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

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

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
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
To summarize results of CDC’s findings, about 1.7 million healthcare-associated infections occurred in U.S. hospitals. Of these, most (1.3 million) were outside of intensive care units. These numbers can also be presented as 9.3 infections per 1,000 patient-days, or 4.5 per 100 admissions. There were an estimated 99,000 deaths associated with these infections. The body sites associated with the greatest number of deaths were the estimated 36,000 deaths from pneumonia, and 31,000 from bloodstream infections.
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

7. Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
Calculation of estimates of healthcare-associated infections in U.S. hospitals among adults and children outside of intensive care units, 2002
SSI
20%
BSI
11%
UTI
36%
PNEU
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
The greatest challenge was to estimate the number of infections outside of intensive care units. We chose the surgical site for our calculations because the number of surgical procedures is available for the U.S. population in the NHDS. We multiplied the number of surgical procedures in the National Hospital Discharge Survey by the surgical site infection rate from NNIS 2002 surveillance. From this estimate, we subtracted surgical site infections among newborns and among adults and children in intensive care units, which yielded the total number of such infections among hospitalized adults and children outside of intensive care units, i.e., 244,385, shown here in the blue circle. Surgical site infections accounted for 20% of all healthcare-associated infections in NNIS hospital-wide surveillance; thus, we used that percentage to estimate the number of infections for other body sites.
HRN = high risk newborns WBN -= well-baby nurseries ICU = intensive care unit SSI = surgical site infections BSI – bloodstream infections UTI = urinary infections PNEU = pneumonia
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

8. Estimated number of HAIs by site of infection
Major site of Infection
Estimated 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
$ $ 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, 4th 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.
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
Elderly patients.
Women in labor and delivery.
Premature infants and newborns.
Surgical and burn patients.
Diabetic and cancer patients.
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)
Immunosupressed patients (I. e., patients whose immune systems are not functioning properly)
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
An ever- increasing number of drug-resistant pathogens.
Lack of awareness of routine infection control measures.
Neglect of aseptic techniques and safety precautions.
Lengthy complicated surgeries.
Overcrowding of hospitals.
Nabeel Al-Mawajdeh RN.MCS

16. Major Factors Contributing to Nosocomial Infections (Cont’d)
Shortage of hospital staff.
An increased number of Immunosupressed patients.
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
Many infections are inevitable, although some can be prevented
Each infection is potentially preventable unless proven otherwise
Gerberding JL. Ann Intern Med 2002;137:

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 3rd party payors
Weinstein RA. Emerg Infect Dis 1998;4:
Jarvis WR. Emerg Infect Dis 2001;7:

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:
Safdar N et al. Current Infect Dis Reports 2001;3:

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. Surgical Site Infections (SSI)
First most common nosocomial infection (%31)*
Most common nosocomial infection among surgical patients (38%)
2/3 incisional
1/3 organs or spaces accessed during surgery
7.3 additional postoperative days at cost of $3,152 in extra charges
Surgical site infections are the third most common type of nosocomial infection accounting for 14% to 16% of all infections.
Among surgical patients, however, SSIs are the most common nosocomial infection, observed in 38% of cases. Two-thirds of these infections are due to the incision, whereas one-third are due to infection of the organs or spaces during surgery.
Surgical site infections result in an additional 7.3 postoperative days at an added cost of $3,152.
* Infect Control Hospital Epidemiol 2012;33(3):283-91

25. Definition of Surgical Site Infections
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

26. Superficial Incisional SSI
Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision
Superficial incisional SSI
Skin
Subcutaneous tissue
The first type of surgical site infection is the superficial incisional surgical infection which occurs within 30 days post-op and involves only the skin or subcutaneous tissue.
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

27. 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 incisional SSI
Superficial incisional SSI
A more serious SSI is a deep incisional surgical infection, which extends past the superficial layer. The infection occurs within 30 days post-op only 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, which include the fascia and muscle layers.
Deep soft tissue (fascia & muscle)
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

28. 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
Superficial incisional SSI
Deep incisional SSI
The most extensive of these surgical infections involves the organs and the space surrounding the organs. These infections can occur within 30 days post-op if no implant is left in place or within 1 year if an 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.
Organ/space SSI
Organ/space
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

29. Cross Section of Abdominal Wall Depicting CDC SSI Classifications

30. 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)

31. 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

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

33. National Nosocomial Infections Surveillance System (NNIS)
Classification
Wound Class
SSI Risk
Clean
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

34. NNIS- SSI Surveillance 1992-2004
Cesarean Section
Risk Index
Number of hospitals
Pooled mean rate
Per 100 operations
Median- 50% percentile
130
2.71
2.17 1
117
4.14
3.19
2,3 51
7.53
5.38
Am J Infect Control 2004;32:470-85

35. Preventing Surgical Site Infections
Focus on modifiable risk factors

36. Sources of SSIs Endogenous: patient’s skin or mucosal flora Exogenous
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

37. Downloaded from: Principles and Practice of Infectious Diseases
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.
Downloaded from: Principles and Practice of Infectious Diseases
© 2004 Elsevier

38. 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

39. 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

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

41. 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:

42. 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:

43. URINARY TRACT INFECTIONS

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

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

46. 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).

