Hospital aquired infections

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Hospital Aquired Infections with special consideration to surgical site infections...also case presentation in the begining followed by literature review

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  • A number of studies have documented the high mortality rate associated with MRSA pneumonia, ranging from 38 to 56.3 percent. In the Rello study the risk of death of in MRSA episodes was 20 times higher (Relative risk 20.72, 95% CI = 2.78-154.35) than in episodes caused by MSSA strains treated with Beta-lactams. In addition, these studies confirmed that the most important risk factor for development of MRSA infections was previous antibiotic therapy. 1. Gonzalez C, Rubio M, Romero-Vivas J, Gonzalez M, Picazo JJ. Bacteremia pneumonia due to Staphylococcus aureus: A comparison of disease caused by methicillin-resistant and methicillin-susceptible organisms. Clin Infect Dis. 1999;29:1171 Rello J, Torres A, ricart M, et al. Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med 1994;150:1545-1549. Iwahara T, Ichiyama S, Nada T, Shimokata K, Nakashima N. Clinical and epidemiologic investigations of nosocomial pulmonary infections caused by methicillin-resistant Staphylococcus aureus. Chest 1994 March 105(3):826-31.
  • Hospital aquired infections

    1. 1. Hospital Acquired Infections Dr. Monsif Iqbal Registrar, Surgical-II
    2. 2. Case Presentation
    3. 3. PATIENT’s PROFILE: Name: XYZ Age: 23 yrs. Sex: Male Address : Taxilla. D.O.A: 19-12-2012 M.O.A: OPD
    4. 4.  History of fecal discharge from the appendicectomy wound – 04 days Appendicectomy done in some private hospital
    5. 5.  Lapratomy done  Findings were a 2 cm perforation in the ileum 2 feet away from the ileocecal junction Ileostomy done Tension Sutures applied
    6. 6. Hospital Acquired Infections
    7. 7. Sufficient data now exist to prove that themortality of hospital acquired infectionsrepresents a leading cause of death in theUnited States.Richard P. Wenzel, MD, M.Sc
    8. 8. Outline Epidemiology of nosocomial infections  Incidence  Overview of pathogenesis 4 major nosocomial infections  VAP,UTI,SSI,BSI Risk reduction strategies  Transmission based precautions  Hand hygiene Surveillance  MRSA and VRE problem pathogens
    9. 9. NOSOCOMIAL INFECTIONS Occurring after 48 hours of hospital admission, within 3 days of discharge or within 30 days of an operation.
    10. 10. PATHOGENESIS OF NOSOCOMIAL INFECTIONS 3 ingredients  Susceptible host  Virulent organism  Portal (mode) of entry
    11. 11. The Inanimate Environment Can Facilitate Transmission X represents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~
    12. 12. SITES OF NOSOCOMIAL INFECTIONS Urinary tract 40% Pneumonia 20% Surgical site 17% Bloodstream (IV) 8%
    13. 13. Nosocomial Pneumonia
    14. 14. EPIDEMIOLOGY 13-20% of nosocomial infections 6-10 episodes/1000 hospitalizations Leading cause of death from NI Economic consequences  prolongation of hospital stay 8-9 days  Costs
    15. 15. Nosocomial Pneumonia  Cumulative incidence = 1-3% per day of intubation  Early onset (first 3-4 days of mechanical ventilation)  Antibiotic sensitive, community organisms (S. pneumoniae, H. influenzae, S. aureus)  Late onset  Antibiotic resistant, nosocomial organisms (MRSA, Ps. aeruginosa, Acinetobacter spp, Enterobacter spp)
    16. 16. PREDISPOSING FACTORS Endotracheal intubation!!!!!!!!!!!!!! ICU Antibiotics Surgery Chronic lung disease Advanced age immunosuppression
    17. 17. Multiresistant bacteria are a problem in VAP Organism % of all isolates P. aeruginosa 31.7 MRSA 11.8 A. baumannii 11.8 H. influenzae 8.4 S. pneumoniae 7.7 MSSA 3.1
    18. 18. MRSA Pneumonia:Infection-Related Mortality 70 60 56.3 54.5 50 Mortality (%) 38 40 30 20 10 0 Gonzalez, 1999 Rello, 1994 Iwahara, 1994
    19. 19. DIAGNOSIS AND TREATMENT Clinical diagnosis - fever, change in O2, change in sputum, CXR Microbiologic Confirmation  Suctioned Sputum sample  Bronchoscopy with brochoalveolar lavage Empiric antibiotic- clinical acumen - Rx based on previous cultures, usual hospital flora and susceptibilities - sputum gram stain - colonization vs. infection
    20. 20. PREVENTION  Pulmonary toilet  Change position q 2 hours  Elevate head to 30-45 degrees  Deep breathing, incentive spirometry  Frequent suctioning  Bronchoscopy to remove mucous plugging
    21. 21. Nosocomial Urinary Tract Infections
    22. 22. Nosocomial Urinary Tract Infections 25% of hospitalized patients will have a urinary catheter for part of their stay Incidence of nosocomial UTI is ~5% per catheterized day Virtually all patients develop bacteriuria by 30 days of catheterization Of patients who develop bacteriuria, 3% will develop bacteremiaSafdar N et al. Current Infect Dis Reports 2001;3:487-495.
