2. Hospital infections considered an important factor
for increased hospital morbidity, mortality, and
total treatment costs.
Most frequently found in patients from intensive
care units (ICUs) and comprise 25% of all HIs, even
though ICUs occupy only 10% of hospital bed
capacities.
3. Patients from the neurological ICU, due altered
sensorium, impaired protective reflexes, muscle
weakness, etc.are more prone to acquisition of His.
Contributing factors
◦ Patients in N- ICUs have more chronic comorbid
illnesses and more severe acute physiologic
derangements.
◦ The high frequency of indwelling catheters among N-
ICU patients
◦ The use and maintenance of these catheters
necessitate frequent contact with health care workers,
which predispose patients to colonization and
infection with nosocomial pathogens.
4. Microorganisms that cause HIs are usually of
endogenous origin as a part of the permanent or
transient patient flora.
The most common pathogens that cause the HIs
are Escherichia coli, Klebsiella, Proteus,
Enterobacter and Acinetobacter.
5. Anatomical site % of patients Rate of infections
per 100 patients
Urinary tract infections 73.27% 13.78
Blood infections 10.89% 2.05
Skin and soft tissue
infections
10.89% 2.05
Pneumonia 3.96% 0.74
Surgical site infections 0.99% 0.19
Djordjevic et al. – Hospital infections in a neurological ICU
7. A multicenter, prospective cohort surveillance
study of 46 hospitals in India
Rates of device-associated infection were
determined between 2002 and 2005; an overall
rate of infections was 14.7 percent or 22.5
infections per 1000 ICU days was found.
8. Specific devices:
◦ Ventilator associated pneumonia (VAP); 24.1
cases/1000 ventilator days (range 10.0-52.7)
◦ CVC-related bloodstream infections; 12.5/1000
catheter days (7.8-18.5)
◦ Catheter-associated urinary tract infections;
8.9/1000 catheter days (1.7-12.8)
9. Previous stay in other dept.
Infection at Admission
Other comorbidities (*chronic heart disease, COPD,
HTN, DM, chronic hepatic and renal disease)
Surgical intervention
Urinary catheter ≥ 7 days
Intubation
Glasgow Coma Scale score <9
Prolonged of hospital stay
10. Urinary tract infections (UTI) associated with
urinary catheters are the leading cause of
secondary nosocomial bacteremia.
Asymptomatic bacteriuria is characterized by
a urine culture with >10(5) colony forming
units(cfu)/mL of uropathogenic bacteria in
the absence of fever >38ºC, suprapubic
tenderness or costovertebral angle pain or
tenderness.
11. Symptomatic catheter-related bacteriuria is
defined as the presence of fever >38ºC,
suprapubic tenderness, costovertebral angle
tenderness, or otherwise unexplained
systemic symptoms such as altered mental
status, hypotension, or evidence of a
systemic inflammatory response syndrome,
together with one of the following laboratory
profiles -
12. Urine culture with >10(5) cfu/mL irrespective of
urinalysis results
Urine culture with >10(3) cfu/mL with evidence
of pyuria (dipstick positive for leukocyte
esterase and/or nitrite, or presence of microbes
seen on Gram stain of unspun urine)
Patients who are no longer catheterized but had
indwelling urinary catheters within the past 48
hours are also considered to have catheter-
associated UTI
13. EPIDEMIOLOGY- occurs at a rate of
approximately 3 to 10 percent per day of
catheterization.
RISK FACTORS-
◦ Female sex
◦ Diabetes mellitus
◦ Prolonged catheterization
◦ Bacterial colonization of the drainage bag
◦ Errors in catheter care
14. DIAGNOSIS-
Urine samples for culture should be obtained
by removing the indwelling catheter and
obtaining a midstream specimen.
If a sample is being collected without catheter
removal, urine should be obtained from the
port in the drainage system
15. PREVENTION-
Consider using alternatives to indwelling urethral
catheterization
Using proper Techniques for Urinary Catheter
Insertion.
Unless otherwise clinically indicated, consider
using the smallest bore catheter possible,
consistent with good drainage.
Maintain a closed drainage system
CDC G UIDELINE FOR P REVENTION OF C ATHETER -A SSOCIATED U RINARY T RACT I NFECTIONS
2009
16. Changing indwelling catheters or drainage bags at
routine, fixed intervals is not recommended.
Do not use systemic antimicrobials routinely to
prevent CAUTI in patients requiring either short or
long-term catheterization.
