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    Guia para La Prevención de Neumonia Asociada A Las IAAS - CDC

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    dhcastano

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    IME Recommends January 03,4967 ARR 78 ons and Re Persons sing asistve technology night not be abl o fly access information inthis file, Fr asitanee please send e-mail: mmseric g. Type SOK Ascommods the tie oF the repr inthe subject line of eal Guidelines for Prevention of Nosocomial Pneumonia Summary ‘This document updates and replaces CDC's previously published Guideline for Prevention of Nosocomial Poeamonia Infect Conta 1982:8:32-85, Resp Cae 1983:28 32, and AmJ Infect Control 1985; 11-230-4), Tis rove guidlinci designed to rede the insideaceof nosocomial cumonia and is intended for se by personnel wht responsi for surveillance and contol of infections in acue-arc hospitals th information may ot be applicable in longtemm-care faciliics Because ofthe unigus charac of such stings. This evsed guideline addssses common problens encountered by incon contol pracitionts regarding the prevention and con of hosocomial ae ‘NUS. hospitals. Sections on the prevention of base pocamonis in mechanically vniated andlor ertelly il patel, eae of respalory-thcrapy devices, prvention« contamination, and prevention of vil lower respiratory Wat infections (eg. respteory syaylal vin (RSV) and influenza infections) hays been expanded and update, Sections on Leplonaitesdscse and pacumonia caused by Asperllls sp. have bee included. Lower respiratory wat infection caused by Mycobacterium tuberculosis is = ‘ddresed in hs document, Pat 1, "An Overview of the Prevention of Nosocomial Pacumoni, 1994 provides the background information forthe consensus recommenda the Hospital Infection Control Practices Advisory Comite (HICPAC) ia Part I, "Recommendations for Prevention of Nosocomial Pneumonia” ‘Pneumonia isthe ssond most common nosocomil infection in the Unite Stats andi associated with substantia morbidity and mortaliy. Most patients who have nosoxe [pneumonia ar inf, young clea, ad persons greater tan 65 years of ge; persons who have severe undying disease, immunosuppesson, depressed seusoru, 3k ‘rdopulmonary disease and persons who have had horeoabdoninal surgery. Although patents rcwving mechanially assisted ventilation donot represent a moe pop ‘tpn who have nosocomial pneumonia, they ace at highest risk for acquiring the nein, Mest bacterial nosocomial poeumonia our by aspitton of bacon clo the oropharynx or upper gatostestil rat of te patient. Besnure bition ond mecca ventilation alter fr-line patient cefnsc, they grey increase the ik fot nosocomial baci! prcumonia.Paeumonas caused by Legionella sp, Asperilus sp and iafluenz virus ave often caused by inhalation of contaminated aerosols. RSV i ‘sully occars aller viral inoculaon ofthe conjuncvae or asal macova by contminaed hand Tradional preventive meastes for nosocomial posumoni neue dere: spizaton bythe patient, preventing cross-ontaminstion or colonization win hands of personne, appropriate disiafectioa or sterizntin of espzutory-tberapy devies, se allble vaccines to pro‘et against particular infections, and education of hospital staf and patients. New measures being investigated involve reducing oropharyngeal anc onization by pahogenie misrooganiss. Pact 1, An Overview ofthe Prevention of Nosocomial Passos, 194 | INTRODUCTION ‘This document updates and replaces CDC's previously published "Guideline for Prevention of Nosocomial Pneumonia” (Infect Control 1982;3:327-3, Respir Care 1983; 2 532, and Am Infact Cont 198 11-250-4) This revieed guideline i designed to reduce the incidence of nosocomial poesmonia ands tends for ake by personel wie responsible for surveillance and contol of infections in acue-are hospitals he informaton may not be applicable in longtem-care facilities because ofthe unigue chara: of uch stings ‘This revised guideline areses common problems encountered by infetin-contl practitioner regarding the prevention and ental of nosocomial pneumonia in U.S. Sections conceraing the prevention of bacterial pacurmonia i mechaically venilted andor eiealy il patients, cae of resptatoy-therapy deve, prevention of cross contamination, end prevention of vital lower respratary wat infetions (eg, respittery syncytial vitus (RSV) and influenza infection) have been expanded and peated, Sections on Leplomaiesdscae and pacumonia causoa by Aspeepllus sp. have been ieluded. Lower respiratory tact infection caused by Mycobacterium tbetcuosis st ‘rested in this document; COC published such recommendations previously (1). Part "Aa Overview ofthe Prevention of Nosocomial Pacumnia, 1994," provides the background information forthe consensus recommendations ofthe Hospital Infectc Cont Practies Advisory Commitee (HICPAC) in Pa I, "Recommendations for Prevention of Nosocomial Pacumosia” HICPAC was established in 1991 fo provide ac tnd guidance tothe Seeeary andthe Assistant Seveay for Health, US. Deputnetof Health and Human Services, the Dietoy, CDC, andthe Diestor, Naina Center Infectious Diseases (NCID), COC, regarding the pace of hoypial infection cont) and satepes for surveillance, prevention, and entre of nosocomial infections in hospitals. HICPAC alg advises CDC on