Nosocomial Infections & Prevention PDF

Nosocomial infections & their prevention Healthcare-associated infections 1. 2. 3. 4. 5. Urinary Tract Infection Others Surgical Site Infection Pneumonia Bloodstream Infection R. Monina Klevens at el., Public Health Rep.122(2); Mar-Apr 2007, 160 – 166 Device Related Healthcare-associated infe...

Nosocomial infections & their prevention Healthcare-associated infections 1. 2. 3. 4. 5. Urinary Tract Infection Others Surgical Site Infection Pneumonia Bloodstream Infection R. Monina Klevens at el., Public Health Rep.122(2); Mar-Apr 2007, 160 – 166 Device Related Healthcare-associated infections HAI Infection Rate Bloodstream Infection 9.9% Urinary Tract Infection 12.9% Pneumonia 21.8% Device Related Shelley S.et al. N Engl J Med 2014; 370:1198-1208 Routes of Entry of Uropathogens to Catheterized Urinary Tract Extraluminal Modify from Siddiq DM, Darouiche RO. Nat Rev Urol. 2012 Apr 17;9(6):305-14. Routes of Entry of Uropathogens to Catheterized Urinary Tract Intraluminal • • Break in closed drainage Contamination of collection bag urine Modify from Siddiq DM, Darouiche RO. Nat Rev Urol. 2012 Apr 17;9(6):305-14. Biofilm formation enables the organism to avoid host defenses, resist antibiotic therapy, and provides a reservoir for ongoing infection if the catheter is no removed Zowawi HM, et al. Nat Rev Urol. 2015 Oct;12(10):570-84. Risk factors for catheter-associated urinary tract infection Factor Relative risk Prolonged catheterization > 6 days 5.1 - 6.8 Female gender 2.5 - 3.7 Catheter insertion outside operating room 2.0 - 5.3 Urology service 2.0 - 4.0 Other active sites of infection 2.3 - 2.4 Diabetes 2.2 - 2.3 Malnutrition 2.4 Renal failure (creatinine > 2.0 mg/dL) 2.1 - 2.6 Ureteral stent 2.5 Monitoring of urine output 2.0 Drainage tube below level of bladder and above collection bag 1.9 Emerg Infect Dis. 2001 Mar-Apr;7(2):342-7. Summary of recommendations from published guidelines in preventing CAUTI Recommendations CDC EAU IDSA HICPAC SHEA Evaluate necessity of catheterization Yes Yes Yes Yes Yes Review ongoing need for catheter regularly Yes Yes Yes Yes Yes Evaluate alternative methods of drainage Yes Unresolved Yes Unresolved Yes Use of aseptic technique/sterile equipment Yes Yes Yes Yes Yes Use of barrier precautions for insertion Yes Unresolved Unresolved Unresolved Yes Use smallest bore catheter possible Yes Yes Unresolved Unresolved Yes Maintain closed drainage system Yes Yes Yes Yes Yes Maintain drainage bag below level of bladder Yes Yes Yes Yes Yes Avoid routine irrigation Yes Yes Yes Yes Yes Limitation of catheter use Catheter insertion and selection Catheter maintenance CDC, US Centers for Disease Control and Prevention; EAU, European Association of Urology; HICPAC, Healthcare Infection Control Practices Advisory Committee; IDSA, Infectious Diseases Society of America; SHEA, Society for Healthcare Epidemiology of America;. Curr Opin Infect Dis. 2012 Aug;25(4):365-70. Empty urine bag Designated urine-collecting container  Designated trolley  Disinfect the container and keep it dry after each use Empty the drainage bag 1. Perform hand hygiene 2. Wear clean gloves 3. Disinfect the outlet with alcohol wipe before and after emptying 4. Prevent outlet touching the container 5. Remove gloves immediately and perform hand hygiene SSIs occur in 2%–5% of patients undergoing inpatient surgery Anderson DJ, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. Superficial incisional SSI Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision Skin Superficial incisional SSI Subcutaneous tissue Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78 Anderson DJ, et al. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. Deep incisional SSI Infection occurs within 30 or 90 days after the operation, and the infection involves the deep soft tissue (e.g. fascia and muscle layers) Deep soft tissue (fascia & muscle) Superficial incisional SSI Deep incisional SSI Anderson DJ, et al. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. Organ/space SSI Infection occurs within 30 or 90 days and the infection involves any part of the body deeper than the fascial / muscle layers, that is opened or manipulated during the operative procedure Organ/space Superficial incisional SSI Deep incisional SSI Organ/space SSI Anderson DJ, et al. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. Pathogenesis of SSI Surgical site infection can develop at any time from two to three days after surgery until the wound has healed (usually five to ten days after the operation) Potential consequences of surgical site infection Delay wound healing Revision of surgery Systemic sepsis or death ↑ hospital length of stay ↑ healthcare associated cost November 2016 Key recommendations in the prevention of surgical site infection 1 Decolonization of SA* Surgical site preparation Perioperative care 2 Antibiotic prophylaxis 4 Surgical hand preparation 3 5 6 Surveillance * Decolonization of S. aureus in cardiothoracic & orthopedic surgery Overview of Infection Control Guidelines to Prevent Surgical Site Infection UK NICE US SHEA WHO (2008) (2014) (2016) WHO Strength WHO Quality of evidence Recommendations Decolonization of S. aureus - + + Strong Moderate Antibiotic prophylaxis + + + Strong Moderate Surgical site preparation + + + Strong Low to Moderate Surgical hand preparation + + + Strong Moderate Normothermia - + + Conditional Moderate Blood glucose control + + + Conditional Low Normovolemia + - + Conditional Low https://www.nice.org.uk/guidance/CG74 http://rischioinfettivo.it/archivio/Materiale-2014/SHEA-Prevent-surgical-site-infections,-2014.pdf http://apps.who.int/iris/bitstream/10665/250680/1/9789241549882-eng.pdf?ua=1. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus Relative risk of hospital-acquired Staphylococcus aureus infection Variable MupirocinChlorhexidine (N=504) Placebo (N=413) Relative risk (95% CI) S. aureus infection 17 (3.4%) 32 (7.7%) 0.42 (0.23-0.75) Deep surgical site 4 (0.9%) 16 (4.4%) 0.21 (0.27-0.62) Superficial surgical site 7 (1.6%) 13 (3.5%) 0.45 (0.18-1.11) Lower respiratory tract 2 (0.4%) 2 (0.5%) 0.82 (0.12-5.78) Others 4 (0.9%) 1 (0.2%) NA Localization of infection Bode LG, et al. N Engl J Med. 2010 Jan 7;362(1):9-17. Erasmus University Medical Center, The Netherlands Antibiotic Prophylaxis Appropriate for: • Clean surgery involving the placement of prosthesis or implant • Clean-contaminated surgery 1. Avoid using broad-spectrum antibiotics whenever possible 2. Relatively narrow spectrum antibiotics, such as cefazolin and cefuroxime are preferred Administer surgical antimicrobial prophylaxis as indicated within 120 min prior to incision (1-2 hours infusion for vancomycin) Skin Preparation Prepare the skin at the surgical site immediately before incision using an appropriate antiseptic 1. Remove hair only when it interferes with the operation 2. Pre-op. clipping is preferable to shaving Razor Clipper 3. Hair removal with clippers should be conducted as close as possible to the time of surgery (< 2 hrs) Surgical hand preparation 1. Keep nails short 2. No artificial fingernails 3. Remove rings, wrist-watch and bracelets before surgical hand preparation Surgical hand antiseptic products should be either an antimicrobial soap (scrub hands and forearms for 2-5 minutes) or an alcohol-based handrub Surgical handrubbing technique Surgical handrubbing technique Surgical handrubbing technique Surgical handrubbing technique Maintain Normothermia (core temp. 36-38oC) Pre- and intraoperatively 1. Impair the patient’s immune function  cause vasoconstriction at the incision site  suppress the neutrophil and macrophage activity 2. Decrease oxygen tension in tissues and therefore prolongs wound healing (factor correlated with the occurrence of SSI) Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes ≤ 125 125 – 180 ≥180 35.0 Adverse Events (%) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Composite Adverse Event Cardiac Adverse Event Noncardiac Adverse Event With Diabetes Death Composite Cardiac Noncardiac Death Adverse Adverse Adverse Event Event Event Without Diabetes FIGURE3. Adverse events, by diabetes status and postoperative glucose level. Kotagal M, et al. Ann Surg. 2015 Jan;261(1):97-103. Surgical attire and drapes 1. Sterile