Scribd Logo
Upload

Welcome to Scribd!

  • 50 views

    Nosocomial Infections: Dr. Tjatur Winarsanto SPPD RST Ciremai Cirebon

    Uploaded by

    Novita Trilianty Magdalena
    This document summarizes nosocomial (hospital-acquired) infections. It notes that around 2 million patients per year in the US acquire infections while hospitalized, resulting in around 90,000 deaths annually. The most common sites of nosocomial infections are the urinary tract (40% of cases), pneumonia (20%), and surgical sites (17%). Central line-associated bloodstream infections account for around 8% of cases. Risk factors include prolonged hospitalization, underlying illnesses, invasive devices like urinary catheters and ventilators, and antimicrobial use. The document reviews the pathogenesis, microbiology, diagnosis and treatment of common types of nosocomial infections like pneumonia, UTIs, surgical site infections, and

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Nosocomial Infections: Dr. Tjatur Winarsanto SPPD RST Ciremai Cirebon

    Uploaded by

    Novita Trilianty Magdalena
    50 views48 pages
    This document summarizes nosocomial (hospital-acquired) infections. It notes that around 2 million patients per year in the US acquire infections while hospitalized, resulting in around 90,000 deaths annually. The most common sites of nosocomial infections are the urinary tract (40% of cases), pneumonia (20%), and surgical sites (17%). Central line-associated bloodstream infections account for around 8% of cases. Risk factors include prolonged hospitalization, underlying illnesses, invasive devices like urinary catheters and ventilators, and antimicrobial use. The document reviews the pathogenesis, microbiology, diagnosis and treatment of common types of nosocomial infections like pneumonia, UTIs, surgical site infections, and

    Original Description:

    tropical infection

    Original Title

    Nosocomial Infections (2)

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document summarizes nosocomial (hospital-acquired) infections. It notes that around 2 million patients per year in the US acquire infections while hospitalized, resulting in around 90,000 deaths annually. The most common sites of nosocomial infections are the urinary tract (40% of cases), pneumonia (20%), and surgical sites (17%). Central line-associated bloodstream infections account for around 8% of cases. Risk factors include prolonged hospitalization, underlying illnesses, invasive devices like urinary catheters and ventilators, and antimicrobial use. The document reviews the pathogenesis, microbiology, diagnosis and treatment of common types of nosocomial infections like pneumonia, UTIs, surgical site infections, and

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    50 views48 pages

    Nosocomial Infections: Dr. Tjatur Winarsanto SPPD RST Ciremai Cirebon

    Uploaded by

    Novita Trilianty Magdalena
    This document summarizes nosocomial (hospital-acquired) infections. It notes that around 2 million patients per year in the US acquire infections while hospitalized, resulting in around 90,000 deaths annually. The most common sites of nosocomial infections are the urinary tract (40% of cases), pneumonia (20%), and surgical sites (17%). Central line-associated bloodstream infections account for around 8% of cases. Risk factors include prolonged hospitalization, underlying illnesses, invasive devices like urinary catheters and ventilators, and antimicrobial use. The document reviews the pathogenesis, microbiology, diagnosis and treatment of common types of nosocomial infections like pneumonia, UTIs, surgical site infections, and

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 48

    Nosocomial

    infections
    Dr. Tjatur Winarsanto SpPD
    RST Ciremai
    Cirebon

    NOSOCOMIAL INFECTIONS
    Infection in a hospitalized patient
    Not present or incubating on admission
    Hospital acquired infection

    Nosocomial Infections
    5-10% of patients admitted to acute care

    hospitals acquire infections


    2 million patients/year
    of nosocomial infections occur in ICUs
    90,000 deaths/year
    Attributable annual cost: $4.5 $5.7 billion
    Cost is largely borne by the healthcare facility not
    3rd party payors
    Weinstein RA. Emerg Infect Dis 1998;4:416-420.
    Jarvis WR. Emerg Infect Dis 2001;7:170-173.

