Infection nosocomiale

A Infection is known as nosocomiale or hospital, if it is absent during the admission of the patient to the Hôpital and that it develops at least 48 hours after the admission. This time makes it possible to distinguish a Community infection of acquisition from an infection nosocomiale. This criterion should not be applied without reflection and it is recommended to appreciate, in the doubtful cases, the plausibility of the causal bond between hospitalization and infection.

For the infections of operational site, one regards as nosocomiale the infections occurring in the 30 days following the surgical intervention or if it installation there of a prosthetic material or of an implant in the year which follows the intervention.

The nosocomial term comes from the Greek nosos , disease and of komein to look after.

General information

The increase in the infections nosocomiales is partly related to diagnostic and therapeutic progress of medicine: the assumption of responsibility of patients increasingly fragile, in particular reached congenital deficit of the Immunity or, generally, of a deficit acquired by the administration of drugs Immunosuppresseur S.

It is however necessary to relativize this assertion of increase: between the French investigation of prevalence of 1996 and that of 2001, although the comparison of the results is difficult, one observes a reduction of 13% of the Prévalence of the infections nosocomiales.

The new-born babies, the premature ones and the elderly remain particularly prone to the infections nosocomiales.

The technical invasive S used in the hospitals for the diagnosis, the monitoring and the treatment often open new doors with the Infection: urinary probe with residence, measures central venous Pression, perfusions of any nature, prosthesis installation of…

The infections nosocomiales are thus not all avoidable, even if about half of these infections can be prevented by simple means, like the washing of the hands and an adapted continuing education.

Epidemiology

In France

In France, these infections have a Prévalence of 6,87%, and the prevalence of the infections of 7,5% (certain patients having contracted two IN, even more). Urinary infections accounting for 40% of the pathologies nosocomiales followed by the infections of the skin and soft fabrics to a total value of 10,8%, of the infections of the operational site (10,3%) and pneumopathies (10%).

The infections nosocomiales complicate 5 to 19% of the admissions in the general hospitals and up to 30% of the patients in intensive care. On average, these infections prolong the hospitalization from 4 to 5 days.

It is estimated that there is approximately: 9000 per annum dead, but in only: 4200 cases, the vital prognosis were not engaged before the declaration of the disease.

In Italy

In Italy, the diseases nosocomiales related to in the years 2000 approximately 6,7% of the hospitalized people, that is to say: 450000 and: 700000 victims, causing between: 4500 and: 7000 dead.

With the Polyclinic Umberto-Ier where the conditions of hygiene appeared disastrous in 2006, the rate of infection exceeded 15%.

In the United States

With the the United States, one estimates that 10% of in-patients are victims of an infection nosocomiale, that is to say 2 million patients per annum.

That represented: 88000 died in 1995, and a going cost from 4,5 to 11 billion dollars. A third of the diseases nosocomiales would be avoidable.

Etiology

It is necessary to keep in mind that certain infections nosocomiales are “normal” in comparison with pathology to treat and of average therapeutic to implement. One thus should not confuse the infections nosocomiales making following an error or a negligence, with those related to a complication of a therapy or an invasive act.

Thus the development of a pneumopathy after 1 month of artificial ventilation in reanimation does not have the same significance as which has occurred of an infectious episode the shortly after the installation of a central venous way.

Modes of transmission

There are four great modes of transmission:

Auto-infection

The patient infects herself with his own germs, the “main doors” are the lesions of the mucous membranes, the cutaneous lesions (Plaie S, Brûlure S, skin diseases). The germs will be those of the skin, the mucous membranes, the digestive tract, etc This mechanism is supported by various factors, the dissemination of the germs of the patient in his environment (as for example the bed), by the use of treatment which can deteriorate the Immunocompétence (Corticostéroïde S, Immunosuppresseur S…), by the administration of treatments selecting certain bacteria (Antibiothérapie with broad spectrum…). Lastly, the immunodéprimés patients (aplasic AIDS, …) are the people more at the risk because of the defect of immunizing vigilance of their organization, thus developing strictly endogenous pathologies.

