The nosocomial infection itself is different. Nosocomial infection: pathogens, forms, preventive measures. Causes of occurrence and spread of nosocomial infections
The concept of “nosocomial infection”
Nosocomial infection is any clinically significant disease of microbial origin that affects a patient as a result of his hospitalization or visit to a medical institution for the purpose of treatment, as well as hospital personnel due to their activities, regardless of whether symptoms of this disease appear or do not appear at the time the data is found persons in hospital.
The nature of nosocomial infections is more complex than it seemed for many years. It is determined not only by the insufficient socio-economic provision of the medical sphere, but also by the not always predictable evolution of microorganisms, including under the influence of environmental pressure, and the dynamics of relations between the host organism and microflora. The growth of nosocomial infections may also be a consequence of the progress of medicine when using, for example, new diagnostic and therapeutic drugs and other medical devices, when carrying out complex manipulations and surgical interventions, and the use of progressive, but insufficiently studied solutions. Moreover, in a separate health care facility the whole complex of such reasons may be present, but the specific weight of each of them in the overall spectrum will be purely individual.
Damage associated with nosocomial infections:
· Extending the length of stay of patients in hospital.
· Increase in mortality.
· Material losses.
· Social and psychological damage.
The etiological nature of nosocomial infections is determined by a wide range of microorganisms (according to modern data, more than 300), including both pathogenic and conditionally pathogenic flora. Nosocomial infections
The main pathogens of nosocomial infections:
1. Bacteria
Gram-positive coccal flora: genus of staphylococci (species: st. aureus, st. epidermidis, st. saprophyticus); genus of streptococci (species: str. pyogenes, str. pneumoniae, str. salivarius, str. mutans, str. mitis, str. anginosus, str. faecalis);
Gram-negative rod-shaped flora:
Family of Enterobacteriaceae (20 genera): genus Escherichia (E.coli, E.blattae), genus Salmonella (S.typhimurium, S.enteritidis), genus Shigella (Sh.dysenteriae, Sh. flexneri, Sh. Boydii, Sh. sonnei) , Klebsiella genus (Kl. Pneumoniae, Kl. Ozaenae, Kl. rhinoskleromatis), Rhodproteus (Pr. Vulgaris, pr. Mirabilis), Morganella genus, Yersinia genus, Hafnia serration genus
Pseudomonas family: genus Psudomonas (species Ps. aeroginosa)
2. Viruses: pathogens of herpes simplex, chickenpox, cytomegaly (about 20 species); adenovirus infection; influenza, parainfluenza; respiratory syncytial infection; mumps; measles; rhinoviruses, enteroviruses, rotaviruses, pathogens of viral hepatitis.
3. Fungi (opportunistic and pathogenic): a genus of yeast-like (a total of 80 species, 20 of which are pathogenic for humans); genus of molds: genus radiata (about 40 species)
Sources of nosocomial infections:
· Patients (sick and bacteria carriers) - especially those who have been in the hospital for a long time.
· Medical staff (patients and bacteria carriers) - especially long-term carriers and patients with erased forms.
The role of hospital visitors as sources of nosocomial infections is insignificant; the main mechanisms and routes of transmission of nosocomial infection are:
1. Fecal-oral
2.Airborne
3.Transmissive
4. Contact
Transmission factors:
· Contaminated instruments, breathing and other medical equipment, linen, bedding, beds, patient care items, dressings and sutures, endoprostheses and drainages, transplants, overalls, shoes, hair and hands of staff and patients.
· “Wet objects” - taps, sinks, drains, infusion fluids, drinking solutions, distilled water, contaminated solutions of antiseptics, antibiotics, disinfectants, etc., hand creams, water in flower vases, air conditioner humidifiers.
Classification of nosocomial infections
1. Depending on the routes and factors of transmission, nosocomial infections are classified:
· Airborne (aerosol)
· Introductory and nutritional
· Contact household
· Contact-instrumental (post-injection, post-operative, postpartum, post-transfusion, post-endoscopic, post-transplantation, post-dialysis, post-hemosorption, post-traumatic infections and other forms.
2. Depending on the nature and duration of the course:
Subacute
· Chronic.
3. By severity:
· Heavy
· Medium-heavy
· Mild forms of clinical course.
· The main reason is a change in the properties of microbes due to the inadequate use of antimicrobial factors in the medical field and the creation in health care facilities of conditions for the selection of microorganisms with secondary (acquired) resistance (polyresistance)
Differences between the hospital strain and the usual one:
Long-term survival ability
Increased aggressiveness
Increased stability
Increased pathogenicity
· Constant circulation among patients and staff
Formation of bacteria carriers
The bacteria carrier is the most important source of nosocomial infections!
Bacillary carriage is a form of infectious process in which a dynamic equilibrium occurs between the macro- and microorganisms against the background of the absence of clinical symptoms, but with the development of immunomorphological reactions.
The passage of a m/organism through 5 weakened individuals leads to increased aggressiveness of the microbe.
Prevention of the formation of bacilli carriage as the most important source of nosocomial infection:
Regular high-quality clinical examination of medical staff (smears for culture from the skin of the hands of medical staff, as well as smears from the mucous membranes of the nasopharynx are taken every 2-3 months)
·Bacterial examination of personnel according to epidemiological indications
· Timely detection of infectious diseases among medical staff
· Daily monitoring of the health status of medical staff
Risk contingents:
· Elderly patients
· Young children, premature, weakened due to many reasons
· Patients with reduced immunobiological protection due to diseases (oncological, blood, endocrine, autoimmune and allergic, infections of the immune system, long-term operations)
· Patients with altered psychophysiological status due to environmental problems in the areas in which they live and work.
Dangerous diagnostic procedures: blood drawing, probing procedures, endoscopy, puncture, extrasection, manual rectal and vaginal examinations.
Dangerous medical procedures:
· Transfusions
· Injections
· Tissue and organ transplants
· Operations
· Intubation
Inhalation anesthesia
Catheterization of blood vessels and urinary tract
· Hemodialysis
· Inhalations
· Balneological procedures
Classification of medical devices (according to Spalding)
· “critical” items - surgical instruments, catheters, implants, injection fluids, needles (must be sterile!)
· “semi-critical” - endoscopes, equipment for inhalation, anesthesia, rectal thermometers (must be subject to a high level of disinfection)
· “non-critical” - bedpans, blood pressure cuffs, crutches, dishes, axillary thermometers, i.e. objects in contact with skin. (should be subject to low levels of disinfection or simply be clean)
Orders
Order of the USSR Ministry of Health of July 31, 1978 N 720“ON IMPROVING MEDICAL CARE FOR PATIENTS WITH PURULENT SURGICAL DISEASES AND STRENGTHENING MEASURES TO COMBAT IN-HOSPITAL INFECTION”:
The increase in the number of purulent surgical diseases and complications, including hospital-acquired ones, is a consequence of a number of reasons: changes in the habitat of microbes and their properties, the introduction into practice of increasingly complex surgical interventions, an increase in the number of elderly patients undergoing surgery, etc. Along with this, extremely the widespread, often irrational and unsystematic use of antibiotics, non-compliance with the rules of asepsis and antisepsis, as well as violation of sanitary and hygienic conditions in hospitals and clinics aimed at identifying, isolating sources of infection and interrupting paths have an adverse effect on the development of purulent complications and the occurrence of nosocomial surgical infections its transmission.
The heads of some medical institutions do not always provide systematic examination of medical personnel for carriage of pathogenic staphylococcus and carry out sanitation, if necessary. In a number of medical institutions, patients with purulent processes are in the same wards together with patients without such processes; in the wards and departments of purulent surgery, a strict sanitary and hygienic regime is not provided; high-quality cleaning of wards and premises is not always carried out; hand sanitization of medical personnel is not carried out; systematic bacteriological control; there are cases of violation of the rules for sterilization of instruments and material. As a rule, a detailed epidemiological examination is not carried out when an intrahospital purulent infection occurs in surgical departments, identification of its sources, routes and factors of transmission, and implementation of measures to prevent further spread.
Order of the USSR Ministry of Health dated June 10, 1985 N 770 "ON THE INTRODUCTION OF THE INDUSTRY STANDARD OST 42-21-2-85 "STERILIZATION AND DISINFECTION OF MEDICAL DEVICES. METHODS, MEANS AND REGIMES":
In order to establish uniform methods, means and regimes for sterilization and disinfection of medical devices, I order:
1. Introduce industry standard OST 42-21-2-85 “Sterilization and disinfection of medical devices. Methods, means and regimes” from January 1, 1986.
INDUSTRY STANDARD
STERILIZATION AND DISINFECTION OF PRODUCTS
FOR MEDICAL PURPOSE
METHODS, MEANS AND MODES
OST 42-21-2-85
This standard applies to medical devices that are subjected to sterilization and (or) disinfection during use.
Disinfection
All products that do not come into contact with a wounded surface, blood or injectable drugs must be disinfected.
Products used during purulent operations or
surgical manipulations in an infectious patient are subjected to
disinfection before pre-sterilization cleaning and sterilization.
In addition, medical products are subject to disinfection.
after operations, injections, etc., to persons who have had hepatitis B or
hepatitis with an unspecified diagnosis (viral hepatitis), as well as
are carriers of the HB antigen.
Disinfection methods:
1. Boiling
2. Steam
3.Air
4. Chemical
The chemical disinfection regime is carried out in three options:
1 - should be used for purulent diseases, intestinal and airborne infections of bacterial and viral etiology (influenza, adenoviral diseases, etc.), hibitan - only of bacterial etiology;
2 - for tuberculosis;
3 - for viral hepatitis.
Sterilization
All products that come into contact with a wounded surface, come into contact with blood or injectable drugs, and certain types of medical instruments that, during operation, come into contact with the mucous membrane and can cause damage to it, must be sterilized.
Sterilization methods:
1. Steam sterilization method (saturated water steam under excess pressure)
2. Air sterilization method (dry hot air)
3. Chemical sterilization method (solutions of chemicals)
4. Chemical sterilization method (gas), sterilization with oxide and oxide
5. 5Chemical sterilization method (gas), sterilization with a mixture of water vapor and formaldehyde)
6. Chemical sterilization method(gas), formaldehyde sterilization from paraformaldehydeChemical method
Nurse measures to prevent the introduction of nosocomial infections
1. Infection control measures
Infection control team. The goals of infection control measures are: reducing the acquisition of infection by patients undergoing treatment in hospitals; ensuring adequate care for patients with potentially contagious infections; reducing to a minimum the contamination of personnel surrounding a contagious patient, visitors, etc.
The functions of the infection control team are as follows:
1. Providing measures aimed at the appropriate management of patients with contagious infections.
2. Development of a comprehensive system for identifying patients with contagious infections, determining the incidence and prevalence of nosocomial infections, as well as studying the problem of using medications.
3. Accounting and identification of possible factors and sites of reverse infection, i.e. infection of doctors and other medical personnel from patients (including surgical wound infection).
4. Collaborate with personnel in medical departments, central supply, support services, pharmaceutical and other departments in maintaining appropriate environmental controls.
5. Training of personnel in appropriate techniques aimed at preventing the spread of infection in a health care facility.
6. Collaborate with general health care workers to expand appropriate immunization of medical personnel and provide special measures to protect personnel exposed to potentially contagious diseases.
7. Constant recording of the use of antibiotics and studying the nature of drug sensitivity of the most common pathogens of nosocomial infections.
An effective nosocomial infection control program can reduce its incidence by approximately 30%. Most health care facilities utilize all support staff, nurses, and/or physicians to implement this program to ensure that multiple efforts can be brought together to combat disease.
2. Prevention
The cornerstones in the prevention of nosocomial infection remain the basic principles of epidemiology, including mandatory hand washing when in contact with patients, fairly effective isolation of patients who release the pathogen into the external environment, and the use of epidemiological methods for identifying and identifying sources of infection.
3. Health workers .
The principles of preventive medicine should be applied not only to patients, but also to medical personnel. Health care providers should implement a program to detect contagious infections such as tuberculosis and routinely monitor the immunization of health care personnel exposed to cases of measles, mumps, polio, diphtheria, or tetanus. In addition, health care workers (regardless of gender) who have contact with pregnant women must be tested for rubella virus antibodies and, if necessary, immunized before being allowed to work in areas where contact with pregnant women is possible. Health care workers whose professional activities involve frequent blood tests or direct contact with patients with a high risk of hepatitis B disease or presence should be vaccinated against this disease. Health care workers should be immunized against infection annually. This immunization has the dual purpose of reducing the frequency of transmission of nosocomial infections to patients and minimizing winter loss of working time due to staff illness.
Medical workers who have become infected with certain infectious diseases should not have contact with patients during the entire period when they can serve as a source of spread of the pathogen. The danger of paronychia and other purulent foci caused by S. aureus or group A streptococci is often underestimated. It is also forgotten that upon contact with carriers of the herpes zoster virus, persons sensitive to this infection may develop chickenpox.
4. Screening upon admission of the patient to a medical institution
In the event that a patient with an existing infectious disease or a patient in the incubation period requires hospitalization in a certain medical institution, his placement in a medical institution should be postponed until the infectious period of the disease has ended. Screening for the presence of contagious infections upon admission to a medical facility is especially important for pediatric departments, oncology and transplantation services, where patients with impaired immune status may be concentrated. For such patients, even infections such as chicken pox or measles, which are usually not given much importance, can be extremely dangerous.
