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Nosocomial infection in icu

  1. Page 1 NOSOCOMIAL INFECTION IN CRITICAL CARE Presented by, Ruma sen MN. Final
  2. Page 2 LEARNING OBJECTIVES 1. PUBLIC HEALTH IMPACT OF HOSPITAL ACQUIRED INFECTIONS. 2. EPIDEMIOLOGY 3. INDIAN SITUATION OF THE PROBLEM 4. Estimate the extent and nature of nosocomial infections in hospital 5. Identify the changes in the incidence of nosocomial infections and the pathogens that cause them.
  3. Page 3 Ignaz Semmelweis Decreased Mortality with Improved Hand Hygiene Ignaz Semmelweis (1818-65) Chlorinated lime hand antisepsis
  4. Page 4 Current Climate …….. • Public Concern • Quality Issues – Clinical Governance – Clinical Standards – Accountability Reviews – Performance Assessment Framework
  5. INTRODUCTION • Nosocomial infection comes from Greek words “nosus” meaning disease and “ komeion” meaning to take care of • Also called as HOSPITAL ACQUIRED INFECTION
  6. DEFINITION NOSOCOMIAL INFECTION : • An infection acquired in a patient in a hospital or other healthcare facility in whom it was not present or incubating at the time of admission or the residual of an infection acquired during a previous admission. 6
  7. Nosocomial infections have been recognized for over a century as a critical problem affecting the quality of health care and a principal source of adverse healthcare outcomes. BACKGROUND OF HOSPITAL INFECTIONS 7
  8. Why one may be in icu Ventilator support – respiratory failure – pneumonia Hemodynamic support – shock Renal replacement therapy – renal failure, severe acidosis Monitoring, Neurological dysfunction, Hematologic
  9. ICU Care is more Invasive • More invasive life lines and procedures including surgeries • Longer length of stay • More IV and parenteral drugs • More tube feeding and Parenteral nutrition • More ventilation 9
  10. RISK OF INFECTIONS IN ICU • Patients hospitalized in ICUs are 5 to 10 times more likely to acquire nosocomial infections than other hospital patients. The frequency of infections at different anatomic sites and the risk of infection vary by the type of ICU, and the frequency of specific pathogens varies by infection site. Contributing to the seriousness of nosocomial infections, especially in ICUs, is the increasing incidence of infections caused by antibiotic-resistant pathogens 10
  11. TYPES BY ORIGIN 1.Endogenous: Caused by the organisms that are present as part of normal flora of the patient 2. Exogenous: caused by organisms acquiring by exposure to hospital personnel, medical devices or hospital environment
  12. TYPES OF NCI BY SITE 1. Urinary tract infections (UTI) 2. Surgical Site infections (SSI) 3. Lower respiratory infections (LRI) 4. Blood stream infections (BSI) 5. Catheter related blood stream infections(CRBSI) 6. Meningitis
  13. Page 13 EPIDEMIOLOGICAL INTERACTION Intrinsic host susceptibility Age, Poor nutritional status, Co morbidity, severity of underlying disease Agent factors varieties of organisms Institutional and human Reservoirs & their virulence Environmental factors hospital location, diagnostic procedures, immunosuppressive, chemotherapy, antibiotics, med & surgical devices, exposure to infected patients or health workers, asymptomatic carriers
  14. DISEASE BURDEN • 5-10% in developed countries • 10-30% IN DEVELOPING COUNTRIES • Rates vary between countries, within the country, within the districts and sometimes even within the hospital itself, due to 1) Complex mix of the patients 2) Aggressive treatment 3) Local practices
  15. • In the United States, the Centers for Disease Control and Prevention estimated roughly 1.7 million hospital-associated infections, from all types of microorganisms, including bacteria and fungi combined, cause or contribute to 99,000 deaths each year. • In Europe, where hospital surveys have been conducted, the category of gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year. • United Kingdom ,In 2012 the Health Protection Agency reported the prevalence rate of HAIs in England was 6.4% in 2011,
  17. Page 17 INCIDENCE • Average Incidence - 5% to 10%, but maybe up to 28% in ICU • Urinary Tract Infection - usually catheter related -28% • Surgical Site Infection or wound infection -19% • Pneumonia -17% • Blood Stream infection - 7% to 16%
