Nosocomial Infections Khachornsakdi Silpapojakul MD Prince of Songkla University Hat yai, Thailand
What?
Nosocomial comes from the Greek word nosokomeion meaning hospital ( nosos = disease, komeo = to take care of ). From Wikipedia, the free encyclopedia
Why epidemiologists should pay an attention to nosocomial infections?
Nosocomial Infections: How much?
J Med Assoc Thai 2005; 88 ( Suppl 10): S 1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%
Nosocomial Infection Rate 1985-1986, Thailand Hospital beds Rate (%) >700 15.2 400 – 700 4.1 <400 2.8 Ref.: Pinyowiwat W et al. Dept. of Epidemiology Ministry of Public Health
Nosocomial Infections Mortality-How much?
J Med Assoc Thai 2005; 88 ( Suppl 10): S 1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%
Nosocomial Infections Morbidity-How much?
Why epidemiologists should pay an attention to nosocomial infections?
J Med Assoc Thai 2005; 88 ( Suppl 10): S 1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%
The number of admissions in Thailand is ~6.2 million . With a prevalence rate of 6.4%, the estimated number of nosocomial cases was 396,800 cases with 26,586 deaths attributable to these infections in Year 2001.
Top ten morbidity rate of diseases under surveillance Thailand, 2001 (2544) Morbidity Rate Diseases Cases Deaths Rank (Per 100,000 Pop.) 1 Acute diarrhoea 1020377 176 1643.3 2 Pyrexia of unknown origin 269740 54 434.4 3 Dengue haemorrhagic fever 139355 245 224.4 4 Food poisoning 138795 2 223.5 5 Pneumonia 135768 1057 218.6 6 Haemorrhagic conjunctivitis 107929 0 173.8 7 Influenza 42371 1 68.2 8 Dysentery 37601 2 60.6 9 Malaria 34925 81 56.2 10 Chickenpox 31707 1 51.1 Ref.: Annual Epidemiological Surveillance Report 2001, MOPH
Top ten mortality rate of diseases under surveillance Thailand, 2002 (2545) Mortality Rate Diseases Cases Deaths Rank (Per 100,000 Pop.) 1 Pneumonia 135768 1057 1.7 2 Tuberculosis 30033 287 0.46 3 Dengue haemorrhagic fever 139355 245 0.39 4 Suicide by liquid substance 5241 224 0.36 5 Acute diarrhoea 1020377 176 0.28 6 Leptospirosis 10217 171 0.28 7 Malaria 34925 81 0.13 8 Pyrexia of unknown origin 269740 54 0.09 9 Rabies 37 37 0.06 Encephalitis - total 10 430 30 0.05 Ref.: Annual Epidemiological Surveillance Report 2001, MOPH
Causes of Death of Thai Physicians (1992-2001) No.=262 1= Cancers (35.1%) 1.1 Hepatoma (7.6%) 2= Heart Diseases (28.2%) 3=Accidents (12.6%) 4=Sepsis (3.4%) 5=Suicides (3.4%) Source: Sithisarankul P et al. Intern Med J Thai 2004;20:188-191
Causes of Death Total deaths = 165 (100%) 1. Vascular diseases = 46 (28%) Coronary heart disease = 28 CVA = 16 Other vascular diseases = 2 2. Cancers = 43 (26%) 3. Injuries = 37 (22%) 4. Non-malignant GI & Liver disease= 22 (13%) 5. Unknown causes. = 9 (5%) 6. Sudden deaths. = 5 (3%)
“ There are substantially more nosocomial infections each year than hospital admissions for either cancer or accidents and at least four times more than admissions for acute myocardial infarction.”
Year 2006, Admission Diagnoses,PSU Hospital Number of Rank Diseases patients 1 Senile cataract 1,123 2 Malignant neoplasm of bronchus and lung 734 3 Malignant neoplasm of breast 576 4 Malignant neoplasm of ovary 483 5 Intracranial injury 445 Malignant neoplasm of liver and intrahepatic bile 6 ducts 442 7 Malignant neoplasm of rectum 415 8 Malignant neoplasm of cervix uteri 415 Maternal care for known or suspected 9 abnormality of pelvic organs 385 10 Lymphoid leukaemia 331
Year 2006, Causes of Deaths, In-Patients, PSU Hospital No. of Rank Causes of Deaths Patients 1 Malignant neoplasm of bronchus and lung 56 2 Acute myocardial infarction 51 3 Other septicaemia 38 4 Intracerebral haemorrhage 25 5 Malignant neoplasm of liver and intrahepatic bile ducts 22 6 Diffuse non-Hodgkin's lymphoma 20 7 Aortic aneurysm and dissection 18 8 Chronic renal failure 18 9 Chronic ischaemic heart disease 17 10 Malignant neoplasm of cervix uteri 16 11 [HIV] disease resulting in 15 infectious and parasitic diseases
Impacts of Nosocomial Infections on National Vital Statistics
229 patients were followed for 4.29+/-0.7 years
2 UTIs 1 infected CAPD 1perianal abscess 1pneumonia 4 unknown site
Nosocomial Infections Economical Impacts-How much?
