Summarized causative agents and preventions against different types of HCAIs.
Health care associated infections also termed as nosocomial infections are notable cause of morbidity and mortality especially in resource limited countries like Pakistan. Newborns and aged people have more probability of being infected by Health care associated infections because of immunosuppressant. Central line associated blood stream infections (CLABSI) are considered as one of the promising negotiator associated with Health Care associated infections. Improper health care setting and unaware medical staff play a championship protagonist in prevalence of health care associated infections. Standard hygienic measures should be adopted to reduce risk of Health care associated infections. So, there is a pressing need to take on control policies by Government to handle this dilemma. This chapter gives new intuition to healthcare associated microbes, infections and provides comprehensive detailed on ironic precaution to scientific community.
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In health care safety issues, health care associated infections (HCAIs) are a significant cause of morbidity and mortality in developing countries specially in Pakistan. Environment of hospital favors certain infections during the period of admission patients, these are termed as Health care associated infections. Contaminated equipment’s, unaware medical staff, unhealthy hospital environment and not satisfactory standard measures promote Hospital acquire infections, nosocomial infections/Health care associated infections (HCAIs). Prevalence of health care associated infection is high in developing countries due to unhealthy health care settings, where it affects more than 25–30% patients. Unhealthy Standard hygienic measures and risk of HCAIs are directly related which clearly address a pressing need to follow standard hygienic guidelines [1, 2, 3]. Prevalence of HCAIs is roughly about 10–30% in developing countries and 5–10% in developed countries .
Of all hospitalized patients about 15% are infected by HCAIs. In developing countries ten in every hundred acquire HCAIs. Neonates, patients of organ transplant, patients of burn surgery and patients at Intensive Care Unit (ICU) are more prone to HCAIs. High rate of infection is observed in ICU ward. HCAIs not only down health of patients who are already ill with other diseases but also impose socio economic burden for developing countries by increasing health care cost [5, 6]. This review article not only addresses endemic threat for patients but also covers counter measures to handle this problem as shown in Figure 1.
Role of medicines in treatment of diseases is understood by many of us but in recent years awareness about communication of diseases through health care is increased . Ignaz Phillip Semmelweis was medical doctor who realized communication of puerperal sepsis through hospitals. He found increased rate of women death in clinic. To reduce rate of maternal deaths Semmelweis introduced chlorinated lime for hand washing. It is estimated that about 100,000 people are killing in world through HCAIs .
This review paper provides us advances knowledge about hospital infections and provide instruction to government for the improvement of medical conditions. In this paper, we have summarized the various health care associated infections by which patients are more vulnerable ultimately conditions will be severe.
2. Types of HCAIs
2.1 Central line-associated bloodstream infections (CLABSI)
Central line-association bloodstream infections are the infections of central venous catheter (CVC) by which catheter tube is only route for microorganisms to enter patient body and central line is required for infections progression within 48 hour . There are two major routes which are adopted by microorganism, intraluminal and extraluminal but intraluminal route is important in the sense of causing severity through catheter hub . In above luminal routes, biofilms are formed due catheter hub infection, composed of bacteria which is formed mostly extracellular matrix within 24 hour of catheter insertion . CLABS-infections leads to cancers and other neurodegenerative diseases in those patients which are immunosuppressant , agonize chemotherapy and confess in ICU. Central-Line Insertion  is best method to control CLABSIs in ICU patients, but it is very cost effective.
CLABSIs effect the neonatal life, in the form of sepsis which cause the 20–36%  due to CVCs. In most cases, the babies which are premature, exposed to CLABSIs, have poor growth , high death rate and neurodegenerative diseases. Fever, hypothermia, apnea and bradycardia are most disastrous indicators which are appeared in the 1 year < age children . CLABSIs also effect the adult life, the proportion of gram-negative bacteria including
The potential pathway for source of microorganism are following catheter insertion site, hands of healthcare worker, contaminated disinfected, patient skin flora during catheter hub operation, contaminated drugs or fluids, catheter infections and hematogenous dissemination as a secondary infections . Through these routes, microorganism enters in body and form biofilm at insertion site. Biofilms contains colony of bacteria which is formed firstly extracellular at catheter site but with a passage of time, move towards intracellular matrix . The pathophysiological features are low metabolic rate, tiniest inhibitory concentration, less vulnerable to antibiotics and high penetrance rate to antibiotic, adapted by microorganism to spread the infections .
According recent researches there are 84,000-204,000  people, infected by CLABSIs and 25,000 death. Death incidence rate of CLABSI is about 12–25%. Catheters are used for intravenous therapies, for delivery of specific medicine and specific treatment. Through contaminated infusion of catheter and unhealthy environment microbes gain access to bloodstream which cause CLABSI. Coagulase negative staphylococci for example
To overcome such rate, government and hospital admin should adopt following aliments, sterile barrier  are used during catheter insertion and use disinfectants in case of intravenous administration . Government should also give priority the potent disinfectants including’s, chlorhexidine, povidone iodine, iodophor and 70% alcohol but optimal timing is unclear yet . Awareness in medical staff, PICC site assortment, CVC insertion and maintenance by intervention bundles, applications skin antiseptics, In-line filters, umbilical catheter, catheter dressing, prophylactic antimicrobial and antimicrobial locks are the methods of preventions for CLABSI.