  18. Page 18 INCIDENCE • Depends upon 1. Average level of patient risk depends upon intrinsic host factors and extrinsic environment factors 2. Sensitivity &specificity of surveillance programmes
  19. Page 19 CONSEQUENCES OF NOSOCOMIAL INFECTIONS 1. Prolongation of hospital stay: Varies by site, greatest with pneumonias and wound infections 2. Additional morbidity 3. Mortality increases - in order - LRI, BSI, UTI 4. Long-term physical &neurological consequences 5. Direct patient costs increased- Escalation of the cost of care
  20. Page 20 ECONOMICS OF NCIS • Extra cost of NCI consequences • Bed, • Intensive care unit stay, • Hematological, biochemical, microbiological and radiological tests, • Antibiotics & other drugs, • Extra surgical procedures • Working hours
  21. • Crowded hospital conditions • New microorganism • Increasing number of people with compromised immune system • Increasing Bacterial resistance Rise in nosocomial infection as a result of four factor
  22. ICU : Factors that increase cross- infections • Lack of Hand washing facilities • Patient close together or sharing rooms • Understaffing • Preparation of IVs on the unit • Lack of isolation facilities • No separation of clean and dirty AREAS • Excessive antibiotic use • Inadequate decontamination of items & equipment's • Inadequate cleaning of environment 22
  23. MODES OF TRANSMISSION There are five main modes of transmission • Contact • Droplet • Vector borne • Air borne • Common vehicle
  24. CONTACT TRANSMISSION Most important and frequent mode of transmission of nosocomial infections, is divided into two subgroups: • Direct-contact transmission • Indirect-contact transmission. Direct-contact transmission Involves a direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person, such as occurs when a person turns a patient, gives a patient a bath
  25. • Indirect-contact transmission Involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, or dressings, or contaminated gloves that are not changed between patients
  26. DROPLET TRANSMISSION Droplet generated by sneezing Coughing or respiratory tract procedures like Broncoscopy or suction VECTOR TRANSMISSION Transmitted through insects and Other invertebrates animals such as mosquitoes and fleas.
  27. AIR BORNE TRANSMISSION Tiny droplet nuclei that remain (<5) suspended in air. COMMON VEHICLE TRANSMISSION Transmitted indirectly by materials contaminated with the infections.
  28. Page 28
  31. The inanimate environment is a reservoir of pathogens ~ 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. X represents a positive Enterococcus culture The pathogens are ubiquitous
  32. MRSA- Methicillin-resistant S. aureus (MRSA • 60% of nocosomial infection in ICU • MRSA bacteria are also able to survive for extensive periods on surfaces and objects including door handles, floors, sinks, taps, cleaning equipment and fabric • Cotton: 4-21 days • Terry: 2-14 days • Polyester blend: 1-3 days • Polyester: 1-40 days • Polypropylene: 40-greater than 51.
  33. • A break in the skin barrier, such as a surgical wound, burn, catheter or intravenous line that allows bacteria to enter the body • Older age, comorbidities or multiple complex health issues, and weakened immune systems Those with a weakened immune system can include: • Patients in hospital for a long period of time • Patients on kidney dialysis (hemodialysis) • Patients receiving cancer treatment or specific medications that affect immune function • Those who inject illegal drugs • Individuals who have had surgery within a year of being back in hospital. • Estimates suggest that 49-65% of health care- associated S. aureus infections are caused by methicillin- resistant strains.
  34. The 5 Cs can be used to remember what factors make it easier for MRSA to be transmitted: •Crowding •Contact (skin-to-skin) •Compromised skin (open wounds) •Contaminated (items and surfaces) •Cleanliness (lack of)
  35. Coagulase negative staphylococci (CoNS) • Part of the normal flora of human skin . • Relatively low virulence but are increasingly recognized as agents of clinically significant infection of the bloodstream and other sites. • Risk factors for CoNS • Presence of foreign devices (such as intravascular catheters) • Immune compromise.
