- Email: [email protected]
Nosocomial infection: hospital infection surveillance and control
242 performed because the specimens were diarrhoeal and from patients aged 65 years or over. Overall, therefore, 699 CDT tests were performed during this period. Assuming that the new standards did not influence request patterns (and they were not widely trailed to clinical staff), this suggests an attributable increase in workload of about 40%. Proportionately, the greatest impact has been on testing specimens from primary care, which accounted for 85 (12.2%) of the 699 specimens tested, only 16 of which had been specifically requested. Extrapolation of these figures suggests that introduction of the surveillance standards is likely to cost this laboratory over £4000 per annum in reagents alone. Is this increase in workload and expenditure worth it? Among the 472 specimens that were both requested and tested, 83 (17.6%) were positive. However, only 64 of these would have been included as cases in the surveillance figures—five pertained to patients under 65 years of age (whom we continue to test on request) and 14 had been submitted within four weeks of a previous positive specimen. Among the 227 ‘extra’ tests performed, 34 (14.5%) were positive, and 33 of these were both significant and subject to surveillance (one was an early repeat result that did not contribute to patient management). Of these 33 new cases, relapses and re-infections that our previous testing strategy would have failed to identify, 24 were acute hospital inpatients (five of whom had been in hospital for three days or less) while six had presented in primary care. These six were all new diagnoses of CDAD although five had recently been discharged from this hospital. In summary, in this laboratory, the recent introduction of mandatory surveillance of CDAD according to standardized laboratory procedures has entailed a 40% increase in test throughput, but generated a 40% increase in positive tests and a 50% increase in results subject to surveillance. The extra cases that our previous request-based testing strategy would have missed include those presenting both in hospital and in the community. Our previous strategy would also have entailed unnecessary follow-up of any positive results derived from the 5% of specimens that are not diarrhoeal and which are now rejected. Early indications are therefore that mandatory surveillance based on standardized criteria will lead to improvements in our diagnosis of CDAD and, one hopes to its control. However, the new standards impose significant costs on diagnostic services and these should be considered when funding is allocated.
Letters to the Editor
References 1. Department of Health. CMO to step up fight against hospital infections. Press Release 2003/0222, Monday 9 June 2003. Surveillance of Healthcare Associated Infections (PLCMO2003/4, PLCNO2003/4). 2. National Clostridium difficile Standards Group report to the Department of Health. J Hosp Infect 2004;56(Suppl. 1):1–38.
A. Berrington* Department of Microbiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK E-mail address: [email protected] *Tel.: C44-191-5656256 Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.06.031
Nosocomial infection: hospital infection surveillance and control Sir, Nosocomial infections encompass any infection acquired by a patient in hospital and occupational infections amongst staff.1 During the 1970s, infection control surveillance and control programmes were introduced in US general hospitals. There was a reduction in nosocomial infection rates between 1970 and 1975. Programme goals were achieved by an infection control team and a system for reporting infection rates to practising surgeons.2 Comprehensive information on nosocomial infection in tertiary-care hospitals in India has been lacking. Almost two decades after the introduction of the US hospital strategy of surveillance,2 we instituted a laboratory-culture-based strategy to monitor nosocomial infection in a tertiary-care hospital in Delhi following an outbreak of gastroenteritis caused by enterotoxigenic Escherichia coli in a neonatal intensive care unit.3 An infection control team comprising a clinical microbiologist, a gynaecologist/obstetrician, and two microbiology technologists was charged with the responsibility of surveillance of hospital infection. The team briefed the management about its activities through the Hospital Director. Episodes of bacterial and fungal infections among patients are identified from microbiology cultures on clinical material. Microbes isolated from patients within two to three days of hospital
