Nosocomial Infections. Khachornsakdi Silpapojakul MD Prince of Songkla University Hat yai, Thailand

Transcription

1 Nosocomial Infections Khachornsakdi Silpapojakul MD Prince of Songkla University Hat yai, Thailand

2 What?

3 Nosocomial comes from the Greek word nosokomeion meaning hospital (nosos = disease, komeo = to take care of ). From Wikipedia, the free encyclopedia

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5 Why epidemiologists should pay an attention to nosocomial infections?

6 Nosocomial Infections: How much?

7 J Med Assoc Thai 2005; 88 (Suppl 10): S hospitals Point prevalence survey March ,456 patients. Patients on antibiotics = 48.5%

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12 Nosocomial Infection Rate , Thailand Hospital beds Rate (%) > < Ref.: Pinyowiwat W et al. Dept. of Epidemiology Ministry of Public Health

13 Nosocomial Infections Mortality-How much?

14 J Med Assoc Thai 2005; 88 (Suppl 10): S hospitals Point prevalence survey March ,456 patients. Patients on antibiotics = 48.5%

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17 Nosocomial Infections Morbidity-How much?

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20 Why epidemiologists should pay an attention to nosocomial infections?

21 J Med Assoc Thai 2005; 88 (Suppl 10): S hospitals Point prevalence survey March ,456 patients. Patients on antibiotics = 48.5%

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23 The number of admissions in Thailand is ~6.2 million. With a prevalence rate of 6.4%, the estimated number of nosocomial cases was 396,800 cases with 26,586 deaths attributable to these infections in Year 2001.

24 Top ten morbidity rate of diseases under surveillance Thailand, 2001 (2544) Rank Diseases Cases Deaths Morbidity Rate (Per 100,000 Pop.) 1 Acute diarrhoea Pyrexia of unknown origin Dengue haemorrhagic fever Food poisoning Pneumonia Haemorrhagic conjunctivitis Influenza Dysentery Malaria Chickenpox Ref.: Annual Epidemiological Surveillance Report 2001, MOPH

25 Top ten mortality rate of diseases under surveillance Thailand, 2002 (2545) Rank Diseases Cases Deaths Mortality Rate (Per 100,000 Pop.) 1 Pneumonia Tuberculosis Dengue haemorrhagic fever Suicide by liquid substance Acute diarrhoea Leptospirosis Malaria Pyrexia of unknown origin Rabies Encephalitis - total Ref.: Annual Epidemiological Surveillance Report 2001, MOPH

26 Causes of Death of Thai Physicians ( ) No.=262 1= Cancers (35.1%) 1.1 Hepatoma (7.6%) 2= Heart Diseases (28.2%) 3=Accidents (12.6%) 4=Sepsis (3.4%) 5=Suicides (3.4%) Source: Sithisarankul P et al. Intern Med J Thai 2004;20:

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29 Causes of Death Total deaths = 165 (100%) 1. Vascular diseases = 46 (28%) Coronary heart disease = 28 CVA = 16 Other vascular diseases = 2 2. Cancers = 43 (26%) 3. Injuries = 37 (22%) 4. Non-malignant GI & Liver disease= 22 (13%) 5. Unknown causes. = 9 (5%) 6. Sudden deaths. = 5 (3%)

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33 There are substantially more nosocomial infections each year than hospital admissions for either cancer or accidents and at least four times more than admissions for acute myocardial infarction.

34 Year 2006, Admission Diagnoses,PSU Hospital Rank Diseases Number of patients 1 Senile cataract 1,123 2 Malignant neoplasm of bronchus and lung Malignant neoplasm of breast Malignant neoplasm of ovary Intracranial injury Malignant neoplasm of liver and intrahepatic bile ducts Malignant neoplasm of rectum Malignant neoplasm of cervix uteri Maternal care for known or suspected abnormality of pelvic organs Lymphoid leukaemia 331

35 Year 2006, Causes of Deaths, In-Patients, PSU Hospital Rank Causes of Deaths No. of Patients 1 Malignant neoplasm of bronchus and lung 56 2 Acute myocardial infarction 51 3 Other septicaemia 38 4 Intracerebral haemorrhage 25 5 Malignant neoplasm of liver and intrahepatic bile ducts 22 6 Diffuse non-hodgkin's lymphoma 20 7 Aortic aneurysm and dissection 18 8 Chronic renal failure 18 9 Chronic ischaemic heart disease Malignant neoplasm of cervix uteri [HIV] disease resulting in 15 infectious and parasitic diseases