  36. Vancomycin-resistant enterococci • VRE can live in the human intestines and female genital tract without causing disease (often called colonization). However, sometimes it can cause infections of the urinary tract, the bloodstream, or of wounds associated with catheters or surgical procedures
  37. Pseudomonas aeruginosa • Number 1 cause of intensive care unit (ICU)–related pneumonia • Number 2-ranked gram-negative organism, responsible for 9% of all nosocomial bacterial and fungal isolates • Number 2 cause of nosocomial pneumonia • Number 3-ranked isolate in hospital-acquired UTIs • Number 4 cause of surgical site infections and of hospital- acquired gram-negative rod bacteremia • Number 5 hospital pathogen • Number 8-ranked bloodstream isolate • Causes 10% of nosocomial infections
  38. • Clinical presentation is often identical to other gram- negative organisms. • Fever is usually present, except in very young or premature infants. Fever is often accompanied by tachycardia and tachypnea. • Patients appear toxic and may present with apprehension, disorientation, or obtundation. • Signs of shock, including hypotension, azotemia, or acute renal failure, may be observed. • Respiratory failure occurs in the presence of bacteremic pseudomonal pneumonia or in conjunction with airway restrictive disease syndrome.
  39. Acinetobacter baumanii • Prolonged length of hospital stay • Exposure to an intensive care unit (ICU) • Receipt of mechanical ventilation, colonization pressure • Exposure to antimicrobial agents, recent surgery, invasive procedures, and underlying severity of illness . outbreaks of infection have been traced to respiratory care equipment, wound care procedures, humidifiers, and patient care items. Acinetobacter infection, with environmental contamination found on curtains, laryngoscope blades, patient lifting equipment, door handles, mops, and keyboards.
  40. Page 40 FUNGI • Due to increased antibiotic use &host susceptibility • Candida species– most common, causing BSI (38% mortality) • Changing bacterial & fungal spectrum in the hospital reflects the increased use, particularly of the newer antibiotics • Development of resistance (MRSA, VRE, MDRTB) • Overcrowding & understaffing of nursing units increased the rates of infections
  41. Page 41 Clostridium difficile • Causes antibiotic-associated diarrhoea and pseudo membranous colitis life threatening illnesses • Normally affects only the elderly, especially those on long-term broad-spectrum antibiotics • Produces two powerful toxins and is a spore-former difficult to eradicate, resistant to alcohol • Reasons for recent increases still not known
  42. Page 42 Risk factors • Antibiotics • Healthcare environment • Acid suppression medication
  43. Page 43 Pathophysiology pseudomembrane
  44. Page 44 • Contamination rates after contact with CDAD patients • Physicians medical Students -75 of the time • Dialysis Technicians 66 of the time • Nurses -56 of the time • Physiotherapists 50 of the time • Underside of fingernails 43 • Fingertips and Palms 37 • Underside of Rings 20 • C difficile spores remain in environment in
  45. Page 45 Related to underlying health status Related to acute disease process Related to invasive procedures Related to treatment Advanced age     Surgery     Endotracheal or nasal intubation     * Blood transfusion      Malnutrition     Trauma     * Central venous catheterisation      * Recent antimicrobial therapy     Alcoholism     Burns     Extracorporeal renal support     Immunosuppressiv e treatments      Heavy smoking     Surgical drains     Stress-ulcer prophylaxis      * Chronic lung disease     Nasogastric tube     Recumbent position     Diabetes     Tracheostomy      Parenteral nutrition     Urinary catheter     * Length of stay     Factors that predispose to nosocomial infection
  46. Page 46 Patient Environment Organism  Severity of illness  Underlying disease  Nutritional state  Immunosuppression  open wounds  Invasive devices  Multiple procedures  Prolonged stay  ventilation  Multiple or prolonged antibiotics  Changes in procedures or protocols  Multiple changes in staff  Poor aseptic practice  Patient to patient (busy, crowded unit, staff shortages)  Lack of isolation facilities  No separation of clean and dirty AREAS  Lack of Hand washing facilities Inadequate decontamination of items & equipment's  Resistance  Resilience  Formation of slime  Ability to adhere  Pathogenicity  Prevalence RISK FACTORS
  47. Page 47 Bloodstream infections (BSI) Central line-associated BSI (CLABSI): A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND the line was also in place on the date of event or the day before.
