1) Nosocomial infections
An infection is called "nosocomial" when it is acquired in a care facility and it appears after a period of 48 hours after admission. For surgical site infections, is considered nosocomial infections occurred within 30 days after surgery, or, if there 's introduction of a prosthesis or an implant in one year intervention.
b) Some epidemiological data: prevalence survey 2001 CTIN sponsored by the Ministry of Health
- Type of investigation: it is a point prevalence survey. It is to store a given day in each of the services involved, the proportion of patients with nosocomial infection among active patients present.
- Results: Attendance: 830 establishments serving 236 334 patients participated in the survey. It is the greatest prevalence survey ever undertaken in France or abroad.
Prevalence of infected patients and infections:
The prevalence of patients who acquired infection in the institution was 6.7% and infections acquired in the institution was 7.6%. Each year 600 000 1 100 000 cases of infections are acquired in the hospital for short stays. Approximately 10 000 deaths annually are due to nosocomial infections, a figure higher than that of road accidents.
Location of Infection
Urinary tract infections accounted for over one third of nosocomial infections (36.3%). The most frequent infections were: pneumonia (12.5%), surgical site infections (10.5%), infections of the skin and soft tissue (10.5%) and upper respiratory infections as bronchitis (8.2%).
Infections affecting a site other than the five main sites of nosocomial infections usually monitored for a short stay (urinary tract infections, surgical site infections, bacteremia / sepsis, catheter infections, and pneumonia) accounted for 22% of infections. Nosocomial infections and patients at risk surgery patients (18% of patients) were more often acquired a nosocomial infection than patients not operated on: the prevalence of infected patients was 11.8% in surgical patients against 5.6% the non-operated. Patients with a urinary catheter (9.6% patients) had a urinary tract infection in 17.2% of cases against 1.21% in patients not surveyed. Patients aged over 65 were also more affected by infections: prevalence in patients over 65 years was 8.61% against 4.9% in adult patients less than 65 years. Nosocomial infections and medical specialties Some important diversities were observed according to the specialty study. Three categories of specialties could be distinguished:
- Specialties where infections were infrequent: psychiatry (2.7%), pediatrics (3.8%). The low prevalence was associated with a lower incidence of surgical and urinary catheter.
- Specialties where the incidence of infection was at an intermediate level, such as dermatology (6.2%) or the chest (7.5%).
- Specialties where infections were more frequent as resuscitation (30%) and hematology (8%). This data is regularly found in the various surveys and is associated with a high frequency of performing invasive procedures.
c) Modes of transmission
The hospital and clinic are home to numerous sources of germs (infectious agents such as viruses and bacteria, fungi and prions): The primary source of contamination is the resident flora of the patient, staff play a role as vectors of transmission. More rarely, the material and environmental air or water can be sources of nosocomial infection.
The patient is infected with these germs own during certain treatments (surgery, urinary catheterization, artificial respiration, ...). This is called auto-infection.
The patient is infected by germs from other people (nurses, other patient, visitor) or the environment. There is talk of cross-infection.
Infections are therefore most often a home "endogenous" than "exogenous".
d) Risk Factors
By definition, a risk factor acts by increasing the incidence of disease in individuals exposed to them, but also known as factor when the incidence decreases with decreasing exposure. This concept is important in controlling the extent of exposure is expected to reduce the incidence of the disease. Risk factors fall into intrinsic and extrinsic factors.
Intrinsic factors: they are not all controllable.
- The extreme ages of life.
- Sex: urinary tract infection is more common in women.
- The length of stay which increases the incidence of infections.
- Birth weight premature infants: a weight lower than 1kg double the incidence of infections on catheters ventilated newborns
- Surgery, but especially the specialty of surgery
Extrinsic factors: All prostheses, such as catheters, vascular catheters, drains, catheters digestive ... Infection is favored by:
- Holding time in place of prostheses and their manipulation
- The uncontrolled use of antibiotics among bacteria causing infections in French hospitals, the proportion of strains resistant multi is among the highest in Europe (35% of all staphylococcus germs which are very frequently isolated in hospital are for example methicillin resistant, source: CNR Staphylococci Institut Pasteur). This can be explained by the delayed implementation of strategy for prescribing antibiotics in the city and the hospital.
- Acts other than invasive surgery, such as endoscopy.
e) The main causal bacteria
The main causal bacteria are bacteria, viruses, fungi and prions. Among the agents responsible for nosocomial infections, the bacteria come to mind, although it should consider that viruses have an important role especially in certain specialties such as pediatrics.
We must note that the relative importance of bacteria responsible for nosocomial infections varies among sites of infection.
- Staphylococcus aureus is mainly found in nosocomial catheter infections, pneumonia and surgical site infections.
- Escherichia coli is the "seed" of urinary tract infection. It is also found in the bloodstream.
- Pseudomonas aeruginusa is responsible for many pneumonias.
- The Legionella is a bacterium commonly found in natural streams, in ponds and puddles. Next to the natural resistance, the key problem is acquired resistance to antibiotics of nosocomial bacteria. Currently in France, the percentage of strains resistant to methicillin is a major concern as almost 30% which is significantly higher than that observed in many other European countries like Denmark who observed that 1% were resistant to methicillin .