Do not clean the periurethral area with antiseptics
to prevent CAUTI
Routine irrigation of the bladder with
antimicrobials is not recommended.
Clamping indwelling catheters prior to removal is
not necessarry.
CDC G UIDELINE FOR P REVENTION OF C ATHETER -A SSOCIATED U RINARY T RACT I
NFECTIONS 2009
17. TREATMENT-
EMPERICAL THERAPY-
◦ Gram negative bacilli may be treated empirically
with a third-generation cephalosporin or
fluoroquinolone.
◦ Pseudomonas aeruginosa is suspected, treatment
with ciprofloxacin, ceftazidize or cefepime may be
administered.
◦ Gram positive cocci may represent enterococci or
staphylococci; empiric management
with vancomycin is generally appropriate
18. Refers to the pulmonary consequences
resulting from the abnormal entry of fluid,
particulate exogenous substances, or
endogenous secretions into the lower
airways.
PREDISPOSING CONDITIONS -
◦ Reduced consciousness, resulting in a compromise
of the cough reflex and glottic closure.
◦ Dysphagia from neurologic deficits.
◦ Protracted vomiting
19. Aspiration pneumonia occurs in 6.7-22% of
hospitalized patients with stroke
Three fold increase in 30 day mortality with
Aspiration pneumonia
Many pneumonia cases preventable with stroke
protocols in place:
◦ Swallow screening
◦ Swallow evaluation
◦ Diet modifications
( Katzan, Dawson, Thomas, Votruba and Cebul, 2007)
20. 42-76% patients with acute stroke develop
dsyphagia
Half will experience aspiration
Although not all develop pneumonia
(Katzan, Cebul, Husak, Dawson, Baker, 2003)
21. Risk of pneumonia in the stroke population
demographics:
◦ Older patients
◦ Men
◦ More likely admitted from a nursing home or via
the emergency room
◦ More co-morbid illnesses
◦ Physiologic abnormalities
◦ More severe neurologic impairments at admission
(Katsan, Dawson, Thomas, Votruba, Cebul, 2007)
22. CLASSIFICATION-
◦ Chemical pneumonitis
◦ Bacterial pneumonitis
CHEMICAL PNEUMONITIS- Acute lung injury
following the aspiration of regurgitated gastric
contents and results in a chemical burn of the
tracheobronchial tree and pulmonary parenchyma
with an intense parenchymal inflammatory
reaction
23. Pathophysiology
◦ Animal models demonstrate that clinically
significant pneumonitis results from aspirating at
least 1ml/kg of pH<2.5 gastric contents
The first phase- peaks at 1 to 2 hours af
The second phase- peaks at 4 to 6 hours
24. Clinical features
◦ Abrupt onset of dyspnea
◦ Low grade fever
◦ Pink frothy sputum
◦ Diffuse crackles on exam
◦ CXR: diffuse infiltrates
Treatment
◦ Ventilatory support may be necessary
◦ Corticosteriods: beneficial in animal models,
unsuccessful in humans
◦ Antibiotics
Up to 25% of patients have bacterial superinfection
Dines et al
25.
26. BACTERIAL PNEMONITIS-
Clinical features
◦ Much more insidious onset than chemical
pneumonitis (days to weeks)
◦ Cough
◦ Fever
◦ Purulent sputum
◦ CXR: Infiltrate frequently in dependent segments
27. Patient aspirate in the recumbent position the most
common sites of involvement are the posterior
segments of the upper lobes and the apical
segments of the lower lobes.
patient aspirate in the upright or semi-recumbent
position the basal segments of the lower lobes are
favored.
30. TREATMENT-
◦ clindamycin (600 mg twice daily), ampicillin-
sulbactam ( 3 g twice daily), or imipenem (500
mg twice daily)
◦ Alternative regimens that appear effective
include amoxicillin-clavulanate combined
with metronidazole
31. Strategies to prevent pneumonia after
stroke-
◦ Focus: to identify at –risk patients
◦ Swallow screening
◦ Modify oral intake
◦ Obtain swallow therapy to improve swallow safety
and dsyphagia
◦ HOB elevated 30-45 degrees
◦ Oral decontamination with chlorhexidine
◦ Gastric volume monitoring
◦ Subglottic drainage
32. Pneumonia in patients receiving invasive
machanical ventilation for more than 48
hours.