  48. Page 48
  49. IV Catheter Biofilm 24 hours after Insertion
  50. Coagulase Negative Staphylococci Slime-producing, Catheter Surface
  51. Semi permanent Tunneled Catheters (Groshong, Hickman, Mediport) • long term i.v. therapy • much lower rate of infection • dacron cuff incites inflammatory response, fibrosis at insertion site • prevents bacteria from migrating along external catheter surface • locations of infection: exit site, tunnel, tip • tunnel infection always requires catheter removal • septic thrombophlebitis/pulmonary emboli
  52. Groshong catheter
  53. Intrinsic contamination of infusion fluid Connection with administration set Insertion site Injection ports Administration set connection with IV catheter Port for additives Sources of Infection 54
  54. EXAMPLE • Patient has a central line inserted on June 1. On June 3, the central line is still in place, and the patient’s blood is collected for culture. The culture is positive for S. aureus. • This is a CLABSI because the central line was in place for >2 calendar days (June 1, 2, and 3), and still in place, on the date of event (June 3).
  55. Patient has a central line inserted on June 1. On June 3, the central line is removed and on June 4 the patient’s blood is collected for culture. The culture is positive for S. aureus. •This is a CLABSI because the central line was in place for >2 calendar days (June 1, 2, and 3), and was in place the day before the date of event (June 4).
  56. • Patient has a central line inserted on June 1. On June 3, the central line is removed. On June 5 patient spikes a fever of 38.3°C and the patient’s blood is collected for culture. The culture is positive for S. aureus. • This meets LCBI Criterion 1 but it is not a CLABSI because the Date of Event (June 5) did not occur on the day the central line was discontinued (June 3) nor the next day (June 4).
  57. The CLABSI rate per 1000 central line days is calculated by dividing the number of CLABSIs by the number of central line days and multiplying the result by 1000. The Central Line Utilization Ratio is calculated by dividing the number of central line days by the number of patient days.
  59. Epidemiology of SSI •SSI infection generally occurs within 30 days following surgery •Some procedures monitored up to 90 days for SSI •2% -5% surgical patients acquire SSI (300-500K per year) •3% die (77% of deaths directly attributable to the SSI) •Many result in long term disability •SSI increases hospital length of stay 7-10 days •Cost estimates vary, ~$30,000 per SSI •Most estimates do not account for re-hospitalization, outpatient treatment, post-discharge expenses, quality of life for the patient, or any long term disability costs
  60. Source SSI Microorganisms Surgery Incidence (n/N) Gram+ve Gram-ve Type (%SSI) Bhatia 2003 18.7% (116/615) S. Epidermis (42.24%) MMSE (26.72%), MRSE (15.5%) S.aureus (15.55%) MRSA (12.06%), MSSA (3.2%) Total (12.06%) E. coli, P.aeruginosa CABG (ns) Agarwal 2003 1.6% (40/2558) S. aureus (57.5%) MRSA 35%, MSSA 22.5% P. aeruginosa (10%) Neurosurgeries (1.6%) Pawar 2005 5.1% (7/136) Staphylococcus sp. (10%) - Cardiac surgery with intraaortic balloon pulsation (5.1%) Lilani 2005 8.95% (17/190) S. aureus (35.3%) MRSA (33%) P. aeruginosa (4/17) E.coli (2/17) Thoracotomy (44.44%) Gastrointestinal surgeries Sharma 2009 2.5% (786/31927) Staphylococcus sp. Neurosurgeries (2.5%) Joyce 2009 12% (135/1125) S.aureus (33.3%) MRSA (14.0%) E faecalis (33.3%) VRE (1.4%) P. Aeruginosa (24.4%), E.coli (7.4%), Klebsiella spp(1.4%) Gastrectomy (36.4%), Cholecystectomy (15.4%), Prostatectomy (15.2%), Hysterectomy (10.4%), Appendicectomy (3.4%) Profile of Surgical site infections (SSIs) in India
