Nosocomial infection: whose fault?

A 60-year-old lady was admitted with the complain of epigastric pain and dyspnea. She was previously admitted for few times with the same complain. The ECG was normal and other examinations were within normal limit. The doc suspected she had peptic ulcer. On the 3rd day of admission, she had fever and back pain. On examination, renal punch on left side was positive. The urinalysis showed that leukocytes +, granulocytes level increased. She was then treated as UTI.

At first, the patient had epigastric pain and dyspnea. The patient was then hospitalised due to the unrelieved pain and dyspnea. On the third day, she suddenly had UTI. Why did the patient suddenly had UTI? What do you think? Nosocomial infection? Do you agree?

There are two types of nosocomial infection:

a) endogenous infection: the causative agents comes from the patient and the infection develop during hospitalization as a result of the patient's decrease of resistance.

b) cross contamination followed by cross infection: the patient comes into contact with new infective agents and develops infection.

Source of nosocomial infection:

a) Human: patients, hospital workers
b) Environment: water, air, waste, food, device (endoscope, ventilator), dust

Factors that contribute to this development of nosocomial infection:

a) The microbial agent
b) Patient suscepbility
c) Environmental factors
d) Bacterial resistance

SO, for nosocomial infection cases, whose fault? Can the patients sue the doctors?

If you look at the source and the factors, you will find that we can actually blame a lot of parties:
a) Blame the patient! why do they become weak? Comon, make ur immune system stronger!

    The patient may say: "errr...why do you blame me? I can't help with this! I've already kept the environment clean and always eat healthy food. But, still, I am infected! And maybe you have to blame the doctors! They are the cause!"

b) Blame the hospital workers:

• Doctors: Blame them for giving antibiotcs to the patients. Blame them for using devices,like endoscope, when examing the patients. Blame them for asking the nurses giving them IV line, giving injection.....

         But the doctor may say: "If I don't give them antibiotics, the patients will not be cured. We can't solely rely on their natural defense system, ain't? Furthermore, even if I order blood culture, I still need to give them broad spectrum antibiotics while waiting for the lab result. This is not avoidable; If I don't use a device, I can't make an accurate diagnosis! I can't simply make a diagnosis based on anamnesis and physical examination. I need supporting examination; If I don't give them IV infusion, they may suffer hypovolemic shock or hypoglycemia; and How sure are you that I am the cause of nosocomial infection?"..... etc etc

• Nurses: Blame them for not using antiseptic procedures! Blame them for not washing hands!

Nurses may say: Show me the evidence before you blame me!

• Hospital cleaners: Blame them for not mopping the floor every hour! Blame them for not empty the bin every hour!

Hospital cleaners may say: Do you think I am a robot?

c) Blame the microorganisms! why do they need to develop a resistant strain? why do they invade the human body?

Therefore,

I don't think doctors should be blamed. The main point is DOCTOR is NOT THE ONLY PARTY responsible for this, but ALL PARTIES. How sure are you that the doctor is the factor or the only factor for causing nosocomial infection? How if it is not the doctors' fault, but the nurse or the patient themselves for being too weak? How if the infection is transmitted through dust, air, food, water, but not from the human? So, forget about it. Stop blaming each other. It s better that we human take actions in preventing this-Do it hand in hand!

What are the prevention?

1) Do a surveillance. Perform antibiotic susceptibility test and monitor the trends in prevalence of bacterial resistance to antimicrobial agent.
2) Based on the surveillance, make a list of antiobiotics in which the doctor can prescribe to the patients.
3) Doctors should prescribe narrow spectrum of antibiotics if possible; When waiting for lab test result, apply empirical treatment/ based on guidelines.
4) Use prophylactic antibiotic only in situation where proved valuable.
5) Sterilization
6) Disinfection, eg fogging.
7) Avoid environmental contamination: Maintain the environmental hygiene and sanitation.
8) Use containment isolation procedures for patient infected with resistant organism.
9) Aseptic hand washing procedures.
10) Safe injection method.
11) Apply crop rotation policy: It is used for predetermined period (e.g. 3 months) and rotated to another antibiotic after 3 Mo and another after 3 Mo and finally recycled.
12) Ensure personal hygiene.
13) Wear gloves, mask, etc.

Let's do these together ;)

Reference:
1) Prof. Dr. Irwan Dwiprahasto. Lecture: Pharmocology: Drugs Formulary and Antibiotic Hospital Policy.
2) Dr. Hera Nirwati. Lecture: Nosocomial Infections.