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HOSPITALACQUIRED
INFECTIONS
DrKhushdeep
DrImtiaz
Introduction & Etiology
Hospital infection control
Introduction &Etiology
• Definition
• Criteriafor hospital Acquired Infections
• Impact on Economy & Health state
• Factorsaffecting development HAIs
• Sourcesof Infection
• Modesof Infection
• HAIsat different body sites
• At extremesof age
• Hospitalsbring together vulnerablehosts
• Subject them to particular risksof infection
• Causeof morbidity and mortality
• Limitseffectiveness, addsgreatly to cost
Hospital-acquired infection (HAI)
( nosocomial infection)
• An infectio n acquired in ho spitalby a patient who was
admitted fo r a reaso n o ther than that infectio n .
or
• An infectio n o ccurring in a patient in a ho spitalo r
o ther health care facility in who m the infectio n was no t
present o r incubating at the time o f admissio n. This
includes infectio ns acquired in the ho spitalbut
appearing after discharge, and also o ccupatio nal
infectio ns amo ng staff o f the facility
• ‘healthcare-associated infection’
Hospital acquired infections, management and control
Impact of HAI
• Add to functional disability and emotional stress
• May lead to disabling conditionsthat reducethe
quality of life
• Oneof theleading causesof death
• Add to theimbalancebetween resourceallocation
• Significant cause of increased morbidity and mortality in
hospitalized patients
• 80% of all hospital deaths are directly or
indirectly related to HAIs(Hugheset al., 2005)
• Prevalence varies from 3.8% to 18.6% depending on the
population surveyed and thedefinitionsused (Jensen, 2008)
• Economic burden
Factors influencing
development of HAI
• The microbial agent
- resistanceto antimicrobial agents
- intrinsic virulence
- amount of infectivematerial.
• Patient susceptibility
- age
- immunestatus
- underlying disease
- diagnostic and therapeutic interventions
- extremesof life
• Environmental factors
- Crowded conditionswithin thehospital
- frequent transfersof patientsfrom oneunit to
another
- concentration of patientshighly susceptibleto
infection in onearea
• Bacterial resistance
- Through selection and exchangeof genetic
resistanceelements, antibioticspromotethe
emergenceof multidrug resistant strainsof bacteria
Source of the infecting
organism
• Can be:
- exogenous(equipment)
- another patient ( crossinfection )
- hospital staff
- hospital environment
- endogenous
Modes of Spread of Infection
1. By Contact:
• Staff
• Environment (including operation theatre)
• Equipment (including blood products)
2. Air borne
3. Water borne
4. Food borne
1. Infection by contact
From staff:
• Resident (persistent over timeand not readily removed by hand
washing)
• Transient (recently acquired from another source)
• Important microorganismsare
- S. aureus
- Klebsiellaspp.
- Serratiaspp.
• Other lesscommon organismsare
- antibiotic resistant enterococci
- C. difficile
- Corynebacterium diphtheriae
- candidaalbicans
- RSV
- Rhinoviruses
From the patient’s
environment
• Becomescontaminated with bacteriacarried by a
patient
• Includes
- VRE
- MRSA
- A. baumanii
- P. aeruginosa
- C. difficile
Infection in operating theater
• Most infectionsarisefrom thepatient’sown flora
• Theremainder areacquired mainly from staff in OT
• Ultraclean air – very low ratesof clinical infection
• But
- increased operativeskills
- prophylactic useof antibiotics
may haveplayed apart
From equipment
Patientswith impaired immunity
• Adhesiveplaster contaminated with - Rizopus
• Unsterilewooden tonguedepressors- Rizopus
• Bedpansand urinals
- C. difficile
- antibiotic resistant GNB
• Rectal thermometers
- salmonellae
- enterococci
• Fiberoptic endoscopes
- Salmonellaspp.
- P. aeruginosa
- M. tuberculosis
- H. pylori
- hepatitisB ( rarely )
- HIV not been reported
Infection by inoculation
• Infrequent in developed world
- introduction of single-usedisposableneedles
- satisfactory sterilization of surgical instruments
• Theprions– highly resistant
• Risk of infectionsstill persist in situationslike:
- transmitted by blood transfusion or tissuedonation
- accidental injury from contaminated sharp instruments
- contaminated blood
- contaminated infusion fluids
Blood transfusion and tissue
donation
• Risk of transmission of 3 most important agents
- hepatitisB, C and HIV hasbeen reduced
• Other lesscommon infections
- HepatitisD & G - syphilis
- Cytomegalovirus - salmonellosis
- Epstein-Barr virus - malaria
- Parvovirus - trypanosomiasis
- HTLV-1 - toxoplasmosis
- Brucellosis - babesiosis
- filariasis
Infection from accidental
inoculation
• Tuberculosisof skin ( prosector’swart )
• HepatitisB
• HepatitisC
• HIV
Infection from contaminated
infusion fluid
• TPN fluidssuch asprotein hydrolysatewith or
without dextrose, readily support thegrowth of
organisms, particularly
- Klebsiella
- Enterobacter
- Candidaspp.