periodic updating of guidelines and ole policy statements rezarding prevention of nosocomial infections. This gudeline isthe fir serles of CDC guidelines being revised by HICPAC and NCID. This guideline canbe an important resource fo eduatng healthcare workers (HCW) regarding prevention and conto f nosocomial respiratory wae infections Because suction of IICWs isthe eomerstone ofan efetiveinfectin-contal progr, hospitals should give high priori to continuing infetion-eotoledocational programs for personel BACKGROUND Preumonia i the sesond mast common nosocomial infection inthe United Sats andi stociaed with substantial morbidity and mortality: Most patients who have nosoec peumonin ar inf, young clea and persons gest than 65 years of age; persons who have severe underlying disease, immunosuppresson, dpresscd seoSoru, at fardlopulionary disease and persons who have had bercoabomiaal surgery. Although pacts recwving mechanically assisted ventilation donot represent a maor POD lofpascas who have nosocomial peumonia, ty are at highest risk fr aequing the ineeion “Most bacterial notocomialpreumonis occur by aspitation of bacteria colonizing the oropharyne or upper gatontstinal ret ofthe pent. Becaute ntbation and mech ‘venation ale frt-line patient defenses, they greatly inrease the risk for nosocomial bacterial poesmonin, Paeumonias cared by Legionel p, Aspergli sand nf ‘ins are oflen caused by Iahaltion of contaminated aerosols, RSV infection usually occurs afer vial inoculation ofthe conjuntivas ot nasal icone by eotaminaed a Traitonal preventive measures for nosocomial pneumonia include decreasing aspiration by the pain, preventing eros-contamniaton or colonization via hand of HCW: sppropnt disinfection or slenlization of expiatry-therapy device, we of svabl vaceins lo pole aginst parca nfs, and edacaion of hospital stat snd p [New measures being investigated involve reducing oropharyngeal and gastic colonization by pathogenic microorganisms BACTERIAL PNEUMONIA, 1 Btilopie Agents ‘The rpaed distbuton of etiologic agents tha caate nosocomial pcumonia differs beween hospitals because of iferet paint populations and diagnostic mee employed (2-10) In genral, however, bacteria have bees te most fequctly isolated pathogens (2-69, 11-13). During 1986-1989, erobic bacteria comprised at eas Sd fungi 4 of isolates frm sputum and wacheal aspirates obained fram patets who had pacumonia atthe University of Michigan Hospitals and a hosp Patcpating inthe National Nosocomial lection Sarveilanee (NAIS) System, only afew anaerobic bacteria and no viruses were reported, probably because anaeco ‘rl ealtres were not performed routinely i he reporing hospitals (Lable 1) (3), Simla, cultures of bronchoscopic specimens bained from mechanically vent patients who had pneumonia have rarely yielded anaerobes (5-7.911,1,15) Only one study, which was based primarily on cultures of ranstrachea pres obiaine Patients nt reciving mechanically eesiod venluton, reported a predominance of anaerobes (4), Nosocomial bacterial preumonia ate fequenly polymicrobial (7.9.11, 12,1519), and gram-negative baci are usually the predominant organises Cable 1) (26, 13) Tlowever, Saphylococeus aureus (especially methiilinesisian 8 aureus) (S7.10,18,2021) and other grm-postve cee, incon Stepocoeeus eumonta have emerged reccmly as important isolates (1). I addition, Haemophilsiniuenac hasbeen igoated from mechanically ventated patients whe had peeumonia th occured within 48-96 hous ater iatation (35,12, 15,22), ia hospalsparcipating i the NNIS, Pseudomonas atusiosa, Enterobacter sp. Klebsiella pacumonia scherchia call, Sata marcescens, and Proteus sp. comprised 80% of te soats fom elas of rxpratory wat specimens obiined frm paliens fr wir rnosncoml poeta ws cagnosed by sing cial erera S, aes accounted or 16%, and H.nfensas, fr 6% (Lise) (3), Another sy reported at gr negative baci were present in 75% of quantitative cultures of protecedspecimen brashngs (PSB) obtained fom patients who had aquired nosocomial preumrta ‘ecciving mechanically asistd vention, 40% of thet cultures were polymicobial (3). tn anther published report, 20% of pathogens recovered fom cutee of bod, pearl Mid oe pereutaneos lang aspitate were gram.nepatve bail n pure clr, and 17% were polymirabial; however, 54% of specimens did nt yield rmiroorgansm, probably because te patents fom whom these caltres were aban had been treated with attics (6) U. Diagnosis ‘Nosocomial bacterial preumooia has been difficult o diagnose (7,816,232). Frequently, the eter fo diagnosis have bee fever, cough and development of pars sputum, in conjunction with edolgic evidence of new or progressive pulmonary inflate, a tuggesive Gram sain, and positive ealtaes of sputum, Wackel apie Pleural uid, 0° blood (.4.23,25,3-36), Altnough clinical findings in conjunction wit cultures of sputum or tacheal specimens maybe sensitive for bacterial patho, they are highly nonspeifie, especialy in patents rcsving mechanically assisted ventilation (9,1215,18,4-2629,31,87-42); converses cules of blood or pleut have ery low envy (18 19,8), ecaue ofthese problems, a group of investigators recently formulated content recommendtions for standardizing methods wet diagnose pneumonia in clinic research ties of ventlator-assocated pneumonia 4-46) These methods involve