KATHMANDU: Seventy-one-year-old Bimala Manandhar from Kathmandu was admitted to Norvic Hospital in Kathmandu on June 6 after showing problems in addition to seizure, including issues with nerves and liver. After spending 26 days in Norvic Hospital’s intensive care unit (ICU), she was officially discharged. However, after returning home, her health worsened.

Bimala was taken to Bir Hospital on August 10. Three days later, she had to be placed on a ventilator. On August 29, another problem arose, which in medical terms is called Ventilator-Associated Pneumonia (VAP). VAP is considered deadly for patients and typically occurs 48 to 72 hours after placement on a ventilator.

According to doctors, this infection occurs when bacteria enter the patient’s lungs through the ventilator tube. This is a hospital-acquired infection. Such infections affect not only patients but also their attendants and hospital staff.

According to Bimala’s son, Dibesh, the doctors informed the family that his mother had VAP. “She already had other diseases, and now a new disease added to her condition, which increased our expenses. We do not know how many more days she will have to stay in the hospital,” he said.

According to Dibesh, Rs 1.4 million were spent at Norvic Hospital, and now at Bir Hospital, 15 thousand rupees are spent daily on medicine alone.

Eighty-year-old Thekar Prasad Pokharel from Siraha is also undergoing treatment at Bir Hospital since September 2 due to hospital-acquired infection. Pokharel, a tuberculosis patient brought from Mirchaiya Hospital for further treatment, had to be placed on a ventilator in the ICU on the day of admission, according to his relative, Toyaraj Pokhrel.

Seventy-five-year-old Khim Bahadur KC from Kathmandu, who had a stroke, paralysis, and Parkinson’s, also had to be placed on a ventilator the day he was admitted to the ICU. According to KC’s son-in-law, Deep Shrestha, he was brought from Vayodha Hospital to Bir Hospital on September 4, and doctors told them he also had VAP.

Not only patients, but a radiologist working at Bir Hospital has also been on a ventilator since August 29 due to hospital-acquired infection. He was admitted to the emergency unit when his health deteriorated while on duty. During treatment, it was discovered that he had a heart attack. Although his health improved somewhat, within 24 hours, a new problem appeared. A sputum test revealed pneumonia-causing bacteria. He too had VAP.

According to the World Health Organization (WHO), 20 to 30 percent of hospitalized patients experience hospital-acquired infections. According to Bir Hospital ICU statistics, 6 percent of patients treated there develop VAP.

According to ICU doctor Sunil Bhattarai, patients admitted to the ICU are usually seriously ill. They have often already received many doses of antibiotics, yet some bacteria still survive. Most patients admitted to the ICU at Bir are “referred” from other hospitals. “Bacteria come along with patients from different places. These bacteria accumulate in the ICU and spread infection. These bacteria are strong,” he says.

Seventy-five-year-old Khim Bahadur KC from Kathmandu, who had a stroke, paralysis, and Parkinson’s, also had to be placed on a ventilator the day he was admitted to the ICU. According to KC’s son-in-law, Deep Shrestha, he was brought from Vayodha Hospital to Bir Hospital on September 4, and doctors told them he also had VAP.

In the ICU at Bir, four out of ten patients have VAP.

According to Dr. Bhattarai, patients with this infection are treated with antibiotic doses for seven to fourteen days. If the patient’s condition is complex, the antibiotic dosage is increased or decreased. If there is no improvement, antibiotics must be administered for a long period.

According to critical care specialist Dr. Shubha Kalyan Shrestha of Bir Hospital, an antibiotic prescription audit system has been implemented to control hospital-acquired infections. He says that once an infection is confirmed in the hospital, patients are kept in a separate cabin in isolation for treatment.

Dr. Shrestha says patients are kept in separate cabins to prevent the infection from spreading to other ICU patients. “Although manpower is lacking, we are doing our best to control the infection.”

Before admission, all doctors, health workers, and cleaning staff in the hospital must have training on infection prevention and control (IPC). They should know measures to reduce infections. However, the lack of sufficient training, equipment, and manpower in hospitals adds to the challenge of infection control.

Lack of hospital precautions and the economic burden on patients: According to WHO protocols, health workers must wash their hands or sanitize immediately after touching a patient. Only then should they touch another patient. Masks and gloves must be worn at all times.