Ventilator-associated
pneumonia
• Mortality rate: 6-14%
• Risk factorsinclude
- eventsthat increasecolonization by potential
pathogens
- thosethat facilitateaspiration of oropharyngeal
contentsinto thelower respiratory tract
- thosethat reducehost defencemechanismsin the
lung and permit overgrowth of aspirated pathogens
Infection associated with
indwelling medical devices
• Thepredominating bacteriaare
- CoNS, particularly S. epidermidis
- S. aureus
- Corynebacteria
- Propionibacteria
- Streptococci
- Yeastsand filamentousfungi
Intravascular cannulae
• Plastic cannulaevs. steel needles
• May remain silent
• Simplefever, septicemiaor disseminated infection
• Rateof colonization dependson
- site( LL>UL)
- fluid infused ( TPN )
- design of cannula
- plastic used
- aseptic precautionsat insertion
Intravascular grafts:
• Cardiac valveprosthesis
• Patchesof polymers
• Graftsin vessels
Joint prosthesis:
• A very seriousand costly complication
• Incidencehasreduced to <2%
• - prophylactic antibiotics
• - ultraclean air
• - incorporation of antibiotic in bonecement
• Spectrum of organismsinclude
- S. aureus
- CoNS
- Enterobacteria
- Streptococci ( mainly enterococci )
- Fungal infection - rare
Cerebrospinal fluid shunts:
• Infection may giveriseto
- systemic illnessfrom bacteremia
- ventriculitis
- shunt blockage
• S. epidermidis– most common infecting agent
2. Air-borne spread
• Effectivenessof thisroutedependson
- number of microorganismspresent
- degreeof dispersal
- survival and retention of pathogenicity by the
microorganism in theair or environment
- sizeof theinfecting dose
- local and general susceptibility of thepersons
exposed
• Bacteria, Virus, Fungus: all areculprits
Tuberculosis
• Air bornespread can occur by transfer of Very few
microorganisms
• Patientsdiffer in ability to transmit TB
• Only patientswith smear positivepulmonary
tuberculosisareregarded asconstituting an infection
risk and requiresingleroom isolation
• Infectivity declinesrapidly after effectivetreatment
• MDR TB in HIV patients
Pneumococcal infection
• Most infection by Spneumoniaeisendogenous
• Not customary to isolatepatients
• Diagnosed by Gram stain of sputum- advisableto
isolatepatientsfor thefirst 24 h of treatment
• Protection of vulnerablepatientswith polyvalent
vaccinebecomesmoreimportant asresistance
increases
Meningococcal infection
• Uncommon
• Isolation for first 48 h of treatment isadvisable
• Among staff, only thosewho havehad closecontact
with thepatient need to beoffered prophylactic
antibiotics
Other bacteria:
• Saureus
• Spyogenes
• Paeruginosa
Viral infection
• Chicken pox
• Measles
• Influenza
• Respiratory syncitial virus(RSV)
• Small round structured viruses(SRSV) - noroviruses
Fungal infection
• Dispersal by spores– most filamentousfungi
• Only Aspergillusspp. havebeen shown to bea
significant causeof air borneinfection
- after cardiac surgery
- in immunosuppressed patients
• Phycomycetes– occasionally
• Cryptococcusneoformans– no convincing evidence
3. Infections associated with
water
Legionnaires’ disease
• Thelegionellaceaearewidespread in water
• Legionellapneumophila( particularly serotype1)
• Water in equipment that deliversnebulized spray
• Hot water systems
• Air cooling towers
• Sourceof infection – environmental water
• Person to person spread isunknown
Otherbacteria:
• Aeromonashydrophila– pneumonia
• Pseudomonasspp.
• Burkholderiacepacia
4. Infection acquired from food
• Salmonellainfections- poultry, eggs
• Clostridium perfringens– meat
• Can beasourceof antibiotic-resistant bacteria
- P. aeruginosa
- Escherichiacoli
- Klebsiellaspp.
• Catering faultsmost often responsible:
- failureof staff to follow good practice
- incompletedefrosting of frozen meatsand poultry
- insufficient cooking of largeamountsof food
- useof raw or insufficiently cooked egg products
- inadequatechilling and storage
Hospital Infections at various
body sites
Hospital acquired infections, management and control
Urinary tract
• 40-45% of nosocomial infections
• Associated with
- urethral catheterization
- cystoscopy
- transurethral prostatectomy
• Routeof infection isbetween thecatheter and the
urethral wall
• Early infection isby local commensals
- E. coli
- CoNS
- Enterococci
• Later moreresistant hospital associated GNB
- Klebsiella
- Proteus
- Serratia
- Pseudomonasmay invade
• Benign and symptomlessin many patients
• Somedevelop pyelonephritis, epididymoorchitis
Eye
• Corneaisconsidered sterile
• But conjunctivaiscolonized
- CoNS
- Corynebacterium spp.
- Propionibacterium spp.
• Useof contact lenses, postoperativeinfection
• Infection after cataract surgery hasdeclined
• Endophthalmitis- following surgery, penetrating
trauma
• Keratoconjunctivitiscaused by P. aeruginosa
• Epidemicscaused by adenovirustype8 – speed by
instruments, handsof staff
• Hospital acquired bacterial conjunctivitis-in neonatal
units
GIT
• Gastroenteritis:
• most common nosocomial infection in children
- Rotavirus
• Clo stridium difficile - major causein adults
Peritoneum
• Peritonitisisoneof theclassical association of
surgery
• Peritoneal dialysisisoften complicated by peritoneal
infection by GNB
• CAPD peritonitishasdifferent spectrum of etiologic
agentsand CoNS( S. epidermidis) account for about
half thecases
• Patient motivation, good surgical technique,
occlusivedressing
Nosocomial pneumonia
• 15–20% of nosocomial infections
• Almost all casesarecaused by aspiration of
endogenousor hospital-acquired oropharyngeal (and
occasionally gastric) flora
• associated with moredeathsthan infectionsat any
other body site.
