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Nosocomial infections

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  • Why not useful in post-operative: Systemically Administered Antibiotic does not penetrate the Established Fibrin Matrix in the Wound. 1
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    • 1. Important cause of Additional morbidity Prolonged hospitalization Mortality &Increased cost ofhospitalizationCan occur in all hospitalised childrenbut most common in PICU & NICU
    • 2.  Any infectionthat is notpresent orincubating atthe time thepatient isadmitted to thehospital
    • 3.  INFECTIONS THAT OCCUR AS CONSEQUENCEOF medical care whether or not they ariseduring hospitalisation Infections are considered nosocomial if theyfirst appear 48 hours or more after hospitaladmission or within 30 days after discharge
    • 4.  According to NNIS system of USA 14/100 Discharges in NICU’S 6/100 Discharges in PICU’S
    • 5. • Portal of Entry• Susceptible Host• Causative Agent• Reservoir• Portal of Exit• Mode of Transmission6
    • 6. 7
    • 7. 1. Catheter related blood stream infections(CR-BSI)2. Urinary tract infections (UTI)3. Ventilator related pneumonia (VAP)4. Surgical site infections (SSI)5. Burns infections
    • 8.  host factors, prior invasive procedures , use of catheters and other devices, use of antibiotics and exposure to other patients visitors, orhealth care providers with contagiousdiseases LENGTH OF HOSPITALISATION INFECTION CONTROL PROGRAMM IN THEHOSPITAL
    • 9. FactorsEnvironmentMicrobesHost characteristicsIndwelling devices
    • 10.  URTI GIT INFECTIONS SKIN & SOFT TISSUE INFECTIONS VARIOUS EXANTHEMAS As consequence of invasive procedures UTI’S ; PNEUMONIA; BACTEREMIA;SURGICALSITE
    • 11.  AIR BORNE DROPLET CONTACT TRANSMISSION COMMON VEHICLE VECTORS AUTO INFECTION
    • 12.  AIR BORNE TINY DROPLETSpTB,measles,varicella,legionnaires,aspirgillosis &mucormycosis Droplet transmissionpertusis,meningococcal infections, Contact transmissiongram+ cocci, RSV, C.difficile,enterovirus,hepatitis A
    • 13.  VEHICLE TRANSMISSIONGram- bacteremia, due contaminated ivmedications,post transfusion infections, Auto infectionpatients own flora
    • 14.  Host factors that increase the risk forinfection include anatomic abnormalities (dermoid sinuses,cleft palate, obstructive uropathy), damage to skin, organ dysfunction, malnutrition, and underlying diseases or co-morbidities
    • 15. Diseases and therapies that alter immunityare most likely to predispose to infectionIntravenous and other catheters bypass hostdefenses, provide direct access to sterilesites, provide adherence sites formicrobes, and may occlude normal ostiasuch as the eustachian tubes.
    • 16.  Antibiotics often alter normal bowel floraand encourage colonization by resistantflora, and they may suppress hematopoiesis. Exposure to adults or children withcontagious diseases is a clear risk fornosocomial transmission of disease..
    • 17.  Transmission of infectiousagents occurs by variousroutes, but by far the mostcommon and important route isvia the hands
    • 18.  Fungi and resistant bacteria are frequentcauses of infection in immunocompromisedchildren and in those who require intensive careand prolonged hospitalization
    • 19.  Most effective strategy A good hospital infection control program ismust to orchestrate effective infection controlprogramme
    • 20.  The most important measure in anyinfection control programme the important component of handwashingis placement of the hands under water anduse of friction with or without soap. Studies show that a 15-second scrubremoves the majority of transient flora butdoes not alter the permanent flora.
    • 21.  Alcohol-containing antiseptic hand rubspreferred except when hands visibly aresoiled with blood or other proteinaceousmaterials or if exposure to spores (e.g.,Clostridium difficile, Bacillus anthracis) islikely to have occurred A chlorhexidine based hand rub has beenrecommended as the most suitable for thispurpose
    • 22.  After touching blood, body fluids,secretions, excretions, or contaminateditems; immediately after removing gloves; between patient contacts.
