HOSPITAL INFECTIONS (HCAI)

HOSPITAL INFECTIONS (HCAI)
Meral SÖNMEZOĞLU, MD Yeditepe University Hospital Associate Professor of Department of Infectious Diseases and Clinical Microbiology

HCAI Definition Health Care-associated Infection (HCAI)
Also referred to as “nosocomial” or “hospital” infection “An infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge, and also occupational infections among health-care workers of the facility”

HCAI The World Health Organization has reported that, at any given time, approximately 1.4 million people have an HAI; in developing countries, the risk can be up to 20 times greater than in developed countries. In addition, the emergence of HAIs caused by multidrug-resistant microorganisms is an increasing concern.

Healthcare-Associated Infections (HAIs)
1 out of 20 hospitalized patients affected Associated with increased mortality Attributed costs: $26-33 billion annually HAIs occur in all types of facilities, including: Long-term care facilities Dialysis facilities Ambulatory surgical centers Hospitals

Patient Safety within CDC’s Division of Healthcare Quality Promotion (DHQP)
Healthcare Safety Healthcare-associated Infections Adverse Drug Events Transfusion/ Transplant Safety Antimicrobial Resistance Immunization Safety Healthcare Preparedness Outbreak Investigations Surveillance Prevention Recommendations Intervention Implementation Extramural Research Laboratory Research and Support

HCAIs: emerging priorities
MRSA Clostridium difficile 34 trusts reported zero MRSA bacteraemias between – Surgical site infections Urinary catheter UTIs Ventilator-associated pneumonia Line associated sepsis Enteral feeding tube infections Dialysis related infections Key points to raise: The National Audit Office (2009) reported an improvement in the governance, process and systems used to tackle HCAIs within hospital trusts. Infection control teams report on the whole an active interest in infection prevention and control activities, giving it sufficient priority and responding rapidly to their recommendations. However, the NAO report also revealed that attention was largely focused on mandatory surveillance activities. Therefore, more action is likely to be required to meet the wider requirements of the NICE and HPA quality improvement guide. The Department of Health resource Winning Ways (2003) provides useful information on steps to reduce the infection risk from the use of catheters, tubes, cannulae, instruments and other devices. Mandatory HCAIs surveillance progress to date: The NHS has made considerable progress towards improving infection prevention and control since the introduction of mandatory surveillance for meticillin-resistant Staphylococcus aureus (MRSA) in 2001 and C. difficile. HPA Quarterly report: Analyses of Mandatory MSSA Bacteraemia Data, September 2011 Based on the mandatory data reported by the HPA for NHS hospital trusts, the average reduction in number of cases has been 30% and 26% for MRSA bacteraemias and C. difficile respectively in the last 3 years (between 2007/08 and 2010/11). In addition, there was a 22% and 15% reduction respectively in 2010/11. Of the 4,362 reported MSSA cases between January and June % were Trust apportioned and 67% were non-Trust apportioned. Supplementary questions regarding mandatory surveillance: How does our trusts’ performance compare to the national picture for MRSA? What are we doing to try and achieve a zero cases standard? What do we as a board monitor, to help drive this improvement? MRSA bacteraemias and C.difficile are the tip of the iceberg for HCAIs. What steps are we taking to reduce all other HCAIs? What should we monitor to help drive this improvement?

Healthcare has moved beyond hospitals
Ambulatory Facilities Long-term Care Dialysis Facilities

Estimated rates of HCAI worldwide
At any time, over 1.4 million people worldwide are suffering from infections acquired in health-care facilities In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections In developing countries the risk of HCAI is 2–20 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25% In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%

The impact of HCAI HCAI can cause: more serious illness
prolongation of stay in a health-care facility long-term disability excess deaths high additional financial burden high personal costs on patients and their families

Outbreaks vs. Endemic Problems
Endemic problems represent the majority of HAIs Device-associated infections Catheter-associated urinary tract infections (CAUTI) Central line-associated Blood stream infections (CLABSI) Ventilator-associated Pneumonia (VAP) Procedure-associated infections Surgical site infections (SSI) Adherence problems Antimicrobial stewardship, hand hygiene

