Nosocomial Infections: Literature Review

Nosocomial infections are infections that are a result of treatment in a hospital or a healthcare unit. These infections are identified at least forty-eight to seventy-two hours following admission, so infections incubating, but not clinically apparent, at admission are excluded. It may also be within 30 days after discharge. With recent changes in health care delivery, the concept of nosocomial infections has sometimes been expanded to include other health care associated infections (Weinstein, 1991). These infections are also called hospital-acquired infection. Studies in the passed have reported that during hospitalization, at lest five percent of patients become infected. Similarly, a study carried out by the Centers for Disease Control and Prevention in the United States estimates that roughly 1.7 million hospital-associated infections, from all types of bacteria combined, cause or contribute to 99,000 deaths each year. In Europe the deaths estimated are 25000 each year. However, the case is more seen in the category of Gram-negative infections, which accounts for an estimated two thirds of the total cases reported.

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Nosocomial infections are commonly transmitted as a result of negligence of hygiene by some hospital personnel. Medical officials move from one patient to another. Thus in a situation where they do not maintain high hygiene standards, the officials themselves serve as means for spreading dangerous pathogens. Moreover, body’s natural protective barriers of the patients are bypassed by some medical procedures such as surgeries and injections. Hence with such hygienic negligence in our hospitals and other healthcare units, nosocomial infections become the order of the day and my cause severe cases of pneumonia and infections of the urinary tract, bloodstream or other parts of the body.

Causes of nosocomial infections

Nosocomial infections are caused by various factors. Some of the common ones include improper hygiene. Patients can get infections of diseases such methicillin resistant staphylococcus aureus (MRSA), respiratory illnesses and pneumonia from hospital staff and their visitors (Webster, 1998). Also doctors and nurses who do not practice basic hygienic measures such as washing hands before attending to patients may spread MRSA among them. Other infections are due to injections. There are cases where some hospital staffs do not give injections properly. Infections like HIV and hepatitis B can be as a result of contaminated blood due to sharing syringes and needles between patients when injecting medication into their intravenous lines. Nosocomial infections may also be as a result of torn or improperly bandaged incisions during surgeries. These incisions get contaminated with bacteria from the skin or the surrounding environment. Similarly, bacteria can be introduced into the patient’s body by contaminated surgical equipment. Also breathing machines such as ventilators can spread infections like pneumonia among patients using them. Staffs that do not use the proper infection control measures tend to contaminate these machines with germs. There are also cases where people on breathing machines are unable to cough and expel germs from their lungs. This can be another cause. In addition, urinary track infections can be due to faulty removal of urine from patients who are not able to use the toilet. In most cases catheters are the common cause for such cases. These catheters cause these infections when they become contaminated with bacteria by medical staff during insertion or are not properly maintained while in use (Webster, 1998). Another cause of nosocomial infections is the organ transplant. Illnesses such hepatitis B, hepatitis C, HIV and syphilis can be spread through bone and tissue grafts that may result from blood transfusions, skin and organ transplants. However such cases have become less common today due to factors such as improved technology. Many protective measures have been put in place to cut on these risks.

