[Nosocomial infectious: the realities of an endless fight].

Nosocomial infections (N.I.), contracted while patients are being cured, are the direct price of lightning progress in medicine in the course of the last fifty years. Absolute paradox of the end of century, the very place, where the most famous surgical and medical events are achieved, is also the same scene where a patient may contract infections that sometimes lead to a fatal outcome. With 10000 deaths per year and millions of additional hospitalization days, NI have become a real Public Health problem. They reach especially patients but also the staff, and they can be found everywhere a treatment is given (hospital, clinic, patient's home). Paradoxically, the first great myth of anti-NI struggle is the discovery of antibiotics, one of the hugest advancements for humanity. An excessive antibiotherapy prescription, added to a laxism in basic hygiene actions (individual or collective) increased for the last thirty years this phenomenon, which has now become so extensive that international and national authorities are managing this problem. The fight versus NI is an endless struggle because treatments will always exist. The rising emergence of antibiotics bacterial multiresistance has promoted this whole subject called Hospital Hygiene, a discipline which, little by little, regains a dominating place in our Health establishments. Bacteria are liable for 85% of NI, while virus and fungi are responsible for 15%. Omnipresent on a milliards scale, ubiquitous, the bacterial species will be thwarted only if the staff, who is taking care of patients, shows a constant vigilance. Immunosuppressive pathologies, age and nutritional conditions of the patient, new invasive diagnosis or assistance methods, antibiotics selection pressure, and at least a mismanagement of individual Hygiene and/or of the premises, are the main conditions leading to the outbreak of NI. The NI occurs basically within an early period of ten days after the patient's care. Catheter urinary infections, broncho-pneumonic infections with ventilation assistance, post-operative wounds and catheter bacteremia are the main nosocomial pathologies found in France, and in other european countries or in the United States. Staphylococci, Enterococci, Enterobacteria and Pseudomonas are the leaders of responsible bacteria but any kind of bacterium, can generate a NI, due to associated risk factors. Committees against nosocomial infections (Clin) have been organized in France in every public health establishment in 1988, then in every private health establishment in 1999. Since 1992 inter-aeras coordination committees and one national technical committee were instituted. In that way was the struggle officially set up. At last the Health National Agency of Accredidation and Valuation (ANAES), within the scope of an improvement policy concerning the security of and the quality of treatments in every health establishment, accepted about ten "standards" or "criterions" recommending supervision, education, written proceedings, informations diffusion modes, indicators definition in hospital hygiene. 85% of NI are in relation with direct or indirect hand transmission: that is the main point. So the first measure versus NI is just a fact: "HANDWASHING". It is the most effective method, the least expensive but unfortunately the least steady process. Beyond the struggle versus NI, all iatrogenic risks must be fought with a coherent control strategy. This "multivigilance" is a hard job for every health professional because it must be a daily, steady, rigorous and multidisciplinary task. The "Clin" is the privileged place for abilities round-up with an effective and permanent contribution between clinical structures, microbiology labs, pharmacy, administrative and technical sections. Every people belonging to a care unit must be equally involved in the rising of NI which activated a real mobilization of politicians and professionals who have become sensitive, on a socio-economic and an ethical basis. It is a collective and individual problem. Furthermore, the strict use of basic rules in hospital hygiene appears to be the KEYSTONE of the struggle.