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

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

What?

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

Why epidemiologists should pay an attention to nosocomial infections?

Nosocomial Infections: How much?

J Med Assoc Thai 2005; 88 (Suppl 10): S1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%

Nosocomial Infection Rate 1985-1986, Thailand Hospital beds Rate (%) >700 15.2 400 700 4.1 <400 2.8 Ref.: Pinyowiwat W et al. Dept. of Epidemiology Ministry of Public Health

Nosocomial Infections Mortality-How much?

J Med Assoc Thai 2005; 88 (Suppl 10): S1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%

Nosocomial Infections Morbidity-How much?

Why epidemiologists should pay an attention to nosocomial infections?

J Med Assoc Thai 2005; 88 (Suppl 10): S1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%

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.

Top ten morbidity rate of diseases under surveillance Thailand, 2001 (2544) Rank Diseases Cases Deaths Morbidity Rate (Per 100,000 Pop.) 1 Acute diarrhoea 1020377 176 1643.3 2 Pyrexia of unknown origin 269740 54 434.4 3 Dengue haemorrhagic fever 139355 245 224.4 4 Food poisoning 138795 2 223.5 5 Pneumonia 135768 1057 218.6 6 Haemorrhagic conjunctivitis 107929 0 173.8 7 Influenza 42371 1 68.2 8 Dysentery 37601 2 60.6 9 Malaria 34925 81 56.2 10 Chickenpox 31707 1 51.1 Ref.: Annual Epidemiological Surveillance Report 2001, MOPH

Top ten mortality rate of diseases under surveillance Thailand, 2002 (2545) Rank Diseases Cases Deaths Mortality Rate (Per 100,000 Pop.) 1 Pneumonia 135768 1057 1.7 2 Tuberculosis 30033 287 0.46 3 Dengue haemorrhagic fever 139355 245 0.39 4 Suicide by liquid substance 5241 224 0.36 5 Acute diarrhoea 1020377 176 0.28 6 Leptospirosis 10217 171 0.28 7 Malaria 34925 81 0.13 8 Pyrexia of unknown origin 269740 54 0.09 9 Rabies 37 37 0.06 10 Encephalitis - total 430 30 0.05 Ref.: Annual Epidemiological Surveillance Report 2001, MOPH

Causes of Death of Thai Physicians (1992-2001) 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;20:188-191

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%)

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.

Year 2006, Admission Diagnoses,PSU Hospital Rank Diseases Number of patients 1 Senile cataract 1,123 2 Malignant neoplasm of bronchus and lung 734 3 Malignant neoplasm of breast 576 4 Malignant neoplasm of ovary 483 5 Intracranial injury 445 6 Malignant neoplasm of liver and intrahepatic bile ducts 442 7 Malignant neoplasm of rectum 415 8 Malignant neoplasm of cervix uteri 415 9 Maternal care for known or suspected abnormality of pelvic organs 385 10 Lymphoid leukaemia 331

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 17 10 Malignant neoplasm of cervix uteri 16 11 [HIV] disease resulting in 15 infectious and parasitic diseases

Impacts of Nosocomial Infections on National Vital Statistics

229 patients were followed for 4.29+/-0.7 years

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

Nosocomial Infections Economical Impacts-How much?

J Med Assoc Thai 2005; 88 (Suppl 10): S1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%

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).

Health Expenditure 1980-2002 (Million baht) Wibulpolprasert S et al. Thailand Health Profile 2001-2004 MOPH Bangkok, Thailand 2005 (ISBN: 974-465-889-4)

Allocation of Government Health Budget by Service Category, 1993-2004 Wibulpolprasert S et al. Thailand Health Profile 2001-2004 MOPH Bangkok, Thailand 2005 (ISBN: 974-465-889-4)

Why rising cost of antibiotics???

