Transcript Nosocomial Infections

HOSPITAL INFECTIONS
Meral SÖNMEZOĞLU, MD, Assoc Prof
Infectious Diseases Department
Yeditepe University Hospital
Learning objects
• 1. Know the general terminology and
definitions
• 2. Know epidemiology
• 3. Understand the importance of the hospital
infections
• Explain the prevention
DEFINITION
• The term nosocomial infection or healthcare associated infection is applied to “any
clinical infection that was neither present
nor was in its incubation period at the time
of admission to the acute care setting”.
• Nosocomial infections may also make their
appearance after discharge from the
hospital, if the patient was in the
incubation period at the time of discharge
Most Common Types of Nosocomial
Infections
• Most Common Types of Nosocomial Infections:
1. Urinary tract infections.
2. Surgical wound infections.
3. Lower respiratory Tract infections (primarily
pneumonia).
4. Bloodstream infections (septicaemia)
Nabeel Al-Mawajdeh RN.MCS
Burden of Healthcare-Associated
Infections in the United States, 2002
• 1.7 million infections in hospitals
– Most (1.3 million) were outside of ICUs
– 9.3 infections per 1,000 patient-days
– 4.5 per 100 admissions
• 99,000 deaths associated with infections
– 36,000 – pneumonia
– 31,000 – bloodstream infections
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
Calculation of estimates of healthcare-associated infections
in U.S. hospitals among adults and children outside of
intensive care units, 2002
263,810
274,098
-967
-21
-28,725
244,385
TOTAL
HRN
WBN
Non-newborn ICU
= SSI
Other
22%
BSI
11%
SSI
20%
PNEU
11%
129,519
HRN = high risk newborns
WBN -= well-baby nurseries
ICU = intensive care unit
SSI = surgical site infections
BSI – bloodstream infections
UTI = urinary infections
PNEU = pneumonia
133,368
UTI
36%
424,060
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
Estimated number of HAIs
by site of infection
Major site of Infection
Estimated Number of Infections
Healthcare-Associated Infection (all
HAI)
1,737,125
Surgical Site Infection (SSI)
290,485
Central Line Associated Bloodstream
Infections (CLABSI)*
Ventilator-associated Pneumonia
(VAP)**
Catheter associated Urinary tract
Infection (CAUTI)***
Clostridium difficile-associated disease
(CDI)17
92,011
Range of $ estimates based on
2007 CPI for Inpatient hospital
services
$20,549 - $25,903
$11,087 - $29,443
$ 6,461 - $25,849
52,543
$14,806 - $27,520
449,334
$ 749 - $ 832
178,000
$ 5,682 - $ 8,090
Attributable Costs of
Nosocomial Infections
Cost per Infection
Wound infections
Sternal wound infection
Catheter-associated
BSI
Pneumonia
Urinary tract infection
$3,000 - $27,000
$20,000 - $80,000
$5,000 - $34,000
$10,000 - $29,000
$700
Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections,
4th ed. 2003:36.
SOURCES
• Infectious agents from endogenous or exogenous
sources.
• Endogenous sources are body sites, such as the
skin, nose, mouth, gastrointestinal (GI) tract, or
vagina that are normally inhabited by
microorganisms.
• Exogenous sources are those external to the
patient, such as patient care personnel, visitors,
patient care equipment, medical devices, or the
health care environment
Modes of Transmission of Infections
1. Contact:
- Direct e.g., hands of hospital personnel.
- Indirect e.g., using contaminated objects.
2. Contaminated vehicles used in common for patients e.g.,
instruments, contaminated food, water, solutions, drugs or
blood products.
3. Airborne e.g., aerosol, droplets or dust.
Nabeel Al-Mawajdeh RN.MCS
Modes of Transmission of Infections (Cont’d)
4. Vector borne: e.g., mosquitoes.
5. Blood borne: inoculation injury or sexual transmission
e.g., HBV, HIV.
Nabeel Al-Mawajdeh RN.MCS
Patients Most Likely to Develop Nosocomial
Infections
1.
2.
3.
4.
5.
6.
Elderly patients.
Women in labor and delivery.
Premature infants and newborns.
Surgical and burn patients.
Diabetic and cancer patients.
Patients receiving treatment with steroids, anticancer
drugs, antilymphocyte serum, and radiation.