Hétéro-infection

In this case, the germ responsible for the infection nosocomiale comes from another patient, the transmission being generally manuportée , by medical staff intervening with several patients, thus disseminating the germs from one person to another. These infections are known as “cross”. It is the mode of contamination most frequently found at the time of epidemics. However certain germs, like that of the Tuberculosis, are transmitted by air. It can moreover arrive more rarely than the germs are transmitted by direct contact between two patients.

Xéno-infection

This mode of transmission is separately a little, in this case the disease-causing agents are transmitted by people coming from outside (medical staff, visitors, subcontractors), and presenting themselves an infectious pathology, declared or in the course of Incubation. This mode of transmission is not however to neglect, because it can be devastator for the particularly fragile patients. Thus, the health professionals are more and more encouraged to be made Vaccin er against the Grippe.

Exo-infection

This mode of transmission is due

is with a technical dysfunction of a material (air filter, autoclave…) intended for the protection of the patients which, not filling its office more, lets them in contact with germs which would not have, in theory, not be the subject of an infection, within sight of measurements taken to prevent them (Aspergillose, Légionelle…),
is with an error made in the execution of the procedures of treatment of the medico-surgical material.

Clinical forms

In France:

urinary Infections: 44% of the post-operative cases
Infections: 45% of the cases
Lung infections: 10-30% of the cases
Systemic infections: 5-10% of the cases
viral Infections

Causes of the infections nosocomiales

To develop an infection nosocomiale, it is necessary that three elements are joined together: an infectious agent, a mode of transmission and a receptive subject.

There exist other factors supporting like the insufficiency of the bathrooms and showers, the behavior of the hospital staff which, sometimes, includes/understands the problem with difficulty, or the mobility of the patients who are transferred between the various hospital services.

The infectious agent

The infections nosocomiales are in general the fact of Bactérie S:

Commensale S, i.e. germs which can live only in contact with our organization; these bacteria are often useful for the good performance of the human body, thus the total colony count residing in our digestive tract (Staphylocoque gilded, Pseudomonas aeruginosa …) is essential to digestion; on the other hand, so for a reason or another at the time of an surgical operation, these germs are poured in the abdominal cavity, they become dangerous, Pathogènes;
Saprophyte S, i.e. alive in the environment of the man (water, air…) and being able to colonize it under certain conditions.

The hospital, medium supporting the infections. Pressure of selection of the bacteria

The hospital medium, accessible by definition a vast population, thus puts in the presence of the healthy individuals, but also of the patients presenting of different, infectious pathologies or not. However each person, while moving in the buildings, disperses the germs which it carries on it on the handles of door, the switches, surfaces, in the air…

Thus the hospital environment is a genuine “rotted pot” of germs. The flora thus formed evolves/moves according to the intrinsic capacities of resistances of each bacterium, of the Antiseptique S used for cleaning, but also of the antibiotic prescribed in the establishment.

This flora thus undergoes a Pression of selection: only the most resistant germs survive.

Thus, a hospitalized person will enter to the hospital with her own total colony count. But once in contact with the hospital environment (bed, the night table, personnel…) and the various treatments, this one will change, and in its turn will undergo the pressure of selection. Consequently, the resistant germs of the environment will develop at the expense of those not very resistant of the flora of origin.

The hospital germs are in general able to survive in a hostile environment and to develop a Résistance to the antibiotics usually used. Certain hospitals are confronted with problems involved in the emergence of Staphylocoque S, Entérocoque S and Gram- bacilli resistant to multiples Antibiotique S.

The antibiotic overconsumption, another element facilitating the infections

The antibiotics managed without valid reason are the main cause of the infections nosocomiales. Indeed, they make certain micro-organisms resistant and contribute to the selection of the hospital stocks multirésistantes which can be transmitted of a patient to the other.

These germs, even resistant, are not inevitably pathogenic for the individuals in good health, but they are it for those whose health condition is faded.

The gravity of the infections can be exacerbated by the use of Antibiotique S.

Receptivity of the patient

In-patients have by nature of faded immunizing defenses. He is thus because of pathologies carrying is directly reached with immunizing competences of the patient (Diabète, immunizing respiratory Insuffisance, pathologies, badly burned persons…), that is to say general state of the patient.

