Where does India rank globally and in the South Asian region when it comes to HAIs?
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Dr Victor D Rosenthal
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India is one of the countries with the lowest HAI rates in the South Asian region. The known HAI rate of India is from the private sector, as an example for Central line-associated bloodstream infections (CLAB), it is around 5 CLAB per 1000 CL days; meanwhile in the US the CLAB rate is 1CLAB per 1000 CL days. The HAI rate from public sector is unknown and probably is three to four times higher than private sector.
What are the most common type of HAIs? Do they differ from region to region?
The most common types of HAIs are bloodstream infection, pneumonia, urinary tract infection (UTI) and surgical site infections (SSI). There are no significant differences when comparing HAIs in different regions. Worldwide the most prevalent HAIs are the same as above. UTI and SSI are the most prevalent HAI of these four.
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Type of HAIs (Hospital-acquired infections)
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How much of HAIs can be attributed to antibiotic resistance? How grave an issue is it?
HAI rate is not related to antibiotic resistance rather they are due to lack of compliance with infection control guidelines such as low compliance with hand hygiene, lack of antisepsis with chlorhexidine, use of femoral vascular central line, high use of three ways stop cock, etc. Antibiotics are responsible for higher bacterial resistance.
HAI rates and bacterial resistance are independent and almost unrelated. Changing policies for antibiotics would reduce only bacterial resistance, but not CLAB rates, PNEU rates or UTI rates. Better antibiotic use could help only when used correctly for surgical prophylaxis.
How can physicians and hospital staff ensure a decrease in HAIs and what measures in particular need to be put in place? Where is India lagging?
Physicians and hospital staff can decrease HAIs by applying a multidimensional approach which includes- bundles, education, surveillance of HAIs, surveillance of compliance with guidelines, feedback of HAI rates, and performance feedback. Examples of measures that help preventing HAIs such as CLAB include hand hygiene, use of subclavian vein, maximal barriers, removing a catheter as soon as possible, skin antisepsis with chlorhexidine, chlorhexidine impregnated sponges, split septum, collapsible IV containers, single use pre-filled flushing device, and others.
Other measures include:
- Adherence to hand-hygiene guidelines
- Use of noninvasive ventilation whenever possible
- Minimising the duration of ventilation
- Performing daily assessments of readiness to wean
- Maintaining patients in a semi-recumbent position (30-45 elevation of the head of the bed) unless there are contraindications
- Avoiding gastric over-distention and unplanned extubation and reintubation
- Using a cuffed endotracheal tube with in-line or subglottic suctioning
- Maintaining an endotracheal cuff pressure of at least 20 cm H2O
- Orotracheal intubation is preferable to nasotracheal intubation
- Perform comprehensive oral care with an antiseptic solution
- Remove condensate from ventilatory circuits ad keeping the ventilatory circuit closed during condensate removal changing it only when visibly soiled or malfunctioning
Tell us about the surveillance tool by INICC.
The new International Nosocomial Infection Control Consortium (INICC) online system was designed to keep the effective methodology it has been applying successfully since 1998 in 50 countries of Latin America, the Middle East, Asia, Africa, and Europe. INICC has published more than 300 scientific papers, book chapters, and collaborated with edition and review of bundles to prevent healthcare-associated infections (HAIs) of WHO, JCI, Argentina, Brazil, Peru, Colombia, Mexico, China, Taiwan, Hong Kong and many other countries and international organisations. INICC methods are responsible for the fast, effective and significant reduction of HAI and mortality rates worldwide, as documented, published, and expressed in papers published by different authors and organisation including WHO. The methods and definitions are those of CDC-NHSN (US), plus some extra advantages, such as validation, accuracy, identification of risk factors, measurement of extra mortality, extra length of stay and extra cost, measurement of compliance of bundles to prevent HAIs, and much more.
What is the annual cost that HAIs incur to hospitals?
The extra length of stay of each HAI is at least 10 days. In an ICU with 20 beds there are admitted around 100 patients per month. Around 1200 are admitted in ICU per year. Around 20 per cent acquire HAI representing 2400 extra bed days. If one bed day is $1000, in one year due to HAIs the annual cost incurred to hospitals is around $2,400,000. On the other hand there are surgical site infections that also are responsible for around $2,400,000 per year. Hence, at least half million dollars is the extra cost due to HAIs per hospital.