2.1 Infectious diseases and health care-associated infections.ppt

MTI, Khyber Teaching Hospital, Peshawar
INFECTIOUS DISEASES AND
HEALTH CARE-ASSOCIATED
INFECTIONS
By
Rehmat Ullah
Nursing Director, MTI KTH, Peshawar

Objectives of the Session
 The participants will be able to;
1. Describe the Health care-associated infections
(HAIs)
2. Discuss Burden and impact of HAIs in low-
and middle-income countries
3. Discuss Microorganisms responsible for HAIs
4. Describe factors that contribute to HAIs
5. Discuss appropriate placement, maintenance
and removal of patient care devices

Basic Concepts
 Indwelling urinary catheter: is inserted into the urinary
bladder and left in place for continuous drainage of urine
(e.g., Foley catheter). It should be connected to a drainage
bag
 Urinary tract infection (UTI) is an infection involving any
part of the urinary system, including the urethra, bladder,
ureter, and kidney
 Catheter-associated urinary tract infection (CAUTI) is a
UTI in a patient with an indwelling urinary catheter
 Biofilm is an accumulated thin layer of bacteria &
extracellular material that tightly adheres to surfaces (e.g.,
skin drains, urinary catheters) and cannot be easily
removed

Introduction--- HIA
 An infection that occurs in a patient as a result of care at a
health care facility and was not present at the time of
arrival at the facility.
 The term “health care-associated infection” (HAI)
“nosocomial” or “hospital-acquired” infection are
interchangeably used
 Infections that begin on or after Day 3 of hospitalization
(the day of hospital admission is Day 1), on the day of
discharge, or on the day after discharge. (CDC 2018; WHO
2011)
 They are a major cause of preventable diseases, deaths,
and higher health care costs
HAIs = Hospital Acquired Infections

Introduction--- HIA
 Caused by microorganisms that are present on;
 the patient’s body (resident flora) or from transient
sources such as HCWs’ hands, contaminated
equipment, or the environment.

Health Care-Associated Infections of
Public Health Concern
 Can affect the cardiovascular, respiratory, gastrointestinal,
genitourinary tracts, central nervous systems, and bones
and joints.
 HAIs may also affect skin, soft tissues, and muscles
 HAIs of public health concern in many settings include:
 Urinary tract infection (UTI), including catheter-associated urinary
tract infection (CAUTI)
 Blood stream infection, including central line-associated
bloodstream infection (CLABSI)
 Surgical site infection (SSI)
 Pneumonia, including ventilator-associated pneumonia (VAP)
 Multidrug-resistant infections
 Infectious Diarrhea and Clostridium difficile infections

Burden of Health Care-Associated
Infections
 It has been estimated that for every 100 hospitalized
patients, 10 to 15 acquire at least one HAI.
 This compares to 5 to 7 HAI patients for every 100
hospitalized patients in high-income countries
 WHO (2002) in 55 hospitals in 14 countries
representing four WHO regions (Europe, Eastern
Mediterranean, South-East Asia, and Western Pacific).
 An average of 8.7% of hospitalized patients had HAIs,
resulting in over 1.4 million HAIs.
 CLABSI, CAUTI, VAP, SSI, and infectious diarrhea are
common HAIs in both high-income countries and LMIC.

Microbiology of Health Care-
Associated Infections

Contributing Factors for Health Care-
Associated Infections
 High patient-to-nurse ratio
 Bed space less than 1 meter (3 feet) apart
 Low compliance with hand hygiene practices
 Lack of resources including rooms for isolation or cohorting (grouping
together patients with the same infection)
 Lack of trained IPC practitioners and limited opportunities for staff training
 Increasing use of complex medical and surgical procedures
 Increasing use of invasive medical devices (e.g., mechanical ventilators,
urinary catheters, central intravenous lines) without proper IPC training or
laboratory support
 Inadvertent contamination of prepared supplies/pharmaceuticals (e.g., IV
fluid, infant formula, general medications)
 Suboptimal cleaning, disinfection, and sterilization practices
 Antibiotic resistance due to overuse of broad-spectrum antibiotics (Allegranzi
et al. 2011)

