Presentation by Dr.Jayasoorya P G,Junior resident ,Department of General Medicine,Azeezia medical college,Kollam,Kerala,India

1. AZEEZIA MEDICAL COLLEGE
 DEPARTMENT OF GENERAL MEDICINE

2. HEALTH CARE ASSOCIATED
INFECTIONS
DR.JAYASOORYA P G
JUNIOR RESIDENT
DEPARTMENT OF GENERAL MEDICINE
AZEEZIA MEDICAL COLLEGE
REFERENCE-HARRISON -20 TH

3.  1)INFECTIONS ACQUIRED IN HEALTH CARE FACILITIES
 2)INFECTIONS IN TRANSPLANT RECEPIENTS

4. INFECTIONS ACQUIRED IN HEALTH
CARE FACILITIES

6. EPIDEMIOLOGIC BASIS AND GENERAL
MEASURES FOR PREVENTION AND CONTROL
Nosocomial pathogens have reservoirs,
The mode of transmission
1)cross-infection (e.g., indirect spread of pathogens from one patient to
another on the inadequately cleaned hands of hospital personnel) or
2)autoinoculation (e.g., aspiration of oropharyngeal flora into the lungs along
an endotracheal tube).
Some times spread from person to person via large infectious droplets
released by coughing or sneezing.

7. Factors that increase host susceptibility
 Diabetes
 renal insufficiency
 extremes of age;
 abnormalities of innate defense
 medical-surgical interventions that compromise host defenses

8. HAND HYGIENE
 hand hygiene is cited traditionally as the most important preventive
measure.
 Health care workers’ rates of adherence to hand-hygiene
recommendations are low (often <50%).
 Reasons include inconvenience, time pressures, and skin damage from
frequent washing.
 Sinkless alcohol rubs are quick and highly effective and may improve hand
condition

9.  Use of alcohol hand rubs between patient contacts is recommended for all
health care workers except when hands are visibly soiled or outbreak of
infection with C. difficile, whose spores resist killing by alcohol and require
mechanical removal.
 In these cases, washing with soap and running water is recommended.

10.  A number of innovative electronic monitoring systems have been
developed to track hand-hygiene adherence and to provide real-time
feedback; although this approach is exciting, sustained improvements in
rates remain to be seen.

11. NOSOCOMIAL AND DEVICE-RELATED
INFECTIONS
 The percentage of nosocomial infections that is due to invasive devices—
25-50%—
 URINARY TRACT INFECTIONS
 PNEUMONIA
 SURGICAL WOUND INFECTIONS
 INFECTIONS RELATED TO VASCULAR ACCESS AND MONITORING

14. URINARY TRACT INFECTIONS
 Urinary tract infections (UTIs) account for ~14% of nosocomial infections;
up to 3% of bacteriuric patients develop bacteremia.
 Most nosocomial UTIs are associated with preceding instrumentation or
indwelling bladder catheters, which create a 3-7% risk of infection each
day.
 UTIs generally are caused by pathogens that spread up the periurethral
space from the patient’s perineum or gastrointestinal tract—the most
common pathogenesis in women—or via intraluminal contamination of
urinary catheters, usually due to cross-infection by caregivers who are
emptying drainage bags.

15. Hospitals should monitor performance measures
Prompts to clinicians to assess a patient’s need for continued use of an
indwelling bladder catheter can improve removal rates and lessen the risk of
UTI.
Guidelines for managing postoperative urinary retention may limit use or
duration of catheterization.
Other prevention strategies have included the use of topical meatal
antimicrobial agents, drainage bag disinfectants, and anti-infective catheters.

16.  Irrigation of catheters, with or without antimicrobial agents, may actually
increase the risk of infection.
 A condom catheter for men without bladder obstruction may be more
acceptable than an indwelling catheter and may lessen the risk of UTI if
maintained carefully.
 The role of suprapubic catheters in preventing infection is not well defined.

17.  Treatment of UTIs is based on the results of quantitative urine cultures
 The most common pathogens are Escherichia coli, nosocomial gram-
negative bacilli, enterococci, and Candida.
 In patients with chronic indwelling bladder catheters, especially those in
long-term-care facilities, the catheter flora—microorganisms living on
encrustations within the catheter lumen—may differ from actual urinary
tract pathogens.
 Therefore, for suspected UTI in the setting of chronic catheterization
(especially in women), it is useful to replace the bladder catheter and to
obtain a freshly voided urine specimen.