bronchoscopic techniques suchas quantitative culture of PSB (3.7 9413,1527,313881,47,48),broncoaly colar avage (BAL) (712,4,4749-S4), and protceted BAL (pBAL) (14). The eported sensi of such methods have rng pening onthe ests Or disgnostic ertera with which they were compared, lm 70% 0 100%, and the reported specifies of thee methods have ranged from 60 104% These methods are mvasive ad might cause complications suck as hypoxemia, bleding, or ashthmia (813.42 48,538 50) In ation, the sensivity a th procedure may be deceased for patint receiving ansbatictheapy (913,27). Nenbyonchoscopic (NB) procedares (8 NB-pBAL. (12.27.57, $8} or NB-PSB {13} Uilize Mind catheterization ofthe distal airways and quantiative culture of endotracheal agprate (9,60) have been devcloed recently. Of these procedue, ends ‘pirate ult might be the mos practical. The ute of thet bronchoscopie and nonbranchoscop dagroicvss could elp to beter define the epidersolopy of ‘nosocomial pretmonia especially inpatients receiving mechaniily assisted venation however adtonal stds sre needed to determine each fests apical (hal clinkal practice. Fpidemiology ‘Results of the NNIS indicate that preumonins (diagnosed onthe sis of the CDC surveillance definion of nosocomial presmonia) account for approntatly 15% of ll ‘sociated infetions and ae the second mort comaon type of nosocomial infection afer those ofthe inary tract (2,61) In 198, he overall acience of lower rexprion Infection was sx cass per 1,00 discharged pacts 2). The incidence pe 1,000 discharged paints ange fom 4.2 cases in uoicaching hospitals 07.7 a university hospital, probably ectingistutioal differences i the level of patents rik or aegiing nosocomial preumonia, "Nosocomilbacteril poeumonia ote hs ben identified as a postoperative infection (6263), Inthe Stay ofthe Lfcay of Nosocomial Ifertion Como, wich was ot Inthe 1970s, 75% of reported cass of nosocomial bacterial pneumonia occurred in patents who bad bad a surgical opecation; the risk was 38 times great: fr patients whe thoracoabdominal procedures than for those who hai proceduts involving other body sits (63). Moce resent epidembologe suis, inclading NNIS studs, have deni fubets of piel thigh nk for acquiring nosocomial bacterial preumona. Such patient lade persons greater than 10 yeas ofa; persons who have endoraceal int ‘andor mechanically asited veilation, a depressed lve of consciousness (particulary those wh elosed-ead injury), or undelyng ehronic lang disease; and persons We previously ha an episode of large-olume aepztion, Other risk factor Include 24-hour venltr-cicut change, hospitalization during the fal or winter stsee been Propylexis wih cimetidine (cider with or without antacid), administration of atimicrobals, presence ofa narogsei ube, severe tau, and eect bronchoscopy (634 ny ‘The NNIS has sutifed the incidence density of nosocomial pacumonia by patents use of mechanical venation and type of intensive-ogaive bacilli eg, Pacudomonas sp, Xanthomonas sp, Flaobactevium sp, Legioalla sp. and bortuberculous mycobacra) can multiply to substantial soneent ‘choles (241 249-251) and increas the risk for prcumonia in patents wing sich deviss (127-1024, 24, 252,25), Prope cleaning and sterilization or disinfection of eusble equipment ae important components ofa program to reduce infections associted wit espiatory therap: snchesiaequpmeat (23, 285,257-240,242 254259). Many devices or parts of devios used onthe espiatry tact have bees categorized as semiciial ine Spe lasiiation syste for appropriate strzaion or disinerion of medical devies because they come into die or indie! contact wih mucous membranes Bu do ‘ordinal pence body surfaces (Appendix), and the ssid risk for infection in patients fer thee of ach devies i lens han that aoa with device enotte normally stile issues (260). Thus, if sterilization of these devices by steam autoclave or ehylene oxide isnot possible or cost-cffective (261), they canbe Subject high-ovel disinfection by paseuization at 75 C for 30 mites 262-268) or by use of liquid chemical disinfectants approved bythe Eaviouettal Prot ‘Ageney (FPA) ay stolantisinfecants and approved for use on medial nsueats by the Food and Drag Adainsration (228, 255-258, Is respinntory device needs rising a remove a restau chemical strilansinfecant aller chemical disinfection, sterile water is prefered esas apo oe prepare isiled water might contain microorganisms that can case pneumonia (249,250, 268-272). In some hospitals, atap-watr rinse followed by a= drying wit ‘without an aleobol rinse (i, to hasten dying) s used (273). ln theory, feomplte dying is achieved afer a tap-wate ase, the sk fr nosocomial preumonia asso ‘rth the use a the dove probaly low Air dying reduces te level of mierbil contamination ofthe hands of HCW alr washing and i drying alo reduces “Contamination of gastrointestinal endoscope (74-276), However, many femercal items sed onthe respiratory rc eg, cmt tubing, jet or ulaonie ney tnd bronshoscopes) are dificult to dry, and the dogre of dynes of device i dificult aces (255), Data are ineulicient regarding the safety of outinly uring {ar rnsng (lowed by drying) resale semi epitatry devices afer their dsiafeton or between thelr uses ob the sue patent (242258,273, 277), 1, Mechanical Vnitr, Breathing Circuits, Humidifiers, Hest-Moisure