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NOSOCOMIAL INFECTIONS

NOSOCOMIAL INFECTIONS. Chetan Jinadatha, MD, MPH. OBJECTIVES. CAUTI CDIFF CRBSI SSI Isolation Protocols HAP/VAP/HCAP: Not discussed. CAUTI: Epidemiology. Catheter associated/acquired urinary tract infection Most common healthcare associated infection or nosocomial infections

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NOSOCOMIAL INFECTIONS

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  1. NOSOCOMIAL INFECTIONS Chetan Jinadatha,MD, MPH.

  2. OBJECTIVES • CAUTI • CDIFF • CRBSI • SSI • Isolation Protocols • HAP/VAP/HCAP: Not discussed

  3. CAUTI: Epidemiology • Catheter associated/acquired urinary tract infection • Most common healthcare associated infection or nosocomial infections • 15-25% of hospitalized patients may have a catheter • Rates for CAUTI in acute care: 3.1-7.5/1000 catheter-days • Mortality from CAUTI: >13,000 (2.3%) • Costs per CAUTI: $500 - $40,000

  4. CAUTI: Risk Factors • Female sex • Older age • Prolonged catheterization • Impaired immunity • Lack of antimicrobial exposure • Catheter blockage • ? Low albumin • Positive meatal cultures • Improperly trained personnel • Place of placement (OR better than ER)

  5. CAUTI: Common Organisms • Escherichia coli (21.4%) • Candida spp (21%) • Enterococcus spp (14.9%) • Pseudomonas aeruginosa (10%) • Klebsiella pneumoniae (7.7%) • Enterobacter spp (4.1%) • Rarely Staphylococcus spp or other GNR

  6. CAUTI: Complications • Common complications: • Cystitis • Pyelonephritis • Gram-negative bacteremia • Prostatitis/epididymitis/orchitis in males • Less commonly: • Endocarditis • Vertebral osteomyelitis • Septic arthritis • Endophthalmitis • Meningitis

  7. CAUTI: Investigations • UA/UCx • BCx • Renal USG/CT abd/pelvis: to r/o pyelo/hydro • Prostate exam

  8. CAUTI: Treatment • Asymptomatic bacteriuria: no treatment required unless immunocompromised • Asymptomatic candiduria: no treatment required unless immunocompromised • DC catheter as soon as possible • In pregnancy asymptomatic bacteriuria may need therapy

  9. CAUTI: Treatment • Symptomatic • Duration: • Severe: 10-14 days • Mild/Moderate: 7 days (levofloxacin 5 days) • <65yrs, no catheter, ? 3 days • Route: IV if severe then PO • Empiric: • Sick: Zosyn/unasyn+gent/Carbepenams • Mild: Levofloxacin

  10. CAUTI: Prevention • Proper indication based usage • Proper insertion & maintenance technique • Physician catheter reminders • Early discontinuation • Condom catheters • QI teams monitoring rates

  11. CDIFF: Introduction • Antibiotic induced colitis • Feco-oral transmission • Disruption of the normal flora • Secondary to antimicrobial therapy • Elaborating exotoxins

  12. CDIFF: Epidemiology • Cdiff identified in 1978 • Largely attributed to clindamycin • PCN and Cephalosporin were also blamed • 2003-2006: More frequent, more severe infections, resistant to standard therapy (new strain)(NAP1/BI/027) • Incidence: 31/100,000 to 84/100,000 • Incidence: >65yrs: 228/100,000 • Carriage: 20-50% of adults in hospitals/LTC

  13. CDIFF: Risk Factors • Antibiotic usage (clindamycin, quinolones, PCN, Cephalosporins) • Hospitalization • Advanced age • Severe illness • Gastric acid suppression • Enteral feeding • GI surgery • Cancer chemotherapy

  14. CDIFF: Toxins • Toxin A (Enterotoxin) • Causes: inflammation -> intestinal fluid secretion, mucosal injury and pseudomembrane formation • Toxin B (Cytotoxin) • More potent (10 times) • Causes colonic mucosal damage and inflammation • Binary Toxin • Associated with NAP1/BI/027 • Alone in non pathogenic • Acts in synergy with Toxin A & B

