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Surgical site infections account for most Healthcare-associated infection

TSIRANG, Bhutan (Kuensel/ANN) - Healthcare-associated infection (HCAI) is the most frequent adverse event in health care.

Programme analyst with the Department of Medical Services’ health care and diagnostic division, Pem Zam, said endemic burden and epidemics of HAI were major public health problems.

According to WHO, HCAI, also known as nosocomial or hospital-acquired infections (HAI) is an infection occurring in a patient during the process of care in health facilities, which are not present or incubating at the time of admission but occurs after 48 hours of admission.

In case of surgical site infections, it includes infections up to 30 days after surgery and up to 90 days if there is implant or prosthesis.

Presenting the findings of a study on HAI at the fifth biennial health conference in Tsirang, which ended on September 20, Pem Zam said HAI had a significant economic impact at both the patient and population levels, including out-of-pocket costs to patients and costs incurred through loss of productivity due to morbidity and mortality.

WHO estimates that on an average seven percent in developed and 15 percent in low  and middle-income countries suffer from at least one HAI at any given time, with attributable mortality estimated at 10 percent.

In Bhutan, according to a point prevalence survey (PPS) carried out in 15 hospitals in October last year, the overall prevalence of HAI was found to be 6.7 percent.

A total of 373 eligible patients from 15 hospitals were surveyed on the day of the study, of which 25 patients had HAI. 

It was found that the national referral hospital in Thimphu had the highest prevalence of HAI at 8.83 percent. This, she said could be because the hospital has the highest bed strength with multispecialty facilities.

In terms of types of HAIs, the surveillance found that surgical site infections are the highest at 32 percent, followed by clinical sepsis (24 percent) and ventilator-associated pneumonia (12 percent).

The microbiology findings in the identified HAIs found that 64 percent had no growth while Klebsiella pneumonia accounted the highest with 24 percent, acinetobacter spp at eight percent and E.Coli at 4 percent. 

“These are the three organisms that were present in the culture,” she said.

The PPS provides a snapshot of only one day so she said that this might not reflect the overall HAI in the country. The other limitation of the surveillance is that there was no capacity for routine HAI surveillance.

Poor planning and budgeting for infection control and medical waste management activities at the dzongkhag health facility level, lack of dedicated infection control focal persons, lack of microbiology services, mismanagement of trained infection control focal especially when they are transferred are the challenges faced in infection control.

In 2009, a prevalence survey in JDWNRH hospital, Thimphu was conducted. Prior to this, Pem Zam said that there was no report or baseline on HAI in the country.

Similar to the recent PPS, this study also found that surgical site infection was the most common infection at 54 percent of all HAI cases.

It was also found that there was a lack of established guidelines and protocols for instituting such surveillance system in the hospitals.

In 2012, the infection control and waste management programme with the ministry has developed routine surveillance, ‘the standard protocol on HAI surveillance in hospitals’.

In line with this, monitoring of HAIs was initiated on pilot in the three referral hospitals and Phuentsholing hospital for two years.

HAI rate for 2013 and 2014 from routine HAI surveillance was found to be 0.25 percent and 1.3 percent respectively.

Pem Zam said that the low HAI rate means it is likely underestimated due to under reporting. It could also be because of lack of dedicated infection control focal points. “The focal persons that we have in the hospitals and BHUs’ primary responsibility is patient care and being an infection control focal person is their secondary responsibility.”

The report of the pilot project was presented to the ministry that instructed the programme to go ahead with PPS on HAI. Since the PPS was carried out in 2014, the surveillance was rolled out to 15 hospitals so far.

Surgical site infection, Urinary Tract Infection (UTI), pneumonia (healthcare-associated pneumonia and Ventilator-associated pneumonia) and bloodstream infection including clinical sepsis are the most common HAI in the country.

Hand hygiene, standards precaution, decontamination environment cleaning, infection control in health workers and medical waste management are the components of infection control in place at the health facilities. 

According to WHO, many infection prevention and control measures, including hand hygiene, are simple, low-cost and effective. However, they require staff accountability and behavioural change.

Awareness and training of health professionals on HAI, ensuring adoption of the national infection control and medical waste management guidelines, increasing frequency of HAI point prevalence surveillance two to three times in a year, and rolling out PPS to other hospitals and BHU and establishing facility-based routine reporting and surveillance of HAI for accurate monitoring are some of the future plans to control HAI.

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