Measures to prevent infection. Each pathogenic microorganism has its own characteristic pathways of spread, and based on knowledge of these characteristics, appropriate precautions can be developed to anticipate and manage the situation. Procedures for isolating the pathogen require a long time, are expensive and, if strictly followed, can significantly interfere with the timely provision of care to the patient. They should be used only in cases of extreme necessity and only for the shortest period of time, subject to well-established medical care. The following pathogen isolation techniques and precautions are usually used:
1. Strict isolation of the patient in cases where aerogenic or contact spread of infection is possible, for example, with smallpox pneumonia.
2. Respiratory isolation in cases where the infectious agent is contained in air aerosols in which the particle size corresponds to the size of inhaled particles, such as in tuberculosis.
3. Take precautions in the presence of skin wounds where direct or indirect contact with infected skin lesions or contaminated clothing can lead to the transmission of microorganisms, for example, with staphylococcal wound infections.
4. Observance of precautionary measures in case of intestinal infections, in which the pathogen is transmitted by the fecal-oral route and the main efforts should be aimed at preventing contact with objects contaminated with feces, for example, with hepatitis A.
5. Protective (reverse) isolation, when precautionary measures are aimed at protecting a patient who is extremely sensitive to infection and has impaired defense mechanisms from microorganisms circulating in the environment, for example, for patients with burns.
6. Observe precautions when manipulating blood, when transmission of infection occurs through accidental penetration of an infectious agent through the skin or mucous membranes into the blood, for example, with hepatitis B.
7. Taking precautions to limit the transmission of multidrug-resistant bacteria to other patients.
If preventive measures are ineffective, the following principles must be observed.
1. Prevent further spread of the disease by isolating the patient or, if his condition allows, interrupting his hospital stay.
2. Identify all contacts of this patient and determine their sensitivity to infection and the degree of possible infection.
3. Take all available preventive measures for persons exposed to possible infection.
4. Develop a plan to prevent the spread of the infectious agent by persons susceptible to the infection, based on the significance of the epidemiology of the infection, the effectiveness and availability of various measures to combat it and the possible consequences of its further spread.
Methods used to limit the spread of contagious diseases by persons susceptible to infection include:
- early discharge of the patient from the hospital;
- isolation of persons who were in contact with the patient during the infectious period of the disease;
- association of all persons sensitive to this infection and exposed to contact with the patient (including service personnel)
- treating them (although such association is difficult, it remains an important intervention for controlling nosocomial outbreaks of varicella and epidemic diarrhea).
5. Main directions of prevention of nosocomial infections:
1. Optimization of the epidemiological surveillance system for nosocomial infections.
2. Improving laboratory diagnostics and monitoring of nosocomial pathogens.
3. Increasing the efficiency of disinfection measures.
4. Increasing the efficiency of sterilization measures.
5. Development of strategies and tactics for the use of antibiotics and chemotherapy drugs.
6. Optimization of measures to combat and prevent nosocomial infections with various transmission routes.
7. Rationalization of the basic principles of hospital hygiene.
8. Optimization of the principles of preventing nosocomial infections of medical personnel.
9. Assessment of the cost-effectiveness of measures to prevent nosocomial infections.
Optimization of the epidemiological surveillance system for nosocomial infections
Epidemiological surveillance (ES) is the basis for successful prevention and control of nosocomial infections. Only with clear monitoring of the dynamics of the epidemic process, the spread of nosocomial pathogens, monitoring the factors and conditions affecting their spread, and analyzing the information received, is it possible to develop a scientifically based system of control and prevention measures. EN ensures the collection, transmission and analysis of information for the purpose of making adequate management decisions and is carried out taking into account the specifics of various types of health care facilities.
The purpose of epidemiological surveillance is to form an objective conclusion about the epidemiological situation regarding nosocomial infections in a medical-prophylactic institution and its departments and to develop on this basis scientifically sound practical recommendations for the control of nosocomial infections; establishing trends in the epidemic process to promptly make adjustments to optimize preventive and anti-epidemic measures; assessment of the effectiveness of ongoing activities.
Conducting epidemiological surveillance includes:
Ensuring accounting and registration of nosocomial infections based on the definition of a standard case of nosocomial infections;
Identification and recording of nosocomial infections based on the definition of a standard case of nosocomial infections during clinical observation;
Identification of risk factors and risk groups among personnel in various types of hospitals;
Deciphering the etiology of identified nosocomial infections with determination of the biological properties of the isolated microorganisms and their sensitivity to antibiotics and chemotherapy;
Epidemiological analysis of the incidence of nosocomial infections and the carriage of epidemiologically significant microorganisms in medical personnel by etiology, localization of the pathological process with identification of the leading causes and factors ensuring the spread of nosocomial infections;
Organization of specific prevention for medical personnel;
Providing and training in the use of personal protective equipment when caring for patients;
Development and application of epidemiologically safe technologies for performing therapeutic and diagnostic procedures;
Training of medical workers on the epidemiology and prevention of nosocomial infections in different types of hospitals:
Medical personnel
Mid-level medical workers,
Junior staff;
Assessing the effectiveness of preventive measures taken;
Assessing the effectiveness of treatment of medical workers with nosocomial infections.
Development of a program for medical examination and prevention of nosocomial infections of medical personnel;
Development of training programs for medical personnel on the prevention of nosocomial infections in different types of hospitals:
For doctors of various profiles,
Middle medical level,
Junior staff;
Development and implementation of guidelines for the prevention of nosocomial infections among medical staff of health care facilities.
Economic analysis plays a prominent role in the system of epidemiological surveillance of infectious diseases. It is intended, by assessing the significance of diseases and the effectiveness of implemented measures, to help optimize the work of the sanitary-epidemiological service, which consists in achieving the maximum medical effect with strictly defined expenditures of effort and resources. Economic analysis is of particular importance nowadays in the context of reforming Russian healthcare and the shortage of material resources.
At the same time, it should be noted that in our country there is an almost complete absence of work aimed at assessing the economic aspects of nosocomial infections, which, against the backdrop of the intensive development of research devoted to the economic analysis of various diseases and the epidemiological significance of the problem of nosocomial infections, is surprising and can be qualified as a significant flaw in sanitary epidemiological service. This situation can be explained by the clinical and epidemiological features of nosocomial infections (variety of nosological forms, polyetiology, wide range of profiles of health care facilities, etc.), which complicate the implementation of relevant economic calculations
The goal is to determine the economic significance of nosocomial infections (sum and individual nosoforms) in Russia and the economic effectiveness of disinfection and sterilization measures in health care facilities.
Assessment of the cost-effectiveness of measures to prevent nosocomial infections involves:
Calculation of “standard” values of economic damage caused by one case of nosocomial infections (according to nosological forms);
Determination of the economic significance of nosocomial infections (in total and by nosological forms);
Calculation of costs for carrying out disinfection and sterilization measures;
Determination of the economic efficiency of disinfection and sterilization measures (in combination with the strategy and tactics of their implementation, as well as the nature and level of prevalence of nosocomial infections in hospitals of various profiles).
The main sources of financing for the implementation of the main directions of the "Concept..." may be:
1. Federal Compulsory Medical Insurance Fund. Regulation of the preferential direction of the Fund's funds to the regions and constituent entities of the Federation should be carried out depending on their acceptance of the Concept for implementation.
2. Local Compulsory Health Insurance Funds.
3. Allocation of targeted funds from local budgets (budgets of the constituent entities of the Federation).
4. Allocation of part of the budget funds to institutions of federal subordination.
Additional sources:
Targeted concessional loans.
Increasing the efficiency of disinfection measures
Prevention of nosocomial infections in health care facilities includes a set of disinfection measures aimed at destroying pathogenic and opportunistic microorganisms at objects in the patient’s environment and medical products.
Currently, the most promising group of compounds for disinfecting various types of surfaces in rooms and other objects in health care facilities are quaternary ammonium compounds (QACs), cationic surfactants (CSAS), amine salts, and guanidine derivatives. These products have high bactericidal activity and, along with antimicrobial properties, also have a cleaning effect, which makes it possible to combine disinfection with room cleaning and use them for pre-sterilization cleaning of medical products. These compounds are not volatile, they are not hazardous when inhaled, and can be used at the patient's bedside.
The best means for disinfecting medical products can be considered compositions based on QACs, aldehydes, cationic surfactants and alcohols, since, having a wide spectrum of action, they have the most harmful effect on the material of the products, do not violate their functional properties, and have a cleaning effect, which is often allows them to be used for combined disinfection and pre-sterilization cleaning of products.
As skin antiseptics for disinfecting the hands of medical personnel, treating injection and surgical fields, it is also advisable to use products based on alcohols (ethyl, isopropyl, etc.) with the addition of cationic surfactants, etc.
Increasing the efficiency of disinfection measures involves:
Improving the regulatory framework regulating the use of modern disinfectants;
Optimization of methods for sterilization of endoscopic equipment and products made of light-fiber optics.
It is necessary to prepare guidelines for the use of equipment and means of chemical sterilization in accordance with their intended purpose.
Development of strategies and tactics for the use of antibiotics and chemotherapy drugs
In modern conditions, the problem of drug resistance of microorganisms has become global. The wide distribution of pathogens of infectious diseases that are resistant to the action of various drugs due to the disordered use of antimicrobial agents leads to ineffective chemotherapy for patients with nosocomial infections. Multiresistant microorganisms can cause severe forms of nosocomial infections. Irrational antibiotic therapy increases the length of stay of patients in hospitals, leading to serious complications and deaths.
This dictates the urgent need to develop a policy for the use of antibiotics for the prevention and treatment of nosocomial infections, aimed at increasing the effectiveness and safety of the use of chemotherapy and reducing the possibility of the formation of drug resistance in bacteria.
The antibiotic use policy provides for a set of organizational and medical measures based on monitoring the drug resistance of nosocomial pathogens
The main ones are:
Development of strategies and tactics for chemoprophylaxis, treatment of patients with antibiotics and other chemotherapy drugs;
Providing monitoring of microorganisms circulating in various types of hospitals;
Determination of drug resistance of nosocomial pathogens using standard methods;
Optimization of the basic principles for the selection of antimicrobial drugs for the treatment and prevention of nosocomial infections;
Reasonable limitation of the use of certain types of antibiotics, based on monitoring data of drug resistance of nosocomial pathogens;
Assessing antibiotic use strategies in different departments and types of hospitals;
Assessment of the tactics of using antibiotics in different types of hospitals (regimens, dosages, combinations of drugs);
Determining the effectiveness of using antibiotics to prevent nosocomial infections;
Analysis of factors influencing the success of antibiotic therapy and antibiotic prophylaxis;
Analysis of factors of side effects of antibiotic therapy and antibiotic prophylaxis;
Control over the use of antibiotics for therapeutic and prophylactic purposes;
Development of a scientifically based approach to the compilation of antibiotic and chemotherapy formularies with system analysis and assessment of the cost-effectiveness of the selected antibiotics
It is necessary to develop and implement methodological materials on the strategy of using antibiotics for the treatment and prevention of nosocomial infections.
Optimization of control and prevention measures for nosocomial infections with various transmission routes
The improvement of methods for the control and prevention of nosocomial infections in modern conditions is due to the consistently high incidence rate and changes in the structure of nosocomial infections, the expansion of ideas about the possible factors and routes of transmission of known infections, and the emergence of new nosological forms of nosocomial infections. Along with this, new scientific and practical data and methodological approaches have been accumulated that optimize the organization of preventive and anti-epidemic measures for various groups of infections and individual nosological forms of nosocomial infections, positive experience has been gained in the use of immunomodulators in patients of clinics of various profiles, and the arsenal of modern disinfectants used in practice has expanded.
Optimization of measures to combat and prevent nosocomial infections with various transmission routes involves:
Determination of leading preventive and anti-epidemic measures for various groups of infections in hospitals of various profiles;
Rationalization of emergency prevention methods;
Determining a strategy to reduce the frequency and duration of hospitalization of patients in various types of hospitals;
Optimization of measures aimed at suppressing the artificial (artificial) transmission mechanism associated with invasive medical procedures;
Improving measures aimed at breaking natural transmission mechanisms (airborne dust, contact and household);
Determination of specific prevention tactics for medical personnel (in special cases, patients);
Reducing the number of unnecessary diagnostic and therapeutic procedures of an invasive nature (including transfusions of blood and its components, etc.);
Determination of tactics for the use of immunocorrectors for risk groups in hospitals of various profiles;
Improving the system of disinfection and sterilization measures.
Rationalization of the basic principles of hospital hygiene
The significance of the implementation of this direction is determined by the importance of compliance with sanitary and hygienic rules by hospital staff in the course of their professional activities and by patients undergoing treatment. Hygienic measures form the basis of measures to prevent nosocomial infections, the completeness and quality of which largely determines the success of patient treatment. Given their diversity, they are achieved through a wide range of measures.
The purpose of the direction is to create optimal conditions for patients in the hospital, to prevent nosocomial infection of patients and employees.
