MINISTRY OF EDUCATION AND TRAINING DEPARTMENT OF DEFENSE MILITARY MEDICAL UNIVERSITY DOAN QUANG HA RESEARCH SITUATION OF HOSPITAL NOSOCOMIAL INFECTIONS BY ACINETOBACTER BAUMANNII AND EFFICIENCY APPLICATION OF SOME PREVENTION MEASURES AT THE CENTRAL HOSPITAL OF TROPICAL DISEASES, 2011 - 2013 Majors: Preventive medicine Code: 9720163 UMMARY OF MEDICAL DOCTORAL THESIS HA NOI - 2019 THE DISSERTATION WAS MADE IN VIETNAM MILITARY MEDICAL UNIVERSITY Science instructor: Prof.PhD Nguyen Van Kinh Assoc.Prof.PhD Nguyen Vu Trung Reviewer 1: Assoc.Prof.PhD Le Thi Anh Thu - Cho Ray Hospital Reviewer 2: Assoc.Prof.PhD Tran Viet Tien - Vietnam Military Medical Academy Reviewer 3: Assoc.Prof.PhD Dinh Van Trung - 108 Military Cental Hospital The dissertation is protected before the school's thesis dissertation council at Military Medical University at: … Can learn the dissertation at National Library VMMU Library ………………………… ABSTRACT Hospital nosocomial Infections (HNI) are infections that patients suffer during hospitalization are one of the main causes of high morbidity and mortality rates for patients in hospitals around the world HNI is often caused by multi-antibiotic resistant bacteria When bacteria are resistant to an antibiotic, the treatment will face many difficulties, prolong the time of disease, the risk of death increases, new generation antibiotics have higher costs causing great economic losses Hospital nosocomial Infections occur in the Emergency Department at a higher rate than other departments in the hospital, usually 2-3 times In Vietnam, there is no research on the situation of HNI, in the Emergency Department of infectious diseases hospitals, so it is difficult to compare and assess the quality of implementing preventive measures HNI, as well as insufficient analysis of risk factors associated with HNI, to take appropriate and timely measures to reduce the risk of HNI Objectives of the study: Describe the current situation and factors related to HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases, 2011 Evaluation of results of application of some measures and techniques to improve HNI control activities at the Central Hospital for Tropical Diseases Summary of new main scinetific contributions of the thesis - Assessing the status of HNI at the emergency care department, Hospital for Tropical Diseases, discovering bacteria Acinetobacter baumannii is the most common pathogenic bacteria - Find some risk factors for HNI by Acinetobacter baumannii at emergency resuscitation department, Tropical Diseases Hospital This is the basis for making preventive measures - The study has shown that the basic interventions are the organization of infection control network, improving the knowledge and skills of HNI control for medical staff and closely monitoring the hygiene compliance Hand and surface cleaning, this is the core key to minimize the risk of HNI Thesis layout: The thesis consists of 137 pages, including sections and chapters: Problem: 02 pages Chapter Document overview: 34 pages Chapter Subjects and research methods: 20 pages Chapter Research results: 42 pages Chapter Discussion: 36 pages Conclusion: 02 pages Recommend: 01 page Reference 1267 documents (44 Vietnamese documents, 82 English documents) CHAPTER OVERVIEW DOCUMENT 1.1 Current situation of HNI Developed countries: General HNI 8.7% HNI at ICU 30% Developing countries: out of 10 patients admitted to hospital is patients with HNI At the Faculty of Active Treatment, there were 35.2% (4.4% - 88.9%) patients with HNI 1.2 Risk of HNI caused by Acinetobacter baumannii Factors related to the patient's condition: Chronic disease, immunodeficiency caused by HIV / AIDS, the use of immunosuppressive drugs or anti-mitotic drugs, Patients over 60 years old, or newborns Factors related to invasive techniques: Mechanical ventilation, pacemaker, central vascular catheter placement or other invasive procedures, are risk factors for A.baumannii infection Factors related to the emergence of antibiotic resistant A.baumannii strains: Located in the department of high-risk infection such as positive resuscitation, Neonatology, Burns, are at risk of infection potential A.baumannii and are favorable conditions for the emergence of resistant A.baumannii strains 1.3 Solution to control HNI Research indicates that at least 20% of all HNI can be prevented through a number of interventions Some basic measures in HNI prevention: Hand hygiene, sterility, patient isolation, policy solutions, training and supervision The role of hand hygiene in HNI prevention: WHO recommends hand washing is the cheapest and most effective measure to prevent HNI Many studies show that good hand hygiene reduces the incidence of HNI Infection rate can be reduced from 33% to 12% and from 33% to 