1. HOSPITAL INFECTIONS Infectious Diseases Department Yeditepe University Hospital Meral SÖNMEZOĞLU, MD, Assoc Prof

2. 1. Know the general terminology and definitions 2. Know epidemiology 3. Understand the importance of the hospital infections Explain the prevention Learning objects

3. DEFINITION The term nosocomial infection or health- care associated infection is applied to “any clinical infection that was neither present nor was in its incubation period at the time of admission to the acute care setting ”. Nosocomial infections may also make their appearance after discharge from the hospital, if the patient was in the incubation period at the time of discharge

4. Most Common Types of Nosocomial Infections Most Common Types of Nosocomial Infections: 1. Urinary tract infections. 2. Surgical wound infections. 3. Lower respiratory Tract infections (primarily pneumonia). 4. Bloodstream infections (septicaemia) Nabeel Al-Mawajdeh RN.MCS

5. Burden of Healthcare-Associated Infections in the United States, 2002 1.7 million infections in hospitals –Most (1.3 million) were outside of ICUs –9.3 infections per 1,000 patient-days –4.5 per 100 admissions 99,000 deaths associated with infections –36,000 – pneumonia –31,000 – bloodstream infections Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

7. Calculation of estimates of healthcare-associated infections in U.S. hospitals among adults and children outside of intensive care units, 2002 HRN = high risk newborns WBN -= well-baby nurseries ICU = intensive care unit SSI = surgical site infections BSI – bloodstream infections UTI = urinary infections PNEU = pneumonia SSI 20% BSI 11% UTI 36% PNEU 11% Other 22% 133,368 424,060 263,810 129,519 274,098 -967 -21 -28,725 244,385 TOTAL HRN WBN Non-newborn ICU = SSI Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

8. Estimated number of HAIs by site of infection Major site of InfectionEstimated Number of Infections Range of $ estimates based on 2007 CPI for Inpatient hospital services Healthcare-Associated Infection (all HAI) 1,737,125 $20,549 - $25,903 Surgical Site Infection (SSI)290,485$11,087 - $29,443 Central Line Associated Bloodstream Infections (CLABSI)* 92,011 $ 6,461 - $25,849 Ventilator-associated Pneumonia (VAP)** 52,543$14,806 - $27,520 Catheter associated Urinary tract Infection (CAUTI)*** 449,334$ 749 - $ 832 Clostridium difficile-associated disease (CDI) 17 178,000$ 5,682 - $ 8,090

9. Attributable Costs of Nosocomial Infections Cost per Infection Wound infections$3,000 - $27,000 Sternal wound infection$20,000 - $80,000 Catheter-associated BSI $5,000 - $34,000 Pneumonia$10,000 - $29,000 Urinary tract infection$700 Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4 th ed. 2003:36.

10. SOURCES Infectious agents from endogenous or exogenous sources. Endogenous sources are body sites, such as the skin, nose, mouth, gastrointestinal (GI) tract, or vagina that are normally inhabited by microorganisms. Exogenous sources are those external to the patient, such as patient care personnel, visitors, patient care equipment, medical devices, or the health care environment

11. Modes of Transmission of Infections 1. Contact: - Direct e.g., hands of hospital personnel. - Indirect e.g., using contaminated objects. 2. Contaminated vehicles used in common for patients e.g., instruments, contaminated food, water, solutions, drugs or blood products. 3.Airborne e.g., aerosol, droplets or dust. Nabeel Al-Mawajdeh RN.MCS

12. Modes of Transmission of Infections (Cont’d) 4. Vector borne: e.g., mosquitoes. 5. Blood borne: inoculation injury or sexual transmission e.g., HBV, HIV. Nabeel Al-Mawajdeh RN.MCS

13. Patients Most Likely to Develop Nosocomial Infections 1.Elderly patients. 2.Women in labor and delivery. 3.Premature infants and newborns. 4.Surgical and burn patients. 5.Diabetic and cancer patients. 6.Patients receiving treatment with steroids, anticancer drugs, antilymphocyte serum, and radiation. Nabeel Al-Mawajdeh RN.MCS