Nabeel Al-Mawajdeh RN.MCS
Patients Most Likely to Develop Nosocomial
Infections (Cont’d)
7.
8.
Immunosupressed patients (I. e., patients whose immune
systems are not functioning properly)
Patients who are paralyzed or are undergoing renal
dialysis or catheterization; quite often, these patient’s
normal defence mechanisms are not functioning properly)
Nabeel Al-Mawajdeh RN.MCS
Major Factors Contributing to Nosocomial
Infections
1.
2.
3.
4.
5.
An ever- increasing number of drug-resistant pathogens.
Lack of awareness of routine infection control measures.
Neglect of aseptic techniques and safety precautions.
Lengthy complicated surgeries.
Overcrowding of hospitals.
Nabeel Al-Mawajdeh RN.MCS
Major Factors Contributing to Nosocomial
Infections (Cont’d)
6.
7.
8.
Shortage of hospital staff.
An increased number of Immunosupressed patients.
The overuse and improper use of indwelling medical
devices.
Nabeel Al-Mawajdeh RN.MCS
Outline
• Nosocomial Infections are a significant cause
of morbidity and mortality
• There has been increased public interest in
nosocomial infections
• Shifting paradigm
– Many infections are preventable
Shifting Vantage Points on
Nosocomial Infections
Many infections are
inevitable, although
some can be
prevented
Each infection is
potentially
preventable unless
proven otherwise
Gerberding JL. Ann Intern Med 2002;137:665-670.
Epidemiology
• 5-10% of patients admitted to acute care hospitals
acquire infections
– 2 million patients/year
– ¼ 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
• 70% are due to antibiotic-resistant
organisms
• Invasive devices are more important
than underlying diseases in determining
susceptibility to nosocomial infection
Burke JP. New Engl J Med 2003;348:651-656.
Safdar N et al. Current Infect Dis Reports 2001;3:487-495.
Major Sites of Nosocomial
Infections
•
•
•
•
Urinary tract infection
Bloodstream infection
Pneumonia (ventilator-associated)
Surgical site infection
IMPORTANT SOURCES
(a) Contaminated air, water, food and
medicaments
(b) Used equipments and instruments
(c) Soiled linen
(d) Hospital waste (Bio medical waste)
Surgical Site Infections
Surgical Site Infections (SSI)
• First most common nosocomial infection
(%31)*
• Most common nosocomial infection among
surgical patients (38%)
– 2/3 incisional
– 1/3 organs or spaces accessed during surgery
• 7.3 additional postoperative days at cost of
$3,152 in extra charges
* Infect Control Hospital Epidemiol 2012;33(3):283-91
Definition of Surgical Site
Infections
SSI level classification
Incisional SSI
- Superficial incisional = skin and
subcutaneous tissue
- Deep incisional = involving deeper soft
tissue
Organ/Space SSI
- Involve any part of the anatomy (organs
and spaces), other than the incision,
opened or manipulated during operations
Superficial Incisional SSI
Infection occurs within 30
days after the operation
and involves only skin or
subcutaneous tissue
Skin
of the incision
Superficial
incisional SSI
Subcutaneous
tissue
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Deep Incisional SSI
Infection occurs within 30
days after the operation if
no implant is left in place
or within 1 year if implant
is in place and the infection
appears to be related to the
operation and the infection
involves the deep soft
tissue (e.g., fascia and
muscle layers)
Deep soft tissue
(fascia & muscle)
Superficial
incisional SSI
Deep incisional
SSI
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Organ/Space SSI
Infection occurs within 30 days
after the operation if no implant
is left in place or within 1 year
if implant is in place and the
infection appears to be related
to the operation and the
infection involves any part of
the anatomy, other than the
incision, which was opened or
manipulated during the
operation
Organ/space
Mangram AJ et al. Infect Control Hosp Epidemiol.
Superficial
incisional SSI
Deep incisional SSI
Organ/space SSI
Cross Section of Abdominal Wall
Depicting CDC SSI Classifications
Source of SSI Pathogens
• Endogenous flora of the patient
• Operating theater environment
• Hospital personnel (MDs/RNs/staff)
• Seeding of the operative site from distant
focus of infection (prosthetic device,
implants)
SSI Risk Factors
•
•
•
•
•
Age
Obesity
Diabetes
Malnutrition
Prolonged preoperative
stay
• Infection at remote site
• Systemic steroid use
• Nicotine use
•
•
•
•
•
Hair removal/Shaving
Duration of surgery
Surgical technique
Presence of drains
Inappropriate use of
antimicrobial prophylaxis
Microbiology of SSIs
1986-1989
(N=16,727)
Pseudomonas
aeruginosa
8%
Staphylococcus
aureus
17%
Enterococcus
spp.