Exchanger, and In-Line Nebulizers ‘4 Mechanical ventilators. Te internal machinery of mechanical ventilators sed fr respistory therapy ie not considered an importa: source of bacterial contamination of inhaled gas (278). Thus, rutine sterilization o high-level disinfection ofthe intersal machinery is considered unnecessary. Using high ‘ciency baeterl es a various poston inthe veatlator breathing cect had been advocated previously (279,280). Ptr inerposed between the ‘machinery and the main behing crit ca eliminate contaminants rom the driving gat and prevent retrograde contminaon ofthe machine bythe ps however, hee ites lzo might ale the funtonal pefenons ofthe breathing device by impeding high ga ws (279-281, Plsement of condense tap atthe expinstry-phase tubing ofthe mechanical-venilator circuit may help prevent cost contamination of the vetted patent’ ine ‘vironment (247,282), bu the importance of such ler in preventing nosocomial pacumunis needs further evaluation, b.Breing cites, amides, and estore exchangers. Inthe United Stes, mast hospi se ventilator with either bubble-shrough of wick hue ‘hat produce either insignificant (132,288) or no arosls, respectively, for humidification. Tas, these devices probably dono! pose an important sk fot neurons in patients In adit, bubble-vaugh humidifiers are usally heated to wemperatures thal reduce ot elimisate bacterial pathogens 283,280 ‘rate, however, sill usally use to fl these humdi (248) because tp or distilled water might contain microorganisms, sel as Legionella ph tore heneresistant than other bacteria (252271), ‘Tae potential rik for pucumonia in paints sing mochatcalvenslators that have bested bubbe-hrough humidifers stems primarily fom the condense ferns the ingprtoy- phase tubing of the ventilator cireit x areal ofthe difeence nthe tempertes ofthe inspiratory phase ga ad aent it ‘condensate formation inreaes fhe ting is unbested (286) The bing and condensate can rapidly become contaminate, sally with acters that 0 Inthe patient's oropharynx (286). In one study, 33% of inspiratory circuits were colonized wih actera va tis route within 2 bout, and 80% within 24 fer ination of mechatialveilton (286), Spllage of he contaminated condensate inf the patient rachesbvonchal toe, sean occur daring proce ‘which the hing is moved (efor suctioning, adjusting the ventlaor sting, of Ted or earn fo the patient), may Ineeate he rik for pacuron ‘he patent (286) Thus, many hosp, HCW are rand to preven sch spiliage an o drain te iid periodically Microorganisms contaminating ‘ventilators condensate canbe transite Yo oter patients via he hande of HCW handling the fi, expecially ithe HCW neglects washing hand andling the condensate. ‘Tae ole of ventiatorbing changes in preventing prcsmonis in patents using mechanical veniltors with bubble-broup ums hasbeen investi Inia ste of i-urecontamigton of mecbenial velar cies with Ramis ave indicated tht note he rat of bacterial contamination of Jnsprtor-phase gas nr the incidence of pacumonia was signfcallyinreaseé whet tubing was changed every 24 hours ater than every 8 of 16 hou ‘A late study indicted tat changing the ventatoreitcuit every 48 hours rater than every 24 hours di pot result han inrese i conamiaton ofthe ‘nspratory-phane gas o ting ofthe ventilator ers 248) In addon, te ineidence of nosocomial eumoni was not signicanly higher when ei ‘were changed cvey 48 hours ae than every 24 hours (288) Merc recat reports suggest hat the sk for pacumonia may not increase whea the ies, ‘uit change prolonged beyond 4 hours Aaothersudy indlatd ha the ie for eunonia was not signianly higher when the cus were nov ‘hanged forthe duration of use by te patent (eigh (299) of 28 patients) rather than when the iets were changed every 48 hour (1 {31%) of 35 p (289). ‘These findings indicate that the recommended daily change in ventilator crete may be extended to greats than or equal to 8 hours, This change in ‘recommendation could result insubstantial savings for US, horptals by reducing the numberof evs sed and the mou of personas! ume requ change the ccuils 285,289), The maximum time, however tha a eet ea e tafly lef unchanged 2 patient has not boen deters ‘Condensate formation in he ngprtory-phase ahing of veniatorbresthing cet an be decreased by elevating the tmperatie ofthe inspiatony-ph witha Reated wit inte inspiatory-phase tubing. However in one report tree cases of endatrachea!-oacheostomy-tbe Blockage by died seen ties were atbuted othe decrease isthe relative humiliy of inspite gas tat esled fom the elevation of the gs temperature (290). Until addition ‘nformation regarding he frequency of such cases i availble, IICWs who provide cae lo pens requiring mechanieal venation shoud be avare af | "vantages and ptental complications esacated with using heated venir thing. ‘Condensate formation canbe cliinatd by using hest-mostre exchanger (HME? ora hygroscopic condenser humidifier (i. an “arial nos) (29 ‘An HME recycles beat and moisture exhaled by The ptt and eliminate the need fra lumidfer Inthe absence ofa huni, no condensate forms ‘nspratory.phane bing of the vento eit. Thus, acter colonization ofthe ting prevented, nd the need to change the ting om = pene b ‘obvied (216), Some models of HMEs are equiped wath bacterial fiers, bt the advantage of wing sch filles