Intestinal Healthcare-Associated Infections

Brief summary: This article examines the dependence of the occurrence of the intestinal HAIs on the type of the medical facility, age, seasonality, type of pathogen, mechanisms and ways of spreading of the causative agents of HAIs, immunity, compliance with the sanitary-hygienic and antiepidemic regimes in a medical facility.

Gastroenterology is a young science, which appeared only at the beginning of the 19th century and, as a medical specialty, developed at the end of the 19th century. Gastroenterology (from Ancient Greek γαστήρ, γαστρός – stomach, Ancient Greek ἔντερον – intestines, Ancient Greek λόγος – teaching) is a science, which studies the gastrointestinal tract (GIT) of a person, its structure, functions and is engaged in prevention, diagnosis and treatment of the diseases of the digestive system. The founder of gastroenterology, a great French physiologist, Claude Bernard, whose studies showed an important role of the salivary glands, gastric and intestinal juices, pancreas in the process of digestion and assimilation of food, won two prestigious awards for his outstanding achievements in the field of physiology – Baly Medal (1875) – awarded once in two years (biennale) by the Royal College of Physicians of London and Copley Medal (1876) – the oldest scientific award of the Royal Society of London. William Beaumont – an American gastroenterologist proved the chemical nature of digestion. The William Beaumont Prize in Gastroenterology has been awarded annually since 2015 by the American Gastroenterology Association for the significant researches in the field of gastroenterology. Such outstanding German and Austrian scientists, whose number of discoveries, inventions, awards and prizes can hardly be listed, as Theodor Billroth – a founder of modern abdominal surgery, Theodor Kocher – one of the founders of the European scientific surgery and Anton Eiselsberg – one of the best students of Billroth, made a huge contribution to the development of gastroenterology. Thanks to the following discoveries and inventions: a) gastroscopy (1868); b) the method of gastric intubation (1869, A. Kussmaul – German therapist); c) x-rays (1895, Wilhelm Röntgen – German physicist, Nobel Prize laureate in 1901); d) probes for aspiration of gastric juice – Einhorn duodenal tube (1910, Max Einhorn American gastroenterologist); e) flexible fibrogastroscope (1958, B.I. Hirschowitz – American gastroenterologist with co-authors Curtiss and Peters); f) computed tomography (1979, Sir Godfrey Hounsfield – British electrical engineer and Allan CormackAmerican physicist Nobel Prize laureate); g) magnetic resonance imaging method (2003, Sir Peter Mansfield – British physicist and Paul Lauterbur – American chemist Nobel Prize laureate), there have been left practically no “blind spots” on the “map” of gastroenterology.

In 1958, there was created an international non-governmental professional medical federation, the World Gastroenterology Organization (WGO), which united 110 national and regional associations of gastroenterologists, having more than 60,000 members. The goal of WGO was to increase the level of education in the field of gastroenterology worldwide, to develop effective methods for the prevention and treatment of the disorders and diseases of the digestive system. In 1992, the United European Gastroenterology (UEG) was founded – a nonprofit organization, which brought together 17 ordinary member societies and 49 national societies; has supported the digestive health research community, has developed the prevention; has improved the methods of treatment of the digestive diseases in Europe; and has provided the first-class education. May 29 marks the World Digestive Health Day, established at the initiative of the World Gastroenterology Organization with the aim of drawing attention of the society to the problems of the indigestion in humans and to find effective methods of prevention. Antimicrobial drug resistance (AMR) has been a worldwide problem for the past two decades.

In 2021, the Ireland’s Second One Health National Action Plan on Antimicrobial Resistance 20212025 was published, presenting 5 strategic goals:

1) Improve awareness and knowledge of the AMR;

2) Enhance surveillance of the antibiotic resistance and antibiotic use;

3) Reduce the spread of infection and disease;

4) Optimize the Use of Antibiotics in Human and Animal Health;

5) Promote research and sustainable investment in new medicines, diagnostic tools, vaccines and other interventions. The digestive system is one of the largest systems in human body, responsible for the digestion, assimilation of food and excretion of processed food. It performs the following functions:

1) hormonalproduces the hormones: secretin, serotonin, histamine, gastrin, etc. (Ernest Starling – an outstanding English physiologist introduced the term “hormone” into medicine and discovered the hormone secretin in 1905);

2) protective – about 80% of the cells of the immune system are in the intestine, therefore, a healthy intestine is a guarantee of immunity, which means a guarantee of a good health in general; syndrome, skin diseases and more. All these processes occur for various reasons: malnutrition, stress, lack of physical activity, uncontrolled use of antibiotics, disruption of the immune, nervous, endocrine systems, etc. The intestine (called the “second brain”) controls the health of the human body as a whole and, also, affects the behavior, the mood and the quality of human life. However, the problems with the gastrointestinal tract can also be associated with the pathogens of infectious diseases – bacteria, viruses, fungi, parasites. In terms of morbidity and mortality, the acute intestinal infections are ranked 2nd in the world after the acute respiratory viral infections.