8%
Escherichia
coli
10%
1990-1996
(N=17,671)
Pseudomonas
aeruginosa
8%
Staphylococcus
aureus
20%
Enterococcus
spp.
12%
Coagulase neg.
staphylococci
12%
Escherichia
coli
8%
Coagulase neg.
staphylococci
14%
National Nosocomial Infections
Surveillance System (NNIS)
Classification
Clean
Clean-contaminated:
GI/GU tracts entered in a
controlled manner
Wound Class
0
SSI Risk
Lower
1
Contaminated:
open, fresh, traumatic wounds
infected urine, bile
gross spillage from GI tract
Dirty-infected:
2
3
Higher
NNIS- SSI Surveillance 1992-2004
Cesarean Section
Risk Index Number of Pooled
hospitals mean rate
Per 100 operations
Median50%
percentile
0
130
2.71
2.17
1
117
4.14
3.19
2,3
51
7.53
5.38
Am J Infect Control 2004;32:470-85
Preventing Surgical Site Infections
Focus on modifiable risk factors
Sources of SSIs
• Endogenous: patient’s skin or mucosal flora
– Increased risk with devitalized tissue, fluid
collection, edema, larger inocula
• Exogenous
– Includes OR environment/instruments, OR air,
personnel
• Hematogenous/lymphatic: seeding of surgical
site from a distant focus of infection
– May occur days to weeks following the procedure
• Most infections occur due to organisms
implanted during the procedure
Up to 20% of skin-associated bacteria in skin appendages (hair follicles,
sebaceous glands) & are not eliminated by topical antisepsis. Transection
of these skin structures by surgical incision may carry the patient's resident
bacteria deep into the wound and set the stage for subsequent infection.
Downloaded from: Principles and Practice of Infectious Diseases
© 2004 Elsevier
Risk Factors for SSI
• 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
SCIP Performance Measures
Surgical
infection
prevention
• SSI rates
• Appropriate prophylactic antibiotic chosen
• Antibiotic given within 1 hour before incision
• Discontinuation of antibiotic within 24 hours of
surgery
• Glucose control
• Proper hair removal
• Normothermia in colorectal surgery patients
Infection Rate
Downloaded from: Principles and Practice of Infectious Diseases
Process Indicators:
Duration of Antimicrobial
Prophylaxis
Prophylactic antimicrobials should be
discontinued within 24 hrs after the
end of surgery
Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.
Process Indicators:
Timing of First Antibiotic Dose
Infusion should begin within 60 minutes of
the incision
Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.
URINARY TRACT INFECTIONS
Importance of CAUTI
• Among the most common type of
healthcare-associated infection
• > 30% of HAIs reported to NHSN
• Estimated > 560,000 nosocomial UTIs
annually
• Increased morbidity & mortality
44
Hidron AI et al. ICHE 2008;29:996-1011
Givens CD, Wenzel RP. J Urol 1980;124:646-8
Klevens RM et al. Pub Health Rep 2007;122:160-6 Green MS et al. J Infect Dis 1982;145:667-72
Weinstein MP et al. Clin Infect Dis 1997;24:584-602 Foxman B. Am J Med 2002;113:5S-13S
Cope M et al. Clin Infect Dis 2009;48:1182-8
Saint S. Am J Infect Control 2000;28:68-75
Catheter-Urinary infection
• Health care-associated infections
(HAIs) are one of the most common
complications of hospital care.
45
Importance
• Catheter-associated (CA) bacteriuria is
the most common health care–
associated infection worldwide and
• a result of the widespread use of
urinary catheterization, much of which
is inappropriate, in hospitals and
longterm care facilities (LTCFs).