gown: resistant to liquid penetration 2. Sterile drape: create a barrier between the surgical field and the environment 3. Change surgical gowns and suit if visibly soiled or penetrated by blood / body fluids Sterilize all surgical instruments according to published guidelines Ventilation and environment in OT Filtration of incoming air by using central or point-of-use HEPA filters Well-sealed rooms ~ 0.5sq. ft. leakage Directed room air flow > 125 cf per min supply vs exhaust >15 ACH Positive room air pressure of 2.5 Pa [0.01" water gauge] relative to the corridor Incision site care 1. Cover operative wound with sterile dressing and keep intact for 24-48 hours 2. Replace dressing only if excess oozing is noted 3. Perform hand hygiene before and after (a) touching the surgical site (b) performing dressing change 4. Use normal saline to cleanse and remove surface bacteria and discharge from wound Report and record any signs of discharge or inflammation in a surgical wound Wound swabs should only be sent for culture if there are clinical signs of infection Education Teach the patient and their carers • How to care the incision site • Recognizing signs and symptoms of surgical site infection • When and where to seek treatment Pneumonia - Inflammation of the lung, usually caused by infection - Can be mild or severe - Damages ALVEOLI  exudate (fluid)  consolidates  lack of oxygen Pneumonia Community acquired Hospital acquired Non-VAP > 48 hr after admission & did not appear to be incubating at the time of admission Ventilator associated Pneumonia (VAP) Am J Respir Crit Care Med. 2005 Feb 15; 171(4): 388-416 HAP that develops >48-72 hrs after endotracheal intubation VAP occurs in 8% to 28% of patients undergoing mechanical ventilation Risk of pneumonia is increased at least 7 to 10 fold in patients following surgery or intensive care who require mechanical ventilation Colonization Aspiration MRSA * HAP Care of the Respiratory Equipment High-level disinfection is required after each use to reduce microbial contamination AUTOCLAVE AUTOMATED WASHING MACHINE CHEMICAL DISINFECTANTS Do not reprocess single use equipment Intravascular catheter-related infections Central cuff catheter / Implantable device Peripheral / central Non-cuff catheter Points of access for microbial contamination Clin Infect Dis. 2002 May 1;34(9):1232-42. Central cuff intravascular catheter Bacterial biofilm MIC: 100 - 1000 x Infection control bundle to prevent catheter related infection (especially CABSI) Hand hygiene Maximal barrier precautions One Piece Drape Chlorhexidine skin antisepsis 2% solution The Michigan Experience 103 ICUs (Mar 2004-Sep 2005) 1 doctor & 1 nurse in each ICU Implementing 5 Point Care Bundle Median CABSI Rate: 0 after 18mo Optimal catheter site selection with subclavian vein as the preferred site Daily review of line necessity with prompt removal of unnecessary lines N Engl J Med. 2006 Dec 28;355(26):2725-32. Am J Infect Control. 2008 Dec;36(10):S171.e1-5. Infection control bundle to prevent catheter related infection (especially CABSI) Hand hygiene Maximal barrier precautions One Piece Drape Chlorhexidine skin antisepsis 2% solution The Michigan Experience 103 ICUs (Mar 2004-Sep 2005) 1 doctor & 1 nurse in each ICU Implementing 5 Point Care Bundle Median CABSI Rate: 0 after 18mo Optimal catheter site selection with subclavian vein as the preferred site Daily review of line necessity with prompt removal of unnecessary lines N Engl J Med. 2006 Dec 28;355(26):2725-32. Am J Infect Control. 2008 Dec;36(10):S171.e1-5. Overall and unit costs of the five most common hospital-acquired infections in the United States (2012) SSI 一百億美元 三十三億美元 Data from a meta-analysis of costs and financial impact on the US health care system Zimlichman E, et al. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46. What is the meaning of “US 9.8 billion” in year 2012 to us? (3 億人口) (710 萬人口) Cost in 5 most common HAIs 9.8 billion (~ 100 億美元 ) Estimated cost in the corresponding HAIs 1.8 billion (~ 18 億港元) Cost in Surgical Site Infections 3.3 billion (~ 33 億美元) Estimated cost in Surgical Site Infections 0.6 billion (~ 6 億港元)