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Health Care Associated Infections

Health Care Associated Infections. Prof. Dr. A. Çağrı Büke Yeditepe University Medical Faculty Infectious Diseases and Clinical Microbiology. Ç . BÜKE HCAI / NI. Health care associated infections.

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Health Care Associated Infections

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  1. Health Care Associated Infections Prof. Dr. A. Çağrı Büke Yeditepe University Medical Faculty Infectious Diseases and Clinical Microbiology

  2. Ç. BÜKE HCAI / NI Health care associated infections • Health care-associated infections, or infections acquired in health-care settings are the most frequent adverse event in health-care delivery worldwide • Hundreds of millions of patients are affected by health care-associated infections worldwide each year, leading to significant mortality and financial losses for health systems

  3. Ç. BÜKE HCAI / NI HCAIs • Of every 100 hospitalized patients at any given time, 7 in developed (7%) and 10 (10%)in developing countries will acquire at least one health care-associated infection • While urinary tract infection is the most frequent health care-associated infection in high-income countries, • Surgical site infection is the leading infection in settings with limited resources, affecting up to one-third of operated patients • This is up to nine times higher than in developed countries

  4. Ç. BÜKE HCAI / NI HCAIs • In high-income countries, approximately 30% of patients in intensive care units (ICU) are affected by at least one health care-associated infection • In low- and middle-income countries the frequency of ICU-acquired infection is at least 2─3 fold higher than in high-income countries • Newborns are at higher risk of acquiring HCAIs

  5. Ç. BÜKE HCAI / NI Epidemiology • Studies indicate that each year, hundreds of millions of patients are affected by HCAIs around the world • The European Centre for Disease Prevention and Control reports an average prevalence of 7.1% in European countries • The estimated incidence rate in the United States of America (USA) was 4.5%

  6. Ç. BÜKE HCAI / NI Definition of HCAIs • Health care-associated infections, or “nosocomial” and “hospital” infections, affect patients in a hospital or other health-care facility, and are not present or incubating at the time of admission • That appear more than 48 h after admission • They also include infections acquired by patients in the hospital or facility but appearing after discharge • 10 days – 1 month – 1 year

  7. Ç. BÜKE HCAI / NI Risk factors for HCAIs • Prolonged and inappropriate use of invasive devices and antibiotics • immuno-suppression and other severe underlying patient conditions; • Insufficient application of standard and isolation precautions Urinary tract infection Ventilator associated infection CVC related blood stream infection Surgical site infection

  8. Ç. BÜKE HCAI / NI Determinants of HCAIs • Inadequate environmental hygienic conditions and waste disposal; • Poor infrastructure; • Insufficient equipment; • Understaffing; • Overcrowding; • Poor knowledge and application of basic infection control measures; • Lack of procedure; • Lack of knowledge of injection and blood transfusion safety; • Absence of local and national guidelines and policies.

  9. Ç. BÜKE HCAI / NI Magnitude of HCAIs • Health care-associated infections create additional suffering and come at a high cost for patients and their families • Infections prolong hospital stays, create long-term disability, increase resistance to antimicrobials, represent a massive additional financial burden for health systems and cause unnecessary deaths • Such infections annually account for 37 000 attributable deaths in Europe and potentially many more that could be related, and they account for 99 000 deaths in the USA

  10. Ç. BÜKE HCAI / NI Economic impact of HCAIs • Annual financial losses due to health care-associated infections are also significant: • They are estimated at approximately €7 billion in Europe, including direct costs only • and reflecting 16 million extra days of hospital stay, and at about US$ 6.5 billion in the USA.

  11. Ç. BÜKE HCAI / NI Sources of HCAIs

  12. Ç. BÜKE HCAI / NI Surgical site infections • Most common nosocomial infection among surgical patients (38%) • 2/3 incisional • 1/3 organs or spaces accessed during surgery • Clinical signs generally occur • Systemic and local signs of inflammation • Bacterial counts ≥ 105cfu/mL • Purulent versus non-purulent leakage • Surgical chemoprophylaxis is important for prevention

  13. Ç. BÜKE HCAI / NI SSI Staphylococcus aureus, Enterococci, CNS, E.coli, K.pneumoniae, A. baumannii, P.aeruginosa • Superficial SSI; involves only skin or subcutaneous tissue of the incision • Infection occurs within 30 days after the operation • Deep incisional SSI; involves the deep soft tissue (e.g., fascia and muscle layers) • Infection occurs within 30 days after the operation without implant, within 1 year with implant • Organ/space SSI; involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation

  14. Ç. BÜKE HCAI / NI Risk factors for SSI • Duration of surgical scrub • Maintain body temp • Skin antisepsis • Preoperative shaving • Duration of operation • Antimicrobial prophylaxis • Operating room ventilation • Inadequate sterilization of instruments • Surgical drains • Surgical technique • Poor hemostasis • 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

  15. Ç. BÜKE HCAI / NI SSI wound classification Class 1 = Clean • Operativewoundclean, non-traumatic, withnoinflammationencountered, nobreak in technique • Gastrointestinal, respiratoryandgenitourinarytractsnot entered • Neurologicalprocedures • Endocrineprocedures • Eyesurgery • Orthopedicprocedures • Penileprosthesis • Vascularprocedures • Skin (mastectomy, lumpectomy, lesions, • lipoma, cosmetic • Exploratory Lap (nobowelinvolvement II) • Expected rate of infection: 1.5-2.9%

