Avoidable medical harms in hospitals

3. Hospital Acquired
Infections
Assigned Reading (16 pages)
Overviews of Hospital acquired infections (2+ 3= 5 pages)
https://www.huffpost.com/entry/hospital-acquired-infections_b_1665
929
https://psnet.ahrq.gov/primers/primer/7/Health-Care-Associated-Infec
tions
Urinary tract infections (8 pages)
https://www.ajicjournal.org/article/S0196-6553(10)00151-3/fulltext
Antibiotic resistant infections (3 pages)
https://www.nejm.org/doi/full/10.1056/NEJMp1408040
 Group Assignments 1/2
Group 5 Hospital acquired infections:
What are the five most common HAIs?
What fraction of hospitalized patients will contract an HAI?
What do they all have in common?
What can generally be done to prevent them?
 
Group 6 Catheter related blood stream infections (CRBSI)
What types of intravascular lines are associated with BSI?
What is the incidence in acute care hospitals?
What is the mortality and cost of CRBSIs?
Why are central lines used?
What is being done to reduce this?
Are there any results of these efforts in the past 10 years?
Possible starting points:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805442/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093967/
 
Group Assignments 2/2
Group 7 Catheter Related Urinary Tract Infections (CAUTI)
Describe what these are and how they are used
Why are most urinary catheters placed?
How long are they usually left in and why?
Are most urinary catheters “avoidable harms”?
What is the incidence of urinary infections when catheters are in place?

Group 8 Clostridium difficile(c diff) colitis

What is c diff colitis?
What factors predispose to c diff colitis?
What is the mortality and cost?
How is it treated and what is the success rate of various treatments?
What steps are being taken to reduce c diff colitis?
Include antibiotic selection, prophylaxis, and other strategies
Give a brief overview of biome disruption by antibiotics and its consequences
 An Overview of
Hospital Acquired
Infections
AKA Nosocomial Infections
Group 5 Hospital acquired
infections:
What are the five most common HAIs?
What fraction of hospitalized patients will contract an HAI?
What do they all have in common?
What can generally be done to prevent them?
 
Hospital-Acquired
Infections (HAI’s)
ALS 480: Medical Harm, Lecture 3, 9/18/19

Group 5: Alec Botros, Mikaela Jamieson, Alvin Nagi,

Ashley Nakamura, Lorenzo Santamaria, Nathan Yawata
 Common HAI’s (USA, EU)
Catheter 25.6%** 17.6%
associated
urinary tract
infections
(CAUTI)
Common HAI’s Surgical site 21.8% -
infections (SSI)
Bloodstream 25.6%** 12%
infections (BSI)
Pneumonia 21.8% 46.9%
(PNA)
Clostridium 12.1% -
difficile (c. diff)

References:
Magill, S. S. et al. (2014). doi:10.1056/NEJMoa1306801 NB**: Placed under same category in the
Vincent, Jean-Louis et al. (1995). doi:10.1001/jama.1995.03530080055041 study
https://www.healthypeople.gov/2020/topics-objectives/topic/healthcare-associated-infections#1
 How many
people are
affected?
1 in 20…
(Schimmel, 2003)
1 in 21…
of which 1 in 17 will die
(Haque, 2018)
1 in 31…
References:
(CDC, 2019)
Schimmel E. M. (2003). doi:10.1136/qhc.12.1.58
https://www.cdc.gov/hai/data/index.html
Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). doi:10.2147/IDR.S177247
 These diseases are all
preventable.
● HANDWASHING
● PPE
● Influenza/Pneumococcal vaccines
● Get the catheter out
● Use antimicrobials wisely

References:
Collins AS. Preventing Health Care–Associated Infections. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook
for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 41. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK2683/
Hospital Acquired
Infections
• 1.7 million per year
• 99,000 deaths in 2007
• 35,000 pneumonia
• 30,665 bloodstream
• 8,205 surgical
• 11,062 other
(CDC, Estimates of Healthcare-Associated Infections
5/30/07)

