Introduction

Hospital is an integral part of a social and medical organization that provides treatment, and all health care benefits to disease patients.

Functions of hospital:

  • Providing health care services to patients

  • Monitoring financial operations of the hospital

  • Conducting research activities in the hospital

  • Construction of hospital policies, administration laws and rules, and regulations of hospital

  • Management of hospital pharmacy

  • Hospital waste management

Hospital types:

  • Acute care hospital

  • Addiction abuse treatment hospital

  • Community hospital

  • Rural Hospital

  • Urban Hospital

  • Psychiatric Hospital

  • Rehabilitation Hospital

  • Teaching and charitable Hospital

  • Multi specialty hospital

  • Super specialty hospital

List of departments in Hospital:

  • In patient department

  • Outpatient department

  • Administrative department

  • Nursing Department

  • Pathology Department

  • Paramedical Department

  • Pharmacy Department

  • Dietary Department

  • Operation Theatre Complex

  • Radiology Department

  • Medical Record Department

Clinical pharmacy:

Pharmaceutical care is to improve the patient’s health related quality of life by encouraging rational prescribing of drugs in the health care. Clinical pharmacist has good knowledge on therapeutics and regularly interacts with various health care professionals to enhance the effective drug prescribing pattern in the hospitals. Clinical pharmacist is placed in the various hospitals to improve the health care standards in the health care settings. Clinical pharmacy services are professional services provided by clinical pharmacist to improve the health care services to the individual patients and minimize the health care burden to the individual patients in health care settings. Clinical pharmacists are continuously work with physicians, and other health professionals, and patients to ensure effective medications to achieve best treatment outcome for the each patient1-2.

Clinical pharmacy services include:

  • Adverse reactions reporting

  • Drug interactions management

  • Creating awareness on disease prevention and management

  • Hospital policies designing

  • Hospital treatment guidelines design

  • Provision of drug and poison information

  • Medication history interview

  • Clinical history review

  • Patient counseling

  • Ward round participation

  • Anti microbial stewardship

Healthcare associated infections:

Healthcare associated infections are nosocomial infections which occur at the time of hospital admission. Infections are appears 48 hours after admission to the hospital.

Risk factors for healthcare associated infections include:

  • Immuno suppression

  • Older age

  • Chronic length of stay in the hospital

  • Multiple co-morbidities

  • Regular hospital visit

  • Admitted in intensive care unit

Types of healthcare associated infections:

  • Surgical site Infections

  • Clostridium difficile infections

  • Catheter associated urinary tract infections

  • Sepsis

  • Methicillin resistant staphylococcus aureus

  • Ventilator-associated pneumonia

Microbes associated with healthcare associated infections:

  • Acinetobacter baumannii

  • Clostridium difficile

  • Staphylococcus aureus

  • Escherichia coli

  • Pseudomonas aeruginosa

  • Candida albicans

  • Stenotrophomonas maltophilia

  • Enterococcus

Surgical site infections:

It occurs when the incision is created by invasive surgical procedures.3-4

Risk factors:

  • Old age

  • Diabetes mellitus

  • Malnutrition

  • Obesity

  • Abdominal surgery

  • Prolong hospital stay

  • Weak immune system

  • Wound contamination

  • Previous medical history of chronic diseases

  • Having cancer

  • Tobacco

  • Steroid use

  • Infections

Clinical features:

  • Wound dehiscence

  • Erythema

  • Pus formation

  • Pain

Prevent surgical site infections5:

  • Regular hand washing practice

  • Maintaining clean skin

  • Use of sterile clothing and drapes

  • Maintaining controlled blood sugar levels

  • Wound care

  • Regular wound dressing

Antibiotics:

Sulfonamides:

  • Sulfadiazine

  • Sulfamethizole

  • Sulfamethoxazole

  • Sulfasalazine

  • Sulfisoxazole

Fluoroquinolones:

  • Ciprofloxacin

  • Gemifloxacin

  • Levofloxacin

  • Moxifloxacin

  • Norfloxacin

  • Ofloxacin

Clostridium difficile infection:

  • It causes severe

Signs and symptoms6:

Mild to moderate infection:

  • Diarrhea

  • Abdominal cramping and

  • Abdominal tenderness

Severe infection:

  • Fever

  • Loss of appetite

  • Rapid heart rate

  • Diarrhea

  • Kidney failure

  • Severe abdominal pain

  • Blood in the stool

  • Weight loss

  • Abdominal swelling

Complications:

  • Bowel perforation

  • Toxic megacolon

  • Coma

Clostridium difficile diagnosis:

It is diagnosed through using below tests that include:

  • Polymerase chain reaction

  • Cell cytotoxicity assay

  • Stool Test

  • Blood Test

  • Colonoscopy or sigmoidoscopy

  • CT Scan

Prevention/infection control of Clostridium difficile infection7-8:

  • Adhering to effective hygiene and cleansing procedures

  • Following antimicrobial stewardship

  • Providing education to all healthcare staff

  • Approaching antimicrobial stewardship in hospitals

  • Avoid use of unnecessary use of antibiotics

  • Regular practice of hand-washing practices

Novel therapies for clostridium difficile infection:

  • Metronidazole

  • Fidaxomicin

  • Nitazoxanide

  • Rifaximin

Catheter associated urinary tract infection:

Catheters are commonly used medical devices in the hospital. However, prolong use of catheters are increase the risk of infection. Catheter-associated urinary tract infections are represented with CAUTIs. Improper control of catheter associated urinary tract infections causes several medical complications such as septicaemia, bladder stones, pyelonephritis and endotoxic shock. Catheter-associated urinary tract infections are caused by Gram-positive and Gram-negative bacteria.9-10

Risk factors:

  • Older age

  • Previous medical history of urinary tract infection

  • Renal problems

  • Diabetes mellitus

  • Poor immune function

Clinical symptoms :

  • Hematuria

  • Abnormal urine color

  • Strong urine odor

  • Fever

  • Pelvic pain

  • Pain around the testicles

  • Blood in the urine

  • Burning pain when passing urine

Laboratory tests:

  • Urine analysis

  • Urine culture

  • Ultrasound of the abdomen

  • CT scan of the abdomen

Prevent ion11:

  • Regular clean of catheter surroundings

  • Maintaining the drainage bag below the urinary bladder

  • Daily empty of drainage bag several times

  • Hand hygiene before and after touching the catheter

  • Washing of hands before and touching drainage bag

Treatment12:

  • Trimethoprim

  • Sulfamethoxazole

  • Methenamine

  • Ciprofloxacin

  • Levofloxacin

  • Ceftriaxone

  • Cefepime

Sepsis :

It is a life-threatening condition caused by body abnormal response to infectious condition. The human body responds to various inflammatory stimulations and releases chemicals into blood circulation and damages multiple organs. In this condition the microbial species enter into blood vessels causes inflammation and infection all parts of the body. The chronic condition of the sepsis causes septic shock to infected patients.13-16

Causes:

It includes:

  • Bacterial infections

  • Fungal infections

  • Viral infections

  • Pneumonia

  • Infections in the digestive system

  • Bloodstream infection

Risk factors 17-18 :

  • Older people

  • Pregnant woman

  • Cancer

  • Liver disease

  • Kidney disease

  • Auto immune disease

  • People with weakened immune systems

  • People with chronic illnesses

  • Have a compromised immune system

  • Wound infections

  • Previously medical treatment history of antibiotics

  • Previously medical treatment history of corticosteroids

Diagnosis:

  • Blood tests

  • Urine examination

  • Wound secretions

  • Respiratory secretions

  • X-ray test

  • Computerized tomography (CT)

  • Ultrasound scan

  • Magnetic resonance imaging (MRI)

Complications :

It includes:

Blood clot

Heart failure

kidney failure

Loss of a portion of the bowel

Stroke

Liver failure Respiratory infections

Symptoms :

  • Fever

  • Chills

  • Tachycardia

  • Difficulty breathing

  • Sweaty skin

  • Extreme pain

  • Redness

  • Swelling around a wound

Clinical symptoms of severe sepsis:

  • Low blood pressure

  • Dizziness

  • Low urine output

  • Confusion

  • Slurred speech

  • Diarrhea

  • Severe pain

  • Shortness of breath

  • Loss of consciousness

  • Dementia

Sepsis prevention19:

  • Prevention of infection in the community

  • Using proper hand hygiene practices

  • Safe preparation of food

  • Improving sanitation facilities

  • Annual vaccination to children’s and newborn babies

  • Proper care of wounds

Treatment:

It includes:

  • Corticosteroids

  • Insulin

  • Kidney dialysis

  • Oxygen therapy

  • Hypertensive medications

Commonly prescribed antibiotics are20:

  • Cefepime

  • Piperacillin

  • Tazobactam

  • Ampicillin

  • Sulbactam

  • Levofloxacin

  • Ceftriaxone

  • Meropenem

  • Ceftazidime

  • Cefotaxime

  • Clindamycin

Methicillin-resistant staphylococcus aureus (MRSA infection):

Methicillin-resistant staphylococcus aureus infection is caused by bacteria. This bacteria shows more resistant to many antibiotics which are used in the treatment of staph infections21.

Clinical symptoms:

  • Chest pain

  • Shortness of breath

  • Muscle pain

  • Headache

  • Cough

  • Fever

Risk factors22:

  • Hospitalized patients

  • Long-term treatment care facility

  • Living in crowded conditions

  • Sexual contacts

  • Consuming intravenous drugs

Complications :

It includes:

  • Bloodstream

  • Lungs

  • Heart

  • Bones

  • Joints

Diagnos is:

  • Wound cultures

  • Sputum cultures

  • Urine cultures

  • Blood cultures

Preventing CA-MRSA23-24:

  • Proper washing of hands.

  • Proper care of wounds

  • Sanitizing central linens

  • Avoid of using injecting illicit drugs

  • Avoiding contact with infected patients

  • Avoid of using infected patients personal items such as razors, towels etc.

Treatment for HA-MRSA25:

  • Teicoplanin

  • Telavancin

  • Daptomycin

  • Ceftaroline

  • Oxazolidinones

  • Tigecycline

Ventilator-associated pneumonia:

Ventilator-associated pneumonia is most commonly seen in patients who need treatment in intensive care units. Detection of ventilator-associated pneumonia requires thorough clinical examination of individual patients which includes radiographic examination, and microbiologic analysis of respiratory secretions could helpful for detection of ventilator-associated pneumonia in the hospitals.26-27

Pneumonia types:

Hospital-acquired pneumonia It occurs in 48 hours Ventilator-associated pneumonia: It is develops more than 48 hours. Healthcare-associated pneumonia: It occurs with infected patients

Microbiology:

It is caused by various pathogens include pseudomonas aeruginosa, staphylococcus aureus, klebsiella pneumoniae, enterobacter spp, Acinetobacter spp, streptococcus spp, Escherichia coli.

Risk factors:

It include:

Hospitalization more than 5 days Past medical history of antibiotic treatment Antibiotic resistance Immunosuppressive diseases

Diagnosis:

  • Chest X rays

  • Microbiologic Diagnosis

  • Blood and pleural fluid culture

  • Sputum culture

  • Polymerase chain reaction

Prevention28:

  • Following good hand hygiene practice

  • Maintaining individual patient’s oral hygiene

  • Maintaining the patient in a semi recumbent position

Treatment29-30:

Commonly used empiric anti pseudomonal antibiotics includes:

  • Imipenem

  • Ciprofloxacin

  • Cefepime

  • Gentamicin

  • Piperacillin

  • Ceftazidime

  • Tazobactam

  • Meropenem

  • Levofloxacin

  • Amikacin

  • Linezolid

  • Vancomycin

  • Imipenem

  • Meropenem

Central Line-associated Bloodstream Infections:

Central line is a catheter tube which is placed in a large vein in the neck, chest to collect blood for various medical examinations. It is a serious infection that occurs when the contaminated blood enter into the central line and causes severe infection. Central lines are most commonly used in the intensive care units31-32.