36 Impacts of Nosocomial Infections on National Vital Statistics

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38 229 patients were followed for 4.29+/-0.7 years

39 2 UTIs 1 infected CAPD 1perianal abscess 1pneumonia 4 unknown site

40 Nosocomial Infections Economical Impacts-How much?

41 J Med Assoc Thai 2005; 88 (Suppl 10): S hospitals Point prevalence survey March ,456 patients. Patients on antibiotics = 48.5%

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43 The number of admissions in Thailand is ~6.2 million. With a prevalence rate of 6.4%, the annual hospital costs for management of N.I. was about 7 billion baht (175 million U.S. dollars).

44 Health Expenditure (Million baht) Wibulpolprasert S et al. Thailand Health Profile MOPH Bangkok, Thailand 2005 (ISBN: )

45 Allocation of Government Health Budget by Service Category, Wibulpolprasert S et al. Thailand Health Profile MOPH Bangkok, Thailand 2005 (ISBN: )

46 Why rising cost of antibiotics???

47 Antibiotic Resistance: PSU

48 MRSA PSU 5% 15% 25% 30% Siriraj 14% 14% 23% -

49 PSU Antibiotic Resistance : MRSA Year Resistance % % % % % % % % % % %

50 PSU Antibiotic Resistance - E. coli Ciprofloxacin 7% 6% 8% 16% 18% 18% 25% 24% 25% 25% Amikacin 9% 6% 6% 4% 6% 7% 5% 5% 4% 5%

51 PSU Antibiotic Resistance : Ps. aeruginosa Imipenem Resistance % resistance 4% 9% 12% 8% 8% 10% 7% 11% 16%

52 PSU Antibiotic Resistance : Ps. aeruginosa Imipenem 16% 19% 20% 18% 13% 17% Sulperazone 22% 19% 14% 13% 14% 10% Cefipime 20% Tazobactam 19% Amikacin 28% 28% 25% 25% 18% 14%

53 PSU Antibiotics: Cost/Day Amikacin 15 mg./kg q d. 262 bht. Sulperazone 2 g. q 12 hr bht Imipenem Meropenem Meropenem Ertapenem Cefipeme Tazocin 500 mg. q 6 hr bht. 0.5 g. q 6 hr bht. 1 g. q 8 hr bht. 1g. q d bht. 2 g. q 12 hr bht. 4.5 q 8 hr bht.

54 J Med Assoc Thai 2005; 88 (Suppl 10): S hospitals Point prevalence survey March ,456 patients. Patients on antibiotics = 48.5%

55 The number of admissions in Thailand is ~6.2 million. With a prevalence rate of 6.4%, the annual hospital costs for management of N.I. was about 7 billion baht (175 million U.S. dollars).

56 PSU Antibiotic Resistance : Acinetobacter Imipenem Resistance % 2% 4% 3% 3% 2% 9% 31% 39%

57 Percentage of susceptible Acinetobacter baumanii, Jan - Dec 2005

58 Source of infection and organisms:psu ( ) 2004) Lower respiratory tract infection 1 S.aureus 41.7%(MRSA 50%), 2 Acinetobacter spp. 25%, 3 K.pneumoniae 12.5% 4 Pseudomonas aeruginosa 12.5%

59 Hand contamination of personnel in NICU Knittle M A et.al. J Ped 1975, 88, 433 No. of nurses 13 No. of cultures 151 Positive cultures % E. coli % Klebsiella % Pseudo aeruginosa %

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62 Is there any other national impact of nosocomial infections besides their impacts on mortality and economy???