Thus the people dénutries or at the extreme ages of the life are more receptive with the infections in general, and nosocomiales in particular.

Other treatments, medical devices favourable with the infections at the hospital

Finally the treatments or the medical devices used, like the urinary probes, the probes of intubation, the catheters, the drains, but also the treatments by corticoids, antibiotics, immunosuppresseurs… constitute a ground favourable with the development of pathologies nosocomiales.

Evitability. Measurements taken and first results

It is estimated that 30% of the infections nosocomiales could be avoided: On the whole, taking into account the multiple origins of the infections nosocomiales, one estimates at 70% the proportion of those which could not be avoided by a better prevention (measurements of hygiene, buildings adapted, etc), in particular because of their endogenous origin .

Possible preventive measures

Independent measurements to fight the infections nosocomiales concern the Hygiène:

hygiene of the hands of looking after, the patients and their entourage;
septic insulation (in particular in an individual room) of the patients likely to propagate the infection;
protective insulation of the abnormally likely subjects to the infections;
monitoring of the Antibiotic use of the S in the hospital;
monitoring of the engineering services (ventilation, water…), of the kitchens and wash-houses: disinfection of the conduits transporting the fluids, in particular water and the air (heating, air-conditioning), in particular with respect to the Légionellose;
training and periodic medical control of the personnel of the hospital: washing of the hands between each patient (Detersion with soap so necessary, and Disinfection with the Solution hydro-alcoholic), use of Glove S deads and Mask S so necessary, disinfection of the material (in particular with the Hermetically-sealed ) and destruction of the material of single use…
constitution of a committee of the hospital in charge of a program for the control of the infections nosocomiales.

Example of France

The alarm system set up in France is effective

the InVS developed an effective alarm system. This system connects the establishments which alert the InVS when an epidemic or a resistant infection occurs; GRAPE (Network of Alarm, Investigation and monitoring of the Nosocomiales Infections) then produced recommendations if it is necessary. Two recent examples can be quoted:

Entérocoque resistant to the vancomycine (alarm in July 2005)
Acinetobacter baumannii Multi-resistant to the Antibiotic S, announced in 54 establishments distributed in 15 departments (recommendations June 2004)

…

Encouraging results by places, but vigilance remains of setting

Encouraging results corroborate those recorded for example with the AP-HP where the percentage of SARM decreased by ¼ in short stay and half in reanimation between 1993 and 2002 (passing from 55% to 24%). A downward trend of the percentage of SARM in reanimation during the 4 last years was also recorded in the CCLIN Paris-North and Sud-Ouest.

These results which go in the good sense seem to be the fruit of an installation of a special program of prevention of the cross transmission of the Bactérie S Multi-resistant are, and of a better use of the Antibiotique S.

But vigilance remains of setting and of progress remain to be made. For example, the proportion of the stocks EBLSE decreased since 1993 (regular reduction in time) but, on the other hand, the resistance of these bacteria gained the species E. coli, species Commensal E major, which makes fear a diffusion in the community. It also gained the species E. aerogenes.

Evaluation of the means of fight against the infections nosocomiales

The ministry for health installed a composite indicator of the activities of fight against the infections nosocomiales " ICALIN ", whose objective is to encourage all the health care institutions to measure their actions and their results in the field of the fight against the infections nosocomiales.

Organization of the fight against the infections nosocomiales

In France

In France, it is in 1998, that the COVERING JOINT ( C omity of L utte against the I nfections NR osocomiales) like these cells regional girls, the C.CLIN ( C enter of C oordination of the L utte against the I nfections NR osocomiales) are instituted. These structures of State have the role:

of auditer the Prevalence and the Incidence of the infections nosocomiales of the structures of care public or private;
to publish this information in the form of an official statement with the public, of a documentary bibliography or a report/ratio of alarm to the InVS or the Afssa;
to support by average techniques or bibliographical the internal fight plans with each structure of care (and this in particular by annually publishing the “Guide of good practices and recommendations” for the health professionals at the conclusion of the conferences of consensus).