Letters to the Editor
243
Table I Nosocomial infections per 100 hospital admissions, 2003 Month January 2003 February 2003 March 2003 April 2003 May 2003 June 2003 July 2003 August 2003 September 2003 October 2003 November 2003 December 2003
Nosocomial infections/100 admissions 0.53 1.5 0.28 0.59 0.15 0.32 0.61 0.62 0.28 0 0 0.13
admission are recorded as ‘community acquired’, and any isolate cultured after three days of hospitalization is recorded as ‘nosocomial’. The culture reports and the antibiotic susceptibility pattern are communicated instantly to the clinician responsible for the patient and the nursing personnel. The hospital has been successful in preventing any secondary spread of infection from patients. The team has close contact with clinicians and reviews the hospital scenario regularly. The infection control team reviews the clinical profile and outcome of patients with nosocomial infections once a month. Furthermore, the team monitors any secondary microbial spread from a community- or hospital-infected patient to other patients on the ward or the hospital personnel handling the patient. Environmental cultures from operative sites, intensive care wards, dialysis and neonates are scrutinized for any potential pathogens. Any site harbouring such pathogens is dealt with. During 2003, the rate of nosocomial infections per 100 admissions declined from 0.53–1.5 to 0–0.13 (Table I). There has been no administrative hurdle as no additional budget was sought from the hospital management. The team are well motivated and clinicians receive details of any infected patients under their charge promptly so that appropriate treatment can be instituted. Ward-based clinical surveillance is not currently a part of our programme. We plan to strengthen the existing surveillance for any missed episodes of
hospital-acquired cases, both during hospitalization and in the postdischarge period, in a phased manner. At present, there is hardly any antibiotic policy in the hospital and antibiotic audit is unknown. Most clinicians would resent such a practice and regard it as interference. Nevertheless, the infection control team hopes to introduce a mutually acceptable antibiotic policy. The patients also get antimicrobial agents from independent pharmacies located in different parts of the city. Future evaluation of antimicrobial use by the patients4 should be intriguing and offer insights into possible therapeutic failures. To conclude, even a pilot programme to monitor episodes of nosocomial infection using a microbialculture-based strategy is an effective weapon in reducing the incidence of hospital-acquired infection. Even without the existence of ward-based clinical surveillance in the hospital, this should strengthen efforts to address the global scourge of nosocomial infections.1
References 1. World Health Organization. Prevention of hospital-acquired infection: a practical guide. WHO/CDS/CSR/EPH/2002.12. Geneva: WHO; 2002. 2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121:182–205. 3. Taneja N, Das A, Raman Rao DS, Jain N, Singh M, Sharma M. Nosocomial outbreak of diarrhoea by enterotoxigenic Escherichia coli among preterm neonates in a tertiary care hospital in India: pitfalls in healthcare. J Hosp Infect 2003;53:193–197. 4. Arya SC, Agarwal N. Nosocomial infection in adult intensivecare units. Lancet 2003;362:493–494.
S.C. Arya*, N. Agarwal, S. Agarwal, S. George, K. Singh Sant Parmanand Hospital, 18 Alipore Road, Delhi 110054, India E-mail address: [email protected] *Corresponding author. Tel.: C91-11-9810642269 Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.07.008
Letters to the Editor
References 1. Department of Health. CMO to step up fight against hospital infections. Press Release 2003/0222, Monday 9 June 2003. Surveillance of Healthcare Associated Infections (PLCMO2003/4, PLCNO2003/4). 2. National Clostridium difficile Standards Group report to the Department of Health. J Hosp Infect 2004;56(Suppl. 1):1–38.