  61. Patel 2011 12.72% (7/55) S. aureus (42.86%) Klebsiella sp. (ESBL) (57.14%) Colon surgery (29.41%), Amputation (50%) Sarma 2011 21% (14/66) MRSA 67%, S. aureus MSSA 33% E.faecalis E coli ESBL (43%), ESBL+ Amp-C hyperproducers (29%) Amp-C hyperproducers (14%) NDM-1 producer (14%) Post-operative patients Patel S 2012 16% (32/200) CoNS (14.3%) S. aureus (7.1%) E. coli (35.7%) Klebsiella sp. (21.4%) P. aeruginosa (14.3%) Proteus mirabilis (7.1%) Appendicetomy (0-40%) Laparotomy (19.2- 31.6%) Amputation (10-60%) Cholecystectomy (7.1- 28.6%) Nephrectomy (13.3-40%)
  62. Pathogenesis of SSI •Endogenous • Patient Flora •Skin •GI tract •Mucous membranes •Seeding from pre- existing sites of infection • Exogenous • Surgical personnel flora • Breaks in aseptic techniques • Inadequate hand hygiene • Contaminated garments • Equipment, surgical tools, materials within operative field • OR environment, including ventilation
  63. SSI Pathogens  Staphylococcus aureus - 30.0%  Coagulase-negative staphylococci - 13.7%  Enterococcus spp - 11.2%  Escherichia coli - 9.6%  Pseudomonas aeruginosa - 5.6%  Enterobacter spp - 4.2%  Klebsiella pneumonia - 3.0%  Candida spp - 2.0%  Klebsiella oxytoca - 0.7%  Acinetobacter baumannii - 0.6%
  64. SSI Surveillance Definition Categorized based on depth infection
  65. Superficial Incisional SSI Surveillance Definition Infection occurs within 30 days after surgical procedure AND Involves only skin and subcutaneous tissue of the incision AND Patient has at least 1 of the following: • Purulent drainage from the superficial incision • Organism isolated from an aseptically-obtained culture of fluid or tissue • Superficial incision that is deliberately opened by a surgeon and is culture positive or not cultured and Patient has at least one of the following signs or symptoms: pain or tenderness, localized swelling, redness, heat • Diagnosis of superficial SSI by surgeon or attending physician
  66. Deep Incisional SSI Definition Infection occurs within 30 (or 90 days) after the operative procedure AND Involves deep soft tissues of the incision, e.g., fascial & muscle layers AND Patient has at least 1 of the following: • Purulent drainage from deep incision • Deep incision spontaneously dehisces or opened by surgeon and is culture positive or not cultured and fever >38 C, localized pain or tenderness (Note: a culture negative finding does not meet this criterion) • Abscess or other evidence of infection found on direct exam, during invasive procedure, by histopathologic exam or imaging test • Diagnosis of deep SSI by surgeon or attending physician
  67. Organ Space SSI Definition Infection occurs within 30 or 90 days after the operative procedure AND Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers that is opened or manipulated during the operative procedure AND Patient has at least 1 of the following: • Purulent drainage from drain placed into the organ/space • Organism isolated from an aseptically-obtained culture of fluid or tissue in the organ/space • Abscess or other evidence of infection found on direct exam, during invasive procedure, or by histopathologic or exam or imaging test
  68. Interpreting SSI Data • To make comparisons of SSI, use a number called the SIR (standardized infection ratio) Observed SSI • SIR = -------------------- • Predicted SSI •
  69. •Consider implementing in addition to Core when infections persist or rates are high Should become standard practice
  70. SSI Prevention Strategies: Core • Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines • Administer within 1-hour prior to incision (2hr for vancomycin and fluoroquinolones) • Select appropriate agents on basis of: Surgical procedure Most common SSI pathogens for the procedure Published recommendations Discontinue antibiotics within 24hrs after surgery (48 hrs for cardiac)
  71. • Identify and treat remote infections – when possible Before elective operation • Postpone operation until infection resolved Hair removal • Do not remove hair at the operative site unless it will interfere with the operation • Do not use razors If necessary, remove by clipping or by use of a depilatory agent .