unknown, HME can inrease he dst (Ge the area ofthe lung in which ar isnot exchanged) and resistance to breathing, might lak around the endotracheal abs, and might result i ying © Spur and blockage ofthe wachesbronchial tee (297)-Although recent developed HMEs that have hundiers increase airway humidity without net ‘lonization faces (293,298), additonal sides ave needed ta determine whether the ineidence of preumonia it decreased (299-302), «.Small-volume "n-tine") medication nebulizes,Small-volame medication nebulizer that are inserted i the ingprtory circuit of mechanical veils produce bacterial aerosols (22). If such devices become comaminated by condensate inthe ispustary tubing ofthe eating esc, they can increase Patients rick for proumonia because the nebulizer serosa is dsced through he endotachcal tube and bypasses many of the normal host defenses again Infection 26), 2. Large-Wolume Nebulizers. Nebulizers wih lange-olume (greater than $00 co) reservoirs, inctudng thse used in intermittent posive-pressure breathing (PPE ‘machines and uleasoni or spining-disk roorvat humidifiers, pos he greats sk fr pneumonia fo patients, probably because of te large amount of ers ijenerate (237-241 252,03), Thee retro ean become contaminated by the hands of HICWs, unsere huriicaon Mail, or adequate sein oF “sinfection berween uses (126) Once introduced into the reservoir. varous bacteria, inelvding Legionella sp, can mutipy to suit large numbers witht hours to pose arisk for infection in patents who receive inhalation therapy (128, 129.241,258 503. Steilizatin or high-level disinfection ofthese nebulies & sliminate vegetative Bacteria rom ter reserves and make tem Safe fr patent use (260) Howevet, unite nebulizer tached io TPPB machines, oon humidifiers have high costhenefit ratio evidence fei] beni rom leit use n hosp sucking an the poten cost of daily seiiaton isin ff and wee of tel water oil, sich devices sbtani. 5. Hand-Hald Smal-Volume Medication Nebulizers, Smllvolune mediation nebulzers used to administer bronchodilators, including nebulizer tht are band) a produce basil aerosols, Hand-held nebulzers have been associated with nosocomial pheumona, including Legionnaires disease, resulting fom ether ontamintion with medications from multidose vials (304) or Legioneli-contaminated tap water used for rinsing and filing the reserva (258. 4. Suction Catheters, Resuscitation Bags, Oxygen Analyzers and Ventilator Spirometers. Tracheal suction catheters can introduce microorganisms int patents ‘espzatory tact. Two tyes of sution-ctheter systoms are sed in US hospital: the open single-use eater system andthe closed multi-use cate systom Studies compatng th to systems have svolved lw numberof pail; the resus of thet tes suggest that he isk fr eatetr contamination o peu doesnot fer between pens on whom te single-ste suction method i wed and thote on whom the cowed mule eathetr sytem i wed (305-307, Alk ‘vantages of cost snd dovreacedeovtonmentl contamination have been afisbutd toute of the closed ucion ystena (308,30), argc studies ze needed to ‘ompate the advantages and disadvantage ofboth eyes (310). Reaibleresutiation bas are psticlarly difcult to clean and dey between we mieroorganitms in secretions ai lef in the bag may be aroolized anc sprayed into the lower respiratory trict of he patient on whom the Bagi en aditon,contaminaing microorganisms might be anemited fom ne pater shother vi hands of HCWs (311-318). Oxygen analyzes and venslatorspvoreters have been associated with oubreaks of gram-negative respiratory att, clonization and pnoumoaia resulting fom patent patient wansmission of egatsms vi hands of HCWs (253,248), These devies rege either seriization high-level disinfection between uses on diferent patients. Education of physicians, respiratory therapss, and nursing stall regarding the asain risks ad appropiate care of hese devices is essential ‘5. Anesthesia Eouipment. The contbutry role of anesthesia equipment in utreaks of nosocomial pacumonia was reported before hospitals implemented outs Use cleaning and dsinfecton'eiization of reusable anesthesia-equptentcompoaents tha could become containated with pathogens during use (314,313). 4. Anesthesia machine, Te intemal components of anesthesia machines, which include the gas sources and outlets, as valves, pressure regulators, flowme tnd vaporiers, re nol considered an iporiant sores of bacterial eataminaton of inhaled gases (316). Thu, rotine serization or highlvel dng ‘he internal machinery is unnecessary Bathing system or paint circuit Th breathing system o patient ici including the wachel tube or face mask, inspiratory and expiratory thing, (CO2 abseber andi camber, anesthesia ventilator bellows and tubing, humid, adjustable pessueliiting valve, and aherdovees and acesharies ‘trough which inaled andor exhaled ase ow oad fom patien, ean become contaminaled with mierooreanis ha might crpnate rm te pas oropharynx orwackeu. Recommendations for inase care, maintenance, and reprocesig i cleaning and dissection o terization) ofthe comsponen treuhing system hae been published (317,318) In gonsral, reusable commponcats ofthe breabing system tat dey touch he paints mucous eb, (Ge fce mask or trachea ube) or become renily cntaicated with the patients respiratory seevtions (ea y-pltce,inapraocy