Health Care-associated

Infections and Microorganisms

Indonesia

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December 18, 2012
 Common Nosocomial Pathogens

Organisms Example Potential Source

Gram Positive Staph, strep, clostridia,
Gram Negative E. coli, pseudomonas,
klebsiella, enterobacter,
stenotrophomonas,
acinetobacter, etc
Tuberculosis
Fungus Candida, mucormyces,
Molds, aspergilus, etc.
Venous/arterial catheter,
vascular graft, artificial
joints, open wounds
Urinary tract, open
wounds, respirator-
associated, catheters.
Catheters, perforated
intestine, lungs,
immunocompromised host

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virus Herpes, HIV, hepatitis A,B, Skin, blood, feces, wound,
C, etc. Ebola, influenza, etc. respiratory droplets, etc..
 Biofilm
• A biofilm is an aggregate of microorganisms in which
cells adhere to each other on a surface:Composed of
extracellular DNA, proteins, and polysaccharides
 Resistant to the battery of immune system and
antibiotics.

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 Biofilm
Planktonic bacteria

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 Biofilm-associated Microorganisms Isolated
from Indwelling Medical Devices
Indwelling Medial Device Organism
Central Venous Catheter Coagulase-negative Staph., S. aures, E.
faecalis, klebsiella, pseudomonas, candida
albicans.
Prosthetic Heart Valve Viridans streptococci, CANS, enterococci, S.
aureus,
Urinary Catheter S. epidermidis, e. coli, klebsiella, E. faecalis,
Proteus
Artificial Hip Prosthesis CANS, s. aureus, hemolytic strep., other
gram-negative bacteria
Artificial Valve Prosthesis Candida albicans, streptococcus mitis, other
viridans streptococcus, CANS, etc..

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Intrauterine Device S. epidermidis, corynebacterium,
S. aureus, micrococcus, lactobacillus,
enterococcus, group B streptococcu,
candida albicans.
 Environmental and other Factors

 Other important factors

– Survival in the air, as a droplet, on inanimate
objects/fomites or various surfaces (floor, wall,
curtains, handles, etc.)
– Spore forming organisms: clostridium, bacillus sp.
– Humidity
– Temperature
– Moisture

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 What is multidrug resistant organism
(MDRO)?

 Microorganisms, mostly bacteria, that have

become resistant to one or more classes of
antimicrobial agents.

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 What are the serious infections caused by
MDRO?

 Central-line associated blood stream infection

(CLAB)
 Ventilator-associated pneumonia (VAP)
 Catheter-associated urinary tract infection (CA-UTI)
 C. difficile associated diseases (CDAD)
 Surgical site infection (SSI)

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 What are the threats of MDRO?

A patient with MDRO infections are likely to have;

 a two-fold increased risk of death
 increased risk and duration of ICU stay
 increased length of hospital stay
 delayed return to the base-line health
 higher risk of adverse events
 increase cost of care

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 EM
Staphylococcus

Gram’s Stain

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 MRSA
 Resistance to methicillin is mediated via the mec operon, part of the
staphylococcal cassette chromosome mec (SCCmec) which codes for an
altered penicillin-binding protein (PBP2a or PBP2') that has a lower affinity
for binding ALL β-lactams.
 Panton–Valentine leukocidin, a two-component staphylococcal
membrane toxin: Principal virulence factor for the community associated
infection. Rarely found in the nosocomial clones.
 CA-MRSA: necrotizing pneumonia in children, a toxic shock–like

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syndrome, necrotizing fasciitis.
Gram negative bacteria
E. coli, Proteus, Klebsiella, etc.

E. coli Gram’s Stain

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 ESB L
(Extended spectrum beta lactamase)
 The ESBL enzymes are plasmid-mediated enzymes capable
of hydrolyzing and inactivating a wide variety of ß-Lactams,
including third-generation cephalosporins, penicillins, and
aztreonam.
 Easily transferrable to other bacterial species.
 Mutations of TEM1, TEM2 and SHV1, all of which are ß-
Lactamase
 Enzymes commonly found in Enterobacteriaceae family.
 Major cause: Widespread use of third-generation

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cephalosporins and aztreonam.
 EM
Streptococci

Gram’s Stain

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 Carbapenem Resistant Enterobactriaceae
(CRE) and AmpC

CRE
 KPC
– “Plasmid-Mediated Carbapenem-Hydrolyzing B-Lactamase
e.g:KPC in a Klebsiella pneumoniae

AmpC
– The AmpC ß-Lactamases are encoded by genes located on
chromosomes, are often inducible,
– Since genes encoding these enzymes are located on chromosomes,
they are not easily transferable to other bacterial species.

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 A new comer: The “superbug”- Metallo Beta
Lactacmase-1 Producer

 Metallo Beta Lactamase (MBL) Producing Gram Negative Bacteria

Serious infection caused by MBL producing bacteria caused higher

mortality among patients with diabetes in an ICU setting. Usually
Klebsiella, but other bacteria such as E. coli and pseudomonas
produced the enzyme that inactivated carbapenems (such as
ertapenem, meropenem) AND almost all other antibiotics available

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at the moment.
 EM
Candida species

Gram’s Stain

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 What to do to prevent it?

 All healthcare associated infections are evaluated by the infection

control practitioner, infectious disease specialists, microbiology
laboratory and the infection control committee.
 Active surveillance of MDROs for pre-operative patients and new
admissions to ICU/CCU (soon to include all high risk patients).
 Appropriate contact precaution as soon as possible.
 A hospital-wide CLAB Bundle including policy, check list and reporting of
the incident per 1,000 line days.
 A hospital-wide VAP Bundle similar to the above.

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 Indwelling urinary catheter policy for the insertion, care and removal.
(cont’d)
 What to do to prevent it
3

 Austere antibiotic formulary: stewardship

 Publish annual antibiogram.
 Medical Center-wide hand hygiene campaign.
 “Speak up” program to involve the patients and
families in their care.

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 Antibiotic Stewardship

 Formulary Restrictions
 Guidelines and clinical pathways
 Antimicrobial order forms
 Clinical Interventions
 Parenteral to Oral Therapy Conversion
 Quality Assurance

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 Antibiogram

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