Causes:

  • Catheter insertion areas contamination

  • Contaminated infusion

  • Individual patient’s skin flora

Risk factors:

  • Aging

  • Immunosuppression

  • Previous history of infections

  • Poor food intake

  • Pale skin

  • Antibiotic therapy

  • Diabetes mellitus

  • Parenteral nutrition

  • Lengthy hospitalization

  • Poor hygiene

  • Lack of non-adherence to aseptic technique

  • Prolonged duration of the catheter

Clinical Symptoms:

  • Symptom of breathlessness

  • Diaphoresis

  • Hypotension

  • Fever

  • Redness

  • Swelling

  • Tachycardia

  • Pain

  • Formation of pus

Prevention and management:

Prevention:

  • Doing proper hand hygiene after touching the line

  • Applying effective antiseptic to the hand after touching the line

Management33:

It includes:

Penicillin Cephalosporins Aminoglycosides Anti fungal drugs

Conclusion

Hospital associated infections are commonly caused by bacteria, fungal, vial species. It include acinetobacter, clostridium difficile, taphylococcus aureus, candida, enterococcus can increase the risk of hospital infections in the health care settings. Surgical site infection, bloodstream infection, urinary tract infection pneumonia, methicillin-resistant staphylococcus aureus infection and sepsis is most commonly observed in the hospitals. Intensive care treatment is more risk for development of antibiotic resistant bacteria. Gram-positive and gram-negative organisms cause nosocomial infections. In effective prescribing of antibiotic therapy is linked with bacterial resistance. Infection control practices are essential for prevention of new episodes of infections in the hospitals.34-38Wearing face mask, hand gloves and regular hand washing, hand sanitization could lower the progression of infections. Designing of new antibiotic protocol, appropriate use of anti microbial drugs, conducting awareness programme on infection control, antibiotic stewardship practice, continuous medical education on infection control, and proper training of health care professionals could reduce the emergence of pathogenic infections in the hospitals. Clinical pharmacy is a branch of science which deals with pharmaceutical care activities in the health care. Clinical pharmacists are posted in the hospitals to improve the patient health care. Clinical pharmacist regularly interacts with many health care professionals to solve various patient related problems in the clinical practice. Clinical pharmacist has important role in designing of infection control guidelines, antibiotic therapy monitoring, hygiene protocols, drug problems management, detection of infectious species, infection sources and control, patient referral services can lower the infection incidences in the hospitals. Regular implementation of clinical pharmacist services in the hospitals can prevent the occurrence of hospital infections in the health care.39-40 The prevention and control of health care associated infections include individual isolation, rapid detection and treatment of infectious species, practice of health safety protocol, avoiding unwanted use of catheters, tracing and treatment of infected person, developing new health care technology based infection detection devices can prevent the repeated episodes of health care infections and also reduces the health care economical cost to the infected patients.

Acknowledgement:

I would like to thank our respected Principal,

Dr. S. Mohan, Karpagam College of Pharmacy,

Coimbatore, for his continuous help, support and

encouragement to write this article.

.

Conflict of interest: Authors declare no conflict of interest.