18.  Second, as in all nosocomial infections, at the time treatment is initiated on the
basis of a positive culture, it is useful to repeat the culture to verify the
persistence of infection.
 Third, the frequency with which UTIs occur may lead to the erroneous
assumption that the urinary tract alone is the source of infection in a febrile
hospitalized patient.
 Fourth, recovery of Staphylococcus aureus from urine cultures may result from
hematogenous seeding and indicate an occult systemic infection.
 Finally, although Candida is now the most common pathogen in nosocomial
UTIs among patients on intensive care units (ICUs), treatment of candiduria is
often unsuccessful and is recommended only when there is upper-pole or
bladder-wall invasion, obstruction, neutropenia, or immunosuppression.

19. PNEUMONIA
 Pneumonia accounts for ~24% of nosocomial infections; ventilator-
associated pneumonia (VAP) occurs in ~10% of patients on ventilators
 Most cases of bacterial nosocomial pneumonia are caused by aspiration
of endogenous or hospital-acquired oropharyngeal (and occasionally
gastric) flora.

20.  Nosocomial pneumonias have been associated with more deaths than
have infections at any other body site.
 Surveillance and accurate diagnosis of pneumonia have been problematic
in hospitals because many patients, especially those in the ICU, have
abnormal chest XRAY, fever, and leukocytosis potentially attributable to
multiple causes.

21.  Risk factors for nosocomial pneumonia include those events that increase
colonization by potential pathogens (e.g., prior antimicrobial therapy,
contaminated ventilator circuits or equipment, or decreased gastric
acidity); those that facilitate aspiration of oropharyngeal contents into the
lower respiratory tract (e.g., intubation, decreased levels of consciousness,
or presence of a nasogastric tube); and those that reduce host defense
mechanisms in the lung and permit overgrowth of aspirated pathogens
(e.g., chronic obstructive pulmonary disease or upper abdominal surgery).


22.  Among the logical preventive measures that require further investigation
are placement of endotracheal tubes that provide channels for subglottic
drainage of secretions, which has been associated with reduced infection
risks during short-term postoperative use, and noninvasive mechanical
ventilation whenever feasible.


23.  First, clinical criteria for diagnosis (e.g., fever, leukocytosis, development of
purulent secretions, new or changing radiographic infiltrates, and changes
in oxygen requirement or ventilator settings) have high sensitivity but
relatively low specificity.
 These criteria are useful for selecting patients for bronchoscopic or
nonbronchoscopic procedures that yield lower respiratory tract samples
protected from upper-tract contamination; quantitative cultures of such
specimens have diagnostic sensitivities in the range of 80%.

24.  Second, early-onset nosocomial pneumonia, which manifests within the
first 4 days of hospitalization, is most often caused by community-acquired
pathogens such as Streptococcus pneumoniae and Haemophilus species.

25.  Late-onset pneumonias most commonly are due to S. aureus, P.
aeruginosa, Enterobacterspecies, Klebsiella pneumoniae, or Acinetobacter.
 Third, one multicenter study suggested that 8 days is an appropriate
duration of therapy for nosocomial pneumonia and lessened emergence of
resistant pathogens.
 Fourth, a controversial study of health care-associated pneumonia
suggested that therapy based on guidelines from professional societies did
not improve patient outcomes.
 Finally, in febrile patients (particularly those who have tubes inserted
through the nares), occult bacterial sinusitis and otitis media should be
considered.

26. SURGICAL WOUND INFECTIONS
 account for ~24% of nosocomial infections, contribute up to 11 extra
postoperative hospital days
 the common risks for postoperative wound infection are related to the
surgeon’s technical skill, the patient’s underlying conditions (e.g., diabetes
mellitus, obesity) or advanced age, and inappropriate timing of antibiotic
prophylaxis.
 Additional risks include the presence of drains, prolonged preoperative
hospital stays, shaving of operative sites by razor the day before surgery,
long duration of surgery, and infection at remote sites (e.g., untreated UTI).

27. INFECTIONS RELATED TO VASCULAR
ACCESS AND MONITORING
 Intravascular device-related bacteremias cause ~10-15% of nosocomial
infections; central vascular catheters (CVCs) account for most of these
bloodstream infections
 Catheter-related bloodstream infections derive largely from the cutaneous
microflora of the insertion site, with pathogens migrating extraluminally to
the catheter tip, usually during the first week after insertion—a risk that
has been lessened greatly by use of bundled catheter-insertion guidelines.