EARLY vs LATE ONSET VAP :
◦ EARLY ONSET (<4 days) – antibiotic
sensitive,better prognosis
◦ LATE ONSET (5 days or more) – MDR
pathogens,increased mortality
33. INCIDENCE IN INDIA :-
◦ Incidence of HAP in india is 53.9%.
◦ Incidence of VAP in india is 8.95/1000 ventilator days.
◦ Mortality rate(attributable) is 37% - 47.3%
Park Es et al Am j inf control(2000)
Cook et al demonstrated that, risk of VAP is 3%
on first 5 days of MV,2% from 5-10 days,& 1%
for remaining days
34. Type of icu Mean VAP rate
( cases /1000 vent days)
Trauma 15.1
Neurology 12.9
Surgical 9.9
Medical 9.6
Cardiothorasic 7.9
35.
36. CAUSATIVE ORGANISMS-
Early onset:
◦ Hemophilus influenza
◦ Streptococcus pneumoniae
◦ Staphylococcus aureus (methicillin sensitive)
◦ Escherichia coli
◦ Klebsiella
Late onset:
◦ Pseudomonas aeruginosa
◦ Acinetobacter
◦ Staphylococcus aureus (methicillin resistant)
Most strains responsible for early onset VAP
are antibiotic sensitive. Those responsible for
late onset VAP are usually multiple antibiotic
resistant
Am J Resp Crit Care (1995
37.
38. HOST RELATE D
Medical /surgical disease,
Immunosuprssion,
Malnutrition (Alb<2.2g/dl ),
Advanced age, Supine
position, Level of
conciousness, Medication-
NMB, sedation, steroids,
Previous antibiotic use
DEVICE
RELATED
MV with ETT or
TRACHEOSTOMY
TUBE , MV>48 hrs,
Reintubations, NGT
or Oro- gastric tube,
Use of Humidifier
HEALTHCARE
PERSONNEL RELATED
Improper hand
washing, Failure to
change gloves and
use mask gown when
ever required .
39.
40.
41. • TREATMENT PROTOCAL-
• Initial therapy is empiric
• Individualize to institution-
-Hospital epidemiologic data
-Drug cost and availability
• Individualize to patient-
-Early onset versus Late onset of VAP
◦ -Underlying disease Renal, liver disease etc
◦ -Surveillance cultures
◦ -Use gram stain results if possible
42. Early onset of VAP and no risk for MDR -
Cefrioxone, fluroquinolones, ampicillin-sublactum
Late onset of VAP and risk for MDR-
Antipseudomonal cephalosporin
(cefepime,ceftazidime)
Carbapenems(imipenem,meronem),
Beta lactam/betalactamase inhibitors- piperacillin-
tazobactam Amonoglycocides with vancomycine,
linezoid
ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE
BASIS OF CULTURE REPORT
43. CRBSI (catheter related blood stream infection)-
refers to blood stream infection attributed to an
intravascular catheter by quantitative culture of the
catheter tip or by differences in growth between
catheter and peripheral venipuncture blood
cultures specimens.
EPIDEMOLOGY
In India Mehta et al reported an overall CRBSI rate
of 7.9 per 1000 CL days
A central venous catheter responsible 72%,
peripheral intravenous catheter in 35 %, and an
arterial catheter in 16 %.
44. RISK FACTORS-
Patient Factors-
Increasing severity of illness
Granulocytopenia
Compromised integrity of skin
Presence of distant infection.
Operator Factors- risk increases after breaks in
aseptic technique during placement and
maintenance and with frequency of catheter
access
45. Catheter factors-
Catheter type- risk of bsi increases with increasing
lumen number.
Antibiotic or antimicrobial coating of catheter can
reduce risk of CRBSI.
For non tunneled catheters risk of bsi varies by
anatomical sites- max for groin insertion,
intermediate for neck insertion and lowest for
chest or upper extremity insertion
46. PATHOGENESIS-
Migration of skin organism at the insertion site
into catheter tract along the surface of catheter
with colonization of catheter tip- M/C
Direct contamination of catheter or catheter hub
by contact with hands or contaminated fluid or
device.
Hematogenous spread of infection from another
focus.
Contamination of infusate
47. Microbiology- Organisms commonly associated
with CLABSIs are-
◦ Coagulase negative staph-31%
◦ S. aureus- 20%
◦ Enterococci- 9%
◦ E. coli- 6%
◦ Klebsiella species-5%
◦ Candida species- 9%
• A large study (SCOPE study) found that the rates of
MRSA has increased from 22% in 1995 to 57% in
2001.