11
 number % Per105

All causes 2,416,425 100 848.5

1. Diseases of heart 700,142 29.0 245.8
2. Malignant neoplasms 553,768 22.9 194.4
3. Pulmonary Emboli 296,370 12.2 104.4
4. Cerebrovascular disease 163,538 6.8 57.4
5. Chronic resp. diseases 123,013 5.1 43.2
6. Adverse Drug Reactions 106,000 4.4 37.3
7. Accidents (unintentional) 101,537 4.2 35.7
8. Hosp. Acquired Infections 99,000 4.1 35.7
9. Medical Errors 98,000 4.1 35.6
10. Diabetes mellitus 71,372 3.0 25.1
Influenza and pneumonia 62,034 2.6 21.8
Alzheimer's disease 53,852 2.2 18.9
Kidney Failure 39,480 1.6 13.9 12
 Hospital acquired* infections
64%: Devices
21%: Bloodstream infections/sepsis due to vascular catheters
15%: Urinary Tract Infections/sepsis due to bladder catheters
21%: Ventilator associated Pneumonia
12% pneumonia of bedrest (no ventilator)
10% skin and soft tissue
8% GI (mainly c diff associated colitis)
Am J Infect Control, 1998; 26:522

*Definition: recognized after two days post admission

 Causes of Hospital Acquired
Infections
1. Devices
2. Bedrest
skin/pneumonia
3. Promiscuous antibiotic use
• Biome disruption
• Antibiotic associated colitis
• Resistant bacteria
4. Poor adherence to personal hygiene
• mini epidemics
• Major driver of all infections
14
 12

Devices:
The Nosocomial Infection Driver

Frankenstein lives in the ICU

 1. Ventilator-
Associated Pneumonia
VAP
The Fatal Position

17
Effects of Bedrest on Normal Lungs
• Atelectasis
• Nearly 100% at 72 hours
• Elevating head of bed 30◦ reduces to ~50%
• Sitting up in bed 60◦ reduces to ~20%
• Up in chair reduces to <5%
• Pneumonia occurs in about 15%/day in atelectatic areas
So why are hospital patients kept
in bed?
• Sick patients don’t like to move
• Evolutionary calorie conservation?
• Culture
• The Bedrest Cure
• It’s easier to take care of them
• They “look better”
• They fall less frequently (provably untrue)
• It’s expected/ always been done
• Sympathy
 Effects of Mechanical Ventilation on Lungs

 “high” Vt causes edema in animals (ARRD

148:1194,132:880,142:321,110:556, J AppPhys 1990;69:956)

 inspiratory microbubbles (Marini ATS, 1998)

 bacteremia due to high Vt (Marini ATS, 1998)
 mechanical shear and inflammatory
mediator release (J App Phys 1992;73:123)
 decreased death rates with lower Vt (New
Engl J Med, 2000;342:1301)

20
Endotracheal Tubes
• Bypass multiple layers of defense
• Interrupt mucociliary secretion clearance ladder
• Secretions reach tube and fall back into lung
• Require sedation
• Decreased cough
• Little movement
• Ciliary retardation
 2. Vascular Line-
Associated
Bloodstream Infections
AKA Catheter-Related Bloodstream Infections (CRBSI)
Group 6
Catheter related blood stream infections (CRBSI)
What types of intravascular lines are associated with BSI?
What is the incidence in acute care hospitals?
What is the mortality and cost of CRBSIs?
Why are central lines used?
What is being done to reduce this?
Are there any results of these efforts in the past 10 years?
Possible starting points:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805442/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093967/
 Catheter Related Blood Stream
Infections (CRBSI)
Group 2: Kaitlyn Shim, Grace Kim, Nirali Patel, Samhitha Boyapalli, Carolyn
Nguyen
Why are central lines used?

