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Nosocomial Infection

Definition
Nosocomial infections are defined as infections acquired during or as a result of hospitalization
– Most infections that become manifest after 48 hours – After being discharged from the hospital if the organism apparently was acquired in the hospital.
Surgical wound infection developing in the weeks after hospital discharge is an example of such nosocomial infection

Incidence and cost
Contribute significantly to morbidity and mortality as well as to excess costs for hospitalized patients 10% of patients admitted to an acute care hospital in the United States acquire a new infection (US) 8.7% (survey on 55 hospitals in 14 countries in 4 WHO regions) >2 million nosocomial infections per year and an annual cost of $5 - $11 billion.

Impact
The ICU mortality rate of infected patients was more than twice that of noninfected patients
(Vincent et al, 2009)

Common nosocomial infections occur even in immunocompetent hosts 99,000 death per year (US) (Feb, 2010) Increased length of stay or therapeutic activity Imbalance between resource allocation between primary and secondary health care Multi-drug resistance strain in community

Pathogens
Bacteria Virus Fungal

X-ray machine). and methicillin-resistant Staphylococcus aureus – Pathogen with probable survival in environmental reservoirs include norovirus. aspergillus – GNB – P. aeruginosa .g. and Candida species.Sources Inanimate environment include surfaces & equipment (e. vancomycinresistant enterococci. severe acute respiratory syndromeassociated coronavirus. candida. acquired colonisation Endogenous. aeruginosa & Acinetobacter baumannii (strongly ass with environmental contamination but ? Inanimate as source) Health care workers (cross infection). influenza virus. usually indirectly – Pathogen with more-compelling evidence of survival in environmental reservoirs include Clostridium difficile. P. thermometer.g. self colonisation e.

food. devices. TB. Legionella. 5 micron Inhaled E.g.g.Main Routes of Transmission Contact – most common – direct and indirect (contaminated glove / instrument / dressing / syringes) Droplets Airborne droplet nuclei – – – small-particle residual. varicella Common vehicle e. water .

Development of NIs Microbial agent Environment factor Host susceptibility Bacterial resistance .

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chemotherapy . blood transfusion. immunocompromised.Risk Factors Intrinsic factors – age. tracheostomy tube. Patient’s treatment e. underlying chronic disease.g. antibiotics. nutrition status Invasive devices & procedures – various catheter. drains. suction. antacid. steroid.

Development of NIs .

enterococci and C. US) – ↑ % nosocomial (NI) lower respiratory tract or bloodstream – ↓ % NI in the urinary tract or in surgical wounds 1990 to 1996 – lower respiratory tract (13%) and the bloodstream (14%) were sites of nosocomial infections Types of organisms change with antibiotics development Noted coagulase-negative staphylococci.1992) .Trends in NIs 1975 to 1996 (National Nosocomial Infections Surveillance Group. albicans are pathogens of increasing importance (William.

2005) Infections caused by antimicrobialresistant pathogens (50-60% of NIs in US) . 2006) Emergence of ESBL producing organism in community (Pitout et al.Trends in NIs Re-emergence of GN organism in HCABSI (Albrecht et al.

and Stenotrophomonas maltophilia (JONES.Resistance Patterns Gram-positive organisms. 2001) . Acinetobacter. Gram-negative organisms: – Extended-spectrum b-lactamases (ESBLs) in Klebsiella pneumoniae. and – multidrug resistance genes observed in Pseudomonas aeruginosa. – high-level third-generation cephalosporin (Amp C) b-lactamase resistance among Enterobacter species and Citrobacter freundii.(oxacillin-)resistant Staphylococcus aureus. Escherichia coli. the most important resistant pathogens: – Methicillin. blactam-resistant and multidrugresistant pneumococci. and vancomycin-resistant enterococci. and Proteus mirabilis.

9%) Lower respiratory tract infection (17.6%) Bloodstream infection (12%) Most frequently reported microorganisms: – – – – – Enterobacteriaceae (34.8%) Urinary tract infection (17. Fungi (17.4%) Staphylococcus aureus (30. .ICU A point prevalence study in Europe: Prevalence of ICU-acquired infection: 20.1%.1%).7%) Coagulase-negative staphylococci (19.6% (among ICU patients) Most frequent NIs: – – – – Pneumonia (46.Most Common .274:639-644 ) (JAMA.1%) 1995. [60% resistant to methicillin]) Pseudomonas aeruginosa (28.

274:639-644 ) . 1995.ICU-acquired infection .Risk Factors Increasing length of ICU stay (>48 hours) Mechanical ventilation Diagnosis of trauma Central venous Pulmonary artery Urinary catheterization Stress ulcer prophylaxis (JAMA.