Nosocomial infections of viral origin are primarily found at:
- Children with Rotavirus infections and respiratory syncytial virus.
- Elderly people with the flu virus, the virus responsible for conjunctivitis, nasopharyngitis ...
f) Committees of the fight against nosocomial infections
• Every hospital requires a Committee for the Fight against nosocomial infections (CLIN) which is charged with organizing and coordinating the monitoring, prevention and training in the fight against nosocomial infections. It is composed of physicians, pharmacists, nurses and school principals. The CLIN is assisted in most health facilities, staff of hospital hygiene.
• The five focal points of the fight against nosocomial infections (CClin) serve as technical support to hospitals, and working at an inter-region. They are responsible to implement the policy set at national level and facilitate inter-hospital cooperation (network monitoring, training, documentation, education ...).
• Nationally, the National Technical Committee for Nosocomial Infections (CTIN) is an instance of motion, coordination and evaluation, consisting of experts hospital, which is chaired by Dr. John CARLSON. The committee proposes priority objectives and standardized methodology for monitoring and preventing the minister.
• Cell "nosocomial infection" of the Ministry, the Directorate General Joint Health and Hospitals Branch is responsible for coordinating all of the device. Surveillance of nosocomial infections poses several problems, the reliability of information collected: the establishment of rates based on knowledge of complex information.
- The validity of the indicators: prevalence surveys provide only a snapshot of the situation. The impact studies are more difficult to achieve. They require the input of complex information often not available in medical records. One of the obstacles to carrying out the surveys is the lack of human and material resources. The monitoring has a cost, it is highly cost-effective when targeted where it is based on criteria and reliable when performed by trained and experienced.
g) Liability and compensation for caregivers of victims
• Cases of June 29, 1999:
On June 29, 1999, the First Civil Chamber of the Supreme Court has adopted a safety obligation of result at the expense of private health establishments, as well as doctors, they can not exempt itself by showing a external cause. Before this case, the clinics were presumed responsible for an infection contracted by a patient during surgery, unless to prove the absence of fault on his part. Thus, the victim who wanted to question the responsibility of a health facility had to demonstrate that its state was due to an infection contracted in healthcare facilities. But in the case where the victim suffered injury through no fault of health facilities, it would result in an unfair situation for her because she obtained no redress. By judgments of 29 June 1999, the Supreme Court has taken an important step because now the only exemption is to provide evidence of a foreign cause, the mere absence of proof of fault no longer exempting him from responsibility. The extension of liability to physicians: In previous cases, only the health institutions were allegedly responsible for infections. Now, health facilities and physicians are bound by an obligation of safety results in this area, so that victims will act against one another and severally. The court of cassation is part of the principle that doctors are required to fulfill as well as aseptic health facilities.
• Law of 4 March 2002:
According to article L.1142-1, paragraph 2 of the Code of Public Health in the form adopted in the Act of March 4, 2002, "Institutions and bodies mentioned above (which are made in the prevention of acts of diagnosis or treatment ) are liable for damages resulting from nosocomial infections unless they produce evidence of a foreign cause. This article calls for two comments: Firstly, the Act establishes jurisprudence on liability clinics and health facilities in case of nosocomial infections. The victim is required to prove the fault of these institutions. In addition, those responsible may be exonerated by the evidence of the absence of fault. Only evidence of an external cause is exculpatory. Secondly, the law condemns the jurisprudence that had put the burden on physicians an obligation of result on nosocomial infection. Doctors can now be responsible for nosocomial infections due to that in the event of proven fault by the victim in accordance with the principle of proof of guilt placed in the first paragraph of Article L.1142-1. The law refers to the state of the law prior to the judgments of 1996 and 1999. When nosocomial infection can not be repaired under the liability (no fault of the physician or evidence of external causes reported by health facilities), they may under certain conditions obtain compensation under the National Solidarity. (See Annex 3)
h) Economic costs, social and psychological
The human drama, accompanied by a financial disaster: in 1997, the overall direct cost of nosocomial (health care) was estimated at 1 billion euros, the indirect costs (sick leave, disability etc ....) 3 billion. In comparison, the total budget of clinics and private care, amounted to France in 2000 to 7 billion euros.
The micro-economic studies of calculation show that nosocomial infections are not only responsible for:
- The increase in mortality and morbidity
- The average length of stay (varies according to the site of infection)
- The cost of treating the causative disease
- Social consequences that may affect the patient himself and his family.
The costs are divided into three groups: hospital costs, non-hospital costs and social costs.
Hospital costs represent all costs directly attributable to nosocomial added indirect costs of hospitals that aggregate all overhead assumed proportional to the length of hospitalization.
The costs relate to non-hospital expenses related to medical consumption at home plus the costs of eventual rehabilitation of the patient.
The social costs consist of a rather heterogeneous difficult to assess as lost wages, lost production, disability or death. Another aspect of economic analysis for the evaluation of the cost of prevention. The establishment of a prevention program to reduce by 30% on average nosocomial infections cost nearly € 200 000 per year for a 250-bed hospital ...
