Hospital Acquired Infections- India

An infection acquired in hospital by a patient who was admitted for a reason other than that infection.
An infection occurring in a patient in a hospital or other health care facility in whom the infection was
not present or incubating at the time of admission. This includes infections acquired in the hospital but
appearing after discharge, and also occupational infections among staff of the facility. As a general
timeline, infections occurring more than 48 hours after admission are usually considered nosocomial.
Nosocomial infections are also divided into two classes, endemic or epidemic. Most are endemic,
meaning that they are at the level of usual occurrence within the setting. Epidemic infections occur
when there is an unusual increase in infection above baseline for a specific infection or organism.

Nosocomial infections occur worldwide, both in the developed and developing world. They are
a significant burden to patients and public health. They are a major cause of death and increased
morbidity in hospitalized patients. They may cause increased functional disability and emotional
stress and may lead to conditions that reduce quality of life. Not only do they affect the general health
of patients, but they are also a huge burden financially. The greatest contributors to these costs are
the increased stays that patients with nosocomial infections require. The increased length of stay
varies from 3 days for gynecological procedures to 19.8 days for orthopedic procedures. Other costs
include additional drugs, the need for isolation, and the use of additional studies. There are also
indirect costs due to loss of work.

Burden of healthcare associated infection (HAI) -HAI Fact Sheet (WHO)

  • HAI are the most frequent form of adverse event in healthcare delivery worldwide.
  • Hundreds of millions of patients are affected by HAI worldwide each year, leading to significant mortality and financial losses for health-systems.
  • Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one HAI.
  • The endemic burden of HAI is also significantly higher in low- and middle-income than in high-income countries, in particular in-patients admitted to intensive care units and in neonates.

A review of studies performed revealed an extremely fragmented picture of the endemic burden of HAI in India. The limited no. of studies with broad scope, together with a lack of national surveillance systems, significantly hamper any attempts to estimate the burden of HAI in the country at regional/ national level. Studies from single hospitals cannot be considered representative of the endemic epidemiology of HAI in the country. In particular most of these studies were conducted in private hospitals, which represent a specific type of context and not the broad range of healthcare settings in
India. Consolidated data on device associated infection from India has been published as a part of the INICC study (Annals of Internal Medicine 2006). All the hospitals were private,corporate hospitals, and fails to reflect the actual scenario.

The disparate health systems, wherein the public hospitals are free, too few and overloaded, the majority of healthcare (80%) lies in private hands in the form of large corporate hospitals, smaller nursing homes and day care clinics which are profit making.

  • The overwhelming number of sick people with a huge dearth of trained, skilled healthcare professionals (nurse to patient ratio being 1:100 & doctor: patient = 1: 900)
  • Care is individualized and concentrates on curative medicine
  • Lack of systems approach and poor underdeveloped public health facilities
  • The arrogant hierarchy which pushes the clinical practice to perception based rather than evidence-based medicine
  • Cost of healthcare is largely borne by the patient themselves, and therefore there is no accountability of healthcare providers on cost-effective care.
  • No regulatory body to oversee or monitor quality of care.
  • Lack of transparency of healthcare organizations whether public or private.
  • Indians are brilliant and successful individuals, but fail miserably when it comes to team work.

The Way forward– In a democratic country like ours we can choose to:

  • Have tubular vision
  • Enjoy the new technologies as they become available
  • Create state-of-the-art hospitals, without putting the systems in place
  • Use 7 antimicrobials as empiric therapy (to cover our back)
  • Take pride in creating Guinness records of 20 angioplasties or joint replacements in a day
  • Bask in the glory of numbers and not the outcome

If we are as serious and far-sighted, we should, At the organization level:

  • Set up the Infection Control Program with a multidisciplinary committee to guide the processes and monitor the outcome.
  • Surveillance of healthcare associated infections and antimicrobial resistant pattern (using standardized international methods), to measure the burden of the disease.
  • Implement practical evidence based, low cost and simple preventive strategies first.
  • Antimicrobial stewardship programs and other interventions to reduce the development of MDROs.
  • Do studies that include analysis of economic, behavioral, communication and organizational strategies that optimize the implementation of and adherence to the best practices.

At state / national level:

  • Promote funded research projects through ICMR, DBT and state agencies.
  • Produce more trained infection control professionals; nurses, hospital epidemiologists and public health personnel.
  • Promote growth of microbiology laboratories and involve the Clinical Microbiologists in decision making.
  • Regulatory bodies to monitor the quality of drugs, and over the counter sale of antibiotics.
  • Develop state laws for compulsory HAI reporting.
  • Physicians should be made responsible for HAI and condition of their patients.
  • Empowerment of Hospital Infection Control Committees.

In conclusion:

  • We must change the culture of clinical care in India
  • This will come by mandatory reporting of HAI and it is the consumer who must push for it
  • Clinicians, health system leaders, payers, purchasers, and above all, patients need to demand care that is proven to be effective as a condition of delivering, paying for, or receiving it.
  • A time has come, when we need to move together, move towards preventive medicine than curative medicine

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