Health care associated infection ( HCAI )

Health care associated infection (HCAI), also known as nosocomial infection or hospital infection, is an infection occurring in a patient during the process of care in a hospital or other health care facility which was not present or incubating at the time of admission 1 . This includes infection acquired in the health care facility but appearing after discharge and also occupational infections among health care workers of the facility 1 .

(Key words: antiseptic; colonization; contaminate; disinfectant; hygiene; infection; outbreak; sterilizing; transmission) Health care associated infection (HCAI), also known as nosocomial infection or hospital infection, is an infection occurring in a patient during the process of care in a hospital or other health care facility which was not present or incubating at the time of admission 1 .This includes infection acquired in the health care facility but appearing after discharge and also occupational infections among health care workers of the facility 1 .

HCAI can cause:
• More serious illness • Prolongation of hospital stay • Long term disability • Increased mortality • High financial burden to the health care system.
• High personal cost to patients and their families.
Eight to twelve percent of patients in acute care hospitals in developed countries acquire some form of infection from the hospital 2 .The risk is higher in critical care, estimated to be about 30%, and the mortality may reach 44% 3 .Less data is available from developing countries but it is thought that the risk is 2-20 times higher, and that the proportion of affected patients can exceed 25% 3 .It is a serious problem prevailing in every health facility irrespective of the country, level of facilities or system.In the USA it is among the 10 top leading causes of death and the economic impact in year 2004 was 6.5 billion US dollars 2 .
Clean care is safe care 4 The first global patient safety challenge "Clean Care is Safer Care" was launched by the World Health Organisation (WHO) in 2005 to tackle HCAI .
• Incorrect skin preparation

Standard precautions
By definition, standard precautions are a series of procedures and guidelines which are followed / practised in health care setting to prevent HCAI 6 .This includes: • Hand washing (hygiene) (Figure 1 Hands are the most common vehicle to transmit HCAI.At least 50% HCAI are preventable using simple, non resource demanding measures which can be implemented in developed, transitional and developing countries 3 .

Hand hygiene can be performed in 2 ways:
1. Wash with soap and water (Figure 2) 2. Use of alcohol hand rub (Figure 3) Time constraint is thought to be a major obstacle for hand hygiene.However, adequate hand hygiene with soap and water needs only 40-60 seconds but average time usually adopted by health care workers in <10 seconds 3 .

Figure 3: Use of alcohol hand rub
Hand hygiene with alcohol hand rub requires 20-30 seconds 3 . 7steps have been described in the process of transmission of organisms by hands:

Ways of transmission of organisms by hands
1. Hand transmission: Step I (Figure 4) Organisms like staphylococcus aureus, proteus mirabilis, klebsiella species and acinetobacter species (100-1,000,000 colony forming units (CFU) /cm 2 ) are present on intact areas of some patients 7 .Rarely, one million skin squames containing viable germs are shed daily from the normal skin and patients' immediate surroundings become contaminated by these organisms (especially staphylococcus aureus and enterococci) 7 .

Hand Transmission:
Step II (Figure 5) By direct and indirect contact patient's germs contaminate the health care workers' hands.Nurses could contaminate their hands with 100-1000 CFU of species during 'clean activities' (checking pulse, blood pressure (BP).turning and lifting patients).Fifteen percent of nurses working in an isolation unit carried a median of 10,000 CFU of staphylococcus aureus in their hands 7 .In a general health care facility 29% of nurses carried staphylococcus aureus on their hands (median 3800 CFU) and 17-30% carried gram negative bacilli (median 3400 -38000 CFU) 7 .

Hand transmission:
Step III (Figure 6) Organisms survive on health care workers' hands for differing lengths of time (2-60min) 3 .In the absence of hand hygiene action, the longer the duration of care, the higher the degree of contamination and more and more colonies of organisms will be formed.

Hygiene at the point of care
There should be 3 elements coming into play for a point of care in relation to a clinical setup: 1. Patient 2. Health care worker 3. Care / treatment Concept is to perform hand hygiene at the moment when care is given.Hand hygiene products / facilities should be easily accessible and as close as possible for this to be successful.This can be achieved by keeping the hand rub in small pocket bottles, containers fixed to the patients bed, bedside cupboards / lockers, medicine trolleys, dressing trolleys, incubators or mounted on dispensers fixed to the wall.
Availability of alcohol hand rub at the point of care helps the health worker to fulfill the "5 moments for hand hygiene" 1 My 5 moments of hand hygiene (Figure 9)

Figure 9: Five moments of hand hygiene
The following BEFORE indications are to protect the patient from infections whereas AFTER indications are to protect the healthcare worker/healthcare environment and other patients.