10% immediately after two times of intervention to promote routine hand washing The role of surface sanitation in HNI prevention: Many studies show that contaminated surface environment is an important cause of the spread of pathogens causing hospital outbreaks Proper sanitation and disinfection of surface environments contribute to reducing HNI and controlling outbreaks that may occur in medical facilities CHAPTER STUDY SUBJECT AND METHODOLOGY 2.1 Subjects, locations, study time 2.1.1 Research subjects * Descriptive study - The patient was treated at the Emergency Department of the Central Hospital of Tropical Diseases from January 1, 2011 to December 31, 2011 * Intervention study - Patients who are treated at the Emergency Department from January 1, 2012 - December 31, 2013 - Medical staff: Doctors, nurses, infection control staff working at the departments of the Central Hospital of Tropical Diseases - Organizational system, infrastructure related to HNI prevention of Central Hospital of Tropical Diseases 2.1.2 Study location: Central Hospital of Tropical Diseases 2.1.3 Research time: - The study describes: January 1, 2011 to December 31, 2011 - Intervention study: January 1, 2012 to December 31, 2013 2.2 Research methods 2.2.1 research design Research design includes studies: - Research to assess the status of HNI and factors related to HNI in the Department of Emergency Medicine - Intervention study: Develop, implement and evaluate the effectiveness of a number of measures and techniques to improve infection control activities at the Central Hospital for Tropical Diseases 2.2.2 Sample size and sampling method * Descriptive study - Sample size: All patients with HNI in the Emergency Department are from January 1, 2011 to December 31, 2012 - Sampling: Choose samples without probability, successively All patients qualify for research into the Emergency Department - Criteria to select patients: The patient is in the Emergency Department for 48 hours or more - Exclusion criteria: The patient had a HNI before entering the Emergency Department; The patient showed signs of HNI within the first 48 hours after entering the Emergency Department; The patient died within 48 hours after entering the Emergency Department * Intervention study - Patients with HNI at the Emergency Department: All patients with HNI in the Department of Emergency Medicine from January 1, 2012 to December 31, 2013 - Sample size of medical staff: All doctors, nurses, sanitation workers, infection control staff working in the departments of the Hospital 2.3 Content, research variables and data collection methods 2.3.1 Descriptive study 2.3.1.1 Research variables * The main variable - Determination of HNI: Based on WHO 2002 standards Time is counted as a case from 48 hours after admission to the Emergency Department to 48 hours after leaving the Emergency Department - Date of onset of HNI: The time of determining the case according to WHO standards For patients with multiple HNI, the time of onset is calculated from the first HNI If bacterial isolation is performed, the time is calculated at the time of sampling * The secondary variable + Duration of treatment in the Department of Emergency Medicine: Calculated from the time of arrival to the exit of the Emergency Department + Full treatment period: The time the patient is in the hospital + Treatment costs: The entire cost of treatment for the patient during the hospital stay + Pathogen: Is an isolated agent from a patient's sample corresponding to a specific HNI * Independent variable - Epidemiological factors: Age, gender - Factors: (1) Background disease: Select the main disease type for this admission; (2) Comorbidities: The disease is accompanied by the main disease and affects the current medical condition at many levels - Intervention factor + Invasive intervention: Intubation, peripheral intravenous clearance, central venous catheterization, catheterization, gastric emptying, pleural drainage, peritoneal membrane + Drug treatment: Antibiotic treatment: When antibiotics are used in patients with evidence of infection Other drugs: Corticosteroids, H2 inhibitors, vasomotor, muscle relaxants, sedation are calculated when appointing patients for at least 24 hours + Blood transfusion: patients receive blood transfusions and blood products + Intravenous feeding: When the patient is nourished by infusing a solution containing protein or fat for at least 24 hours - Time to put the device: Calculated from the time of intervention to the detection of HNI If the patient does not have a HNI, it will be calculated from the time of placing the device to the end of the intervention or when leaving the Emergency Department 2.3.1.2 The method of data collection * Initial assessment of patients