The greatest problem the acute intestinal infections create particularly in the context of medical facilities, contributing to the emergence and the development of the infections, associated with the provision of medical care (HAIs). HAI is “any clinically recognizable infectious disease, which occurs in patients as a result of their medical hospitalization, when seeking medical care, or in employees of a medical facility as a result of their work at such facility, regardless of the time of the onset of the symptoms of the disease” (WHO) . The share of the acute intestinal infections in the total number of the HAIs is 8-15%. HAIs affect the rates of morbidity, mortality, the quality of human life (moral damage), cause significant harm to the health of medical staff and, moreover, create economic problems in the healthcare systems of all countries of the world. Getting into a medical facility for treatment, surgery, childbirth; coming to an appointment or consultation with a family doctor; undergoing various endoscopic examinations and more, an individual must be protected from a possible infection with HAIs. Unfortunately, absolutely any person who got into a medical facility risks of getting infected with HAIs; however, the highrisk groups, such as premature, newborn babies; children under age 3; elderly people; people with chronic diseases, who regularly undergo various medical examinations or have tests; patients with inflammatory bowel disease; pregnant women; immunocompromised people, are more susceptible to it. As a rule, the infection with HAIs occurs in patients, who have already been treated in hospitals of various profiles: surgical, neurological, psychiatric, maternity hospitals, etc. This increases the number of days spent at a medical facility, thus, the likelihood of more death cases. Many pathogens are already present in the body of a patient or a medical staff (carriage) and, therefore, the cross-infection from patient to patient or from patient to medical staff is also possible. Furthermore, the environment of a medical facility – air, surfaces, equipment, apparatus; underwear, patient care items, can serve as infection transmission factors. A large number of premises: wards, corridors, waiting rooms in medical facilities also contribute to the spread of infections. The causative agents of hospital strains, especially the intestinal ones, are resistant to antibiotics, disinfectants, therefore, very difficult to eliminate.

The causative agents of intestinal HAIs are numerousEnterococcus, Escherichia coli, Enterobacter spp., Salmonella and others, but the most common and recognized pathogens of the intestinal HAIs are Clostridioides (Clostridium) difficile, rotavirus and norovirus. C. difficile – a spore-forming, toxigenic bacterium, which lives in the large intestine of humans and animals and can remain in the environment in a form of spores for a long time (soil, water, etc.). In medical facilities, the endoscopic devices – fibrogastroscope, duodenoscope, etc.; surfaces – equipment, furniture, etc., as well as hands of medical personnel can be contaminated with it. The pathogen was first described in 1935, but only in 1975 an American infectious disease scientist, John Gill Bartlett, discovered the Clostridioides difficile infection as the main cause of the nosocomial infections. In recent years, C. difficile accounts for 60% of all cases of diarrhea, associated with HAIs. C. difficile can cause outbreaks of nosocomial infections in intensive care units (ICU), hematology, oncology, surgery, maternity hospitals, etc. Infection is also possible in nursing homes, hospices, or on an outpatient basis (the risk of infection for the outpatients is less, than for the hospitalized). The main mechanism of transmission of C. difficile spores from person to person is fecal-oral – through the hands of personnel, contaminated food, drugs (especially in liquid dosage forms), etc. The main risk factors are a) uncontrolled, irrational use of antibiotics (they increase the risk of infection by 8 times, destroy a normal microflora of the large intestine, which ensures the colonization of the opportunistic and pathogenic microflora); b) hospitalization, c) surgical interventions on the gastrointestinal tract; d) various endoscopic studies; e) use of probes – nasogastric, gastric, duodenal, cleansing enemas. The toxins A and B of C. difficile cause diarrhea and inflammatory processes in the intestines in humans – pseudomembranous colitis (PMC), which is also called “nosocomial colitis”, “antibiotic-associated colitis” or “C. difficile-associated colitis”. PMC can be complicated by the toxic megacolon – a significant expansion of the lumen of the colon, leading to a sharp deterioration of the patient’s condition, intestinal perforation, sepsis, possibly death. About 5% of C. difficile strains also have a binary toxin, which increases the virulence and aggravates the course of the disease. For the past two decades, C. difficile has been the leading cause of the infectious hospital-acquired diarrhea and adult death in the United States, Canada, and Europe; for the most part, in developing countries. In Ireland, since January 2012, the new and recurrent infections have been reported as “C. difficile infection”. According to the Q2 2022 National Report Enhanced Surveillance of Clostridioides (Clostridium) difficile Infection in Ireland, 207 cases were recognized as nosocomial cases, 187 of which were new. Prevention of C. difficile is aimed primarily at a proper hand hygiene – washing hands with soap and water is more preferable than using antiseptics, observing personal hygiene rules, observing sanitary-hygienic and anti-epidemic regimes in medical institution, a rational use of antibiotics, minimum length of stay at a medical facility.