Finding sources: Nil 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40

References

  1. The Environment as a Factor in Methicillin-Resistant Staphylococcus aureus Transmission Smith T.C., Moritz E.D., Larson K.R. Leedom, Ferguson D.D.. Reviews on Environmental Health.2010;25(2):121-134.
  2. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care Angus Derek C., Linde-Zwirble Walter T., Lidicker Jeffrey, Clermont Gilles, Carcillo Joseph, Pinsky Michael R.. Critical Care Medicine.2001;29(7):1303-1310.
  3. Methicillin-Resistant Staphylococcus aureus: An Update Durai Rajaraman, Ng Philip C.H., Hoque Happy. AORN Journal.2010;91(5):599-609.
  4. The Systemic Septic Response: Maltiple Systems Organ Failure Cerra Frank B.. Critical Care Clinics.1985;1(3):591-607.
  5. Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis Ziegler Matthew J., Pellegrini Daniela C., Safdar Nasia. Infection.2015;43(1):29-36.
  6. Infection Control, Hospital Epidemiology, and Patient Safety Coffin Susan E., Zaoutis Theoklis E.. Infectious Disease Clinics of North America.2005;19(3):647-665.
  7. Impact of Source Control in Patients With Severe Sepsis and Septic Shock Martinez M L, Ferrer R, Torrents E. Crit Care Med.2017;45(1):11-20.
  8. The epidemiology of community-acquired Clostridium difficile infection: a population based study Khanna S, Pardi D S, Aronson S L. Am J Gastroenterol.2012;107:89-95.
  9. Risk factors for central line-associated bloodstream infections in the era of best practice Lissauer Matthew E., Leekha Surbhi, Preas Michael Anne, Thom Kerri A., Johnson Steven B.. The Journal of Trauma and Acute Care Surgery.2012;72(5):1174-1180.
  10. Antibiotic resistance & pathogen profile in ventilator-associated pneumonia in a tertiary care hospital in India Chaudhury Abhijit, Rani AShobha, Kalawat Usha, Sumant Sachin, Verma Anju, Venkataramana B. Indian Journal of Medical Research.2016;144(3):440-440.
  11. Relationship of catheter-associated urinary tract infection to mortality and length of stay in critically ill patients: A systematic review and meta-analysis of observational studies Chant Clarence, Smith Orla M., Marshall John C., Friedrich Jan O.. Critical Care Medicine.2011;39(5):1167-1173.
  12. Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials Calfee Carolyn S, Delucchi Kevin, Parsons Polly E, Thompson B Taylor, Ware Lorraine B, Matthay Michael A. The Lancet Respiratory Medicine.2014;2(8):611-620.
  13. Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries Chawla R. Am J Infect Control.2008;36(4).
  14. Introducing a population-based outcome measure to evaluate the effect of interventions to reduce catheter-associated urinary tract infection Fakih Mohamad G., Greene M. Todd, Kennedy Edward H., Meddings Jennifer A., Krein Sarah L., Olmsted Russell N., Saint Sanjay. American Journal of Infection Control.2012;40(4):359-364.
  15. Impact of a Hospital‐Based Antimicrobial Management Program on Clinical and Economic Outcomes Gross Robert, Morgan Amy S., Kinky Denise E., Weiner Mark, Gibson Gene A., Fishman Neil O.. Clinical Infectious Diseases.2001;33(3):289-295.
  16. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center* Warren David K., Shukla Sunita J., Olsen Margaret A., Kollef Marin H., Hollenbeak Christopher S., Cox Michael J., Cohen Max M., Fraser Victoria J.. Critical Care Medicine.2003;31(5):1312-1317.
  17. Clinical pharmacy services in an Iranian teaching hospital: a descriptive study Dashti-Khavidaki Simin, Khalili Hossein, Hamishekar Hadi, Shahverdi Sheida. Pharmacy World & Science.2009;31(6):696-700.
  18. Metabolic Adaptation Establishes Disease Tolerance to Sepsis Weis S, Carlos A R, Moita M R. Cell.2017;169(7):1263-1275.
  19. Bacterial Pathogens of Ventilator Associated Pneumonia in a Chi S Y, Kim T O, Park C W. Tertiary Referral Hospital. Tuberc Respir Dis.2012;73(1):32-37.
  20. Impact of clinical pharmacist in an Indian Intensive Care Unit Sivakumar Mudalipalayam N., Veerasekar Ganesh. Indian Journal of Critical Care Medicine.2016;20(2):78-83.