46
CAUTI
• The most effective way to reduce the
incidence of CA-ASB and CA-UTI is to
reduce the use of urinary
catheterization by restricting its use to
patients who have clear indications
and by removing the catheter as soon
as it is no longer needed
47
CAUTI
• Strategies to reduce the use of
catheterization have been shown to be
effective and are likely to have more
impact on the incidence of CA-ASB and
CA-UTI than any of the other
strategies addressed in these
guidelines
48
CAUTI
• CA-UTI in patients with indwelling urethral,
indwelling suprapubic, or intermittent
catheterization is defined by the presence
of symptoms or signs compatible with UTI
with no other identified source of infection
along with 103 colony-forming units
(cfu)/mL of 1 bacterial species in a single
catheter urine specimen
49
Catheter-associated Urinary Tract
Infection (CAUTI)
• Single most common healthcare-associated
infection (HAI), accounting for 34% of all
HAIs.
• Associated with significant morbidity and
excess healthcare costs.
• Since 2008, CMS no longer reimburses for
additional costs required to treat CAUTIs.
CDC Surveillance Definition of CAUTI
A urinary tract
infection that
occurs while a
patient has an
indwelling urinary
catheter or within
48 hours of its
removal.
Source: Dennis G. Maki and Paul A. Tambyah.
Engineering Out the Risk of Infection with Urinary
Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April
2001.
Evidence-Based Guidelines
Since 2008, multiple evidence-based guidelines for
CAUTI prevention have been published
1980
CDC
1990
2000
2010
NHS
JBI
SHEA
NHS APIC
NHSN*
CDC IDSA
CDC= US Centers for Disease Control
JBI=Joanna Briggs Institute
NHS=UK National Health Service
SHEA=Society of Healthcare Epidemiologists of America
APIC=Association of Professionals of Infection Control
NHSN=CDC’s National Healthcare Safety Network (*revised surveillance definition)
IDSA=Infectious Diseases Society of America
Importance of CAUTI
• Estimated 13,000 attributable deaths
annually
• Leading cause of secondary BSI with ~10%
mortality
• Excess length of stay –2-4 days
• Increased cost – $0.4-0.5 billion per year
nationally
• Unnecessary antimicrobial use
53
Catheterization rate
•
•
•
•
•
15-25% of hospitalized patients
5-10% (75,000-150,000) NH residents
Often placed for inappropriate indications
Physicians frequently unaware
In a recent survey of U.S. hospitals:
– > 50% did not monitor which patients
catheterized
– 75% did not monitor duration and/or
discontinuation
Weinstein JW et al. ICHE 1999;20:543-8 Munasinghe RL et al. ICHE 2001;22:647-9 Warren JW et al. Arch Intern Med 1989;149:1535-7 Saint S
et al. Am J Med 2000;109:476-80 Benoit SR et al. J Am Geriatr Soc 2008;56:2039-44 Jain P et al. Arch Intern Med 1995;155:1425-9 Rogers MA
et al J Am Geriatr Soc 2008;56:854-61 Saint S. et al. Clin Infect Dis 2008;46:243-50
Pathogenesis
• Formation of biofilms by
urinary pathogens common
on the surfaces of catheters
and collecting systems
• Bacteria within biofilms
resistant to antimicrobials
and host defenses
• Some novel strategies in
CAUTI prevention have
targeted biofilms
55
Scanning electron micrograph of S. aureus
bacteria on the luminal surface of an
indwelling catheter with interwoven complex
matrix of extracellular polymeric substances
known as a biofilm
Catheter-associated Urinary Tract
Infection (CAUTI)
• Urinary catheters are often placed
unnecessarily, in place without
physician awareness and not removed
promptly when no longer needed.
• Prolonged catheterization is the #1 risk
for catheter-associated urinary tract
infection.
56
Complications of CAUTI’s:
• Cystitis
• Pyelonephritis
• Prostititis
• Endocarditis
• Sepsis/Septic shock
• Meningitis
(Lo, E; Nicolle, L; Classen, D; Arias, A M; Podrgorny, K; Deverick, J
A; Burstin, H; Calfee, D; Coffin, S E; Dubberke, E R; Frasier, V;
Gerding, D N; Griffin, F A; Gross, P; Kaye, K S; Klompas, M;
Marschall, J; Mermel, L A; Pegues, D A; Perl, T M; Saint, S; Salgado,
C D; Weinstein, R A; Deborah, S, 2008)
CAUTI
• Patient has at least 2 of the following signs
or symptoms with no other recognized
cause: fever (38.8C), urgency, frequency,
dysuria, or suprapubic tenderness
• and at least 1 of the following
CAUTI
•
positive dipstick for leukocyte esterase and/ or
nitrate
• pyuria (urine specimen with >10 white blood cell
[WBC]/mm or >3 WBC/highpower field of
unspun urine)
• organisms seen on Gram’s stain of unspun urine
• at least 2 urine cultures with repeated isolation of
the same uropathogen (gram negative bacteria or
Staphylococcus saprophyticus) with >10
colonies/mL in non voided specimen.