Rationalization of the basic principles of hospital hygiene involves:
Providing conditions for optimal accommodation, nutrition and treatment of patients;
Ensuring optimal working conditions for medical personnel;
Preventing the spread of nosocomial infections in health care facilities.
Implementation of this direction includes:
Use of modern architectural and planning solutions in the construction and reconstruction of health care facility buildings;
Rational placement of functional departments of the hospital on floors and buildings, taking into account the requirements of the anti-epidemic regime;
Optimization of the distinction between “clean” and “dirty” functional flows of movement of personnel, patients, food, linen, instruments, waste, etc.;
Strict compliance with mandatory sanitary standards for the placement of functional premises;
Compliance of the cleanliness class of the premises of hospital complexes with the production processes carried out in them;
Improving the parameters of the microclimate and air purity of the working area through the introduction of modern technologies for air purification and air conditioning of wards, operating units and aseptic boxes;
Compliance with anti-epidemic requirements and sanitary standards for the collection, temporary storage, and disposal of healthcare facility waste;
Compliance with the rules of personal hygiene and sanitary standards for caring for patients;
Compliance with linen regime, sanitary standards for preparation, transportation and distribution of food;
Conducting health education work among hospital staff and patients.
Optimization of principles for the prevention of nosocomial infections of medical personnel
According to the WHO definition, the incidence of infectious diseases among medical workers associated with their professional activities is classified as nosocomial infections.
The incidence of infectious diseases among medical personnel significantly exceeds the incidence in many leading industries. This is due to the presence in health care facilities of a large number of sources of infection (patients and carriers among patients), the colossal concentration of weakened people in them, the abundance of invasive diagnostic and therapeutic procedures, the uniqueness of the microbial landscape, and the specific routes of transmission of the infectious agent. The widespread use in health care facilities of antibiotics and cytostatics is important, changing the biocenosis of the mucous membranes and skin of personnel and opening the “entry gate” for fungi and other microorganisms. Infection of medical workers with multidrug-resistant strains of a number of pathogens can cause disability and even death of a number of them.
Optimizing the principles of preventing nosocomial infections among medical personnel involves:
Examination of medical personnel for the presence of infectious diseases when hiring and the occurrence of outbreaks of nosocomial infections;
Development of scientific foundations for planning and monitoring the consumption of disinfectants in health care facilities of various profiles;
Development, study and implementation of new effective, low-toxic, environmentally friendly means of disinfection and pre-sterilization cleaning into the practice of medical disinfection in health care facilities;
Creation and economic support for the development of production of domestic disinfectants based on QACs, aldehydes, cationic surfactants and alcohols;
Elimination of the use of ineffective, environmentally hazardous disinfectants (chlorine-containing preparations) in daily activities;
Widespread use in everyday practice of disinfectants that optimize the stages of pre-sterilization treatment;
Development of optimal conditions and regimes for the use of new disinfection equipment;
Creation, in accordance with scientific and methodological developments, of strategic reserves of disinfectants at the level of regions, territorial medical associations, and large hospitals.
In order to implement this direction, it is necessary to prepare a package of regulatory documents, including Sanitary rules for the disinfection and sterilization regime in health care institutions, methodological recommendations for organizing state sanitary and epidemiological supervision and production control over the disinfection and sterilization regime in health care institutions, for organizing a pre-licensing examination of disinfection and sterilization activities in health care institutions. It is required to develop guidelines for the use of disinfectants in accordance with their intended purpose; a list of the most rational drugs for use in health care facilities; uniform forms for health care facilities for recording the receipt and consumption of disinfectants.
It is also necessary to develop a system of economic measures to stimulate domestic producers of modern disinfectants.
Increasing the efficiency of sterilization measures
An important element in the prevention of nosocomial infections in healthcare facilities is sterilization measures aimed at destroying all vegetative and spore forms of microorganisms in the air of functional rooms and ward sections, at objects in the patient’s environment, and medical products
The development by domestic manufacturers of steam, air and gas sterilizers of a new generation involves the introduction into practice of devices that differ from previously produced models in the automatic control method, the presence of process locks, light and digital indications, as well as sound alarms. Narrower intervals of maximum deviations of sterilization temperature from nominal values (+1°C in steam sterilizers, +3°C in air sterilizers) may in some cases allow recommending modes with a reduced sterilization holding time.
In recent years, work has been carried out to create glasperlene sterilizers for small dental instruments using heated glass beads, ozone and plasma sterilizers as a sterilizing medium. The development of conditions for sterilization of products in these devices will expand the possibilities for choosing the most suitable (material-friendly products, optimal exposure time) methods and sterilization regimes for specific groups of medical products.
Improving the process of pre-sterilization cleaning of products is also possible through the development and implementation of installations in which the cleaning process is carried out by treating products with detergents or detergents and disinfectants in combination with ultrasound.
It is worthy of attention to continue research to assess the conditions for using UV radiation for air disinfection in the functional rooms of health care facilities. These works are aimed at developing new principles for the use of bactericidal irradiators in the presence and absence of patients, introducing into practice domestic recirculators, the principle of operation of which is based on forced pumping of air through a device in which UV lamps are placed. In this case, it may be possible to use recirculators without limiting the time of their operation in rooms in the presence of patients.
An important section remains the further development and optimization of the use of chemical sterilization agents, which are of particular importance for the sterilization of endoscopic equipment and fiber optic products.
Increasing the efficiency of sterilization measures involves:
Creation of a regulatory framework regulating the use of modern sterilization equipment;
Development, study and implementation of new effective, low-toxic, environmentally friendly means of chemical sterilization into the practice of health care facilities;
Development and implementation of highly effective modern sterilization equipment into the practice of medical sterilization in health care facilities;
Development of optimal conditions and modes for using new sterilization equipment;
Replacement of outdated fleet of sterilization equipment and sterilizing equipment;
Development of a system of economic measures to stimulate domestic producers;
Optimization of methods of chemical, bacteriological and thermal control of the operation of sterilization equipment;
Identification of risk factors for nosocomial infection in certain categories of patients in various types of hospitals;
Epidemiological analysis of patient morbidity with identification of leading causes and factors contributing to the spread of infection;
Epidemiological analysis of the incidence of nosocomial infections of medical personnel (dynamics of the incidence of nosocomial infections, level, etiological structure of the disease, localization of the pathological process, carriage of epidemiologically significant strains of microorganisms);
Implementation of microbiological monitoring of pathogens of nosocomial infections, determination and study of the biological properties of microorganisms isolated from sick, deceased, medical personnel and from individual environmental objects;
Determination of the spectrum of resistance of microorganisms to chemotherapy to develop a rational strategy and tactics for the use of antibiotics;
Determination of precursors of complications of the epidemiological situation in different types of hospitals;
Assessing the effectiveness of preventive and anti-epidemic measures;
Forecasting the epidemiological situation.
In order to improve methods and unity of approaches to the implementation of epidemiological surveillance of nosocomial infections, it is necessary to develop and implement guidelines for conducting epidemiological surveillance in health care facilities.
Improving laboratory diagnostics and monitoring
Laboratory diagnosis and monitoring of nosocomial pathogens is one of the most important factors in the successful fight against nosocomial infections.
Currently in Russia, the state of the microbiological service in most health care facilities does not meet modern requirements both in terms of material and technical equipment and in the level of professional training of clinical microbiologists. Available resources are used irrationally and ineffectively.
In fact, there is no analysis of the antibacterial sensitivity of hospital strains, which makes it difficult to develop scientifically based antibiotic prescription regimens for the treatment and prevention of nosocomial infections.
The system of interaction between clinical microbiologists and other health care specialists is insufficiently developed.
Improving laboratory diagnostics and monitoring of nosocomial pathogens involves:
Optimization of the system for collecting and delivering clinical material to the laboratory;
Improving methods for isolating and identifying microorganisms that cause nosocomial infections based on the use of automated (semi-automated) systems with a short incubation mode (3-5 hours);
Development of methods for quantitative accounting and analysis of opportunistic microorganisms isolated from various clinical materials based on the creation and use of an automated workstation for a doctor - clinical microbiologist and local networks for the rapid transfer of information;
Standardization of methods for determining the sensitivity of nosocomial pathogens to antibiotics and chemotherapy drugs, as well as to disinfectants;
Development and application of express methods for microbiological diagnosis of nosocomial infections.
In order to improve laboratory diagnostics in health care facilities, it is necessary to develop methodological documentation that unifies the rules for the collection, storage, transportation of typical material and its examination.
Nosocomial infection (nosocomial infection) is any infectious disease contracted in a medical facility. Since the mid-20th century, nosocomial infections have represented a major health problem in various countries around the world. Their pathogens have a number of characteristics, thanks to which they successfully live and reproduce in a hospital environment. According to official data, annually in the Russian Federation up to 8% of patients become infected with nosocomial infections, which amounts to 2-2.5 million people per year. However, the statistical method of accounting is imperfect and a number of researchers believe that the real incidence is tens of times higher than the declared one.
The concept of nosocomial infection combines a large number of different diseases, which leads to difficulties in its classification. The generally accepted approaches to dividing nosocomial infections are etiological (by pathogen) and by localization of the process:
Pathogens
Nosocomial infections are caused by bacteria, viruses and fungi. Only a small part of them relate to pathogenic microorganisms; much more important are opportunistic microorganisms. They live on human skin and mucous membranes normally, and become pathogenic only when the immune defense is reduced. The immune system reacts poorly to the presence of opportunistic flora in the body, since its antigens are familiar to it and do not cause powerful production of antibodies. Often pathogens form various associations of several types of bacteria, viruses, and fungi.
The list of pathogens causing nosocomial infections is constantly growing; today the following types are of greatest importance:
| Opportunistic microflora: | Pathogenic microflora: |
|---|---|
| (golden, epidermal); | Hepatitis B, C viruses; |
| (groups A, B, C); | ; |
| Enterobacteriaceae; | ; |
| Escherichia coli; | ; |
| ; | ; |
| Proteus; | (for people who have not had chickenpox in childhood and children); |
| (pseudomonas); | Salmonella; |
| Acinetobacter; | Shigella; |
| Pneumocyst; | Clostridia; |
| Toxoplasma; | ; |
| Cryptococcus; | . |
| Candida. |
The listed microorganisms have one of the mechanisms of wide distribution and high infectiousness. As a rule, they have several transmission routes, some are able to live and reproduce outside a living organism. The smallest particles of viruses easily spread throughout a medical facility through ventilation systems and infect a large number of people in a short time. Crowding, close contact, weakened patients - all these factors contribute to the outbreak and maintain it for a long time.
Bacteria and fungi are less contagious, but they are extremely stable in the external environment: are not susceptible to disinfectants or ultraviolet irradiation. Some of them form spores that do not die even after prolonged boiling, soaking in disinfectants, or freezing. Free-living bacteria successfully multiply in humid environments (on sinks, in humidifiers, containers with disinfectants), thereby maintaining the activity of the focus of nosocomial infection for a long time.
The causative agents of nosocomial infections are usually called the “hospital strain”. Such strains periodically replace each other, which is associated with antagonistic relationships between bacteria (for example, Pseudomonas aeruginosa and staphylococcus), changes in disinfectants, updating of equipment, and the introduction of new treatment regimens.
Epidemiological process
Sources of infection are sick people and asymptomatic carriers of the pathogen. Most often they are found among patients, somewhat less often among staff, and extremely rarely the source is hospital visitors. The role of the latter is small due to the restriction of visits to the hospital, the organization of meeting places in the foyer, and not in hospital wards. Transmission of pathogens occurs in various ways:
a) Natural distribution routes:
- Horizontal:
- fecal-oral;
- contact;
- airborne;
- airborne dust;
- food.
- Vertical - through the placenta from mother to fetus.
b) Artificial (artificial) distribution routes:
- Associated with parenteral interventions (injections, blood transfusions, organ and tissue transplants).
- Associated with therapeutic and diagnostic invasive procedures (artificial ventilation, endoscopic examination of body cavities, laparoscopic intervention).
The leaders in the frequency of outbreaks of nosocomial infections are:
- Maternity;
- Surgical hospitals;
- Reanimation and intensive care units;
- Therapeutic hospitals;
- Children's departments.
The structure of morbidity depends on the profile of the hospital. Thus, in surgery, purulent-septic infections take first place, in therapy - and in urological hospitals - infections of the urinary system (in connection with the use of catheters).
The infectious process develops when the patient has diseases aggravating his condition. There are groups of patients susceptible to nosocomial pathogens:
- Newborns;
- Aged people;
- Exhausted;
- Patients with chronic pathology (diabetes mellitus, heart failure, malignant tumors);
- Those receiving antibiotics and antacids for a long time (reducing the acidity of gastric juice);
- HIV-infected;
- People who have undergone chemotherapy/radiation therapy;
- Patients after invasive procedures;
- Patients with burns;
- Alcoholics.
The incidence of nosocomial infections is outbreak or sporadic, that is, one or several cases of the disease occur simultaneously. The sick are connected by being in the same room, using common equipment, sharing hospital food, and using a common sanitary room. There is no seasonality in outbreaks; they are recorded at any time of the year.