● To give medications for treatment

○ Pain, infections or other medical issues
● Delivers treatment within seconds
● Provide fluids for nutrition
● Can help conduct certain medical tests quickly
● It can remain in place for weeks to months
○ Patients can receive treatment several times a day

Frequently Asked Questions about Catheters | HAI | CDC. (n.d.). Retrieved from
https://www.cdc.gov/hai/bsi/catheter_faqs.html
 What types of intravascular lines are associated
with CRBSI?
● Administer fluids, medications,
monitor patient status
● Short-term CVC: most
commonly used
○ Long-term and short term
→ majority of CRBSI

Clinical Infectious Diseases, Volume 49, Issue 1, 1 July 2009, Pages 1–45,
https://doi.org/10.1086/599376
What is the incidence in acute care
hospitals?
● ~250,000 CRBSIs occur every
year in U.S.
○ ~80,000 appear in ICUs

● Incidences of infection of long

term CVCs are high
○ 22.5% incidence

Shah, Harshal et al. “Intravascular catheter-related bloodstream infection.” The

Neurohospitalist vol. 3,3 (2013): 144-51. doi:10.1177/1941874413476043
What is the mortality and cost of
CRBSIs?
● Attributable mortality rate of such infections in critically ill patients is around
25%
● Each episode of CRBSI will cost $28,690 per survivor and result in an additional
average stay of 6.5 days in the ICU.
○ Between $33,000 and $44,000 in the general adult ICU
○ Between $54,000 and $75,000 in the adult surgical ICU
○ Approximately $49,000 in the pediatric ICU

Hollenbeak, C. S. (2011). The cost of catheter-related bloodstream infections: implications for the value of
prevention. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21915004
New Approaches for Prevention of Intravascular Catheter-Related... (2001, January 1). Retrieved from
https://www.medscape.com/viewarticle/410124
What is being done to reduce CRBSI?
● Implementation of quality improvement
interventions
● Skin disinfection with chlorhexidine alcohol
instead of povidone iodine alcohol
● Avoid using the femoral vein for central venous
access in adult patients
● In pediatric patients, the upper or lower
extremities or the scalp (in neonates or young
infants) can be used as the catheter insertion site

Lorente, L. (2016, March). What is new for the prevention of catheter-related bloodstream infections? Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4828748/
Recommendations | BSI | Guidelines Library | Infection Control | CDC. (n.d.). Retrieved from
https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html
 Are there any results of these efforts in the past
10 years?
● Incidence of CBRSIs have decreased
by 50% according to 2011 data

● Incidence rate decreased to 1

episode per 1000 catheter-days

● Since 2015, low incidence

sustained: 19% decline in 2017

● Data varies depending on country

Gahlot, R.(2014). Catheter-related bloodstream infections. International journal of
critical illness and injury science. doi:10.4103/2229-5151.134184

and type of patient Retrieved from

https://www.uptodate.com/contents/intravascular-catheter-related-infection-epidemiology
-pathogenesis-and-microbiology
https://www.ncbi.nlm.nih.gov/pubmed/29271210
Peripheral vs Central
Central Vein Catheter Related
Bloodstream Infections
• 48% of ICU patients have central lines
• Infection rate increases dramatically with # of days
• ~25% at two weeks
• Attributable mortality: 18%.
• Higher mortality rate than most diseases
• Central lines cause 20,000 deaths per year

32
 1215
Central Line Related Blood Stream Infections

Rate/1000 Patient Days

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

May-10
Jan-10

Feb-10

Jun-10

Aug-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11
Mar-10

Apr-10

Jul-10

Sep-10

Jul-11
The above graph reflects Central Line Related Blood Stream Infections for the 12-month period from July 2010 through June 2011. The
black horizontal line represents the 2011 Goal, a 20% reduction in CLBSI from the 2010 average rate of .21. The dotted maroon trend line
reflects the overall decrease in CLBSI throughout the period with the exclusion of a spike in January 2011 due to new type of patient
population of neurosurgery patients.
 Many hospitals now report zero central line
infections per year and have halved (or more)
their general nosocomial infection rates.
 When do you need a central line?
Wrong answer: when you are in the ICU
Right Answer: Rarely
• Low blood pressure
• Reliable route of rapid volume expansion
• Reliable route of vasoactive and emergency drugs
• Need for central venous pressure monitoring
• Administration of medications that irritate veins
• No available peripheral veins
• Vanishingly rare in the era of ultrasound
So why are central lines left in when
peripherals would do?*
• Culture
• Convenience
• Staff comfort
• Worry-free availability in emergencies
• Someone else inserts
• More stable
• Can get infected and not have to be replaced