28.  The most common pathogens isolated from vascular device-associated
bacteremias include coagulase-negative staphylococci, S. aureus (with
≥50% of U.S. isolates resistant to methicillin), enterococci, nosocomial
gram-negative bacilli, and Candida

29. ISOLATION TECHNIQUES
 Standard precautions are designed for the care.
 These are gloving and hand cleansing for potential contact with (1) blood;
(2) all other body fluids, secretions, and excretions, whether or not they
contain visible blood; (3) nonintact skin; and (4) mucous membranes.
 Depending on exposure risks, standard precautions also include use of
masks, eye protection, and gowns.


30. EPIDEMIC AND EMERGING PROBLEMS
 VIRAL RESPIRATORY INFECTIONS: PANDEMIC INFLUENZA
 EMERGING VIRAL PATHOGENS
 NOSOCOMIAL DIARRHEA
 CHICKENPOX
 MYCOBACTERA
 GROUP A STREPTOCOCCAL INFECTIONS
 FUNGAL INFECTIONS
 LEGIONELLOSIS

31. VIRAL RESPIRATORY INFECTIONS:
PANDEMIC INFLUENZA
 Infections caused by the severe acute respiratory syndrome (SARS)-
associated coronavirus challenged health care systems globally in 2003
and in 2012 Middle East respiratory syndrome coronavirus (MERS-CoV)
emerged as a more geographically localized problem

32. EMERGING VIRAL PATHOGENS
 The re-emergence of Ebola virus in West Africa
 The emergence of epidemic Zika virus disease in Brazil

33. CHICKENPOX
 routine varicella vaccination of children and susceptible health care
employees has made nosocomial spread less common

34. GROUP A STREPTOCOCCAL
INFECTIONS
 The potential for an outbreak of group A streptococcal infection should
be considered when even one or two nosocomial cases occur
 Investigation can be confounded by carriage at extrapharyngeal sites such
as the rectum and vagina.

35. FUNGAL INFECTIONS
 When dusty areas—common sources of fungal spores—are disturbed
during hospital repairs or renovation, the spores become airborne.
Inhalation of spores by immunosuppressed (especially neutropenic)
patients creates a risk of pulmonary and/or paranasal sinus infection and
disseminated aspergillosis

36. LEGIONELLOSIS
 Nosocomial Legionella pneumonia is most often due to contamination of
potable water or of water used in decorative fountains. This disease
predominantly affects immunosuppressed patients, particularly those
receiving glucocorticoid medications

37. BIOTERRORISM AND OTHER SURGE-
EVENT PREPAREDNESS
 The horrific attack on the World Trade Center. subsequent mailings of
anthrax spores in the United States; the Boston Marathon bombing in
2013; and ongoing terrorist activities globally have made bioterrorism a
prominent source of concern to hospital infection-control programs

38. EMPLOYEE HEALTH SERVICE ISSUES
 An institution’s employee health service is critical for infection control.
 New employees should be processed through the service, where a
contagious-disease history can be taken; evidence of immunity to a variety
of diseases, such as hepatitis B, chickenpox, measles, mumps, and rubella,
can be sought;

39. Infections in Transplant
Recipients

40. INFECTIONS IN HEMATOPOIETIC STEM
CELL TRANSPLANT RECIPIENTS
 BACTERIAL INFECTIONS
 FUNGAL INFECTIONS
 PARASITIC INFECTIONS
 VIRAL INFECTIONS

41. VIRAL INFECTIONS
 Herpes Simplex Virus
 Varicella-Zoster Virus
 Cytomegalovirus
 Human Herpesviruses 6 and 7
 Epstein-Barr Virus
 Human Herpesvirus 8 (KSHV)
 Other (Non-Herpes) Viruses

42. INFECTIONS IN SOLID ORGAN
TRANSPLANT RECIPIENTS

43.  KIDNEY TRANSPLANTATION
 HEART TRANSPLANTATION
 LUNG TRANSPLANTATION
 LIVER TRANSPLANTATION
 PANCREASE TRANSPLANTATION
 COMPOSITE-TISSUE TRANSPLANTATION

49. MISCELLANEOUS INFECTIONS IN
SOLID ORGAN TRANSPLANTATION
 Indwelling IV Catheter Infections
 Tuberculosis
 Virus-Associated Malignancies

50. VACCINATION OF TRANSPLANT
RECIPIENTS

52. THANK YOU