Alcohol Hand Rub
It is a preparation with alcohol, glycerin and hydrogen peroxide.If locally prepared, up to 50 litres can be prepared at a time but this can be increased depending on the demand.Shelf life is about 2 years and 80% ethanol V/V or 75% isopropyl alcohol V/V is used as the main component.Up to now there has not been any risk of developing resistance.It must be stored away from hot/fire places.Prepared alcohol hand rub can be stored in plastic or glass containers.If large volumes (50 L) are prepared, use plastic containers made up of polypropylene which is translucent enough to see the level.Stainless steel tanks are another option.Alcohol hand rub can be used again and again after initial hand washing.Glycerin is added to improve acceptability of the product and hydrogen peroxide to destroy the spores.If gloves are to be worn, hands must be dried after using alcohol hand rub.Containers/tanks must have levels marked outside.Hydrogen peroxide and glycerin are added with a measuring cylinder and rinsed with distilled water. 1 The first formulation contains:

Following terminologies are used in Standard Precautions 6
Detergents: These agents will remove oil and dirt, but will not remove micro-organisms e.g.general purpose detergents like soap.
Antiseptics: These agents are used only in living tissues to remove micro-organisms e.g.70% alcohol, Savlon, Dettol, Iodine and Hibiscrub.
Decontamination: Process of removing or destroying micro-organisms to a certain extent.
Disinfection: Process of destroying micro-organisms on inanimate objects.Spores would not be destroyed e.g.Hypochlorite, TCL, Cidex.

Sterilization:
Removing all microorganisms including virus, fungi, parasites and spores from inanimate objects and equipment.

Obstetric procedures which increase the risk of infection during pregnancy, labour and delivery:
• Amniocentesis • Artificial rupture of membranes

Instructions on arterial catheters and central venous lines
• Hand wash and clean with antiseptic (alcohol hand rub or 2% chlorhexidine) let it dry and put on sterile gloves.• Cap, mask, sterile gown.
• Should be done in a designated area theatre / ICU.• Clean the site with 70% alcohol followed by 10% povidone-iodine.• After insertion, secure with a sterile dressing and record the date.• Have minimal number of ports.
• Disinfect the port before and after injections.
• Before removal of line, clean the surroundings with 2% chlorhexidine or 10% povidone-iodine.• If culture is planned, avoid the top of the catheter touching anywhere using a sterile scissor at a length of about 5cm and place in a sterile container and send to the microbiology laboratory.• Send a peripheral sample of blood for culture.
• Cover the site with a sterile dressing and wash hands.

Precautions about IV cannula / long lines once inserted
• Cover with a sterile dressing after securing preferably with transparent plasters.
) • Wearing gowns, gloves, goggles • Protection from blood and other body fluids • Safe sharp disposal • Safe waste disposal • Dealing with contaminated laundry • Sterilizing and cleaning of contaminated equipment • Cleaning, disinfecting and sterilizing gloves • Environmental cleaning.

Figure 1 -
Figure 1 -Compliance with Hand Washing among Healthcare staff Simple evidence has shown that hand hygiene in the single most effective measure to reduce HCAI 1 .

Figure 2 :
Figure 2: Wash with soap and water

Figure 6 :
Figure 6: Hand transmission Step III4.Hand transmission:Step IV (Figure7)Insufficient duration of hand hygiene / incorrect method / insufficient amount of product will lead

Figure 7 :
Figure 7: Hand transmission Step IV 5. Hand transmission: Step V (Figure 8) Manipulation of invasive devices with contaminated hands leads to transmission of patients' germs to sites at risk of infection e.g.long lines, umbilical catheters.

Figure 8 :
Figure 8: Hand transmission Step V Therefore particular attention must be paid for Hand Hygiene which can be done in two ways as described earlier.Washing the hands with soap and water must be performed in the following instances: • When hands are visibly dirty / soiled with body fluids or when you feel your hands are dirty.• After going to the toilet / before entering the unit.• If there is exposure to potential spore forming pathogens e.g.clostridium difficile outbreaks Alcohol Hand Rub can be used in other instances to clean the hands.WHO has recommended alcohol based hand rub due to the following factors 8 : • Evidence based, fast acting and broad spectrum • Better compliance • Economic benefits • Minimal side effects

Types of organisms which can spread due to poor hand hygiene 9
Use 70% alcohol to clean the skin and let it dry.•Other steps as above.
• Date of insertion recorded on BHT • Inspect daily and re-site at first sign of inflammation • If gauze is used for dressing, change gauze every 48-72 hours or earlier if damp or soiled.• Remove long lines as soon as a peripheral line in secured unless there are special indications.• Remove the peripheral lines as soon as medications are changed over to oral.• Cover the puncture site with a sterile dressing.-Steps of urinary catheterization • Clean the vulval area after separating labia / meatus with a normal saline swab.• Wash hands and wear sterile gloves.• Lubricate and insert the catheter gently.• If unsuccessful, use a new catheter.• Record the date of insertion in case of an indwelling catheter.• Maintain a closed system.• Perform daily meatal / perineal care with a normal saline swab • Keep the urine bag at a lower level but never allow it to touch the floor.• Foley's catheters (later) can be kept up to 28 days if necessary.Do only if clinically indicated • Wash hands, wear clean gloves • Gown / splash proof mask if indicated.• Sterile suction catheter, single use only • Connect to suction machine while rest of the tube is inside the pack.• Take out the rest of the catheter with gloved hand just before suction.• Remove gloves and wash hands.Clinical waste, e.g.dead tissues, must be collected into a separate bag and buried or incinerated.• Sharps -collect into sharp bins • Send for incineration when the bin is 2/3 rd full • Contaminated equipment / linen with body fluids must be washed first with soap before sending for sterilization.