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

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

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

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

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

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

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 $ 749 - $ 832 Clostridium difficile-associated disease (CDI)17 178,000 $ 5,682 - $ 8,090

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.

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

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

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

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

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

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

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

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

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;137:665-670.

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;4:416-420. Jarvis WR. Emerg Infect Dis 2001;7:170-173.

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.

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

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

Surgical Site Infections

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

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

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;20:250-278.

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;20:250-278.

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;20:250-278.

Cross Section of Abdominal Wall Depicting CDC SSI Classifications

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)

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

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

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

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

Preventing Surgical Site Infections Focus on modifiable risk factors

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

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

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

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

Infection Rate Downloaded from: Principles and Practice of Infectious Diseases

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.

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.

URINARY TRACT INFECTIONS

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;29:996-1011 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

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

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).

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

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

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

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.

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.

Evidence-Based Guidelines Since 2008, multiple evidence-based guidelines for CAUTI prevention have been published 1980 1990 2000 2010 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

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

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

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

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.

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)

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

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.

CAUTI Urinary sampling from catheter Bacteria entry

Nosocomial Bloodstream Infections

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.

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.

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 0.2 - 2.2

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

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 Chlorhexidine/silver sulfadiazine vs. minocycline/rifampin catheters

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)

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

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

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

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

Health-Care Associated (Nosocomial) Pneumonia

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

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.

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

Pathogenesis

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.

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

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.

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.

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

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

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

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.

Antimicrobial Resistant Pathogens of Ongoing Concern Vancomycin resistant enterocci 12% increase in 2003 when compared to 1998-2002 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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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