Prevention of nosocomial infections
Prevention of nosocomial infections is the most effective way to solve the problem. To treat nosocomial infections, the most modern antibiotics are needed, to which microorganisms have not yet developed resistance. Thus, antibacterial therapy turns into an endless race in which humanity's capabilities are very limited.
Doctors of the last century understood the state of affairs, and therefore, in 1978, the USSR Ministry of Health issued a document that fully regulates the prevention of nosocomial infections and is in effect on the territory of the Russian Federation to this day.
The most important link in preventing the spread of hospital strains are specialists with a nursing certificate. Nursing staff are directly involved in patient care, invasive procedures, disinfection and sterilization of hospital facilities. Only strict adherence to sanitary rules in medical institutions significantly reduces the frequency of outbreaks of nosocomial infection.
Prevention measures include:
With the development of the pharmaceutical and chemical industries, the problem of nosocomial infections has acquired incredible proportions. Inadequate prescription of antibiotics and the use of increasingly powerful disinfectants in excessive/insufficient concentrations lead to the emergence of hyper-resistant strains of microorganisms. There are known cases when, due to an aggressive and resistant strain of staphylococcus, entire hospital buildings went up in flames - there were no more gentle ways to deal with the bacterium. The problem of nosocomial infection is a kind of reminder to humanity of the power of microorganisms, their ability to adapt and survive.
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HOSPITAL INFECTION
1. Sources of origin and pathsfood nosocomial infections
nosocomial infection epidemiological
Nosocomial infection-- this is any clinically recognizable disease of microbial etiology associated with a person’s stay, treatment, examination or seeking medical care in a health care facility, or an infectious disease of an employee as a result of his work in this institution. WHO Regional Office for Europe definition of nosocomial infections.
The addition of nosocomial infections to the underlying disease often negates the results of treatment, increases postoperative mortality and the length of the patient’s hospital stay.
The increase in the incidence of nosocomial infections is due to a number of objective and subjective reasons:
1) Demographic changes in society, primarily an increase in the number of older people who have reduced body defenses;
2) An increase in the number of people belonging to high-risk groups (patients with chronic diseases, premature newborns, etc.);
3) Widespread, sometimes uncontrolled use of antibiotics (often the use of antibiotics and chemotherapy drugs contributes to the emergence of drug-resistant microorganisms, characterized by higher virulence and increased resistance to environmental factors, including disinfectants);
4) The introduction of more complex surgical interventions into healthcare practice, the widespread use of instrumental (invasive) methods of diagnosis and treatment;
5) Widespread occurrence of congenital and acquired immunodeficiency conditions, frequent use of drugs that suppress the immune system;
6) Violation of sanitary-hygienic and anti-epidemic regimes.
Sources of nosocomial infections that have the most important epidemiological significance can be:
* patients with acute or chronic forms of infectious diseases, including wound infections, as well as carriers of various types of pathogenic and opportunistic microorganisms;
* medical personnel: carriers, as well as those suffering from severe or erased forms of infections;
* visitors.
Infection of patients in the clinic can occur in the following ways:
|
Transmission path |
Factors |
|
|
airborne or airborne dust |
when coughing, sneezing and are introduced into the human body when inhaling contaminated air |
|
|
contact-household |
through patient care items, linen, medical instruments, equipment, as well as the hands of staff |
|
|
parenteral |
when administering infected blood products, isotonic solutions and other drugs |
|
|
Nutritional |
through milk, drinking solutions, food products |
|
|
Vertical (transplacental) |
from mother to fetus or newborn via the placenta |
The emergence and development of nosocomial infections in health care facilities is facilitated by:
1) Underestimation of the epidemic danger of nosocomial sources of infection and the risk of infection during contact with patients with purulent-septic infections, their untimely isolation;
2) The presence of undetected patients and carriers of nosocomial strains among medical personnel and patients;
3) Violation by staff of the rules of asepsis and antiseptics, personal hygiene, current and final disinfection, and cleaning regime;
4) Violation of the sterilization and disinfection regime for medical instruments, devices, devices, etc.;
5) Violation of restrictive and protective regime measures.
2. Prevention of nosocomial infections
HAIs represent a major safety concern in the hospital environment. To combat nosocomial infections, health care facilities use a set of measures, one of which is the organization and implementation of preventive measures.
Preventive measures for nosocomial infections are divided into four groups.
IActivities aimed at creating an epidemiological systemsupervision:
* accounting and registration of VBI;
* deciphering the etiological structure of nosocomial infections;
* sanitary and bacteriological studies of environmental objects in health care facilities, especially in intensive care units;
* study of the circulation features of pathogenic and opportunistic microorganisms;
* determination of the breadth of distribution and spectrum of resistance of microorganisms to antibiotics, antiseptics, disinfectants;
* monitoring the health status of medical personnel (morbidity, carriage of epidemiologically significant microorganisms);
* monitoring compliance with the sanitary-hygienic and anti-epidemic regime in health care facilities;
IIMeasures aimed at the source of infection:
* timely identification of patients with nosocomial infections;
* conducting an epidemiological investigation of each case;
* timely isolation of patients in special departments and wards; it is necessary that isolation is carried out taking into account the etiological factor, otherwise the possibility of cross-infection of patients in the departments (wards) themselves cannot be excluded;
* regular identification of carriers of nosocomial pathogens among personnel;
* sanitation of carriers of pathogens of nosocomial infections among staff and patients.
IIIMeasures aimed at breaking the transmission mechanism.
There are three types of events in this group:
1) Architectural and planning activities in accordance with San Pi No. 51-79-S0 “Sanitary rules for the design, equipment, operation of hospitals, maternity hospitals and other health care facilities” include:
* maximum separation of patients up to the creation of boxed wards;
* separation of “purulent” and “clean” flows of patients;
*installation of operating airlocks with bactericidal “locks”;
*introduction of quarantine measures for epidemiological reasons;
*planning a sufficient number of premises with a large set of utility rooms;
*creation of “aseptic” operating rooms with effective ventilation and air conditioning;
*planning a centralized sterilization department;
*allocation of four to five operating rooms for every 100 surgical beds.
2) Compliance with sanitary and hygienic conditions includes:
* hand washing by staff;
* treatment of the surgical field, skin, birth canal;
* use of disposable medical instruments, protective clothing, toiletry and care items, disposable consumables and linen;
* regular change of underwear and bed linen;
* proper storage and disposal of dirty linen and dressings;
* proper sanitary maintenance of premises;
* control over the use of sterile materials and instruments (taking sanitary and bacteriological samples).
Disinfection measures include:
* metrological control of disinfection and sterilization installations;
* disinfection and sterilization of bedding and care items after each patient;
* quality control of disinfection, pre-sterilization cleaning and sterilization;
* monitoring the activity of disinfection solutions;
* wide and correct use of ultraviolet emitters.
IVActivities aimed at increasing immunitybody.
For weakened patients, individual supervision is provided. Rational use of antimicrobial agents, use of specific and nonspecific immunostimulants. Vaccination of healthcare facility employees is being carried out according to epidemiological indications.
Example of official documents related to Prevention of nosocomial infections:
OST (industry standard) 42-41-2-85 - sterilization and disinfection of medical devices.
Orders: No. 408 on measures to reduce the incidence of viral hepatitis in the country, No. 184 guidelines for cleaning, disinfection and sterilization of endoscopes and their instruments.
2.1.3.2630 - 10SanPiN - Sanitary and epidemiological rules and regulations
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PENZA STATE UNIVERSITY
Medical Institute
Department of Hygiene, Public Health and Healthcare
Nosocomial infections:
concept, prevalence, routes and factors of transmission, risk factors, prevention system
Educational and methodological manual for students
(VII semester)
Penza, 2005
Nosocomial infection(nosocomial, hospital, hospital) - any clinically significant disease of microbial origin that affects the patient as a result of his admission to the hospital or seeking medical help, as well as the disease of a hospital employee as a result of his work in this institution, regardless of the appearance of symptoms of the disease during stay or after discharge from hospital (WHO Regional Office for Europe, 1979).
Despite advances in healthcare, the problem of nosocomial infections remains one of the most acute in modern conditions, acquiring increasing medical and social significance. According to a number of studies, the mortality rate in the group of hospitalized patients who acquired nosocomial infections is 8-10 times higher than that among hospitalized patients without nosocomial infections.
Damage, associated with in-hospital morbidity, consists of an increase in the length of stay of patients in the hospital, an increase in mortality, as well as purely material losses. However, there is also social damage that cannot be assessed in terms of value (disconnection of the patient from family, work activity, disability, deaths, etc.). In the United States, economic losses associated with hospital-acquired infections are estimated at $4.5–5 billion annually.
Etiological nature Nosocomial infections are determined by a wide range of microorganisms (more than 300), which include both pathogenic and opportunistic flora, the boundary between which is often quite blurred.
Nosocomial infection is caused by the activity of those classes of microflora, which, firstly, are found everywhere and, secondly, are characterized by a pronounced tendency to spread. Among the reasons explaining this aggressiveness are the significant natural and acquired resistance of such microflora to damaging physical and chemical environmental factors, unpretentiousness in the process of growth and reproduction, close relationship with normal microflora, high contagiousness, and the ability to develop resistance to antimicrobial agents.
Main The most important pathogens of nosocomial infections are:
Gram-positive coccal flora: genus Staphylococcus (Staphylococcus aureus, Staphylococcus epidermidis), genus Streptococcus (Streptococcus pyogenes, Streptococcus pneumoniae, Enterococcus);
Gram-negative bacilli: a family of Enterobacteriaceae, including 32 genera, and the so-called non-fermenting Gram-negative bacteria (NGB), the most famous of which is Ps. aeruginosa;
Conditionally pathogenic and pathogenic fungi: the genus of yeast-like fungi Candida (Candida albicans), molds (Aspergillus, Penicillium), pathogens of deep mycoses (Histoplasma, Blastomycetes, Coccidiomycetes);
Viruses: causative agents of herpes simplex and chickenpox (herpviruses), adenovirus infection (adenoviruses), influenza (orthomyxoviruses), parainfluenza, mumps, RS infections (paramyxoviruses), enteroviruses, rhinoviruses, reoviruses, rotaviruses, causative agents of viral hepatitis.
Currently, the most relevant etiological agents of nosocomial infections are staphylococci, gram-negative opportunistic bacteria and respiratory viruses. Each medical institution has its own spectrum of leading pathogens of nosocomial infections, which may change over time. For example, in:
¨ in large surgical centers, the leading pathogens of postoperative nosocomial infections were Staphylococcus aureus and Staphylococcus epidermidis, streptococci, Pseudomonas aeruginosa, and Enterobacteriaceae;
¨ in burn hospitals – the leading role of Pseudomonas aeruginosa and Staphylococcus aureus;
¨ In children's hospitals, the introduction and spread of childhood droplet infections - chickenpox, rubella, measles, mumps - is of great importance.
In neonatal departments, for immunodeficient, hematological patients and HIV-infected patients, herpes viruses, cytomegaloviruses, Candida fungi and Pneumocystis pose a particular danger.
Sources of nosocomial infections are patients and bacteria carriers from among patients and hospital staff, among whom the greatest danger is posed by:
Medical personnel belonging to the group of long-term carriers and patients with erased forms;
Long-term hospitalized patients who often become carriers of resistant nosocomial strains. The role of hospital visitors as sources of nosocomial infections is extremely insignificant.
Routes and factors of transmission of nosocomial infections are very diverse, which significantly complicates the search for causes.
These are contaminated instruments, breathing and other medical equipment, linen, bedding, mattresses, beds, surfaces of “wet” objects (faucets, sinks, etc.), contaminated solutions of antiseptics, antibiotics, disinfectants, aerosols and other medications, care items patients, dressing and suture material, endoprostheses, drainages, transplants, blood, blood and blood replacement fluids, overalls, shoes, hair and hands of patients and staff.
In the hospital environment, so-called secondary, epidemically dangerous reservoirs of pathogens, in which the microflora survives for a long time and multiplies. Such reservoirs may be liquid or moisture-containing objects - infusion fluids, drinking solutions, distilled water, hand creams, water in flower vases, air conditioner humidifiers, shower units, drains and sewer water seals, hand washing brushes, some parts of medical equipment. diagnostic instruments and devices, and even disinfectants with a low concentration of the active agent.
Depending on the routes and factors of transmission of nosocomial infections classify in the following way:
Airborne (aerosol);
Water and nutritional;
Contact and household;
Contact-instrumental:
1) post-injection;
2) postoperative;
3) postpartum;
4) post-transfusion;
5) post-endoscopic;
6) post-transplantation;
7) post-dialysis;
8) post-hemosorption.
Post-traumatic infections;
Other forms.
Clinical classifications of nosocomial infections suggest their division, firstly, into two categories depending on the pathogen: diseases caused by obligate pathogenic microorganisms on the one hand and opportunistic pathogens on the other, although such a division, as noted, is largely arbitrary. Secondly, depending on the nature and duration of the course: acute, subacute and chronic, thirdly, according to the degree of severity: severe, moderate and mild forms of the clinical course. And finally, fourthly, depending on the extent of the process:
1. Generalized infection: bacteremia (viremia, mycemia), sepsis, septicopyemia, infectious-toxic shock.
2. Localized infections:
2.1 Infections of the skin and subcutaneous tissue (wound infections, post-infectious abscesses, omphalitis, erysipelas, pyoderma, paraproctitis, mastitis, dermatomycosis, etc.).