According to Dr. Sunil Bhattarai, WHO standards require one nurse to care for only one patient. However, at Bir, one nurse must care for four patients daily. This also leads to the spread of infection. Bacteria may also come from visitors who bring them from outside. “Visitors may carry bacteria from outside,” he says.

Because of hospital-acquired infections, patients’ families bear additional financial burdens. A study published in the journal published by National Library of Medicine in 2022 noted that in Nepali teaching hospitals, hospital-acquired infection and antimicrobial resistance increased treatment time by seven to nine days and increased patients’ financial burden.

The study reported that patients with hospital-acquired infections spent USD 164.63. Those affected by hospital-acquired infection and antimicrobial resistance spent USD 381.15.

Dr. Shrestha says patients are kept in separate cabins to prevent the infection from spreading to other ICU patients. “Although manpower is lacking, we are doing our best to control the infection.”

Typically, the price of a single antibiotic is Rs 1,500. The cost varies according to dosage. Patients with these infections often need 3–4 doses per day. Additional expenses include vaccines and other equipment.

According to Dr. Sunil Bhattarai’s experience, most patients with infections are unable to complete the full course of antibiotics. Families of poor patients sometimes take the patient home before the course ends because they cannot afford the treatment, increasing the risk of death.

Lack of data

A study by the National Health Research Council identifies hospital-acquired infection as a major factor increasing mortality and treatment costs in Nepal. However, the number of deaths caused by hospital-acquired infection has not been made public.

According to WHO and the Centers for Disease Control and Prevention (CDC), globally 15 to 25 percent of all deaths are caused by infection. According to the Antimicrobial Resistance and Infection Committee, the mortality rate among ICU patients with infection is 30 to 48 percent.

A study of patients at Dhulikhel Hospital from December 2017 to April 2018 showed 4.5 percent with “poor outcomes.” The study noted that patients with hospital-acquired infection had five times higher mortality or poor outcomes than uninfected patients. Surviving patients’ hospital stays were prolonged, and costs and organ damage increased.

Hospital-acquired infections spread due to poor hospital environment, inappropriate treatment practices, unnecessary antibiotic use, narrow buildings, and physical structures. Infections spread via respiration, contact with patient skin, thermometers, doors, taps, wheelchairs, catheters, cannulas, endotracheal tubes, masks, ventilator pipes, and other equipment.

Only two percent infection!

According to monitoring by the Department of Health Services last year, hospital-acquired infection rates in major hospitals in the Kathmandu Valley were only two percent. The low rate is suspected to be due to excessive use of antibiotics.

Hospital-acquired infections spread due to poor hospital environment, inappropriate treatment practices, unnecessary antibiotic use, narrow buildings, and physical structures.

According to WHO, in developed countries, seven out of one hundred hospitalized patients and in developing countries, ten out of one hundred patients acquire hospital-acquired infections. A study conducted across 55 hospitals in 14 countries reported an 8.7 percent infection rate. Among them, infection rates were higher in Southeast Asian countries. According to WHO, the infection rate in Nepal is 11 percent.

Although the Ministry of Health and Population implemented the National Guideline on Infection Prevention and Control (IPC) in 2022, monitoring in many health institutions has not been carried out. Hira Niraula, head of the Nursing and Social Security Division of the Department of Health Services and member-secretary of the Infection Prevention and Control Directorate Committee, says that most hospitals and health institutions in the country still do not meet minimum standards.

Official data on hospital-acquired infections in Nepalese hospitals are not systematically maintained. According to the directives, hospitals are classified into basic, medium, and specialized categories. However, this system is not effective in small or local-level health institutions. According to committee member-secretary Niraula, infection control committees in many hospitals exist only in name. The absence of monitoring and reporting systems makes it difficult to know the actual situation of hospital-acquired infections.

Extreme misuse of antibiotics

In Nepal, antibiotics are easily available, so both patients and health workers tend to overuse them. This not only hides infections but also increases the problem of drug-resistant bacteria.

A study conducted jointly by 17 hospitals in Nepal and Japanese institutions from 2011 to 2013 highlighted antibiotic resistance as a major problem. It stated that antibiotic resistance hides hospital-acquired infections and complicates treatment.