  72. • Skin Prep • Use appropriate antiseptic agent and technique for skin preparation Operating Room (OR) Traffic • Keep OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient Colorectal surgery patients • Mechanically prepare the colon (Enemas, cathartic agents) • Administer non-absorbable oral antimicrobial agents in divided doses on the day before the operation
  73. • Maintain immediate postoperative normothermia Surgical Wound Dressing • Protect primary closure incisions with sterile dressing for 24-48 hours post-op • Control blood glucose level during the immediate post-operative period - cardiac • Measure blood glucose level at 6 am on post-op day 1 and 2 (procedure day = day 0) • Maintain post-op blood glucose level at <200mg/dL
  74. SSI Prevention Strategies: Supplemental • Nasal screen for Staphylococcus aureus on patients undergoing elective cardiac surgery, orthopedic, neurosurgery procedures with implants. • decolonize carriers with mupirocin prior to surgery • Screen preoperative blood glucose levels and maintain tight glucose control post-op day 1 and 2 in patients undergoing select elective procedures. i.e., arthroplasties, spinal fusions, etc.
  75. Redose antibiotic at 3 hr intervals in procedures with duration >3 hours . Adjust antimicrobial prophylaxis dose for patients who are obese (body mass index >30) •Use at least 50% fraction of inspired oxygen intraoperatively and immediately postoperatively in select procedure(s) •Perform surveillance for SSI •Feedback surgeon-specific infection rates
  76. Page 78 Catheter-associated Urinary Tract Infections (CAUTI)
  77. • Major predisposing factor • indwelling urinary catheter • average of 26% of hospitalised patients are catheterised • risk of CAUTI is 1-2% per procedure • Risk ↑ for each additional day of catheterisation • Common in long-term catheterised patients Background to CAUTI surveillance Risk Factors
  78. Associated Risk Factors • A history of previous catheter use • Duration the catheter is in situ • Length of stay in hospital prior to catheter insertion • Location of catheter insertion
  79. CAUTI Data Definitions A healthcare associated UTI considered to be catheter associated if: • An indwelling catheter is in situ at time of onset of UTI (Criterion 1) OR • An indwelling catheter was removed within 3 days prior to the onset of UTI (Criterion 2)
  80. AND The first positive urine specimen is taken or the physician makes a diagnosis more than 48 hours after the catheter was inserted
  81. For patient’s with an indwelling catheter in situ AND ≥104 micro-organisms per ml from a catheter specimen of urine AND CAUTI Criterion 1 Definition CAUTI Data DefinitionsCAUTI Data Definitions
  82. CAUTI Criterion 1 cntd…. ONE or more of the following with no other recognised cause: • Loin Pain • Loin or suprapubic tenderness • Fever (≥38o C skin temp) • Pyuria (≥104 WBC per ml) CAUTI Data DefinitionsCAUTI Data Definitions
  83. CAUTI Criterion 2 Definition For patient’s who had catheter removal within 3 days before the onset of CAUTI AND ≥ 105 micro-organisms from a mid stream specimen AND CAUTI Data DefinitionsCAUTI Data Definitions
  84. CAUTI Criterion 2 cntd…. ONE or more of the following with no other recognised cause: • Urgency • Frequency • Dysuria • Loin Pain • Loin or suprapubic tenderness • Fever (≥ 38o C skin temp) • Pyuria (≥ 104 WBC per ml) CAUTI Data DefinitionsCAUTI Data Definitions
  85. CAUTI Definitions • CAUTI must meet one of the criteria 1 or 2 as described • Patients with asymptomatic bacteriuria/bacteria in their urine are NOT considered to have a CAUTI
  86. CASE STUDY • A 52 year male is admitted with a severe headache and is found to have a subarachnoid hemorrhage from a ruptured aneurysm. The neurosurgeons evacuate the hematoma and clip his aneurysm. Post-op he remains on a ventilator. • On hospital day 5 he spikes a fever to 102º F and is noted to have copious secretions from his endotracheal tube. Increasing amounts of inspired O2 are required. Blood and sputum cultures grow highly resistant Enterobacter cloacae.