• Early-onset nosocomial pneumonia
(within thefirst 4 daysof hospitalization)
- Strepto co ccus pneumo niae
- Haemo philus species
• Late-onset pneumonias
- S. aureus
- P. aerugino sa
- Entero bacter species
- Klebsiella pneumo niae
- Acineto bacter
Surgical site infections…
• 0.5-15% of HAI
• A causeof morbidity, prolonged hospital stay
• S.aureus( MRSA )- dominating species
SSI…
Predisposing factors
- ageover 60 years
- long post operativestay
- pre-existing infection at thesiteof thewound
- underlying diseases-DM, immunosuppression, irradiation,
malnutrition
infection isusually acquired during theoperation itself;
- either exogenously (e.g. from theair, medical
equipment, surgeonsand other staff)
- endogenously from thefloraon theskin or in the
operativesite( predominantly )
- rarely, from blood used in surgery
…SSI
• Themain risk factorsare
- Extent of contamination during theprocedure
(clean, clean-contaminated, contaminated, dirty)
- Presenceof foreign bodiesincluding drains
- Virulenceof themicroorganisms,
- Concomitant infection at other sites
- Useof preoperativeshaving
- Experienceof thesurgical team
Burns
• A suitablesitefor bacterial multiplication
• S. aureusand P. aeruginosa-most common isolates
• Enterobacteria
• Other gram negativebacilli such asacinetobacter
• Bacteriareach burnsmainly by indirect contact
• Colonization without invasion isfar morecommon
than invasiveinfection
• Air borneinfection ismoreimportant for S. aureus
than for GNB
Hospital Infections at
extremes of life
How are these different…?
• Immunocompromised states
• Hospital infection and infection control isoften
neglected
- Declining defenses
- Multipleunderlying chronic diseases
- Long stay at hospitals
• CAUTION:
- Proteus, Providenciaspp.
- tuberculosis, influenzaA virus
- Salmonellainfection
- CDAD
Neonatal units
• Underdeveloped defenses, lack of normal flora
(particularly in prematurebabies)
• Ill babiesrequiremuch handling by staff
• CAUTION:
- MRSA
- Klebsiella
- P. aeruginosa
- Serratia
- S. epidermidis
Hospital acquired infections, management and control
Hospital acquired infections, management and control
Hospital acquired infections
Management and control
HAI control
• Although eradication of HAI is impossible, a well-conducted
surveillance and prevention program may significantly reduce
HAI and associated costs
• Identification of high risk population
• Identification of diseases at an early stage
• Treatment
• Environment
• Periodic surveillance
Surveillance
• Systematic observation and recording of diseases
• An active ongoing process
• Results can be used as an indicator of quality of
care
• Prospective surveillance is costly; therefore,
point prevalence surveyspoint prevalence surveys are preferred for
determining the magnitude of HAIs in
countries with limited resources
Guidelines
• Identifying patients at risk
• Observing hand hygiene
• Standard precautions to reduce
transmission of infection
• Strategies to reduce VAP, CR-BSI, CAUTI
• Designated infection control team(s)
*VAP: ventilator associated pneumonia
*CRBSI: catheter related blood stream infection
*CAUTI: catheter associated urinary tract infection
Identifying patient at risk
• Burns patients
• Immunodeficient patients
• Transplant recipients
• Chronically debilitated patients
• Major surgery
• Ventilator support
• Indwelling catheters
• Prolonged ICU stay (>3 days)
• Old age
• Frequent blood transfusion
Isolation
• Keep the patient away from potential sources of
infection
• Assess the need for isolation
– Neutropenia and immunological disorder
– Burns
– Diarrhea
– Skin rashes
– Known communicable disease
– Carriers of an epidemic strain of bacterium
• Identify the type of isolation
– Protective isolation
– Source isolation
• Isolation rooms should have:
– Tight-fitting doors
– Glass partitions for observation
– Negative -pressure (for source isolation) ventilation
– Positive- pressure (for protective isolation)
ventilation
Hand hygiene
• Hands are the most common vehicle for
transmission of organisms
• Single most effective means of preventing the
horizontal transmission of infections among
hospital patients and health care personnel
Hospital acquired infections, management and control
Hospital acquired infections, management and control
Hand hygiene
• During surgical hand preparation, all hand
jewelries (e.g. rings, watches and bracelets)
must be removed
• Finger nails should be trimmed
Standard precautions
• All cases
• Gloves
• Gown
• Mask, eye protection/face shield
• Shoe and head coverings
• Patient ­care equipments
• Avoid wearing long sleeves
• House coats are discouraged and
wearing scrubs is encouraged
Transmission­ based
precautions
• Patients known or suspected to have airborne,
contact or droplet infections:
1. Isolate with negative­ pressure ventilation
2. Respiratory protection
3. Disposable N­95 respirator mask
4. Limit transport of the patient
Specific strategies ­ specific
nosocomial infections
1. Strategies to reduce VAP
2. Strategies to reduce CRBSI
3. Strategies to reduce UTI
Strategies to reduce UTI
• Catheters only for
appropriate indications
• Closed drainage system
• Unobstructed urine flow
• Changing indwelling
catheters at fixed intervals
is not recommended
• Remove the catheter
when it is no longer
needed
Strategies to reduce VAP
• Avoid intubation whenever possible
• Prefer oral intubations to nasal
• Keep head elevated at 30° ­ ­45° in the
semi­­recumbent position
• Daily oral care with chlorhexidine solution
• Sedation­vacationSedation­vacation and readiness to intubate
• Routine change of ventilator circuits is not
required
• Prefer endotracheal tubes with a subglottic
suction port
• Closed endotracheal suction systems are
better
• Periodically drain and discard any
condensate
Strategies to reduce CRBSI
• Avoid femoral route for central venous
cannulation, prefer upper extrimity
• Maximal sterile barrier precautions, and a sterile
full­body drape while inserting CVCs