* it is estimated that 75% of central lines are avoidable

3. Urinary Catheter-Related
Urinary Tract Infections
AKA Catheter-Related Urinary Tract Infections (CAUTI)
Group 7: Catheter Related Urinary Tract Infections (CAUTI)
Describe what these are and how they are used
Why are most urinary catheters placed?
How long are they usually left in and why?
Are most urinary catheters “avoidable harms”?
What is the incidence of urinary infections when catheters are in place?
Possibly helpful:
• https://www.medline.com/media/mkt/pdf/research/Infection-Preven
tion/Rothfeld-Study-Limit-Urinary-Catheter-Study.pdf
• https://www.nejm.org/doi/full/10.1056/NEJMe1604647
 Catheter-Related Urinary Tract
Infections

Team 7: Candy Carillo, Diana Katz, Jessica Lee, Lovedeep Singh,

Calvin Bron Susbilla, and Thanh Tran
Questions

● Describe what these are and how

they are used
● Why are most urinary catheters
placed?
● How long are they usually left in
and why?
● Are most urinary catheters
https://www.spc-yearbooks.co.uk/yearbook-ideas-questions-students/
“avoidable harms”?
● What is the incidence of urinary
infections when catheters are in
place?
Introduction

What are Urinary Catheters?

● The word “catheter” comes from
the Greek, meaning “to let or
send down”
● Early use as of 3,000 BC
● Straws, pipes, palm leaves

https://www.semanticscholar.org/paper/Urinary-catheters%3A-histor
y%2C-current-status%2C-adverse-Feneley-Hopley/cd31d70f5d6caa18
60ebc1148990a4b8bf6fdf40/figure/2
r
Introduction
Describe what these are and how they are used?

Types of Urinary Catheters

● Intermittent and indwelling https://images.app.goo.gl/1AsGVfqvwQVmThNW8

● Indwelling- two types: Urethral catheter

(Foley) and subrapubic catheter

● External Catheter- Condom like device that

fits over the penis . For males with urinary
incontinence .
https://www.compactcath.com/condom-catheters/
Catheter Insertion

https://www.healthywa.wa.gov.au/Articles/S_T/Troubleshooting-for-your-catheter
Catheter Use

Why are most urinary catheters placed?

Indications
● Physician order for hourly urinary
output reporting
● Inability to void spontaneously (usually
due to obstruction)
● Active urinary tract infection in patients
with stage 3 or 4 sacral decubitus ulcer
● Obvious inflammation of the perineum
as determined by wound care nurse https://www.ndtv.com/health/womens-urine-may-contain-good-a
nd-bad-bacteria-this-could-help-with-uti-treatment-6-best-home-r
emedi-1876514
Length of Time

How long are they usually left in and

why?
● Depends on the type of catheter
● Intermittent- One time use and
thrown away. Longer use can
cause UTI
● Indwelling- Usually used for a
month at a time. Bag is changed
often. http://media.medicalbag.com/images/2016/03/31/doctor-time.jpg

● Bladder spasms, blockages, 75%

UTI risk, pain and discomfort
Avoidable Harms

Are most urinary catheters “avoidable

harms”?
An estimated 17% to 69% of CAUTI may
be preventable with recommended
infection control measures, which
means that up to 380,000 infections and
9000 deaths related to CAUTI per year
could be prevented https://hhp-blog.s3.amazonaws.com/2015/10/do-no-harm-oath-
doctoriStock_000049120102_Medium.jpg
https://www.cdc.gov/infectioncontrol/guidelines/cauti/background.html
CAUTI Incidence

What is the incidence of urinary -infections

when catheters are in place? https://www.sltinfo.com/wp-
content/uploads/2016/02/incidence-and-prevalence-
Among UTIs acquired in the hospital, 1200x600-c-default.jpg

approximately 75% are associated with a

urinary catheter. Between 15-25% of
hospitalized patients receive urinary
catheters during their hospital stay
(https://www.cdc.gov/hai/ca_uti/uti.html).

https://klebsiella-
pneumoniae.org/klebsiella_pneumoniae_
urinary_tract_infection_2.jpg
CARTI Incidence