47. CAUTI
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

48. CAUTI
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

49. CAUTI
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 103 colony-forming units (cfu)/mL of 1 bacterial species in a single catheter urine specimen

50. 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.

51. CDC Surveillance Definition of CAUTI
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.

52. Evidence-Based Guidelines
Since 2008, multiple evidence-based guidelines for CAUTI prevention have been published
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

53. 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 – $ billion per year nationally
Unnecessary antimicrobial use

54. Catheterization rate 15-25% of hospitalized patients
5-10% (75, ,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

55. Pathogenesis
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

56. 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.

57. 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)

58. CAUTI
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

59. CAUTI 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.

60. CAUTI
Urinary sampling from catheter
Bacteria entry

61. Nosocomial Bloodstream Infections

62. Nosocomial Bloodstream Infections, 1995-2002
Rank
Pathogen
Percent 1
Coagulase-negative Staph
31.3% 2
S. aureus
20.2% 3
Enterococci
9.4% 4
Candida spp
9.0% 5
E. coli
5.6% 6
Klebsiella spp
4.8% 7
Pseudomonas aeruginosa
4.3% 8
Enterobacter spp
3.9% 9
Serratia spp
1.7% 10
Acinetobacter spp
1.3%
N= 24,847
52 BSI/10,000 admissions
Edmond M. SCOPE Project.

63. Nosocomial Bloodstream Infections, 1995-2002
Obstetrics and Gynecology
Proportion of all BSI 0.9% (n=209)
E.coli (33%)
S.aureus (11.7%)
Enterococci (11.7)
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
Edmond M. SCOPE Project.

64. Nosocomial Bloodstream Infections
12-25% attributable mortality
Risk for bloodstream infection:
BSI per 1,000 catheter/days
Subclavian or internal jugular CVC
5-7
Hickman/Broviac (cuffed, tunneled) 1
PICC

65. 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

66. Prevention of Nosocomial BSIs
Coated catheters
In meta-analysis C/SS catheter decreases BSI (OR 0.56, CI )
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
Chlorhexidine/silver sulfadiazine vs. minocycline/rifampin catheters

67. 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
Peripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central
venous catheters (CVCs)

68. Catheter Insertion Site
Risk of infection:
Central vein >>> Peripheral vein
Femoral >>> IJ > Subclavian
Subclavian = preferred

69. Components of IHI CR-BSI Prevention Bundle
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin prep
Optimal site selection
Daily review of line necessity

70. 30%-40% of all Nosocomial Infections are Attributed to Cross Transmission- Implication For The Spread Drug Resistant Pathogens

71. NNIS: Selected antimicrobial resistant pathogens associated with HAIs
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

72. Health-Care Associated (Nosocomial) Pneumonia

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

74. Introduction
Nosocomial pneumonia is the 2nd 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.

75. 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

76. Pathogenesis

77. Pathogenesis
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.

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

79. 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.

80. 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.

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

82. 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

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

84. 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.

85. Antimicrobial Resistant Pathogens of Ongoing Concern
Vancomycin resistant enterocci
12% increase in 2003 when compared to
MRSA
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

86. Transfer of VRE via HCW Hands
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
Duckro et al. Archive of Int Med. Vol.165,2005

87. The inanimate environment is a reservoir of pathogens
X represents a positive Enterococcus culture
The pathogens are ubiquitous
~ 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.

88. 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:
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:

89. 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:
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:

90. 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:
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:

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

92. 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

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

94. 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

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

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

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

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

99. 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

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

101. 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

102. 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

103. TUS 2012 Aşağıdakilerden hangisi temiz-kontamine yaraya örnektir?
A) Kolesistektomi B) Tiroidektomi C) İnguinal fıtık onarımı D) Mastektomi E) Perfore apandisit varlığında apendektomi

104. TUS 2012 Aşağıdakilerden hangisi temiz-kontamine yaraya örnektir?
A) Kolesistektomi B) Tiroidektomi C) İnguinal fıtık onarımı D) Mastektomi E) Perfore apandisit varlığında apendektomi

105. TUS 2012
Protez, greft gibi implantların uygulandığı ameliyatlarda cerrahi alan enfeksiyonu tanısı koyabilmek için enfeksiyon en geç ne zaman ortaya çıkmalıdır? A) 1 ay B) 3 ay C) 6 ay D) 1 yıl E) 2 yıl

106. TUS 2012
Protez, greft gibi implantların uygulandığı ameliyatlarda cerrahi alan enfeksiyonu tanısı koyabilmek için enfeksiyon en geç ne zaman ortaya çıkmalıdır? A) 1 ay B) 3 ay C) 6 ay D) 1 yıl E) 2 yıl