Along with C. difficile, the enteric viruses, such as rotavirus and norovirus, are one of the main etiological causes of nosocomial infections. In 1973, Ruth Bishop, an outstanding Australian virologist, a winner of many prestigious awards, prizes and a holder of the Order of Australia (2019), professor, together with a group of researchers discovered rotavirus. Thanks to the structure similar to a wheel, the virus received a name “rota” – from Latin “wheel”. The WHO approved the term “rotavirus” in 1979.

In the late 1990s, Ruth Bishop created the first oral rotavirus vaccine, which could be injected immediately after birth to prevent infection in the maternity hospital. The vaccine was included into the 2007 Australian vaccination calendar and then into the vaccination calendars of more than 110 countries around the world. Ruth Bishop’s rotavirus discovery and the creation of the vaccine helped save hundreds of thousands of children’s lives. Currently, RotaTeq® and Rotarix® are two licensed oral vaccines in use worldwide. WHO recommends the inclusion of rotavirus vaccine for infants to all national immunization programs and strongly recommends vaccination in countries with a high mortality rate from diarrhea, which is the second leading cause of death from infections in children under 5 in the world. Rotavirus vaccines are already included in the vaccination schedules of 114 countries around the world, including Ireland. In Ukraine, the rotavirus vaccine is not included into the vaccination calendar, it is advisory and can be obtained from private medical facilities. Also, WHO has developed the “Immunization Action Agenda (IA 2030) Programme – A Global Strategy to Leave No One Behind”, communicating the benefits and a need for vaccines.

Rotavirus belongs to the Reoviridae family and infects the mucosa of the small intestine. The disease proceeds, according to the type of gastroenteritis (diarrhea, vomiting), with a possible development of dehydration syndrome, which can lead to death. Rotavirus is one of the most common and contagious intestinal viruses in the world. The disease is more often recorded in premature infants, newborns and children under 3, as well as in children who are bottle-fed. In the structure of nosocomial viral intestinal infections, Rotavirus ranks first (70% and above). It is very stable in the environment, can remain for a long time on objects, equipment, apparatus in medical institutions; virus carriers are common among medical personnel (>20% – WHO data); dirty hands play a key role. Hospital rotavirus infections often occur in maternity hospitals, wards and departments for premature babies, departments of early childhood. In winter, the incidence of rotavirus gastroenteritis increases, which coincides with the rise in the incidence of the acute respiratory viral infections and may contribute to the emergence of nosocomial outbreaks of rotavirus infection due to the greater number of children in hospitals. The source of infection are patients with rotavirus gastroenteritis, virus carriers, medical staff. The mechanism of transmission is fecal-oral. Prevention is aimed at hand hygiene, compliance with the sanitary-hygienic and antiepidemic regime in the health care facilities – a thorough disinfection and sterilization of instruments and equipment, especially incubators (an apparatus for the temporary stay of premature or sick newborns to maintain their vitality).