  87. Epidemiology ofEpidemiology of Ventilator AssociatedVentilator Associated Pneumonia (VAP)Pneumonia (VAP) 90
  88. NOSOCOMIAL PNEUMONIA • The most important are patients on ventilators in ICU. • Recent and progressive radiological opacities of the pulmonary parenchyma, purulent sputum and recent onsite fever. Most commonly caused by acinetobacter.
  89. 92 Nosocomial Pneumonias Account for 15% of all hospital associated infections Account for 27% of all MICU acquired infections Primary risk factor is mechanical ventilation (risk 6 to 21 times the rate for nonventilated patients)
  90. 93 Susceptibility to Nosocomial Pneumonias IntubatioIntubatio nn AlteredAltered HostHost DefensesDefenses TrachealTracheal ColonizationColonization IncreasedIncreased NosocomialNosocomial PneumoniaPneumonia ss
  91. 94 Primary Route of Bacterial Entry into Lower Respiratory Tract  Micro or macro aspiration of oro pharyngeal pathogens  Leakage of secretions containing bacteria around the ET cuff
  92. 95 VAP Etiology  Most are bacterial pathogens, with Gram negative bacilli common  Pseudomonas aeruginosa  Proteus spp  Acinetobacter spp  Staphlococcus aureus  Early VAP associated with non-multi- antibioticresistant organisms  Late VAP associated with antibiotic- resistant organism
  93. • Hospital-acquired fevers occur in one-third of all medical inpatients • Nosocomial fevers even more common in the ICU Nosocomial Fevers 96
  94. 97 Fever in the ICU • ICU patients have several underlying medical/surgical conditions • ICU patients undergo many invasive diagnostic and therapeutic procedures • Therefore, fever in ICU patients must be thoroughly and promptly evaluated to discriminate infectious from non- infectious etiologies
  95. 98 Causes of Fever in the ICU • Surgical site infections • Intravenous-line infections • Nosocomial pneumonia • Nosocomial sinusitis • Intraabdominal infections • Urinary catheter- associated bacteriuria • Drug fever • Post-operative fever • Neurosurgical causes
  96. How To Diagnose?? • A positive result of semi quantitative Culture ( 15 CFU per catheter segment) or quantitative ( 102 CFU per catheter segment) catheter culture, whereby the same organism isolated from a catheter segment and a peripheral blood sample • Simultaneous quantitative cultures of blood samples with a ratio of 5 : 1 (CVC vs. peripheral) • Differential time to positivity :positive result of culture from a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood) 99
  97. Biomarkers • Procalcitonin (PCT)-: The peptide procalcitonin is synthesized by monocytes that are in the process of adhesion. PCT levels rise when there is local or systemic bacterial infection but not in the presence of a virus or autoimmune disease. Thus, PCT is more specific than CRP for detecting bacterial infection. • C-reactive protein (CRP)-This acute phase protein is released by the liver in response to inflammation or tissue insult and is widely used as a highly nonspecific marker of sepsis.