Most frequent sites of infection and their risk factors
URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% 13% LOWER RESPIRATORY TRACT INFECTIONS Mechanical ventilation Aspiration Nasogastric tube Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency LACK OF HAND HYGIENE Most common sites of health care- associated infection and the risk factors underlying the occurrence of infections SURGICAL SITE INFECTIONS Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision BLOOD INFECTIONS Vascular catheter Neonatal age Critical care Severe underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision Central nervous system depressants 17% 14%

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

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. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20: * Infect Control Hospital Epidemiol 2012;33(3):283-91

Colonization vs Contamination – Definitions
Bacteria present in a wound with no signs or symptoms of systemic inflammation Usually less than 105 cfu/mL Contamination Transient exposure of a wound to bacteria Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours SSI prophylaxis best strategy Colonization is defined as bacterial presence in a wound without signs or symptoms of inflammation, usually less than 105 cfu/mL. Contamination is defined as a transient exposure of a wound to bacteria of varying concentrations. Exposure to the bacteria is less than 6 hours. In this case surgical site infection prophylaxis is the best strategy.

SSI – Definitions Infection Surgical wound infection is SSI
Systemic and local signs of inflammation Bacterial counts ≥ 105 cfu/mL Purulent versus nonpurulent LOS effect Economic effect Surgical wound infection is SSI Surgical sites are considered infected when there are signs of systemic and local inflammation and bacterial counts are 105 cfu/mL or higher. Infections are also differentiated by purulence or nonpurulence. The length of stay for the patient and economic effects of the hospital stay are important factors to consider in SSIs. It is important to note is that a surgical wound infection is a surgical site infection. LOS=length of stay.

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:

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:

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 ;20:

SSI – Risk Factors Operation Factors
Foreign material at surgical site Surgical drains Surgical technique Poor hemostasis Failure to obliterate dead space Tissue trauma Duration of surgical scrub Maintain body temp Skin antisepsis Preoperative shaving Duration of operation Antimicrobial prophylaxis Operating room ventilation Inadequate sterilization of instruments Both operation factors and patient characteristics may influence the risk of surgical site infection. Depending on the conditions of the operation a patient can be at an even greater risk of infection. These factors can include duration of surgical scrub, maintenance of body temperature, the use of skin antisepsis, preoperative shaving, duration of the operation, antimicrobial prophylaxis, ventilation of the operating room, inadequate sterilization of instruments, the presence of foreign material at the surgical site, surgical drains, and surgical technique. Poor surgical technique includes poor hemostasis, failure to obliterate dead space, and tissue trauma. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

SSI – Risk Factors Patient Characteristics
Age Diabetes HbA1C and SSI Glucose > 200 mg/dL postoperative period (<48 hours) Nicotine use: delays primary wound healing Steroid use: controversial Malnutrition: no epidemiological association Obesity: 20% over ideal body weight Prolonged preoperative stay: surrogate of the severity of illness and comorbid conditions Preoperative nares colonization with Staphylococcus aureus: significant association Perioperative transfusion: controversial Coexistent infections at a remote body site Altered immune response This slide shows risk factors for patients who are considered to be at a higher risk for surgical site infection. High-risk characteristics include advanced age, diabetes, smoking, poor nutritional status, obesity, coexisting infections at a particular body site, and altered immune response, among other factors. Prolonged preoperative stay is also a risk, depending on the severity of illness and comorbid conditions. There is also a significant association between preoperative nares colonization with Staphylococcus aureus and surgical site infection. Perioperative transfusion remains a controversial issue. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

SSI – Wound Classification
Class 1 = Clean Class 2 = Clean contaminated Class 3 = Contaminated Class 4 = Dirty infected Prophylactic antibiotics indicated Therapeutic antibiotics Surgical site infections are categorized into four classes depending on wound type. Class 1 is a clean wound, class 2 is a clean contaminated wound, class 3 is a contaminated wound, and class 4 is a dirty infected wound. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

SSI – Wound Classification

SSI – Risk Stratification NNIS Project
3 independent variables associated with SSI risk Contaminated or dirty/infected wound classification ASA > 2 Length of operation > 75th percentile of the specific operation being performed Three independent variables have been shown to be associated with surgical skin infection risk through the National Nosocomial Infections Study. These include an ASA greater than 2, classification of the wound as contaminated or dirty, and length of operation being longer than the 75th percentile of the specific operation being performed. NNIS=National Nosocomial Infections Surveillance. NNIS. CDC. Am J Infect Control. 2001;29:

Principles of Antibiotic Prophylaxis
Preop administration, serum levels adequate throughout procedure with a drug active against expected microorganisms. High Serum Levels Preop timing IV route Highest dose of drug During Procedure Long half-life Long procedure–redose Large blood loss–redose Duration None after wound closed 24 hours maximum Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

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:

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:

CATHETER ASSOCIATED UTI (CAUTI)

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).