Catheter Associated Urinary Tract
Infection (CAUTI)
 The majority (70–97%) of health care associated UTIs
are caused by indwelling urinary catheters
 Complications include;
 discomfort to the patient, longer hospital stay, increased cost,
and increased morbidity and mortality rates
 promotes antimicrobial resistance and increases the risk of
Clostridium difficile infection (i.e., bacterial infection that
causes diarrhea and colitis) (Lo et al. 2014).
 12–16% of adult patients will have an indwelling
urinary catheter inserted during their hospitalization

CATHETER-ASSOCIATED URINARY
TRACT INFECTION (CAUTI)
 In US, more than 13,000 deaths are associated
with health care-associated UTIs
 making up 36% of the total number of all HAIs in the
United States and 27% in Europe (WHO 2011)
 Among adult ICU patients, the CAUTI rate
between 1995 and 2010 was;
 4.1 per 1,000 urinary catheter-days in High income
countries
 8.8 per 1,000 urinary catheter days In low- and middle-
income countries (LMICs),

Urinary catheters
Indications
 Monitor urine output during certain types of
surgery and with critically ill patients
 Manage urinary retention and obstruction
 Assist in healing of certain open wounds in
incontinent (inability to control bladder) patients
 Improve comfort of patients at end of life, when
requested

Mechanism of UTI
 The normal defenses against UTI are free flow of urine
down the urethra & complete evacuation of the
bladder during the voiding process
 The catheter,
 introduces microorganisms from the end of the perineum and
urethra,
 provides a pathway for organisms to reach the bladder,
 a foreign body on which biofilm can form
 Microorganisms causing CAUTIs are derived from: l
 The patient’s intestinal and perineal area
 The hands of HCWs during catheter insertion or manipulation
of the collection system

Intra- and Extraluminal Sources of Infection
Outside of the catheter
(extraluminal)
 Migrate to the bladder along
the outside of the catheter via
the mucosa of the urethra.
 Maybe lodged early & directly
into the bladder during
insertion or may later move up
into the bladder from
surrounding skin (capillary action).
Inside of the catheter
(intraluminal
 Gain access to the bladder via
movement along the inside
(lumen) of the catheter.
 Contamination occurs when:
 A break in the closed
drainage system occurs,
resulting in contamination of the
inside of the tubing or the
catheter
 Urine flows in the opposite
direction, toward the bladder
(reflux), thereby introducing
contamination from the
collection bag to the bladder.

Catheter-Associated Urinary Tract Infections
Risk Factors
CATHETER-RELATED FACT
 Duration of
catheterization
 Insertion technique
 Catheter care
 Failure to maintain a
closed drainage system
PATIENT-RELATED FACTORS
 Compromised immune
system
 Diabetes mellitus
 Renal dysfunction
 Fecal incontinence
 Female sex
 Elderly age
(Gould et al. 2009; Lo et al. 2014)

Limit the Use of Urinary Catheters
(Appropriate Use)
 The primary CAUTI prevention strategy is to:
 Use catheters only when catheterization is appropriate.
 Remove catheters as soon as they are no longer clinically indicated
 Use alternative methods for indwelling catheters
 Intermittent catheterization using a reusable “red rubber” straight
catheter
 Condom catheters for male
 Regular toileting schedule or voiding on patient demand
 Adult diaper pads
 Bladder retraining to manage incontinence when coughing or
sneezing (stress incontinence)
 Medical management of incontinence (e.g., medications)

Urinary Catheter Insertion Guidelines
 Provide written guidelines for catheter insertion and educate HCWs on
correct insertion technique.
 Ensure that only properly trained persons insert catheters
 Provide HCWs with a checklist for urinary catheter insertion.
 Ensure that all supplies (hand hygiene supplies, sterile gloves, drapes, antiseptic solution,
syringes and sterile water, etc.) are available and conveniently located
 Follow IPC practices during insertion, removal, and replacement of
indwelling catheters.
 Consider using the smallest bore (diameter) catheter
 Secure indwelling catheters properly after insertion
 Keep the collection bag off the floor and secure in a position below the
bladder.
 Do not use antimicrobial-coated catheters for short-term
catheterization.