and expire bing ached senor) are cleaned and subjected to high-level disinfection o eration between patents The other pars of the breathing system (eg, CO2 ‘sheorer and ts chamber), for wick n appropiate snd coeffi sod f zeprovertng hae not Den mly determined (319) are changed, ead ‘sled or subjected to hig-veldsinfvtonpeiadcally in accordance with published guidelines (317.318) andor the manufactur insractons Using high-fiieny bacterial iter at various positions in the patient ect (et the piece oro the inspiratory and expiratory sides of the patie ‘iret has bsen advocated (317320.32) and shown to decrease contamination a the cia (21-823), However, the wse of bacterial ters to preven! ‘nosocomial pulmonary infection has nt been proven tbe effective ad requiesaddnal analysis (524326), 6. Pulmonary Function Testing Apparats 4 Ileal pars of pulmonary fenton esting apparatus, The ineral prs of pulmonary function testing apparatus usualy are nt considered an mporan’ of bute contamination of inhaled gas (327) However, because of concer about posible cary-oer of bacterial aerosols Hom an infeeious patent ‘he apparatus tothe next patient (245,228), placement of bacterial ites (Le tal remove exaled bacteria) between the patlest and the testing equpmen been advocated (246529), More sidis ate needed to evaluate the need fr and eicacy ofthe filters in preventing nosocoal pneunoni (330) 1 Tubing, breathing valves, ad moutpisces, Tubing, connector, breathing valves, nd mouthpieces could become contaminated with patent seretion dkving nse ofthe pulmonary fnction testing appara, Ths, these ems shoul he cleaned snd subjected to high-level disinection o terization Bet fon diferent pation. F. Thoracoabdominal Suc Procedures Certain patients ae at highs for developing postoperative pulmonary complications, including poeumonia. These persons include those who are obese or ae re ‘To years of age or who have chronic obstructive pulmonary discase (31-834). Alora results fom pulmonary funtion tests (especially decreased manzzun exp ‘ow rt) history of smoking, the presence of tracheostomy or prolonged itubon, or protein dpledon tht ean ens espistory-tuscle weaknes at ls isk (62,6813) Patents who undergo surgery ofthe ead neck, thor, or abdomen might have impairment of normal swallowing snd respiratory ciearance mechs: result of insumentton ofthe respiratory ret, anesthe, or inereaed ae of marae an sedatives (932,335, 336), Patents who ergo per abdominal ureer ‘oually have diaphragmatic dysfunction hat rsuls ia deceared functional esidulcapoity ofthe ung, closueof sways, and lets (237.38). Interventions sme at educing the postoperative paint’ risk fr pneumonia have been developed (329). These include deep beating exercise chest physotersp sf incenive spitamery, IPPB, and continuous postive sway prestore by face mak (33949), Sales evaluating the relative efficacy of thete modalities reported resus and were iu to compare because of eilferences in outcome variables assessed, paint populations stuied nd study design (539,41 342.48.830, ‘Novertelee, many side have reported tha deep bresthing excises use of incentive suomi. and IPB are advantageous matters, especially i patests wh preoperative pulmonary dysfuncion (42,343 845,346, 148.850). Ip ation, contol of pin tat interes with cough and deep breathing daring the isedite Desloperative period decreases the incidence af pulmonary complications afer sirery. Several meds of conrling pain be Deen sed these nce bth ita borinravenous chiding psen-contolld) administration of analgesia and regional eg pidral) analgesia (351354) Other Prophylactic Measures 1. Vaccination of Patios. Although preumococei ae not a major cause of nosocomial pneumonia, these organisms have been identified as tila agent of set rnosocemilpumonary infection and bacteremia (359-361). The following factors pace pins at high rk for complications fom pneumacoceal infections = treater than or equa o 65 year of age, chronic cardiovascular or pulmonary disease, diabetes melts, alebolism. ihoss, cerebrospinal ud leaks, umunoeuppresion, functional or anatomic aplni,or infection with human inumunodefiiecy viru (HIV), Pneumococcal vacsne i effective fn preventing pneumococcal dea (362,363), Becaut two thirds or mote of patents wil serous paeumococeal disease have bon spilled a east once within he St preceding thei pewmocoral ness, offering pasumcocealvacine i hospital (eat he time of ate dtchare) shoul contrite soba o pre the disease (302,368), Prophylaxis wit Systemic Antimicrobial Agents. The systemic adnisraton of antimicrobial is commonly uted to prevent nosacomitl peumonia ~ expe pallens who are receiving mechanical ventilation, re posaperatve, andlor ae ritlly il (368-367) However, the elfeay ofthis practice questionable, a= uperinfectioa, whch s possible sa result of any antimicrobial therapy, ould occur (7491,366-371. ‘Use of "Kinetic Beds o Continuous Lateral Rotational Therapy (CLRT) for Immobilized Patents. Use of kinetic bods, of CLRT, is a mancuvr for prevention pulmonary and other complications resulting fom prolonged tmabilzaton or bed tet, such asin pallens with acute stoke, ral les, head inry ore Bint chest rama, andlor mechanically assed ventlation (372-877), Tis procedure involves the use fa bed that turns continously and slowly (tom lest gua o 40 for CLRT to greater than o equal 40 for kine therapy along is longitudinal xis. Among the hypothesized beefs ar improved drainage of Scotetios wihia he lings and lower airways, increased tidal volume, and reduction of venous thesis with result pulmonary embolization (378-381). 