    • 23. Compliance < 40%
    • 24. Handwashing …an action of the past(except when hands are visibly soiled)Alcohol-basedhand rubis standard of care
    • 25. Alcohol-basedhandrub at point ofcareAccess to safe,continuous watersupply, soap andtowels2. Training and Education3. Observation and feedback4. Reminders in the hospital5. Hospital safety climate++++The 5 corecomponents of theWHO MultimodalHand HygieneImprovementStrategy1. System change
    • 26. - Team and multidisciplinary team work- Successful interventions- Adaptability of actions- Scaling up- Sustainability of actions / interventions- Leadership commitment / Governance
    • 27. SAVE LIVES: Clean YOURHands5 May 2009-2020A WHO Patient Safety Initiative 2009
    • 28.  formerly known as universal precautions,are intended to protect health careworkers from blood and body fluids andshould be used whenever providing care Standard precautions involve the use ofbarriers—gloves, gowns, masks, goggles,and face shields—as needed to preventtransmission of microbes associated withcontact with blood or body fluids
    • 29.  Restriction of visitors Cleaning Rigorous sterilisation Disinfection procedures Appropriate waste disposal Limiting antibiotic therapy less invasive procedures Preventing hyperglycemia Education &training of health workers in infcontrol is mandatory
    • 30.  Good surveillance programme to detectprevailing pattern of pathogens Antimicrobial susceptability
    • 31.  Isolation of patients infected with certainpathogens decreases the risk fornosocomial transmission Contact transmission Droplet transmission Airborne transmission
    • 32.  RTIrsvinfluenzaparainfluenza virusGIT infectionsvirusesc.difficileVaricella, measles
    • 33. Use and care of vascular access linesUse and care of urinary cathetersTherapy and support of pulmonary functionsExperience with surgical procedures
    • 34. Sources of the catheter-associatedbloodstream infectionSkinVeinIntraluminal fromtubes and hubsIntraluminal fromtubes and hubsHematogenousfrom distant sitesHematogenousfrom distant sitesExtraluminal fromskinExtraluminal fromskin
    • 35. Multimodal intervention strategies to reducecatheter-associated bloodstream infections:- Hand hygiene- Maximal sterile barrier precaution at insertion- Skin antisepsis with alcohol-based chlorhexidine-containing products- Subclavian access as the preferred insertion site- Daily review of line necessity- Standardized catheter care using a non-touch technique- Respecting the recommendations for dressing change
    • 36. Chlorhexidinegluconate-impregnatedspongeChlorhexidinegluconate-impregnatedsponge
    • 37. Chlorhexidine-Impregnated Sponges andLess Frequent Dressing Changes forPrevention of Catheter-Related Infections inCritically Ill AdultsMulti-centre randomized controlled trial- 3’778 catheters- 28’931 catheter-days- Baseline rate of major catheter-related infections:1.4/1000 catheter-days!