J Med Assoc Thai 2005; 88 ( Suppl 10): S 1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%
The number of admissions in Thailand is ~6.2 million . With a prevalence rate of 6.4%, the annual hospital costs for management of N . I . was about 7 billion baht (175 million U . S . dollars ).
Health Expenditure 1980-2002 (Million baht) Wibulpolprasert S et al. Thailand Health Profile 2001-2004 MOPH Bangkok, Thailand 2005 (ISBN: 974-465-889-4)
Allocation of Government Health Budget by Service Category, 1993-2004 Wibulpolprasert S et al. Thailand Health Profile 2001-2004 MOPH Bangkok, Thailand 2005 (ISBN: 974-465-889-4)
Why rising cost of antibiotics???
Antibiotic Resistance: PSU
MRSA 1986 1987 1988 1989 PSU 5% 15% 25% 30% Siriraj 14% 14% 23% -
PSU Antibiotic Resistance : MRSA Year Resistance 1990 38% 1991 20% 1992 25% 1993 27% 1994 26% 1995 31% 1996 29% 1997 35% 1998 35% 1999 34% 2000 33%
PSU Antibiotic Resistance - E. coli 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Ciprofloxacin 7% 6% 8% 16% 18% 18% 25% 24% 25% 25% Amikacin 9% 6% 6% 4% 6% 7% 5% 5% 4% 5%
PSU Antibiotic Resistance : Ps. aeruginosa Imipenem Resistance 1992 1993 1994 1995 1996 1997 1998 1999 2000 % resistance 4% 9% 12% 8% 8% 10% 7% 11% 16%
PSU Antibiotic Resistance : Ps. aeruginosa 2000 2001 2002 2003 2004 2005 Imipenem 16% 19% 20% 18% 13% 17% Sulperazone 22% 19% 14% 13% 14% 10% Cefipime 20% Tazobactam 19% Amikacin 28% 28% 25% 25% 18% 14%
PSU Antibiotics: Cost/Day Amikacin 15 mg./kg q d. 262 bht. Sulperazone 2 g. q 12 hr. 1578 bht Imipenem 500 mg. q 6 hr. 3213 bht. Meropenem 0.5 g. q 6 hr. 3780 bht. Meropenem 1 g. q 8 hr. 4200 bht. Ertapenem 1g. q d. 1498 bht. Cefipeme 2 g. q 12 hr. 2088 bht. Tazocin 4.5 q 8 hr. 1890 bht.
J Med Assoc Thai 2005; 88 ( Suppl 10): S 1-9 42 hospitals Point prevalence survey March 2001 18,456 patients. Patients on antibiotics = 48.5%
The number of admissions in Thailand is ~6.2 million . With a prevalence rate of 6.4%, the annual hospital costs for management of N . I . was about 7 billion baht (175 million U . S . dollars ).
PSU Antibiotic Resistance : Acinetobacter Imipenem Resistance 1997 1998 1999 2000 2001 2002 2003 2004 2005 3% 2% 4% 3% 3% 2% 9% 31% 39%
http://narst.dmsc.moph.go.th/ Percentage of susceptible Acinetobacter baumanii , Jan - Dec 2005
Source of infection and Source of infection and organisms:PSU (2003- -2004) 2004) organisms:PSU (2003 • Lower respiratory tract infection 1 S.aureus 41.7%(MRSA 50%), 2 Acinetobacter spp. 25%, 3 K.pneumoniae 12.5% 4 Pseudomonas aeruginosa 12.5%
Hand contamination of personnel in NICU Knittle M A et . al . J Ped 1975, 88, 433 No . of nurses 13 No . of cultures 151 130 86.1% Positive cultures E . coli 25 18.6% 119 78.7% Klebsiella 25 16.5% Pseudo aeruginosa
Is there any other national impact of nosocomial infections besides their impacts on mortality and economy???
Prevalence of primary MDR-TB in Thailand Year MDR-TB % Central Chest hospital 1995-6 HIV + 5.2 HIV - 0.4 TB Division 1998 3.64 1999 3.58 Drug resistance survieillance 1997-8 2.1 Central prison 1998-9 4.8 Chiang Rai hospital 1999 5.52 2000 3.39 Drug-resistant Tuber- culosis research fund 2001-2 HIV + 4.1 HIV - 2.0 (Courtesy: Manoon Leechavengvongs MD)
MDR-TB surveillance, Chiangrai (1995- 1997) 1 o resistance 2 o resistance INH 14.5% 40.8% Rifampicin 11.5% 36.9% EMB 7.0% 17.7% MDR-TB 7.2% 30.8%
Bacteremia, Bamrasnaradura Hospital (CID 1999, 180:87; Lancet 1999, 354, 1159) - 246 febrile patients - 182(74%) = HIV - 119(48%) had positive blood culture - 114 = HIV, only 5 = non-HIV
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