What is the incidence of urinary -infections http://bryanmbrandenb

when catheters are in place? urg.com/wp-
content/uploads/2013/
01/ecoli-by-bryan-
brandenburg-
Once a catheter is placed, the daily 900x900.png
incidence of bacteriuria is 3-10%. Between
10% and 30% of patients who undergo
short-term catheterization (ie, 2-4 days)
develop bacteriuria and are asymptomatic
(https://emedicine.medscape.com/article/2
040035-overview)
https://www.sltinfo.com/wp-
content/uploads/2016/02/incidence-and-prevalence-
1200x600-c-default.jpg
Recap

What are some things that you

learned?

https://madeyouthinkpodcast.com/

https://byrslf.co/life-lessons-on-learning-60d2056f1000
References
1. https://www.medline.com/media/mkt/pdf/research/Infection-Prevention/Rothfeld-Study-Limit-Urinary-Cath
eter-Study.pdf

2. https://www.nejm.org/doi/full/10.1056/NEJMe1604647
3. https://www.medicalnewstoday.com/articles/324187.php
4. https://www.hcd.com/urology/catheter-types/#intermittent
Thanks! :)

https://pics.me.me/thank-you-for-listening-memegenerator- https://cdn.shopify.com/s/files/1/0005/4522/6812/produc
net-thank-you-for-listening-53633672.png ts/d5c5eeba61159876f241a0e6007ba121_360x.jpg?
v=1530248380
Overall Effect of Project on UTIs
Rothfeld AF, Stickley,A
A program to limit urinary catheter use at an acute care hospital
Am J Infect Control 2010;38:568-71
Nosocomial UTIs per 1000 Patient Days

Control Period
Intervention Period

(p<.05)

1.06

0.45

52
When do you need a urinary (Foley) catheter?*
Wrong answer: when you are in the hospital
Right Answer: Rarely
• Obstruction
• Extremely uncommon in females and males under 60
• Need for hourly output measurements
• Only in shock states
• Open perineal or sacral wounds
• Not all agree – barriers are available (and urine is bacteriostatic)
• Certain urological situations
• Very uncommon

*it is estimated that 90% of Foleys are avoidable

So why are urinary catheters left in when not
needed?
• Culture
• Culture
• Convenience
• Urine disposal is hassle free
• Confusion
• “patient comfort”
• Fewer falls and less need for restraints
• Avoids skin breakdown
 1230

4. Effects of Antibiotics on
Infections
Group 8 Clostridium difficile (c diff) colitis

Group 8 Clostridium difficile(c diff) colitis

What is c diff colitis?
What factors predispose to c diff colitis?
What is the mortality and cost?
How is it treated and what is the success rate of various treatments?
What steps are being taken to reduce c diff colitis?
Include antibiotic selection, prophylaxis, and other strategies
Give a brief overview of biome disruption by antibiotics and its
consequences
Group 8 Clostridium difficile (c diff) colitis

What is c diff colitis?

What factors predispose to c diff colitis?

What is the mortality and cost?

How is it treated and what is the success rate of

various treatments?

What steps are being taken to reduce c diff colitis?

Include antibiotic selection, prophylaxis, and

other strategies

Give a brief overview of biome disruption by

antibiotics and its consequences
Group 8 Clostridium difficile colitis
Viviana Gonzalez

Ariel Tang

Matthew Banooni

Eliaz Lynch

Minh-Tuan Tran

Joselin Vizcaya
What is c diff colitis? What factors
predispose to c diff colitis?
● Caused by bacterium called Predispositions
Clostridium difficile ● Antibiotics
○ Disrupts bacteria in the gut
● Toxins kill microbes in the gut
● Hospitals / Nursing Homes
● Symptoms: fever, diarrhea, and ○ Found in furniture, toilet seats, jewelry, fingernails,
stethoscopes, etc.
pain in the abdomen
● Infection could spread to other
parts of the body or rupture
the colon
https://www.medicinenet.com/clostridium_difficile_colitis/article.htm#what_is_clostridium_difficile_c_difficile
 What is the mortality and cost?
● Ten year review of c. diff infection in acute care hospitals ● The total mean cost per patient was
from 2005-2014 ○ US$34, 104
● When applied to US national costs an annual cost of
○ Increased Incidence BUT decreased ○ US$2.8 billion was extrapolated
mortality
● Overall rate of mortality among the C. difficile
hospitalizations was 8.5%
○ 2005 the mortality rate was 9.7%
○ 2014 the mortality rate was 6.8%