Problem no 1 Nosocomial Pneumonia .

1.0% of inpatients Most common HACI contribute to death Increased hospital say by 7-9 days Hospital-acquired pneumonia (HAP) & Ventilator-associated peumonia .Nosocomial Pneumonia Affects 0.5% .

which was not incubating at the time of admission Ventilator-associated pneumonia (VAP) Refers to pneumonia that develops more than 48 to 72 hours after endotracheal intubation.Hospital Acquired Pneumonia Occurs 48 hours or more after admission. .

Hospital Acquired Pneumonia Early Onset – within 4–5 days of admission and tends to be caused by antibiotic-susceptible communitytype pathogens Late onset – infections tend to be caused by antibioticresistant hospital opportunists .

aeruginosa or MRSA .Ventilator-Associated Pneumonia Early onset – occurs during the first 4 days of mechanical ventilation when the pneumonia is often caused by typical community organisms Late onset – develops 5 days after the initiation of mechanical ventilation and is commonly caused by typical opportunistic and antibiotic-resistant hospital pathogens such as P.

without risk factors for resistant pathogens – Streptococcus pneumoniae or Haemophilus influenzae.Common Pathogens Early onset. S. aeruginosa or other antimicrobial-resistant opportunistic Gram-negative bacteria or by MRSA . aureus. and Enterobacteriaceae spp Late onset – P.

with a frequency of 21%. Staphylococcus aureus was next most common at 20%.Likely organism The major organisms of concern in nosocomial pneumonia are gram-negative aerobic bacteria. Pseudomonas aeruginosa was the most common isolate in the NNIS survey of ICUs. Acinetobacter has become a more common pathogen in ventilator-associated pneumonia .

Escherichia coli. Klebsiella pneumoniae. .Likely organism Other common pathogens include aerobic gram-negative bacilli (eg. Enterobacter spp) Nosocomial pneumonia due to viruses or fungi is significantly less common except in the immunocompromised patient.

Or resided in a long term care facility.Healthcare-associated pneumonia (HCAP) Includes any patient who was either hospitalized in an acute care hospital for two or more days within 90 days of the infection. or received intravenous antimicrobial therapy. or wound care within the 30 days prior to the current infection. . chemotherapy. or attends a hospital or hemodialysis clinic.

. especially those with naso gastric tubes Elderly patients. patients with chronic lung disease Postoperative patients Patients taking H2 blockers or antacids. especially those who are intubated Patients with an altered level of consciousness.Who are at risk? Patients in an ICU.

or delayed gastric emptying . altered consciousness.Nosocomial pneumonia Oropharyngeal and gastric colonization plays a critical role in the pathogenesis of pneumonia in hospitalized patients – The oropharynx can become colonized by many species of aerobic gram-negative organisms within 48 h of the patient's hospitalization Aspiration occurs commonly during sleep and is increased by such factors as a nasogastric tube. decreased gag reflex.

as well as in malnourished. 1991) . such as H2 blockers and antacids. a medication that heals ulcers without altering gastric pH (Cook et al. acholic. bacterial counts in the stomach rise in the presence of medications that raise gastric pH. and some elderly patients The prevalence of pneumonia is reportedly two to three times higher among intubated patients receiving H2 blockers or antacids for stress-ulcer prophylaxis than among intubated patients receiving sucralfate.Nosocomial pneumonia As for gastric colonization.

leukocytosis. congestive cardiac failure.Hospital acquired pneumonia Diagnosis Outside the ICU. fever. and a new infiltrate on chest xray Not all SOB is due to pneumonia Atelectasis. metabolic acidosis all can cause SOB . pneumonia should be suspected when a patient develops a new cough. sputum production.

. or humidifiers But …. the signs of pneumonia are relatively subtle. and thus the diagnosis is often relatively complex Ventilated patients are at risk of developing pneumonia by exposure to bacteria leaking around the cuff of the endotracheal tube or to bacteria from nebulizers.Ventilator associated pneumonia Diagnosis In ICU patients. especially those who are intubated. condensate within ventilator circuits.

and acute respiratory distress syndrome (ARDS) are all common findings in intubated patients An important clue to pneumonia is a change in the output or character of these secretions. a sputum Gram's stain should be performed and pneumonia seriously considered in the differential diagnosis .Ventilator associated pneumonia The chest x-rays are difficult to interpret. congestive heart failure. If their volume or thickness increases or their color changes. because fluid overload.