• Clean skin usually with 2% chlorhexidine with
70% ethanol
• Chlorhexidine/silver sulfadiazine or minocycline /
rifampin­­impregnated CVCs
• Ultrasound­ guided insertion
• 2% chlorhexidine wash daily for skin cleansing
Environmental factors
1. Cleaning and disinfection
2. Architecture and layout
3. Organizational and administrative measures
Cleaning and disinfection
• Some pathogens can survive for long periods in the
environment, particularly MRSA, VRE, Acinetobacter species
• High ­quality cleaning and disinfection of all patient ­care
areas, bedrails, bedside tables, doorknobs and equipment
• Disinfectants or detergents that best meet the overall needs
of the ICU should be used for routine cleaning and
disinfection
• Surface cleaning (walls) twice weekly, floor cleaning 2­­3
times/day and terminal cleaning (patient bed area) after
discharge or death
Architecture and layout
• Situated close to the operating theater and emergency
department for easy accessibility, but should be away from the
main ward areas
• Central air­ conditioning systems with appropriate filters, air
should be filtered to 99% efficiency down to 5 μm5 μm
• Minimum of six total air changes per room per hour, with two
air changes per hour composed of outside air
• Isolation facility should be with both negative­ and positive­
pressure ventilations
• Adequate space around beds is ideally 2.5­­3 m
• Adequate number of washbasins with alcohol gel dispensers
Organisational and administrative
measures
• Better patient to nurse ratio in the ICU
• Controlling traffic flow to and from the unit to reduce
sources of contamination
• Waste and sharp disposal policy
• Education and training for ICU staff
• ICU protocols and SOPs
• Audit and surveillance of infections and infection control
practices
• Infection control team (multidisciplinary approach)
• Antibiotic stewardship
• Vaccination of health care personnel
Infection Prevention in Burns Patients
• Burn wounds can provide optimal conditions for colonization,
infection and transmission of pathogens
• Source of infection: staphylococcistaphylococci located deep within sweat
glands and hair follicles
• Routine surveillance cultures:
– Early identification of organisms
– Monitor the effectiveness of current wound
treatment
– Guide an appropriate antibiotic therapy
– Weekly
• Stringent isolation guidelines
• Antibiotic prophylaxis: role of topical antimicrobials > systemic
antibiotics
• Early enteral feeding: increases circulation to the bowel,
thereby decreasing ischemia post ­injury and the translocation
of bowel flora
• Human tetanus immunoglobulin (250­­500 IU)
Immuno­compromised and
Transplant Patients
• Greatest risk of infection caused by airborne or waterborne
microorganisms
• Neutropenic for prolonged periods (ANC < 500 cell/cumm)
• Opportunistic infectionsOpportunistic infections
– Exogenous acquisition of a particularly virulent
pathogen, e.g. meningococcal meningitis or
pneumococcal pneumonia
– Reactivation of an endogenous latent organism, eg,
herpes zoster virus, Mycobacterium tuberculosis
– Endogenous invasion of a normally commensal or
saprophytic organism
Post ­transplant period
1. During the first month after transplantation:
– >95% of the infections are due to bacterial or candida
infection of the surgical wound, vascular access,
endotracheal tube, or drainage catheters
1. During the period 1­­6 months after transplantation:
1.Two classes of infection : Infections caused by
immunomodulatory viruses and infections caused by
opportunistic pathogens such as Pneumocystis carinii,
Listeria monocytogenes and Aspergillus species
• In the late period:
1.Cryptococcus neoformans, P. carinii and L.
monocytogenes
Monitoring of Infection Control
Antimicrobial Stewardship
• Multidisciplinary antimicrobial stewardship program
• Antibiotic stewardship refers to a set of coordinated strategies
to improve the use of antimicrobial medications with the goal
of enhancing patient health outcomes, reducing resistance to
antibiotics, and decreasing unnecessary costs
• Infectious disease physician and a clinical pharmacist with
infectious disease training
• Clinical microbiologist, an information system specialist, an
infection control professional and hospital epidemiologist
• Close collaboration between the antimicrobial stewardship
team, microbiology lab, hospital pharmacy and infection
control team
Goal
• Reduce inappropriate use of antibiotics; use of appropriate
antibiotics based on C&S reports
• Antimicrobial cycling to decrease antibiotic resistance (? use)
• Routine use of combination therapy
• Optimizing antibiotic dose taking into consideration pk/pd
characteristic
• Early switch from parenteral to oral antibiotics
• Decreasing duration of antibiotic use as per clinical guideline
• Optimal use of microbiology lab is an essential ingredient of
any stewardship program
Conclusion
• Nosocomial infections are widespread. They are important
contributors to morbidity and mortality
• They will become even more important as a public health
problem with increasing economic and human impact
because of:
­ Increasing numbers and crowding of people
­ New microorganisms
­ Increasing bacterial resistance to antibiotics
• Prevention is better than control
Thank you
References
• Guidelines for prevention of hospital acquired infections Yatin Mehta,
Abhinav Gupta, Subhash Todi, SN Myatra, D. P. Samaddar, Vijaya Patil,
Pradip Kumar Bhattacharya, and Suresh Ramasubban; Indian J Crit Care
Med. 2014 Mar; 18(3): 149–163.
• WHO guidelines on hand hygiene in health care: A summary. 2014. Mar 10
• Maselli DJ, Restrepo MI. Strategies in the prevention of ventilator­associated
pneumonia. Ther Adv Respir Dis. 2011;5:131–41. [PubMed: 21300737]
• Guidelines for the prevention of intravascular catheter ­related infections;
http://www.cdc.gov/hicpac/pdf/guidelines/bsi­guidelines­2011.pdf
• Guidelines for prevention of catheter­ associated urinary tract infections;
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf .
• Malhotra S, Sharma S, Hans C; Prevalence of Hospital Acquired Infections in
a tertiary care hospital in India; Department of Microbiology, PGIMER and Dr
RML Hospital New Delhi; International Invention Journal of Medicine and
Medical Sciences (ISSN: 2408­7246) Vol. 1(7) pp. 91­94, July, 2014

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Hospital acquired infections, management and control

  • 3. Introduction &Etiology • Definition • Criteriafor hospital Acquired Infections • Impact on Economy & Health state • Factorsaffecting development HAIs • Sourcesof Infection • Modesof Infection • HAIsat different body sites • At extremesof age
  • 4. • Hospitalsbring together vulnerablehosts • Subject them to particular risksof infection • Causeof morbidity and mortality • Limitseffectiveness, addsgreatly to cost
  • 5. Hospital-acquired infection (HAI) ( nosocomial infection) • An infectio n acquired in ho spitalby a patient who was admitted fo r a reaso n o ther than that infectio n . or • An infectio n o ccurring in a patient in a ho spitalo r o ther health care facility in who m the infectio n was no t present o r incubating at the time o f admissio n. This includes infectio ns acquired in the ho spitalbut appearing after discharge, and also o ccupatio nal infectio ns amo ng staff o f the facility • ‘healthcare-associated infection’
  • 7. Impact of HAI • Add to functional disability and emotional stress • May lead to disabling conditionsthat reducethe quality of life • Oneof theleading causesof death • Add to theimbalancebetween resourceallocation
  • 8. • Significant cause of increased morbidity and mortality in hospitalized patients • 80% of all hospital deaths are directly or indirectly related to HAIs(Hugheset al., 2005) • Prevalence varies from 3.8% to 18.6% depending on the population surveyed and thedefinitionsused (Jensen, 2008) • Economic burden
  • 9. Factors influencing development of HAI • The microbial agent - resistanceto antimicrobial agents - intrinsic virulence - amount of infectivematerial. • Patient susceptibility - age - immunestatus - underlying disease - diagnostic and therapeutic interventions - extremesof life
  • 10. • Environmental factors - Crowded conditionswithin thehospital - frequent transfersof patientsfrom oneunit to another - concentration of patientshighly susceptibleto infection in onearea • Bacterial resistance - Through selection and exchangeof genetic resistanceelements, antibioticspromotethe emergenceof multidrug resistant strainsof bacteria
  • 11. Source of the infecting organism • Can be: - exogenous(equipment) - another patient ( crossinfection ) - hospital staff - hospital environment - endogenous
  • 12. Modes of Spread of Infection 1. By Contact: • Staff • Environment (including operation theatre) • Equipment (including blood products) 2. Air borne 3. Water borne 4. Food borne
  • 13. 1. Infection by contact From staff: • Resident (persistent over timeand not readily removed by hand washing) • Transient (recently acquired from another source) • Important microorganismsare - S. aureus - Klebsiellaspp. - Serratiaspp. • Other lesscommon organismsare - antibiotic resistant enterococci - C. difficile - Corynebacterium diphtheriae - candidaalbicans - RSV - Rhinoviruses
  • 14. From the patient’s environment • Becomescontaminated with bacteriacarried by a patient • Includes - VRE - MRSA - A. baumanii - P. aeruginosa - C. difficile
  • 15. Infection in operating theater • Most infectionsarisefrom thepatient’sown flora • Theremainder areacquired mainly from staff in OT • Ultraclean air – very low ratesof clinical infection • But - increased operativeskills - prophylactic useof antibiotics may haveplayed apart
  • 16. From equipment Patientswith impaired immunity • Adhesiveplaster contaminated with - Rizopus • Unsterilewooden tonguedepressors- Rizopus • Bedpansand urinals - C. difficile - antibiotic resistant GNB • Rectal thermometers - salmonellae - enterococci
  • 17. • Fiberoptic endoscopes - Salmonellaspp. - P. aeruginosa - M. tuberculosis - H. pylori - hepatitisB ( rarely ) - HIV not been reported
  • 18. Infection by inoculation • Infrequent in developed world - introduction of single-usedisposableneedles - satisfactory sterilization of surgical instruments • Theprions– highly resistant • Risk of infectionsstill persist in situationslike: - transmitted by blood transfusion or tissuedonation - accidental injury from contaminated sharp instruments - contaminated blood - contaminated infusion fluids
  • 19. Blood transfusion and tissue donation • Risk of transmission of 3 most important agents - hepatitisB, C and HIV hasbeen reduced • Other lesscommon infections - HepatitisD & G - syphilis - Cytomegalovirus - salmonellosis - Epstein-Barr virus - malaria - Parvovirus - trypanosomiasis - HTLV-1 - toxoplasmosis - Brucellosis - babesiosis - filariasis
  • 20. Infection from accidental inoculation • Tuberculosisof skin ( prosector’swart ) • HepatitisB • HepatitisC • HIV
  • 21. Infection from contaminated infusion fluid • TPN fluidssuch asprotein hydrolysatewith or without dextrose, readily support thegrowth of organisms, particularly - Klebsiella - Enterobacter - Candidaspp.