Recommended Catheter Maintenance
Practices
 Educate HCWs & family on the insertion, care, and maintenance of urinary
catheters
 Perform hand hygiene and follow Standard Precautions
 Ensure no blockage by checking the flow of urine through the catheter
several times a day
 Maintain catheter securement to the patient’s leg or abdomen to prevent
movement and pulling
 Cleanse the perineal area daily with soap and water
 Keep the catheter and collecting tube free from kinks and dependent loops
 Secure the collection bag below the level of the bladder at all times
 Do not raise the bag above the patient,
 Drain all urine before the patient stands up
 Empty the drainage bag before transferring the patient
 Never rest the bag on the floor

Surgical site infection (SSI)
 is an incisional or organ/space infection occurring at
the site of the surgery, either within 30 days of
surgery if there was no implant, or within 90 days if
there was an implant.
 Common procedures such as appendectomies and
cesarean sections (C-sections) are associated with
high infection rates and mortality
 SSIs are divided into;
 Superficial incisional infections (i.e., involvement of the skin
and subcutaneous tissue),
 Deep incisional infections (i.e., involvement of deeper soft
tissue, including fascia and muscle layers), and
 organ space infections

Surgical site infection (SSI)
 SSI depends on the following factors:
 Number of microorganisms entering the wound
 Type and virulence (i.e., ability to cause disease) of the
bacteria
 Strength of the patient’s defense mechanisms (e.g.,
status of the immune system)
 External factors, such as the patient’s preoperative
length of stay at the health care facility or the duration of
the surgery (more than 4 hours)

Surgical Site Infection Risk Factors
 Patient
 Coexistent infections at a remote body site
 Colonization with microorganisms (i.e., S.
aureus or methicillin-resistant S. aureus
[MRSA])
 Age (e.g., elderly or < 5 years)
 Poor nutritional status
 Uncontrolled diabetes
 Smoking or use of other tobacco products
 Obesity (body mass index ≥ 30 kg/m²)
 Altered immune response (e.g., HIV/AIDS
and chronic corticosteroid use)
 Length of preoperative stay
 Preoperative
 Lack of preoperative bathing
 Inappropriate preoperative patient hair
removal
 Inappropriate preoperative patient skin
preparation
 Inadequate preoperative HCW hand and
forearm antiseptic surgical scrub
 Intraoperative
 Deficiencies in OT environment (e.g., lack of appropriate
ventilation, cleanliness)
 Failures in instrument processing (e.g., lapses in
cleaning, high-level disinfection, and/or sterilization
processes)
 Lapses in surgical attire of HCWs and draping of patients
 Long duration of surgery
 Lack of appropriate perioperative antimicrobial
prophylaxis
 Foreign material in the surgical site
 Poor surgical technique
 Ineffective hemostasis
 Not maintaining normal body temperature (normothermia)
 Tissue trauma
 Entry into hollow viscus
 Presence of surgical drains and suture material
 Failure to obliterate dead space
 Postoperative
 • Lack of normal glucose levels
 • Poor wound care practices

Surgical Wound Classification System
 Clean surgical wound (Class I) is a surgical incision with no
inflammation or infection
 Clean-contaminated surgical wound (Class II) incision with no
inflammation or infection, in which the respiratory, GI, genital, or
urinary tract was entered, under controlled conditions, but without
evidence of major break in technique, contamination, or spillage of
contents.
 Contaminated surgical wound (Class III) is an open, fresh accidental
wound or an incision with a major break in aseptic technique (e.g.,
open cardiac massage) or gross spillage from the GI tract during a
procedure.
 Dirty or infected surgical wound (Class IV) is a surgical incision that
involves an old traumatic wound with retained dead tissue or one that
involves existing clinical infection or a perforated organ.

Intravascular catheters
(central lines, arterial lines, and peripheral IV lines)
 Often necessary for administering fluids, medications, and
nutritional products to patients
 also used for monitoring hemodynamics (i.e. monitoring blood
pressure & blood flow in the veins, arteries, and heart) in ICU
settings & for providing hemodialysis.
 Alos put patients at risk for infection
 up to 90% of health care-associated bloodstream infections are
caused by some form of vascular access
 Study in India found up to a 53% reduction in CLABSI rates
after hospitals implemented evidence-based infection
prevention and control (IPC) practices CLABSI Rates,
performance improvement and feedback program

Infection Risk Factors Related to Intravascular
Catheters
 Handling of the catheter with
contaminated hands
 Contamination of the insertion site
 Contamination of the catheter hub
(including touching the patient’s skin)
 Contamination of end caps
 Contamination of tubing ends
 Contamination of injection ports
 Contamination of IV fluids or
medications (either introduced by the
manufacturer or during medication
mixing and preparation)
 Excessive or substandard
manipulation of the catheter or
tubing