One can also think that nosocomial infections can affect patients' confidence in our health system and thus increase their anxieties or fears during their hospitalization.
1.2) Hospital hygiene
After discussing the problem of public health are nosocomial infections, we now turn our attention to its primary prevention, hospital hygiene. It takes into account all clinical, epidemiological and microbiological infections, but also the organization of care, maintenance of hospital equipment, management of environmental protection personnel. It is an indicator of quality of care and safety.
Here are some basic rules.
Simple washing of hands:
The objective is to prevent transmission handborne and eliminate transient flora
For the patient:
- Act associated with the care of comfort and hospitality
- At the taking of service
- After each gesture and contaminants before any activity or care for patients:. In the care of hygiene, comfort and continuity of life. Noninvasive nursing
For the caregiver:
- At the service plug and leaving
- After every act of everyday
Antiseptic hand washing:
The objectives are to eliminate transient flora and reduce the commensal flora
- Gesture-invasive and implementation of techniques for isolating septic or aseptic care - or aseptic technique (eg urinary catheter, catheter device)
The objectives are to eliminate transient flora and reduce the commensal flora significantly.
- Act at high risk of infection in care service requiring a surgical procedure (insertion of an invasive device. Examples: central catheterization, lumbar puncture.)
- Act surgery: in operating rooms, interventional radiology and other investigative services; in closed areas, and all Protected Area Service (Burn, hematology, intensive care) hydro-alcoholic solution: It allows rapid and frequent antisepsis hands at any time, in the absence of water. It does not replace hand washing with soap, antiseptic or not, when they are soiled or powdered. The number of use of this solution varies according to our sources (3 to 5 times).
It is necessary when any contact with body fluids (blood, urine, ...) to prevent the risk of infection and to protect healthcare workers. Wearing gloves does not wash hands before and after use. They must be changed between each patient and between treatments.
c) The attire
It must be changed daily and whenever it is soiled. Nails should be short and without polish. The hands and wrists should be naked and long hair. All these measures are intended to reduce the risk of transmission of germs because these places promote their "home". For the taking of meals, clothing is replaced by the proper attire to protect it from dirt and limit the ways of transmission of microorganisms it carries.
The isolation measures are intended to establish barriers to the transmission of micro-organisms:
- From one patient to another patient
- A patient to a caregiver
- A caregiver to a patient
- The environment the patient can be distinguished from septic isolation measures and protective isolation measures.
It is set up to protect fragile or immunocompromised patients (eg patients with burns or bone marrow)
It is indicated whenever a patient is suffering from a contagious disease or carrying an infectious agent may spread in gestures of care. Whatever isolation precautions, standard precautions are required, including: hand hygiene, wearing gloves, surblouse, glasses and / or mask if there is a risk of splashing blood or aérolisation or any other product of human origin. Sometimes, special precautions are necessary in addition to standard precautions. They are defined according to the infectious agent (reservoirs, modes of transmission, resistance in the external environment ...) and infection (location, gravity ...).
There are different types of isolation tanks:
- Respiratory Isolation
- Isolation skin
- Enteric Isolation
- Multi Resistant Bacteria Isolation
These precautions may include:
- Geographic isolation in single room
- Limiting travel
- Strengthening of handwashing
- Wearing protective clothing (gloves, surblouse, goggles, mask)
- Strengthening the precautions for the disposal of waste
To prevent the risk of infection, hospital waste must be disposed according to certain procedures. • The black bags are used for waste comparable to domestic waste. • Yellow bags are used for hazardous health care at risk of infection:
- All objects or instruments that have been in contact with patients infected or at risk
- All objects or instruments contaminated with body fluids
- All objects or instruments from the preparation and administration products include plastic bags used for disposal of hospital waste, there is no official legislation regarding the choice of colors, however, according to European recommendations, the colors black and yellow are preferred. • The bags found in patient rooms are reserved for their personal use. • sharps waste collectors to be used for the disposal of all waste and sharp edges (eg, needles, bulbs ...).
Antisepsis: Operation temporary result to the level of living tissue within the limits of their tolerance, to eliminate or kill micro-organisms and / or inactivate viruses.
An antiseptic: Product or process used for antisepsis in defined conditions.
Antiseptics are used only in living tissue. These are drugs. A good antiseptic should be soluble in water or alcohol, be stable over time, have a broad spectrum of activity, inability to induce resistance, lack of side effects. Antiseptics are bacteriostatic / cides and / or virucidal and / or fungicides.
- Do not apply on clean skin
- Store at 8 to 10 days after opening
- Never mix 2 different ranges of antiseptics
- The foaming antiseptic should be rinsed after use
- Respect the original flasks, prefer single amount
- Check expiration date
- Contact time: 1 minute
Disinfection is an operation in the temporary result to eliminate microorganisms and / or inactivate viruses carried by inert environments (unlike antiseptics). It is intended only to equipment decontaminated and rinsed. Decontamination is an operation in the temporary result to eliminate microorganisms. It extends only