14. Patients Most Likely to Develop Nosocomial Infections (Cont’d) 7.Immunosupressed patients (I. e., patients whose immune systems are not functioning properly) 8.Patients who are paralyzed or are undergoing renal dialysis or catheterization; quite often, these patient’s normal defence mechanisms are not functioning properly) Nabeel Al-Mawajdeh RN.MCS

15. Major Factors Contributing to Nosocomial Infections 1.An ever- increasing number of drug-resistant pathogens. 2.Lack of awareness of routine infection control measures. 3.Neglect of aseptic techniques and safety precautions. 4.Lengthy complicated surgeries. 5.Overcrowding of hospitals. Nabeel Al-Mawajdeh RN.MCS

16. Major Factors Contributing to Nosocomial Infections (Cont’d) 6.Shortage of hospital staff. 7.An increased number of Immunosupressed patients. 8.The overuse and improper use of indwelling medical devices. Nabeel Al-Mawajdeh RN.MCS

17. Outline Nosocomial Infections are a significant cause of morbidity and mortality There has been increased public interest in nosocomial infections Shifting paradigm –Many infections are preventable

18. Shifting Vantage Points on Nosocomial Infections Gerberding JL. Ann Intern Med 2002;137:665-670. Many infections are inevitable, although some can be prevented Each infection is potentially preventable unless proven otherwise

19. Epidemiology 5-10% of patients admitted to acute care hospitals acquire infections –2 million patients/year –¼ of nosocomial infections occur in ICUs –90,000 deaths/year –Attributable annual cost: $4.5 – $5.7 billion Cost is largely borne by the healthcare facility not 3 rd party payors Weinstein RA. Emerg Infect Dis 1998;4:416-420. Jarvis WR. Emerg Infect Dis 2001;7:170-173.

20. Nosocomial Infections 70% are due to antibiotic-resistant organisms Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection Burke JP. New Engl J Med 2003;348:651-656. Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

21. Major Sites of Nosocomial Infections Urinary tract infection Bloodstream infection Pneumonia (ventilator-associated) Surgical site infection

22. IMPORTANT SOURCES (a) Contaminated air, water, food and medicaments (b) Used equipments and instruments (c) Soiled linen (d) Hospital waste (Bio medical waste)

23. Surgical Site Infections

24. SSI level classification Incisional SSI - Superficial incisional = skin and subcutaneous tissue - Deep incisional = involving deeper soft tissue Organ/Space SSI - Involve any part of the anatomy (organs and spaces), other than the incision, opened or manipulated during operations Definition of Surgical Site Infections

25. Superficial Incisional SSI Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250- 278. Subcutaneous tissue Skin Superficial incisional SSI

26. Deep Incisional SSI Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue (e.g., fascia and muscle layers) Deep soft tissue (fascia & muscle) Deep incisional SSI Superficial incisional SSI Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250- 278.

27. Organ/Space SSI Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation Deep incisional SSI Superficial incisional SSI Organ/space SSI Organ/space Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

28. Cross Section of Abdominal Wall Depicting CDC SSI Classifications

29. Source of SSI Pathogens Endogenous flora of the patient Operating theater environment Hospital personnel (MDs/RNs/staff) Seeding of the operative site from distant focus of infection (prosthetic device, implants)

30. SSI Risk Factors Age Obesity Diabetes Malnutrition Prolonged preoperative stay Infection at remote site Systemic steroid use Nicotine use Hair removal/Shaving Duration of surgery Surgical technique Presence of drains Inappropriate use of antimicrobial prophylaxis

31. Microbiology of SSIs Staphylococcus aureus 17% Coagulase neg. staphylococci 12% Escherichia coli 10% Enterococcus spp. 8% Pseudomonas aeruginosa 8% Staphylococcus aureus 20% Coagulase neg. staphylococci 14% Escherichia coli 8% Enterococcus spp. 12% Pseudomonas aeruginosa 8% 1986-1989 (N=16,727) 1990-1996 (N=17,671)

32. National Nosocomial Infections Surveillance System (NNIS) ClassificationWound ClassSSI Risk Clean0 Lower Higher Clean-contaminated: GI/GU tracts entered in a controlled manner 1 Contaminated: open, fresh, traumatic wounds infected urine, bile gross spillage from GI tract 2 Dirty-infected: 3