2.2 Respiratory infections (bronchitis, pneumonia, pulmonary abscess and gangrene, pleurisy, pleural empyema, etc.).
2.3 Eye infection (conjunctivitis, keratitis, blepharitis, etc.).
2.4 ENT infections (otitis, sinusitis, rhinitis, tonsillitis, pharyngitis, epiglottitis, etc.).
2.5 Dental infections (stomatitis, abscess, alveolitis, etc.).
2.6 Infections of the digestive system (gastroenterocolitis, cholecystitis, peritoneal abscess, hepatitis, peritonitis, etc.).
2.7 Urological infections (bacteriouria, pyelonephritis, cystitis, urethritis).
2.8 Infections of the reproductive system (salpingoophoritis, endometritis, prostatitis, etc.).
2.9 Infection of bones and joints (osteomyelitis, arthritis, spondylitis, etc.).
2.10 Infection of the central nervous system (meningitis, myelitis, brain abscess, ventriculitis).
2.11 Infections of the cardiovascular system (endocarditis, myocarditis, pericarditis, phlebitis, infections of arteries and veins, etc.).
Of the “traditional” infectious diseases, the greatest danger of nosocomial spread is diphtheria, whooping cough, meningococcal infection, escherichiosis and shigellosis, legionellosis, helicobacteriosis, typhoid fever, chlamydia, listeriosis, Hib infection, rotavirus and cytomegalovirus infection, various forms of candidiasis, influenza and other RVIs , cryptosporidiosis, enteroviral diseases.
Of great importance at present is the danger of transmission of blood-borne infections to health care facilities: viral hepatitis B, C, D, HIV infection (not only patients suffer, but also medical personnel). The particular importance of blood-borne infections is determined by the unfavorable epidemic situation regarding them in the country and the growing invasiveness of medical procedures.
Prevalence of nosocomial infections
It is generally accepted that there is a pronounced under-registration of nosocomial infections in Russian healthcare; officially, 50-60 thousand patients with nosocomial infections are identified in the country every year, and the rates are 1.5-1.9 per thousand patients. According to estimates, about 2 million cases of nosocomial infections occur in Russia per year.
In a number of countries where registration of nosocomial infections has been established satisfactorily, the overall incidence rates of nosocomial infections are as follows: USA - 50-100 per thousand, Netherlands - 59.0, Spain - 98.7; indicators of urological nosocomial infections in patients with a urinary catheter – 17.9 – 108.0 per thousand catheterizations; postoperative HBI indicators range from 18.9 to 93.0.
Structure and statistics of nosocomial infections
Currently, purulent-septic infections occupy a leading place in multidisciplinary healthcare facilities (75-80% of all nosocomial infections). Most often, GSIs are recorded in surgical patients. Especially in the departments of emergency and abdominal surgery, traumatology and urology. For most GSI, the leading transmission mechanisms are contact and aerosol.
The second most important group of nosocomial infections is intestinal infections (8-12% in the structure). Nosocomial salmonellosis and shigellosis are detected in 80% of weakened patients in surgical and intensive care departments. Up to a third of all nosocomial infections of salmonella etiology are registered in pediatric departments and hospitals for newborns. Nosocomial salmonellosis has a tendency to form outbreaks, most often caused by S. typhimurium serovar II R, while salmonella isolated from patients and from environmental objects are highly resistant to antibiotics and external factors.
The share of blood-contact viral hepatitis (B, C, D) in the structure of nosocomial infections is 6-7%. Patients who undergo extensive surgical interventions followed by blood transfusions, patients after hemodialysis (especially chronic program), and patients with massive infusion therapy are most at risk of infection. During serological examination of patients of various profiles, markers of blood-contact hepatitis are detected in 7-24%.
A special risk group is represented by medical personnel whose work involves performing surgical interventions, invasive manipulations and contact with blood (surgical, anesthesiological, intensive care, laboratory, dialysis, gynecological, hematological departments, etc.). Carriers of markers of these diseases in these units are from 15 to 62% of the personnel, many of them suffer from chronic forms of hepatitis B or C.
Other infections in the structure of nosocomial infections account for 5-6% (RVI, hospital-acquired mycoses, diphtheria, tuberculosis, etc.).
In the structure of the incidence of nosocomial infections, a special place is occupied by flashes these infections. Outbreaks are characterized by the mass of diseases in one health care facility, the action of a single route and common transmission factors in all patients, a large percentage of severe clinical forms, high (up to 3.1% mortality), and frequent involvement of medical personnel (up to 5% of all patients). Most common outbreaks of nosocomial infections were detected in obstetric institutions and neonatal pathology departments (36.3%), in psychiatric adult hospitals (20%), in somatic departments of children's hospitals (11.7%).By the nature of the pathology, intestinal infections predominated among the outbreaks (82.3 % of all outbreaks).
Causes and factors of high incidence of nosocomial infections in medical institutions.
Common reasons:
¨ the presence of a large number of sources of infection and conditions for its spread;
¨ decrease in patients’ body resistance during increasingly complex procedures;
¨ shortcomings in the placement, equipment and organization of health care facilities.
Factors of particular importance today
1. Selection of multidrug-resistant microflora, which is caused by the irrational and unjustified use of antimicrobial drugs in health care facilities. As a result, strains of microorganisms are formed with multiple resistance to antibiotics, sulfonamides, nitrofurans, disinfectants, skin and medicinal antiseptics, and UV irradiation. These same strains often have altered biochemical properties, colonize the external environment of health care facilities and begin to spread as hospital strains, mainly causing nosocomial infections in a particular medical institution or medical department.
2. Formation of bacterial carriage. In a pathogenetic sense, carriage is one of the forms of the infectious process in which there are no pronounced clinical signs. It is currently believed that bacteria carriers, especially among medical personnel, are the main sources of nosocomial infections.
If among the population carriers of S. aureus among the population, on average, account for 20-40%, then among the staff of surgical departments - from 40 to 85.7%.
3. The increase in the number of people at risk of developing nosocomial infections, which is largely due to achievements in the field of healthcare in recent decades.
Among hospitalized and outpatient patients, the proportion of:
· elderly patients;
· young children with reduced body resistance;
· premature babies;
· patients with a wide variety of immunodeficiency conditions;
· unfavorable premorbid background due to exposure to adverse environmental factors.
As the most significant reasons for the development of immunodeficiency states distinguished: complex and lengthy operations, the use of immunosuppressive medications and manipulations (cytostatics, corticosteroids, radiation and radiotherapy), prolonged and massive use of antibiotics and antiseptics, diseases leading to disruption of immunological homeostasis (lesions of the lymphoid system, oncological processes, tuberculosis, diabetes mellitus, collagenosis, leukemia, hepatic-renal failure), old age.
4. Activation of artificial (artificial) mechanisms of transmission of nosocomial infections, which is associated with the complication of medical equipment, a progressive increase in the number of invasive procedures using highly specialized devices and equipment. Moreover, according to WHO, up to 30% of all procedures are not justified.
The most dangerous manipulations from the point of view of transmission of nosocomial infections are:
Diagnostic: blood sampling, probing of the stomach, duodenum, small intestine, endoscopy, puncture (lumbar, sternal, organs, lymph nodes), biopsies of organs and tissues, venesection, manual examinations (vaginal, rectal) - especially in the presence of erosions on the mucous membranes and ulcers;
Therapeutic: transfusions (blood, serum, plasma), injections (from subcutaneous to intramuscular), tissue and organ transplantation, operations, intubation, inhalation anesthesia, mechanical ventilation, catheterization (vessels, bladder), hemodialysis, inhalation of therapeutic aerosols , balneological treatment procedures.
5. Incorrect architectural and planning solutions of medical institutions, which leads to the intersection of “clean” and “dirty” flows, lack of functional isolation of departments, favorable conditions for the spread of strains of nosocomial pathogens.
6. Low efficiency of medical and technical equipment of medical institutions. Here the main meanings are:
Insufficient material and technical supplies with equipment, instruments, dressings, medications;
Insufficient set and area of premises;
Irregularities in the operation of supply and exhaust ventilation;
Emergency situations (water supply, sewerage), interruptions in the supply of hot and cold water, disruptions in heat and energy supply.
7. Shortage of medical personnel and unsatisfactory training of hospital staff on the prevention of nosocomial infections.
8. Failure by the staff of medical institutions to comply with the rules of hospital and personal hygiene and violation of the regulations of the sanitary and anti-epidemic regime.
System of measures for the prevention of nosocomial infections.
I . Nonspecific prevention
1. Construction and reconstruction of inpatient and outpatient clinics in compliance with the principle of rational architectural and planning solutions:
Isolation of sections, wards, operating units, etc.;
Respect and separation of flows of patients, personnel, “clean” and “dirty” flows;
Rational placement of departments on floors;
Correct zoning of the territory.
2. Sanitary measures:
Effective artificial and natural ventilation;
Creation of regulatory conditions for water supply and sanitation;
Correct air supply;
Air conditioning, use of laminar flow units;
Creation of regulated parameters of microclimate, lighting, noise conditions;
Compliance with the rules for the accumulation, neutralization and disposal of waste from medical institutions.
3. Sanitary and anti-epidemic measures:
Epidemiological surveillance of nosocomial infections, including analysis of the incidence of nosocomial infections;
Control over the sanitary and anti-epidemic regime in medical institutions;
Introduction of a hospital epidemiologist service;
Laboratory monitoring of the state of the anti-epidemic regime in health care facilities;
Identification of bacteria carriers among patients and staff;
Compliance with patient placement standards;
Inspection and permission of personnel to work;
Rational use of antimicrobial drugs, primarily antibiotics;
Training and retraining of personnel on issues of regime in health care facilities and prevention of nosocomial infections;
Sanitary educational work among patients.
4. Disinfection and sterilization measures:
Use of chemical disinfectants;
Application of physical disinfection methods;
Pre-sterilization cleaning of instruments and medical equipment;
Ultraviolet bactericidal irradiation;
Chamber disinfection;
Steam, dry air, chemical, gas, radiation sterilization;
Carrying out disinsection and deratization.
II . Specific prevention
1. Routine active and passive immunization.
2. Emergency passive immunization.
Maternity hospitals
According to sample studies, the actual incidence of nosocomial infections in obstetric hospitals reaches 5-18% of newborns and 6 to 8% of postpartum women.
Staphylococcus aureus predominates in the etiological structure; in recent years, there has been a tendency towards an increase in the importance of various gram-negative bacteria. It is gram-negative bacteria that are usually responsible for outbreaks of nosocomial infections in maternity wards. Also, the value of St. increases. epidermidis.
The “risk” department is the department of premature babies, where, in addition to the above pathogens, diseases caused by fungi of the genus Candida are often found.
Most often, nosocomial infections of the purulent-septic group occur in maternity departments; outbreaks of salmonellosis have been described.
Nosocomial infections in newborns are characterized by a variety of clinical manifestations. Purulent conjunctivitis, suppuration of the skin and subcutaneous tissue predominate. Intestinal infections caused by opportunistic flora are often observed. Omphalitis and phlebitis of the umbilical vein are more rare. Up to 0.5-3% of the structure of nosocomial infections in newborns are generalized forms (purulent meningitis, sepsis, osteomyelitis).
The main sources of staphylococcal infection are carriers of hospital strains among medical personnel; for infections caused by gram-negative bacteria - patients with mild and erased forms among medical workers, less often - among postpartum women. The most dangerous sources are resident carriers of hospital strains of St. aureus and patients with indolent urinary tract infections (pyelonephritis).
Intranatally, newborns can be infected from their mothers with HIV infection, blood-borne hepatitis, candidiasis, chlamydia, herpes, toxoplasmosis, cytomegaly and a number of other infectious diseases.
In obstetric departments, there are a variety of transmission routes for nosocomial infections: contact-household, airborne, airborne-dust, fecal-oral. Among the transmission factors, dirty hands of personnel, oral liquid dosage forms, infant formula, donor breast milk, and unsterile diapers are of particular importance.
Groups at “risk” for the development of nosocomial infections among newborns are premature infants, newborns from mothers with chronic somatic and infectious pathologies, acute infections during pregnancy, with birth trauma, after cesarean section, and with congenital developmental anomalies. Among postpartum women, the greatest risk is in women with chronic somatic and infectious diseases, aggravated by obstetric history, after cesarean section.
Pediatric somatic hospitals
According to American authors, nosocomial infections are most often found in intensive care units of pediatric hospitals (22.2% of all patients who passed through this department), children's oncology departments (21.5% of patients), and children's neurosurgical departments (17.7- 18.6%). In cardiology and general somatic pediatric departments, the incidence of nosocomial infections reaches 11.0-11.2% of hospitalized patients. In Russian hospitals for young children, the frequency of infection of children with nosocomial infections ranges from 27.7 to 65.3%.
In children's somatic hospitals, there is a variety of etiological factors for nosocomial infections (bacteria, viruses, fungi, protozoa).