  21. Organ failure in sepsis Gerlach Herwig, Toussaint Susanne. Current Infectious Disease Reports.2007;9(5):374-81.
  22. Methicillin-ResistantS. aureusInfections among Patients in the Emergency Department Moran Gregory J., Krishnadasan Anusha, Gorwitz Rachel J., Fosheim Gregory E., McDougal Linda K., Carey Roberta B., Talan David A.. New England Journal of Medicine.2006;355(7):666-674.
  23. Operating room environment and surgical site infections in arthroplasty procedures Cristina M L, Sartini M, Schinca E, Ottria G, Spagnolo A M. J Prev Med Hyg.2016;57(3).
  24. A Prospective Trial of a Novel, Silicone-Based, Silver-Coated Foley Catheter for the Prevention of Nosocomial Urinary Tract Infections Srinivasan Arjun, Karchmer Tobi, Richards Ann, Song Xiaoyan, Perl Trish M.. Infection Control & Hospital Epidemiology.2006;27(1):38-43.
  25. Prevention and control of methicillin-resistant Staphylococcus aureus Humphreys H., Grundmann H., Skov R., Lucet J.-C., Cauda R.. Clinical Microbiology and Infection.2009;15(2):120-124.
  26. Prevention of Central Line-Associated Bloodstream Infections Bell T, Grady O', N P. 2017.
  27. Methicillin-resistant Staphylococcus aureus (MRSA): burden of disease and control challenges in Europe Köck R, Becker K, Cookson B, van Gemert-Pijnen J E, Harbarth S, Kluytmans J, Mielke M, Peters G, Skov R L, Struelens M J, Tacconelli E, Navarro Torné A, Witte W, Friedrich A W. Eurosurveillance.2010;15(41):19688-19688.
  28. Infection control and changing health-care delivery systems Jarvis W R. Emerg Infect Dis.2001;7:170-173.
  29. Asymptomatic Clostridium difficile colonisation and onward transmission Eyre D W, Griffitths D, Vaughan A. PLoS One.2013;8:78445-78445.
  30. Pharmacist recommendations in an intensive care unit: three-year clinical activities Fideles Giovanni Montini Andrade, Alcântara-Neto José Martins de, Peixoto Júnior Arnaldo Aires, Souza-Neto Paulo José de, Tonete Taís Luana, Silva José Eduardo Gomes da, Neri Eugenie Desirèe Rabelo. Revista Brasileira de Terapia Intensiva.2015;27(2):149-154.
  31. Epidemiology of Clostridium difficile infection: results of a hospital-based study in Krakow, Poland CZEPIEL J., KĘDZIERSKA J., BIESIADA G., BIRCZYŃSKA M., PERUCKI W., NOWAK P., GARLICKI A.. Epidemiology and Infection.2015;143(15):3235-3243.
  32. Healthcare-Associated Bloodstream Infections Secondary to a Urinary Focus The Québec Provincial Surveillance Results Fortin Elise, Rocher Isabelle, Frenette Charles, Tremblay Claude, Quach Caroline. Infection Control & Hospital Epidemiology.2012;33(5):456-462.
  33. Summary of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship Dellit Timothy H.. Infectious Diseases in Clinical Practice.2007;15(4):263-264.
  34. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy Kumar A. Virulence.2014;5(1):80-97.
  35. The impact of ventilator-associated pneumonia on the Canadian health care system Muscedere John G., Martin Claudio M., Heyland Daren K.. Journal of Critical Care.2008;23(1):5-10.
  36. Epidemiology and outcomes of surgical site infections following orthopedic surgery Li G Q, Guo F F, Ou Y, Dong G W, Zhou W. Am J Infect Control.2013;41(12):1268-1271.
  37. Hospital-Onset Infections: A Patient Safety Issue Gerberding Julie Louise. Annals of Internal Medicine.2002;137(8):665-665.
  38. Incidence, treatment, and outcome of severe sepsis in ICU-treated adults in Finland: the Finnsepsis study Karlsson Sari, Varpula Marjut, Ruokonen Esko, Pettilä Ville, Parviainen Ilkka, Ala-Kokko Tero I., Kolho Elina, Rintala Esa M.. Intensive Care Medicine.2007;33(3):435-443.
  39. Clinical Pharmacists and Inpatient Medical Care Kaboli Peter J., Hoth Angela B., McClimon Brad J., Schnipper Jeffrey L.. Archives of Internal Medicine.2006;166(9):955-955.
  40. Prevalence of Surgical Site Infection in Orthopedic Surgery: A 5-year Analysis Al-Mulhim Fahad A., Baragbah Mohammed A., Sadat-Ali Mir, Alomran Abdallah S., Azam Md Q.. International Surgery.2014;99(3):264-268.