The impact of nosocomial infections on healthcare facilities

Nosocomial infections, also known as healthcare-associated infections (HAIs), are infections that occur in healthcare facilities. These infections can have serious consequences for patients, leading to prolonged hospital stays, increased healthcare costs, and even death. By understanding this critical issue, we can work towards creating safer healthcare environments for everyone.

In the EU, it is estimated that over 4 million patients contract a nosocomial infection annually, of which approximately 37,000 die as a result.

In Romania, healthcare-associated infections (HAIs) are an underestimated problem. According to official reports on HAIs (communicated by hospitals), the prevalence rate is only 0.2-0.25%. More accurate data for Romania was identified in a 2018 European study (the most recent data available), which revealed a prevalence of 2.6%, meaning approximately 100,000 cases recorded annually nationwide.

In a study conducted over a 2-year period (2017-2018) in a county with approximately 580,000 inhabitants, HAI cases were analyzed across seven public hospitals, where 1,024 such cases were reported. According to the results, the most frequent HAI cases were recorded in the intensive care unit, accounting for 48.4% of total cases. Also, the most frequent types of HAIs were bronchopneumonia (25.3%), followed by Clostridium difficile infections (CDI) (23.3%).

Of the reported cases, approximately 25.3% were associated with deaths, most of which (39.2%) were caused by A. baumannii infections, followed by P. aeruginosa infections (32.2%). Among the five most common bacteria found in HAI cases were C. difficile, A. baumannii, K. pneumoniae, P. aeruginosa, and S. aureus.

Regarding the causes of specific infections, the most frequent etiology of bronchopneumonia was associated with infections caused by A. baumannii (60.8%), followed by surgical wound infections with S. aureus (41.8%), E. coli (29.2%), and K. pneumoniae (28.9%). Also, nosocomial infections associated with central venous catheters were most frequently caused by K. pneumoniae (28.3%) and S. aureus (23.6%).

The term covers a wide range of cases, from the presence of germs observed during bacteriological sampling (simple contamination) to localized infectious conditions (e.g., urinary or pulmonary infections) or, more rarely, generalized conditions (septicemia). The hospital source of the infection is not always easy to establish.

Nosocomial infections occur in healthcare facilities, such as hospitals, clinics, or nursing homes. These infections can be triggered by various pathogens, including bacteria, viruses, and fungi. They can affect patients of all ages, and the most frequently reported types of healthcare-associated infections are respiratory tract infections, surgical site infections, urinary tract infections, bloodstream infections, and gastrointestinal infections.

Nosocomial infections are a major concern for the medical system because they can lead to increased morbidity and mortality rates, as well as additional healthcare costs.

Prevalence and impact of nosocomial infections in healthcare facilities

Nosocomial infections are a frequent and serious problem in healthcare facilities, with significant implications for both patients and healthcare providers. These infections can lead to prolonged hospital stays, increased costs for patient care, and even death. Nosocomial infections can contribute to the spread of antibiotic-resistant bacteria, making treatment more difficult or ineffective.

The frequency of these infections varies depending on the type of care (higher in intensive care units), the duration of hospitalization (higher in facilities requiring long-term hospitalization and functional rehabilitation due to the presence of indwelling urinary catheters, which favor infections), and the patient's vulnerability: serious acute illnesses, a weakened organism, cancer, chronic alcoholism, HIV-related immunosuppression, chemotherapy, or organ transplants.

Between 2012 and 2017, a longitudinal descriptive study was conducted at the "Sfânta Maria" Emergency Clinical Hospital for Children in Iași on a group of 982 patients diagnosed with nosocomial infections. The study results indicated an overall incidence of nosocomial infections of 0.57%, calculated in relation to an average annual number of 28,685 discharged patients. Furthermore, significant variations in infection rates were observed across different risk departments. The most frequent infection categories were related to mechanical ventilation, surgical wounds, and central venous catheters.

It is essential for healthcare facilities to implement effective infection control measures to prevent the onset and transmission of nosocomial infections. These include proper hand hygiene, appropriate use of protective equipment, and compliance with sterilization and disinfection protocols. By prioritizing infection prevention and control, healthcare facilities can reduce the frequency of nosocomial infections and improve treatment outcomes.

Common types of nosocomial infections and their causes

The germs responsible for a nosocomial infection can originate from the patient themselves (endogenous infection), from one of their natural reservoirs (intestines, skin, etc.), or can come from the outside (exogenous or cross-infection).

There are two main categories of bacteria regarding their potential to cause infections: commensal bacteria and pathogenic bacteria. Commensal bacteria are normally present in the human body's microbial flora. For example, coagulase-negative cutaneous staphylococci can cause infections in vascular catheters, and Escherichia coli, which is found in the intestines, is the most common causative agent of urinary infections.

On the other hand, pathogenic bacteria are endowed with higher virulence and can cause infections regardless of the body's immune status. These include:

• Gram-positive anaerobic bacilli, such as Clostridium perfringens, which can cause gangrene.
• Gram-positive bacteria, such as Staphylococcus aureus, which colonizes the skin and nose of patients and hospital staff and can cause a wide variety of infections, including pulmonary, bone, cardiac, and blood infections; these bacteria are often antibiotic-resistant. Group A beta-hemolytic streptococci are also known as human pathogens.
• Gram-negative bacteria, such as Escherichia coli, Klebsiella, Proteus, Enterobacter, and Serratia marcescens, can colonize certain sites (such as the insertion site of catheters or urinary catheters) when the body's immune system is weakened, which can cause serious infections.