– (ii) leukocytosis of 12 109/ml. and/or – (iii) purulent tracheobronchial secretions Sensitivity of 69% and specificity of 75% for establishing the diagnosis of VAP (Fabregas et al.3°C.VAP. 1999) .Diagnosis A new and persistent (48-h) infiltrate on chest radiograph plus two or more of the three criteria: – (i) fever of 38.

including. imipenem. cefepime. or eight of the antibiotics typically used to treat infections with these organisms Panresistance refers to those gram-negative organisms with diminished susceptibility to all of the antibiotics recommended for the empiric treatment of VAP. and levofloxacin. is variously defined as resistance to at least two. meropenem.Drug Resistance Multidrug resistance (MDR) in gram-negative bacilli. ceftazidime. . ciprofloxacin. which are an important cause of VAP. three. four. piperacillin-tazobactam.

longterm care facility.Late onset HAP Host risk factors for infection with MDR pathogens include – – – Receipt of antibiotics within the preceding 90 days Current hospitalization of 5 days Admission from a healthcare-related facility (eg. dialysis unit) – High frequency of antibiotic resistance in the community or in the specific hospital unit .

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Problem No 2 Blood stream Septicemia and intravascular devices .

7% of admissions to a surgical ICU. with 50% mortality and a prolongation of hospitalization by 24 days in survivors. .Blood stream septicemia One carefully controlled study reported bloodstream infection in 2.

. or hypotension AND meet one of the following criteria: – (a) the common skin contaminant is isolated from two blood cultures drawn on separate occasions AND the organism is not related to infection at another site – or (b) the common skin contaminant is isolated from a single blood culture in a patient with an intravascular access device AND the physician institutes appropriate antimicrobial therapy. chills.Definition A primary BSI must meet one of the following criteria for classification in this category: – The recognized pathogen is isolated from blood culture AND the pathogen is not related to infection at another site. – Organisms which might be considered skin contaminants require that the patient have either fever (>38ºC).

which could be contaminants or actual infecting organisms include coagulase-negative staphylococcus (CoNS). diphtheroids. . Propionibacterium sp. and micrococcus. Bacillus sp.Common skin organisms.

with the next highest increase for Candida spp.Organisms While gram-negative aerobic bacilli are probably the most feared nosocomial bloodstream pathogens. aureus and enterococci . the NNIS data for 1980 through 1989 showed that the isolation of these organisms had not increased in frequency over the decade. The frequency of bloodstream isolation increased the most for coagulase-negative staphylococci. Other leading causes of linerelated bacteremia were S.

an essential step in pathogenesis If a patient has a fever and signs of cutaneous involvement (erythema. tenderness. induration. or purulent drainage) at the insertion site of a catheter. and the catheter tip sent for quantitative culture.Intravascular device Catheter induced NI – Biofilm. full cultures should be performed. . the vascular-access line removed.

Intravascular device If the exit site does not show signs of infection. and there is considerable debate about the necessity of removing a line from a febrile patient at that point Line changes over a guidewire have been shown to be safe .

Problem No 3 UTI .

this benefit is not observed. is generally the easiest to treat and has the least severe sequelae Four principal risk factors have been associated repeatedly with the development of UTI in hospitalized patients: – – – female sex prolonged urinary catheterization lack of systemic antibiotic therapy The administration of systemic antibiotics to patients with urinary catheters in place for 1 to 5 days has been associated with a decrease in rates of bacteriuria. the most common type of nosocomial infection.UTI UTI. however. For patients with catheters in place for >6 days. – Breach of appropriate catheter care .

in whom bacteria track up the short female urethra. such as Proteus and Pseudomonas spp. periurethral colonization often cannot be demonstrated in men Some organisms. most infections seem to arise from intraluminal spread of organisms to the bladder. the typical mechanism involves periurethral colonization with fecal flora and tracking of organisms up the catheter to the bladder The pathogenesis resembles that of UTI in noncatheterized female patients..UTI The pathogenesis of catheter-associated UTI appears to differ in men and women – In women. appear to facilitate the growth along the inside of the urinary catheter of a biofilm that encrusts and obstructs the flow of urine. . – In men.

UTI-pit fall in making diagnosis It is crucial to think carefully about all possible sources of infection and not to assume that UTI is the probable cause White blood cells without epithelial cells in the urine sediment or leukocyte esterase or nitrite on urinalysis. particularly if the patient does not respond to antibiotics. . should raise questions about the validity of the diagnosis of UTI. Inability to recover any organism or the same organism on repeat culture. It is prudent to repeat the culture before the institution of therapy. A urine culture positive for a single organism should not be accepted as definitive evidence of UTI in an asymptomatic patient.

Problem no 4 Surgical wound infection .