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 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

HICPAC Guidelines

CAUTI Catheter associated bacteriuria increase every catheter day:
Week 1: 25% Month 1: 100%

Prevention removing the catheter as soon as it is no longer needed

Nosocomial Bloodstream Infections

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

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, 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

Epidemiology of CVC-BSI
Pathogen (%) Coagulase-negative staphylococci 37 % Gram-negative rods 14 % Enterobacter species 5 % Pseudomonas aeruginosa 4 % Klebsiella pneumoniae 3 % Escherichia coli 2 % Staphylococcus aureus 13 % Enterococcus Candida species 8 %

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

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

Hospitals using NHSN are preventing bloodstream infections
Trends in bloodstream infections* by ICU type, NHSN hospitals, 1 2 3 4 5 6 7 8 9 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Medical Pediatric Surgical Medical/Surgical--Major Teaching Medical/Surgical--Non-Major Teaching Pooled Mean Annual CLABSI Rate per 1,000 Central Line Days Burton DC, et al. Methicillin-Resistant Staphylococcus aureus Central Line-Associated Bloodstream Infections in US Intensive Care Units, JAMA. 2009;301(7):

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

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

Prevention of health care-associated infection
Validated and standardized prevention strategies have been shown to reduce HCAI At least 50% of HCAI could be prevented Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries

SENIC study: Study on the Efficacy of Nosocomial Infection Control
>30% of HCAI are preventable Relative change in NI in a 5 year period (1970–1975) 10 20 30 -40 -30 -20 -10 % Without infection control 14% 9% 19% 26% 18% LRTI SSI UTI BSI Total With infection control -31% -35% -27% -32% Haley RW et al. Am J Epidemiol 1985

Hand transmission Hands are the most common vehicle to transmit health care-associated pathogens Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires sequential steps

5 stages of hand transmission
one two three four five Germs present on patient skin and immediate environment surfaces Germ transfer onto health-care worker’s hands Germs survive on hands for several minutes Suboptimal or omitted hand cleansing results in hands remaining contaminated Contaminated hands transmit germs via direct contact with patient or patient’s immediate environment 5 stages of hand transmission

Prevent Infection Bundles (sets of infection control recommendations) to prevent infection when inserting devices or performing procedures.

Prevent Transmission Hand Hygiene, Isolation, Environmental
Cleaning, etc

Adherence to infection control guidelines is incomplete
Many HAIs are preventable with current recommendations Failure to use proven interventions is unacceptable Only 30%-38% of U.S. hospitals are in full compliance Just 40% of healthcare personnel adhere to hand hygiene Insufficient infection control infrastructure in non- acute care settings has allowed major lapses in safe care

Why should you clean your hands?
Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene Therefore hand hygiene concerns you! You must perform hand hygiene to: protect the patient against harmful germs carried on your hands or present on his/her own skin protect yourself and the health-care environment from harmful germs

The “My 5 Moments for Hand Hygiene” approach

Time constraint = major obstacle for hand hygiene
Adequate handwashing with water and soap requires 40–60 seconds Average time usually adopted by health-care workers: <10 seconds Alcohol-based handrubbing: 20–30 seconds

National Standardized Infection Ratios (SIRs) and facility-specific percentiles using HAI data reported from all NHSN facilities reporting during 2010 by HAI and patient population: Central Line-associated Bloodstream Infections (CLABSIs), Catheter-associated Urinary Tract Infections (CAUTIs), and Surgical Site Infections (SSIs)

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 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

HOSPITAL INFECTIONS (HCAI)

Similar presentations

Presentation on theme: "HOSPITAL INFECTIONS (HCAI)"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

HOSPITAL INFECTIONS (HCAI)

Similar presentations

Presentation on theme: "HOSPITAL INFECTIONS (HCAI)"— Presentation transcript:

Similar presentations

About project

Feedback