Indications of Intravascular Catheters
 Infusion of intravenous solution for rehydration
 Emergency venous access
 Hemodialysis: a process of purifying the blood of a
person whose kidneys are not working normally
 Nutritional support
 Administration of certain medications (e.g., vasopressors
used to raise blood pressure)
 Monitoring of central venous pressure
 Pulmonary artery catheterization

Maintaining IV Lines
 Follow recommended IPC practices at all times.
 Check at least every 8 hours for phlebitis or evidence of
infection.
 Rotate the IV catheter site at 72–96 hours (3–4 days)
 The infusion (administration) sets should be changed
whenever they are damaged, the tubing becomes
disconnected or routinely ad follows:
 Change continuous infusion sets at 96 hours (4 days).
 Change intermittent infusion sets every 24 hours.
 Provide instructions to the patient/family members on
maintaining the IV line.

CENTRAL LINE DRESSING CHANGE

Removing a Central Line
 Several serious risks associated with removal of a central
line, including;
 Infection, air embolisms, bleeding, & catheter fractures
 The following are general guidelines
 Assess the patient and check the insertion site for signs of
infection: redness, tenderness, and drainage.
 Use a trolley or kit containing all supplies needed for the procedure
and practice sterile technique.
 Stop the infusion.
 Put on non-sterile gloves.
 Remove the old dressing.
 Remove gloves, perform hand hygiene, and put on sterile gloves

Removing a Central Line
 Prepare the site and drape the area to produce a
sterile field.
 Cut sutures & withdraw the central line slowly and
steadily without resistance. Stop and seek assistance
if resistance is encountered.
 Apply firm pressure to the catheter exit site until
bleeding stops.
 Inspect the catheter to ensure it is intact; if it is not,
seek assistance.
 Apply a sterile, dry dressing to the exit site and cover
with an airtight bandage

Basic Concepts
 Aspiration, the breathing in of material (such as
food, liquids, or stomach contents) from the
oropharynx or gastrointestinal tract into the larynx
and lower respiratory tract, including the lungs
 Intubation is the medical procedure in which an
endotracheal tube is placed in the trachea via the
mouth or nose
 Ventilator-associated pneumonia (VAP) is
pneumonia that develops more than 2 calendar
days after the patient is placed on mechanical
ventilation

Hospital-acquired pneumonia
 Hospital-acquired pneumonia (HAP), accounts for
15% of all HAIs.
 Half of all cases of HAP occur after surgery
 VAP accounts for 32% of all infections acquired in
intensive care units
 HAP increases hospital stay by an average of 7–9
days per patient & carries a high risk of morbidity
and mortality

 Surgery, intubation, and mechanical ventilation greatly increase the risk of
infection because they:
 Block the normal body defense mechanisms—coughing, sneezing, and
the gag reflex
 Prevent the washing action of the cilia (fine hair in the airways that aid in
the movement of particles in the nose and lungs) and mucus-secreting cells
lining the upper respiratory system that aid in removing foreign substances
 Cause pooling of secretions in the subglottic area where
microorganisms can grow and then migrate to the lower respiratory tract
 Reduce oral immunity leading to accumulation of dental plaques, which
may then be colonized by oral microorganisms
 Provide a direct pathway for microorganisms to get into the lung
Hospital Acquired Pneumonia
Mechanism

Hospital-Acquired Pneumonia Risk Factors
 Surgery
 Intubation and mechanical ventilation (risk increases
with the duration of ventilation)
 Aspiration of stomach or oropharyngeal fluids
contaminated with colonizing organisms
 Enteral feeding in a supine body position
 Subglottic pooling of secretions
 Oropharyngeal colonization
 Stress ulcer prophylaxis

Reducing the Risk of Pneumonia
among Surgery Patients
 Preoperative pulmonary care using deep
breathing techniques, moving in bed, coughing
frequently, and moving soon after the operation
(e.g., sitting up and walking)
 Postoperative management Optimizing the
use of pain medication, Moving and exercising
patients on a regular schedule, Encouraging deep
breathing