  15. CDIFF: Toxins

  16. CDIFF: Symptoms • Asymptomatic carriers (20%) • Watery diarrhea • Colitis • Lower abdominal pain cramping • Low grade fever • May present 10 weeks after antibiotic therapy

  17. CDIFF: Signs • Lower abdominal tenderness • Colonoscopy: patchy mild erythema, friability to severe pseudomembranous colitis or fulminant colitis • Unexplained leucocytosis • Relapse can occur in 10-25% of treated patients

  18. CDIFF: Gross & Histology

  19. CDIFF: Unusual Presentations • Protein losing enteropathy with ascites • Cdiff and inflammatory bowel disease • Extracolonic involvement: appendicits, small bowel enteritis, rarely cellulitis, soft tissue infection, and reactive arthritis

  20. CDIFF: Lab Diagnosis • Cytotoxicity assay: • Gold standard • High sensitivity (10pg of toxin) and high specificity • Long turnaround time • Not done often • Organism culture • Patients can be colonized without toxin production • Long turn around time • Cannot differentiate toxin and non toxin strains

  21. CDIFF: Lab Diagnosis • EIA • Can detect both A & B toxin • Relatively simple • Fast turn over time (24hrs) • Good specificity (99%) • High false negative results (100pg-1000pg needed) • PCR • Faster turnaround time • Higher specificity and sensitivity • Test of choice in S&W

  22. CDIFF: Serial Repeating Of Tests • Cdiff x 3 : Is there any evidence? • Journal of clinical microbiology: Nov 2008 P 3795-3797 & P 3686-3689 • Initial negative result followed by positive result within a 7 day period were 1.9 and 1.7 by EIA & PCR respectively. Hence there is no value in repeating the test within the first 7 days

  23. CDIFF: Infection Control • Most common cause of nosocomial diarrhea • Contact isolation/precautions • Hand hygiene • Alcohol is not effective and does not eradicate spores • Soap and water with vigorous mechanical scrubbing and rinsing more effective

  24. CDIFF: Infection Control • Hospital Environmental cleaning • Spores can survive on dry surfaces for several months • Hypochlorite solutions effective: 1:10 solution • Hydrogen peroxide vapor : Infection control and Hospital Epidemiology August 2008 Vol 29 No 8 P: 723-729 • Antibiotic restrictions: • Clindamycin • Fluoroquinolones • Cephalosporins

  25. CDIFF: Treatment • General considerations: • Stopping the culprit antibiotic ASAP or switching • Institution of infection control policies • Therapy should be instituted in a patient with more than a mild disease • Empiric therapy is acceptable while awaiting results • Treatment not indicated in a toxin positive, symptom negative patient

  26. CDIFF: Treatment • Antibiotic therapy • Role of Probiotics (?) • Surgery • Anion binding resins (?) • IV immunoglobulin • Fecal bacteriotherapy

  27. TREATMENT

  28. CLABSI/CRBSI: Introduction • Central Line-Associated Blood Stream Infection/Central line Related Blood Stream Infection • Estimated 248,000 bloodstream infections occur in U.S. hospitals each year • Average rate of CVC-associated BSIs is 5.3 per 1,000 catheter days in the ICU • The attributable cost per infection is an estimated $34,508–$56,000 and $296 million to $2.3 billion annually in US

  29. CLABSI: Criteria Must meet one of the following criteria: • Criterion 1: • Patient has a recognized pathogen cultured from one or more blood cultures and • organism cultured from blood is not related to an infection at another site • Criterion 2: • Patient has at least one of the following signs or symptoms: fever (>38oC), chills, or hypotension and • signs and symptoms and positive laboratory results are not related to an infection at another site and • common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions

  30. CLABSI: Caveats • There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated • Catheter in place for 48 hours before, onset of the event are also included • Catheter types: Umbilical catheter, temporary non tunneled central lines, tunneled catheters including dialysis catheters, & ports • Growth of >15 colony-forming units (cfu) from a 5-cm segment of the catheter tip by semiquantitative (roll-plate) culture or growth of >102 cfu from a catheter by quantitative (sonication) broth culture reflects catheter colonization • BCx & Tip Cx