  16. Ç. BÜKE HCAI / NI SSI wound classification Class 2 = Clean contaminated • Non-traumatic wound with minor break in technic • Gastrointestinal, respiratory and genitourinary tracts entered without significant spillage. Thoracic procedure (except mediatinoscopy I) • GI procedures (including: laparoscopy, colonoscopy, gastroscopy), (it is III) • GU procedures (infected III) • Ear surgery (infected III) • Nose/Oropharynx procedures • GYN procedures (oophorectomy I, inflammed III, infective IV, Histerectomy) Expectedrate of infection: 2.9-7.7%

  17. Ç. BÜKE HCAI / NI SSI wound classification Class 3 = Contaminated • Operativewoundcontaminated • Freshtraumaticwoundfromcleansource • Operativewoundwith a major break in techique • Grossspillagefromthegastrointestinaltract • Incisionencounteringacutenon-purulentinflamation Expected rate of infection: 8.5-15.2 %

  18. Ç. BÜKE HCAI / NI SSI wound classification Class 4 = Dirty infected • Operative wound dirty • Traumatic wound from dirty source • Fecal contamination • Foreign body • Retained devitialized tissue • Operative wound with acute bacterial • Operative wound where clean tissue is transected to gain access to a collection of pus Infected Abscess Wound debridement Expected rate of infection: 12.6-40 %

  19. Ç. BÜKE HCAI / NI Organisms responsible for SSI • Staphylococcus aureus • Enterococci • CNS • E.coli • K.pneumoniae • A. baumannii • P.aeruginosa

  20. Ç. BÜKE HCAI / NI Prevention of SSIs • Proper hair removal • Take a bath with chlorhexidine containing shampoo • Antisepsis of surgical area with 2% chlorgexidine • Appropriate prophylactic antibiotic chosen • Antibiotic given within 1 hour before incision • Discontinuation of antibiotic within 24 hours of surgery • Glucose control • Normothermiain colorectal surgery patients

  21. Ç. BÜKE HCAI / NI Urinary tract infection • Associated with urinary catheter and invasive urological procedures • Catheter-associated (CA) bacteriuria is the most common HCAI infection worldwide • The rate of widespread andinappropriate use is high

  22. Ç. BÜKE HCAI / NI Diagnosis of CA-UTI • 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 • Positive dipstick for leukocyte esterase and/ or nitrate • Pyuria • Organisms seen on Gram’s stain of unspun urine and • Isolation the uropathogenwith >102-3cfu/ml in non voided specimen

  23. Ç. BÜKE HCAI / NI Prevention of CA-UTI • Closed system integrity should not be impaired • The most effective way to reduce the incidence of 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 x

  24. Ç. BÜKE HCAI / NI Catheter associated bloodstream infection Risk factors • Heavy skin colonization at the insertion site • Internal jugular or femoral vein sites • Duration of placement • Contamination of the catheter hub • 12-25% attributable mortality

  25. Ç. BÜKE HCAI / NI Catheter associated bloodstream infection Risk for bloodstream infection:

  26. Ç. BÜKE HCAI / NI Epidemiology of CA-BSI

  27. Ç. BÜKE HCAI / NI Prevention of CA-BSI • Limit duration of use of intravascular catheters • No advantage to changing catheters routinely (except for Staphylococcus spp. and Candida spp.) • Change PICCs every 72 hours • Maximal barrier precautions for insertion • Sterile gloves, gown, mask, cap, full-size drape • Chlorhexidineprep for catheter insertion • Maximal barrier precautions • Daily review of line necessity

  28. Ç. BÜKE HCAI / NI Nosocomia pneumonia • 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. 30-70 % • The incidence of nosocomial pneumonia is highest in ICU, especially due to invasive mechanical ventilation (Ventilator associated pneumonia). 10-fold higher than non-ventilated patients

  29. Ç. BÜKE HCAI / NI Definition of NP • 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 spp., E.coli, Enterobacter, Serratia) or MRSA. Anaerobesare common in patients predisposed to aspiration Legionella spp.

  30. Ç. BÜKE HCAI / NI Ventilator associated pneumonia • Ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or longer after mechanical ventilation is given by means of an endotracheal tube or tracheostomy • Results from the invasion of the lower respiratory tract and lung parenchyma by microorganisms • Intubation compromises the integrity of the oropharynx and trachea and allows oral and gastric secretions to enter the lower airways

  31. Ç. BÜKE HCAI / NI Diagnosis of VAP • New or progressive radiographic consolidation or infiltrate • In addition, at least 2 of the following: Temperature > 38 °C Leukocytosis (white blood cell count ≥  12,000 cells/ mm3 or leukopenia (white blood cell count <  4,000 cells/mm3) • Presence of purulent secretions

  32. Ç. BÜKE HCAI / NI Prevention of HCAIs Transmission of HCAIs • By direct contact with patients • By droplets • By airborn

  33. Ç. BÜKE HCAI / NI Prevention of HCAIs Goals; • Protect the patients Patients to patients transmission by HCWs • Protect the health care workers By contact, airborne and droplets Needle stick injury

  34. Ç. BÜKE HCAI / NI Prevention of HCAIs • Standard precautions • Isolation • Contact isolation • Airborn isolation • Droplet isolation Gloves Mask Eyeglasse Hand hygiene Gown

  35. Ç. BÜKE HCAI / NI Dressing and undressing of protective equipment • Perform hand hygiene • Place the gown • over the scrubs • Put on a mask • Put on eyeglasseor a faceshield • Put on gloves • Remove gloves • Remove gown • Perform hand hygiene • Remove eyeglasseor a faceshield • Remove mask • Perform hand hygiene

  36. Ç. BÜKE HCAI / NI Hand hygiene

  37. Ç. BÜKE HCAI / NI Hand hygiene 40–60 second by washing with soap and water

  38. Ç. BÜKE HCAI / NI Hand hygiene 20–30 second by handrubbing with antiseptics

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