Ten-year review of Clostridium difficile infection in acute care hospitals in the USA, 2005–2014
Luo, R. et al.
Journal of Hospital Infection, Volume 98, Issue 1, 40 - 43
 How is it treated and what is the
success rate of treatments?
● Current recommendations for treatment of initial CDI ● Between 20% and 35% of patients will fail initial
include: antibiotic treatment
○ oral metronidazole or vancomycin for 10–14 days ○ 40–60% will have a second recurrence
○ cessation of antibiotic therapy that may have predisposed ● Recurrence after initial treatment causes increased
to the infection morbidity

Hopkins, Roy J, and Robert B Wilson. “Treatment of recurrent Clostridium difficile colitis: a narrative review.”
Gastroenterology report vol. 6,1 (2018): 21-28. doi:10.1093/gastro/gox041
 What steps are being taken to reduce c
diff?
Antibiotic selection: Prophylaxis: Other methods:

Extended antibiotic use and use of
multiple antibiotics further increase the
risk of CDI
Antibiotic stewardship programs:
optimizes antibiotic selection has been
shown to significantly reduce hospital
rates of CDI
Vancomycin and Metronidazole
Highly effective antibiotics for known
infections and recurrent infections
But should not be used for patients that are
not diagnosed because it can promote CDI
and antibiotic resistance
Environmental disinfection and hand
hygiene
Reduce inappropriate use of gastric-acid
suppression
Glove use for patients with feeding tubes

Dale N. Gerding, Carlene A. Muto, Robert C. Owens, Measures to Control and Prevent Clostridium difficile Infection, Clinical
Infectious Diseases, Volume 46, Issue Supplement_1, 15 January 2008, Pages S43–S49, https://doi.org/10.1086/521861
 Brief overview of biome disruption by
antibiotics and its consequences
- Intestinal microbiota plays beneficial roles in
humans
- Excessive dosing of antibiotics elicits the loss of
naturally occurring intestinal microbiota
- This loss increases the numbers of yeasts (C. diff)
that normally exist at low numbers
- Consequences:
- Intestinal inflammatory response
- Proliferation of infectious bacteria by
increased glucose concentrations and O2

Yoon, Mi Young, and Sang Sun Yoon. “Disruption of the Gut Ecosystem by Antibiotics.”
Yonsei medical journal vol. 59,1 (2018): 4-12. doi:10.3349/ymj.2018.59.1.4
Antibiotic Related Colitis
 Clostridium difficile enterotoxin
• Pseudomembranous enterocolitis
 Can be fatal
 Treatment
• Stop antibiotics: 2 weeks
• More antibiotics
• metronidazole, vancomycin
• 15% relapse rate
• Fecal transplant

64
 Fooling with God:
How to undo 3 billion years of evolution in one dose
• There are 10x as many nonhuman cells in your body
as human ones.
• Most are antibiotic sensitive prokaryocytes.
• They have been present throughout our evolution
• ‘unincorporated organ systems’
• Most human cell types are clearly derived from
bacteria

65
 Consequences of altering biomes

• Overgrowth of foreign bacteria

• Inflammatory bowel diseases
• Impaired first line defenses
• Altered immunity
• Vitamin deficiencies
• Bleeding
• ‘Stunned’ mitochondria
• A strange new world
66
 The altered biome
• Numerous diseases are linked to the disruption of the
biome
• And can be cured by its replacement
• And duplicated by biome transplantation
• Ongoing research with some evidence
• ?obesity
• ?autism
• ?Alzheimer’s