• Rates of ceftazidime resistant P. aeruginosa has
increased from 12% in 1995 to 29% in 2001
48. Diagnosis-
CRBSI should be suspected in pt with iv cath who
develop clinical or lab criteria of SIRS i.e.
temperature <36ºC or > 38ºC, HR> 90/min,
RR>20/min or TLC <4000/µl or >12000/µl
Quantitative culture of the distal (5 cm) tip of
central venous and arterial catheters should be
performed when they are removed for suspected
infection.
At least 2 blood cultures should be obtained when
catheter infection is suspected
49. Diagnostic criteria-
◦ Culture of the same organism from both the
catheter tip and at least one percutaneous blood
culture.
◦ Culture of the same organism from at least two
blood samples
50. MANAGEMENT-
Catheter Removal- Not necessary unless: pt is
severely ill, complicated infection is apparent
(tunnel infection, port abscess, secondary
infections present)
51. Empiric Antibiotic Therapy-
Gram + pathogen:
◦ Vancomycin is recommended
Daptomycin if MRSA MIC consistently > 2 mcg/mL
Gram – pathogen:
◦ Choice based on severity of illness
◦ Third-generation cephalosporin
Single agent vs. double coverage of P. aeurginosa
Double coverage should be used if pt is neutropenic,
severely ill with sepsis, or colonized with P. aeurginosa
52. Empiric Antifungals-Not necessary unless patient
is septic AND has any of the following:
◦ TPN
◦ Prolonged use of broad-spectrum antibiotics
◦ Malignancy
◦ Transplant recipient
◦ Femoral catheter in place
◦ Multi-site Candida colonizaton
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-
related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
53. Preventative Strategies-
o Hand hygiene
o Sterile precautions during insertion
o Skin antisepsis (chlorhexidine, iodine)
o Daily inspection and documentation of exit site
o Avoidance of femoral site utilization
o Removal of device as soon as it is no longer
required
o Utilization of antimicrobial impregnated catheters
Edgeworth, J. Intravascular catheter infections. J Hosp Infect. 2009;10:1-8
54. Pressure ulcers are localized areas of tissue
necrosis that tend to develop when soft tissue
is compressed between a bony prominence
and an external surface for a prolonged
period of time.
PATHOGENESIS -
◦ Breaks in the integrity of the skin barrier,
◦ Pressure-induced changes,
◦ Contamination from contiguous dirty areas.
◦ Colonization of the pressure ulcer by
microorganisms
55.
56. SUPERFICIAL INFECTION-Superficial infection includes
localized infection without systemic signs, and non-
healing ulcer.
Management-
local wound care-
◦ Debridement of necrotic tissue
◦ Use of a moist wound dressing
◦ Nutritional support
◦ Pressure relief
Topical antimicrobial agents-silver sulfadiazine 1%
cream, combination antibiotic ointments, and
propylene glycol.
povidone-iodine and chlorhexidine gluconate , are
cytotoxic to human fibroblasts, can delay healing
57. DEEP INFECTION -Deep infection includes
ulcers complicated by cellulitis, osteomyelitis,
bacteremia, and/or sepsis, and requires
systemic antimicrobial therapy.
Management -
local wound care
Systemic Antibiotic therapy-antimicrobial
therapy should be based upon culture results.
58. EMPIRIC THERAPY-
◦ Vancomycin PLUS an agent with activity against gram
negative organisms.
DEFINATIVE THERAPY
1. MSSA-Oxacillin1-2 g intravenously every 6 hours
Cefazolin1 g intravenously every 8 hours
2. MRSA- Vancomycin30 mg/kg intravenously every 24 hrs
in 2 equally divided doses
3. Gram negative organisms (including Pseudomonas)-
Levofloxacin750 mg orally once daily
Ceftazidime2 g intravenously every 8 hours
Cefepime2 g intravenously every 12 hours
60. Djordjevic et al. – Hospital infections in a
neurological ICU, Infect Dev Ctries 2012;
6(11):798-805.
CDC infection control guidelines 2009
Uptodate. Com
Thomas DR. The new F-tag 314: prevention and
management of pressure ulcers. J Am Med Dir
Assoc 2006
61. American Thoracic Society, Infectious Diseases
Society of America. Guidelines for the management
of adults with hospital-acquired, ventilator-
associated, and healthcare-associated pneumonia.
Am J Respir Crit Care Med 2005