    23. 23.  Vast majority of catheter-associated UTIs are silent, but these comprise the largest pool of antibiotic-resistant pathogens in the hospital
    24. 24. PATHOGENESIS Source of uropathogens  Endogenous- most common - catheter insertion - retrograde movement up the urethrea (70-80%) - patient’s own enteric flora (E.coli)  Exogenous - cross contamination of drainage systems - may cause clusters of UTI’s
    25. 25. PATHOGENESIS Major risk factors:  1) pathogenic bacteria in periurethral area  2) indwelling urinary catheter  Duration catheterization Growth in biofilm Bladder trauma decreases local host defenses Urinary (Foley) Catheter
    26. 26. ETIOLOGIC AGENTS: catheter associated UTIBacteria % DistributionE. coli 32Proteus spp 14Enterococcus 12Klebsiella 9Pseudomonas 9Enterobacter 4Candida 4Serratia 1Other 15
    27. 27. TREATMENT Is this a UTI vs asymptomatic bacteruria?  Use clinical judgement - urine WBC- pyuria - bacterial colony counts > 103 - clinical signs/symptoms No antibiotic treatment for bacteruria - resolves with catheter removal 7-10 days of therapy for UTI Empiric therapy typically initiated pending microbiologic results
    28. 28. Prevention of Nosocomial UTIs  Avoid catheter when possible & discontinue ASAP- MOST IMPORTANT  Aseptic insertion by trained HCWs  Maintain closed system of drainage  Ensure dependent drainage  Minimize manipulation of the system  Silver coated catheters
    29. 29. Surgical Site Infections
    30. 30. SURGICAL SITE INFECTIONS 325,000/year (3rd most common) Superficial surgical wound infections  Infection at surgical site  Within 30 days of surgery  Involves skin, subcutaneous tissue, or muscle above fascia  Accompanied by:  Purulent drainage  Dehiscence of wound  Organism isolated from drainage  Fever, erythema and tenderness at the surgical site
    31. 31. SSI: Superficial
    32. 32. SURGICAL SITE INFECTIONS Deep surgical wound infection  Occurs beneath incision where operation took place  Within 30 days after surgery if no implant, 1 year if implant  Infection appears to be related to surgery  Occurs at or beneath fascia with:  Purulent drainage  Wound dehiscence  Abscess or evidence of infection by direct exam  Clinical diagnosis
    33. 33. SSI: Deep
    34. 34. SURGICAL SITE INFECTIONS Risk of infection dependent upon:  Contamination level of wound  Length of time tissues are exposed  Host resistance
    35. 35. SURGICAL SITE INFECTIONS Clean wound * elective, primarily closed * nontraumatic, uninfected Clean-Contaminated wound * GI, resp, GU tracts entered in a controlled manner * oropharynx, biliary tract entered Contaminated wound * open, fresh, traumatic wounds * gross spillage from GI tract * infected urine, bile Dirty Wounds
    36. 36. SURGICAL SITE INFECTIONSWOUND CLASS % OF OPERATIONS SWI RATE (%)Clean 58 3.3Clean-contaminated 36 10.8Contaminated 4 16.3Dirty-infected 2 28.6
    37. 37. PATHOGENS ASSOCIATED WITH SWIPathogen % of IsolatesS. aureus 17Enterococci 13Coag - Staph 12E. coli 10P. aeruginosa 8Enterobacter 8P. mirabilis 4K. pneumoniae 3Streptococci 3
    38. 38. RISK FACTORS Age (extremes) Sex * ♀post cardiac surgery Underlying disease * obesity (fat layer < 3 cm 6.2%; >3.5 cm 20%) * malnutrition * malignancy * remote infection
    39. 39. RISK FACTORS Duration of pre-op hospitalization * increase in endogenous reservoirPre-op hair removal * esp if time before surgery > 12 hours * shaving>>clipping>depilatories Duration of operation *increased bacterial contamination * tissue damage * suppression of host defenses * personnel fatigue
    40. 40. SWI PREVENTION Limit pre-op hospitalization Stabilize underlying diseases Avoid hair removal by shaving  Clipping of skin is preferred Skin decolonization  Chlorhexidine  Intranasal Mupirocin for S.aureus carriers Impermeable drapes  Maximum sterile barrier precautions
    41. 41. PROPHYLACTIC PREOPERATIVE ANTIBIOTICS Indicated for clean-contaminated, contaminated operations High risk or devastating effect of infection Dirty wounds already infected (therapy) Administer at appropriate time (tissue levels)  30-60 minutes prior to skin incision
    42. 42. Nosocomial Bloodstream Infections