67
5. Handwashing
Handwashing reduces infections dramatically
Labarraque AG. In: Instructions and Observations Regarding the Use of
the Chlorides of Soda and Lime.Porter J, editor. New Haven, CT: Baldwin
and Treadway; 1829. 
Semmelweis I. In: Etiology, Concept, and Prophylaxis of Childbed
Fever. 1st. Carter KC, editor. Madison, WI: The University of Wisconsin
Press; 1983. (This is an English translation of Semmelweis’ 1861
publication, which is in German)
Pratt RJ, Pellowe CM, Wilson JA, et al. Epic 2: national evidence-based
guidelines for preventing healthcare-associated infections in NHS
hospitals in England. J Hosp Infect. 2007;65:S2–S127. 
More recent outcome Studies on infection decreases as
a result of imposition of hand hygiene programs
• In hospitals
• American Journal of Infection Control. 2003;31:109–116
• Medical Journal of Australia. 2005;183:509–514.
• Journal of Hospital Infection. 2004;56:56–63
• Infection Control and Hospital Epidemiology. 2007;28:837–844

• In Adult ICUs
• Medical Journal of Australia. 2008;188:633–640
• Lancet. 2000;356:1307–1312
• BMJl. 1977;2:1315–1317.
• Critical Care Medicine. 2004;32:358–363 (with electronic monitoring)
• Infection Control and Hospital Epidemiology. 1990;11:589–594.
• New England Journal of Medicine. 1992;327:88–93
• American Journal of Infection Control. 1984;12:247–248
• NICUs
• Pediatrics. 2007;120:e382–390. 
 Effect of handwashing on infections with
82% vs 49% compliance
Crit Care Nurse 2017;37:e1-e8
J Infect Public Health. 2013;6:27-34.

Overall infections ↓60%

Bloodstream infections ↓81%
Pneumonia ↓67%
Various other infections ↓40-67%
Avoidable Causes of Hospital -Acquired Infections
“The Four Failures”
1. Failure of competent device management
Central lines and Foleys called a “National Tragedy”
Failure of checklist compliance on insertion and during
maintenance
Failure of daily rounding with checklists to remove unneeded
lines/catheters/tubes
Evidence based studies: more than half of all devices are unneeded
2. Failure to mobilize patients
3. Failure of personal hygiene (handwashing, appropriate attire)
4. Failure of effective antibiotic stewardship
ITTK Hospital Acquired Infections
• Most are device related
• Urinary and vascular catheters, endotracheal tubes
• These are thought to be vastly overused, often for the convenience of staff
• Overuse of antibiotics leads to avoidable harms
• Resistant organisms
• C diff colitis
• Biome disruption
• Many hospitals have zero rates for acquired infections
• Aggressive device management
• Effective antibiotic stewardship
• Limitation of hospital days
• Handwashing has emerged as an unexpectedly effective preventative
Assigned Reading (17 pages)
• 1. Drug overprescribing overview (7 pages)
https://www.readersdigest.ca/health/healthy-living/medicines-harm-good/
• 2. Serious Adverse Drug Reactions (1 page – abstract only)
JAMA. 1998;279(15):1200-1205. doi:10.1001/jama.279.15.1200
• 3. The most common drug harms (1 page – abstract only)
https://www.nejm.org/doi/full/10.1056/NEJMsa1103053
• 4. Drug interactions overview (you do not need to know specific interactions;
this paper is for a flavor of the problem rather than a detailed analysis) (8
pages)
https://www.aafp.org/afp/2000/0315/p1745.html
Group Assignments 1/2
1. List the 5 most commonly prescribed and the 5 most commonly fatal legal
nonprescription drugs.
How many units (Pills, etc) would it take for each of these drugs to kill the average adult
and the average child (LD50)?
How do these drugs cause death?
What measures are taken to reduce this danger?
2. Drug administration errors
What fraction of drugs given in hospitals are given in error (wrong drug/wrong patient,
wrong dose, wrong time, not ordered, etc)?
What fraction of these are reported?
What is “Just Culture” or “No Fault Reporting” and what results have institutions that
have instituted this reported?
What is the cause of most drug errors?
What measures have been successful in preventing these?
Group Assignments 2/2
3. Drug interactions
What are the chances that a given hospitalized patient will experience a drug
interaction?
What are the most common types of drug interactions?
Can these be reliably anticipated?
What measures have been shown to reduce the number of interactions
4. Drug toxicity
Give a commonly used classification of drug toxicity
Excluding errors and intentional misuse, what is the incidence of death and
hospitalization from drug toxicity
What can be done to reduce this?
END