63 Prevalence of primary MDR-TB in Thailand Year MDR-TB % Central Chest hospital TB Division Drug resistance survieillance Central prison Chiang Rai hospital Drug-resistant Tuberculosis research fund HIV HIV HIV HIV (Courtesy: Manoon Leechavengvongs MD)

64 MDR-TB surveillance, Chiangrai ( ) 1 o resistance 2 o resistance INH 14.5% 40.8% Rifampicin 11.5% 36.9% EMB 7.0% 17.7% MDR-TB 7.2% 30.8%

65 Bacteremia, Bamrasnaradura Hospital (CID 1999, 180:87; Lancet 1999, 354, 1159) febrile patients - 182(74%) = HIV - 119(48%) had positive blood culture = HIV, only 5 = non-hiv

66 TB Bacteremia, Bamrasnaradura Hospital (CID 1999, 180:87; Lancet 1999, 354, 1159) (1) = Cryptococcus (31) (2) = M. tbc. (27) (3) = MACS (24) (4) = Salmonella (16) - 5 of 20 (25%) of TB isolates= MDR-TB

67 HIV & OPD; T.B. OUTBREAK ST Vincent Hospital, Sydney, Australia O.P.D : Air conditioned treatment room September One T.B. index case 91 HIVs followed for 7.4 mo. ( 1-14 mo.) 3 developed T.B. with identical RFLP All within 15 wks. of follow - up. Ref: Couldwell D.L. et al : AIDS 1996,

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70 วารสารว ณโรค โรคทรวงอกและเวชบ าบ ดว กฤต 2548;27:35-46

71 Year = ER personnels had TB 3=TB lung (one with MDR-TB) 2=TB lung& LN TB rate =1,701per100,000 person-year

72 TB Prevalence/100,000 populations: Terms >1,000 = TB epidemic >100 = High risk for TB =<10 = Low risk for TB <1 = Entering the elimination phase 0.1 = TB eliminated

73 MDR TB. OUTBREAKS-? WHERE? Enviroments where inmunocompromised persons are likely to be found, including health care facilities, homeless shelters and prisons. Virtually all MDR - TB. outbreaks have occurred in settings such as these. Ref : Beck - sague C et al : JAMA 1992: 268 :

74 Prevalence of primary MDR-TB in Thailand Year MDR-TB % Central Chest hospital TB Division Drug resistance survieillance Central prison Chiang Rai hospital Drug-resistant Tuberculosis research fund HIV HIV HIV HIV (Courtesy: Manoon Leechavengvongs MD)

75 The prevalence of smear-positive pulmonary tuberculosis was 568 per 100,000 inmates, which was eight times higher than that in the general population.

76 Eight (38%) of 21 culture-positive Mycobacterium tuberculosis isolates had DNA fingerprints matching those of another inmate who was housed in the same room or in the same dormitory unit;

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78 Prisoners at the Bangkok jail are locked in 40x14 feet wide cells housing 67 people with a concrete floor to sleep on and a personal space the size of an average coffin. They are banged up for 15 hours a day with one stinking hole, which serves as a lavatory for 67 people. A total of ten holes are for some 700 prisoners.

79 A hospital ward in Malaysia

80 An OPD. in a Thai provincial hospital

81 An OPD. in a Thai provincial hospital

82 Fig. 1 Reported Cases of Tuberculosis (Total) per 100,000 Population. by Year, Thailand, Rate per 100,000 Pop

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84 Is there any other example of the role of hospital as an amplification place for diseases???

85 SARS

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87 Second Wave of Epidemic: in the Hospitals

88 Nosocomial transmission was the primary acceleration of SARS infections accounting for 72% of cases in Toronto and 55% of probable cases in Taiwan. Ref.: Booth CM et al. JAMA 2003;289: CDC. MMWR 2003;52:461-6

89 SARS occurred in healthcare workers in >70 hospitals throughout Beijing, and clusters of >20 probable SARS cases among healthcare workers occurred in four Beijing hospitals.

90 Where in the hospital did the outbreak occur?

91 EID 2004;10: Thirty- one cases of SARS occurred after exposure in the emergency room of the National Taiwan University Hospital.

92 Crit Care Med 2005;33:S53-S60 Four hospitals had major nosocomial outbreaks of SARS. Three of these outbreaks occurred in ICUs.

93 Within 18 hrs of presentation, the patient was admitted to the ICU and 3 hrs later was placed in an isolation room.this 21-hr period of unprotected contact led to128 cases of SARS resulted from transmission of the virus within this hospital. (42% HCWs, 28% patients or visitors, and 30% household contacts).

94 What Next??? Avian Flu????

95 A chicken farm An OPD

96 A chicken farm A hospital ward