In all children's departments, the introduction and nosocomial spread of respiratory tract infections, for the prevention of which vaccines are either absent or used in limited quantities (varicella, rubella, etc.), are of particular relevance. The introduction and emergence of group foci of infections, for which mass immunoprophylaxis is used (diphtheria, measles, mumps), cannot be ruled out.
Sources of infection are: patients, medical personnel, and less commonly, caregivers. Patients, as primary sources, play the main role in the spread of nosocomial infections in nephrology, gastroenterology, pulmonology, and pediatric infectious diseases departments.
Children with activation of endogenous infection against the background of an immunodeficiency state also pose a threat as a source of infection.
Among medical workers, the most common sources of infection are persons with indolent forms of infectious pathology: urogenital tract, chronic pharyngitis, tonsillitis, rhinitis. In case of streptococcal infection, carriers of group B streptococci (pharyngeal, vaginal, intestinal carriage) are of no small importance.
In children's somatic departments, both natural and artificial transmission routes are important. The airborne droplet mechanism is characteristic of the nosocomial spread of influenza, RVI, measles, rubella, streptococcal and staphylococcal infections, mycoplasmosis, diphtheria, and pneumocystis. During the spread of intestinal infections, both contact and household routes and nutritional transmission routes are active. Moreover, the nutritional route is most often associated not with infected foods and dishes, but with orally administered dosage forms (saline solution, glucose solutions, infant formula, etc.). The artificial route is usually associated with injection equipment, drainage tubes, dressing and suture material, and breathing equipment.
Among children over one year of age, the “risk” groups include children with blood diseases, cancer processes, chronic pathologies of the heart, liver, lungs and kidneys, receiving immunosuppressants and cytostatics, and receiving repeated courses of antibacterial treatment.
Planning box-type departments for young children and placement of older children in single-double wards;
Organization of a reliable supply and exhaust ventilation system;
Organization of high-quality work of the admission department in order to prevent joint hospitalization of children with somatic pathologies and children with foci of infections;
Compliance with the principle of cyclicity when filling wards, timely removal of patients with signs of infectious diseases from the department;
Granting the status of infectious diseases departments for young children, nephrology, gastroenterology and pulmonology.
Surgical hospitals
General surgical departments should be considered as departments at increased “risk” for the occurrence of nosocomial infections, which is determined by the following circumstances:
The presence of a wound, which is a potential entry gate for pathogens of nosocomial infections;
Among those hospitalized in surgical hospitals, about 1/3 are patients with various purulent-inflammatory processes, where the risk of wound infection is very high;
In recent years, indications for surgical interventions have expanded significantly;
Up to half of surgical interventions are performed for emergency reasons, which contributes to an increase in the frequency of purulent-septic infections;
With a significant number of surgical interventions, microorganisms from nearby parts of the body may enter the wound in quantities that can cause a local or general infectious process.
Surgical wound infections (SWI) play a leading role in the structure of nosocomial infections in these departments.
On average, the incidence of CRI in general surgical departments reaches 5.3 per 100 patients. CRIs cause additional morbidity and mortality, increase the length of hospitalization (at least 6 days), and require additional costs for diagnosis and treatment. CRI causes up to 40% of postoperative mortality.
Classification of surgical wounds
Types of HRI:
Superficial (involving the skin and subcutaneous tissue through which the incision is made);
Deep (involving deep soft tissues - muscles and fascia);
CXR of a cavity (organ) – in this case, any anatomical structures are involved in the pathological process.
Infection can occur both exogenously and endogenously, and the ratio of these two types of infection is determined by the profile of the patient population admitted to the surgical department. It is believed that up to 80% of CRI in abdominal surgery is associated with endogenous infection, the leading pathogens being Escherichia coli. Exogenous infection is a consequence of the transmission of pathogens from the external environment, from patients and from medical personnel. For CRI, the etiological factor of which is Pseudomonas aeruginosa, the leading category of source reservoirs is the external environment, for staphylococcal etiology - medical personnel and patients.
The leading route of transmission is contact, transmission factors are the hands of personnel and medical instruments.
The most common sites of infection are operating rooms and dressing rooms; infection in the operating room is more likely if the incubation period of the disease does not exceed 7 days and there is deep suppuration of the wound (abscesses, phlegmon).
Risk factors for CRI are numerous:
Severe background condition of the patient;
The presence of concomitant diseases or conditions that reduce anti-infective resistance (diabetes mellitus, obesity, etc.);
Inadequate antibiotic prophylaxis;
Inadequate treatment of the skin of the surgical field with antiseptics;
Long hospital stay before surgery;
The nature of the surgical intervention and the degree of contamination of the surgical wound;
Technique of the operating surgeon (traumatic handling of tissues, poor comparison of wound edges, surgical approach, pressure bandage, etc.);
Quality of suture material;
Duration of the operation;
The nature and number of postoperative procedures;
Technique and quality of dressings.
Features of the organization of CRI prevention:
Adequate preoperative preparation of the patient, assessment of the risk of nosocomial infections;
According to strict indications - antibiotic prophylaxis before surgery with the administration of an antibiotic no earlier than 2 hours before the intervention;
The correct choice of a broad-spectrum antiseptic for treating the surgical field;
Reducing the patient's stay in the hospital before surgery;
Shaving is carried out only if necessary, and it should be carried out immediately before the start of the operation;
Correct surgical technique: effective hemostasis, suturing surgical wounds without tension, correct position of the bandage, suturing the wound with excision of necrotic areas, etc.;
Widespread use of biologically inert suture material (lavsan, polypropylene);
Reducing the risk of infection of postoperative wounds through the use of epidemiologically safe algorithms for postoperative procedures and manipulations, strict adherence to the anti-epidemic regime in dressing rooms, a clear division of dressing rooms into clean and purulent ones.
Burn hospitals
Burn departments are high-risk units for the development of hospital infections, which is determined by a number of circumstances:
Thermal tissue damage creates favorable conditions for the life of microorganisms in wounds with their subsequent generalization;
Patients with burns of more than 30% of the body surface are often hospitalized in burn departments, which is usually accompanied by infection;
In patients with burn injury as a result of burn shock, severe immunosuppression often occurs, which favors the development of nosocomial infections.
Mortality for burn wounds of III-IV degrees reaches 60-80%, with about 40% caused by hospital-acquired infections of the burn wound. Mortality in sepsis caused by gram-negative flora reaches 60-70%, Pseudomonas aeruginosa - 90%. The addition of gram-negative flora increases, on average, the duration of hospitalization by 2 times.
¨ sepsis;
¨ wound suppuration;
¨ abscess;
¨ phlegmon;
¨ lymphangitis.
As a rule, nosocomial infections of burn wounds occur at least 48 hours after hospitalization. Burn wounds of the lower 2/3 of the body are most early and abundantly contaminated. The leading etiological factors of hospital infections of a burn wound are Pseudomonas aeruginosa, staphylococci, bacteria of the genus Acinetobacter; less often - mushrooms, proteas, E. coli.
Both exo- and endogenous infection are typical. Endogenous infection is associated with the activation of the patient’s microflora, which populates the gastrointestinal tract and skin of the patient. The main source of infection during exogenous infection is the external environment of the hospital and patients with nosocomial infections.
Transmission is most often carried out by contact through the hands of personnel; infection is possible through instrumental means when treating burn surfaces.
The “risk” factors for the occurrence of nosocomial infections in burn hospitals include:
Depth and size of the burn;
Severe immunosuppression due to decreased phagocytosis of neutrophils and the level of IgM antibodies;
Formation of hospital strains of Ps.aeruginosa and Acinetobacter;
Pollution of the hospital environment (presence of reservoirs of infection).
Features of the organization of CRI prevention:
Prompt and rapid closure of a burn wound, the use of polymer and other coatings;
Administration of immunopreparations (vaccines, immunoglobulins);
Application of adapted bacteriophages;
Effective disinfection of personnel hands, environmental objects, sterilization of instruments;
Application of laminar air flows for patients with large burns;
Conducting epidemiological surveillance of hospital infections with mandatory microbiological monitoring.
Urological hospitals
Features of urological hospitals that are important for the spread of nosocomial infections in these departments:
Most urological diseases are accompanied by disruption of the normal dynamics of urine, which is a predisposing factor for infection of the urinary tract;
The main contingent of patients are elderly people with reduced immunological reactivity;
Frequent use of various endoscopic equipment and instruments, the cleaning and sterilization of which is difficult;
The use of multiple transurethral manipulations and drainage systems, increasing the likelihood of microorganisms entering the urinary tract;
In a urological hospital, patients with severe purulent processes (pyelonephritis, kidney carbuncle, prostate abscess, etc.) are often operated on, in whom microflora is detected in the urine in a clinically significant amount.
The leading role in the pathology of patients in these hospitals belongs to urinary tract infections (UTIs), which account for 22 to 40% of all nosocomial infections, and the frequency of UTIs is 16.3-50.2 per 100 patients in urological departments.
Main clinical forms of UTI:
Pyelonephritis, pyelitis;
Urethritis;
Cystitis;
Orchiepidedimitis;
Suppuration of postoperative wounds;
Asymptomatic bacteriouria.
The main etiological factors of UTI are Escherichia coli, Pseudomonas aeruginosa, Proteus, Klebsiella, streptococci, enterococci and their associations. In 5-8% anaerobes are detected. The widespread use of antibiotics for UTIs has led to the emergence of L-forms of microorganisms, the identification of which requires special research techniques. The release of a normally sterile urine monoculture of one microorganism in combination with a high degree of bacteriouria is characteristic of an acute inflammatory process, while an association of microorganisms is characteristic of a chronic one.
Endogenous infection of the urinary tract is associated with the presence of natural contamination of the external parts of the urethra, and during various diagnostic transurethral manipulations, the introduction of microorganisms into the bladder is possible. Frequent stagnation of urine leads to the proliferation of microorganisms in it.
Exogenous nosocomial infections occur from patients with acute and chronic UTIs and from hospital environmental objects. The main places of UTI infection are dressing rooms, cystoscopic manipulation rooms, wards (if dressings of patients are carried out in them and when open drainage systems are used).
The leading factors for the transmission of nosocomial infections are: open drainage systems, the hands of medical personnel, catheters, cystoscopes, various specialized instruments, solutions contaminated with microorganisms, including antiseptic solutions.
In 70% of UTIs of pseudomonas etiology, exogenous infection occurs; the pathogen is able to persist for a long time and multiply on environmental objects (sinks, containers for storing brushes, trays, antiseptic solutions).
Risk factors for developing UTI:
Invasive therapeutic and diagnostic procedures, especially in the presence of inflammatory phenomena in the urinary tract;
Presence of patients with indwelling catheters;
Formation of hospital strains of microorganisms;
Massive antibiotic therapy for patients in the department;
Violation of the processing regime for endoscopic equipment;
Use of open drainage systems.
Features of organizing the prevention of nosocomial infections:
The use of catheterization only for strict indications, the use of single-use catheters, training of medical staff in the rules of working with catheters;
If you have permanent catheters, remove them as early as possible; in the area of the external urethral opening at least 4 times a day it is necessary to treat catheters with an antiseptic solution;
Organization of epidemiological surveillance in a hospital with microbiological monitoring of circulating strains; use of adapted bacteriophages;
Various tactics of antibiotic therapy in patients with mandatory study of the sensitivity of circulating strains to antibiotics;
Strict adherence to the processing regime for endoscopic equipment;
Use of closed drainage systems;
Bacteriological examination of planned patients at the prehospital stage and dynamic bacteriological examination of patients in urology departments.
Reanimation and intensive care units
Resuscitation and intensive care units (ICU) are specialized high-tech medical departments of hospitals for hospitalization of the most severe patients with various types of life-threatening conditions.
A distinctive feature of the departments is the control and “prosthetics” of the functions of body systems that ensure the process of human existence as a biological object.
The need to concentrate severely ill patients and personnel constantly working with them in a limited space;
The use of invasive methods of research and treatment associated with possible contamination of conditionally sterile cavities (tracheobronchial tree, bladder, etc.), disruption of the intestinal biocenosis (antibacterial therapy);
The presence of an immunosuppressive state (forced fasting, shock, severe trauma, corticosteroid therapy, etc.);
are important factors contributing to the occurrence of nosocomial infections in these departments.
The most significant “risk” factors for patients in the ICU are: the presence of intravascular and urethral catheters, tracheal intubation, tracheostomy, mechanical ventilation, the presence of wounds, chest drainage, peritoneal dialysis or hemodialysis, parenteral nutrition, administration of immunosuppressive and anti-stress drugs . The incidence of nosocomial infections increases significantly if ICU stay lasts more than 48 hours.
Factors that increase the likelihood of death:
ICU acquired pneumonia;
Bloodstream infection or sepsis confirmed by blood culture.
According to studies, about 45% of ICU patients had various types of nosocomial infection, including 21% - an infection acquired directly in the ICU.
The most common types of infection were: pneumonia - 47%, lower respiratory tract infections - 18%, urinary tract infections - 18%, bloodstream infections - 12%.
The most common types of pathogens are: enterobacteriaceae - 35%, Staphylococcus aureus - 30% (of which 60% are methicillin-resistant), Pseudomonas aeruginosa - 29%, coagulase-negative staphylococci - 19%, fungi - 17%.