  • 22. Ventilator-associated pneumonia • Mortality rate: 6-14% • Risk factorsinclude - eventsthat increasecolonization by potential pathogens - thosethat facilitateaspiration of oropharyngeal contentsinto thelower respiratory tract - thosethat reducehost defencemechanismsin the lung and permit overgrowth of aspirated pathogens
  • 23. Infection associated with indwelling medical devices • Thepredominating bacteriaare - CoNS, particularly S. epidermidis - S. aureus - Corynebacteria - Propionibacteria - Streptococci - Yeastsand filamentousfungi
  • 24. Intravascular cannulae • Plastic cannulaevs. steel needles • May remain silent • Simplefever, septicemiaor disseminated infection • Rateof colonization dependson - site( LL>UL) - fluid infused ( TPN ) - design of cannula - plastic used - aseptic precautionsat insertion
  • 25. Intravascular grafts: • Cardiac valveprosthesis • Patchesof polymers • Graftsin vessels
  • 26. Joint prosthesis: • A very seriousand costly complication • Incidencehasreduced to <2% • - prophylactic antibiotics • - ultraclean air • - incorporation of antibiotic in bonecement • Spectrum of organismsinclude - S. aureus - CoNS - Enterobacteria - Streptococci ( mainly enterococci ) - Fungal infection - rare
  • 27. Cerebrospinal fluid shunts: • Infection may giveriseto - systemic illnessfrom bacteremia - ventriculitis - shunt blockage • S. epidermidis– most common infecting agent
  • 28. 2. Air-borne spread • Effectivenessof thisroutedependson - number of microorganismspresent - degreeof dispersal - survival and retention of pathogenicity by the microorganism in theair or environment - sizeof theinfecting dose - local and general susceptibility of thepersons exposed • Bacteria, Virus, Fungus: all areculprits
  • 29. Tuberculosis • Air bornespread can occur by transfer of Very few microorganisms • Patientsdiffer in ability to transmit TB • Only patientswith smear positivepulmonary tuberculosisareregarded asconstituting an infection risk and requiresingleroom isolation • Infectivity declinesrapidly after effectivetreatment • MDR TB in HIV patients
  • 30. Pneumococcal infection • Most infection by Spneumoniaeisendogenous • Not customary to isolatepatients • Diagnosed by Gram stain of sputum- advisableto isolatepatientsfor thefirst 24 h of treatment • Protection of vulnerablepatientswith polyvalent vaccinebecomesmoreimportant asresistance increases
  • 31. Meningococcal infection • Uncommon • Isolation for first 48 h of treatment isadvisable • Among staff, only thosewho havehad closecontact with thepatient need to beoffered prophylactic antibiotics Other bacteria: • Saureus • Spyogenes • Paeruginosa
  • 32. Viral infection • Chicken pox • Measles • Influenza • Respiratory syncitial virus(RSV) • Small round structured viruses(SRSV) - noroviruses
  • 33. Fungal infection • Dispersal by spores– most filamentousfungi • Only Aspergillusspp. havebeen shown to bea significant causeof air borneinfection - after cardiac surgery - in immunosuppressed patients • Phycomycetes– occasionally • Cryptococcusneoformans– no convincing evidence
  • 34. 3. Infections associated with water Legionnaires’ disease • Thelegionellaceaearewidespread in water • Legionellapneumophila( particularly serotype1) • Water in equipment that deliversnebulized spray • Hot water systems • Air cooling towers • Sourceof infection – environmental water • Person to person spread isunknown
  • 35. Otherbacteria: • Aeromonashydrophila– pneumonia • Pseudomonasspp. • Burkholderiacepacia
  • 36. 4. Infection acquired from food • Salmonellainfections- poultry, eggs • Clostridium perfringens– meat • Can beasourceof antibiotic-resistant bacteria - P. aeruginosa - Escherichiacoli - Klebsiellaspp.
  • 37. • Catering faultsmost often responsible: - failureof staff to follow good practice - incompletedefrosting of frozen meatsand poultry - insufficient cooking of largeamountsof food - useof raw or insufficiently cooked egg products - inadequatechilling and storage
  • 38. Hospital Infections at various body sites
  • 40. Urinary tract • 40-45% of nosocomial infections • Associated with - urethral catheterization - cystoscopy - transurethral prostatectomy • Routeof infection isbetween thecatheter and the urethral wall
  • 41. • Early infection isby local commensals - E. coli - CoNS - Enterococci • Later moreresistant hospital associated GNB - Klebsiella - Proteus - Serratia - Pseudomonasmay invade • Benign and symptomlessin many patients • Somedevelop pyelonephritis, epididymoorchitis
  • 42. Eye • Corneaisconsidered sterile • But conjunctivaiscolonized - CoNS - Corynebacterium spp. - Propionibacterium spp. • Useof contact lenses, postoperativeinfection
  • 43. • Infection after cataract surgery hasdeclined • Endophthalmitis- following surgery, penetrating trauma • Keratoconjunctivitiscaused by P. aeruginosa • Epidemicscaused by adenovirustype8 – speed by instruments, handsof staff • Hospital acquired bacterial conjunctivitis-in neonatal units
  • 44. GIT • Gastroenteritis: • most common nosocomial infection in children - Rotavirus • Clo stridium difficile - major causein adults
  • 45. Peritoneum • Peritonitisisoneof theclassical association of surgery • Peritoneal dialysisisoften complicated by peritoneal infection by GNB • CAPD peritonitishasdifferent spectrum of etiologic agentsand CoNS( S. epidermidis) account for about half thecases • Patient motivation, good surgical technique, occlusivedressing
  • 46. Nosocomial pneumonia • 15–20% of nosocomial infections • Almost all casesarecaused by aspiration of endogenousor hospital-acquired oropharyngeal (and occasionally gastric) flora • associated with moredeathsthan infectionsat any other body site.