Prevention of nosocomial infections

Several measures can be put in place to prevent the spread of nosocomial infections. The most important measure to reduce the risk of transmitting skin microorganisms from one patient to another is hand washing. Medical staff washing hands as thoroughly and promptly as possible after attending to one patient where they may have come into contact with body fluids, excretions and blood, or equipment with these fluids, is a very important measure of nosocomial infection control. Even though it appears as a simple process, it is mostly overlooked or done incorrectly (Hiramatsu, Aritaka, Hanaki, Kawasaki, Hosoda & Hori, 1997). As a result practitioners and visitors should be continuously reminded on the advantages of proper washing of hands. This can be achieved through use of signals on responsible hand washing. In addition to hand washing, gloves are very important since they prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, and mucous membranes. They offer a protective barrier, in cases of exposure to blood borne pathogens. Similarly there is emphasis on surface sanitation. In health care environments, this is a critical component of breaking the cycle of infections. In cases concerning influenza, gastro enteritis and MRSA modern methods such as NAV-CO2 have been effective. Alcohol has been shown to be ineffective in endospore-forming bacteria such as Clostridium difficile and thus hydrogen peroxide is appropriate in this case. In addition, use of hydrogen peroxide vapor reduces infection rates and risks of acquisition. Some causes of infections are agent and host factors that are hard to control. In such cases isolation precautions can be designed to prevent transmission in common routes in health centers. For example a patient suffering from an air borne disease can be put in a separate room so as to control the spread of the disease. Another prevention measure is putting on protective clothing. An apron reduces the risk of infection as it covers most parts of the body. However with all this said, strategically implementing QA/QC measures in health care sectors and evidence-based management are the most effective technique of controlling nosocomial infections. For example, in cases of diseases such as ventilator-associated pneumonia and hospital-acquired pneumonia, the management of the health center should pay more emphasis on the control and monitoring of the quality of the hospital’s indoor air (Hiramatsu, Aritaka, Hanaki, Kawasaki, Hosoda, & Hori, 1997).

A Review of the Literature

Robert A Weinstein

(Cook County Hospital & Rush Medical College, Chicago, Illinois, USA)

In his research paper Robert Weinstein begins by a comparison of the cases of nosocomial infections now and in the past. Even though he agrees that there has been a reduction in number of cases, he goes a head to state that the numbers of death are still high. According to him, a study carried out in the United States estimated that in 1995, nosocomial infections cost $4.5 billion and contributed to more than 88,000 deaths (one death in every six minutes). I concur with these findings. Poor hygiene standards in most health centers have contributed to these high figures. There have been cases of medical practitioners who overlook basic hygienic measures such as a proper hand washing when attending to patients. There are cases where some medical services like injections are not administered in a proper manner. This is due to unqualified medical expertise especially in small health care centers. I think the research’s large numbers of deaths from nosocomial infections is due to such factors. I also agree with Weinstein that there is an approximately one third reduction in rate of infections in hospitals with the four basic infection control components (one infection control practitioner for every 250 beds, an effective hospital epidemiologist, ongoing control efforts and an active surveillance mechanism). As a result I think these infections can be controlled to a higher percentage if all hospitals and health centers could employ these basic components.

Robert A Weinstein also states that there has been an increase in viral infections. Most nosocomial infections in Semmelweis’s era were due to group A streptococci. In 1990 to 1996, 34% of nosocomial infections were due to the three most common gram-positive pathogens-S. aureus, enterococci and coagulase-negative staphylococci while the four most common gram-negative pathogens-Escherichia coli, P. aeruginosa, Enterobacter spp., and Klebsiella pneumoniae, accounted for 32%. With this trend I agree with Weinstein report. There has also been an increase in the blood transmitted infections hence increase in the cases of herpes viruses HIV-infections.

On the other hand Weinstein’s reveals that there is a higher rate of infection among the intensive care unit (ICU) patients. This is evident in our hospitals today. I think the increasingly aggressive medical and therapeutic interventions, including modern medical advancements like organ transplantations, implanted foreign bodies and xenotransplantations, have created a cohort of particularly vulnerable persons (Fridkin, Welbel & Weinstein, 1997). In most cases, patients affected by nosocomial infections are those immunocompromised by underlying diseases, age or medical/surgical treatments. More cases of bloodstream infections coagulase-negative staphylococci occur in the ICU because it is in these areas that patients with invasive vascular catheters and monitoring devices could come into contact with these bloodstream infections. Due to these factors, I concur with Weinstein’s research findings that infection rates in adult and pediatric ICUs are approximately three times higher than elsewhere in hospitals.

In conclusion, Robert A Weinstein’s research paper portrays a comprehensive research. It addresses changes in the medical fraternity that have affected nosocomial infections in one way or another. It also shows the significant impact of advancement in technology in medical and health care in relation to nosocomial infections.