    • 38. 0.60 per 1000catheter-days1.40 per 1000catheter-daysHR = 0.39;p=0.03Chlorhexidine-gluconate impregnated dressingsdecreased major catheter-related infections:Catheter-daysCumulativeRiskControldressingsControldressingsChGdressingsChGdressings
    • 39. Use and care of vascular access linesUse and care of urinary cathetersTherapy and support of pulmonary functionsExperience with surgical procedures
    • 40. • Urinary tract infection (UTI) causes~ 40% of hospital-acquired infections• Most infections due to urinary catheters• 25% of inpatients are catheterized• Leads to increased morbidity and costs
    • 41. Avoid unnecessary catheterizationTwo main principlesLimit the duration of catheterization
    • 42.  Practice hand hygiene before insertion of the catheter before and after anymanipulation of the catheter sitehttp://www.who.int/gpsc/tools/en/
    • 43.  Insert catheters by use of aseptic technique and sterileequipment Cleanse the meatal area with antiseptic solutions isunnecessary routine hygiene is appropriate Properly secure indwelling catheters after insertion toprevent movement and urethral traction Maintain a sterile, continuously closed drainage system Do not disconnect the catheter and drainage tube unlessthe catheter must be irrigated
    • 44.  Do not use (avoid) catheter irrigation Do not use systemic antimicrobials routinely asprophylaxis Do not change catheters routinely
    • 45. Use and care of vascular access linesUse and care of urinary cathetersTherapy and support of pulmonary functionsExperience with surgical procedures
    • 46. Patient Age Burns Coma Lung disease Immunosuppression Malnutrition Blunt traumaDevices Invasive ventilation Duration of invasiveventilation Reintubation Medication Prior antiobiotictreatment Sedation
    • 47.  Staff education, handhygiene, isolationprecautions Surveillance of infectionand resistance with timelyfeedback Adequate staffing levels
    • 48. Effect of staffing level in late onset VAP
    • 49.  Avoid intubation and reintubation Prefer non-invasive ventilation Prefer orotracheal intubation & orogastrictubes - Continous subglottic aspiration Cuff pressure > 20 cm H2O Avoid entering of contaminate consendateinto tube/nebulizer Use sedation and weaning protocols toreduce duration Use daily interruption of sedation and avoidparalytic agents -
    • 50.  Oral chlorhexidine application reduces VAP inone study but not for general use
    • 51.  Selective decontamination of the digestive tract(SDD) reduces the incidence of VAP & helps tocontain MDR outbreaks But SDD not recommended for routine use Prior systemic antibiotics helps to reduce VAP inselected patient groups but increases MDR 24-hour AB prophylaxis helps in one study butnot for routine use
    • 52. 1. Adherence to hand hygiene2. Adherence to glove and gown use3. Backrest elevation maintenance4. Correct tracheal-cuff maintenance5. Orogastric tube use6. Gastric overdistention avoidance7. Good oral hygiene8. Elimination of non-essential tracheal suction2 year interventionstudy:Compliance withpreventivemeasuresincreasedVAP prevalencerate decreasedby 51%
    • 53. 1. Hand hygiene before and after patient contact,preferably using alcohol-based handrubbing2. Avoid endotracheal intubation if possible3. Use of oral, rather than nasal, endotrachealtubes4. Minimize the duration of mechanical ventilation5. Promote tracheostomy when ventilation isneeded for a longer term6. Glove and gown use for endotracheal tube manip
    • 54. Use and care of vascular access linesUse and care of urinary cathetersTherapy and support of pulmonary functionsExperience with surgical procedures
    • 55.  ObjectivesReduce the inoculum of bacteria at the surgical site Surgical Site Preparation Antibiotic Prophylaxis StrategiesOptimize the microenvironment of the surgical siteEnhance the physiology of the host (host defenses) In relation to risk factors, classified asPatient-related (intrinsic)Pre-operativeOperative
    • 56.  Diabetes - RecommendationPreoperative Control serum blood glucose; reduce HbA1C levels to <7% beforesurgery if possiblePost-operative (cardiac surgery patients only) Maintain the postoperative blood glucose level at less than 200mg/dL (A-I)• Smoking- Rationale– Nicotine delays wound healing– Cigarette smoking = independent RF for SSI after cardiac surgery- Studies: None- Recommendation– Encourage smoking cessation within 30 days before procedure
    • 57. Hair removal techniquePreoperative infectionsSurgical scrubSkin preparationAntimicrobial prophylaxisSurgeon skill/techniqueAsepsisOperative timeOperating room characteristics
    • 58.  Recommendations Administer within 1 hour of incision to maximizetissue concentration Once the incision is made, delivery to the wound isimpaired
    • 59.  Duration of prophylaxis (A-I) Stop prophylaxis within 24 hours after the procedure within 48 hours after cardiac surgery To: Decrease selection of antibiotic resistance Contain costs Limit adverse events
    • 60.  Excellent surgical technique reduces the riskof SSI IncludesGentle traction and handling oftissuesEffective hemostasisRemoval of devitalized tissuesObliteration of dead spacesIrrigation of tissues with salineduring long proceduresUse of fine, non-absorbedmonofilament suture materialWound closure without tensionAdherence to principles of asepsis
    • 61. ryryryMaking healthcare safe
    • 62. THANK YOU