When caring for ventilated patients:
 Avoid intubation if possible and use oro-tracheal rather than naso-
tracheal tubes in patients who receive mechanically assisted ventilation.
 Use aseptic technique for intubation, suctioning, and other procedures
that involve entering the endotracheal tube
 Minimize sedation.
 Minimize pooling of secretions above the endotracheal tube cuff
 Use single-use suction catheters and other respiratory care items
appropriately.
 Prevent condensed fluids in ventilator tubing from flowing back toward
the patient.
 Elevate the head of the bed.
 Provide oral-hygiene care.
Hospital Acquired Pneumonia

Strategies for Preventing Hospital-
Acquired Pneumonia
 Perform hand hygiene
 Use PPE appropriately
 Use single-use respiratory care items where possible (e.g., oxygen
masks, nebulizer sets)
 Teach patients to cough or sneeze into a tissue
 Assess patients with clinical signs or symptoms of respiratory illnesses
 Space beds 1 meter (3 feet) or more from other beds.
 Place only one person in a bed
 Avoid crowding patients in wards or outpatient treatment areas.
 Ensure proper air ventilation in the room
 Provide airborne infection isolation rooms (Negative pressure room) or
single room

Basic Concepts
 Colonization is the establishment of a site of pathogen reproduction in
or on a host individual that does not necessarily result in clinical
symptoms or findings (e.g., cellular change or damage).
 Endemic is the usual prevalence (occurrence) of cases of a disease or
infectious agent in a population in a geographic area
 Health care-associated diarrhea is diarrhea of infectious origin that
begins on or after the third calendar day of hospitalization (the day of
hospital admission is calendar Day 1).
 Opportunistic pathogen is a pathogen that can cause an infection
only when introduced into an unusual location or in a host with a
compromised immune system
 Fecal-oral route is route of transmission of Organisms causing
diarrhea to susceptible people via hands contaminated from direct
contact with feces or indirectly from contact with contaminated (usually
not visible) articles

Diarrhea (including C. difficile
diarrhea)
 A common symptom of GI tract infection & is generally
defined as the passage of three or more loose or liquid
stools per day.
 Can be caused by bacteria, viruses, or parasites and
are spread through contaminated food or water
 Diarrhea in hospitalized patients can often have non-
infectious causes including:
 Medications such as antibiotics
 Procedures such as endoscopy, nasogastric feeding, x-ray
studies using barium, enemas
 Disease processes such as HIV
 Psychological stress

Diarrhea (including C. difficile diarrhea)
 Diarrhea is common in health care facilities
 10% of pediatric patients
 Bacterial Gastroenteritis:
 Mostly gram negative (e.g., Salmonella, E. coli, Shigella, Campylobacter)
 Releasing enterotoxins (e.g., E. coli,C. difficile)
 Rotaviruses are the most common community causes of diarrhea,
making up 15–25
 Noroviruses is easily aerosolized
 C. difficile is the most common cause of health careassociated
infectious diarrhea
 Risk factors include;
 Extremes of age (newborns and the elderly); poor nutrition; impaired immunity;
 Decreased gastric acidity; disruption of normal GI function from medical or
surgical conditions; and altered, protective microorganisms in the gut, which
occur from antibiotic treatment.

 Apply Standard Precautions including gloves use for
patient care.
 Comply with recommended hand hygiene practices.
 Use Contact Precautions for the duration of diarrhea,
include isolating symptomatic patients presumptively.
 Clean and disinfect patient care equipment.
 Carry out environmental cleaning using a disinfectant as
per the health care facility protocol.
 Educate HCWs, housekeeping, administration, patients,
and families about prevention of health care-associated
diarrhea, including diarrhea caused by C. difficile infection
(if relevant in the setting).
Interventions to Prevent HAI

For settings with C. difficile consider also:
 Extending use of Contact Precautions beyond the duration of diarrhea
 Conducting laboratory tests to isolate C. difficile, if the capacity to perform
laboratory testing is available
 Isolating symptomatic patients presumptively, pending confirmation of C. difficile
infection
 Cleaning and disinfecting patient-care equipment with disinfectants effective
against spores.
 Carrying out environmental cleaning using a disinfectant effective against spores
as per the health care facility protocol
 Implementing an antimicrobial stewardship program
 Carrying out active surveillance for health care-associated diarrhea particularly
caused by C. difficile
 Making soap and water available for HCWs’ hand hygiene after contact with a
patient with C. difficle infection in case of an outbreak of C. difficile diarrhea
Interventions to Prevent HAI

THANKS
QUESTIONS

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