CAUTI
Bacteria entry
Urinary sampling from catheter
Nosocomial Bloodstream
Infections
Nosocomial Bloodstream
Infections, 1995-2002
Rank
N= 24,847
52 BSI/10,000 admissions
Pathogen
Percent
1
Coagulase-negative Staph
31.3%
2
S. aureus
20.2%
3
Enterococci
9.4%
4
Candida spp
9.0%
5
E. coli
5.6%
6
Klebsiella spp
4.8%
7
Pseudomonas aeruginosa
4.3%
8
Enterobacter spp
3.9%
9
Serratia spp
1.7%
10
Acinetobacter spp
1.3%
Edmond M. SCOPE Project.
Nosocomial Bloodstream
Infections, 1995-2002
Obstetrics and Gynecology
•Proportion of all BSI 0.9% (n=209)
•E.coli (33%)
•S.aureus (11.7%)
•Enterococci (11.7)
N= 24,847
52 BSI/10,000 admissions
In obstetrics, BSIs are uncommon.
However, the principal pathogen is
E.coli and not coagulase negative
staphylococci.
The source is typically genitourinary
Edmond M. SCOPE Project.
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)
1
PICC
0.2 - 2.2
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
• Coated catheters
– In meta-analysis C/SS catheter decreases BSI
(OR 0.56, CI95 0.37-0.84)
– M/R catheter may be more effective than C/SS
– Disadvantages: potential for development of
resistance; cost (M/R > C/SS > uncoated)
• Use of heparin
– Flushes or SC injections decreases catheter
thrombosis, catheter colonization & may
decrease BSI
Chlorhexidine/silver sulfadiazine vs. minocycline/rifampin catheters
Prevention of Nosocomial BSIs
• Limit duration of use of intravascular
catheters
– No advantage to changing catheters routinely
• Change CVCs to PICCs when possible
• Maximal barrier precautions for insertion
– Sterile gloves, gown, mask, cap, full-size drape
– Moderately strong supporting evidence
• Chlorhexidine prep for catheter insertion
Peripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central
venous catheters (CVCs)
Insertion
Catheter Insertion Site
Risk of infection:
• Central vein >>> Peripheral vein
• Femoral >>> IJ > Subclavian
Subclavian = preferred
Components of IHI CR-BSI
Prevention Bundle
1)
2)
3)
4)
5)
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin prep
Optimal site selection
Daily review of line necessity
30%-40% of all Nosocomial
Infections are Attributed to Cross
Transmission- Implication For The
Spread Drug Resistant Pathogens
NNIS: Selected antimicrobial resistant
pathogens associated with HAIs
Fig 1. Selected antimicrobial-resistant pathogens associated with nosocomial infections in
ICU patients, comparison of resistance rates from January through December 2003 with
1998 through 2002, NNIS System.
Am J Infect Control 2004;32:470-85
Health-Care Associated
(Nosocomial) Pneumonia
Definition
Occurring at least 48 hours after admission and
not incubating at the time of hospitalization
Introduction
• Nosocomial pneumonia is the 2nd most common
hospital-acquired infections after UTI. Accounting for
31 % of all nosocomial infections
• Nosocomial pneumonia is the leading cause of
death from hospital-acquired infections.
• The incidence of nosocomial pneumonia is highest
in ICU.
Introduction
• The incidence of nosocomial pneumonia in
ventilated patients was 10-fold higher than nonventilated patients
• The reported crude mortality for HAP is 30% to
greater than 70%.
--- Medical Clinics of North America
Therapy of Nosocomial pneumonia 2001 vol.85 1583-94
Pathogenesis
Pathogenesis
• For pneumonia to occur, at least one of the
following three conditions must occur:
1. Significant impairment of host defenses
2. Introduction of a sufficient-size inoculum to overwhelm
the host's lower respiratory tract defenses
3. The introduction of highly virulent organisms into the
lower respiratory tract
• Most common is microaspiration of oropharyngeal
secretions colonized with pathogenic bacteria.