2 the efficacy of CLRT in preventing paeumonia needs further evaluation because studies have yielded variable els (372-37) In addition, the stds either sal names of patients (373), lacked adequate andomizaton (372), had no clear definition of pneumonia (372), di not distinguish between communiy-acg ‘nd nosocomial pheumonia (373,377), ordi nt adjust or possible confounding factors (eg, mechanical vente, endotracheal intubation, nasogste ist td enteral feding) (372), LEGIONNAIRES DISEASE 1 Epidemiology Legionnste disease ia multisystem lass, with pneumonia, caused by Legionella sp, (382), Since the edologie agent of Legionnaires disease ws denied, ume rosocoml outbreak of the disease have ben eptd, thus enabling reveachers to tidy the epidemiology of epidemic lepanelois n conta, the epidemoony nordic (ce, onoutreakrelsed) nosocomial Legionnaires deeae fas not been well defined Homever, when one casei debi, the presence of addtional care [esuspeted OT 196 cases of nosocomial Legionnaires dicate reported in England and Wales during 1980-1982, 69% occured during 22 nosocomial oubeaks (el two of more cases outing aa hospital daring 2 Spot period) (33). Nine pecen of cases oecumed greater than 6 months before oars hospital outbreak, an smother 13% oceared in hopitals in which oer sporadic eases, bt no outbreaks, were denied. Only 87 occurred at sitions in which 9 outbreaks oF air Sporadic cases wee idee, Jn North Amerie, the overal proportion of nosocomial pneumonias caused by Legionels sp. has not ben determined, although the reported proportions frm indivi hospital have angod from zero to 14% (384-3R8). Beeausediagnoste els or Legionella. infection steno pertormoed rote onl patents who ave hospital acquired pacumonia inmost U.S. hospitals, this range probbly underestimates the incidence of Legionnaires disease. “Legionella sp are commonly found in varius natural and man-made aquatic environments (387388) and may enter hospital water systems in ow or undetectable ny (339,390) Cooling towers, evaporative condensers, heed pouble-watr-distrbuton systems within hospitals, and locally produced distilled water can provide a suit ‘vironment fr lepionellae to multiply. Factors known to enhance cloniaton and ampliieton of leponelae in man-made water environment ielude temperaut 35442 C (91-395), stagnation (396), scale and sediment (392), an the presence of ceva ee-lving nul amoebae tha ae capable of supporting intcella re lepioneliae (397,358), ‘A person's rik for acuirng legionellosis afer exposure to contaminated water depends ona nuberoffctor, ited the type and intensity ofexponure andthe health tats (399-401, Persons wo ae severely immunasoppressed or wo have chronic underlying ins soch at hematologic maligna or endstage real ae ata markedly increased rik for epionelsis (401-408), Persons in the ater stages of acquired immunodeficiency syndrome (AIDS) alg are probably at increase {br legionellosis, but data ate lined becaute of infequent testing of patients (401) Persons who have diabetes melts, chronic lung diacae, or nahematologe tmalignaney those wh smoke ciarties andthe elder areal moderne increased isk (382). Nosocomial Leyionis dace alo as boca reported among ate petite hospital 205,406). Underying disease and advanced age are rik factors not only for sequiing Legionnaires disease bu also for yng as a result ofthe illes. In a multivariate analysis 352 cases ported to CDC from 1980 teugh 1989, imumunosuppression, advanced age, end-age ent dicate, cancey, and nosocomial sequston of discase wet ‘ndependemly associated with fatal otcome (101). The mori rae was 40% among 803 persons who had norocomialy acquired cscs, compared with 20% ane 2:7 persons who bad communiy-acquired cases (401) tis dercace probably reflected the increased seventy of underying disease ia hospitalized patcats U, Diagnosis ‘The linia spectrum of disease caused by Legionella s,s brond and ranges fom asymptomatic infection to rapidly progressive poeumonia, Legionnsres disease Astinginhedcinealy or radiographically fom poeumeni cused by other ents (407 408), nd evidence a nfestion with other espiaory pathogens doe no x the possibility of concomitant Legionella p. infection (409-41), ‘The diagnosis of legionellosis may be confirmed by any one ofthe flowing: culture isolation of Legion from resptstoy seertions or sues, microscopic visua fhe bacterium in respiratory seeetions or tsue by inmmunoflurescen microscopy, or, or egal caused by Legionella prearophi serogroup 1, detection peumophil serogroup-1 antigens in une by radioimmunoassay, or Sbseration of four-fold ose in. paeumophila serogroup] aby eto greeter han ore 1128 in pared eeate and convalescent serum specimens by use ofan nditetiimunofuorescent anshody (IFA) tet (41,813) singe elevated amiboey ter does confi eae ofLegionmasdieare becuse IFA irs geser than or equ to 256 are found it 146% of heathy ade (41, 414-417), Because the above ets complement each aber, performing each test when Lapionaies dea i suspected increases the probably of