Jessica Lietz

Jessica Lietz presents her research on nosocomial infections putting more emphasis on the causes and prevention measures of the infections. She introduces her research stating that there are higher rates of infections in public hospitals as compared to private health centers. I concur with her findings on the basis of the difference in management in the two setups. Private centers tend to be managed in a better manner than public centers. This is because private hospitals are business oriented and the management is always doing all it can to better the institution so as to cope with the high market competition. As a result of this emphasis on good management, medical staff tends to adhere to rules and regulations. Hence the hygiene standards of these institutions are always high. Similarly there is close supervision of staff, another factor that advantages private hospitals over public ones. For the public medical institutions, the case is not the same. In most centers hygiene is not to standard. This may be due to several reasons. There is no close supervision of staff and same take this advantage of lack of a questioning authority to bypass basic hygiene measures. Similarly, public setups are prone to the effects of political differences between the staffs. Cases of corruption tend to take root in such centers and as a result, unqualified medical personnel find themselves in these institutions.

In her take on the causes of nosocomial infections, she states lack of adequate public education on the infections as a key factor in their spread. I think the point holds water since there are same cases of transmission of these infections due to ignorance. For instance one may visit a patient suffering from an air borne disease and contact the disease without knowing. Similarly patients may share personal items such as towels, not knowing that they are subjecting themselves to harmful infections. I think enlightening the public in general on the dangers of these infections and the basic control measures like maintaining a high personal hygiene can go a greater mile in trying to control these infections. It is therefore important to create a society that empresses these basic measures. This can be achieved through airing nosocomial infection related articles in the media, organized open air lessons in villages and also be taught in learning institutions.

Jessica Lietz on the other hand, argues out that just as hand washing is important as a measure of control; more emphasis should also be put on wearing of gloves. She states that gloves can also be used in the same context as hand washing as long as one glove is used on only one patient. I seem to disagree with this since there are challenges that come with it. Even though gloves offer a protective barrier, there are cases where these gloves tear. Moreover in instances where the gloves are not properly worn both the expertise and the patient may be a risk of infections. I strongly believe that a high standard of hygiene is the most appropriate way of fighting infections. As such, a basic, prompt and thorough hand wash is always the better option due its advantages. However, this does not rule out the use of gloves as they are equally important.

In conclusion, this research article gives a general view of nosocomial infections. It does not reflect a deep research into the subject. Jessica gives more emphasis on general arguments. There are some issues concerning these infections that have not been covered or have been covered shallowly. Jessica does not explain in length how nosocomial infections have been affected by technology. Advancement in technology has revolutionalized the medical fraternity and has come with its own advantages and disadvantage. Therefore one can not make a general decision from this article as it is shallow and needs further research.

National Center for Infectious Diseases

This is an article on the research carried out on the nosocomial infections by the National Center for Infectious Diseases in the United States. It points out young children, the elderly and persons with compromised immune systems as people who are more prone to these infections. Long hospital stays, failure of healthcare workers to wash hands, use of indwelling catheters and overuse of antibiotics have also been highlighted to cause some cases of the infection (Fridkin, Welbel, & Weinstein, 1997). Moreover the research acknowledges the effects of the diversification of technology on the spread and control of the infections highlighting organ transplant, catheters, xenotransplantations among others, as examples.

Invasive procedures expose patient to the possibility of infection. The research highlights the percentages below.

Causes of Urinary Tract Infections in Hospital Patients:

Escherichia coli: 40%

Proteus mirabilis: 11%

‘Other’ Gram-negative bacteria: 25%

Coagulase-negative staphylococci: 3%

‘Other’ Gram-positive bacteria: 16%

Candida albicans: 5%

Causes of Urinary Tract Infections that are Community-acquired:

Escherichia coli: 80%

Coagulase-negative staphylococci: 7%

Proteus mirabilis: 6%

‘Other’ Gram-negative bacteria: 4%

‘Other’ Gram-positive bacteria: 3%

This is a comprehensive research that has covered nosocomial infections at length. It discusses key components of the infections giving considerations to both past and today world. Moreover, it compares the rate of the infections both in the urban and rural setting. Hence it is an article that tries to solve nosocomial infection dilemma.

