Nosocomial infections lurking in hospital wards

By Bambang Tiong

YOGYAKARTA (JP): It once happened that all the babies in a ward in a famous Yogyakarta hospital were struck by diarrhea. At first the hospital thought the cases were attributable to the garbage dump, but after a more thorough study, it was discovered that source of the attack was to be found in insufficiently sterilized baby bottles.

The case above, just like thousands others of the same nature, is known in medical circles as a nosocomial infection (from the Greek nosocomium meaning hospital). A nosocomial infection, then, is one that originates or takes place in a hospital.

"In hospital there are a lot of bacterium that are resistant to antibiotics," said Dr. Ristanto S. of Gadjah Mada University in Yogyakarta, and also a core member of the Indonesian Association of Clinical Microbiologists (PAMKI).

According to him, nosocomial infections are not a new threat, particularly to inpatients. Their danger has been known of since the late 18th century, when viruses, bacteria, fungi and parasites were blamed.

Of these four culprits, viruses and bacterium were the most dangerous because of the quick and easy way they become resistant to antibiotics.

The first nosocomial was detected by an obstetrician in Vienna, Austria, Iqnas Philip Semmelweis, while he was observing women in labor. What attracted his attention was the fact that 30 percent of women who gave birth in hospital contracted a fever, while none of those giving birth at home did.

This finding raised many questions among doctors at the time, who were still unaware of nosocomial dangers.

As time went on, the threats from nosocomial infection diversified, a fact leading to the surprising discovery by doctors that 40 percent of Staphylococcus aerus bacterium were resistant to antibiotics.

"The more advanced a country is the more nosocomial cases will be found," Ristanto said.

He said that in developed countries medical advances have led to advanced antibiotics, with the result that many bacterium have a high resistance against these antibiotics.

Dr. Yovita Y., chairwoman of the nosocomial management team at Panti Rapih Hospital, Yogyakarta, said that a number of factors are responsible for the emergence of nosocomial infections:

"A patient in a weak physical condition is more prone to have a nosocomial infection. Also, if a hospital is not hygienic, the patients are more likely to suffer nosocomial infections," he said.

Dr. Ristanto added that hospital visitors were also sometimes to blame for nosocomial infections.

Someone with tuberculosis, for example, visits a patient suffering a bout of malaria. As this malaria patient is physically weak, it is likely that he or she too will get tuberculosis

"Nosocomial cases are also brought about by interaction between patients. A malaria patient staying in the same room as a patient with tuberculosis is also likely to get tuberculosis," Risanto said.

The Ministry of Health has issued instructions that every hospital should have a special team to deal with and cut down to the minimum the occurrences of nosocomial infections.

The team should be comprised of experts and should also include hospital security guards, who should be the first people monitoring visitors to a hospital.

Apart from these internal teams, PAMKI, whose operations are nationwide, is always ready to fight nosocomial cases across the country.

This association was established with the following rationale: "Control over infection in hospital is a necessity in order to prevent patients from having infection and efforts will be made in the form of prevention, surveillance and rational therapy."

The basic impetus underlying the establishment of PAMKI was an awareness of nosocomial hazards, which led to a determination to cut down on their frequency. Nosocomial infections can and must be prevented and a patient has the right to enjoy hospital treatment with the minimum risk of being nosocomially infected.

Therefore, PAMKI is now actively accrediting hospitals to ensure that they meet the standard set for 12 areas, including administration, management and medical services.

Ristanto said it was difficult for hospitals to meet the standards in all the 12 areas because of money. Operating theater walls, for example, must not have any curves because it is in these curves that many pathogenic bacteria hide.

PAMKI has defined nosocomial infections as infections that a patient sustains after having hospital treatment for more than 48 hours, excluding patients who have diseases that incubated while still at home.

According to a PAMKI study, nosocomial infections are most likely to be found in intensive care and constitute between 13 percent and 42 percent of all such cases in a hospital. This is because there are many invasive procedures in intensive care, such as infusions or transfusions.

The records kept by Dr. Karyadi Hospital in Semarang, Central Java, say that nosocomial infections are usually found in the following areas: urethra (42 percent), surgery-related wounds (20 percent), lower respiratory tract (14 percent), blood (8 percent) and others (16 percent).

Dr. Ristanto said that although PAMKI was established in early 1990, the association has yet to produce maximum results because of limited funds and reluctance on the part of experts to engage in social work.

"I have great concerns over the fact that many experts are unwilling to join the association because it means social work. In some cases, we have to fork out our own savings. Just imagine, that for a national organization PAMKI has only 42 members," he said.

Therefore, at present PAMKI can only observe nosocomial infections with short incubation periods, such as when a patient gets a fever when he or she is being treated in hospital. The association, he added, is still unable to observe nosocomial infection cases with long incubation periods such as tuberculosis.

In addition, apart from accrediting hospitals, PAMKI is also engaged in research to find antibiotics that fight bacterium or viruses responsible for nosocomial infections.

The first activity in this respect is capturing bacterium and putting them into a Mullerhinton jelly by means of a disc dysfunction in order that potent antibiotics may be discovered.

Stressing the dangers of nosocomial infections may bring about, Dr. Ristanto finally said that some AIDS patients may have lost their lives not because of HIV infection but because they contracted a nosocomial infection when they were physically weak.