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:
1. Prof.PhD. Nguyen Van Kinh
2. 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

to reduce the risk of HNI.
1. Objectives of the study:
1. Describe the current situation and factors related to HNI caused
by Acinetobacter baumannii at the Emergency Department, Central
Hospital of Tropical Diseases, 2011.
2. Evaluation of results of application of some measures and
techniques to improve HNI control activities at the Central Hospital
for Tropical Diseases.
2. 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.


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3. Thesis layout: The thesis consists of 137 pages, including sections
and 4 chapters:
Problem: 02 pages
Chapter 1. Document overview: 34 pages
Chapter 2. Subjects and research methods: 20 pages
Chapter 3. Research results: 42 pages
Chapter 4. Discussion: 36 pages

hand washing is the cheapest and most effective measure to prevent


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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 2
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:

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


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the main disease and affects the current medical condition at many

+ 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:


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1) There are 2 of the following 4 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

Data are statistically processed by SPSS 22.0 software.
CHAPTER 3
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)

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.


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A.baumannii
Yes
No
HNI Time for
Resuscitation
10,2 ± 3,5 4,6 ± 1,6 5,6 (3,5 – 10,7)


47
8.10
5
4.90
0.075
Invasive interventions were associated with HNI, including:
gastric catheterization, intubation-mechanical ventilation, central
venous catheterization, venous disclosure, arterial catheterization and
put arterial catheter.
Table 3.7. Compare the index of instrument use between 2 groups
with and without HNI by type of intervention

Intervention
Gastric
catheterization
Intubation
Put the central
venous catheter
venous disclosure
Put arterial catheter
Put urine catheter
Pleural drainage

Not HNI by
A.baumannii
(n = 580)
Time set Index
(n = 2843) SDDC

HNI by

0
15
350
115

0.005
0.123
0.04

212
171
299
103

0.055
0.044
0.091
0.027

P
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.004


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index to use the tool. The length of time to place the device increases
the index of instrument use and increases the risk of HNI. Time and
index of instrument use of endotracheal procedure, central venous
catheterization and catheterization were markedly different between
the group with HNI and no HNI by A.baumannii.


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Chart 3.4. Correlation between the number of HNI by
A.baumannii and the number of days treated at the Emergency
Department
The number of HNI increased gradually in patients treated after 5
days. The number of HNI is highest in patients with 10-15 days of
treatment. The number of HNI decreased gradually in the treatment
group after 15 days. Thus, the group of patients hospitalized for 10-15
days has the highest risk of HNI by A.baumannii.
Table 3.8. Relationship between some risk factors with hospital
pneumonia by A.baumannii
Hospital pneumonia
by A.baumannii
Research
OR
Total
p
information
(95% CI)
Yes
No
(n = 46) (n = 636)

catheterizatio
n
Sedative
Muscle
relaxants

(44.7)
198
(29.0)
107
(15.7)

(0.8 – 1.7)
1.3
(0.9 – 1.9)
1.4
26(24.30) 81 (75.70)
(0.8 – 2.2)
25(12.63) 173 (87.37)

0.244
0.234

For multivariate analysis, the risk factors for hospital pneumonia
were intubation with OR: 3.0 (2.5 - 3.6), intubation time with OR: 3.9
(3.1 - 5.1). Using sedative, H2 receptor inhibition, muscle relaxation
and gastric catheterization are not risk factors in multivariate analysis
(p> 0.05).



0.104
(0.9 – 3.5)
lines ≥ 3
Feeding by
75 (11.0) 25 (33.33) 50 (66.67)
0.001
intravenous
Blood
1.0
155 (22.7) 17 (10.97) 138 (89.03)
1.00
transfusion
(0.6 – 1.8)
By multivariate analysis showed that the risk factors for sepsis
were: Place the central venous catheter with OR: 2,3 (1,9 - 2,8); The
venous catheter is centered over 3 days with OR: 2,3 (1,9 - 2,8).
Table 3.10. Single analysis of risk factors for urinary tract infections
by A.baumannii
Urinary tract infections
by A.baumannii
Research
OR
p
information
(95% CI)
Yes
No
n = 6 (%) n = 676 (%)
1.08
Put urine catheter

7.2
22 (16.54) 111 (83.46)
0.001
venous catheter
(4.2 – 12.4)
Intravenous infusion
0.9
21 (30.0) 49 (70.0)
0.692
≥2
(0.5 – 1.5)
Use vasomotor
0.8
13 (7.8) 153 (92.17)
0.540
medicine
(0.4 – 1.5)
Risk factors for vascular infection are: Place the central venous
catheter with OR: 7.2 (4.2 - 12.4). The number of intravenous lines
and the use of vasomotor drugs is not a risk factor for infection due to
vasculature.
3.2. Results of applying some measures and techniques to improve
HNI control activities at the Central Hospital for Tropical Diseases
3.2.1. Results of building HNI control model
Intervention to establish an infection control system consists of
three levels: the control committee for infection of infection and
infection control network in each department.
Infection Control Council
The council consists of the CHNIrman, 01 Vice CHNIrman, 01
permanent member and members. CHNIrman of the Infection Control

aspects
* Effective for hand hygiene
Table 3.12. Effective intervention for hand hygiene conditions
Maximum
PreScore after
interventio
Evaluation criteria
point
∆
intervention
n points
(WHO)
The infrastructure

