Sunday, July 8, 2001		Keeping fit

Why people get infections in the hospital
B.K. Sharma

IT is said that in the 19th century people lost fear of God and acquired that of microbes. It was around about that time that rapid discoveries in the field of microbiology dealing with the disease causing microbes took place. It was the time of Louis Pasteur and Robert Koch. Breakthroughs were made in many diseases like anthrax, rabies, tuberculosis and cholera. Soon this fear was replaced by the hope of conquering these microbes.

Then came a plethora of antimicrobial drugs and technology. For a while it was thought that man had conquered the infectious diseases but we soon found its limitations. Hospital-acquired infections are still a problem. We all are familiar with the reports appearing in the Press and the frustrating experience when things went wrong because of the infections in the hospital when everything seemed smooth. Recently, a newspaper report about an infection occurring in a burn patient was highlighted in the Press.

The hospital-acquired infections are referred to as nosocomial infections in the technical language and is derived from the Greek word ‘Nosokomeian’ meaning a place where disease is cared for. Nosocomial infections are mean infections acquired during or as a result of hospitalisation for more than 48 hours. They may actually manifest after the person has left the hospital. We do not have ready figures from our own country but one can take a clue from the figures from USA which are readily available. It is estimated that nearly 5 per cent of the patients admitted in the acute care hospitals get new infections and more than 2 million such infections take place annually. Both the economic cost and morbidity is staggering. The annual estimated cost of these hospital-acquired infections is over 2 billion dollars and they considerably increase the morbidity and mortality.

Many people cannot understand as to why a patient should get a new infection when he goes to the hospital. A hospital, in fact, is not a safe place and the reasons are obvious to anybody working there and visiting the hospital. The environment is conducive to infections because of the prevailing diseases among the patients, various procedures done there, strong antibiotics and other drugs used and the modern interventional technology that is used for various procedures.

Predisposing factors for hospital-acquired infections

Infections by their very nature spread through various routes which include air (air borne), through the droplets in the exhaled air while breathing, coughing or sneezing, through water and food, person to person, through food handlers and other care-givers, self-perpetuating oro-faecal route, through injections and blood and finally various devices like catheters, intravenous drips, drains, respirators and surgical procedures. If one considers the above mechanisms it would become clear that hospital is, in fact, a playground for microbes. A concentrated number of patients with all kinds of infections, closed environment, a compromised sanitation because of overcrowding and a lack of facilities would help in the spread of infections.

Another predisposing factor would be the presence of a large number of individuals who are sitting ducks for infections. These are the people whose immunity is compromised for various reasons like diseases of AIDS and viral infections, malnutrition, those receiving strong immunosuppressive drugs for the treatment diseases and organ transplantation, patients receiving radiotherapy treatment and anti-cancer drugs and those recovering from long-standing, debilitating diseases and surgical procedures.

Modern technology is a double-edged weapon. Over the years, I found that virtually in every hospitalised patient there was a canula in the vein. It is placed for the convenience of taking blood samples, giving intravenous medication and emergency procedure and a urinary catheter for tidy drainage of urine of a very sick patient and measuring the urine volume. A big catheter may be put in a vein for intravenous nutrition and also for injecting drugs. A catheter may be put in one of the big vein of the heart to measure various pressures and endotracheal tube is put in the trachea (big tube connecting the throat with the lungs) for suction of secretions and giving oxygen. Endless number of procedures are now done in all the specialities for taking biopsy, injecting drugs and performing small procedures (endoscopic procedures). The purpose of mentioning these is not to discredit these important advancements but only to make people aware that all these carry certain amount of risk of infections. Bacteria, virus, fungi and parasites are present almost everywhere and they come along with these tubes and instruments even if utmost precautions are taken.

Prevention of hospital-acquired infections

It is not my intention to write in detail about the various precautions which should be taken by the hospital, medical and paramedical workers and management because that is a speciality itself in any big hospital. An infection control committee is set up to monitor the infections and carry out the surveillance of emerging trends in various organisms, suggest preventive measures in the field of sanitation, use of antibiotics and in general to educate all the staff of the hospital. Various steps which can be taken are briefly given in the adjoining box. (I)

The role of patients and their attendants

The public in general and concerned families have a great role in helping the hospital management to decrease hospital-acquired infections. Even with all the constraints of funds, space and other facilities, a lot of improvement can be done with the active help of the patients, their families and other visitors. In the PGI, where there are about a million outpatient attendance and nearly 50,000 annual indoor admission, a rough estimate of three times of this number i.e. 3 million visitors are expected to visit the hospital annually. This is based on our rough perception that every patient is at least accompanied by two or three attendants and the indoor patient is visited by a large number of people. One has only to see the wards during the visiting hours in the evening to believe what I am referring to. The visit to the patients admitted in the hospital sometimes acquires a festive appearance and I have seen people visiting the patients on a Sunday with full families, including children, as this was some kind of entertainment experience.

We should remember that every visitor who comes to the hospital brings with him or her some dust and some kind of microbes. He needs to visit the toilet and there is a possibility of his and her taking some drink and food. This arithmetic of visitors alone can give a rough idea as to what an enormous load of pathogens is delivered to the hospital every day. This in fact poses a problem for sanitation of the hospital and no amount of safai karamcharis can keep the cleanliness up to the requisite standards even if they work up to their maximum capacity. Apart from this, the single-most important factor of hospital visitors, the other contributions which the patients and the society can make are given in the adjoining box. (II)

Role of health workers in the hospital

The hospital workers of all categories have a special place in the scheme of hospital-acquired infections. They are simultaneously the agents as well as the victims of hospital-acquired infections. Medical and paramedical staff may carry infections like hepatitis, HIV (God-forbid), malaria and other viral infections. These can be transmitted to the patients through blood handling and other procedures without any awareness. They can themselves be a victim of some infections acquired from the patients and by handling blood, tissues and performing surgery. It is too well known that certain number of medical and paramedical persons come down with tuberculosis in any hospital, acquire hepatitis B and C and finally certain numbers get the very dangerous infection of HIV.

It is, therefore, desirable that to prevent both the possibilities, these paramedical workers should be thoroughly screened for these infections at the time of entry into service, a regular check-up during their stay and they should be promptly treated when they acquire such an infection. They should be regularly vaccinated, whenever a vaccine is available for a particular disease. One such example is vaccination for hepatitis B. This vaccine should be made available to all exposed paramedical workers like doctors, nurses and technicians free of cost.

It is hoped that greater understanding of the genesis of these infections and improvement in the general upkeep of the hospital will decrease the incidence of these infections. It is also expected from the public at large that each time a patient gets a hospital-acquired infection he should not jump to the conclusion that something necessarily has gone wrong on the part of the hospital or is management. This suggestion is however not to put the hospitals in any kind of complacency. The fight against nosocomial infections should be fought relentlessly.