HOSPITAL INFECTIONS

Infectious Diseases DepartmentYeditepe University Hospital

Meral SÖNMEZOĞLU, MD, Assoc Prof

• 1. Know the general terminology and definitions

• 2. Know epidemiology

• 3. Understand the importance of the hospital infections

• Explain the prevention

Learning objects

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

• 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

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

HRN = high risk newbornsWBN -= well-baby nurseriesICU = intensive care unitSSI = surgical site infectionsBSI – bloodstream infectionsUTI = urinary infectionsPNEU = pneumonia

SSI20%

BSI11%

UTI36%

PNEU11%

Other22%

133,368

424,060

263,810

129,519

274,098

-967

-21

-28,725

244,385

TOTAL

HRN

WBN

Non-newborn ICU

= SSI

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.

3. 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

1. Elderly patients.

2. Women in labor and delivery.

3. Premature infants and newborns.

4. Surgical and burn patients.

5. Diabetic and cancer patients.

6. 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)

7. Immunosupressed patients (I. e., patients whose immune systems are not functioning properly)

8. 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

1. An ever- increasing number of drug-resistant pathogens.

2. Lack of awareness of routine infection control measures.

3. Neglect of aseptic techniques and safety precautions.

4. Lengthy complicated surgeries.

5. Overcrowding of hospitals.

Nabeel Al-Mawajdeh RN.MCS

Major Factors Contributing to Nosocomial Infections (Cont’d)

6. Shortage of hospital staff.

7. An increased number of Immunosupressed patients.

8. 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

Gerberding JL. Ann Intern Med 2002;137:665-670.

Many infections are inevitable, although

some can be prevented

Each infection is potentially

preventable unless proven otherwise

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

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

Definition of Surgical Site Infections

Superficial Incisional SSI

Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Subcutaneous tissue

SkinSuperficial incisional SSI

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 soft tissue (fascia & muscle)

Deep incisional SSI

Superficial incisional SSI

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

Deep incisional SSI

Superficial incisional SSI

Organ/space SSIOrgan/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

Staphylococcusaureus17%

Coagulase neg.staphylococci

12%

Escherichiacoli10%

Enterococcusspp.8%

Pseudomonasaeruginosa

8%

Staphylococcusaureus20%

Coagulase neg.staphylococci

14%

Escherichiacoli8%

Enterococcusspp.12%

Pseudomonasaeruginosa

8%

1986-1989(N=16,727)

1990-1996(N=17,671)

National Nosocomial Infections Surveillance System (NNIS)

Classification Wound Class SSI Risk

Clean 0Lower

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 ratePer 100 operations

Median- 50% percentile

0 130 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– 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

© 2004 Elsevier

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.

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

Downloaded from: Principles and Practice of Infectious Diseases

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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

• Most common type of healthcare-associated infection

• > 30% of HAIs reported to NHSN • Estimated > 560,000 nosocomial UTIs

annually • Increased morbidity & mortality

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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.

44

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).

45

• 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

46

• 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

47

• 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

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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 GuidelinesSince 2008, multiple evidence-based guidelines for

CAUTI prevention have been published

1980 1990 2000 2010

CDC JBI

NHS

NHS SHEA APIC NHSN* CDC IDSA

CDC= US Centers for Disease ControlJBI=Joanna Briggs InstituteNHS=UK National Health ServiceSHEA=Society of Healthcare Epidemiologists of AmericaAPIC=Association of Professionals of Infection ControlNHSN=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

52

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

Weinstein JW et al. ICHE 1999;20:543-8 Munasinghe RL et al. ICHE 2001;22:647-9 Warren JW et al. Arch Intern Med 1989;149:1535-7 Saint S et al. Am J Med 2000;109:476-80 Benoit SR et al. J Am Geriatr Soc 2008;56:2039-44 Jain P et al. Arch Intern Med 1995;155:1425-9 Rogers MA et al J Am Geriatr Soc 2008;56:854-61 Saint S. et al. Clin Infect Dis 2008;46:243-50

Pathogenesis

54

• 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.

55

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)

• 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

HAI-UTI

• 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.

HAI-UTI

Bacteria entry Urinary sampling from catheter

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= 24,84752 BSI/10,000 admissions

Edmond M. SCOPE Project.

Nosocomial Bloodstream Infections, 1995-2002

Edmond M. SCOPE Project.

•Proportion of all BSI 0.9% (n=209)

•E.coli (33%)

•S.aureus (11.7%)

•Enterococci (11.7)

Obstetrics and Gynecology

In obstetrics, BSIs are uncommon. However, the principal pathogen is E.coli and not coagulase negative staphylococci.

The source is typically genitourinary

N= 24,84752 BSI/10,000 admissions

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

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

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

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

NNIS: Selected antimicrobial resistant pathogens associated with HAIs

Health-Care Associated (Nosocomial) PneumoniaHealth-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

PathogenesisPathogenesis

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– 12% increase in 2003 when compared to 1998-2002– 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

Duckro et al. Archive of Int Med. Vol.165,2005

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

The inanimate environment is a reservoir of pathogens

~ 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.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

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 solutionsQuick Easy to use

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

1. Contact – most common• Direct (physical contact)

• Indirect (via contaminated objects)

2. Airborne Transmission• Droplet respiratory secretions on surfaces

• Inhalation of infectious particles

3. Blood-borne transmission

4. 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

INFECTIOUS AGENTBacteria - Fungi -Viruses Rickettsiae – Protozoal

Prions – Protozoa Helminths

RESERVOIRSPeople

EquipmentEnvironment

Water

SUSCEPTIBLE HOSTImmunosuppression

Diabetes – Surgery – BurnsCardiopulmonary -

Neonates

PORTAL OF ENTRY

Mucous membrane GI / urinary / Respiratory track

Broken skin

PORTAL OF EXITExcretions - Secretions

Skin - Droplets

MEANS OF TRANSMISSION

Direct Contact Fomites

- Injection / Ingestion - Airborne aerosol

MEANS OF TRANSMISSION

Direct Contact Fomites

- Injection / Ingestion - Airborne aerosol

HEALTH CARE WORKERS

Air flow control

Food handling

Isolation

Trash & waste

disposal

Control of excretions

and secretions

Hand-hygiene

Disinfection/sterilization

Environmental sanitation

Employee health Care

Rapid accurate identification of

organismTreatment of underlying disease

Recognition of high risk patients

Aseptic Technique

Catheter Care

Wound Care

Hand-hygiene

Sterilization

 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