33. NNIS- SSI Surveillance 1992-2004 Cesarean Section Risk IndexNumber of hospitals Pooled mean rate Per 100 operations Median- 50% percentile 01302.712.17 11174.143.19 2,3517.535.38 Am J Infect Control 2004;32:470-85

34. Preventing Surgical Site Infections Focus on modifiable risk factors

35. Sources of SSIs Endogenous: patient’s skin or mucosal flora –Increased risk with devitalized tissue, fluid collection, edema, larger inocula Exogenous –Includes OR environment/instruments, OR air, personnel Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection –May occur days to weeks following the procedure Most infections occur due to organisms implanted during the procedure

36. Downloaded from: Principles and Practice of Infectious Diseases © 2004 Elsevier Up to 20% of skin-associated bacteria in skin appendages (hair follicles, sebaceous glands) & are not eliminated by topical antisepsis. Transection of these skin structures by surgical incision may carry the patient's resident bacteria deep into the wound and set the stage for subsequent infection.

37. Risk Factors for SSI Duration of pre-op hospitalization * increase in endogenous reservoir Pre-op hair removal * esp if time before surgery > 12 hours * shaving>>clipping>depilatories Duration of operation *increased bacterial contamination * tissue damage * suppression of host defenses * personnel fatigue

38. SCIP Performance Measures Surgical infection prevention SSI rates Appropriate prophylactic antibiotic chosen Antibiotic given within 1 hour before incision Discontinuation of antibiotic within 24 hours of surgery Glucose control Proper hair removal Normothermia in colorectal surgery patients

39. Downloaded from: Principles and Practice of Infectious Diseases Infection Rate

40. Process Indicators: Duration of Antimicrobial Prophylaxis Prophylactic antimicrobials should be discontinued within 24 hrs after the end of surgery Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

41. Process Indicators: Timing of First Antibiotic Dose Infusion should begin within 60 minutes of the incision Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

42. URINARY TRACT INFECTIONS

43. Importance of CAUTI Most common type of healthcare- associated infection > 30% of HAIs reported to NHSN Estimated > 560,000 nosocomial UTIs annually Increased morbidity & mortality 43 Hidron AI et al. ICHE 2008;29:996-1011 Givens CD, Wenzel RP. J Urol 1980;124:646-8 Klevens RM et al. Pub Health Rep 2007;122:160-6 Green MS et al. J Infect Dis 1982;145:667-72 Weinstein MP et al. Clin Infect Dis 1997;24:584-602 Foxman B. Am J Med 2002;113:5S-13S Cope M et al. Clin Infect Dis 2009;48:1182-8 Saint S. Am J Infect Control 2000;28:68-75

44. Catheter-Urinary infection Health care-associated infections (HAIs) are one of the most common complications of hospital care. 44

45. Importance Catheter-associated (CA) bacteriuria is the most common health care– associated infection worldwide and a result of the widespread use of urinary catheterization, much of which is inappropriate, in hospitals and longterm care facilities (LTCFs ). 45

46. The most effective way to reduce the incidence of CA-ASB and CA-UTI is to reduce the use of urinary catheterization by restricting its use to patients who have clear indications and by removing the catheter as soon as it is no longer needed 46

47. Strategies to reduce the use of catheterization have been shown to be effective and are likely to have more impact on the incidence of CA-ASB and CA-UTI than any of the other strategies addressed in these guidelines 47

48. CA-UTI in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is defined by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with 10 3 colony-forming units (cfu)/mL of 1 bacterial species in a single catheter urine specimen 48

49. Catheter-associated Urinary Tract Infection (CAUTI) Single most common healthcare-associated infection (HAI), accounting for 34% of all HAIs. Associated with significant morbidity and excess healthcare costs. Since 2008, CMS no longer reimburses for additional costs required to treat CAUTIs.

50. CDC Surveillance Definition of CAU TI A urinary tract infection that occurs while a patient has an indwelling urinary catheter or within 48 hours of its removal. Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April 2001.