Toni Rizzo

Toni Rizzo presents his research on the common types of infections in our hospital. He highlights respiratory procedures, intravenous (IV) procedures, surgery and wound and urinary bladder catheterization as the common types of infections. He states that most hospital-acquired UTIs happen after urinary catheterization. A healthy urinary bladder does not have bacteria or microorganisms (it is sterile). A catheter picks up bacteria that may be in or around the urethra and take them up into the bladder hence infecting it.

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This is a standard research as it touches on almost key issues in the subject matter. I agree with the findings. Fungus infections from Candida are prone to affect patients who are taking antibiotics or that have a poorly functioning immune system. Hence bacteria from the intestinal track are the most types of UTIs. Similarly respiratory procedures done in our hospitals today are the common causes of bacteria getting into the throat. Pneumonia thus becomes another common type of hospital-acquired infections. Once the throat is colonized, it is easy for a patient to inhale the microorganisms into the lungs. Moreover, patients who are unable to cough or gag very well are most likely to inhale colonized bacteria and microorganisms into their lungs.

In general Toni Rizzo tries to address affects in medicine today. Infections due to modern advancements like organ transplant among others have been effectively discussed. Thus this is a comprehensive research.

Emmanuelle Girou and Francois Stephan

(Case-control Study of ICU Patients)

This is an article on a study done in the ICU patients. Generally ICU patients are at a high risk of acquiring nosocomial infections and in same cases some die from these infections. There is a need for therapy whether infections in the ICU occur or not. The objectives of the study was to define the interrelationships between underlying disease, severity of illness, therapeutic activity and nosocomial infections in ICU patients, and their influence on these patients’ out come. The study was conducted in a 10-bed medical ICU. Initial severity of illness was matched, with daily monitoring of severity of illness and therapeutic activity scores, and with analysis of the contribution of nosocomial infections to patients’ outcomes. The study ran for one year and data carefully taken.

Result

Global incidence rate of 14.6 infections per 100 admissions was estimated as forty one out of the 281 studied patients developed at least one nosocomial infection. During their ICU stay, the 41 case-patients developed 98 nosocomial infections (2.4 episodes per patient): 15 pneumonias, 35 bacteremias, 33 urinary-tract infections, 12 central-venous-catheter-related infections, two sinusitides, and one surgical wound infection. Of the 35 episodes of bacteremia, only four were primary; the other 31 complicated the following nosocomial infections: 14 urinary tract infections, eight catheter-related infections, eight instances of pneumonia, and one surgical-site infected. The characteristics of patients in both groups were compared through use of the Mann-Whitney nonparametric test for continuous variables and the chi-square test for categorical variables. Wilcoxon’s test was used to compare two continuous variables within one group. To identify risk factors independently associated with nosocomial infection, variables found to be significantly different between cases and controls in the univariate analysis were entered into a forward stepwise logistic-regression model (Statistica 4.5; Statsoft, Inc., Tulsa, OK). When patients developed multiple nosocomial infections during their hospitalization, only the first episode was used in the risk factor analysis. A value of p < 0.05 constituted a significant difference.

This is a very detailed and comprehensive case study. It clearly explains why the rate of infection is high in the ICU. This high rate is attributed to various factors. The immune system of most patients in the ICU is always low. Similarly these patients are subjected to taking more antibiotics. Long hospital stays is also another factor. Also it is in the ICU that most medical procedures like organ transplant, catheter, xenotransplantations among others, take place. The research also accounts for the effects of technology and other factors that affect these infections. It accounts for the findings given reasons based on concrete facts. As result, it’s a dependable research that can be used to study nosocomial infections especially in the ICU.

In conclusion, all the articles above points out improved hygiene especially hand washing and immunization have resulted to the overall advances in control of infectious diseases. Negligence of hygiene is also portrayed as a major challenge to the efforts of control of nosocomial infections. I think for us to significantly control the infections, we must join forces and work together with medical personnel on implementation of existing infection control technologies. We should empress positive changes towards the control of nosocomial infection and observe high standards of hygiene so that we do not rely solely on technologic advances.