A. Berrington* Department of Microbiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK E-mail address: [email protected] *Tel.: C44-191-5656256 Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.06.031
Nosocomial infection: hospital infection surveillance and control Sir, Nosocomial infections encompass any infection acquired by a patient in hospital and occupational infections amongst staff.1 During the 1970s, infection control surveillance and control programmes were introduced in US general hospitals. There was a reduction in nosocomial infection rates between 1970 and 1975. Programme goals were achieved by an infection control team and a system for reporting infection rates to practising surgeons.2 Comprehensive information on nosocomial infection in tertiary-care hospitals in India has been lacking. Almost two decades after the introduction of the US hospital strategy of surveillance,2 we instituted a laboratory-culture-based strategy to monitor nosocomial infection in a tertiary-care hospital in Delhi following an outbreak of gastroenteritis caused by enterotoxigenic Escherichia coli in a neonatal intensive care unit.3 An infection control team comprising a clinical microbiologist, a gynaecologist/obstetrician, and two microbiology technologists was charged with the responsibility of surveillance of hospital infection. The team briefed the management about its activities through the Hospital Director. Episodes of bacterial and fungal infections among patients are identified from microbiology cultures on clinical material. Microbes isolated from patients within two to three days of hospital
Letters to the Editor
243
Table I Nosocomial infections per 100 hospital admissions, 2003 Month January 2003 February 2003 March 2003 April 2003 May 2003 June 2003 July 2003 August 2003 September 2003 October 2003 November 2003 December 2003
Nosocomial infections/100 admissions 0.53 1.5 0.28 0.59 0.15 0.32 0.61 0.62 0.28 0 0 0.13
admission are recorded as ‘community acquired’, and any isolate cultured after three days of hospitalization is recorded as ‘nosocomial’. The culture reports and the antibiotic susceptibility pattern are communicated instantly to the clinician responsible for the patient and the nursing personnel. The hospital has been successful in preventing any secondary spread of infection from patients. The team has close contact with clinicians and reviews the hospital scenario regularly. The infection control team reviews the clinical profile and outcome of patients with nosocomial infections once a month. Furthermore, the team monitors any secondary microbial spread from a community- or hospital-infected patient to other patients on the ward or the hospital personnel handling the patient. Environmental cultures from operative sites, intensive care wards, dialysis and neonates are scrutinized for any potential pathogens. Any site harbouring such pathogens is dealt with. During 2003, the rate of nosocomial infections per 100 admissions declined from 0.53–1.5 to 0–0.13 (Table I). There has been no administrative hurdle as no additional budget was sought from the hospital management. The team are well motivated and clinicians receive details of any infected patients under their charge promptly so that appropriate treatment can be instituted. Ward-based clinical surveillance is not currently a part of our programme. We plan to strengthen the existing surveillance for any missed episodes of
hospital-acquired cases, both during hospitalization and in the postdischarge period, in a phased manner. At present, there is hardly any antibiotic policy in the hospital and antibiotic audit is unknown. Most clinicians would resent such a practice and regard it as interference. Nevertheless, the infection control team hopes to introduce a mutually acceptable antibiotic policy. The patients also get antimicrobial agents from independent pharmacies located in different parts of the city. Future evaluation of antimicrobial use by the patients4 should be intriguing and offer insights into possible therapeutic failures. To conclude, even a pilot programme to monitor episodes of nosocomial infection using a microbialculture-based strategy is an effective weapon in reducing the incidence of hospital-acquired infection. Even without the existence of ward-based clinical surveillance in the hospital, this should strengthen efforts to address the global scourge of nosocomial infections.1
References 1. World Health Organization. Prevention of hospital-acquired infection: a practical guide. WHO/CDS/CSR/EPH/2002.12. Geneva: WHO; 2002. 2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121:182–205. 3. Taneja N, Das A, Raman Rao DS, Jain N, Singh M, Sharma M. Nosocomial outbreak of diarrhoea by enterotoxigenic Escherichia coli among preterm neonates in a tertiary care hospital in India: pitfalls in healthcare. J Hosp Infect 2003;53:193–197. 4. Arya SC, Agarwal N. Nosocomial infection in adult intensivecare units. Lancet 2003;362:493–494.
S.C. Arya*, N. Agarwal, S. Agarwal, S. George, K. Singh Sant Parmanand Hospital, 18 Alipore Road, Delhi 110054, India E-mail address: [email protected] *Corresponding author. Tel.: C91-11-9810642269 Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.07.008