats Ties Long sleeves Watches bracelets

Bare below elbow policy since 2008 Cleaning equipment after every patient contact Strict hand hygiene- hand washing, alcohol rub

Banned

Practice in the US

Society of healthcare epidemiology of America (SHEA) - Recommendations

A bare below elbow policy Hanging white coat prior to contact patient contact Cleaning stethoscopes and other medical equipment before

seeing next patient. Daily laundering of clothes that touch patients

Recommendations

Use alcohol rub Wash with soap + water -contact with body fluids Bare-below-the-elbow in all clinical settings No wrist watches/ jewellery/ bracelets- except for wedding

rings White coat – wash everyday or don’t use it A nation wide HAI data collection is needed

References1. Tikhomirov E. WHO programme for the control of hospital

infections. Chemioterapia. June 1987. 6(3):148-51

2. Health-care associated infection in Africa: a systemic review by WHO- 2011

3. Klevens RM, Edwards JR, Richards CL, et al. Estimating healthcare-associated infections in US hospitals, 2002. Public Health Rep. Mar 2007. 122(2):160-6.

4. Local production of WHO-recommended alcohol-based handrubs: feasibility, advantages, barriers and costs -Joanna Bauer-Savage , Didier Pittet , EunMi Kim & Benedetta Allegranzi

5. Prevalence of Methicillin resistant Staphylococcus aureus (MRSA) among isolates from surgical site infections in Mulago hospital- Kampala, Uganda. J Ojulong, T Mwambu, M Jolobo, E Agwu, F Bwanga, C Najjuka, D Kaddu-Mulindwa

6.

Summary HAI- cause increased morbidity/ mortality/ financial burden to

patients and hospitals Patient safety is our priority Please don’t hesitate to tell your colleague to wash hands/

alcohol rub. Its everyone's responsibility

THANK YOU ALL

UPA & RCPCH !!