2.2 Catheter associated urinary tract infections (CAUTI)
Catheterization is a process of introducing urinary catheter into urinary bladder which functions both as therapeutic tool and diagnostic tool. In health care facilities catheter associated urinary tract infections (UTIs) are most common infection. Infection can occur during insertion of catheter and cleaning of catheter if process is done inadvertently. For number of reasons about 25% of all hospitalized patients need catheter and risk of catheter associated urinary tract infection is much higher in Intensive Care Unit (ICU). Among all HCAIs catheter associated urinary tract infection account for about 40% [39, 40], catheter related UTIs 70% and 95% UTIs in intensive care units . To reduce risk of catheter associated urinary tract infections there is a pressing need to follow standard measures during catheterization process and safe maintenance of catheterization. If Catheter associated urinary tract infections are ignored for long time serious kidney disorders may arise [42, 43].
Pandemic nature of CAUTIs, 150 million affect the people annually which show following symptoms such as somber sequelae, recurrences, pyelonephritis with sepsis, blood with urine, catheter obstruction and renal damage . Accounted symptoms are the result of severe complex metabolic reactions due to overdose of antibiotic, frequently usage of antimicrobial drugs such as
Recent discoveries proved that complicated UTIs totally dependent on physiological pools of patients . If a person has weak immune defense system, renal failure, renal stones, urodynamics and indwelling catherization (IC), are major indicator for UTIS but the IC is most communal agents to progress the infections .
This infection can be diagnosed by urinalysis test which address the presence of leucocytes and nitrites in urine but not detach these compound. The presence of leucocytes and nitrites signpost that a person is suffered from CAUTIs and progression of infections. Leucocytes in urine are the result of, activation of leucocytes esterase (LE), which is immune system product, triggering the malformed and break down of normal WBCs through the action of microorganisms. But the presence of nitrites, developed curiosity in nitrogen-feeding bacterial colony reside inside the catheter site, which break the nitrogen wastes .
The most effective way to prevent the CAUTIs, give proper guidance to medical staff and insist the nurse to do more practice . In United Kingdom  developed the set rules in the name of “epic3 Guidelines “which based one scientific literature and expertise of medical staff. This booklet proposed that application catheter insertion must be done when there is no alternative because catheter insertion exceed the chance of urinary tract infections . Catheter dressing, sterile catheter bag, length of catheter accordance to patient, gloves and aprons are properly used during catheter-insertion. One most important point to change the urinary drainage bag after every 7 days .
2.3 Surgical site infections
After urinary tract infections surgical site infections are most common HCAIs. According to a study about 13% of patients who undergo surgery become infected with Surgical Site Infections and SSI account for about 20% of all Health care associated infections and account for 77% deaths of surgical patients. SSI adopt the pandemic nature; overdose of antibiotic and hospital stay cause the recorded cases in Spain (26.1%) and Europe (19.6%). Reported data shown that SSIs are most common in china, but major microbes associated with SSIs are
A recent study shows that Patients with neurosurgery have evidences of meningitides mostly caused by
Despite of pathophysiological feature of SSIs, government and medical staff should be recommended the preoperative and intraoperative measures to control infections.
2.4 Ventilator associated pneumonia (VAP)
Ventilator associated pneumonia is one of significant health care issue among health care associated infections. 9–27% patients on ventilators have Ventilator associated pneumonia. 86% of nosocomial pneumonia is ventilator associated. Patients at Intensive Care Unit are more prone to VAP. In Asian countries especially in developing countries incidence of VAP is higher than European countries where poor implementation of standard measures make ICU a major transmitter of Pathogens.
Inflammation of Gastrointestinal tract is termed as infectious diarrhea or Gastroenteritis. In 2015 globally 1.3 million deaths were reported due to gastroenteritis. In developing countries prevalence of gastroenteritis is most. Most common causative agent is virus (rotavirus, norovirus, astrovirus and adenovirus) however bacteria, parasites and fungi can also cause gastroenteritis. Most studies in literature show that most of nosocomial gastroenteritis infections were caused by rotavirus and mostly effects children under age of five [90, 91]. According to a study conducted in Pakistan in 2015 about 80% of hospitalized children have viral infections and about 95% were positive for rotavirus in addition to others .
2.6 Puerperal fever
During childbirth and after childbirth or miscarriage women get infected with puerperal sepsis. Annually about 75,000 women die worldwide due to puerperal sepsis and developing countries have more death annually than developed countries. Puerperal sepsis is a leading cause of maternal mortality in developing countries like Pakistan due to multiple reasons. Most common causative agent of puerperal fever is bacteria. Data from developing countries as Pakistan shows that more than half of women do not get hospital facilities during delivery. Unhygienic conditions during delivery, long duration of labour, miscarriage, frequent vaginal examination, malnutrition, premature membrane rupturing, and anemia are risk factors for puerperal fever . Most common infection that cause postpartum is endometritis and mostly occur in women who gave birth by cesarean section .