51. Evidence-Based Guidelines Since 2008, multiple evidence-based guidelines for CAUTI prevention have been published 1980199020002010 CDC JBI NHS SHEA APIC NHSN* CDC IDSA CDC= US Centers for Disease Control JBI=Joanna Briggs Institute NHS=UK National Health Service SHEA=Society of Healthcare Epidemiologists of America APIC=Association of Professionals of Infection Control NHSN=CDC’s National Healthcare Safety Network (*revised surveillance definition) IDSA=Infectious Diseases Society of America

52. Importance of CAUTI Estimated 13,000 attributable deaths annually Leading cause of secondary BSI with ~10% mortality Excess length of stay –2-4 days Increased cost – $0.4-0.5 billion per year nationally Unnecessary antimicrobial use 52

53. Catheterization rate 15-25% of hospitalized patients 5-10% (75,000-150,000) NH residents Often placed for inappropriate indications Physicians frequently unaware In a recent survey of U.S. hospitals: –> 50% did not monitor which patients catheterized –75% did not monitor duration and/or discontinuation Weinstein JW et al. ICHE 1999;20:543-8 Munasinghe RL et al. ICHE 2001;22:647-9 Warren JW et al. Arch Intern Med 1989;149:1535-7 Saint S et al. Am J Med 2000;109:476-80 Benoit SR et al. J Am Geriatr Soc 2008;56:2039-44 Jain P et al. Arch Intern Med 1995;155:1425-9 Rogers MA et al J Am Geriatr Soc 2008;56:854-61 Saint S. et al. Clin Infect Dis 2008;46:243-50

54. Pathogenesis 54 Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems Bacteria within biofilms resistant to antimicrobials and host defenses Some novel strategies in CAUTI prevention have targeted biofilms Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm

55. Catheter-associated Urinary Tract Infection (CAUTI) Urinary catheters are often placed unnecessarily, in place without physician awareness and not removed promptly when no longer needed. Prolonged catheterization is the #1 risk for catheter-associated urinary tract infection. 55

56. Complications of CAUTI’s: Cystitis Pyelonephritis Prostititis Endocarditis Sepsis/Septic shock Meningitis (Lo, E; Nicolle, L; Classen, D; Arias, A M; Podrgorny, K; Deverick, J A; Burstin, H; Calfee, D; Coffin, S E; Dubberke, E R; Frasier, V; Gerding, D N; Griffin, F A; Gross, P; Kaye, K S; Klompas, M; Marschall, J; Mermel, L A; Pegues, D A; Perl, T M; Saint, S; Salgado, C D; Weinstein, R A; Deborah, S, 2008)

57. Patient has at least 2 of the following signs or symptoms with no other recognized cause: fever (38.8C), urgency, frequency, dysuria, or suprapubic tenderness and at least 1 of the following

58. HAI-UTI positive dipstick for leukocyte esterase and/ or nitrate pyuria (urine specimen with >10 white blood cell [WBC]/mm or >3 WBC/highpower field of unspun urine) organisms seen on Gram’s stain of unspun urine at least 2 urine cultures with repeated isolation of the same uropathogen (gram negative bacteria or Staphylococcus saprophyticus) with >10 colonies/mL in non voided specimen.

59. HAI-UTI Bacteria entry Urinary sampling from catheter

60. Nosocomial Bloodstream Infections

61. Nosocomial Bloodstream Infections, 1995-2002 RankPathogenPercent 1Coagulase-negative Staph31.3% 2S. aureus20.2% 3Enterococci9.4% 4Candida spp9.0% 5E. coli5.6% 6Klebsiella spp4.8% 7Pseudomonas aeruginosa4.3% 8Enterobacter spp3.9% 9Serratia spp1.7% 10Acinetobacter spp1.3% N= 24,847 52 BSI/10,000 admissions Edmond M. SCOPE Project.

62. Nosocomial Bloodstream Infections, 1995-2002 Edmond M. SCOPE Project. Proportion of all BSI 0.9% (n=209) E.coli (33%) S.aureus (11.7%) Enterococci (11.7) Obstetrics and Gynecology In obstetrics, BSIs are uncommon. However, the principal pathogen is E.coli and not coagulase negative staphylococci. The source is typically genitourinary N= 24,847 52 BSI/10,000 admissions

63. Nosocomial Bloodstream Infections 12-25% attributable mortality Risk for bloodstream infection: BSI per 1,000 catheter/days Subclavian or internal jugular CVC5-7 Hickman/Broviac (cuffed, tunneled)1 PICC0.2 - 2.2