  • 47. • Early-onset nosocomial pneumonia (within thefirst 4 daysof hospitalization) - Strepto co ccus pneumo niae - Haemo philus species • Late-onset pneumonias - S. aureus - P. aerugino sa - Entero bacter species - Klebsiella pneumo niae - Acineto bacter
  • 48. Surgical site infections… • 0.5-15% of HAI • A causeof morbidity, prolonged hospital stay • S.aureus( MRSA )- dominating species
  • 49. SSI… Predisposing factors - ageover 60 years - long post operativestay - pre-existing infection at thesiteof thewound - underlying diseases-DM, immunosuppression, irradiation, malnutrition infection isusually acquired during theoperation itself; - either exogenously (e.g. from theair, medical equipment, surgeonsand other staff) - endogenously from thefloraon theskin or in the operativesite( predominantly ) - rarely, from blood used in surgery
  • 50. …SSI • Themain risk factorsare - Extent of contamination during theprocedure (clean, clean-contaminated, contaminated, dirty) - Presenceof foreign bodiesincluding drains - Virulenceof themicroorganisms, - Concomitant infection at other sites - Useof preoperativeshaving - Experienceof thesurgical team
  • 51. Burns • A suitablesitefor bacterial multiplication • S. aureusand P. aeruginosa-most common isolates • Enterobacteria • Other gram negativebacilli such asacinetobacter • Bacteriareach burnsmainly by indirect contact • Colonization without invasion isfar morecommon than invasiveinfection • Air borneinfection ismoreimportant for S. aureus than for GNB
  • 53. How are these different…? • Immunocompromised states • Hospital infection and infection control isoften neglected - Declining defenses - Multipleunderlying chronic diseases - Long stay at hospitals • CAUTION: - Proteus, Providenciaspp. - tuberculosis, influenzaA virus - Salmonellainfection - CDAD
  • 54. Neonatal units • Underdeveloped defenses, lack of normal flora (particularly in prematurebabies) • Ill babiesrequiremuch handling by staff • CAUTION: - MRSA - Klebsiella - P. aeruginosa - Serratia - S. epidermidis
  • 58. HAI control • Although eradication of HAI is impossible, a well-conducted surveillance and prevention program may significantly reduce HAI and associated costs • Identification of high risk population • Identification of diseases at an early stage • Treatment • Environment • Periodic surveillance
  • 59. Surveillance • Systematic observation and recording of diseases • An active ongoing process • Results can be used as an indicator of quality of care • Prospective surveillance is costly; therefore, point prevalence surveyspoint prevalence surveys are preferred for determining the magnitude of HAIs in countries with limited resources
  • 60. Guidelines • Identifying patients at risk • Observing hand hygiene • Standard precautions to reduce transmission of infection • Strategies to reduce VAP, CR-BSI, CAUTI • Designated infection control team(s) *VAP: ventilator associated pneumonia *CRBSI: catheter related blood stream infection *CAUTI: catheter associated urinary tract infection
  • 61. Identifying patient at risk • Burns patients • Immunodeficient patients • Transplant recipients • Chronically debilitated patients • Major surgery • Ventilator support • Indwelling catheters • Prolonged ICU stay (>3 days) • Old age • Frequent blood transfusion
  • 62. Isolation • Keep the patient away from potential sources of infection • Assess the need for isolation – Neutropenia and immunological disorder – Burns – Diarrhea – Skin rashes – Known communicable disease – Carriers of an epidemic strain of bacterium • Identify the type of isolation – Protective isolation – Source isolation
  • 63. • Isolation rooms should have: – Tight-fitting doors – Glass partitions for observation – Negative -pressure (for source isolation) ventilation – Positive- pressure (for protective isolation) ventilation
  • 64. Hand hygiene • Hands are the most common vehicle for transmission of organisms • Single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel
  • 67. Hand hygiene • During surgical hand preparation, all hand jewelries (e.g. rings, watches and bracelets) must be removed • Finger nails should be trimmed
  • 68. Standard precautions • All cases • Gloves • Gown • Mask, eye protection/face shield • Shoe and head coverings • Patient ­care equipments • Avoid wearing long sleeves • House coats are discouraged and wearing scrubs is encouraged
  • 69. Transmission­ based precautions • Patients known or suspected to have airborne, contact or droplet infections: 1. Isolate with negative­ pressure ventilation 2. Respiratory protection 3. Disposable N­95 respirator mask 4. Limit transport of the patient
  • 70. Specific strategies ­ specific nosocomial infections 1. Strategies to reduce VAP 2. Strategies to reduce CRBSI 3. Strategies to reduce UTI
  • 71. Strategies to reduce UTI • Catheters only for appropriate indications • Closed drainage system • Unobstructed urine flow • Changing indwelling catheters at fixed intervals is not recommended • Remove the catheter when it is no longer needed
  • 72. Strategies to reduce VAP • Avoid intubation whenever possible • Prefer oral intubations to nasal • Keep head elevated at 30° ­ ­45° in the semi­­recumbent position • Daily oral care with chlorhexidine solution • Sedation­vacationSedation­vacation and readiness to intubate • Routine change of ventilator circuits is not required • Prefer endotracheal tubes with a subglottic suction port • Closed endotracheal suction systems are better • Periodically drain and discard any condensate
  • 73. Strategies to reduce CRBSI • Avoid femoral route for central venous cannulation, prefer upper extrimity • Maximal sterile barrier precautions, and a sterile full­body drape while inserting CVCs • Clean skin usually with 2% chlorhexidine with 70% ethanol • Chlorhexidine/silver sulfadiazine or minocycline / rifampin­­impregnated CVCs • Ultrasound­ guided insertion • 2% chlorhexidine wash daily for skin cleansing
