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HOSPITAL INFECTIONS
(HCAI)
HOSPITAL INFECTIONS
(HCAI)Meral SÖNMEZOĞLU, MD
Yeditepe University HospitalAssociate Professor of
Department of Infectious Diseases and Clinical Microbiology
Meral SÖNMEZOĞLU, MD
Yeditepe University HospitalAssociate Professor of
Department of Infectious Diseases and Clinical Microbiology
HCAI Definition• Health Care-associated
Infection (HCAI)– Also referred to as “nosocomial”
or “hospital” infection • “An infection occurring in a
patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge, and also occupational infections among health-care workers of the facility”
HCAI
• The World Health Organization has reported that, at any given time, approximately 1.4 million people have an HAI;
• in developing countries, the risk can be up to 20 times greater than in developed countries.
• In addition, the emergence of HAIs caused by multidrug-resistant microorganisms is an increasing concern.
Healthcare-Associated Infections (HAIs)
1 out of 20 hospitalized patients affected
Associated with increased mortality Attributed costs: $26-33 billion annually HAIs occur in all types of facilities,
including:• Long-term care facilities• Dialysis facilities• Ambulatory surgical centers• Hospitals
Healthcare Safety
Healthcare-
associated Infections
Antimicrobial ResistanceAdverse Drug Events Transfusion/
Transplant Safety
Healthcare Preparedness
Outbreak Investigations
Surveillance
Prevention Recommendations
Intervention Implementation
Extramural Research
Laboratory Research and Support
Immunization Safety
Patient Safety within CDC’s Division of Healthcare Quality Promotion (DHQP)
HCAIs: emerging priorities
MRSA bacteraemias and C.difficile are the tip of the iceberg for HCAIs. What steps are we taking
to reduce all other HCAIs? What should we monitor to help drive this improvement?
MRSA
Clostridium difficile
Surgical site
infections
Urinary
catheter
UTIs
Ventilator-associated
pneumonia Enteral feeding tube
infections
Line
associated
sepsis
Dialysis related
infections
34 trusts reported zero
MRSA bacteraemias
between 11.2010 –
11.2011
Hospitals
Ambulatory Facilities
Long-term Care
Dialysis Facilities
Healthcare has moved beyond hospitals
Estimated rates of HCAI worldwide
– At any time, over 1.4 million people worldwide are suffering from infections acquired in health-care facilities
– In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections
– In developing countries the risk of HCAI is 2–20 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25%
– In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%
The impact of HCAI
• HCAI can cause:– more serious illness– prolongation of stay in a health-care
facility– long-term disability– excess deaths – high additional financial burden– high personal costs on patients and
their families
Outbreaks vs. Endemic Problems
Endemic problems represent the majority of HAIs
Device-associated infections• Catheter-associated urinary tract infections
(CAUTI)
• Central line-associated Blood stream infections (CLABSI)
• Ventilator-associated Pneumonia (VAP)
Procedure-associated infections• Surgical site infections (SSI)
Adherence problems• Antimicrobial stewardship, hand hygiene
Most frequent sites of infection and their risk factors
LOWER RESPIRATORY TRACT INFECTIONS
Mechanical ventilation
Aspiration
Nasogastric tube
Central nervous system depressants
Antibiotics and anti-acids
Prolonged health-care facilities stay
Malnutrition
Advanced age
Surgery
Immunodeficiency
13%
BLOOD INFECTIONS
Vascular catheter
Neonatal age
Critical care
Severe underlying disease
Neutropenia
Immunodeficiency
New invasive technologies
Lack of training and supervision
14%
SURGICAL SITE INFECTIONS
Inadequate antibiotic prophylaxis
Incorrect surgical skin preparation
Inappropriate wound care
Surgical intervention duration
Type of wound
Poor surgical asepsis
Diabetes
Nutritional state
Immunodeficiency
Lack of training and supervision
17%
URINARY TRACT INFECTIONS
Urinary catheter
Urinary invasive procedures
Advanced age
Severe underlying disease
Urolitiasis
Pregnancy
Diabetes
34%
Most common
sites of health care-
associated infection
and the risk factors
underlying the
occurrence of
infections
LACK OF HAND
HYGIENE
Patients Most Likely to Develop Nosocomial Infections
1. Elderly patients.2. Women in labor and delivery.3. Premature infants and newborns.4. Surgical and burn patients.5. Diabetic and cancer patients.6. 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. Immunosupressed patients (I. e., patients whose immune systems are not functioning properly)
8. 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. An ever- increasing number of drug-resistant pathogens.