3. Causative agents
Bacteria, viruses, and fungus parasites are causative agent responsible for nosocomial infections however most common causative agents are bacteria. In bacteria
80–87% of HCAIs are caused by 12–17 microorganisms
|Sr. No||Type of HCAIs||Description||Causative agents||Preventions||References|
|1||Central line -associated bloodstream infections||Fever, tendered site of insertion of IV access of CVP catheter||Hand hygienic, sterilizing techniques, appropriate setting of site, prefer upper extremities for catheter insertion, prefer ultrasound guided insertion, make sure sterile precaution during whole procedure of insertion||[99, 100, 101, 102]|
|2||Catheter associated urinary tract infections||Fever, Lower abdominal pain, changes in urine characteristics||Appropriate setting of catheter and site, hand hygienic, sterilizing techniques, sure closed drainage system,sure unobstructed urine flow,||[100, 101, 102, 103]|
|3||Surgical site infections||Fever, wound healing problems, pain, redness||Sterilizing techniques, Safe operating theater, good quality surgical procedure||[104, 105, 106]|
|4||Ventilator associated pneumonia||Decreased intensity of breath sounds,fever, pleuritic chest pain, increase in rales||Reduce patient time on ventilator,sterilizing techniques, avoid intubation, elevate head of bed, suction oro pharynx regularly, reduce ventilator circuit changes||[100, 107, 108, 109, 110]|
|5||Gastroenteritis||Increase infrequency of stool, dehydration, fever||Norovirus, Astrovirus Rotavirus, Torovirus,||Use of Probiotics, sterilizing techniques, hand hygiene||[100, 111, 112, 113, 114, 115, 116, 117, 118]|
|6||Puerperal fever||Fever, abdominal distension, wound infection, septicemia and disseminated intravascular coagulation.||Use of sterilized equipment and good health care setting, antiseptic shower after surgery||[119, 120, 121]|
3.1 Risk factors
Unhealthy hospital environment (poor hygienic conditions, poor medical waste management), unaware medical staff (improper use of invasive devices and medical devices) and susceptibility of patient are risk factors for Health care associated infections (HCAIs).
As these risk factors are mostly associated with poverty so resource limited countries are at more risk to develop HCAIs due to impropriate control policies .
4. Transmission of HAIs
4.1 Hospital environment
Unhealthy hospital setting serves as best source to transmit infections. Contaminated utensils, medical devices, air, food, beds, and windows can transmit pathogens. Supply of filtered air must be maintained in ICU [61, 98].
4.2 Medical staff
Medical staff plays a significant role in prevalence of nosocomial infection. Use of unsterilized medical equipment by unaware medical staff in healthcare delivery increases chances of infection of HCAIs. Improper handling and management of hazardous medical waste by unaware medical staff can act as significant reservoir of HCAIs. Most of studies in Pakistan show non satisfactory behavior of medical staff towards standard precautions  Micro flora of patient can also become source of infection if they effect surgical site or wounds .
5. Preventions for HCAIs
5.1 Standard precautions
In health care unit medical staff should adopt proper standard hygienic measures (hand hygienic, sterilized equipment, use of gowns, gloves, respiratory hygienic) to reduce chances of HCAIs. Medical staff should be trained for biosafety and hazardous waste management should also be maintained. Public should be aware about risk factors consequences of HCAIs as there are number of group of bacteria and viruses in health care centers. Medical staff must be aware with appropriate use of antibiotic to avoid antibiotic resistance which is a significant cause of death in south-East Asian countries where one child died in every five minutes due to antibiotic resistance [5, 97, 122, 123, 124]. Preventive measures are the best way to control these type of infections as shown in Figure 2.
5.2 Government policies
As HCAIs is leading cause of morbidity and mortality, health institute must plan efficient infection control programs to handle this problem. It is responsibility of government to promote safety of health care centers through availability of trained medical staff, appropriate use of medications and medical equipment and quality eye care. Workload and staff capacity of health care must be directed by government to encourage good health care settings. Government must plan control policies (awareness about HCAIs through media) to reduce risk of Health care associated infections .
HCAIS is posing serious threat to economy of world specially to developing countries. In resource limited countries infections control program are unsatisfactory. Surveillance for HCAIs mainly serves purpose of prevention interventions. Unhealthy hospital environment and unaware medical staff and susceptibility of patient mainly lead to HCAIs. Government must play its role by forming new policies and committees for modification in national guidelines and for hiring trained and educated staff to promote healthy health care setting. Government should promote implementation of standard strategies by providing resources and policies.
The authors declare that they have no competing interests.
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Ayesha Noor and Ali Raza Ishaq both are working as a First author.
All Authors contributed equally.