Since July 1st, 1998, the law of public health of the Public health code provides that each health care institution must obtain a fight plan against the infections nosocomiales. The reinforcement of the prevention of the health hazards doubled by the organization of the fight against the infections nosocomiales by the COVERING JOINT, make it possible each health care institution to constitute a cell of fight against the infections nosocomiales animated by the Operational Team of Hygiene (EOH).

The example given on SARM in the Scandinavian countries

A work was made to compare protocols of ousting of the gilded staphilococca resistant to the méticilline (SARM) in the Scandinavian countries. Because " in the Scandinavian Netherlands and countries, the rate of SARM is lower than 1% whereas it is in France of 28% according to the EARSS 2004, and is also atimportant rates at the United Kingdom, in Germany, in Belgium and in the United States (50% according to the National Nosocomial Infections System8 Monitoring (*) ".

The Scandinavian countries and the Netherlands, to obtain a so low rate of SARM, developed the protocol called Search and Destroy (S & D). The impacts of measurements of this program S & D were studied by using mathematical models by considering either a low level of SARM (<1%), or a strong rate of SARM (>10%).

Impact study of measurements of the protocol Search and Destroy

The 6 studied precautionary measures were:

Measurement I: the assumption of responsibility of the carriers of SARM in room alone
Measurement II: the search for a colonization and the insulation of the patients at the risk, i.e. patients already identified like carriers of SARM or coming from services at the risk
Measurement III: the systematic search for SARM among all patients after the detection of one In a service
Measurement IV: measure III associated with systematic research with a colonization by SARM in medical staff with an infected service, and sick leave until decontamination of the members of the personnel infected
Mesure V: prohibition of new admissions in the services presenting a transmission proven between the patients, this measurement being prolonged until insulation in room alone of all the carriers of SARM
Measurement VI: the colonization of SARM is éradiquée at the end of the hospitalization.

Simple measurements of hygiene of the hands are implied in the behavior of the health workforce and are thus not mentioned as such although they essential and are necessarily respected.

First observation : in the models with low level of SARM (<1%), the absence of any control measures is accompanied in 10 years by an increase by the rate reaching more than 15%. The application of measure I only is not sufficient to maintain the rate of IN with SARM with less than 1% but the increase is very slow (1,5% in 30 years). The association of measurement I with measurement II or measurement III makes it possible to maintain a rate of SARM to less than 1%. The association of measurements I, II and III gives the best results. Measurements IV, V, and VI offer each one a tiny additional benefit.

Second observation : in the models atstrong rate of SARM (>10%), the application of the whole of measurements of the program S & D reduce the rate of SARM to 1% into 6 to 12 years. The application of measure I only the tiny room to 5% in 15 years. And the applications, by stage or overall, of measurement I with measurement II or measurement III or measurements II and III lead to a reduction in the rate of active SARM of less than 2% with less than 1% out of 20 to 30 years according to the model. The full number of necessary days in insulation by hospital over 30 years is of a hundred thousands of days.

How to take as a starting point this protocol Search and Destroy ?

The countries having a strong rate of SARM could take as a starting point this program S & D and by its 6 measurements.

It should be noted that these measurements, to be effective, must be respected in an exhaustive way : for example, an effectiveness of insulation of the patients from only 50% could not lead to a reduction in the rate of SARM.

Limits are essential immediately to apply such a program in France:

an architectural problem exists which makes that often in the intensive care units, the réanimateurs do not have room of insulation or do not have which it of sufficient number (rooms in reanimation with 3 beds, fortunately less and less frequent…) ;
a behavioral cultural problem also exists which blocks simplest measurements of hygiene, measurements applied for a long time in the Scandinavian countries.

But this model is to be kept in mind. It will be noticed on this subject that the countries having good performances as regards resistance to antibiotics are not always those which have good performances as regards IN. The measures to be taken for these two objectives, however very dependant, are distinct.