64. Risk Factors for Nosocomial BSIs Heavy skin colonization at the insertion site Internal jugular or femoral vein sites Duration of placement Contamination of the catheter hub

65. Prevention of Nosocomial BSIs Coated catheters –In meta-analysis C/SS catheter decreases BSI (OR 0.56, CI95 0.37-0.84) –M/R catheter may be more effective than C/SS –Disadvantages: potential for development of resistance; cost (M/R > C/SS > uncoated) Use of heparin –Flushes or SC injections decreases catheter thrombosis, catheter colonization & may decrease BSI

66. Prevention of Nosocomial BSIs Limit duration of use of intravascular catheters –No advantage to changing catheters routinely Change CVCs to PICCs when possible Maximal barrier precautions for insertion –Sterile gloves, gown, mask, cap, full-size drape –Moderately strong supporting evidence Chlorhexidine prep for catheter insertion

67. 30%-40% of all Nosocomial Infections are Attributed to Cross Transmission- Implication For The Spread Drug Resistant Pathogens

68. Fig 1. Selected antimicrobial-resistant pathogens associated with nosocomial infections in ICU patients, comparison of resistance rates from January through December 2003 with 1998 through 2002, NNIS System. Am J Infect Control 2004;32:470-85 NNIS: Selected antimicrobial resistant pathogens associated with HAIs

69. Health-Care Associated (Nosocomial) Pneumonia

70. Definition Occurring at least 48 hours after admission and not incubating at the time of hospitalization

71. Introduction Nosocomial pneumonia is the 2 nd most common hospital-acquired infections after UTI. Accounting for 31 % of all nosocomial infections Nosocomial pneumonia is the leading cause of death from hospital-acquired infections. The incidence of nosocomial pneumonia is highest in ICU.

72. Introduction The incidence of nosocomial pneumonia in ventilated patients was 10-fold higher than non- ventilated patients The reported crude mortality for HAP is 30% to greater than 70%. --- Medical Clinics of North America Therapy of Nosocomial pneumonia 2001 vol.85 1583-94

73. Pathogenesis

74. For pneumonia to occur, at least one of the following three conditions must occur: 1. Significant impairment of host defenses 2. Introduction of a sufficient-size inoculum to overwhelm the host's lower respiratory tract defenses 3. The introduction of highly virulent organisms into the lower respiratory tract Most common is microaspiration of oropharyngeal secretions colonized with pathogenic bacteria.

75. Pathogenesis --- The Prevention of Ventilator-Associated Pneumonia Vol.340 Feb 25, 1999 NEJM

76. Classification Early-onset nosocomial pneumonia: Occurs during the first 4 days Usually is due to S. pneumoniae, MSSA, H. Influenza, or anaerobes. Late-onset nosocomial pneumonia: More than 4 days More commonly by G(-) organisms, esp. P. aeruginosa, Acinetobacter, Enterobacteriaceae (klebsiella, Enterobacter, Serratia) or MRSA.

77. Causative Agent Enteric G(-) bacilli are isolated most frequently particularly in patients with late-onset disease and in patients with serious underlying disease often already on broad-spectrum antibiotics. Prior use of broad-spectrum antibiotics and an immunocompromised state make resistant gram- negative organisms more likely.

78. Causative Agent P. aeruginosa and Acinetobacter are common causes of late-onset pneumonia, particularly in the ventilated patients.

79. Causative Agent S. aureus is isolated in about 20~40% of cases and is particularly common in : 1. Ventilated patients after head trauma, neurosurgery, and wound infection 2. In patients who had received prior antibiotics or Prolonged care in ICU MRSA is seen more commonly in patients Received corticosteroids Undergone mechanical ventilation >5 days Presented with chronic lung disease Had prior antibiotics therapy

80. Causative Agent Anaerobes are common in patients predisposed to aspiration VAP with anaerobes occurred more often with oropharyngeal intubation than nasopharyngeal intubation.

81. Causative Agent Legionella pneumophilia occurs sporadically but may be endemic in hospitals with contaminated water systems. The incidence is underestimated because the test to identify Legionella are not performed routinely. Because the incubation period of Legionella infection is 2 to 10 days. cases that occur more than 10 days after admission are considered to be nosocomial, and cases that develop between 4 and 10 days are considered as possible nosocomial. Patients who are immunocompromised, critically ill, or on steroids are at highest risk for infection.