. with the rates doubling for each week of preoperative hospitalization – preoperative shaving of the field. especially if performed >24 h beforehand – a long duration of surgery. – Surgical tissue handling – Number of persons present in the operating room – Infection rates also vary with the surgeon. and the presence of an untreated remote infection.Surgical wound infection Risk factors for the development of postoperative wound infection include : – the presence of a drain – a long preoperative length of stay.

Surgical wound infection Perioperative antibiotic prophylaxis has been shown to decrease rates of wound infection in a number of careful studies. including those of clean surgical procedures Antibiotic coverage after the surgical wound is closed has not been shown to provide additional benefit .

and dehiscence of sutures The most common pathogens causing SSI are coagulase-negative Staphylococcus and S. aureus.Surgical wound infection A surgical wound should be examined for localized tenderness and induration. fluctuance. drainage of purulent material. but antibiotic-resistant bacteria and fungi are also becoming more frequent etiologies .

Not to forget Tuberculosis infection .

In summary You grow what you plant Hand washing and proper isolation nursing is the key to the control of nosocomial infection .

THANK YOU .

small sample sizes.78). there was a trend favoring a decreased incidence of pneumonia (0. and outcomes were evaluated by duplicate independent review. A meta-analysis.TI . Ontario.28 to 1. Laine LA.42.24 to 1. RESULTS: The incidence of pneumonia was lower in critically ill patients receiving antacids and/or histamine-2-receptor antagonists as compared with patients receiving no stress ulcer prophylaxis (common odds ratio 0. However. 95 percent CI 0. STUDY SELECTION: Independent review of 48 randomized controlled trials of prophylaxis identified eight relevant studies. In trials comparing sucralfate with pHaltering drugs. intervention. and the failure to examine the effects of antacids and histamine-2-receptor antagonists separately make a large prospective randomized trial necessary to confirm or refute these findings. Guyatt GH.11). Raffin TA SO . PURPOSE: To examine the differential effect of drugs used for stress ulcer prophylaxis on nosocomial pneumonia in critically ill patients. the common odds ratio of 0. When stress ulcer prophylactic therapy was titrated to achieve a gastric pH of 3. 95 percent CI 0. DATA ABSTRACTION: The population.100(1):7-13. Hamilton.Cook DJ.55 (0. DATA IDENTIFICATION: Computerized bibliographic search of published and unpublished research. .17 to 1. methodologic deficiencies. AD .Department of Medicine.Chest 1991 Jul.06) suggests a 45 percent risk reduction with the use of sucralfate. McMaster University Faculty of Health Sciences. The use of sucralfate is associated with a lower incidence of nosocomial pneumonia in comparison to agents which raise gastric pH. CONCLUSION: Stress ulcer prophylaxis with drugs which raise gastric pH does not increase the incidence of pneumonia in comparison to placebo or control therapy.Nosocomial pneumonia and the role of gastric pH. Canada.5 or greater.66. AU .

During the following 5 months. The purpose of this study was to determine whether adherence to a ventilator weaning protocol (WP) and the use of chlorhexidine gluconate (CH) oral rinse for oral hygiene would decrease the incidence of VAP in surgical ICU patients. duration of ventilation. The risk of nosocomial pneumonia increases with age. CONCLUSIONS: Improved oral hygiene via topical CH application in conjunction with the use of a WP is effective in reducing the incidence of VAP and the duration of mechanical ventilation in surgical ICU patients. a CH 0. length of stay.12% oral rinse administered twice daily was added to the protocol. race. and incidence of VAP and in-hospital mortality rates. p < 0. a WP was applied to all patients requiring mechanical ventilation. Both WP and WP+CH groups were compared using the National Nosocomial Infection Surveillance (NNIS) and hospital databases as historic controls. initiated on ICU admission in all intubated patients. RESULTS: The institution of the WP alone led only to a slight decrease in the incidence of VAP but a significant reduction in the median duration of mechanical ventilation by 40% (4. comorbid conditions. The median duration of mechanical ventilation in this group was similar to that of the WP group. 75% for late VAP. ICU and total-hospital length of stay.05). risk factors. severity of acute illness and preexisting co-morbid conditions. . There was no significant difference in the overall hospital or ICU length of stay between the groups.008). severity of the acute illness (APACHE II) at admission. During the first 5 months. The data collection included age. METHODS: A prospective study was conducted over a period of 10 months (October 1998-July 1999) in surgical ICU patients requiring mechanical ventilation (n = 95). resource utilization and mortality.5 days. p < 0. The addition of CH to the WP led to a significant reduction and delay in the occurrence of VAP (37% overall. Ventilator-associated pneumonia (VAP) significantly increases morbidity. gender.Nosocomial pneumonia BACKGROUND: Pneumonia is one of the most common nosocomial infections in hospitalized patients.