Pathogenesis
--- The Prevention of Ventilator-Associated Pneumonia Vol.340 Feb 25, 1999 NEJM
Classification
• Early-onset nosocomial pneumonia:
Occurs during the first 4 days
Usually is due to S. pneumoniae, MSSA, H. Influenza,
or anaerobes.
• Late-onset nosocomial pneumonia:
More than 4 days
More commonly by G(-) organisms, esp. P. aeruginosa,
Acinetobacter, Enterobacteriaceae (klebsiella,
Enterobacter, Serratia) or MRSA.
Causative Agent
• Enteric G(-) bacilli are isolated most frequently
particularly in patients with late-onset disease and
in patients with serious underlying disease often
already on broad-spectrum antibiotics.
• Prior use of broad-spectrum antibiotics and an
immunocompromised state make resistant gramnegative organisms more likely.
Causative Agent
• P. aeruginosa and Acinetobacter are common
causes of late-onset pneumonia, particularly in the
ventilated patients.
Causative Agent
•
S. aureus is isolated in about 20~40% of cases and
is particularly common in :
1. Ventilated patients after head trauma, neurosurgery, and
wound infection
2. In patients who had received prior antibiotics or
Prolonged care in ICU
•
MRSA is seen more commonly in patients
Received corticosteroids
Undergone mechanical ventilation >5 days
Presented with chronic lung disease
Had prior antibiotics therapy
Causative Agent
• Anaerobes are common in patients predisposed to
aspiration
• VAP with anaerobes occurred more often with
oropharyngeal intubation than nasopharyngeal
intubation.
Causative Agent
• Legionella pneumophilia occurs sporadically but may be
endemic in hospitals with contaminated water systems. The
incidence is underestimated because the test to identify
Legionella are not performed routinely.
• Because the incubation period of Legionella infection is 2 to
10 days. cases that occur more than 10 days after admission
are considered to be nosocomial, and cases that develop
between 4 and 10 days are considered as possible
nosocomial.
• Patients who are immunocompromised, critically ill, or on
steroids are at highest risk for infection.
Antimicrobial Resistant Pathogens of
Ongoing Concern
• Vancomycin resistant enterocci
– 12% increase in 2003 when compared to 1998-2002
• MRSA
– 12% increase in 2003 when compared to 1998-2002
– Increased reports of Community-Acquired MRSA
• Cephalosporin and Imipenem resistant gram
negative rods
– Klebsiella pneumonia
– Pseudomonas aeruginosa
Am J Infect Control 2004;32:470-85
Transfer of VRE via HCW Hands
16 transfers (10.6%) occurred in 151
opportunities.
•13 transfers occurred in rooms of
unconscious patients who were unable to
spontaneously touch their immediate
environment
Duckro et al. Archive of Int Med. Vol.165,2005
The inanimate environment is a
reservoir of pathogens
X represents a positive Enterococcus
culture
The pathogens are ubiquitous
~ 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.
The inanimate environment is a
reservoir of pathogens
Recovery of MRSA, VRE, C.diff CNS and GNR
Devine et al. Journal of Hospital Infection. 2001;43;72-75
Lemmen et al Journal of Hospital Infection. 2004; 56:191-197
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:849-869
The inanimate environment is a
reservoir of pathogens
Recovery of MRSA, VRE, CNS. C.diff and GNR
Devine et al. Journal of Hospital Infection. 2001;43;72-75
Lemmen et al Journal of Hospital Infection. 2004; 56:191-197
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:849-869
The inanimate environment is a
reservoir of pathogens
Recovery of MRSA, VRE, CNS. C.diff and GNR
Devine et al. Journal of Hospital Infection. 2001;43;72-75
Lemmen et al Journal of Hospital Infection. 2004; 56:191-197
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:849-869
Alcohol based hand hygiene solutions
Quick
Easy to use
Very effective antisepsis due to bactericidal properties of alcohol
Hand Hygiene
• Single most important method to limit cross
transmission of nosocomial pathogens
• Multiple opportunities exist for HCW hand
contamination
– Direct patient care
– Inanimate environment
• Alcohol based hand sanitizers are ubiquitous
– USE THEM BEFORE AND AFTER PATIENT
CARE ACTIVITIES
Contact
Precautions
for drug
resistant
pathogens.