  31. CLABSI: Organisms • Staphylococcus aureus • Enterococcus sp • Escherichia coli • Klebsiella sp • Enterobacter sp • Pseudomonas aeroginosa • Candida sp • Corynebacterium sp • Coagulase negative staph • Bacillus sp • Propioniobacterium sp

  32. Cefazolin is the preferred agent for treatment of MSSA vancomycin is the preferred agent for treatment of MRSA Ceftazidime, gentamicin, or ciprofloxacin can be used for treatment of gram-negative Ampicillin is the preferred agent for infections due to ampicillin-sensitive Enterococcus species Ethanol lock can be considered for the treatment of a mixed gram-positive and gram-negative infection For antibiotic lock therapy, the antibiotic is combined with heparin and instilled into each catheter lumen at the end of each dialysis session CLABSI: Antibiotic Lock

  33. CLABSI: Prevention • Site of Catheter Insertion: Subclavian best site • Type of Catheter Material: Teflon or polyurethane catheters have been associated with fewer infectious • Hand Hygiene and Aseptic Technique: Useful • Skin Antisepsis: ? Chlorhexidine better than iodide • Catheter Site Dressing Regimens: Transparent, semipermeable polyurethane dressings have become a popular means of dressing catheter insertion sites • Antibiotic coated catheters: Useful • Platinum/silver coated catheters: No evidence • Silver cuffs: Not useful • Systemic Antibiotic Prophylaxis: No evidence • Antibiotic/Antiseptic Ointments: No strong evidence • Antibiotic Lock Prophylaxis: May be useful

  34. SSI: Epidemiology 2nd most common cause of nosocomial (hospital-acquired) infections Estimated 780,000 SSIs occur annually 2.6% of nearly 30million operations in US Each infection is estimated to increase hospital stay by average of 7 days and add over $3,000 in charges (1992 data) 93% were serious infections involving organs or spaces accessed during the operation

  35. SSI: Definition: Superficial Incisional

  36. SSI: Definition: Deep Incisional

  37. SSI: Definition: Organ Space

  38. SSI: Common Pathogens

  39. SSI: Timing of the first dose of antimicrobial therapy Goal: achieve serum and tissue drug levels that exceeds, for the duration of the operation, the MICs for the organisms likely to be encountered during the operation Infusion of the first abx dose should begin within 60min before incision When vanc or quinolone used, infusion should begin within 120min before incision to avoid abx-associated reactions When proximal tourniquet required, entire abx dose should be administered before tourniquet inflated

  40. SSI: Other Factors • Appropriate hair removal • Post operative glucose control (esp cardiac pts) • Perioperativenormothermia (colorectal pts)

  41. CID 2004:38

  42. SSI: Duration of Abx Prophylaxis Prophylactic abx should be discontinued within 24h after the end of surgery Majority of published evidence demonstrates that antibiotic prophylaxis after wound closure is unnecessary Most studies have not shown benefit of additional doses vs single dose Prolonged use of prophylactic antibiotics is associated with emergence of resistant bacteria! For majority of operations in SIP project, guidelines recommend prophylaxis end within 24h of operation Exception: cardiothoracic surgery abx prophylaxis up to 72h after operation Based on expert opinion (ASHP) and authors suggest that prophylaxis <=24h may be appropriate

  43. SSI: Antibiotic Prophylaxis for MRSA HICPAC suggests “high” frequency of MRSA infections in an institution should influence the use of vancomycin for prophylaxis No consensus about what constitutes “high” prevalence For patients with known MRSA colonization, vancomycin should be considered the appropriate prophylactic antibiotics No evidence that routine vanc use in institutions with perceived high rates of MRSA infection will result in fewer SSIs than cefazolin or related If use cefazolin and develop SSI: more likely to be infected with MRSA If use vanc and develop SSI: more likely to be infected with MSSA Changes flora of infections but did not alter infection rate

  44. SSI: Treatment • Superficial infection: • 10-14 days • Deep infection: • 2-4 weeks + appropriate surgical drainage • Organ Space/Prosthetic device: • 6-8 weeks IV abx + appropriate surgical drainage & may need oral suppressive therapy

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