    43. 43. NOSOCOMIAL BACTEREMIA 4th most frequent site of NI Attributable mortality 20% Primary * IV access devices * gram positives (S. aureus, CNS) Secondary * dissemination from a distant site * gram negatives
    44. 44. The CVC is theThe risk factors interact in a greatest riskdynamic fashion factor for Nosocomial BSI The Host The CVC: Subclavian, Femoral and IJ sites The intensity of the Catheter ManipulationAs the host cannot be altered, preventive measures are focused on risk factor modification of catheter use, duration, placement and manipulation
    45. 45. PATHOGENESIS Direct innoculation * during catheter insertion Retrograde migration * skin→subcutaneous tunnel→fibrin sheath at vein Contamination * hub-catheter junction * infusate
    46. 46. Nosocomial Bloodstream Infections  12-25% attributable mortality  Risk for bloodstream infection: BSI per 1,000 catheter/days Subclavian or internal jugular CVC 5-7 Hickman/Broviac (cuffed, tunneled) 1 PICC 0.2 - 2.2 Catheter type and expected duration of use should be taken into consideration
    47. 47. Nosocomial Bloodstream Infections Rank Pathogen Percent 1 Coagulase-negative Staph 31.3% 2 S. aureus 20.2% 3 Enterococci 9.4% 4 Candida spp 9.0% 5 E. coli 5.6% 6 Klebsiella spp 4.8% 7 Pseudomonas aeruginosa 4.3% 8 Enterobacter spp 3.9% 9 Serratia spp 1.7% 10 Acinetobacter spp 1.3% .
    48. 48. Shifting Vantage Points on NosocomialInfections Many infections are Each infection is inevitable, although potentially some can be preventable unless prevented proven otherwise
    49. 49. STRATEGIES TO REDUCE NI Modify host.  Risk factors such as age, underlying disease are difficult to change. Reduce patient exposure to pathogens  Important! Reduce the number and virulence of nosocomial pathogens  Important!
    50. 50. EXPOSURE REDUCTION Aseptic technique during patient care Hand washing Proper isolation of patients known or suspected of harboring infectious diseases
    51. 51. Goal of Isolation Prevent transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and healthcare workers
    52. 52. Standard Precautions Used for all patients Must wear gloves when touching:  Blood  All body fluids  Non-intact skin  Mucous membranes Wash hands immediately after glove removal and between patients
    53. 53. Standard Precautions Masks, eye protection, face shield:  Wear during activities likely to generate splashes or sprays Gowns  Protect skin and soiling of clothing  Wear during activities likely to generate splashes or sprays Sharps  Avoid recapping of needles  Avoid removing needles from syringes by hand  Place used sharps in puncture –resistant containers
    54. 54. Airborne Precautions Designed to prevent airborne transmission of droplet nuclei or dust particles containing infectious agents For patient with documented or suspected:  Measles  Tuberculosis (primary or lanryngeal)  Varicella (airborne + contact)  Zoster (disseminated or immunocompromised patient; (airborne and contact)  SARS (Contact+airborne)
    55. 55. Droplet Precautions Designed to prevent droplet (larger particle) transmission of infectious agents when the patient talks, coughs, or sneezes For documented or suspected:  Adenovirus (droplet+contact)  Group A step pharyngitis, pneumonia, scarler fever (in infants, young children)  H. Influenza meningitis, epiglottitis  Infleunza, Mumps, Rubella  Meningococcal infections
    56. 56. MRSA (methicillin resistant S.aureus)• appeared in 1980s• some epidemic strains• carriers not necessarily ill• reduce transmission by detecting and treating all infected andcolonised patients•infection control procedures •esp handwashing and patient contact isolation• drug of choice is vancomycin• recent reports of a vancomycin resistant strains of S.aureus•Certain to be an increasingly difficult management problem
    57. 57. VRE (vancomycin resistant enterococci)• Enterococcus faecalis and E. faecium• normal inhabitants of bowel• can cause UTI and wound infections in seriously ill patients• enterococci now becoming more resistant to many antibiotics• this includes vancomycin •cross infection via contaminated equipment •Thermometers•Patients with VRE are placed on contact isolation
    58. 58. Thanks

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