2. Lack of awareness of routine infection control measures.
3. Neglect of aseptic techniques and safety precautions.
4. Lengthy complicated surgeries.5. Overcrowding of hospitals.
Nabeel Al-Mawajdeh RN.MCS
Major Factors Contributing to Nosocomial Infections (Cont’d)
6. Shortage of hospital staff.7. An increased number of Immunosupressed
patients.8. The overuse and improper use of indwelling
medical devices.
Nabeel Al-Mawajdeh RN.MCS
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 chargesMangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
* Infect Control Hospital Epidemiol 2012;33(3):283-91
Colonization vs Contamination – Definitions • Colonization
– Bacteria present in a wound with no signs or symptoms of systemic inflammation
– Usually less than 105 cfu/mL• Contamination
– Transient exposure of a wound to bacteria
– Varying concentrations of bacteria possible
– Time of exposure suggested to be < 6 hours
– SSI prophylaxis best strategy
SSI – Definitions
• Infection– Systemic and local signs of
inflammation– Bacterial counts ≥ 105 cfu/mL– Purulent versus nonpurulent– LOS effect– Economic effect
• Surgical wound infection is SSI
LOS=length of stay.
Superficial Incisional SSI
Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Subcutaneous tissue
Skin
Superficial incisional
SSI
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)
Deep incisional SSI
Superficial 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
Deep incisional SSI
Superficial incisional SSI
Organ/space SSIOrgan/space
Mangram AJ et al. Infect Control Hosp Epidemiol.
1999;20:250-278.
SSI – Risk FactorsOperation Factors
• Duration of surgical scrub
• Maintain body temp• Skin antisepsis• Preoperative shaving• Duration of operation• Antimicrobial
prophylaxis• Operating room
ventilation• Inadequate sterilization
of instruments
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
•Foreign material at surgical site
•Surgical drains
•Surgical technique
–Poor hemostasis
–Failure to obliterate dead space
–Tissue trauma
SSI – Risk FactorsPatient Characteristics
• Age• Diabetes
– HbA1C and SSI– Glucose > 200 mg/dL
postoperative period (<48 hours)
• Nicotine use: delays primary wound healing
• Steroid use: controversial• Malnutrition: no
epidemiological association
• Obesity: 20% over ideal body weight
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
•Prolonged preoperative stay: surrogate of the severity
of illness and comorbid conditions
•Preoperative nares colonization with Staphylococcus
aureus:
significant association
•Perioperative transfusion: controversial
•Coexistent infections at a remote body site
•Altered immune response
SSI – Wound Classification
• Class 1 = Clean• Class 2 = Clean contaminated• Class 3 = Contaminated• Class 4 = Dirty infected
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Prophylactic
antibiotics indicated
Therapeutic antibiotics
SSI – Risk Stratification NNIS Project
3 independent variables associated with SSI risk
– Contaminated or dirty/infected woundclassification
– ASA > 2– Length of operation > 75th
percentile of the specific operation being performed
NNIS=National Nosocomial Infections Surveillance.
NNIS. CDC. Am J Infect Control. 2001;29:404-421.
Principles of Antibiotic Prophylaxis
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Preop administration, serum levels adequate
throughout procedure with a drug active
against expected microorganisms.
High Serum Levels
1. Preop timing
2. IV route
3. Highest dose
of drug
During Procedure
1. Long half-life
2. Long procedure–redose
3. Large blood loss–redose
Duration
1. None after wound closed
2. 24 hours maximum
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
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.
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).