In Swiss

In the canton of Geneva, the study " Clean Care is Safer Care" carried out by the University hospitals of Geneva (HUG) in partnership with WHO could highlight that by providing a bottle of pocket of solution hydro-alcoholic (SHA) to each Health professional, the Prévalence of the infections nosocomiales of origne manuportée was reduced of half. One of the principal explanation proposed by the audit is that a washing of the hands to water and the soap is more constraining than to practice a Hygiène of the hands using a friction of SHA.

Following this study revealing that while raising certain constraints (time of a washing, cutaneous intolerance with the paper of wiping, user friendliness of the SHA and availability over the moment of the product), the VigiGerme cell of the HUG recommends that to equal opportunity, it is to better privilege a friction of SHA to a traditional washing.

Case of France

One admits commonly that, in France, 6% to 7% of the hospitalizations are complicated by a more or less serious (IN) infection nosocomiale, that is to say approximately 750.000 cases out of the 15 million annual hospitalizations.

Always according to this last report/ratio of the OPEPS (June 2006), the infections nosocomiales constitutes 22% of the serious events related to the care, against 37,5% for the other continuations from an surgical operation and 27,5% for the medicamentous accidents.

4200 deaths per annum?

The usual estimate of the number of deaths annual is of 7.000-10 000. A recent investigation (C.CLIN Paris-North, PHRC, 2001) table rather into 4.200. On the whole, the infections nosocomiales would be thus causes some for 9.000 deaths per annum, of which 4.200 concern patients for which the Vital prognosis was not short-term volunteer at their entry at the hospital. For half of these 4.200 deaths, no other causes death is not detected. .

The imputability is in any event delicate to establish. Few studies were carried out but it would seem that them IN multiply the risk of death by 3 if one compares the number of deaths of the patients having acquired one IN with that of the “identical” patients not having acquired one IN . …

Finally one can estimate the number of Décès in hospital sector with IN at approximately 9.000, including 4.200 among patients whose Vital prognosis was not short-term volunteer, of which the half without other causes death.

It is probable that the 3/4 of these 4200 deaths are victims of Bactéries multirésistantes with antibiotics

Unquestionable economic costs, expensive than the prevention

The infections nosocomiales involve an important financial overcost, primarily due to a lengthening of the duration of hospitalization (4 days on average), to the anti-infectious treatment and the tests of laboratory necessary for the diagnosis and the monitoring of the infection. One estimates thus that the supervening of an infection lengthens the stay in orthopedic surgery of almost 2 weeks and increases the costs of assumption of responsibility of the patient of 300%.

The various studies available give a report on a very broad scale of costs, going 340 euros on average for a urinary Infection with 40.000 euros for a severe Bactériémie in Réanimation. The estimates thus vary appreciably according to the anatomical site of the Infection, of the nature of the Germe, the Pathologie dealt with but also of the service of hospitalization.

By applying a fork of average overcost from 3.500 to 8.000 euros per infection to the 750.000 annual infections nosocomiales, one reaches an amount of expenditure from 2,4 to 6 billion euros.

Thus, a reduction of 10% of the number of infections would lead to a saving in 240 to 600 million euros, that is to say up to 6 times more than the effort of Prévention authorized by the hospitals, which is established to a hundred million euros.

This rapid calculation shows how much the cost not-quality is higher than that of the Prévention.

A prevention policy which starts to bear its fruits

Several measurements since 1995 have produces considerable results in terms of prevalence of the infections nosocomiales among in-patients. Thus, between the investigation of Prevalence of 1996 and that carried out in 2001, this rate was brought back from 8,3% to 7,2% in the university hospitals and from 6,5% to 5% in the hospitals .

A collective awakening, but insufficient information

An investigation Ipsos (2006) watch that 83% of the questioned people heard of the infections nosocomiales, and that these risks constitutes the source of concern first of the French within the framework of a hospitalization, before the medical errors. Fear underestimated by the health professionals, which estimate that the fear of being anaesthetized would be their first factor of anxiety.

On the other hand, the general public is not estimated correctly informed on the causes and the consequences of the infections nosocomiales. . The Opeps concludes that the effort as regards fight against the infections nosocomiales will have, in the years to come, to stress the information of the health professionals, like population as a whole.

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