Features of organizing the prevention of nosocomial infections:
Architectural and design solutions for the construction of new intensive care units. The main principle is the spatial separation of the flow of patients who enter the department for a short time, and patients who will be forced to stay in the department for a long time;
The main mechanism of contamination is the hands of staff; it would be ideal to follow the principle: “one nurse - one patient” when serving patients who are in the department for a long time;
Strict adherence to the principles of asepsis and antisepsis when carrying out invasive methods of treatment and examination, using disposable devices, materials and clothing;
The use of clinical and microbiological monitoring, which makes it possible to make maximum use of the possibilities of targeted antibiotic therapy and avoid the unreasonable use of empirical therapy, including antifungal therapy.
Ophthalmological hospitals
The ophthalmology hospital follows the same principles as other surgical hospitals. The main pathogens of nosocomial infections are Staphylococcus aureus and Staphylococcus epidermidis, Enterococci, Pneumococci, Group A and B streptococci, and Pseudomonas aeruginosa.
The peculiarities lie, on the one hand, in the large number of patients, and on the other hand, in the need to examine patients with the same instruments. Due to the complex and delicate mechanical-optical and electron-optical design of diagnostic and surgical instruments, classical methods of washing, disinfection and sterilization are excluded.
The main sources of infection are patients and carriers (patients and medical personnel) who are in the hospital.
Leading routes and factors of transmission of nosocomial infections:
Direct contact with patients and carriers;
Indirect transmission through various objects, objects of the external environment;
Through common transmission factors (food, water, drugs) infected by a sick person or carrier.
The risk of developing an nosocomial infection increases if:
Frequencies and technologies for daily wet cleaning of hospital wards, examination rooms and other premises;
Anti-epidemic regime when conducting diagnostic and therapeutic procedures for patients;
Systematic filling of hospital wards (preoperative and postoperative patients);
Rules and schedule for visiting patients by visitors;
Instilled in the acceptance of transmissions and conditions for their storage
Graphics and flow of patients during treatment and diagnostic procedures;
Quarantine and isolation measures when identifying a patient with an infectious lesion of the organs of vision.
Features of organizing the prevention of nosocomial infections:
1. The wards of the ophthalmology department should have 2-4 beds. It is also necessary to provide for the presence in the department of a single room for isolation of a patient with suspected nosocomial infections.
2. Ophthalmic operating rooms have a number of differences from ordinary operating rooms. Most operations are performed under local anesthesia, the operation time does not exceed 20–30 minutes, the number of operations performed during a working day is at least 20–25, which increases the likelihood of violation of aseptic conditions in the operating room. As part of the operating unit, it is necessary to have an operating room in which operations are performed on patients with infectious diseases of the organs of vision. This operating room must be equipped with all necessary surgical equipment to avoid the use of equipment from “clean” operating rooms.
In operating rooms, it is preferable to create a unidirectional laminar flow in the area of the surgical wound.
The thorough preoperative treatment of surgeons' hands is of great importance, since most ophthalmologists currently operate without gloves.
3. Organization of effective ventilation operation (change rate of at least 12 per hour, preventive cleaning of filters at least 2 times a year).
4. Clear organization of the ultraviolet bactericidal irradiation regime for premises.
5. Use of gas, plasma sterilizers and chemical sterilization techniques for processing highly specialized fragile instruments.
6. When it comes to preventing the occurrence of nosocomial infections, special attention should be paid to patients.
First of all, it is necessary to identify from the general flow of patients most susceptible to infection, that is, the “risk group”, directing the main attention to them when carrying out preventive measures: preoperative bacteriological examination, the use of protective surgical cut films on the surgical field, discharge from the hospital only for medical reasons .
7. In their design, most ophthalmic diagnostic devices have a chin rest and a support for the upper part of the head.
To comply with the anti-epidemic regime in diagnostic rooms, it is necessary to regularly, after each patient, wipe the chin rest and the forehead support with a disinfectant solution. You can touch the patient's eyelids only through a sterile napkin. Swabs and tweezers for cotton balls must be sterilized.
When conducting a diagnostic examination of patients, it is necessary to follow a certain sequence: first of all, examinations are carried out using non-contact methods (determining visual acuity, visual fields, refractometry, etc.), and then a set of contact techniques (tonometry, topography, etc.).
8. Examination of patients with purulent lesions of the organs of vision must be carried out with gloves. If blenorrhea is suspected, staff should wear protective eyewear.
9. Particular importance is attached to strict adherence to the technology of disinfection of diagnostic equipment that comes into contact with the mucous membranes of the eye during use.
Therapeutic hospitals
The features of the therapeutic departments are:
The majority of patients in these departments are elderly people with chronic pathologies of the cardiovascular, respiratory, urinary, nervous systems, hematopoietic organs, gastrointestinal tract, and cancer;
Violations of the local and general immunity of patients due to the long course of the disease and the courses of non-surgical treatment used;
An increasing number of invasive therapeutic and diagnostic procedures;
Among patients in therapeutic departments, patients with “classical” infections (diphtheria, tuberculosis, RVI, influenza, shigellosis, etc.) are often identified who are admitted to the hospital during the incubation period or as a result of diagnostic errors;
There are frequent cases of infections that have intrahospital spread (nosocomial salmonellosis, viral hepatitis B and C, etc.);
An important problem for patients in a therapeutic hospital is viral hepatitis B and C.
One of the leading “risk” groups for infection with nosocomial infections are gastroenterological patients, among whom up to 70% are people with gastric ulcer (GUD), duodenal ulcer (DU) and chronic gastritis. The etiological role of the microorganism Helicobacter pylori in these diseases is now recognized. Based on the primary infectious nature of ulcers, DU and chronic gastritis, it is necessary to take a different approach to the requirements of the sanitary and anti-epidemic regime in gastroenterological departments.
In hospital settings, the spread of helicobacteriosis can be facilitated by the use of insufficiently cleaned and sterilized endoscopes, gastric tubes, pH meters and other instruments. In general, per patient in gastroenterology departments there are 8.3 studies, including 5.97 instrumental (duodenal intubation - 9.5%, gastric - 54.9%, endoscopy of the stomach and duodenum - 18.9%). Almost all of these studies are invasive methods, always accompanied by a violation of the integrity of the gastrointestinal mucosa, and if processing and storage methods are violated, microorganisms from contaminated instruments penetrate through damage to the mucosa. In addition, given the fecal-oral mechanism of transmission of helicobacteriosis, the quality of hand cleaning of medical personnel is of great importance.
Sources of infection in gastroenterology departments are also patients with chronic colitis, who often release various pathogenic and opportunistic microorganisms into the external environment.
High-quality prehospital diagnostics and prevention of hospitalization of patients with “classical” infections;
A full range of isolation-restrictive and anti-epidemic measures for the introduction of “classic” infections into the department (including disinfection and emergency immunization of contact persons);
Strict control over the quality of pre-sterilization treatment and sterilization of instruments used for invasive manipulations, reducing an unreasonably large number of invasive procedures;
Use of gloves during all invasive procedures, vaccination of personnel against hepatitis B;
Strict adherence to personal hygiene by staff and patients;
Prescribing eubiotics to patients (atsipol, biosporin, bifidumbacterin, etc.).
Psychiatric hospitals
The etiological structure of nosocomial infections in psychiatric hospitals differs sharply from that in other health care facilities. Basically, what is presented here is not nosocomial infections caused by opportunistic flora, but “classical” infections with nosocomial spread. Among them, intestinal infections dominate: shigellosis (usually Flexner's shigellosis), salmonellosis (typhimurium, enteritidis), typhoid fever, and cases of intestinal clostridiosis (Cl. deficile) and cryptosporidiosis.
Against the backdrop of an aggravation of the epidemic situation with diphtheria and tuberculosis in the country, diphtheria was brought into psychiatric wards, and the risk of hospitalization of patients with unrecognized tuberculosis increased. Nosocomial outbreaks of tuberculosis appeared.
Sources of infection during nosocomial infections are patients and carriers from among patients, and occasionally, medical workers. The role of carriers is most significant in typhoid fever.
In psychoneurological departments, various mechanisms, pathways and factors of transmission of nosocomial infections operate.
Since the material and technical base of a number of psychiatric hospitals does not meet modern requirements (overcrowding of ward departments, multiple beds in wards, lack of the necessary set of production and auxiliary premises), the prerequisites are created for the activation of the fecal-oral mechanism of infection spread. Contributing factors are a decrease in hygiene skills in patients due to personality deformation. The main active transmission factors are the hands of patients and contaminated household items. In addition, foodborne outbreaks of intestinal infections associated with disruptions in the functioning of catering units are recorded.
In overcrowded hospitals, the airborne transmission mechanism is active, which is facilitated by the transfer of patients from ward to ward depending on changes in mental status.
Since the proportion of invasive procedures in psychoneurological hospitals is low (mainly injections are performed), the instrumental route of infection with nosocomial infections is less significant.
At-risk groups":
Elderly people with concomitant somatic and infectious diseases;
For intestinal nosocomial infections - persons with a severe course of the underlying disease, which led to a violation of hygienic skills;
For tuberculosis - migrants, alcoholics, former prisoners and homeless people.
Features of organizing the prevention of nosocomial infections:
1. In order to prevent the introduction of OKI, hospitalization is carried out in the presence of negative results of a bacteriological examination for pathogenic enterobacteria.
In case of emergency hospitalization, the patient is sent to an isolation ward and material is collected for bacteriological examination in the emergency department.
2. Creation of reception and quarantine departments for patients.
3. Creation of separate isolation wards for identified typhoid carriers, where they remain throughout their stay in the psychoneurological hospital.
4. Increased alertness for infectious pathology in patients undergoing hospital treatment; It is mandatory to conduct a bacteriological examination of feces and vomit in case of intestinal dysfunction, a smear for diphtheria - for sore throat, for fever of unknown etiology lasting more than 3 days - examination for typhoid and typhus + microscopy of blood smears for malaria.
Immediate transfer to the isolation ward and infectious diseases hospital of the patient in case of suspicion of having an infectious disease with the organization of appropriate anti-epidemic and disinfection measures in the department.
5. Creation of the necessary conditions in the department for patients and staff to observe personal hygiene rules.
6. Carrying out additional invasive procedures with strict justification for their need.
Test questions for the lesson
“Nosocomial infections: concept, prevalence, routes and factors of transmission, risk factors, prevention system.”
Note: a number of questions contain multiple correct answer options:
1. The most dangerous sources of nosocomial infections are:
a) visitors to patients suffering from chronic tonsillitis and pharyngitis;
b) caring for seriously ill patients with inflammatory gynecological pathology;
c) medical personnel returning to work after suffering intestinal infections;
d) medical personnel who returned to work after suffering from acute respiratory viral infections;
e) long-term hospitalized patients.
2. A patient with manic-depressive psychosis, who is being treated in a psychiatric department, continues to have a fever for four days, the cause of which has not been established. For this patient:
a) it is necessary to establish dynamic clinical observation;
b) discharged from the hospital;
c) conduct a serological blood test for typhoid and typhus and microscopy of blood smears for malaria;
d) conduct a bacteriological study of feces for the presence of pathogenic enterobacteria.
3. The increased risk of nosocomial infections in general surgical departments is determined by:
a) high frequency of surgical interventions performed for emergency indications;
b) a large number of intramuscular injections;
c) a large number of intravenous infusions given to patients;
d) the frequent need for patients to undergo bladder catheterization;
e) non-compliance with space standards in the wards of most existing general surgical departments.
4. With the nosocomial spread of intestinal infections in children's somatic hospitals, the most common infections occur:
a) with oral consumption of infected dosage forms;
b) when consuming food contaminated in a hospital catering unit or in a pantry.
5. The leading sources of nosocomial infections in pediatric pulmonology departments are:
a) medical personnel;
b) sick;
c) caregivers.
6. Features of organizing the prevention of nosocomial infections in general surgical hospitals:
a) administration of an antibiotic for prophylactic purposes according to strict indications;
b) strict control over compliance with the norms of the anti-epidemic regime in manipulation rooms;
c) implementation of microbiological control over the state of the sanitary and anti-epidemic regime;
d) widespread use of biologically inert suture material;
e) implementation of bacteriological etiological decoding of nosocomial infections.
7. Features of organizing the prevention of nosocomial infections in children's somatic departments include:
a) the use of catheterization only for strict indications and the use of single-use catheters;
b) organization of epidemiological surveillance in a hospital with microbiological monitoring of circulating strains; use of adapted bacteriophages;
c) different tactics of antibiotic therapy in patients with mandatory study of the sensitivity of circulating strains to antibiotics;
d) compliance with the principle of cyclicity when filling wards, timely removal of patients with signs of infectious diseases from the department;
8. Nosocomial infection is:
a) any clinically significant disease of microbial origin that affects the patient as a result of his stay in the hospital, as well as the disease of hospital staff as a result of his work in this institution, regardless of the appearance of symptoms of the disease during his stay or after discharge from the hospital;
b) any clinically significant disease of microbial origin that affects the patient as a result of his admission to the hospital or seeking medical care, as well as the disease of a hospital employee as a result of his work in this institution, regardless of the appearance of symptoms of the disease during his stay or after discharge from the hospital ;
c) any clinically significant disease of microbial origin that affects the patient as a result of his admission to the hospital or seeking medical help, as well as the disease of the patient’s relatives who became infected through contact with him.