34
• 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
35
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• Catheter associated bacteriuria
increase every catheter day: • Day 1: 5%• Week 1: 25%• Month 1: 100%
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
Epidemiology of CVC-BSIPathogen (%)
Coagulase-negative staphylococci 37 %
Gram-negative rods 14 %
Enterobacter species 5 %
Pseudomonas aeruginosa 4 %
Klebsiella pneumoniae 3 %
Escherichia coli 2 %
Staphylococcus aureus 13 %
Enterococcus 13 %
Candida species 8 %
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
Catheter Insertion Site
Risk of infection:• Central vein >>> Peripheral vein• Femoral >>> IJ > SubclavianSubclavian = preferred
Insertion
Components of IHI CR-BSI Prevention Bundle
1) Hand hygiene2) Maximal barrier precautions3) Chlorhexidine skin prep4) Optimal site selection5) Daily review of line necessity
Hospitals using NHSN are preventing bloodstream infections
Trends in bloodstream infections* by ICU type, NHSN hospitals, 1997-2007
Medical/Surgical--Major Teaching
Medical/Surgical--Non-Major Teaching
Burton DC, et al. Methicillin-Resistant
Staphylococcus aureus Central Line-Associated
Bloodstream Infections in US Intensive Care
Units, 1997-2007. JAMA. 2009;301(7):727-736.
0
1
2
3
4
5
6
7
8
9
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Medical
Pediatric
Surgical
Po
ole
d M
ean
An
nu
al C
LA
BS
I Ra
te p
er 1
,000
Ce
ntr
al L
ine
Day
s
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 non-ventilated 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
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 gram-negative 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.
Prevention of health care-associated infection
– Validated and standardized prevention strategies have been shown to reduce HCAI
– At least 50% of HCAI could be prevented
– Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries
SENIC study: Study on the Efficacy of Nosocomial Infection Control
– >30% of HCAI are preventable
With infection
control
-31%-35%-35%
-27%-32%
Without
infection control
14%
9%
19%
26%
18%
LRTI SSI UTI BSI Total
Relative change in NI in a 5 year period (1970–1975)
0
10
20
30
-40
-30
-20
-10
%
Haley RW et al. Am J Epidemiol 1985
Hand transmission
– Hands are the most common vehicle to transmit health care-associated pathogens
– Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps
5 stages of hand transmission
Germs present on
patient skin
and immediate
environment
surfaces
Germ transfer
onto health-care
worker’s hands
Germs survive on
hands for several
minutes
Suboptimal or
omitted hand
cleansing results
in hands
remaining
contaminated
Contaminated
hands transmit
germs via direct
contact with
patient or
patient’s
immediate
environment
one two three four five
Bundles (sets of infection control
recommendations) to prevent infection
when inserting devices or performing
procedures.
Prevent Infection
Adherence to infection control guidelines is incomplete
Many HAIs are preventable with current recommendations
Failure to use proven interventions is unacceptable
Only 30%-38% of U.S. hospitals are in full compliance
Just 40% of healthcare personnel adhere to hand hygiene
Insufficient infection control infrastructure in non-acute care settings has allowed major lapses in safe care
Why should you clean your hands?
– Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene
– Therefore hand hygiene concerns you!
– You must perform hand hygiene to:
– protect the patient against harmful germs carried on your hands or present on his/her own skin
– protect yourself and the health-care environment from harmful germs
• Adequate handwashing with water and soap requires 40–60 seconds
• Average time usually adopted by health-care workers: <10 seconds
• Alcohol-based handrubbing: 20–30 seconds
Time constraint = major obstacle for hand hygiene
National Standardized Infection Ratios (SIRs) and facility-specific percentiles using HAI data reported from all NHSN facilities reporting during 2010 by HAI and patient population:
Central Line-associated Bloodstream Infections (CLABSIs), Catheter-associated Urinary Tract Infections (CAUTIs), and Surgical Site Infections (SSIs)
TUS 2012• Aşağıdakilerden hangisi temiz-
kontamine yaraya örnektir?A) KolesistektomiB) TiroidektomiC) İnguinal fıtık onarımıD) MastektomiE) Perfore apandisit varlığında apendektomi
TUS 2012• Aşağıdakilerden hangisi temiz-
kontamine yaraya örnektir?A) KolesistektomiB) TiroidektomiC) İnguinal fıtık onarımıD) MastektomiE) 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 ayB) 3 ayC) 6 ayD) 1 yılE) 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 ayB) 3 ayC) 6 ayD) 1 yılE) 2 yıl
TUS 2010 Aşağıdaki ameliyat tiplerinin
hangisinde cerrahi alan enfeksiyonu en fazla görülür?
A) KolesistektomiB) TiroidektomiC) Memeden kitle eksizyonuD) Kolon rezeksiyonuE) İnguinal herni ameliyatı