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RISKS OF INFECTION RELATED TO EXPOSURE TO BLOOD

RISK OF NOSOCOMIAL INFECTION

RISK OF NOSOCOMIAL INFECTION

- DGS / VS / VS2-DH / EO1- Circular No. 17 dated 19th April 1995 relating to the combat against nosocomial infection in public or private health establishments which contribute to the provision of public service.

5 to 10 % of the patients in hospital acquire a nosocomial infection.
Every year, 600 000 to 1 100 000 patients admitted for a short stay will develop an infection.
There are about 10 000 deaths per year.

To this unacceptable fact for patients must be added a financial cost of 2 to 5 % of the days of hospitalisation for short stays and more than a third of the budget for antibiotics is spent for treatment.
- For the Appeals Court, and according to a decision dated 13th February 2001, relating to nosocomial infection, a doctor has an obligation of security of the result, particularly if the infection is consecutive to a medical act carried out in a health establishment or in the surgery of the practitioner. In the matter judged by the Appeals Court, the septic arthritis from which the patient suffered was caused by an arthography of one of his knees, which was carried out by his doctor.

- Comité Technique National des Infections Nosocomiales ( National Technical Committee on Nosocomial Infection )
National survey of the prevalence of nosocomial infection, May - June 1996. Report 1997.

22 % of the patients in reanimation are carriers of a nosocomial infection.
The rate of prevalence varies according to the specialty, from 8 % ( cardiological reanimation ) to 37 % ( polyvalent reanimation ).
-"Guide for the Prevention of Nosocomial Infection in Reanimation" Réanis Group - 1999

The ILCs increase mortality, and above all morbidity, by a significant amount. They produce an average excess cost of 50 000 F per septicaemic event.
· In intensive care units, they are at the origin of 25 to 40 % of the nosocomial septicaemias.
- HA Moss, TSJ Elliot, "The cost of infections related to Central Venous Catheter designed for long term use". British Journal of Medical Economics 1997 - n°11 - 1-7-

The average cost of an antibiotherapy is of the order of € 1 000.
A nosocomial infection increases the hospitalisation time by 3 to 13 days ( or an oncost of about € 1 700 / day in a general ward, and about € 2 000 / day in reanimation ).
- D. Pittet, D. Tarara, R. P. Wenzel : " Nosocomial bloodstream infections in critically ill patients " JAMA 1994 - 271 : 1598 - 608

The oncost due to ILCs may be more than € 30 000 per surviving patient.

RISKS OF INFECTION RELATED TO EXPOSURE TO BLOOD

Risk management is one of the priority branches of health. It is part of a process of continuous improvement which should enable quality care to be provided for patients while protecting the nursing staff.
With the appearance of AIDS, many recommendations note the necessity to respect the rules of hygiene which enable the risks of staff contamination to be limited.

In 1985, universal measures and categories of isolation were defined to reinforce the precautions intended to protect the nursing staff from the risk of exposure to blood.
The universal precautions ( DGS / DH Circular No. 23 dated 3rd August 1989 ) intended to prevent the risks of exposure to blood acknowledge the universal character of the rules of hygiene to be applied for all patients, whatever their serological status, and at every invasive act.
The DGS / DH Circular No. 98/249 dated 20th April 1998 relating to the prevention of the transmission of infectious agents carried by the blood or biological liquids during care in health establishments updated the recommendations for the management of risk and the means of prevention. The universal precautions were extended to all biological products and subsequently designated standard precautions ( want to see them ? Word format ).
The decree dated 4th May 1994, relating to the protection of workers against risks which result from their exposure to biological agents, obliges the heads of establishments to provide workers with collective means of protection or, when exposure cannot be avoided by other means, individual measures of protection.

An accident involving exposure to blood ( AEB ) is defined as an accidental contact with blood or a biological liquid when the skin ( injections, cuts, damaged skin ) or a mucous membrane ( projection of liquid into the eye, etc. ) is broken.

The average of transmission after exposure to the blood of an infected patient is :

HIV : 0,3% HVC : 2 à 3%
HBV : 2 à 40%
The contamination figures collected in France from health staff after AEBs ( data for June 1998 ) are respectively :
HIV : 13 cases proved and 29 cases presumed ; HCV : 35 cases proved.