  • 74. Environmental factors 1. Cleaning and disinfection 2. Architecture and layout 3. Organizational and administrative measures
  • 75. Cleaning and disinfection • Some pathogens can survive for long periods in the environment, particularly MRSA, VRE, Acinetobacter species • High ­quality cleaning and disinfection of all patient ­care areas, bedrails, bedside tables, doorknobs and equipment • Disinfectants or detergents that best meet the overall needs of the ICU should be used for routine cleaning and disinfection • Surface cleaning (walls) twice weekly, floor cleaning 2­­3 times/day and terminal cleaning (patient bed area) after discharge or death
  • 76. Architecture and layout • Situated close to the operating theater and emergency department for easy accessibility, but should be away from the main ward areas • Central air­ conditioning systems with appropriate filters, air should be filtered to 99% efficiency down to 5 μm5 μm • Minimum of six total air changes per room per hour, with two air changes per hour composed of outside air • Isolation facility should be with both negative­ and positive­ pressure ventilations • Adequate space around beds is ideally 2.5­­3 m • Adequate number of washbasins with alcohol gel dispensers
  • 77. Organisational and administrative measures • Better patient to nurse ratio in the ICU • Controlling traffic flow to and from the unit to reduce sources of contamination • Waste and sharp disposal policy • Education and training for ICU staff • ICU protocols and SOPs • Audit and surveillance of infections and infection control practices • Infection control team (multidisciplinary approach) • Antibiotic stewardship • Vaccination of health care personnel
  • 78. Infection Prevention in Burns Patients • Burn wounds can provide optimal conditions for colonization, infection and transmission of pathogens • Source of infection: staphylococcistaphylococci located deep within sweat glands and hair follicles • Routine surveillance cultures: – Early identification of organisms – Monitor the effectiveness of current wound treatment – Guide an appropriate antibiotic therapy – Weekly • Stringent isolation guidelines • Antibiotic prophylaxis: role of topical antimicrobials > systemic antibiotics
  • 79. • Early enteral feeding: increases circulation to the bowel, thereby decreasing ischemia post ­injury and the translocation of bowel flora • Human tetanus immunoglobulin (250­­500 IU)
  • 80. Immuno­compromised and Transplant Patients • Greatest risk of infection caused by airborne or waterborne microorganisms • Neutropenic for prolonged periods (ANC < 500 cell/cumm) • Opportunistic infectionsOpportunistic infections – Exogenous acquisition of a particularly virulent pathogen, e.g. meningococcal meningitis or pneumococcal pneumonia – Reactivation of an endogenous latent organism, eg, herpes zoster virus, Mycobacterium tuberculosis – Endogenous invasion of a normally commensal or saprophytic organism
  • 81. Post ­transplant period 1. During the first month after transplantation: – >95% of the infections are due to bacterial or candida infection of the surgical wound, vascular access, endotracheal tube, or drainage catheters 1. During the period 1­­6 months after transplantation: 1.Two classes of infection : Infections caused by immunomodulatory viruses and infections caused by opportunistic pathogens such as Pneumocystis carinii, Listeria monocytogenes and Aspergillus species • In the late period: 1.Cryptococcus neoformans, P. carinii and L. monocytogenes
  • 83. Antimicrobial Stewardship • Multidisciplinary antimicrobial stewardship program • Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs • Infectious disease physician and a clinical pharmacist with infectious disease training • Clinical microbiologist, an information system specialist, an infection control professional and hospital epidemiologist • Close collaboration between the antimicrobial stewardship team, microbiology lab, hospital pharmacy and infection control team
  • 84. Goal • Reduce inappropriate use of antibiotics; use of appropriate antibiotics based on C&S reports • Antimicrobial cycling to decrease antibiotic resistance (? use) • Routine use of combination therapy • Optimizing antibiotic dose taking into consideration pk/pd characteristic • Early switch from parenteral to oral antibiotics • Decreasing duration of antibiotic use as per clinical guideline • Optimal use of microbiology lab is an essential ingredient of any stewardship program
  • 85. Conclusion • Nosocomial infections are widespread. They are important contributors to morbidity and mortality • They will become even more important as a public health problem with increasing economic and human impact because of: ­ Increasing numbers and crowding of people ­ New microorganisms ­ Increasing bacterial resistance to antibiotics • Prevention is better than control
  • 87. References • Guidelines for prevention of hospital acquired infections Yatin Mehta, Abhinav Gupta, Subhash Todi, SN Myatra, D. P. Samaddar, Vijaya Patil, Pradip Kumar Bhattacharya, and Suresh Ramasubban; Indian J Crit Care Med. 2014 Mar; 18(3): 149–163. • WHO guidelines on hand hygiene in health care: A summary. 2014. Mar 10 • Maselli DJ, Restrepo MI. Strategies in the prevention of ventilator­associated pneumonia. Ther Adv Respir Dis. 2011;5:131–41. [PubMed: 21300737] • Guidelines for the prevention of intravascular catheter ­related infections; http://www.cdc.gov/hicpac/pdf/guidelines/bsi­guidelines­2011.pdf • Guidelines for prevention of catheter­ associated urinary tract infections; http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf . • Malhotra S, Sharma S, Hans C; Prevalence of Hospital Acquired Infections in a tertiary care hospital in India; Department of Microbiology, PGIMER and Dr RML Hospital New Delhi; International Invention Journal of Medicine and Medical Sciences (ISSN: 2408­7246) Vol. 1(7) pp. 91­94, July, 2014

Hinweis der Redaktion

  1. many items do not need to be supplied sterile