    NOSOCOMIAL INFECTIONS
    Infections acquired in the hospital
    infection was neither present nor incubating when admitted
    2 million infections in 1995 in USA
    90,000 deaths
    may range from mild to serious (including death)
    Although acquired in the hospital-may appear after discharge from
    hospital
    Some infections occur in outbreaks or clusters (10%)
    but majority are endemic
    Can result from diagnostic or therapeutic procedures
    catheters in bladder or blood vessel, surgery
    correlate with length of stay

    PATHOGENESIS OF NOSOCOMIAL INFECTIONS

    3 ingredients
    Susceptible host
    Virulent organism
    Portal (mode) of entry

    Where do the microbes come from?

    patient's own flora


    cross infection from medical personnel
    cross infection from patient to patient
    hospital environment- inanimate objects
    - air
    - dust
    - IV fluids & catheters
    - washbowls
    - bedpans
    - endoscopes
    - ventilators & respiratory equipment
    - water, disinfectants etc

    The Inanimate Environment Can


    Facilitate Transmission
    X

    represents VRE culture positive sites

    ~ Contaminated surfaces increase cross-transmission ~


    Abstract: The Risk of Hand and Glove Contamination after Contact with
    a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

    SOURCES OF PATHOGENS IN NI
    Reactivation of latent infection: TB, herpes

    viruses

    Less common

    Endogenous: normal commensals of the skin,

    respiratory, GI, GU tract


    common

    Exogenous
    Inanimate environment: Aspergillus from hospital

    construction, Legionella from contaminated water


    Animate environment: hospital staff, visitors,
    other patients

    Cross transmission- common

    MECHANISMS OF TRANSMISSION
    Contact: direct (person-person), indirect

    (transmission through an intermediate object-contaminated instruments


    Cross transmission

    Airborne: organisms that have a true airborne

    phase as pattern of dissemination (TB, Varicella)


    Common-vehicle: common animate vehicle as
    agent of transmission (ingested food or water,
    blood products, IV fluids)
    Droplet: brief passage through the air when the
    source and patient are in close proximity
    Arthropod: not reported in US

    SITES OF NOSOCOMIAL INFECTIONS


    Urinary tract 40%
    Pneumonia 20%
    Surgical site 17%
    Bloodstream (IV) 8%

    Nosocomial Pneumonia

    NOSOCOMIAL PNEUMONIA
    Lower respiratory tract infection
    Develops during hospitalization
    Not present or incubating at time of

    admission
    Does not become manifest in the
    first 48-72 hours of admission

    EPIDEMIOLOGY
    13-18% of nosocomial infections
    6-10 episodes/1000 hospitalizations
    Leading cause of death from NI
    Economic consequences
    prolongation of hospital stay 8-9 days
    Costs $1 billion/year

    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)

    PREDISPOSING FACTORS
    Endotracheal intubation!!!!!!!!!!!!!!
    ICU
    Antibiotics
    Surgery
    Chronic lung disease
    Advanced age
    immunosuppression

    PATHOGENESIS
    Oropharyngeal colonization
    - upper airway
    colonization affected by
    host factors, antibiotic use,
    gram negative adherence
    - hospitalized pts have
    high rates of gram
    negative colonization
    Gastric colonization
    -increased gram
    negatives with high
    gastric pH
    - retrograde colonization
    of the oropharynx

    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

    PREVENTION
    Pulmonary toilet
    Change
    Elevate

    Deep

    position q 2 hours
    head to 30-45 degrees

    breathing, incentive spirometry


    Frequent suctioning
    Bronchoscopy to remove mucous
    plugging

    Nosocomial Urinary Tract Infections

    URINARY TRACT INFECTIONS


    Most common site of NI (40%)
    Affects 1/20 (5%) of admissions
    80% related to urinary catheters
    Associated with 2/3 of cases of nosocomial

    gram negative bacteremias


    Costs to health care system up to $1.8
    billion

    Nosocomial Urinary Tract


    Infections
    25% of hospitalized patients will have a urinary catheter for part of

    their stay
    20-25 million urinary catheters sold per year in the US
    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 bacteremia
    Vast majority of catheter-associated UTIs are silent, but these
    comprise the largest pool of antibiotic-resistant pathogens in the
    hospital

    Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

    PATHOGENESIS
    Source of uropathogens
    Endogenous- most common

    - catheter insertion
    - retrograde movement up the urethrea (7080%)
    - patients own enteric flora (E.coli)
    Exogenous

    - cross contamination of drainage systems


    - may cause clusters of UTIs

    PATHOGENESIS
    Major risk factors: 1)

    pathogenic bacteria in
    periurethral area 2)
    indwelling urinary
    catheter
    Duration catheterization