Noroviruses are number two after rotaviruses, among the acute intestinal infections (about 1 billion cases in the world annually) and in countries where mass vaccination against rotavirus infection is carried out – number one. In 1968, American researchers discovered an unknown virus in schoolchildren in Norfolk (USA). Only 4 years later, in 1972, the virus was seen with an electron microscope and was named Norwalk virus in honor of the city it was first discovered in. In 2002, the International Committee on Taxonomy of Viruses approved the name Norovirus. Noroviruses are highly contagious, especially when circulating indoors – in healthcare facilities, early childhood health centers, hospices, nursing homes, child care facilities, etc. The share of nosocomial noroviruses varies from 50% to 65%. Noroviruses are very contagious, remain in the environment for a long time (premises of medical facilities – wards, doctors’ offices, etc.), and are resistant to disinfectants and antiseptics. They affect all age groups, especially children, elderly people and people with weakened immune systemsafter surgery, transplantology, with oncopathology and others. Hospital outbreaks of norovirus infection occur more often in the winter season (called “winter vomiting”), when the number of diseases and outbreaks increases among population. The bringing of norovirus is carried out exogenously – by patients, medical staff, visitors who are in the incubation period or by virus carriers. The infection is transmitted by the fecal-oral mechanism through contaminated food, water, surfaces, fomites (appliances, furniture, utensils, door handles, etc.) and then spreads within the medical facility. It proceeds in a form of gastroenteritis, accompanied by vomiting, diarrhea. The department or a hospital may be closed for quarantine due to the occurrence of a large-scale outbreak of norovirus infection for an indefinite period of time until a complete elimination of all cases of the disease. The admission of new patients and visitors during this period is prohibited. Infected catering staff and food distributors in medical facilities are suspended from work. Prevention is based on washing hands with soap and water for 30 seconds, as well as on the disinfection of rooms, objects, etc. in medical facilities. A norovirus vaccine has not yet been developed. A group of American researchers, led by Professor Nihal Altan-Bonnet of the US National Institute of Health, made a groundbreaking discovery that enteric viruses, such as norovirus and rotavirus, replicate in the salivary glands and can be transmitted through saliva (Ghosh et al., Nature 2022). Scientists suggest that the airborne route of transmission (the most contagious) of intestinal viruses – by coughing, talking, kissing, sharing utensils or food, may contribute to a greater spread of these viruses. The results of the study will help develop more effective methods for the prevention, diagnosis and treatment of the diseases caused by the intestinal rotaand noroviruses.

In May 2022, WHO published the first-ever global report on infection prevention and control – a set of scientific and practical measures aimed at protecting the health of patients, medical workers and visitors to medical facilities from preventable infections, including those, resistant to antimicrobials during the provision of medical care. According to the report, every 7th patient out of 100 in high-income countries, every 15th in low- and middle-income countries contracts at least one HAI, and one in 10 dies. When infected with HAIs, which are resistant to antimicrobials, mortality increases two to three times. The correct organization of the infection prevention and control can reduce the number of HAIs by 70%, following the rules of the hand hygiene and other prevention methods. The key to safety of patients and staff is clean hands. By the decision of the UN General Assembly, together with the WHO, the Global Handwashing Day was established on May 5, 2008. Its motto: “Clean hands save lives!”. Hands are a major factor in the transmission of infectious agents, especially in the healthcare settings. Awareness of the population about the need to wash hands will help maintain health.

Over the past decades, several organizations have been created around the world to support patients, such as the International Alliance of Patients’ Organization (IAPO 1999), the World Patient Advocacy Alliance (October 27, 2004) and the World Patiens Alliance – a new International Coalition (September 25, 2020), which all protect the interests of patients in all countries of the world. Patients’ safety is one of the main indicators of the quality of the healthcare services worldwide, therefore, the 72nd World Health Assembly has declared September 17 as the World Patient Safety Day since 2019. Ukraine supported this decision by the Decree of the President of Ukraine of September 4, 2019. The theme of the World Patient Safety Day in 2022 was “A safe use of drugs” and its slogan – “Drugs without harm”. In October 2022, the 1st World Patient Conference, “New Normal, New Challenges for Patients”, took place in Rome.

The digestive system plays a huge role in human life. A healthy intestine protects the body from the occurrence of infectious diseases, namely, from the pathogens of intestinal infections, in particular, from HAIs; which are a serious problem in medical facilities of various profiles in all countries of the world. Optimization of the epidemiological surveillance system of HAIs caused by the intestinal pathogens: C. difficile, rotaviruses and noroviruses in medical facilities; proper organization of infection prevention and control: compliance with the sanitaryhygienic and anti-epidemic regimes – a competent use of disinfectants, taking into account the type of pathogen, especially in seasonal periods of the rising incidence; hand hygiene; rational use of antibiotics; reduction of hospital stays; isolation and quarantine measures will significantly reduce the risks of the occurrence and the spread of the intestinal HAIs, the incidence and mortality in healthcare facilities from HAIs.

Written by Tatiana Iarmak –http://orcid.org/0000-0001-53712958. Lecturer of the Department of Advanced Training of Junior Medical Specialists at the Municipal Health Care Institution ‘Kharkiv Regional Medical Vocational College’, Kharkiv, Ukraine. An independent trainer, consultant to medical facilities and non-medical facilities to instruct medical staff on how to safely provide services to patients/clients.

Key words: Gastroenterology, gastrointestinal tract, intestines, digestive system, intestinal infections, risk factors; healthcare-associated infections, hospital-acquired infections, nosocomial infections, outbreaks, viruses, enteric viruses, Clostridium difficile, C. difficile, rotaviruses, noroviruses, antibiotics, epidemiological surveillance, infection control, immunity, vaccines, prevention.