9. The main etiological factors of nosocomial urinary tract infections include:
a) Pseudomonas aeruginosa;
b) clostridia;
c) epidermal staphylococcus;
d) actinomycetes.
10. The leading etiological agents of hospital-acquired burn wound infections include:
a) bacteria of the genus Citrobacter;
b) proteas;
c) Corynebacterium diphtheria;
d) Pseudomonas aeruginosa;
e) micrococci;
f) staphylococci;
g) bacteria of the genus Acinetobacter.
11. The greatest risk of nosocomial infection with blood-contact hepatitis is typical for:
a) patients in psychiatric hospitals;
b) patients undergoing treatment in day hospitals for exacerbation of chronic pathology of the bronchopulmonary system;
c) patients who received extensive surgical interventions followed by transfusions of blood components;
d) women who undergo mini-abortion in outpatient settings;
e) women who undergo artificial abortion in a hospital setting;
f) patients receiving hemodialysis procedures.
12. Outbreaks of nosocomial infections are characterized by:
a) the action of various routes of transmission of the pathogen;
b) the action of a single route of transmission of infection;
c) high proportion of mild clinical forms of nosocomial infections;
d) high mortality;
e) absence of illness among service personnel.
13. Classification of surgical wounds according to the degree of danger of the occurrence of nosocomial infections involves their division into:
a) clean;
b) conditionally pure;
c) conditionally dirty;
d) contaminated;
d) dirty.
14. Secondary reservoirs of nosocomial pathogens that form in the hospital environment include:
a) medical personnel;
b) air conditioner humidifiers;
c) used cleaning equipment;
d) shower installations;
e) disinfectants with a low concentration of the active agent.
15. Features of organizing the prevention of nosocomial infections in therapeutic hospitals:
a) strict control over the quality of pre-sterilization treatment and sterilization of instruments used for invasive manipulations while simultaneously reducing the number of invasive procedures;
b) prescribing eubiotic drugs to patients;
c) periodic bacteriological examination of medical personnel as planned.
16. The leading risk groups for occupational infection with viral hepatitis B and C include medical workers:
a) anesthesiology and intensive care departments;
b) paramedic of rural medical outpatient clinics;
c) hemodialysis centers and departments;
d) therapeutic departments;
e) guard nurses of psychoneurological departments.
17. The structure of nosocomial infections in intensive care units is dominated by:
a) urinary tract infections;
b) bloodstream infections;
c) pneumonia.
18. Depending on the routes and factors of transmission of nosocomial infections, the following groups of nosocomial infections are distinguished:
a) airborne;
b) contact and household;
c) contact-alimentary;
d) water and nutritional;
e) localized;
f) contact and household;
g) generalized.
19. The leading route of transmission of surgical wound infections is:
a) contact;
b) airborne dust;
c) nutritional;
d) blood transfusion.
20. Contaminated surgical wounds include:
a) surgical wounds in which microorganisms that caused nosocomial infections were present in the surgical field before the operation;
b) surgical wounds with significant violation of sterile technique or with significant leakage of gastrointestinal tract contents
c) surgical wounds penetrating the respiratory tract, digestive tract, genital or urinary tract.
21. Common reasons for the high incidence of nosocomial infections in medical institutions include:
a) the presence of a large number of sources of infection and conditions for its spread;
b) reduction in the number of inpatient beds in health care facilities;
c) a decrease in the resistance of the patient’s body during increasingly complex procedures;
d) introduction of the principle of shared stay in obstetric hospitals;
e) shortcomings in the placement, equipment and organization of work of health care facilities.
22. Sources of infection during nosocomial infections in neuropsychiatric hospitals most often are:
a) patients and carriers from among medical workers;
b) patients and carriers from among the patients.
23. Currently, the structure of nosocomial infections in medical institutions is dominated by:
a) blood-borne viral hepatitis (B, C, D);
b) intestinal infections;
c) purulent-septic infections;
d) hospital mycoses;
e) tuberculosis;
e) diphtheria.
24. Disinfection and sterilization measures to prevent nosocomial infections:
a) the use of chemical disinfectants;
b) pre-sterilization cleaning of instruments and medical equipment;
c) correct air supply;
d) compliance with the rules for the accumulation, neutralization and disposal of waste from medical institutions;
e) ultraviolet bactericidal irradiation.
25. The most significant “risk” factors for the development of nosocomial infections in patients in intensive care units:
a) re-compaction of the compartment;
b) lack of qualified medical personnel;
c) tracheal intubation;
d) use of cytostatics;
e) performing peritoneal dialysis or hemodialysis.
26. In ophthalmology hospitals, the following routes and factors of transmission of nosocomial infections are most active:
a) indirect transmission through various objects and objects of the external environment;
b) through common transmission factors infected by a sick person or carrier;
c) direct contact with patients and carriers.
27. The main clinical forms of nosocomial infections in urological departments:
a) viral hepatitis B;
b) pneumonia;
c) bronchitis;
d) cystitis;
d) pyelonephritis.
28. The set of measures to prevent nosocomial infections in ophthalmology hospitals includes:
a) designing wards with no more than 6 beds;
b) layout of the operating room directly within the department;
c) preoperative bacteriological examination of patients;
e) mandatory preoperative prescription of broad-spectrum antibiotics for prophylactic purposes.
29. Currently, the most relevant etiological agents of nosocomial infections are:
a) coccidiomycetes;
b) gram-negative opportunistic bacteria;
c) respiratory viruses;
d) enteroviruses;
d) staphylococci.
30. Generalized clinical forms of nosocomial infections include:
a) bacteremia;
b) peritoneal abscess;
c) osteomyelitis
d) infectious-toxic shock.;
e) peritonitis;
e) myelitis.
31. The “risk” group for the occurrence of nosocomial infections in psychiatric hospitals includes:
a) patients receiving a significant number of intramuscular injections;
b) patients returning from short-term vacations;
c) persons with a severe course of the underlying disease, which has led to a violation of hygienic skills.
32. Sanitary measures for the prevention of nosocomial infections are:
a) control over the sanitary and anti-epidemic regime in medical institutions;
b) training and retraining of personnel on issues of regime in health care facilities and prevention of nosocomial infections;
c) air conditioning, use of laminar flow units;
d) rational use of antimicrobial drugs, primarily antibiotics;
e) compliance with the standards for the placement of patients.
Evaluation criteria: The answer (multifactorial) is considered correct if all accurate answers are given. For “excellent” - at least 30 correct answers, for “good” - at least 28 correct answers, for “satisfactory” - at least 25 correct answers.
Nosocomial infection, nosocomial infection (hospital, nosocomial) is any disease of viral, bacterial or fungal etiology that develops in a patient who is in a hospital for inpatient or outpatient treatment, as well as within a month from the moment of discharge from the hospital.
Pathogens of nosocomial infections also affect medical personnel, whose specific work involves contact with a potential pathogenic microorganism.
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What is a nosocomial infection, what are its pathogens, mechanisms and routes of transmission? What activities must be organized in a medical institution to prevent nosocomial infections?
See the article for ready-made algorithms and instructions.
A new approach to determining nosocomial infections
The concept of nosocomial infections has currently changed. Today, most regulatory documents replace “hospital-acquired infections” with the term “health care-associated infections” (HAI).
It is specified in GOST R 56994-2016 “Disinfectology and disinfection activities. Terms and definitions”, which came into force on January 1, 2017.
Samples and special collections of standard operating procedures for nurses that can be downloaded.
According to GOST, nosocomial infections are any microbial pathologies that arise:
- in patients while in hospital, on outpatient treatment or at home;
- from health care facility workers in the course of performing their professional duties.
Prevention of nosocomial infections includes measures aimed at preventing outbreaks and spread of infectious pathologies. This work is carried out by a commission specially created by the head of the medical institution.
It includes the chief nurse of the institution as an official and member of the commission for the prevention of nosocomial infections.
Download instructions
- Styling for emergency personal prevention of acute respiratory infections.
- Universal installation for collecting biomaterial.
- Emergency notification scheme when identifying a patient with AIO.
- Report on the identification of DUI.
- How to use a protective suit.
Epidemiology and etiology of nosocomial infections
By origin, the following sources are distinguished:
- patients with manifest forms (considered the most dangerous sources of infections);
- carriers of various strains of pathogenic and opportunistic microorganisms, including those resistant to antimicrobial drugs;
- employees of medical institutions with infectious diseases.
Medical personnel must clearly know what the main causes of infectious diseases exist - this will allow them to more effectively plan and implement preventive measures.
Mechanisms and routes of transmission of nosocomial infections
Classification of nosocomial infections
- Taking into account the mechanisms and routes of spread of the infectious agent, the following are distinguished:
- aerosol (airborne);
- nutritional (food);
- contact and household;
- contact-instrumental (postoperative, postpartum, postdialysis, posttransfusion, postendoscopic and others).
- post-traumatic;
- other forms.
- Taking into account the nature and duration of the course:
- spicy;
- chronic;
- subacute.
- Taking into account the severity of the current:
- lungs;
- medium-heavy;
- heavy.
- Taking into account the degree of spread of the pathological process:
- generalized (bacteremia, mycemia, viremia, septicemia, septicopyemia, infectious-toxic shock, etc.):
- localized (skin and subcutaneous fat, eyes, genitourinary tract, ENT organs, gastrointestinal tract, central nervous system, heart and blood vessels, musculoskeletal system, etc.).
We have prepared a manual for you that explains how to monitor the epidemiological situation in a hospital. in the journal Chief Nurse.
They also described the reference points of current control on which management decisions need to be made.
Factors involved in the development and spread of nosocomial infections may include:
- immunity deficiency;
- spread of strains of pathogenic and opportunistic microbes resistant to antibiotics;
- age, increase in the number of elderly and weakened patients;
- neglect of safety rules during medical procedures and patient care.
Types of pathogens of nosocomial infections
According to the World Health Organization, hospital-acquired infections pose a serious threat to the health and life of the population, as they are characterized by a high degree of resistance to antimicrobial drugs, which significantly complicates treatment.
Microorganisms that can cause nosocomial infection belong to different groups. The main ones are presented in the table.
|
Type of pathogen |
Sustainability |
|
|
Critical level |
Acinetobacter baumannii |
to the action of a wide range of antibiotics, including: carbapenems third generation cephalosporins |
|
Pseudomonas aeruginosa |
||
|
Enterobacteriaceae (including Klebsiella, E. coli, Serratia and Proteus) |
||
|
High level |
Enterococcus faecium |
to vancomycin |
|
Staphylococcus aureus |
to methicillin moderately sensitive or resistant to vancomycin |
|
|
Helicobacter pylori |
to clarithromycin |
|
|
Campylobacter spp. |
to fluoroquinolones |
|
|
to fluoroquinolones |
||
|
Neisseria gonorrhoeae |
to cephalosporins, fluoroquinolones |
|
|
Average level |
Streptococcus pneumoniae |
not sensitive to penicillin |
|
Haemophilus influenzae |
to ampicillin |
|
|
to fluoroquinolones |
||
|
Streptococci A and B and chlamydia have a lower level of resistance and currently do not pose a serious threat. The US Centers for Disease Control and Prevention (CDC) announced that a patient with urinary tract pathology had a bacterial infection with Escherichia coli and was drug-resistant to colistin. Plasmids (extrachromosomal circular DNA) have been discovered in bacteria |
||
The types of pathogens are varied, but 90% of them are infectious agents of bacterial origin. Fungi, viruses and protozoa are much less common.
The types of infectious pathogens largely depend on the profile of the hospital. Thus, in the burn department, Pseudomonas aeruginosa is a particular danger, transmitted through the hands of medical workers and environmental objects. The source in this case is people.
Staphylococcus aureus infection predominates in maternity hospitals, the main source of which is medical personnel. The mode of transmission of Staphylococcus aureus is airborne.
In surgical hospitals, the predominant infectious agent is Escherichia coli (E. coli), and urological hospitals are striking with a variety of pathogenic microflora - here you can find E. coli, Klebsiella, Chlamydia, and Proteus.
The same can be said about trauma departments - here there is Pseudomonas aeruginosa, Staphylococcus aureus, Proteus, etc.
The hospital admission department should prevent the admission of patients with signs of an infectious disease to the ward.
Harbingers
This allows us to minimize the danger for both patients and hospital staff.
Diseases related to nosocomial
The risk group includes such nosological forms in which the development of nosocomial infection is most likely:
- purulent-inflammatory processes of subcutaneous tissue, mucous membranes and skin (phlegmon, abscess, mastitis, erysipelas);
- damage to the ENT organs (pharyngitis, laryngitis, tonsillitis);
- infections of the bronchopulmonary tree (aspiration and congestive pneumonia);
- damage to the gastrointestinal tract (toxic and injection hepatitis);
- infectious diseases of the eyeball;
- purulent-inflammatory lesions of the bone and joint system;
- genitourinary system infections;
- damage to the meninges and brain matter;
- Infectious genesis of the membranes of the heart and great vessels.