82. Antimicrobial Resistant Pathogens of Ongoing Concern Vancomycin resistant enterocci –12% increase in 2003 when compared to 1998-2002 MRSA –12% increase in 2003 when compared to 1998-2002 –Increased reports of Community-Acquired MRSA Cephalosporin and Imipenem resistant gram negative rods –Klebsiella pneumonia –Pseudomonas aeruginosa Am J Infect Control 2004;32:470-85

83. Transfer of VRE via HCW Hands Duckro et al. Archive of Int Med. Vol.165,2005 16 transfers (10.6%) occurred in 151 opportunities. 13 transfers occurred in rooms of unconscious patients who were unable to spontaneously touch their immediate environment

84. The inanimate environment is a reservoir of pathogens ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents a positive Enterococcus culture The pathogens are ubiquitous

85. The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, C.diff CNS and GNR Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

86. The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, CNS. C.diff and GNR Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

87. The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, CNS. C.diff and GNR Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

88. Alcohol based hand hygiene solutions Quick Easy to use Very effective antisepsis due to bactericidal properties of alcohol

89. Hand Hygiene Single most important method to limit cross transmission of nosocomial pathogens Multiple opportunities exist for HCW hand contamination –Direct patient care –Inanimate environment Alcohol based hand sanitizers are ubiquitous –USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

90. Contact Precautions for drug resistant pathogens. Gowns and gloves must be worn upon entry into the patient’s room

91. Biofilms Biofilms are microbial communities (cities) living attached to a solid support eg catheters/ other medical devices Biofilms are involved in up to 60% of nosocomial infections Antibiotics are less effective at killing bacteria when part of a biofilm

92. Transmission 1.Contact – most common Direct (physical contact) Indirect (via contaminated objects) 2.Airborne Transmission Droplet respiratory secretions on surfaces Inhalation of infectious particles 3.Blood-borne transmission 4.Food-borne

93. Role of infection control teams Education and training Development and dissemination of infection control policy Monitoring and audit of hygiene Clinical audit

94. Isolation & barrier precautions Decontamination of equipment Prudent use of antibiotics Hand washing Decontamination of environment

95. Surveillance Continuous monitoring of the frequency and distribution of infectious diseases Determines the most important causes of infectious diseases and identifies at risk groups

96. Uses of surveillance Used to identify new “problems” Used to identify where resources are most needed Used to determine the burden of disease Used for strategic planning and policies Use surveillance for measuring outcomes of intervention strategies

97. INFECTIOUS AGENT Bacteria - Fungi -Viruses Rickettsiae – Protozoal Prions – Protozoa Helminths RESERVOIRS People Equipment Environment Water SUSCEPTIBLE HOST Immunosuppression Diabetes – Surgery – Burns Cardiopulmonary - Neonates PORTAL OF ENTRY Mucous membrane GI / urinary / Respiratory track Broken skin PORTAL OF EXIT Excretions - Secretions Skin - Droplets MEANS OF TRANSMISSION Direct Contact Fomites - Injection / Ingestion - Airborne aerosol HEALTH CARE WORKERS Air flow control Food handling Isolation Trash & waste disposal Control of excretions and secretions Hand-hygiene Disinfection/ sterilization Environmental sanitation Employee health Care Rapid accurate identification of organism Treatment of underlying disease Recognition of high risk patients Aseptic Technique Catheter Care Wound Care Hand-hygiene Sterilization

98. Aşağıdaki ameliyat tiplerinin hangisinde cerrahi alan enfeksiyonu en fazla görülür? A) Kolesistektomi B) Tiroidektomi C) Memeden kitle eksizyonu D) Kolon rezeksiyonu E) İnguinal herni ameliyatı

99. TUS 2010 Aşağıdaki ameliyat tiplerinin hangisinde cerrahi alan enfeksiyonu en fazla görülür? A) Kolesistektomi B) Tiroidektomi C) Memeden kitle eksizyonu D) Kolon rezeksiyonu E) İnguinal herni ameliyatı