confirming the diagnosis (4 However, because none f the nbortry test 100% sensitive tbe dingaoss of legionellosis ot excluded even if one o more of he tests ae negative (413,418. svailabl ests, the most spi is culture isolation of Legionella sp. rom any resputoy act specimen (319,420) Modes of Transmission [ahalaion of acrsols of wae contaminated with Lapionela sp. mit be the primary mechanism by which these organisms ener a ptint respiratory act (382), fn seve hospital outbreaks, patcus were considered o be infected through exposure to contanated acoso gencrated by cooling towers, showers, faueos, respiratory tery gulpment, and roomait humidifier (11241288, 421-427) In eter studies, aspiration of cotaminate potable Water or phryageal colonizers was proposed a thc ods trassmision to certain putin (425 428430}. However, person-a-persontassision has nat bee observed 1. Definition of Nosocomial Lepionsires Disease ‘The incubation perio fr Legionnaires diseases usually 2-10 dys (481; thus, forthe purposes of his document andthe accompanying HICPAC recommendations, labor confirmed leplonellosis that occurs ine paticnt who has beca hospitalized continuously fr peat than or egual o 10 days before the onset of ines is considered a det ‘trosocotal Legionnaires diease, and lhortory confirmed infection tat occurs 29 dye afer hospital admission is a possible cae ofthe dca {Prevention snd Control Measures ‘A. Prevention of Legionmazes Disease in Hospitals with No Meni Cases (Primary Prevention) Prevention suatepes in healthcare alts in which no cases af nosocomial legionellosis have ben deified have difered depending onthe immunologie stats © alien, the design and constuction ofthe facil, he rexources available for iriplementing prevention sali, ad slate ad local repulaions. A ens vo statogics ar practiced with rgard othe mos appropiate and cost-fetive means of preventing nosocomial legionellosis, specially in hospital in wh cass or only sporadic eass of te lines have been detected. However, a study comparing he cost-benefit rallos ofthese stateies has nt boea conducted, ‘The first approach is based on period, routine culturing of water samples ftom the hospitals potable water system fr the pupose of detecting Legionella sp, (8324 ‘When meter than or eq to 30% ofthe samples obtined are ealture-poiive for Lagronela sp the hospital’ polale water system is decolaminated (333), and Aingostc laboratory tess fr leieneliosis are made availabe fo clnictns is the hospi’ microbiology depariment so that achive surveillance for eases canbe {implemented (433,434). This approach ie based onthe poss tat no cues of torocomial legionellosis can accrif Legionella ep. 1 oot preset inthe poable wate ‘stem, and, conversely i Legionella sp, ae cultured from the wae, cases of nosocomial leionllosis could occur (12K 3), Proponents ofthis sategy indicate th ysis ae informed tht the potble water system ofthe hospitals eltire-postve for Leponele sp hey ave more ielned to condct the necessary test fot Tegionelloss (434). A potetialadvamage of using this approach in hospitals in which no eases of nosocomial legionellosis have occurred is that ouiely curing & umber of water samples is less cosy than routaly performing abaatory diagnostic testing foal patients Who have nosocomial pacuonia, ‘The main rpument against thi approach sha, inthe absence of eases, the relationship between the resus of water cultures and the isk for legionellosis remains tnefined. The bactertm hs been frequently present in water ystems of bung: (46), often without being aeocifed with known cates of dscns (271,385.97, rudy of 4 hospital in Quebec, 6s ofthe water systems were found tbe colonized with Legionella py, and 26% were colonized a greater than 30% of ste san however, cases of Legionaies disease were reported rely from these hospals (271. Sia, tone hospitals which ative suvelance or lepionelosis and ‘vironment cltrng for Lepionella sp. wre dove, no cates of legionellosis occurred na urology ward daring a3 Sanomth pera when TOY of water samples Eo ‘ward were cuture-psive for. pneumophila serogroup 1 (55). nerpreation of the resis of routinely curing the water might be confounded by dieing esl ‘ong the sits sampled within a single water aysem etd by Qucutions in he concentration of Legionella sp at hese ie (39,440), In aon he isk fo il ter exposure oa given source might be influenced by a umber of fatos oer than the presence or concentration of egunim these factors ich he degre to onlaminaed waer is seroslied ino respirable droplets, the proximity ofthe infects aero tothe polenta hot, the ascepiliy of te hos, and the virlence properties ofthe contaminating sai 281-483), Ths, data are insulisient to assign a level of risk for disease even on the basis ofthe number of colony-forming i ‘ctovtd in sarples fom the hep eqvionmient. By routinely culturing water sampler, many hospital admnistators wil ave to nite water decontamination ps ‘FLegionelia spare dented. Because of thi rable, routine monitoring of wate rom the hospitals potable wae stem ad fom erooloducing devices it widely recommended (448), The second approach o preventing nd controling nosocomial egionllosis involves 2 maintaining 2 high index of suspicion fr legionellosis and appropriately ust

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