Patients who meet the criteria for study will be examined, perform diagnostic tests and record information filled in the collection form * Monitor and evaluate patients All patients are cared for, monitored and treated according to the regimen appropriate to the condition and have the same conditions for HNI control Interventions on patients and treatments are recorded on the date of implementation and duration of use Monitor and evaluate signs of HNI of each location + Urinary catheterization: Urine testing every 72 hours until urination is withdrawn, urine urine + (+) and leukocytes (+) will be considered suspected urinary infection + Intubation: When clinically there is a fever or changes in sputum or hearing of the lungs with a new burst will appear for chest X-ray + Intravenous catheter placement: When there is a change in place of the injection site, or the presence of an infection syndrome for carrying out infection determination tests - The test identifies the case: + Blood culture: Conducted when the patient has the symptoms of infection syndrome: 1) There are of the following criteria: fever> 38.50C; Rapid pulse; Fast breathing; white blood cells increase or decrease compared to Band neutrophil age> 10% 2) Evidence of infection or suspicion through examination and examination Blood was taken from the periphery, inserted into Bactec Peds plus / F blood culture bottle and implanted with an automatic implant + Implant urine on the third day after catheterization and repeat when there are signs of: Urine pain, dysuria, pain on the pubic bone when pressed, or opaque urine; If no urinary catheterization is available, a urine culture will be performed when there are symptoms on or with leukocytes or nitrites (+) in the total urine analysis The inoculum is considered to be positive when there is at least 105 cfu/mm3 + Transplant from the wounds and secretions of the drainage pipes to find the pathogen The specimen will be inoculated with bacteria on aerobic environment and fungal environment if it is suspected to be fungus Interpretation of transplanting results: If there is an isolated agent, it will be considered as the cause of the disease In the case of a specimen that has two or more agents, the predominant agent is considered to be the cause of infection In cases where the microbiological result is negative but suspicion can still be replanted - Determination of case: the patient was followed up 48 hours after leaving the Emergency Department, if there was a HNI during this period, it was also considered a HNI associated with the Emergency Department The end result of the patient is calculated until discharge, the time in the Emergency Department, the length of hospital stay and the patient's treatment cost are recorded 2.3.2 Intervention study 2.3.2.1 Intervention content Building a HNI control system, establishing an Infection Control Council, an infection control network, developing rules and operation mechanism of the council and a network of HNI monitoring Develop training programs and contents for ongoing HNI Develop programs, content and implement training on knowledge and skills to practice HNI control for health workers 2.3.2.2 Research variables HNI control system Reality of hand hygiene before and after intervention Reality of surface hygiene before and after intervention Knowledge and practice of HNI control by medical staff Efficacy index for HNI control capacity 2.3.3 Data processing Data are statistically processed by SPSS 22.0 software CHAPTER RESEARCH RESULTS 3.1 Current situation, factors related to HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases, 2011 3.1.1 Situation and factors related to HNI caused by Acinetobacter baumannii at the Emergency Department Figure 3.1 The cause of HNI in the Emergency Department The cause of HNI at the Department of Emergency is the highest due to Acinetobacter baumannii (34.1%) Other causes of other HNI are P.aeruginosa (18.2%), K.pneumoniae (11.4%) and Providencia spp (9.1%) Table 3.1 Distribution of HNI by A.baumannii according to accompanying diseases HNI Total Diseases p Yes No n = 682 n = 102 (%) n = 580 (%) Alcoholism 13(12.75) 67(11.55) 80(11.73) > 0.05 COPD 9(8.82) 53(9.14) 62(9.09) > 0.05 Diabetes 7(6.86) 478.10) 54(7.92) > 0.05 immunodeficiency 7(6.86) 17(2.93) 24(3.52) < 0.05 Cancer 4(3.92) 21(3.62) 25(3.67) > 0.05 Hepatitis progresses 2(1.96) 15(2.59) 17(2.49) > 0.05 HIV 1(0.98) 10(1.72) 11(1.61) >0.05 TNMMN 1(0.98) 5(0.86) 6(0.88) >0.05 renal impairment 33(32.35) 174(30.00) 207(30.35) > 0.05 Heart disease 25(24.51) 171(29.48) 196(28.74) > 0.05 The rate of HNI by A.baumannii in patients with renal impairment is highest (32.35%), followed by heart disease (24.51%), alcoholism (12.75%), COPD (8.82%), diabetes (6.86%), immunodeficiency (6.86%) Table 3.2 Time of HNI by A.baumannii appearance Time appears Type of HNI by A.baumannii Averaged ± SD (day) General HNI by A.baumannii 6.25 ± 2.26 Hospital pneumonia by A.baumannii 7.12 ±1.65 Sepsis by A.baumannii 6.20 ± 2.23 Urinary tract infections by 4.56 ± 1.12 A.baumannii The onset of HNI averaged 6.25 ± 2.26 days Urinary tract infections have the earliest time of occurrence 4.56 ± 1.12, the longest is hospital pneumonia is 7.12 ±1.65 Table 3.3 Rate of HNI by A.baumannii to location (n = 102) Type of HNI Number of cases Rate (%) Hospital pneumonia 46 45.10 Sepsis 26 25.49 Bacterial infection of vascular catheter placement 22 21.57 Urinary tract infections 5.88 Other infections 4.90 Hospital pneumonia was highest (45.10%), septicemia (25.49%), infection of vascular catheter placement (21.57%) and urinary tract infection (5.88%) Table 3.4 The duration of treatment in the Emergency Department and the hospital stay of HNI locations by A.baumannii Type of HNI by HNI by A.baumannii Difference p 11 Peritoneal drainage 70 0.025 45 0.012 < 0.001 Medium 185.3 0.065 664.8 0.171 < 0.001 Index of instrument use = Time of tooling/ Treatment time Chart 3.2 Correlation between the time at which the device was placed and the use index of the instrument in the group with HNI by A.baumannii Chart 3.3 Correlation between the time to place the device and the index using the device of the group without the HNI by A.baumannii The average use index in patients with HNI by A.baumannii was higher than for patients without HNI (p days Results of applying some measures and techniques to improve HNI control activities at the Central Hospital for Tropical Diseases 24 Successfully builds the hospital's infection control system and the infection control board's working regulations and infection control network For hand hygiene: The hospital has its own budget, plans to improve infrastructure for hand hygiene The level of improved environmental safety on hand hygiene increased by 35 points Hand hygiene rate increased for all health care workers, in midwifery groups, reached 86.3%, nursing 53.4% and doctors 49.7% For face disinfection activities: The rate of health-care workers reached 36.3%, the efficiency index was 72.3% The hospital ensures adequate facilities, equipment, own budgets and has adequate training materials and promotes regular training and guidance for health workers on surface hygiene The rate of HNI decreased by 21.4% The reserve value of HNI is 49.0% In particular, the highest value of prevention of hospital pneumonia 52,5% RECOMMENDATION Through this study, we have some suggestions as follows: Continue to maintain HNI control solutions at the Emergency Department as well as throughout the hospital Implementing some HNI prevention measures in the Emergency Department: (1) There is a separate area for patients at high risk of HNI; (2) Arrange isolation of patients infected with HNI by multiresistant bacteria into a separate area; (3) Nursing arrangement and control of the number of patients residing in the Department of Emergency Resuscitation to ensure nursing numbers: patients reach 1: or maximum 1: 2; (4) Shorten emergency resuscitation time if possible; (5) Limit invasive interventions on unnecessary patients; (6) Make recommendations for prevention for each type of HNI 25 LIST OF WORKS PUBLISHING THE RESEARCH’S RESULTS OF THE THESIS Doan Quang Ha, Nguyen Van Kinh, Nguyen Nguyen Van Chuyen (2018), “Some related nosocomial infection in the intensive care unit Hospital for Tropical Diseases” Journal of Military Medicine, Vol 43, No.9 (12/2018), pp 185-193 Vu Trung, factors to of National Pharmaco - Doan Quang Ha, Nguyen Van Kinh, Nguyen Vu Trung, Nguyen Van Chuyen (2018), “Current situation of HNI in the Emergency Department - Positive treatment, Central Hospital of Tropical Diseases (2011-2012, Vietnam Journal of Medicine, No.2 (10/2018), pp 121-125 Doan Quang Ha, Nguyen Van Kinh, Nguyen Vu Trung, Nguyen Van Chuyen (2019), “Results of application of hygiene technical measures to improve HNI control activities at the Central Hospital for Tropical Diseases, Vietnam Journal of Medicine, No.1&2 (2/2019), pp 95-99 ... HNI caused by Acinetobacter baumannii at the Emergency Department, Central Hospital of Tropical Diseases, 2011 3.1.1 Situation and factors related to HNI caused by Acinetobacter baumannii at the... HNI by A .baumannii appearance Time appears Type of HNI by A .baumannii Averaged ± SD (day) General HNI by A .baumannii 6.25 ± 2.26 Hospital pneumonia by A .baumannii 7.12 ±1.65 Sepsis by A .baumannii. .. from January 1, 2011 to December 31, 2011 * Intervention study - Patients who are treated at the Emergency Department from January 1, 2012 - December 31, 2013 - Medical staff: Doctors, nurses,