Antibiotic Resistance: PSU

MRSA 1986 1987 1988 1989 PSU 5% 15% 25% 30% Siriraj 14% 14% 23% -

PSU Antibiotic Resistance : MRSA Year Resistance 1990 38% 1991 20% 1992 25% 1993 27% 1994 26% 1995 31% 1996 29% 1997 35% 1998 35% 1999 34% 2000 33%

PSU Antibiotic Resistance - E. coli 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Ciprofloxacin 7% 6% 8% 16% 18% 18% 25% 24% 25% 25% Amikacin 9% 6% 6% 4% 6% 7% 5% 5% 4% 5%

PSU Antibiotic Resistance : Ps. aeruginosa Imipenem Resistance 1992 1993 1994 1995 1996 1997 1998 1999 2000 % resistance 4% 9% 12% 8% 8% 10% 7% 11% 16%

PSU Antibiotic Resistance : Ps. aeruginosa 2000 2001 2002 2003 2004 2005 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%

PSU Antibiotics: Cost/Day Amikacin 15 mg./kg q d. 262 bht. Sulperazone 2 g. q 12 hr. 1578 bht Imipenem Meropenem Meropenem Ertapenem Cefipeme Tazocin 500 mg. q 6 hr. 3213 bht. 0.5 g. q 6 hr. 3780 bht. 1 g. q 8 hr. 4200 bht. 1g. q d. 1498 bht. 2 g. q 12 hr. 2088 bht. 4.5 q 8 hr. 1890 bht.

J Med Assoc Thai 2005; 88 (Suppl 10): S1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%

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).

PSU Antibiotic Resistance : Acinetobacter Imipenem Resistance 1997 1998 1999 2000 2001 2002 2003 2004 2005 3% 2% 4% 3% 3% 2% 9% 31% 39%

http://narst.dmsc.moph.go.th/ Percentage of susceptible Acinetobacter baumanii, Jan - Dec 2005

Source of infection and organisms:psu (2003-2004) 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%

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 130 86.1% E. coli 25 18.6% Klebsiella 119 78.7% Pseudo aeruginosa 25 16.5%

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

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 1995-6 1998 1999 1997-8 1998-9 1999 2000 2001-2 HIV + 5.2 HIV - 0.4 3.64 3.58 2.1 4.8 5.52 3.39 HIV + 4.1 HIV - 2.0 (Courtesy: Manoon Leechavengvongs MD)

MDR-TB surveillance, Chiangrai (1995-1997) 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%

Bacteremia, Bamrasnaradura Hospital (CID 1999, 180:87; Lancet 1999, 354, 1159) - 246 febrile patients - 182(74%) = HIV - 119(48%) had positive blood culture - 114 = HIV, only 5 = non-hiv

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

HIV & OPD; T.B. OUTBREAK ST Vincent Hospital, Sydney, Australia O.P.D : Air conditioned treatment room September 1993 - 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, 10-521

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

Year = 2004-2005 5 ER personnels had TB 3=TB lung (one with MDR-TB) 2=TB lung& LN TB rate =1,701per100,000 person-year

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

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 : 1280-1286

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 1995-6 1998 1999 1997-8 1998-9 1999 2000 2001-2 HIV + 5.2 HIV - 0.4 3.64 3.58 2.1 4.8 5.52 3.39 HIV + 4.1 HIV - 2.0 (Courtesy: Manoon Leechavengvongs MD)

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

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;

www.insidetime.org/.../bangkokhilton.htm

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.

A hospital ward in Malaysia

An OPD. in a Thai provincial hospital

An OPD. in a Thai provincial hospital

Fig. 1 Reported Cases of Tuberculosis (Total) per 100,000 Population. by Year, Thailand, 1993-2005. 70 Rate per 100,000 Pop. 60 50 40 30 20 10 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

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

SARS

Second Wave of Epidemic: in the Hospitals

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;289:2801-9 CDC. MMWR 2003;52:461-6

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.

Where in the hospital did the outbreak occur?

EID 2004;10:782-788 Thirty- one cases of SARS occurred after exposure in the emergency room of the National Taiwan University Hospital.

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

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).

What Next??? Avian Flu????

A chicken farm An OPD

A chicken farm A hospital ward