100

35

95

60

Training

100

35

100


25

∆: Points difference before - after intervention.
Assessment of infrastructure for hand hygiene: Increase 60 points
after intervention. The hospital has a separate budget for hand
hygiene, plans to improve the infrastructure for hand hygiene, fully
equipped with hand sanitizing solutions in departments and rooms.
Training on hand hygiene: Increased by 65 points after
intervention. The hospital has built a training system and has teaching


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staff on hand hygiene; Strengthen training, hand hygiene training and
regulations on hand hygiene training for medical staff.
Monitoring of hand hygiene compliance: Increasing 42.5 points
after intervention. The hospital has strengthened most of the activities
of supervising hand hygiene in departments and rooms and informed
hand hygiene status to all employees in the hospital..
Hand hygiene communication activities: Increase 20 points
compared to before intervention. The hospital has strengthened
posters to guide the use of hand sanitizing solutions at departments
and rooms.
Degree of improvement of safe environment on hand hygiene:
Increased by 35 points compared to before intervention. The hospital
has established an official program for patients to participate in hand
hygiene programs and has organized monitoring and evaluation of
personal responsibility in implementing hand hygiene at departments.
Table 3.13. Knowledge of research subjects, on hand hygiene, before after intervention
Before
After

Overall assessment of hand hygiene knowledge of the subjects
showed that the proportion of subjects with knowledge gained after
the intervention increased from 31.7% to 86.1%. Performance index
171.6%. The difference is statistically significant with p

After
intervention

∆

Means and chemicals for
hygiene and surface
100
55
100
45
disinfection
Training and guidance on
surface disinfection at
100
50
90
40
hospitals
Frequency of disinfection
by surface position,
100
55
85
30
according to the time of
day at the hospital
After the intervention, the hospital has facilities, chemicals for
disinfection hygiene and personal protective equipment. Score

index (%)
n
%
n
%
Achieved
130
50,2
224
86,5

136

9,4
5,5

52,5
50,1

63

9,2

124

5,0

45,9

16
14
299

2,3
2,1
43,8

32
30
555


HNI was 14.48%. Ha Manh Tuan's study at the Emergency
Department, Children's Hospital in 2006 was 24.4%. Like some other
research results, the incidence of HNI in the Emergency Department
is higher than that of other departments.
Regarding the position of HNI, the rate of pneumonia accounts for
the highest rate (45.10%), followed by septicemia (25.49%), infection
of blood vessels (21.57%) and the lowest is urinary tract infections
(5.88%). This result is consistent with the research results of Huynh
Van Hue (hospital pneumonia 49.33%) and Ha Manh Tuan (hospital
pneumonia accounts for 49.3%).
The cause of the rate of HNI in the Department of Emergency
Medicine, Central Hospital of Tropical Diseases is higher than that of
other domestic research results, possibly due to one of the following
reasons: High patient density At the Emergency Department of the
Central Hospital of Tropical Diseases currently 5m2 / 1 patient,
compared with the standard of infection of 7.4 - 9m2 / patient; The
ratio of nursing to patients at the time of the survey was 1/4 lower
than the standard of 1/1 of the Emergency Department. The lack of
nursing makes compliance with HNI control measures inadequate.
From the above analysis to reduce the risk of HNI in the Emergency
Department in addition to implementing routine HNI prevention
measures, attention should be paid to: Reducing patient density and
strengthening direct care nursing patients.


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4.1.2. Factors related to HNI by Acinetobacter baumannii at the
Emergency Department, Central Hospital of Tropical Diseases
Results of analysis of each type of HNI by A. baumannii: The risk
factor for hospital pneumonia is intubation, prolonged intubation

prevention; Procedures for prevention of primary HNI; Procedures for
prevention of skin and soft tissue infections; Regulating architecture,
organization and environmental standards in clinical departments;
Hospital hygiene process; Hospital solid waste management process
The study results showed that, both before and after the
intervention, the health workers adhere to good hand hygiene at the
time before touching the patient. This can be said that health workers
are conscious of protecting patients from the risks of HNI. After the
intervention, hand hygiene rate increased in all target groups. The
preventive value is highest in the nurse group, reaching 86.3%,
followed by the nursing group 53.4% and the lowest being the doctor
49.7%.
This result shows that the implementation of the training program
at the Central Hospital of Tropical Diseases is effective. The program
contributes to improving the infection control capacity of medical
staff. For other infectious disease hospitals, this training program can
be used to strengthen HNI control capabilities for medical staff.


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CONCLUSION
1. Situation, factors related to HNI caused by A.baumannii at the
Emergency Department, Central Hospital of Tropical Diseases, 2011
1.1. Situation and factors related to HNI caused by A.baumannii at
the Emergency Department
The rate of HNI in the Emergency Department is 43.8%. In
particular, infection caused by A.baumannii is the highest (34.1%).
Hospital pneumonia by A.baumannii accounted for the highest
proportion (45.10%), septicemia (25.49%), infection of vascular
catheter placement (21.57%), urinary tract infection (5.88% ). The