Bala Rai, senior nursing officer of the Department of Health Services’ Nursing Capacity Development Section, says that although infection rates have decreased in many hospitals in Nepal, this should be questioned. “Some hospitals do not have an antibiotic prescription audit. If antibiotics are given immediately, infections may not appear, so even if the data shows a decline, the reality may be different,” she says.

She adds that controlling hospital-acquired infections in Nepalese hospitals remains a challenge.

According to the department’s study, the main infections observed in Nepalese hospitals are surgical site infection, ventilator-associated pneumonia, and urinary tract infection. The World Health Organization says that with effective measures, these infections can be reduced by up to 70 percent.

Because of excessive antibiotic use in Nepal, their effectiveness has decreased, and bacteria have become more resistant. This makes treatment difficult and adds challenges to infection control.

Hospital-acquired infections in high-level hospitals

The Department of Health Services classifies hospitals into high-level, medium, basic, and substandard categories based on services provided. High-level hospitals include Gangalal, Tribhuvan Teaching Hospital, National Trauma Center, and Maternity Hospitals. However, even in these hospitals, improvement in manpower and monitoring systems is needed, according to Hira Niraula.

Monitoring at Gangalal Hospital showed that 12 percent of patients developed surgical site infection within 30 days after surgery. At the National Trauma Center, seven percent of patients developed bloodborne infections.

Dr. Pranishsundar Shrestha, head of the hospital-acquired infection control committee at Tribhuvan Teaching Hospital, says that old buildings lack infection-free structures, increasing the risk. A 100-bed hospital should have at least one infection control officer, but most hospitals do not have this position. “At Tribhuvan Teaching Hospital, we manage with existing manpower,” he says.

Lack of regular monitoring and regulation by the health ministry and department adds to the challenge. Hospitals also lack systems for collecting and analyzing data on hospital-acquired infections.

Lessons not learned

Before the COVID-19 pandemic, Nepali hospitals did not give sufficient attention to infection control. According to Dr. Gopal Sedhain, spokesperson for Tribhuvan Teaching Hospital, COVID-19 taught hospitals important lessons about infrastructure, equipment, and policy requirements. However, many hospitals in Nepal still lack manpower and resources. ICUs and sensitive areas are being separated, “but there is still a shortage of manpower and resources,” says Dr. Sedhain.

According to WHO standards, the rate of infections should decrease every year. However, many hospitals have not been able to reduce infection rates.

According to monitoring by Tribhuvan Teaching Hospital, over three years, patients admitted to the hospital had 13 percent pneumonia, 6.4 percent urinary tract infections, 6 percent bloodstream infections, and 4 percent surgical site infections.

According to WHO standards, at least 50 percent of observed infections should improve. “We have not been able to achieve more than 60 percent improvement,” says Dr. Shrestha. Although many hospitals have infection control committees, regular meetings are often not held.

According to Dr. Gopal Sedhain, spokesperson for Tribhuvan Teaching Hospital, COVID-19 taught hospitals important lessons about infrastructure, equipment, and policy requirements. However, many hospitals in Nepal still lack manpower and resources. ICUs and sensitive areas are being separated, “but there is still a shortage of manpower and resources,” says Dr. Sedhain.

A study conducted from 2011 to 2013 in 17 hospitals in Kathmandu and Japanese health institutions found that nine hospitals did not have an infection control directive. Most directives were outdated. Only seven hospitals had established control directives. Many hospitals lacked adequate infection control equipment.

Public health expert Dr. Mahesh Maskey says hospitals need to ensure infection prevention and control (IPC) standards during hospital construction, implement mandatory antibiotic prescription audits, improve monitoring and data management, provide regular training and awareness on infection prevention, and monitor private hospitals regularly.

Infectious disease specialist Dr. Anup Subedi also emphasizes that hospitals require policy-level reforms to become infection-free. “Active infection control committees, regular evaluation, and strict policy implementation are necessary to make hospitals infection-free,” he says.

In India, mandatory reporting systems for hospital-acquired infections have been implemented. Experts recommend that Nepal also implement mandatory data collection and public reporting.

After the federal structure, health services in Nepal are the responsibility of local governments. However, many local levels do not prioritize infection control in hospitals. Public health expert Dr. Sharad Onta says, “Local governments could play a major role in infection control. But clear policies are lacking. Policy reforms are necessary.”