    Bacterial factors:
    properties which favor

    attachment to
    uroepithelium, catheters

    Growth in biofilm
    Bladder trauma decreases

    local host defenses

    Urinary (Foley)
    Catheter

    ETIOLOGIC AGENTS: catheter associated


    UTI
    Bacteria
    E. coli
    Proteus spp
    Enterococcus
    Klebsiella
    Pseudomonas
    Enterobacter
    Candida
    Serratia
    Other

    % Distribution
    32
    14
    12
    9
    9
    4
    4
    1
    15

    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

    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

    Surgical Site Infections

    SURGICAL SITE INFECTIONS


    325,000/year (3rd most common)
    Incisional 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

    SSI: Superficial

    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

    SSI: Deep

    SURGICAL SITE INFECTIONS


    Risk of infection dependent upon:
    Contamination level of wound
    Length of time tissues are exposed
    Host resistance

    SURGICAL SITE INFECTIONS


    Clean wound

    * elective, primarily closed, undrained


    * nontraumatic, uninfected
    Clean-Contaminated wound
    * GI, resp, GU tracts entered in a controlled manner
    * oropharynx, vagina, biliary tract entered
    Contaminated wound
    * open, fresh, traumatic wounds
    * gross spillage from GI tract
    * infected urine, bile

    PATHOGENS ASSOCIATED WITH SWI


    Pathogen
    S. aureus
    Enterococci
    Coag - Staph
    E. coli
    P. aeruginosa
    Enterobacter
    P. mirabilis
    K. pneumoniae
    Streptococci

    % of Isolates
    17
    13
    12
    10
    8
    8
    4
    3
    3

    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

    RISK FACTORS
    Duration of pre-op hospitalization

    * increase in endogenous reservoir


    Pre-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

    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

    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

    Nosocomial Bloodstream Infections

    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

    The risk factors


    interact in a
    dynamic fashion
    The Host

    The CVC is the


    greatest risk
    factor for
    Nosocomial BSI
    The CVC: Subclavian, Femoral and IJ sites

    The intensity of the Catheter Manipulation

    As the host cannot be altered, preventive measures are focused on risk factor
    modification of catheter use, duration, placement and manipulation

    The major risk factor is the Central Venous Catheter


    (CVC)

    The CVC- is one of the most


    commonly used catheters in
    medicine
    The CVC is typically placed
    through a central vein such as
    the IJ, Subclavian or femoral

    These serve as
    direct line for
    microbial
    bloodstream
    invasion

    PATHOGENESIS
    Direct innoculation

    * during catheter insertion


    Retrograde migration
    * skinsubcutaneous tunnelfibrin sheath at
    vein
    Contamination
    * hub-catheter junction
    * infusate

    Risk Factors for Nosocomial BSIs


    Heavy skin colonization at the insertion site
    Internal jugular or femoral vein sites
    Duration of placement
    Contamination of the catheter hub

    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)

    PICC

    0.2 - 2.2

    Catheter type and expected duration of use should be


    taken into consideration

    Nosocomial Bloodstream Infections,


    1995-2002
    Rank

    N= 20,978

    Pathogen

    Percent

    Coagulase-negative Staph

    31.3%

    S. aureus

    20.2%

    Enterococci

    9.4%

    Candida spp

    9.0%

    E. coli

    5.6%

    Klebsiella spp

    4.8%

    Pseudomonas aeruginosa

    4.3%

    Enterobacter spp

    3.9%

    Serratia spp

    1.7%

    10

    Acinetobacter spp

    1.3%

    Edmond M. SCOPE Project.

    Risk Factors for Nosocomial BSIs


    Heavy skin colonization at the insertion site
    Internal jugular or femoral vein sites
    Duration of placement
    Contamination of the catheter hub

    Prevention of Nosocomial BSIs


    Limit duration of use of intravascular

    catheters

    No advantage to changing catheters routinely

    Maximal barrier precautions for insertion


    Sterile gloves, gown, mask, cap, full-size drape
    Moderately strong supporting evidence

    Chlorhexidine prep for catheter insertion


    Significantly decreases catheter colonization; less

    clear evidence for BSI


    Disadvantages: possibility of skin sensitivity to
    chlorhexidine, potential for chlorhexidine
    resistance

    You might also like