In addition to bacteria, viruses are another category of pathogens that can cause infections:

• Hepatitis B and C viruses can be transmitted through blood transfusions, dialysis, injections, endoscopy, dental treatments, etc.
• Viruses such as Rotavirus and Enteroviruses are transmitted via the fecal-oral route, often through contaminated hands.
• Other viruses, such as Respiratory Syncytial Virus, Cytomegalovirus, HIV, Ebola virus, influenza viruses, and herpes viruses, can cause various infections depending on the type of virus and the mode of transmission.

Consequences of nosocomial infections on patients and healthcare facilities

Some patients are more susceptible and predisposed to nosocomial infections: elderly patients and newborns, immunocompromised patients (who have diseases or treatments that affect their defense system, such as chemotherapy), patients with severe burns, diabetic patients, and patients undergoing antibiotic treatment (which can unbalance the usually present bacterial flora and select resistant bacteria, etc.). Invasive procedures, such as the introduction of IV drips or urinary catheters, mechanical ventilation, or surgical interventions, although necessary for treatment, are also factors that favor nosocomial infections.

These infections can be difficult to treat because they are often caused by antibiotic-resistant bacteria. The most commonly involved germs are the bacteria: Escherichia coli (a germ usually found in the digestive tract), Staphylococcus aureus (a germ usually found on the skin and in the nostrils), and Pseudomonas aeruginosa.

Beyond the impact on patients, nosocomial infections also represent a challenge for healthcare facilities. The appearance of these infections can lead to an increased workload for medical staff, as well as the need for additional resources to control and prevent the spread of the infection. Also, healthcare facilities may face financial penalties or reputational damage if they fail to effectively manage and prevent these infections.

In Europe, acute nosocomial infections cause costs of over 7 billion euros annually. For example, a study showed that in Germany, HAIs can generate additional costs ranging between 5,823 and 11,840 EUR for each infected patient.

To mitigate the consequences of nosocomial infections, healthcare facilities must prioritize infection prevention and control measures. These include implementing strict hand hygiene protocols, proper disinfection of equipment and surfaces, and promoting vaccination among medical staff and patients. By taking proactive steps to prevent these infections, healthcare facilities can protect both their patients and their own operations.

Strategies for the prevention and control of nosocomial infections.

With the entry into force of Order no. 1101 of 2016, which aims to approve the Norms for the surveillance, prevention, and limitation of nosocomial infections in healthcare units in Romania, the reporting rate for nosocomial infections has increased. However, the prevalence rate still remains far from the European average of 7.5%.

Under Order no. 1101/2016, healthcare-associated infections (HAIs) are defined as infections contracted in healthcare facilities (private or state-owned) with beds. These infections can affect either patients, as a result of the medical care received, or healthcare personnel, as a result of their professional activity.

Surveillance and prevention programs are effective and depend on close collaboration between the various actors involved: infectious disease specialists, other physicians, nurses, pharmacists, medical-technical engineers, and administration. These programs are subject to national recommendations. Some infections are subject to mandatory reporting, and their surveillance is recommended as part of a quality and practice improvement approach.

The prevention and control of nosocomial infections is crucial for the safety and well-being of patients and for the proper functioning of healthcare facilities. Here are some strategies that can be implemented:

• Strict hand hygiene: Medical staff must follow proper hand hygiene protocols, including regular hand washing with soap and water or using alcohol-based hand sanitizers. This helps prevent the spread of bacteria and viruses.
• Proper disinfection: Equipment and surfaces must be cleaned and disinfected regularly to eliminate any potential source of infection. This includes using appropriate disinfectants and following recommended cleaning procedures.
• Isolation precautions: Patients with known or suspected infections should be placed in isolation to prevent the spread of infection to other patients and medical staff. This may involve the use of private rooms or the implementation of specific infection control measures.
• Vaccination: Medical staff and patients should be encouraged to complete their mandatory vaccination schedule to protect themselves against common infections. This can help reduce the risk of nosocomial infections and their consequences.
• Education and training: Medical staff should receive periodic education and training on infection prevention and control measures. This ensures that they are up to date with the latest prevention trends and best practices and that they can implement them effectively.
• Surveillance and monitoring: Healthcare facilities should have systems in place for monitoring and tracking nosocomial infections. This allows for the early detection of outbreaks and the implementation of appropriate control measures.
• Antibiotic administration: Proper use of antibiotics is essential to prevent the development of antibiotic-resistant bacteria. Healthcare facilities should have antibiotic stewardship programs in place to promote responsible antibiotic use.
• Collaboration and communication: Effective communication and collaboration between medical staff, patients, and other stakeholders are essential for the prevention and control of nosocomial infections. This involves information sharing, effort coordination, and the implementation of consistent infection control practices.
• Environmental controls: Healthcare facilities should have environmental control systems in place and minimize the risk of infection. These can include proper ventilation, air filtration, and maintaining a clean and hygienic environment.
• Continuous quality improvement of medical care: Periodic evaluation of infection prevention and control practices is important to identify areas for improvement and to implement necessary changes. This ensures that healthcare facilities are making constant efforts to improve their infection control measures.