  98. Diagnosis of ventilator-associated pneumonia • Gram staining, quantifying microorganisms in polymorphonuclear cells in bronchoalveolar lavage samples. PCR assays • Nuclear material extracted from BAL • qPCR amplified up 16s DNA –i.e. quantifies bacterial load • Quantitative assay, therefore the time to crossing the ‘threshold’ is inversely proportional to the amount of 16s DNA present. • Shorter time to crossing threshold (Ct) indicates higher burden of bacteria • Compared to conventional culture as the ‘gold standard’
  99. Surviving Sepsis Campaign
  100. • Step 1: Screening and Management of Infection • Step 2: Screening for Organ Dysfunction and Management of Sepsis (formerly called Severe Sepsis)
  101. Sepsis Core Measure (SEP-1) Highlights SIRS Criteria • Temp >101 • Temp < 96.8 • HR > 90 • RR > 20 • WBC > 12,000 • WBC < 4000 • > 10% Bandemia Organ Dysfunction Variables • SBP < 90 • MAP < 70 • SBP decrease > 40 from known baseline • Cr > 2.0 • UOP < 0.5 ml/kg/hr for > 2 hours • Bilirubin > 2.0 • Platelets < 100,000 • INR > 1.5 or PTT > 60 secs • Altered Mental Status • Lactate > 2
  102. Septic shock • severe sepsis with hypoperfusion despite adequate fluid resuscitation or a lactate > 4. • Within 3 hours of presentation: Measure serum lactate Obtain blood cultures prior to antibiotics Administer antibiotics Within 6 hours of presentation: Repeat serum lactate if initial lactate is >2 For septic shock: • Within 3 hours of presentation: Measure serum lactate Obtain blood cultures prior to antibiotics Administer antibiotics Resuscitation with 30mL/kg crystalloid fluids Within 6 hours of presentation: Repeat volume status and tissue perfusion assessment Vasopressor administration (If hypotension persists after fluid)
  103. Recommendations: Initial Resuscitation and Infection Issues sepsis-2 • Initial Resuscitation • Screening for Sepsis and Performance Improvement. • Diagnosis • Antimicrobial therapy. • Source control • Infection Prevention
  104. BUNDLES • WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L • With in 6 hours • Vasopressors - to maintain a mean arterial pressure (MAP) ≥65 mm Hg • Re-assess volume status and tissue perfusion and document findings. • Re-measure lactate if initial lactate elevated.
  105. Conclusion Nosocomial infections are associated with a great deal of morbidity, mortality and increased financial burden. Intensive care is a risk factor for the emergence of antibiotic resistant bacteria. Gram-positive bacteria have overtaken Gram-negative organisms as the predominant cause of nocosomial infections.
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Hinweis der Redaktion

  1. Ignaz Philipp Semmelweis (1818-65), a Hungarian obstetrician, introduced antiseptic hand hygiene techniques. Semmelweis noted that post-partum women examined by medical students who did not wash their hands after performing autopsies had high mortality rates. He required students to clean their hands with chlorinated lime before examining patients Maternal mortality declined from 12% to less than 1% after this hand hygiene intervention was implemented.
  2. Nosocomial infections have been recognized for over a century as a critical problem affecting the quality of health care and a principal source of adverse healthcare outcomes. Today, nosocomial infections affect over 2 million patients annually in the United States, at a cost in excess of $4.5 billion. Among all major complications of hospitalization, nosocomial infections account for 50%; the remaining are medication errors, patient falls, and other noninfectious adverse events.
  3. (Glynn et al, 1997)
  4. 2nd point: This is to ensure detection of CAUTI’s which may have been incubating prior to the removal of the catheter.
  5. Accounts for 15% of all hospital associated infections Accounts for 27% of all MICU acquired infections Primary risk factor is mechanical ventilation (risk 6 to 21 times the rate for nonventilated patients). Within 48 hours of intubation, the upper respiratory tract is colonized with bacteria, most commonly Gram negative bacilli.
  6. A primary factor in the high incidence of nosocomial pneumonias in critically ill patients is probably related to the intubation of their respiratory tract for airway management and ventilatory support. This invasion, coupled with altered host defenses, is a treacherous combination. Many critically ill patients are immunocompromised due to their underlying problem, such as HIV disease, cancer or related to the stress of the critical illness. Quickly the trachea becomes colonized with a variety of organisms, most notably, Gram negative bacilli, leading to infection of the lower respiratory tract, pneumonia.
  7. Early VAP (within 96 hours) is associated with non-multi-antibiotic-resistant organisms: E coli Klebsiella Proteus Streptococcus pneumoniae Hemophylus influenza Oxacillin sensitive Staphlococcus aureus Late VAP associated with antibiotic-resistant organisms: Pseudomonas aeruginosa Oxacillin resistance Staphaerius and Acinetobacter