Gowns and gloves
must be worn upon
entry into the
patient’s room
Biofilms
• Biofilms are microbial
communities (cities) living
attached to a solid support
eg catheters/ other medical
devices
• Biofilms are involved in up
to 60% of nosocomial
infections
• Antibiotics are less effective
at killing bacteria when part
of a biofilm
Transmission
1. Contact – most common
•
•
Direct (physical contact)
Indirect (via contaminated objects)
2. Airborne Transmission
•
•
Droplet respiratory secretions on surfaces
Inhalation of infectious particles
3. Blood-borne transmission
4. Food-borne
Role of infection control teams
• Education and training
• Development and dissemination of infection
control policy
• Monitoring and audit of hygiene
• Clinical audit
Isolation & barrier precautions
Decontamination of equipment
Prudent use of antibiotics
Hand washing
Decontamination of environment
Surveillance
• Continuous monitoring
of the frequency and
distribution of infectious
diseases
• Determines the most
important causes of
infectious diseases and
identifies at risk groups
Uses of surveillance
• Used to identify new “problems”
• Used to identify where resources are most
needed
• Used to determine the burden of disease
• Used for strategic planning and policies
• Use surveillance for measuring outcomes of
intervention strategies
INFECTIOUS AGENT
Bacteria - Fungi -Viruses
Rickettsiae – Protozoal
Prions – Protozoa
Helminths
Treatment of
underlying disease
Recognition of
high risk
patients
SUSCEPTIBLE HOST
Immunosuppression
Diabetes – Surgery – Burns
Cardiopulmonary Neonates
HEALTH CARE
WORKERS
Rapid accurate
identification of
organism
RESERVOIRS
People
Equipment
Environment
Water
Employee
health
Care
Environmental
sanitation
Aseptic
Technique
Catheter
Care
Wound
Care
Disinfection/
sterilization
Hand-hygiene
PORTAL OF
ENTRY
Mucous membrane
GI / urinary /
Respiratory track
Broken skin
PORTAL OF EXIT
Excretions - Secretions
Skin - Droplets
Hand-hygiene
Sterilization
MEANS OF
TRANSMISSION
Direct Contact
Fomites
- Injection / Ingestion
- Airborne aerosol
Isolation
Food handling
Air flow control
Control of
excretions
and
secretions
Trash &
waste
disposal
TUS 2010
Aşağıdaki ameliyat tiplerinin hangisinde
cerrahi alan enfeksiyonu en fazla görülür?
A) Kolesistektomi
B) Tiroidektomi
C) Memeden kitle eksizyonu
D) Kolon rezeksiyonu
E) İnguinal herni ameliyatı
TUS 2010
Aşağıdaki ameliyat tiplerinin hangisinde
cerrahi alan enfeksiyonu en fazla görülür?
A) Kolesistektomi
B) Tiroidektomi
C) Memeden kitle eksizyonu
D) Kolon rezeksiyonu
E) İnguinal herni ameliyatı
TUS 2012
• Aşağıdakilerden hangisi temiz-kontamine
yaraya örnektir?
•
A) Kolesistektomi
B) Tiroidektomi
C) İnguinal fıtık onarımı
D) Mastektomi
E) Perfore apandisit varlığında apendektomi
TUS 2012
• Aşağıdakilerden hangisi temiz-kontamine
yaraya örnektir?
•
A) Kolesistektomi
B) Tiroidektomi
C) İnguinal fıtık onarımı
D) Mastektomi
E) Perfore apandisit varlığında apendektomi
TUS 2012
• Protez, greft gibi implantların uygulandığı
ameliyatlarda cerrahi alan enfeksiyonu
tanısı koyabilmek için enfeksiyon en geç ne
zaman ortaya çıkmalıdır?
A) 1 ay
B) 3 ay
C) 6 ay
D) 1 yıl
E) 2 yıl
TUS 2012
• Protez, greft gibi implantların uygulandığı
ameliyatlarda cerrahi alan enfeksiyonu
tanısı koyabilmek için enfeksiyon en geç ne
zaman ortaya çıkmalıdır?
A) 1 ay
B) 3 ay
C) 6 ay
D) 1 yıl
E) 2 yıl