If there is an accident with exposure to blood, the following should be done

follow the recommendations of the DGS / DH / DRT / DSS circular No. 98/228 dated 9th April 1998 ( recommendations for setting up an anti-retroviral treatment after exposure to the risk of transmission of HIV ), and the DGS / DH / DRT circular No. 99/680 dated 8th December 1999 relating to the recommendations to be set up against a risk of transmission of HBV and HCV by blood and biological liquids.
make out a declaration of an accident at work to the employer and notify the accident to the employment medical service.
Extract from the " guide to safety equipment ", 1999-2000 edition

A very rare accident in the medical world

Contamination by the AIDS virus ( HIV ) of a patient by a member of the hospital staff is exceptional, as the virus survives for a very short time in the open air. It is much more rare than the transmission of hepatitis B or hepatitis C. Up to now, only two cases of transmission of HIV from a surgeon to a patient have been found in the world.

In France first of all, at Saint-Germain-en-Laye, in the Yvelines. Between 1983 and 1993, an orthopaedic surgeon who was a carrier of the virus had operated on 3,004 patients. A test was then carried out on 983 of them and only one person was found to be HIV positive. In the United States later, where a dentist in Florida who was a carrier of the virus probably transmitted HIV to six patients.

On the other hand the contamination of a member of the health staff by an infected patient is much more common, as an article in the " Bulletin épidémiologique annuel " ( Annual Epidemiological Bulletin ) notes in all 42 cases of HIV transmission, of which 13 confirmed and 29 presumed. At present, AIDS is mainly transmitted sexually and to a lesser extent by blood on condition that there is contact with a bleeding wound. An injection with soiled equipment may also be the source of contamination, while blood transfusions have become much more safe since 1985.

Extract from the article " Mieux Vivre " ( Live Better ) in Le Parisien dated 28th May 1999

- Circulaire DGS/VS/VS2-DH/EO1- n°17 du 19 avril 1995 relative à la lutte contre les infections nosocomiales dans les établissements de santé publics ou privés participants à l'exécution du service public.

5 à 10 % des malades hospitalisés acquièrent une infection nosocomiale.
Chaque année, 600 000 à 1 100 000 patients admis en court séjour développeront une infection.

environ 10 000 décès par an.

À cette réalité inacceptable pour les patients s'ajoute un coût financier de 2 à 5 % des journées d'hospitalisation en court séjour et plus d'un tiers du budget antibiotiques est dépensé pour le traitement.

- Pour la Cour de Cassation, et selon un arrêt du 13 février 2001, en matière d'infection nosocomiale, un médecin est tenu d'une obligation de sécurité de résultat notamment si cette infection est consécutive à un acte médical réalisé dans un établissement de santé ou dans le cabinet du praticien. Dans l'affaire jugée par la Cour de Cassation, l'arthrite septique dont souffrait le patient trouvait son origine dans l'arthrographie d'un genou pratiquée par son médecin.

- Comité Technique National des Infections Nosocomiales
Enquête nationale de prévalence des infections nosocomiales, mai-juin 1996. Rapport 1997.

22 % des malades en réanimation sont porteurs d'une infection nosocomiale.
Le taux de prévalence variant selon la spécialité, de 8 % (réanimation cardiologique) à 37 % (réanimation polyvalente).

- "Guide pour la Prévention des Infections Nosocomiales en Réanimation" Groupe Réanis - 1999

Les ILC augmentent significativement la mortalité et surtout la morbilité.Elles induisent un surcoût moyen de 50 000 F par épisode septicémique.

Dans les unités de soins intensifs, elles seraient à l'origine de 25 à 40 % des septicémies nosocomiales.

- HA Moss, TSJ Elliot, "The cost of infections related to Central Venous Catheter designed for long term use". British Journal of Medical Economics 1997 - n°11 - 1-7-

Le coût moyen d'une antibiothérapie est de l'ordre de 1000 €.

Une infection nosocomiale augmente le temps d'hospitalisation de 3 à 13 jours (soit un surcoût d'environ 1 700 €/jour dans un service général, et environ 2 000 €/jour en Réanimation).

- D.Pittet, D. Tarara, R.P. Wenzel : "Nosocomial bloodstream infections in critically ill patients" JAMA 1994 - 271 : 1598-608

Le surcoût lié aux ILC peut être supérieur à 30 000 € par patient survivant.